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Fiser Chapter 32 BILIARY SYSTEM Flashcards

1
Q

Gallbladder function

A

Stores bile

Concentrates bile by active resorption of NaCl and water (has more sodium, bile salts, and cholesterol than hepatic bile; hepatic bile has more chloride)

Postprandial emptying (maximum at 2 hours)

Cholecystectomy -> decreased total bile salt pools

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2
Q

45yo man with UC presents with jaundice, fatigue, pruritis, weight loss, and RUQ pain

A

Primary sclerosing cholangitis: associated with UC, pancreatitis, DM

Multiple strictures throughout hepatic ducts (string of beads)

Leads to portal HTN, hepatic failure (progressive fibrosis of intrahepatic and extrahepatic ducts) -> cirrhosis, cholangiocarcinoma

Tx: PTC tube drainage, choledochojejunostomy or balloon dilatation of dominant strictures may provide symptomatic relief, cholestyramine to decrease bile acids and pruritis, UDCA (ursodiol) to decrease bile acids and improve liver enzyms; LIVER TXP EVENTUALLY NEEDED FOR MOST; Colon resection does NOT help PSC

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3
Q

Cholangitis dx

A

Elevated AST/ALT, bilirubin, alk phos, WBC

US shows dilated CBD (> 8 mm, > 10 mm after cholecystectomy) if d/t biliary obstruction

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4
Q

GB wall normal size

A

< 4 mm

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5
Q

Pigmentes stones

A

Most common worldwide

  1. Calcium bilirubinate stones: from increased bilirubin load, decreased hepatic function, and bile stasis -> solubilization of unconjugated bilirubin with precipitation; dissolution agents (monooctanoin) do NOT work
  2. Black stones: Hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic TPN; tx cholecystectomy if symptomatic
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6
Q

Cholecystitis most common organisms

A

E coli (#1), Klebsiella, Enterocococcus

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7
Q

Biliary colic

A

Transient cystic duct obstruction caused by passage of gallstone

RESOLVES IN 4-6 HOURS

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8
Q

Patient with sepsis following lap chole

A
  1. Fluid resuscitation, stabilize
  2. US to look for dilated intrahepatic ducts or fluid collection (cystic duct leak versus transection)
  3. Could also be cholangitis
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9
Q

Charcot’s triad

A

RUQ pain, fever, jaundice

Reynaud’s pentad: altered mental status and shock

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10
Q

Diabetic with severe rapid-onset abdominal pain, nausea, vomiting, sepsis, gas in gallbladder wall on plain film

A

Emphysematous gallbladder disease: risk of perforation

Usually d/t clostridium perfringens
Tx: emergent cholecystectomy, percutaneous drainage if unstable

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11
Q

Enterohepatic circulation

A
  1. Bile secreted by hepatocytes (80%) and bile canalicular cells (20%); broken down in gut to stercobilin (makes stool brown); reabsorbed
  2. Terminal ileum: active resorption of conjugated bile salts; Small intestine (45%) and colon (5%): passive resorption of non-conjugated bile salts
  3. Absorbed bile gets converted to urobilinogen and eventually urobilin, which is released in urine (yellow color)
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12
Q

Drugs that affect sphincter of Oddi

A

Morphine: contracts (why meperidine used to be used)

Glucagon: relaxes

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13
Q

Cholesterol and bile acid synthesis

A

HMG CoA -> (HMG CoA reductase) -> cholesterol -> (7-alpha-hydroxylase) -> bile salts (acids)

HMG CoA reductase is rate limiting step in cholesterol synthesis

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14
Q

Shock after lap chole causes

A

First 24 hours: hemorrhagic shock from clip that fell off cystic artery

After 24 hours: septic shock from accidental clip on CBD with subsequent cholangitis

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15
Q

Gallstone risk factors

A

> 40yo

Female

Obesity

Pregnancy

Rapid weight loss

Vagotomy

TPN (pigmented stones)

