GALLBLADDER Flashcards
Length and Capacity of Gallbladder
7-10 cm long
30-50 mL capacity
lacks muscularis mucosa and submucosa
Hepatocystic triangle or Budde Triangle
cystic duct to the right
common hepatic duct to the left
margin of the R lobe of liver superiorly
Triangle of Calot
Borders
cystic duct common hepatic duct cystic artery
Calot node - located w/n the triangle; ENLARGED during cholecystitis or cholangitis
Moosman area
circular area, 30 mm in diameter that fits into the hepatocystic duct angle
Arterial Supply of Common Bile Duct
gastroduodenal artery
Right hepatic artery
Neurohormonal Regulation
VAGUS gallbladder contraction
CCK Sphincter of Oddi relaxation and GB contraction
VIP inhibits GB contraction
somatostatin inhibits GB contraction
Regulates flow of bile and pancreatic juice into the duodenum
Prevents regurgitation of duodenal contents into the biliary tree
Diverts bile into the GB
Sphincter of Oddi
Recommendations for Prophylactic Cholecystectomy
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
2018 Tokyo Guidelines
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
Diagnostic test of choice for acute cholecystitis
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
Involves IV injection of technetium labeled analogues of iminodiacetic acid which are excreted in the bile
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
Formed in the CBD
PRIMARY STONES
Brown pigment type
biliary stasis and infection
Formed in the GB and migrate to CBD
SECONDARY STONES
more common cholesterol stones
Stones identified by cholangiography shortly after cholecystectomy
MISSED during operation
Retained Choledocholithiasis
Stones that are found later (<2 years after cholecystectomy) Same composition (black pigment or cholesterol) as the GB stones
Residual Choledocholithiasis
Assumed to be primary common duct stones (usually of brown pigment type)
Stones discovered > 2 years after choleystectomy
Recurrent Choledocholithiasis
useful for documenting stones in the gallbladder (if still present), as
well as determining the size of the common bile duct
Ultrasonography
dilated CBD (>8 mm in diameter) in patient w/ gallstones, jaundice, and biliary pain - highly suggestive of common bile duct stones
Gold standard test for acute choledocholithiasis
Provide definitive or temporary treatment of CBD stones
Endoscopic Retrograde Cholangiopancreatography (ERCP)
POSSIBLE COMPLICATION: pancreatitis
Indications for IOC during laparoscopic cholecystectomy
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
Common hepatic duct obstruction caused by an exttrinsic compression from/an impacted stone in the cystic duct of Hartmann pouch of the gallbladder
Mirrizi Syndrome
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
Bouveret syndrome
Rigler triad - pneumobilia, SBO, ectopic gallstoone
Ascending bacterial infection of the biliary tress in association w/ partial or complete blockage of the bile duct
Cholangitis
Diagnostic Criteria for Acute Cholangitis (2018 Tokyo Guidelines)
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)
At risk for developing acalculous cholecystitis
patients on parenteral nutrition
extensive burns
sepsis
major operations
multiple trauma
prolonged illness with multiple organ system failure
Congenital cystic dilatations of the biliary tree
Females
Childhood
Choledochal cysts
Type I choledochal cyst
fusiform or cystic dilatations of extrahepatic biliary tree
MOST COMMON
HIGHEST risk for MALIGNANCY
Type choledochal cyst management
Excision + Roux-en Y hepaticojejunostomy
resection of CBD, cholecystectomy and hepatico jejunostomy
Type II choledochal cyst
Saccular diverticula of the CBD
increase risk of developing malignancy ANYWHERE in the biliary tree - GALLBLADDER - highest incidence
Type II choledochal cyst management
excision; defect in CBD is closed over a T tube
Type III choledochal cyst
Bile duct dilatation w/n the duodenal wall
LOWEST risk of malignancy
Type III choledochal cyst management
sphincterotomy and surveillance
Type IVa choledochal cyst management
segmental liver resection, excision and Roux en y hepaticojejunostomy
Type IV a choledochal cyst
extra and intrahepatic ducts
Type IV b choledochal cyst
extrahepatic bile ducts only
Type V choledochal cyst
Intrahepatic ducts only (Caroli disease)
Type V choledochal cyst management
liver transplantation
Factors associated w/ malignancy in gallbladder polyps
(+) single polyp size of polyp >1 cm age > 50 yrs rapid growth sessile morphology adenomatous in histology
The most important risk factor for gallbladder carcinoma
Cholelithiasis
larger stones (>3 cm) - associated with a 10 fold ↑ risk of cancer
Gallbladder Carcinoma
T1a - invades LAMINA PROPRIA
simple cholecystectomy
Gallbladder Carcinoma
T1b - invades MUSCLE LAYER
extended cholecystectomy + lymphadenectomy of nodes in the porta hepatis, gastrohepatic ligament and retroduodenal space
Gallbladder Carcinoma
T2 - invades PERIMUSCULAR CONNECTIVE TISSUE
extended cholecystectomy + lymphadenectomy of nodes in the porta hepatis, gastrohepatic ligament and retroduodenal space
Gallbladder Carcinoma
T3 - perforates SEROSA and/or invades the LIVER or ADJACENT organ
extended R hepatectomy + en bloc of CBD for grossly positive periportal lymph nodes followed by Roux-en Y hepaticojejunostomy
Gallbladder Carcinoma
T4 - invades MAIN PORTAL VEIN or HEPATIC ARTERY or MULTIPLE EXTRAHEPATIC ORGANS
extended R hepatectomy + en bloc resection of the CBD for grossly positive periportal lymph nodes followed by Roux-e y hepaticojejunostomy
tumor marker most commonly used to aid the diagnosis of cholangiocarcinoma
CA 19-9
Risk Factors for Bile Duct Carcinoma (Cholangiocarcinoma)
PSC
choledochal cysts
hepatolithiasis
biliary enteric anastomosis
biliary tract infections (Clonorchis, chronic typhoid)
exposure to nitrosamines, thorotrast, dioxin
The MC type of gallbladder cancer
Adenocarcinoma
The gallbladder lymphatics drain into which of the following liver segments
IV and V
Different Classifications of Bile Duct Carcinoma
nodular - MC
scirrhous
diffusely infiltrating
papillary
Perihilar cholangiocarcinoma (Klatskin tumor)
Bismuth Corlette Classification
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
The best initial imaging test or evaluating or suspected cholangiocarcinoma includes
Ultrasound
Hepatic cells that provide the primary defense against lipopolysaccharide
Kuppfer cells
In the early postoperative period, what is the most common presentation of a patient with a biliary injury?
elevated transaminases
