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IM GASTRO > Gallbladder > Flashcards

Gallbladder Flashcards

1
Q
  • Isotonic fluid
  • Major solute components of bile by moles percent include bile acids (80%), lecithin and traces of other phospholipids (16%), and unesterified cholesterol (4.0%)
  • total daily basal secretion of hepatic bile ~500— 600 mL
A

HEPATIC BILE

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2
Q
  • cholic acid and chenedeaexycholic acid (CDCA)
    + synthesized from cholesterol in the liver
  • conjugated with glycine or taurine.
  • secreted into the bile
A

Primary bile acid

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3
Q
  • deoxycholate and lithecholate
  • formed in the colon as bacterial metabolites of the primary
    acids
  • ursodeoxycholic acid (UDCA)
    + astereoisomer of CDCA
A

Secondary bile acids

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4
Q

BILE ACID FUNCTIONS

A
  • biliary excretion of cholesterol
  • facilitate the normal intestinal absorption of dietary fats
  • serve as a major physiologic driving force for hepatic bile flow
  • aid in water and electrolyte transport in the small bowel and colon
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5
Q
  • normal bile acid pool size is ~2-4 g
  • bile acid pool circulates ~5—10 times daily
  • Intestinal reabsorption of the pool is about 95% efficient
  • fecal loss of bile acids is in the range of 0.2-0.4 g/d
  • maximum rate of synthesis is ~5 g/d
  • bile acids are absorbed by passive diffusion
  • active transport mechanism for conjugated bile acids in the
    distal ileum
  • reabsorbed bile acids enter the portal bloodstream ,taken
    up rapidly by hepatocytes, reconiugated, and resecreted into bile
A

ENTEROHEPATIC CIRCULATION

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6
Q
  • high-pressure zone of resistance to bile flow from the CBD
    into the duodenum
  • Its tonic contraction serves to
    + prevent reflux of duodenal contents into the pancreatic and bile ducts
    + promote filling of the gallbladder
A

Sphincter of Oddi (SOD)

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7
Q
  • major factor controlling the evacuation of the gallbladder
  • released from the duodenal mucosa in response to the ingestion of fats and amino acids
  • powerful contraction of the gallbladder
  • decreased resistance of the SOD
  • enhanced flow of biliary contents into the duodenum
A

Cholecystokinin (CCK)

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8
Q

normal capacity of the gallbladder is ____ of bile

A

~30 ml

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9
Q

clinically innocuous entity in which a partial or complete septum (or fold) separates the fundus from the body

A

Phrygian Cap

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10
Q

Anomalies of position or suspension

A

A. intrahepatic.
B. Left sided
C. Transverse.
D. Retrodisplaced.

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11
Q

Types of Gallstone

  • account for >90% of all gallstones in Western industrialized
    countries
  • contain >50% cholesterol monohydrate plus an admixture
    of calcium salts, bile pigments, proteins, and fatty acids
A

Cholesterol stones

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12
Q

Types of Gallstone

  • composed primarily of calcium bilirubinate
  • contain <20% cholesterol
  • classified into “black” and “brown” types
  • Brown type are formed secondary to chronic biliary infection
A

Pigment stones

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13
Q
  • thick, mucous material that reveals lecithin-cholesterol
    liquid crystals, cholesterol monohydrate crystals, calcium
    bilirubinate, and mucin gels
  • crescent-like layer in the most dependent portion of the
    gallbladder
A

BILIARY SLUDGE

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14
Q

BILIARY SLUDGE

The presence of biliary sludge implies two abnormalities:

A

(1) the normal balance between gallbladder mucin secretion and elimination has become deranged
(2) nucleation of biliary solutes has occurred

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15
Q

key changes that contribute to a “cholelithogenic state”
- a marked increase in cholesterol saturation of bile during the third trimester
- sluggish gallbladder contraction in response to a standard
meal, resulting in impaired gallbladder emptying.

A

Pregnancy

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16
Q

Other conditions associated with cholesterol-stone or biliarysludge formation:

A
  • pregnancy

- rapid weight reduction through a very-low-calorie diet

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17
Q

cholesterol gallstone disease occurs because of several defects

A

(1) bile supersaturation with cholesterol
(2) nucleation of cholesterol monohydrate with subsequent crystal retention and stone growth,
(3) abnormal gallbladder motor function with delayed emptying and stasis.

