Fiser ABSITE Ch. 32 Gallbladder Flashcards
the gallbladder lies between these 2 liver segments
segment 4 and 5
cystic artery is a branch off of this
right hepatic artery
name the boundaries of callot triangle
cystic duct laterally, common bile duct medially, liver superior
these arteries were considered longitudinal blood supply to the hepatic and common bile duct, lies in a 3 and 9:00 position
right hepatic, retroduodenal, (branches of gastroduodenal artery)
where the cystic veins drain
right branch of the portal vein and into the liver
where the biliary lymphatics located with respect to the common bile duct
right side
name the parasympathetic and sympathetic innervation to gallbladder
parasympathetic: Left (anterior) the trunk of the vagus, sympathetic from T7-T10
which epithelial layer as the gallbladder lack compared to the rest of the GI tract
no submucosa
this hormone relaxes the sphincter of oddi
glucagon
give the normal size for: common bile duct, gallbladder wall, pancreatic duct
common bile duct -less than 8 mm; Gallbladder wall - less than 4 mm; pancreatic duct - less than 4 mm
where is the highest concentration of CCK and secretin cells
duodenum
these are invagination of the epithelium of the wall of the gallbladder, formed by increased gallbladder pressure
Rokitansky-Aschoff sinuses
name 3 things that increase bile excretion
CCK, Secretin, Vagal input
name 3 things that decrease bile excretion
VIP, Somatostatin, Sympathetics
name 3 essential functions of bile
fat-soluble vitamin absorption, bilirubin excretion, cholesterol excretion
where does bile become concentrated and how
in the gallbladder, resorption of sodium and water
where does the active resorption of conjugated bile acids occur
terminal ileum
name the 2 cells which secrete bile
bilateral canalicular cells, 20%; hepatic sites, 80%
we gives bile its green color
conjugated bilirubin
this is a breakdown product of conjugated bilirubin in the gut, it gives stool a brown color
stercobilin
breakdown product of conjugated bilirubin, gives urine its yellow color
urobilin
this is the rate limiting step in cholesterol synthesis
HMG coA reductase
name the 2 enzymes in bile acids synthesis
HMG coA reductase, 7-alpha- hydroxylase
give cause of cholesterol stone formation in thin versus overweight people
thin, underactive 7-alpha- hydroxylase; overweight, overactive HMG coA reductase
name 4 factors that increased cholesterol insoluabilization
1) stasis 2) calcium nucleation 3) increased water absorption in the gallbladder 4) decreased lecithin and bile acids
which gallstone is more common in United States
nonpigmented, cholesterol
black pigmented gallstones: 4 common causes
1) hemolytic disorders 2) cirrhosis 3) chronic TPN 4) status post ileal resection
black pigmented gallstones: 3 key factors for development
increased bilirubin load, decreased hepatic function, bile stasis
black pigmented gallstones: where do they form, treatment
within the gallbladder, cholecystectomy
brown pigmented gallstones: pathophysiology of formation
infection causing deconjugation of bilirubin
brown pigmented gallstones: most common cause, commonly seen in this population
E. coli, Asian
brown pigmented gallstones: where do they form
common bile duct
these 2 gallstones are considered secondary common bile duct stones. (formed in the gallbladder)
cholesterol stones, black stones
3 most common bacteria in cholecystitis
1) E. coli 2) Klebsiella 3) Enterococcus
name 4 preemptive conditions which increased risk for acalculus cholecystitis
1) Severe burns 2) Prolonged TPN 3) Trauma 4) Major surgery
emphysematous gallbladder disease: Describe, Seen in this population, Most common etiology
gas within the gallbladder wall; diabetics; Clostridium perfringens
emphysematous gallbladder disease: Signs and symptoms, Treatment
severe, rapid onset abdominal pain, nausea, vomiting and sepsis; Emergency cholecystectomy or percutaneous drainage if unstable
pathophysiology of gallstone ileus
fistula between the gallbladder and duodenum, releases stone causing small bowel obstruction… seen in the elderly
gallstone ileus: Common finding on plain film, Most common site of obstruction
pneumobilia; terminal ileum
gallstone ileus: Treatment
enterotomy and possible resection to remove stone, cholecystectomy with fistula resection
pelvis common bile duct injury treatment differentiated
if greater than 2 mm will need hepaticojejunostomy
this is the most important cause of the leak postoperative biliary stricture
ischemia
name 2 treatments for common bile duct or hepatic duct strictures
ERCP with sphincterotomy and stent placement; PTC tube
most common cancer of the biliary tract: First site of metastasis, Typical symptoms
gallbladder adenocarcinoma; Segments 4 and 5 of the liver; Jaundice first then right upper quadrant pain
differentiate stage I versus stage II gallbladder: adenocarcinoma, treatment for each
1-limited to the gallbladder mucosa; cholecystectomy; 2-into the muscle; wide resection around liver bed with possible Whipple
choledochal cyst: common etiology, signs and symptoms
female, Asian, 90% extrahepatic, 15% cancer risk; episodic pain, fever, jaundice, cholangitis
choledochal cyst: most common type, describe
1, fusiform or saccular dilation of extrahepatic ducts
give treatment for type one choledochal cyst
cyst excision with hepaticojejunostomy and cholecystectomy
described type 4 and type V choledochal cysts
4-partially intrahepatic, 5-caroli’s disease, total he intrahepatic requiring partial liver resection
30-40-year-old male patient presents with fatigue, fluctuating jaundice, pruritis, weight loss, right upper quadrant pain
primary sclerosing cholangitis
in 2 complications of primary sclerosing cholangitis
cirrhosis; cholangiocarcinoma
2 medications which can be used in primary sclerosing cholangitis, give affect of each
cholestyramine – decrease pruritis symptoms by decreasing bile acids; UDCA – decrease symptoms and improve liver function
primary biliary cirrhosis: Most common in, Symptoms, Key lab value
women; Fatigue, itching, jaundice, xanthomas; Positive antimitochondrial antibodies
Charcot’s triad
right upper quadrant pain, Fever, Jaundice
reynolds Pentad
1) Right upper quadrant pain 2) Fever 3) Jaundice 4) Altered mental status 5) Shock
2 most common pathogens associated with cholangitis
Escherichia coli, Klebsiella
give differential diagnoses for shock following laparoscopic cholecystectomy: Early-first 24 hours, Late-after 24 hours
early hemorrhagic shock from clip falling off the cystic artery; Late-septic shock from accidental clip the common bile duct with subsequent cholangitis
thickened nodule the mucosa and muscle associated with Rokitansky Ashcroft sinuses, Not premalignant; Give treatment
adenomyomatosis; Cholecystectomy
benign neuroectoderm tumor of gallbladder, Can occur in biliary tract with signs of cholecystitis; Give treatment
granular cell myoblastoma; Cholecystectomy
speckled cholesterol deposits on the gallbladder wall
cholesterolosis
2 signs concerning for malignancy and gallbladder polyps
greater than 1 cm; Patient greater than 60 years old
type of bilirubin down to albumin covalently, half-life of 18 days
delta bilirubin
compression of the common hepatic duct by a stone in the infundibulum of the gallbladder or inflammation arising from the gallbladder or cystic duct extending to the contiguous hepatic duct causing stricture and hepatic duct obstruction
mirizzi syndrome
this antibiotic can cause gallbladder sludge and cholestatic jaundice
ceftriaxone
