Gallbladder & Biliary Tract Flashcards
BILIARY–Rush
During palpating of the hepatoduodenal ligament, a pulsation is felt dorsal and slightly to the right of the CBD. Which of the following does this pulsation most likely represent?
A. A normal common hepatic artery B. A normal right hepatic artery C. A replaced right hepatic artery D. A gastroduodenal artery E. A right renal artery
C
Most common variation in hepatic arterial anatomy is replaced R hepatic artery with origination from the SMA.
If hepatic artery is small or absent, must be alert to the possibility of a replaced R hepatic vessel
When replaced R hepatic originates from SMA, courses dorsal to the head of the pancreas and portal vein and is usually identified dorsolateral to the CBD. Rarely does it course through the pancreas
Replaced L hepatic originates from the L gastric artery and is located in the gastrohepatic ligament
BILIARY–Rush
Which of the following anatomic features may contribute to stricture formation after injury to the CBD?
A. Blood supply to supraduodenal bile duct has a longitudinal pattern
B. Blood supply to supraduodenal bile duct has a lateral pattern
C. Blood supply to supraduodenal bile duct has a segmental end-artery arrangement
D. Blood supply to CBD is derived primarily from common hepatic artery
E. Blood supply to CBD has a fragile anastomotic network
A
Ischemia is a contributing factor to post op bile duct stricture. Blood supply to the area of bile duct bifurcation and distal retropancreatic duct is primarily lateral in arrangement, whereas the blood supply to the supraduodenal portion has a axial or longitudinal pattern. The 3 o’clock and 9 o’clock arteries arise from the R hepatic artery and retroduodenal artery, which is a branch of the GDA. An additional source of blood supply is the retro portal artery from the celiac axis or SMA and generally joins retroduodenal artery. In 1/3 of individuals, it ascend the back of the CBD to the R hepatic artery.
The portion of the CBD supplied by the longitudinal vessels receives its supply from below, thus rendering the proximal portion subject to ischemia after injury or transection.
BILIARY–Rush
If a patient has complete bile duct obstruction, which of the following does not occur?
A. Triglyceride absorption B. Vitamin K absorption C. Cholesterol synthesis D. Bilirubin conjugation E. All of the above
B
Bili has function related to digestion and absorption of fats and elimination of endogenous and exogenous substances.
Bile interacts with pancreatic lipase and colipase in intraluminal hydrolysis of dietary triglycerides. Solubilizes mono glycerine she and fatty acids produced by triglyceride metabolism by forming mixed micelles. Micelles facilitate mucosal uptake of triglycerides by permitting transport across water barrier adjacent to enterocyte membrane. Triglycerides can be absorbed in the absence of bile because of the long length of intestine.
Fat soluble vitamins (A,D,E and K) are minimally water soluble and are not absorbed in any substantial amount in the absence of micelles. Patients with longstanding cholestasis require supplementation of these fat soluble vitamins to prevent deficiency.
Bile is the sole pathway for elimination of bilirubin and cholesterol from the body. Bilirubin is secreted into hepatic bile by an active transport mechanism following hepatic uptake and conjugation. Cholesterol is eliminated both by synthesis of bile acids from cholesterol and by solubilizing of cholesterol in bile during secretion
BILIARY–Rush
What change in bile flow would be expected in a patient with an external biliary fistula?
A. Increased total canalicular flow
B. Decreased bile acid dependent canalicular flow
C. Increased bile acid dependent canalicular flow
D. Decreased bile acid independent canalicular flow
E. Increased bile acid independent canalicular flow
B
~600 cc of hepatic bile are produced daily. 75% formed in bile canalicular and remainder is secreted by the ducts. Canalicular bile divided into equal bile acid dependent and independent fractions
Bile acid dependent fraction results from active secretion of bile acid by the hepatocyte. This secretion depends on the intestinal absorption and enterohepatic circulation of bile acids.