Ileal resection (pigmented stones)

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16
Q

Most sensitive test for cholecystitis

A

CCK-CS test (cholecystokinin cholescintigraphy), also uses HIDA scan (technetium taken up by liver and excreted in biliary tract)

Indications for cholecystectomy afterward:

  • GB not seen (stone in cystic duct)
  • Take >60 min to empty (chronic cholecystitis)
  • EF < 40% (biliary dyskinesia)
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17
Q

Cystic vein

A

Drain into R branch of portal vein

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18
Q

Best treatment for late CBD stone

A

ERCP (sphincterotomy allows for removal of stone)

Risks: bleeding, pancreatitis, perforation

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19
Q

Most common cause of positive bile cultures

A

Postoperative strictures, usually E coli, or polymicrobial

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20
Q

Longitudinal blood supply of hepatic and common bile ducts

A

Right hepatic artery (9 oclock on ERCP), gastroduodenal artery retroduodenal branches (3 oclock on ERCP)

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21
Q

Pancreatic duct normal size

A

< 4 mm

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22
Q

Rokitansky-Aschoff sinuses

A

Epithelial invaginations in GB wall, formed from increased gallbladder pressure

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23
Q

Patient with sepsis, cholangitis, and jaundice

A

Bile duct stricture: cancer until proven otherwise (unless history of pancreatitis or biliary surgery)

Dx: MRCP to define anatomy, look for mass -> ERCP with brush biopies

Tx: if d/t ischemia or chronic pancreatitis -> choledochojejunostomy (best long-term solution), otherwise if cancer then appropriate workup

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24
Q

Todani classification of choledochal cysts

A

I: saccular or fusiform dilatation of a portion or whole CBD

II: isolated diverticulum from CBD

III: right by duodenum

IV: multiple (extrehepatic +/- intrahepatic)

V: intrahepatic (if multiple intrahepatic, is Carroli’s disease)

