Gall Bladder Flashcards
Shape of gallbladder
Pyriform
Gallbladder lacks which layer of GI
Submucosa
Which valve is present at GB Neck
Valve of heister
What are the function of GB
I. Reservoir for bile.
a. Secretes mucin.
3. The concentration of bile.
Boundaries of Cholecystohepatic triangle
1) The inferior edge of the liver.
2) Common hepatic duct.
3) Cystic duct.
contains a cystic artery.
Boundaries of calot’s triangle
Smaller triangle within bigger Cholecystohepatic triangle.
Bounded by: Cystic artery.
Cystic duct.
Common hepatic duct.
Which is the 1st LN to enlarged in GB cancer
Harbours cystic lymph lode of lund
What is Moynihan’s Hump
Right hepatic artery can have a tortuous course and can lie in the hepatocystic triangle.
The right hepatic artery can get injured and lead to hemorrhage during surgery.
What is Phrygian Cap (fundus folded inwards)
It is an anatomical variation of GB . Which is not an indication of sx
Most common Gall Stone in asia
Pigment Stones
Most common Gall Stone overall
Mixed stones
Composition of Brown Gall stones
Ca Palmitate ; Ca Stearate ;
Ca Bilirubinate
Composition of Black Gall stones
Ca Phosphate & Ca Bicarbonate
RF of gallstones
(1)Lithogenic Bile : Obese ; Increased cholesterol ; Post ileal resection
(2) Stasis : Pregnancy ; OCP’s ; TPN ; Rapid weight loss ; Post vagotomy
(3) Nucleation : Infections ; Clonorchis
; Cholangitis ; Ascariasis
How much percentage of gallstones are Radiolucent
90%
How much percentage of gallstones are Radioopaque
10%
How to differentiate on Ulrasound between gallbladder stone and polyp.
Gall bladder stone has shadow present .
Gall bladder polyp has no shadow present on ultrasound
Which sign is seen in radio opaque gall stones
Seagull sign (biradiate sign) ;;
Mercedes Benz sign (triradiate sign)
What is acute cholecystitis
Inflammation of gallbladder
Which sign is seen in acute cholecystitis
Murphy’s sign ;
boa’s sign
Describe Murphy’s sign
Patient catches his/her breath when pressed in the right hypochondrium
Describe boa’s sign
Hyperesthesia in the region of the 12th rib
WHAT IS HIDA Scan
Comes into gallbladder in 30 minutes (90% cases) . comes into bowel in 90 minutes. non-visualization of gallbladder in case of acute cholecystitis
Emergency cholecystectomy is done only if
Patient presents within 2-3 days
HPE of Chronic cholecystitis
Rokitansky aschoff sinuses if it ruptures leads to Xanthogranulomatous cholecystitis.
Emphysematous cholecystitis is occurs due to which condition?
Clostridium.
Emphysematous pyelonephritis occurs due to which organism
E.Coli
What is mucocele
Aseptic dilatation of GB.
In mucocele stones get impacted at
Hartmann pouch
What is mirizzi syndrome
GB becomes adherent to CBD due to inflammation . The stones inside GB presses on CBD
IOC for mucocele
MRCP
What is gallstones ileus
Dynamic bowel obstruction.
Secondary to a cholecysto-duodenal fistula. Due to inflammation GB becomes adherent to the duodenum.
MC site for gallstone ileus
Terminal 2 feet off the ileum
What is Bouveret syndrome
Stone leads to gastric outlet obstruction.
Clinical features: Distension, obstipation, pain and vomiting.
Initial investigation : X-ray abdomen
What is Rigler’s triad
1) Pneumobilia
2) Features of small intestine obstruction
3) Radio-opaque shadow in right iliac fossa.
What is choledocholithiasis
Stones in the CBD which were formed in GB (90% of cases) ;; in 10% it is formed in CBD.
Charcot’s triad includes
Intermittent pain; Intermittent fever; Intermittent jaundice
Reynolds pentad includes
Charcot’s triad + Shock + AMS/altered mental status
IOC for CBD stones
MRCP
IOC for CBD microliths
Endoscopic ultrasound
What is burhenne technique
Insert a T-tube in CBD
ERCP
In ERCP a side viewing deodenoscope is introduced.
(Is both Diagnostic and therapeutic).
A cut is made in the spincter at 11’O’ clock position.
Complications: ERCP induced pancreatitis (mc).
Duodenal perforation (2nd mc).
In Which position the patient of kept during lap.cholecystectomy
Reverse Trendelenburg position.
(Head ends up, foot end down and right side up)
MC complication following lap. Chole
Right shoulder tip pain. (Retained CO2 under dome of the diaphragm)
What is Post cholecystectomy syndrome
Clinical features of cholecystitis even after laparoscopic cholecystectomy.