Patient with external bile losses have reduce bile acid dependent canalicular flow and consequently reduced total canalicular flow.
The bile acid independent portion of canalicular flow is result of secretion of inorganic electrolytes. Ductular secretion modifies canalicular bile flow by adding fluid and inorganic electrolytes.
BILIARY–Rush
Cholic acid is converted by bacteria to which of the following secondary bile acids?
A. Deoxycholic acid B. Chenodeoxycholic acid C. Lithocholic acid D. Ursodeoxycholic acid E. None of the above
A
Primary human bile acids cholic acid and chenodeoxycholic acid are synthesized from cholesterol in the liver
Secondary bile acids deoxycholic acid and lithocholic are form in the intestine as a result of bacterial enzyme activity. 7 Ketholithocholic acid is also a secondary bile acid
Tertiary bile acid urodeoxycholic acid is converted from 7 ketholithocholic acid in the liver
BILIARY–Rush
Conjugated bile acids are primarily absorbed in the intestine by which of the following mechanisms?
A. Active transport in the colon B. Passive transport in the colon C. Active transport in the ileum D. Passive transport in the ileum E. Bacterial translocation
C
Enterohepatic cycling of bile acids begins at hepatocyte level. Bile acids are conjugated in the liver with glycine or taurine, secreted into biliary system, concentrated and stored in the gallbladder and then delivered to the duodenum after gallbladder contraction
Most bile acids are efficiently resorted in the intestine. Site and mechanism of intestinal absorption differ depending on the form of bile acid and its corresponding lipid solubility. Conjugated bile salts are ionized in the intestinal pH range and are relatively lipid insoluble. Conjugated forms are absorbed by active transport mechanisms in the TI. Accounts for 70-80% enterohepatic circulation.
Bacterial deconjugation of bile acids occurs in the colon and small intestine, as does conversion of primary bile acids to secondary forms. Deconjucation raises pKa and enables resorption by passive non ionic diffusion, which occurs in the colon but to some extent in the small intestine. Both primary and secondary are resorted and taken back to the liver. Unconjugated forms are then reconjugated and resecreted.
Hepatic bile contains both primary and secondary bile acids, with the primary bile acid pool normally constituting 60-90% of the total bile pool. Hepatic synthesis of new bile acids approximated fecal losses of 300-600 mg/day
Bile acid pools cycle 4-8x perk day and hepatic secretion is dependent on enteral return. Disruption of this cycle diminished bile acid secretion. Clinical conditions that may be associated with bile acid malabsorption include ileal disease or resection, small bowel dysmotility or obstruction, and blind loop syndrome. Clinical consequence of this disordered physiology may include fat malabsorption, deficiencies of fat soluble vitamins, choleretic diarrhea cause by impaired colonic water absorption by bile acids and formation of gallstones.
BILIARY–Rush
Normal function of the gallbladder epithelium include all but which of the following?
A. Absorption of water B. Absorption of sodium and chloride C. Absorption of conjugated bile acids D. Secretion of hydrogen ion E. Secretion of glycoproteins
C
Primary function of gallbladder is to concentrate and store bile between feedings. Epithelium absorbs solutes and water across concentration gradients by active and passive mechanisms. Main concentrating force is active absorption of sodium (coupled to chloride transport), which leads to passive absorption of water.
Abnormalities in gallbladder reabsorption are part of the pathophysiologic process of gallstone formation. Absorption of organic solutes is normally minimal and depends on lipid solubility. Unconjugated bile acids are more lipid soluble than conjugated forms. Absorption of unconjugated bile acids that form in the presence of bacteria or inflammation damages the mucosa, promoting absorption of other solutes and destabilizing cholesterol in solution.
Gallbladder epithelium is also secretory. Secretion of hydrogen ion lowers the pH of gallbladder bile in relation to hepatic bile. Mucin glycoproteins secreted by the mucosa have both a protective function and a role as a nucleating factor during gallstone formation
BILIARY–Rush
Which of the following usually produces gallbladder contraction?
