Gallbladder Flashcards
Anatomy of the GB
RUQ of abd under liver
Cystic duct exits and joins common hepatic duct to form common bile duct
CBD empties into the duodenum at ampulla of Vader, which is surrounded by the sphincter of Oddi
What stimulates bile rls from the GB
CCK (cholecystokinin) causes the GB to contract, which rls’s bile into the duod.
Why isn’t there bile reflux back into the GB?
spiral valves of Heister
Arterial supply to the GB
cystic artery, which usu comes from the R hepatic artery
What is the triangle of calot?
cystic duct
common hepatic duct
cystic artery (some say edge of liver and the cystic artery goes through the triangle)
What is cholelithiasis
Gallstones
What is biliary colic
Pain produced when the GB contracts against a stone in the neck of the GB or as a stone passes through the bile duct
What is acute cholecystitis
inflammation and infection of the GB
usu w total or partial obstruction of the cystic duct
What are the most common organisms cultured during an episode of acute cholecystis?
E. coli Klebsiella enterococci Bacteroidies fragilis Pseudomonas
What is cholodocholithiasis
Stone in the CBD
What are stones made of?
Cholesterol (80%)
Calcium carbonate
or both
How do stones form?
Bile becomes supersaturated with cholesterol, stones precipitate out of soln.
High cholesterol diet can be a cause of cholesterol stones.
Calcium bilirubinate stones are found in a/w which diseases?
chronic biliary infection
cirrhosis
hemolytic processes- sickle cell anemia, thalassemia, spherocytosis
T/F Spinal cord injury predisposes to pigment stones (calcium bilirubinate)
False- predisposes to cholesterol stones
Px of gallstones
most pts are asx
Px of biliary colic
RUQ or epigastric pain, often radiates to right side or back
Usu postprandial, precipitated by fatty food intake
Lasts several hours before resolving
Also nausea/vom with it
But NO fever
Px of cholecystitis
Constant pain w progressive worsening. Fever chills sweats. It’s inflam/infection, so it’s signs of that- signs of peritoneal irritation, including RUQ rebound and guarding.
Murphy’s sign- arrest of inspiration on deep palpation of RUQ
Px of choledocholithiasis
Dark urine or light colored stools- since the CBD is blocked, bile pigments can’t get to the GI tract- so it’s not cleared in stool, and instead it’s cleared renally.
Also a/w jaundice and signs of biliary colic
Ascending cholangitis px
RUQ pain plus fever and chills. It’s infection of bile duct from ascending bacteria.
Gallstone pancreatitis px
epigastric tenderness/pain radiating to the back
pancreatitis is dt choledocholithiasis- stone in the CBD
WHat is the Charcot triad?
For cholangitis
- Fever
- RUQ pain
- Jaundice
What is the Reynolds pentad
For cholangitis that progressed to sepsis- charcot plus hypotension and mental status chgs
(charcot - fever, RUQ, jaundice)
Dx eval for cholecystitis
increased WBC
US- fluid around GB, thickened GB wall, GB distention
if it’s acalculus cholecystitis, use HIDA (cholescintigraphy)- inject radioactive nucelotide into liver, it’s excreted into biliary tree- if it’s acute cholecystitis, then the cystic duct is obstructed so the GB will not fill- all radionucelotide will go out to the duodenum
Dx eval for cholodocholithiasis
Increased serum bilirubin and alk phos
US- detects stones
Best for CBD stones is ERCP- use endoscope to visualize ampulla, put contrast in retrograde. Can also extract stones.
MRCP good for detecting CBD stones but not therapeutic like ERCP
Dx eval for Cholangitis
Elevated serum bilirubin and transaminase levels
Dx eval for Gallstone pancreatitis
Elevations in serum amylase and lipase
US-detects stones
What happens if the dx of cholecystitis is delayed?
GB necrosis
What kind of cholecystitis is seen in diabetic pts?
Emphysematous cholecystitis d/t Clostridium perfringens
What is gallstone illeus?
Large gallstone erodes wall bt GB and bowel, making a fistula. The stone goes into the bowel and then down to the ileo-cecal junction, where it gets caught and causes distal bowel obstruction.
Rx for pts w asx stones
Usu not surgery. Incidence of complications only 2% per year.
Rx for biliary colic
Lap chole- elective
Rx for common duct stones
ERCP or intraop cholangiography (+ lap chole if colic)
Rx for acute cholecystitis
Fluids (vom/d cause dehydration)
IV abx
Lap chole
If pts too sick for surg, place a cholecystostomy tube for decompression/drainage, do surg when they are stable
Rx for gallstone pancreatitis
Fluids and observation
80% of cases are mild
Severe cases (necrosis, infection complications) get abx
Do early ERCP if signs of CBD obstruction.
After pancr is less inflamed, do cholecystectomy w intraop cholangiography.
Recurs a lot.
Rx for cholangitis d/t choledocholithiasis
Rapid dx and Rx!
IV abx and urgent biliary decompression and drainage.
ERCP with sphincterotomy is main Rx.
Can also do percutaneous or open surgical drainage.
Risk factors for cancer of GB
gallstones, porcelain GB, adenoma
females have 3x risk
What kind of ca is GB ca?
80% adenocarcinoma
10% anaplastic
5% sq cell
HPE for GB ca
vague RUQ pain
weight loss, anorexia
RUQ mass may be palpated
If jaundice- means invasion/compression of biliary system
Rx for GB ca
Radical resection of GB
+ partial hepatic resection
other palliative op- pgx is really bad. 4% 5yrs.
Risk factors for bile duct cancer
UC, sclerosing cholangitis, infection w Clonorchis sinensis (liver fluke)
HPE for bile duct ca
RUQ pain in advanced dz
Distended GB or jaundice (tumor obstructs biliary tree)
Dx eval for bile duct ca
US or CT can show obstruction, but need PTC or ERCP usu necessary to see lesion
Rx and pgx for bile duct ca
Rx surgical resection
Pgx really bad. 90% mortality at 5 years.