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18
Q
  • composed of either pure calcium bilirubinate or polymer-like complexes with calcium and mucin glycoproteins
  • more common in patients who have chronic hemolytic states, liver cirrhosis, Gilbert’s syndrome, or cystic fibrosis, ileal diseases, ileal resection, or ileal bypass
  • Enterohepatic recycling of bilirubin in ileal disease states contributes to their pathogenesis
A

Black pigment stones

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19
Q
  • are composed of calcium salts of unconjugated bilirubin with varying amounts of cholesterol and protein
  • presence of increased amounts of unconjugated, insoluble bilirubin in bile that precipitates to form stones
  • frequent in Asia and is offen associated with infections in the gallbladder and biliary tree
A

Brown pigment stones

20
Q
  • Rapid
  • Accurate identification of gallstone
  • “Real-time” scanning allows assessment of GB volume, contractility
  • Stones as small as 1.5 mm in diameter may be confidently identified provided that firm criteria are used (e.g., acoustic
    “shadowing” of opacities that are within the gallbladder lumen and that change with the patient’s position by gravity)
A

Gallbladder Ultrasound

21
Q
  • low cost
  • readily available
  • detect gallstones containing sufficient calcium to be
    radiopaque (10-15% of cholesterol and ~50% of pigment
    stones)
A

Plain Abdominal X-ray

22
Q
  • Accurate identification of cystic duct obstruction
  • Contraindicated in pregnancy
  • Indicated for confirmation of suspected acute cholecystitis
A

Radioisotope Scans (HIDA, DIDA, etc.)

23
Q
  • most specific and characteristic symptom of gallstone disease
  • constant and often long-lasting pain
  • visceral pain is characteristically a severe, steady ache or fullness in the epigastrium or right upper quadrant (RUQ) of the abdomen with frequent radiation to the interscapular area, right scapula, or shoulder
  • begins quite suddenly and may persist with severe intensity for 30 min to 5 h, subsiding gradually or rapidly.
A

Biliary colic

24
Q

An episode of biliary pain persisting beyond 5h should raise the suspicion of

A

acute cholecystitis

25
Q

An elevated level of serum bilirubin and/or alkaline phosphatase suggests a

A

common duct stone

26
Q

Fever or chills (rigors) with biliary pain usually imply a complication,

A
  • cholecystitis,
  • pancreatitis,
  • cholangitis.
27
Q
  • a minimal-access approach for the removal of the gallbladder together with its stones
  • Advantages
    > markedly shortened hospital stay
    > minimal disability
    > decreased cost y,
    > procedure of choice for most patients referred for elective cholecystectomy
  • gold standard” for treating symptomatic cholelothiasis
A

Laparoscopic cholecystectomy

28
Q
  • Acute inflammation of the gallbladder wall
  • usually follows obstruction of the cystic duct by a stone
  • evoked by three factors:
    > mechanical inflammation
    > chemical inflammation
    > bacterial inflammation
  • Frequently isolated organisms
    » Escherichia coli, Klebsiella spp., Streptococcus spp., and Clostridium spp
A

ACUTE CHOLECYSTITIS

29
Q
  • Pain radiate to the interscapular area, right scapula, or shoulder
  • Anorexia, nausea and vomiting
  • Jaundice is unusual early in the course
A

ACUTE CHOLECYSTITIS

30
Q

triad of ACUTE CHOLECYSTITIS

A
  • RUQ tenderness,
  • fever,
  • leukocytosis
31
Q
  • rare complication in which a gallstone becomes impacted
    in the cystic duct or neck of the gallbladder causing
    compression of the CBD, resulting in CBD obstruction and
    jaundice
  • Ultrasound shows gallstone lying outside the hepatic duct y
  • ERCP, PTC, MRCP -characteristic extrinsic compression of the CBD
  • Surgery consists of removing the cystic duct, diseased
    gallbladder, and the impacted stone
A

