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SURGERY > GALLBLADDER > Flashcards

GALLBLADDER Flashcards

1
Q

Length and Capacity of Gallbladder

A

7-10 cm long
30-50 mL capacity

lacks muscularis mucosa and submucosa

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2
Q

Hepatocystic triangle or Budde Triangle

A

cystic duct to the right
common hepatic duct to the left
margin of the R lobe of liver superiorly

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3
Q

Triangle of Calot

A

Borders

cystic duct
common hepatic duct
cystic artery

Calot node - located w/n the triangle; ENLARGED during cholecystitis or cholangitis

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4
Q

Moosman area

A

circular area, 30 mm in diameter that fits into the hepatocystic duct angle

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5
Q

Arterial Supply of Common Bile Duct

A

gastroduodenal artery

Right hepatic artery

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6
Q

Neurohormonal Regulation

A

VAGUS gallbladder contraction

CCK Sphincter of Oddi relaxation and GB contraction

VIP inhibits GB contraction

somatostatin inhibits GB contraction

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7
Q

Regulates flow of bile and pancreatic juice into the duodenum

Prevents regurgitation of duodenal contents into the biliary tree

Diverts bile into the GB

A

Sphincter of Oddi

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8
Q

Recommendations for Prophylactic Cholecystectomy

A

PROPHYLACTIC CHOLECYSTECTOMY INDICATED
hemoglobinopathies (SCD)
hereditary spherocytosis and thalassemia
transplant recipient (cardiac and lung)

PROPHYLACTIC CHOLECYSTECTOMY NOT INDICATED
diabetic patients
cirrhotic patients
transplant recipients (kidney and pancreas)
porcelain bladder
patients receiving prolonged TPN
spinal cord injury

PROPHYLACTIC CHOLECYSTECTOMY CONTROVERSIAL
morbid obesity
after bariatic surgery

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9
Q

2018 Tokyo Guidelines

A

LOCAL SIGNS OF INFLAMMATION
Murphy sign
RUQ mass or pain or tenderness

SYSTEMIC SIGNS OF INFLAMMATION
fever
elevated CRP
elevated WBC

IMAGING FINDINGS
characteristics of acute cholecystitis

1 item in A + 1 item in B = SUSPECTED DIAGNOSIS
1 item in A + 1 item in B + C = DEFINITE DIAGNOSIS

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10
Q

Diagnostic test of choice for acute cholecystitis

A

Ultrasound

enlarged gallbladder
thickening of the gallbladder wall (>5 mm)
gallbladder stones
debris echo
direct tenderness when probe is pushed against the gallbladder (ultrasonographic Murphy sign)

gangrenous and emphysematous cholecystitis: irregular thickening of GB wall and imaging of the ruptured GB

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11
Q

Involves IV injection of technetium labeled analogues of iminodiacetic acid which are excreted in the bile

A

Hepatobiliary Scintigraphy (Tc-HIDA scan)

failure of GB to fill w/n 60 mins after administration of tracer indicates that cystic duct is obstructed

RIM SIGN - blush of increased pericholecystic radioactivity in cholecystitis
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12
Q

Formed in the CBD

A

PRIMARY STONES

Brown pigment type
biliary stasis and infection

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13
Q

Formed in the GB and migrate to CBD

A

SECONDARY STONES

more common
cholesterol stones
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14
Q

Stones identified by cholangiography shortly after cholecystectomy
MISSED during operation

A

Retained Choledocholithiasis

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15
Q 
Stones that are found later (<2 years after cholecystectomy)
Same composition (black pigment or cholesterol) as the GB stones
A

Residual Choledocholithiasis

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16
Q

Assumed to be primary common duct stones (usually of brown pigment type)
Stones discovered > 2 years after choleystectomy

A

Recurrent Choledocholithiasis

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17
Q

useful for documenting stones in the gallbladder (if still present), as
well as determining the size of the common bile duct

A

Ultrasonography

dilated CBD (>8 mm in diameter) in patient w/ gallstones, jaundice, and  biliary pain - highly suggestive of common bile duct stones
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18
Q

Gold standard test for acute choledocholithiasis

Provide definitive or temporary treatment of CBD stones

A

Endoscopic Retrograde Cholangiopancreatography (ERCP)

POSSIBLE COMPLICATION: pancreatitis

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19
Q

Indications for IOC during laparoscopic cholecystectomy

A 
jaundice or history of jaundice or history of pancreatitis
elevated liver function tests
CBD larger than 5-7 mm in diameter
cystic duct > 3 mm in diameter
multiple small GB stones
unclear anatomy
CBD stones visualized on preoperative US
palpable CBD stones intraop
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20
Q

Common hepatic duct obstruction caused by an exttrinsic compression from/an impacted stone in the cystic duct of Hartmann pouch of the gallbladder

A

Mirrizi Syndrome

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21
Q

Uncommon form of gallstone ileus of the duodenum characterized by gastric outlet obstruction caused by gallstone impaction in the pylorus or proximal duodenum after its passage through a cholecystoduodenal fistula

A

Bouveret syndrome

Rigler triad - pneumobilia, SBO, ectopic gallstoone
22
Q

Ascending bacterial infection of the biliary tress in association w/ partial or complete blockage of the bile duct