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25
Cystic artery anatomy
Branches off right hepatic artery Found in triangle of Calot (cystic duct latera, CBD medial, liver superior)
26
Most common route of bacterial infection of bile
Dissemination from portal system (NOT retrograde through sphincter of ODD)
27
Benign neuroectoderm tumor of gallbladder
Granular cell myoblastoma: can occur in biliary tract with signs of cholecystitis Tx: cholecystectomy
28
CBD normal size
< 8 mm (< 10 mm after chole)
29
Causes of bile duct strictures
- Ischemia after lap chole (most important cause) - Chronic pancreatitis - Gallbladder cancer - Bile duct cancer
30
Indications for asymptomatic cholecystectomy
Patients undergoing liver transplant, or gastric bypass procedure (if stones are present)
31
Cystic lymphatics are where
Right side of common bile duct
32
Galbladder wall layers
Mucosa (columnar epithelium) | No submucosa
33
Speckled cholesterol deposits on gallbladder wall
Cholesterolosis
34
Patient with persistent nausea, emesis, jaundice after lap chole: first step
Get US to look for fluid collection 1. Fluid collection (bile leak): percutaneous drainage -> if bilious get ERCP - > if cystic duct remnant leak, small injuries to hepatic or common bile duct, or leak from duct of Luschka -> sphincterotomy 2. Dilated hepatic ducts and no fluid collection (completely transected CBD): PTC tube initially, then hepaticojejunostomy or choledochojejunostomy
35
Old Asian woman with episodic RUQ pain, fever, jaundice, and cholangitis
Choledochal cyst: 90% are extrahepatic, most type 1, 15% risk of cholangiocarcinoma In infant can present like biliary atresia; caused by abnormal reflux of pancreatic enzymes during uterine development
36
Patient after PTC tube presents with UGI bleed, jaundice, and RUQ pain
Hemobilia: fistula between bile duct and hepatic arterial system (most commonly) Most commonly occurs with trauma or percutaneous instrumentation to liver (PTC tube) Dx: angiogram Tx: angioembolization; operation if that fails
37
Bile essential functions
Fat-soluble vitamin absorption Essential fat absorption Bilirubin and cholesterol excretion
38
Nerve fibers of gallbladder
Parasympathetic fivers from Left (anterior) vagus trunk Sympathetic fibers from T7-T10 (splanchnic and celiac ganglions)
39
Old patient with SBO and pneumobilia on plain film
Gallstone ileus: fistula between gallbladder and duodenum that releases stone, causing SBO TI most common site of obstruction Tx: Remove stone through enterotomy proximal to obstruction; perform cholecystectomy and fistula resection if patient can tolerate it
40
Cholesterol stones
Caused by stasis, calcium nucleation, and increased water reabsorption from GB; also by decreased lecithin and bile salts Most common type in US
41
Bacteria causes cholecystitis, pneumobilia bile infection, emphysematous gallbladder disease
Cholangitis: E coli (#1) and kleb Cholecystitis: E coli (#1), kleb, enterococcus Pneumobilia bile infection from postop stricture: E coli, or often polymicrobial Emphysematous GB disease: Clostridium perfringens
42
Most common biliary tract cancer
Gallbladder adenocarcinoma (rare but most common cancer of biliary tract), 4x more common than bile duct cancer; most have stones Most common met site is liver: first to segments IV and V First nodes are cystic duct nodes (right side) 15% risk in patients with porcelain GB (they need cholecystectomy if found) High incidence of tumor implants in trocar sites when discovered after lap chole 5% 5-year survival
43
hormones that increase and decrease bile excretion
Increase: CCK, secretin, vagal input (CCK and secretin cells highest concentration in duodenum) -CCK causes constant, steady, tonic GB contraction Decrease: somatostatin, sympathetic stimulation
44
Gallbladder polyp tx
If > 1 cm or < 60yo, worry about malignancy Tx: cholecystectomy
45
Indications for immediate and pre-op ERCP
Immediate: -Jaundice, cholangitis, US shows stone in CBD (signs that CBD stone is present) Pre-op ERCP: Any of following for > 24 hours -AST or ALT > 200, bilirubin > 4, amylase or lipase > 1,000
46
Causes of cholangitis; complications
Causes: - Bile duct obstruction (most commonly gallstones; also indwelling PTC tube) - Stricture, neoplasm, choledochal cysts, duodenal diverticula Complications: - Systemic bacteremia: colovenous reflux (occurs at > 200 mm Hg) - Renal failure (#1 serious complication; related to sepsis) - Stricture and hepatic abscess are late complications
47
Location of gallbladder relevant to liver
Beneath segments IV and V
48
Cholecystitis tx
Cholecystectomy Very ill: cholecystostomy tube
49
Thickened nodule of mucosa and muscle on gallbladder wall
Adenomyomatosis: associated with Rokitansky-Aschoff sinus, NOT premalignant, does NOT cause stones but can cause RUQ pain Tx: cholecystectomy