Mirizzi’s syndrome

32
Q
  • Disordered motility of the gallbladder
  • Infusion of CCK can be used to measure the gallbladder
    ejection fraction during cholescintigraphy.
  • Criteria
    > recurrent episodes of typical RUG pain characteristic of biliary tract pain
    > abnormal CCK cholescintigraphy. demonstrating a gallbladder ejection fraction of <40%
    > infusion of CCK reproducing the patient’s pain
  • identification of a large gallbladder on ultrasound examination
A

ACALCULOUS CHOLECYSTOPATHY

33
Q
  • thought to begin with acute cholecystitis (calculous or
    acalculous) followed by ischemia or gangrene of the
    gallbladder wall and infection by gas-producing organisms
  • frequently cultured
    > Anaerobes- Clostridium welchii or C. perfringens
    > aerobes,- F. coli
  • clinical manifestations are indistinguishable from those of
    nongaseous cholecystitis
  • plain abdominal film
    > gas within the gallbladder lumen, dissecting within the gallbladder wall to form a gaseous ring, or in the pericholecystic tisues.
A

EMPHYSEMATOUS CHOLECYSTITIS

34
Q
  • Chronic inflammation of the gallbladder wall
  • result from repeated bouts of subacute or acute cholecystitis or from persistent mechanical irritation of the gallbladder wall by gallstones
  • may be asymptomatic for years, which may progress to symptomatic gallbladder disease or to acute cholecystitis, or may present with complications
A

CHRONIC CHOLECYSTITIS

35
Q

TREATMENT OF empyema, emphysematous cholecystitis, or

perforation is suspected or confirmed

A

Urgent (emergency) cholecystectomy or cholecystostomy

36
Q
  • most common biliary anomalies of clinical relevance encountered in infancy
  • clinical picture is one of severe obstructive jaundice during the first month of life, with pale stools
  • diagnosis is confirmed by surgical exploration
    and operative cholangiography
A

BILIARY ATRESIA AND HYPOPLASIA

37
Q
  • Passage of gallstones into the CBD occurs in ~10—15% of
    patients with cholelithiasis
  • 25% of elderly patients may have calculi in the CBD at the
    time of cholecystectomy
  • Undetected duct stones are left behind in ~1—5% of
    cholecystectomy patients
  • cholesterol stones
A

CHOLEDOCHOLITHIASIS

38
Q
  • Primary calculi arising de novo in the ducts
  • Develops in patients with:
    > hepatobiliary parasitism or chronic, recurrent cholangitis
    > Caroli’s disease
    > dilated, sclerosed, or strictured ducts
    > MDR3 (ABCB4) gene defect
A

CHOLEDOCHOLITHIASIS

Brown pigment stones

39
Q

Charcot’s triad

A
  • biliary pain
  • jaundice
  • spiking fevers with chills
40
Q
  • is most common cholangitis

- respond relatively to supportive measures and antibiotics

A

Nonsuppurative acute cholangitis

41
Q
  • “pus under pressure “ cholangitis
    >» mental confusion, bacteremia, and septic shock
    >» ERCP with endoscopic sphincterotomy
A

Suppurative acute cholangitis

42
Q
  • Painless jaundice

- absence of a palpable gallbladder in most patients with biliary obstruction from duct stones

A

OBSTRUCTIVE JAUNDICE

43
Q

the presence of a palpably enlarged gallbladder suggests that the biliary obstruction is secondary to an underlying malignancy rather than to calculous disease

A

Courvoisier’s law

44
Q

Serum bilirubin levels 20 mg/dl suggests

A

neoplastic obstructions

45
Q

Elevated serum alkaline phosphate levels precedes

A

clinical jaundice

46
Q
  • preoperatively by endoscopic retrograde cholangiogram (ERC)
  • MRCP
  • intraoperatively at the time of cholecystectomy
A

Cholangiography

47
Q

CBD stones should be suspected in gallstone patients who have any of the following risk factors:

A

(1) a history of jaundice or pancreatitis
(2) abnormal tests of liver function
(3) ultrasonographic or MRCP evidence of a dilated CBD or stones in the duct

IM GASTRO (10 decks)

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