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Surgery > Gallbladder > Flashcards

Gallbladder Flashcards

1
Q

Pt presents with steady pain in the RUQ for the last 4 hours associated with N,V, and fever.

A

acute cholecystitis

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2
Q

if a pt presents with jaundice, light colored stools, and dark tea colored urine what do they have

A

extrahepatic biliary obstruction

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3
Q

how does a pt with biliary colic present vs acute cholecystitis

A

biliary colic-uncomfortable and restless

cholecystitis-still because pain is aggravated by movement

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4
Q

what is murphy’s sign and what is it associated with

A

cessation of inspiration due to pain on deep palpation of the ruq when the visceral peritoneum overlying the gallbladder is inflamed

acute cholecystitis

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5
Q

courvoisier’s sign

A

nontender palpable gallbladder w jaundice that suggests underlying malignant disease such as carcinoma of the pancreas

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6
Q

what lab tests should be obtained

A 
LFTs
serum level of unconjugated bilirubin (hemolytic disorders);conjugated (extrahepatic obstruction)
alkaline phosphatase (ALP)- syn by biliary tract epithelium; differentiate it from bone by heat stability or elevation of GGT (ALP/GGT >AST/ALT)
INR- elev in pts w obstructive jaundice from malabsorption of vit K
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7
Q

what is the initial study of choice for pts w biliary disease

A

US

stones as small as 3mm in diameter

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8
Q

what does the finding of thickened gallbladder wall or pericholecystic fluid suggest

A

acute cholecystitis

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9
Q

how does the radionuclide biliary scan (HIDA scan) work

A

IV injection of 99techneitum derivative-> radionuclide excreted by the liver into bile in high concentrations –> enters gallbladder and duodenum

normal gallbladder begins to fill in 30m; if cant visualize common bile duct and duodenum wout filling of gallbladder in 4hr=cystic duct obstruction=acute cholecystitis

not useful for showing stones in either the gallbladder or common bile duct

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10
Q

leukocytosis,left shift, mild inc in AST/ALT/ALP, mild hyperbilirubinemia

A

acute cholecystitis

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11
Q

what is the initial management of acute cholecystitis

A

withholding oral intake
administering iv fluids
abx therapy

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12
Q

what bacteria is commonly assoc w acute cholecystitis

A

e choli
klebsiella
streptococcus faecalis

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13
Q

what is the tx for pts w acute cholecystitis who are poor surgical candidates

A

cholecystostomy- percutaneous placement of a tube under us guidance through the liver into the gallbladder to drain its contents

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14
Q

what is acute emphysematous cholecystitis

A

result from gas forming bacteria

will see air on xray

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15
Q

biliary colic, n, v, intolerance to fatty foods, flatulence, belching and indigestion; no fever or chills

A

chronic cholecystitis

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16
Q

management of an episode of biliary colic

A

analgesics and observations

after cholelithiasis is confirmed, the optimum tx is elective cholecystectomy

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17
Q

oral dissolution therapy

A

ursodeoxycholic acid taken for 6m-1yr

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18
Q

gallstones that pass through the cystic duct and enter common bile duct

A

choledocholithiasis

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19
Q

pt presents with jaundice, light colored stools and dark tea colored urine

A

obstruction of the bile duct

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20
Q

characterized y charcots triad

A

acute cholangitis

charcots- jaundice, ruq pain, fever

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21
Q

acute suppurative cholangitis

A

infx accompanying acute cholangitis that progresses to presence of pus in biliary ducts

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22
Q

presents with reynolds pentad

A

acute suppurative cholangitis

reynolds- ruq pain, jaundice, fever, hypotension, mental confusion

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23
Q

mirizzi’s syndrome

A

large stone in the gallbladder compresses the common hepatic duct that can lead to obstructive jaundice

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24
Q

lab results for cholangitis

A

leukocyte count elev
total bili elev
serum ALP/GGT marked elev
AST/ALT mild elevations

25
Q

management of acute cholangitis

A 
urgent intervention
hydrated w IV fluids
abx
bowel rest
blood cx
26
Q

why are gallstones a common cause of pancreatitis

A

transient or persistent obstruction of the ampulla of Vater by a large stone or passage of small stones and biliary sludge

27
Q

management of pts w acute biliary pancreatitis

A

resuscitation
supportive care
correction of any fluid deficits

28
Q

when can a laparoscopic cholecystectomy be safely performed with mild/moderate pancreatitis

A

within the first 48-72hrs of admission

29
Q

what is performed if someone with gallstone pancreatitis is a poor surgical candidate