A. Adrenergic stimulation B. Vasoactive intestinal peptide C. Somatostatin D. Cholecystokinin (CCK) E. Secretin
D
Stimulation of parasympathetic vagal nerves causes gallbladder contraction, and stimulation of sympathetic nerves from celiac ganglion causes gallbladder relaxation.
Regulation of gallbladder function is a complex process that involves interaction of various neural, hormonal, and peptidnergic stimuli on various receptors located on the gallbladder muscle, blood vessel and nerves.
Cholinergic stimuli (including vagal) and CCK cause contraction. CCK receptors can be found on both gallbladder smooth muscle cells and intrinsic cholinergic nerves.
Adrenergic stimulation (sympathetic) usually causes relaxation, but selective stimulation of certain adrenergic receptors can cause contraction.
VIP and somatostatin inhibit gallbladder contraction, which can account for biliary manifestations in patients with tumors that secrete those substances or in patients being administered somatostatin agents.
BILIARY–Rush
Which of the following is true regarding gallbladder emptying in between meals?
A. It does not occur B. It is stimulated by CCK C. It is inhibited by CCK D. It depends on peristalsis of the CBD E. It is stimulated by motilin
E
Bile flow varies according to fasting or fed state.
Cholecystokinin, which is released by the duodenum in response to the ingestion of food, facilitates delivery of bile to the intestine by stimulating contraction of the gallbladder and relaxation of the sphincter of oddi. Normal contraction of gallbladder in response to meals results in ~80% emptying in 2 hrs.
CBD is a passive conduit and does not play an active role in biliary motility
Filling of the gallbladder after it has emptied depends on neural and hormonal factors that relax the gallbladder and increase resistance of the sphincter of oddi. During the interdigestive period, the gallbladder gradually fills but this filling is interrupted by cyclic periods of emptying during which time ~ 1/3 of the gallbladder volume is dispensed. This cyclic pattern during fasting is correlated with the interdigestive myoelecturc migratory complex if the intestine and is related to increased levels of plasma motilin (a 21 amino acid peptide). Plasma motilin levels vary cyclically during fasting.
BILIARY–Rush
Which of the following levels of enzyme activity is most likely to be present in a non obese individual with cholesterol gallstones?
A. Increased HMG-CoA reductase activity
B. Decreased HMG-CoA reductase activity
C. Increased 7 alpha hydroxylase activity
D. Decreased 7 alpha hydroxylase activity
E. Decreased enterokinase activity
D
Cholesterol solubility in bile depends on the concentration of cholesterol relative to bile acids and phospholipids. Increase in hepatocyte cholesterol synthesis and secretion has been implicated in obese patients with gallstones, a relative deficiency of bile acid secretion is thought to be responsible for gallstone formation in non obese patients.
HMG-CoA reductase catalyzes conversion of HMG-CoA to mevalonate and its the early rate limiting enzyme in cholesterol synthesis.
The primary bile acids are formed from cholesterol and the rate limiting enzyme in this process is 7 alpha hydroxylase.
BILIARY–Rush
Which of the following is decreased after cholecystectomy?
A. Size of the bile acid pool B. Rate of enterohepatic recycling C. Rate of bile acid secretion D. Cholesterol solubility in bile E. Rate of bilirubin conjugation
A
Total size of the bile acid pool is diminished after cholecystectomy as a result of loss of the gallbladder reservoir. However cholecystectomy produces more continuous flow of bile into the intestines, which increases the frequency of enterohepatic circulation stimulated bile acid secretion.
Even though size of bile acid pool is diminished, cholecystectomy improves cholesterol solubility bile, which depends on the relative molar concentration of cholesterol in relation to bile acids and the phospholipid lecithin
BILIARY–Rush
Which of the following is the primary form in which cholesterol is transported in bile ?