50
CBD transection tx
Symptoms 7 days or sooner: hepaticojejunostomy immediately Late symptoms after 7 days: hepaticojejunostomy 6-8 weeks after injury (tissue too friable at this time point)
51
RUQ pain, leukocytosis, US shows thickened wall, sludge, and pericholecystic fluid but no stones, HIDA scan positive: diagnosis, etiology, tx
- Acalculous cholecystitis: bile stasis (narcotic, fasting) -> distention and ischemia; also increased viscosity d/t/ dehydration, ileus, transfusion - Most commonly burns, prolonged TPN, trauma, or major surgery - Cholecystectomy, percutaneous drainage if unstable
52
Best initial test for RUQ pain and jaundice
US: 95% sensitive for stones Stones: Hyperechoic focus, posterior shadowing, movement of focus with changes in position Cholecystitis: stones, wall thickening (> 4 mm), pericholecystic fluid Obstruction: dilated CBD (> 8 mm)
53
Cholangitis tx
1. Fluid resuscitation 2. Antibiotics 3. Emergent ERCP with sphincterotomy and stone extraction 4. PTC tube to decompress biliary system if ERCP fails 5. If d/t infected PTC tube, change the tube
54
Elderly male with UC, PSC, presents with pain jaundice, weight loss, pruritis, found to have high bilirubin and alk phos, and on MRCP focal bile duct stenosis (but no history of biliary surgery or pancreatitis)
Cholangiocarcinoma, risk factors: C sinensis, UC, choledochal cysts, PSC, chronic bile duct infection; invades contiguous structures early Dx: MRCP to define anatomy and look for mass; focal bile duct stenosis in patients without a history of biliary surgery or pancreatitis is highly suggestive of bile duct CA
55
Pnuemobilia causes
Most commonly occurs with previous ERCP and sphincterotomy Can also occur with cholangitis or erosion of biliary system into duodenum (gallstone ileus)
56
Mirizzi syndrome
Compression of common hepatic duct by 1) stone in GB infundibulum, or 2) inflammation arising from the gallbladder or cystic duct extending to the contiguous hepatic duct, causing common hepatic duct stricture Tx: cholecystectomy, may need hepaticojejunostomy for hepatic duct stricture
57
Antibiotic that can cause gallbladder sludging and cholestatic jaundice
Ceftriaxone
58
Ducts of Luschka
Biliary ducts in the GB fossa that can leak after chole
59
Percentage of patients undergoing cholecystectomy who will have a reained CBD stone
< 5% and 95% of these are cleared with ERCP
60
Patient with jaundice and then RUQ pain, found to have gallbladder adenocarcinoma, what is tx?
Open cholecystectomy (sufficient if muscle not involved; lap chole contraindicated) Wedge resection of segements IVb and V (if in muscle) Formal resection of segments IVb and V (if beyond muscle and still resectable)
61
How does the gallbladder normally fill?
Contraction of sphincter of Oddi at ampulla of Vater CBD and CHD do NOT have peristalsis
62
Cholangiocarcinoma tx
Upper 1/3 bile duct (Klatskin tumors): most common type, worst prognosis, usually unresectable -Can try lobectomy and stenting of contralateral bile duct if localized to either R or L lobe Middle 1/3: hepaticojejunostomy Lower 1/3: Whipple Unresectable: palliative stenting 20% 5-year survival
63
Gallstone types
Nonpigmented (cholesterol) Pigmented (calcium bilirubinate and black stones) Brown stones
64
Treatment of anastomotic leak after transplant or hepaticojejunostomy
Perc drainage of fluid collection, followed by ERCP with temporary stent (leak will heal)
65
Delta bilirubin
Bound covalently to albumin, t 1/2 18 days, may take a while to clear after long-standing jaundice
66
Brown stones
- Primary CBD stones, most commonly formed in ducts, Asians (brown and cholesterol stones found in CBD are secondary stones) - Infection (E coli most common) -> beta-glucuronidase production -> deconjugation of bilirubin -> calcium bilirubinate formation - Need to check for ampullary stenosis, duodenal diverticula, abnormal sphincter of Oddi - Almost all patients with primary stones need a biliary drainage procedure - sphincteroplasty (90% success)
67
Patient with persistent RUQ pain, referred to R shoulder and scapula, nausea, vomiting, anorexia, frequently after a fatty meal, positive Murphy's sign, elevated WBC and alk phos
Cholecystitis: cystic duct obstruction -> wall distension and inflammation Suppurative cholecystitis: frank purulence in GB, associated with sepsis and shock
68
Woman with jaundice, fatigue, pruritis, xanthomas, positive antimitochondrial antibodies
Primary biliary cirrhosis: cholestasis -> cirrhosis -> portal hypertension NO increased risk of cancer Tx: Liver transplant
69
Tx of intraoperative CBD injury
< 50 % circumference: probably primary repair; otherwise need hepaticojejunostomy or choledocho jejunostomy

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