A

endoscopic sphincterotomy

30
Q

when should a cholecystectomy be performed if pt has severe pancreatitis

A

delayed until pancreatitis has resolved some weeks or months later but make sure pt is placed on abx

31
Q

what is a gallstone ileus

A

mechanical obstruction of the intestine caused by a large gallstone that erodes through the gallbladder into the duodenum; may be assoc w pneumobilia; point of obstruction is often in the distal ileum

32
Q

what do plain abd xray show for gallstone ileus

A

findings of small intestinal obstruction and may show air in the biliary tree

33
Q

what is the preferred dx test for gallstone ileus

A

ct with oral contrast

34
Q

tx for gallstone ileus

A

NG tube for decompression of the obstruction
IV hydration
surgical exploration of the abd and an enterolithotomy

35
Q

why does gallbladder cancer occur

A

chronic inflammation MC from cholesterol gallstones

36
Q

Pt with ruq pain, weight loss, malaise and jaundice

A

gallbladder cancer

37
Q

what are the majority of bile duct strictures a result from and why

A

iatrogenic injury during an operative procedure because of limited blood supply and no redundancy

38
Q

procedure for open common bile duct exploration

A
  1. mobilize the duodenum w Kocher maneuver
  2. id the duct and make small longitudinal incision in common bile duct
  3. irrigate lumen w saline using flexible catheters to flush out stones and debris
  4. inflatable balloon catheters passed prox/dist to extract stones
  5. small endoscope (choledochoscope)
  6. all stones and debri removed, duct is irrigated with saline
  7. T tube placed in lumen of duct and opening of duct is closed around it
39
Q

when there are multiple stones or if stones left in bile duct what is important to be done during surgery

A

anastomosis between bile duct and GI tract (choledochoduodenostomy or choledochojejunostomy) so that residual stones may pass easily from duct into intestine

40
Q

when is the peritoneal drainage catheter removed after T tube has been clamped during bile duct exploration

A

24-48hr

41
Q

when are T tubes removed

A

3-6wks

42
Q

how are MC bile duct stones removed

A

ERCP and sphincterotomy

43
Q

how is a sphincterotomy of the sphincter of Oddi performed

A

special cautery wire passed through the duodenoscope into the sphincter and then the common duct is cleared using special balloon catheters or wire baskets

44
Q

41yo F w 18hrs of N, ruq pain and fever. Ate heavy meal night before. Elev WBC, normal bilirubin, slightly elev AST/ALT. Most appropriate study?

A

US

most likely acute cholecystitis

45
Q

51yo fever and abd pain, Temp 38.4C. tender w guarding of ruq. WBC 17000. LFs and lipase normal. US ids gallstones, gallbladder wall of 5mm, fluid surround gallbladder. what abx?

A

Cefoxitin

MC gram neg (e coli and klebsiella) want 2/3 cephalosporin

46
Q

83yo 2d hx n/v. abd slightly distended and nontender. norm WBC and metabolic alkalosis. abd xray show small bowel obstruction and air in biliary tree. dx?

A

gallstone ileus

47
Q

54yo abd pain for 8hrs. mid abd getting worse. elev wbc, amylase 792, normal lfts. US gallstones. Management?

A

admit, hold intake by mouth, schedule for cholecystectomy before discharge

48
Q

72yo yellow eyes, dark urine, light stool. diminished appetite. afebrile. jaundiced. nontender smooth globular mass consistent w enlarged gallbladder in ruq. dx?

A

pancreatic cancer

49
Q

what regulates bile flow into duodenum

A

sphincter of Oddi which encircles the common channel

50
Q

what makes triangle of calot

A

inferior margin of liver, common hepatic duct, cystic duct

51
Q

where does most bile acid reabsorption happen

A

level of terminal ileum

52
Q

what makes bile more prone to stone formation

A

greater losses=diminished pool= dec concentration

53
Q

what is responsible for the green brown color of bile and brown of stool

A

conjugated bilirubin

direct=water soluble=excreted in urine
indirect=fat soluble=no urine

54
Q

ways to prevent gallstone formation

A

avoid obesity, high fiber diet, eat meals at regular intervals, foods w low levels of sat fatty acids

55
Q

MC type of gallstones

A

cholesterol, bile acids, lecithin (phospholipid)= cholesterol crystals

56
Q

where is the source of most stones found in the biliary ducts (choledocholithiasis)

A

gallbladder

57
Q

how is biliary colic described

A

steady visceral dull/aching pain lasting 1-4hrs postprandial lg/fatty meal

58
Q

what is acute cholecystitis

A

acute inflammation and infection of the gallbladder

Surgery (21 decks)

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