A

Cholangitis

23
Q

Diagnostic Criteria for Acute Cholangitis (2018 Tokyo Guidelines)

A

SYSTEMIC INFLAMMATION
(+) fever/chills
laboratory evidence of inflammatory response

CHOLESTASIS
jaundice
abnormal liver function test

IMAGING
dilated biliary system
imaging shows evidence of etiology (stricture, stone, stent etc)

24
Q

At risk for developing acalculous cholecystitis

A

patients on parenteral nutrition
extensive burns
sepsis
major operations
multiple trauma
prolonged illness with multiple organ system failure

25
Q

Congenital cystic dilatations of the biliary tree
Females
Childhood

A

Choledochal cysts

26
Q

Type I choledochal cyst

A

fusiform or cystic dilatations of extrahepatic biliary tree
MOST COMMON
HIGHEST risk for MALIGNANCY

27
Q

Type choledochal cyst management

A

Excision + Roux-en Y hepaticojejunostomy

resection of CBD, cholecystectomy and hepatico jejunostomy

28
Q

Type II choledochal cyst

A

Saccular diverticula of the CBD

increase risk of developing malignancy ANYWHERE in the biliary tree - GALLBLADDER - highest incidence

29
Q

Type II choledochal cyst management

A

excision; defect in CBD is closed over a T tube

30
Q

Type III choledochal cyst

A

Bile duct dilatation w/n the duodenal wall

LOWEST risk of malignancy

31
Q

Type III choledochal cyst management

A

sphincterotomy and surveillance

32
Q

Type IVa choledochal cyst management

A

segmental liver resection, excision and Roux en y hepaticojejunostomy

33
Q

Type IV a choledochal cyst

A

extra and intrahepatic ducts

34
Q

Type IV b choledochal cyst

A

extrahepatic bile ducts only

35
Q

Type V choledochal cyst

A

Intrahepatic ducts only (Caroli disease)

36
Q

Type V choledochal cyst management

A

liver transplantation

37
Q

Factors associated w/ malignancy in gallbladder polyps

A 
(+) single polyp
size of polyp >1 cm
age > 50 yrs
rapid growth
sessile morphology
adenomatous in histology
38
Q

The most important risk factor for gallbladder carcinoma

A

Cholelithiasis

larger stones (>3 cm) - associated with a 10 fold ↑ risk of cancer
39
Q

Gallbladder Carcinoma

T1a - invades LAMINA PROPRIA

A

simple cholecystectomy

40
Q

Gallbladder Carcinoma

T1b - invades MUSCLE LAYER

A

extended cholecystectomy + lymphadenectomy of nodes in the porta hepatis, gastrohepatic ligament and retroduodenal space

41
Q

Gallbladder Carcinoma

T2 - invades PERIMUSCULAR CONNECTIVE TISSUE

A

extended cholecystectomy + lymphadenectomy of nodes in the porta hepatis, gastrohepatic ligament and retroduodenal space

42
Q

Gallbladder Carcinoma

T3 - perforates SEROSA and/or invades the LIVER or ADJACENT organ

A

extended R hepatectomy + en bloc of CBD for grossly positive periportal lymph nodes followed by Roux-en Y hepaticojejunostomy

43
Q

Gallbladder Carcinoma

T4 - invades MAIN PORTAL VEIN or HEPATIC ARTERY or MULTIPLE EXTRAHEPATIC ORGANS

A

extended R hepatectomy + en bloc resection of the CBD for grossly positive periportal lymph nodes followed by Roux-e y hepaticojejunostomy

44
Q

tumor marker most commonly used to aid the diagnosis of cholangiocarcinoma

A

CA 19-9

45
Q

Risk Factors for Bile Duct Carcinoma (Cholangiocarcinoma)

A

PSC
choledochal cysts
hepatolithiasis
biliary enteric anastomosis
biliary tract infections (Clonorchis, chronic typhoid)
exposure to nitrosamines, thorotrast, dioxin

46
Q

The MC type of gallbladder cancer

A

Adenocarcinoma

47
Q

The gallbladder lymphatics drain into which of the following liver segments

A

IV and V

48
Q

Different Classifications of Bile Duct Carcinoma

A

nodular - MC
scirrhous
diffusely infiltrating
papillary

49
Q

Perihilar cholangiocarcinoma (Klatskin tumor)

Bismuth Corlette Classification

A

Type I tumors - confined to the CHD

Type II tumors - involve the BIFURCATION without involvement of the secondary intrahepatic ducts

Type IIIa and IIIb tumors - extend into the RIGHT intrahepatic ducts

Type IIIb - extend into the LEFT secondary intrahepatic ducts

Type IV tumors - BOTH the right and left secondary intrahepatic ducts

50
Q

The best initial imaging test or evaluating or suspected cholangiocarcinoma includes

A

Ultrasound

51
Q

Hepatic cells that provide the primary defense against lipopolysaccharide

A

Kuppfer cells

52
Q

In the early postoperative period, what is the most common presentation of a patient with a biliary injury?

A

elevated transaminases

SURGERY (27 decks)

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