A. Dissolved as free cholesterol B. Dissolved as conjugated cholesterol C Attached on a protein carrier D. Solubilized in mixed micelles E. Solubilized in phospholipid vesicles
E
Cholesterol is insoluble in water and bile is 90% water
Solubility of cholesterol in bile depends on presence of bile acids and phospholipid lecithin. These molecules aggregate into physiochemical structures that shelter cholesterol within a nonpolar, hydrophobic center and thus permit dissolution.
For many years mixed micelles was recognized as the structure principally responsible for cholesterol solubility. Subsequently it was found that most cholesterol is usually solubilized in larger bilayered lipid structures known as vesicles.
Balance between micelles and vesicles is a dynamic process. Recognition of these vesicles is particularly important b/c crystallization of cholesterol to form stones occurs in this phase
BILIARY–Rush
Which of the following is not part of the process of cholesterol gallstone formation?
A. Supersaturation of bile with cholesterol B. Bilirubin deconjugation C. Crystal nucleation D. Aggregation of cholesterol monomers E. Stone growth
B
Steps include cholesterol saturation, nucleation, and stone growth.
Cholesterol content of bile must exceed capacity for bile to solubilized cholesterol in vescicles and micelles. Cholesterol supersaturation alone is not sufficient to cause stones because the process can occur in normal individuals.
Nucleation must also take place; cholesterol monohydrate crystals must form and aggregate.
Crystals must enlarge by fusion or continued solid deposition to produce a stone to be large enough to be clinically relevant.
Bacterial infection is thought to be an important pathogenic factor in the development of some pigment stones but not generally cholesterol stones. Bacterial infection is associated with deconjugation of bilirubin and subsequent formation of insoluble calcium bilirubinate complexes. Can also result in production of glycocalyx, an adhesive glycoprotein that plays a role in pigment stone formation
BILIARY–Rush
Nucleation during cholesterol gallstone formation involves all but which of the following?
A. Mixed micelles B. Biliary vesicles C. Biliary calcium D. Gallbladder stasis E. Mucus secretion
A
Nucleation = formation and aggregation of solid cholesterol monohydrate crystals
Factors that promote and inhibit.
Mucin glycoprotein secreted by gallbladder epithelium are thought to be key nucleating factors. Increased mucus secretion occurs when there is gallbladder stash is, and this precedes development of cholesterol crystals. Prostaglandins stimulate mucus production in animal models and prostaglandin inhibitors can prevent stones
Associated with the vesicular fraction of bile rather than with the mixed micelles.
Biliary calcium also plays a role in the formation of both cholesterol and pigment stones. Calcium levels in gallbladder bile are increased during cholesterol stone formation. Calcium affects the absorptive function of the gallbladder epithelium and also promotes nucleation from vesicles.
BILIARY–Rush
Cholesterol gallstones are associated with all except which of the following?
A. Obesity B. Rapid weight loss C. Total parenteral nutrition (TPN) D. Exogenous estrogen E. High calorie diet
C
Changes in bile composition that either increase the relative concentration of cholesterol or decrease the relative concentration of bile acids favor cholesterol gallstone formation
Increased hepatocyte cholesterol secretion caused by obesity, rapid wt loss, diets high in calories and polyunsaturated fats, and estrogen therapy.
Drugs that inhibit HMGCoA reductase are used to treat hypercholesterolemia and may prevent gallstone formation.
Relative decrease in size of bile acid pool would predispose to cholesterol gallstone formation in situations in which there were excessive bile acid losses (ileal disease or resection) or decreased bile acid synthesis (reduced 7 alpha hydroxylase activity). Stone associated with ileal disease or resection are the pigment type.
TPN also associated with pigment gallstones in a high proportion of patients depending on duration of therapy
BILIARY–Rush
Which of the following is the main chemical component of pigment gallstones?