Causes : Retained CBD stones.
Biliary dyskinesia
Sphincter of Oddi dysfunction.
Kocher incision is
Right Subcostal incision made in open cholecystectomy.
MRCP is only
Diagnostic ; not therapeutic.
Mgt if bile leak patient presents within 48 hours
Re-exploration and repair
Mgt if bile leak patient presents after 2 days ( inflammed tissue does not hold structure)
ERCP + Stent . ultrasound guided pigtail catheter is inserted to drain collection (Bilioma) till ERCP and stent placement.
Two classifications of bile duct injuries are
Bismuth and Strasberg.
GB cancer is an
Adenocarcinoma
Types of GB cancer
Infiltrating : worst prognosis
Nodular
Papillary : best prognosis
What is a late feature in GB cancer
Jaundice
Structure removed in radical cholecystectomy
{Done in T1B or T2 stage } GB + segment 4B and 5 of liver + lymph node along hepatoduodenal ligament + +- CBD
MIPMP prognostic factor in GB cancer
Depth of invasion (T satge)
Which serum marker should be monitored in GB cancer
Serum CA 19-9
What is cholesterosis
Deposition of cholesterol crystals in wall of gallbladder.
AKA Strawberry gallbladder .
Not an indication of GB cancer or cholecystectomy
What is extra hepatic biliary atresia
Inflammatory fibrosis of biliary tree
C/F of extra hepatic biliary atresia
Jaundice at birth. (Progressive jaundice), Pruritus , Pale stools, Liver failure
IOC AND GOLD STANDARD INVESTIGATION OF Extrahepatic biliary atresia
IOC : HIDA scan
Gold standard : Intraoperative cholangiogram
Which sign is seen in intrahepatic atresia on USG
Triangular cord sign.
Management of biliary atresia
Surgery:
• Type I : Roux-en-Y hepaticojejunostomy.
Best result: Surgery is done < 8 weeks.
• Type II & III : Portoenterostomy (Kasai procedure). irrespective of the surgery, 20 - 30% will show progressive fibrosis -> liver failure -> Transplant.
(SHBA is the mCC of liver transplant in children).
What is the most common cause of liver transplant in children?
Extrahepatic biliary atresia EHBA
What is choledochal cyst
Cystic dilatation of biliary tree
Which classification is used for Choledochal cyst
Todani/modified Alonso - Lej classification
Todani/modified Alonso - Lej classification
Type I: Cystic dilatation of the cRD.
Type II : Diverticulum of CBD.
Type III: Dilatation of intraduodenal portion of CBD (Choledochocele).
Type IV - A : Intrahepatic + extrahepatic biliary tree dilate.
B : Only extrahepatic biliary tree dilated
Type V : Dilatation of only intrahepatic biliary tree (Caroli’s disease).
What is Caroli’s disease
Dilatation of only intra hepatic biliary tree in Type V of Todani/modified Alonso - Lej classification
Management of choledochal cyst
• Туре 1 : Roux-en-Y hepaticojejunostomy.
• Type II : Cut diverticulum + repair cBD.
Roux-en-Y hepaticojejunostomy.
• Type III: ERCP + sphincterotomy.
• Type IVa § V : Liver transplant.
• Type IVb : Kasai procedure (portoenterostomy).
What is thorotrast
“Thorotrast is a suspension containing particles of the radioactive compound thorium dioxide:
What is Cholangiocarcinoma
Carcinoma of biliary tree
Primary sclerosing cholangitis is associated with
IBD (ulcerative colitis) ; HLA B8 & DR3.
In Cholangiocarcinoma ; palpable GB (periampullary ca) is describe by which law
Courvoisier’s law
Bismuth-Corlette classification of perihilar tumor
Type I : Tumor involves common Hepatic duct
Type II : Tumor involves bifurcation of the common hepatic duct
Type IIIa : Tumor involves the right hepatic duct
Type IIIb : Tumor involves the left hepatic duct
Type IV : Tumor involves both right and left hepatic duct
Klatskin tumor removed by which surgery
Portoenterostomy / Kasai
Supraduodenal CBD tumor which surgery is carried out
Hepaticojejunostomy
Distal CBD tumor which sx is carried out
Whipple sx
Which set a marker is used in Colangiocarcinoma for monitoring of progression of the disease
CA 19-9
What is haemobilia
Bleeding from the biliary tree.
Arterial in nature
Quincke’s triad in haemobilia includes
• Jaundice.
• upper Gi hemorrhage (malena) - mc manifestation.
• Pain.
What is bilhemia
Passage of bile into the bloodstream..
A fistula between vein and biliary tree