A. Cholesterol B. Calcium bilirubinate C. Calcium carbonate D. Calcium phosphate E. Calcium oxalate
B
Pigment gallstones are composed primarily of calcium precipitated with bilirubin, carbonate, phosphate, or palmitate anions
Black pigment gallstones are small and speculated. Contain calcium bilirubinate primarily in polymerized form, as well as calcium carbonate or phosphate.
Brown pigment gallstones are soft and yellow-brown, are also composed primarily of calcium bilirubinate, but contain more calcium palmitate (fatty acid derived lecithin) and cholesterol.
Oxalate salts play no role in gallstone disease
BILIARY–Rush
Which of the following features is more characteristic of black pigment gallstones than brown pigment gallstones?
A. Association with hepatic cirrhosis B. Association with bacterial infection C. Location in the common bile duct D. Treatment requiring bile duct drainage E. Higher risk for cholangitis
A
Brown pigment stones require stasis and infection. Bile culture results are positive in most patients with brown pigment gallstones and scanning electron microscopy demonstrates bacterial colonies or casts within the stones. Found more frequently in the common bile duct than in the gallbladder. Occurs in older patients with stasis and in post cholecystectomy patients
Black pigment stones are thought to have a metabolic cause. They often occur in patients with cirrhosis or hemolysis. ~20% have positive bile culture results and some have demonstrated bacteria in black stones.
A subset have combined both black and brown pigment gallstones.
The important therapeutic implications in differentiating black from brown pigment gallstones is that patients with brown pigment gallstones may require a definitive biliary drainage procedure to prevent recurrent, whereas patients with black pigment gallstones may be treated successfully by cholecystectomy alone.
BILIARY–Rush
Which of the following sonography findings is not a feature of gallstone disease?
A. Hyperechoic intraluminal structure
B. Mobility of the intraluminal structure
C. Shadowing posterior to the structure
D. Acoustic enhancement posterior to the structure
E. Sonographic Murphy’s sign in acute cholecystitis
D
U/S sensitivity of 95% for dx of gallstones.
Three sonographic criteria for gallstones are: 1) presence of hyperechoic intraluminal focus, 2) shadowing posterior to that focus, 3) movement of the focus with changes in position of the patient
For optimal elective ultrasound, patients should be fasting for 6 hours.
Posterior acoustic enhancement is a sonographic feature of hypodense structures such as cysts. Signals behind the structure are whiter because the sound wave energy is less attenuated as it passes through. Gallbladder itself is a cystic structure and demonstrates this phenomenon, whereas gallstones do the opposite. Sonographic Murphy’s refers to tenderness when the U/S is placed over the gallbladder. This is a typical finding with gallstones and acute cholecystitis.
BILIARY–Rush
U/S revealed gallstones in an asymptomatic 50 y.o. F. Which of the following is the recommended treatment?
A. Observeration B. Lap chole C. Open chole D. Ursodeoxycholic acid E. Extracorporeal shock wave lithotripsy
A
Controversial
Must determine if in fact asymptomatic b/c GI complaints other than pain may be attributable to biliary tract disease.
Formerly thought that symptoms would eventually develop in most patient with silent gallstones and that the risk of subsequent complications was high. Symptoms develop in 1-2% of patients each year and that serious complications are relatively infrequent. Morbidity, mortality, and cost of intervention may exceed those of expectant therapy
Non operative pharmacologic dissolution and ESWL are neither definitive nor cost effective.
Incidental finding of asymptomatic cholelithiasis is not an indication for therapy in most situations. Exceptions include: 1) transplant patient with anticipated immunosuppresion b/c of risk of sepsis, 2) anticipated long term parenteral nutrition b/c of associated stasis and sludge formation, 3) anticipated pregnancy b;c of possibility of becoming symptomatic as gallbladder emptying is impaired and b/c of potential risk imposed on mother and fetus if complicated cholelithiasis occurs, 4) concurrent abdominal surgery for an unrelated problem b/c of relative ease and safety of incidental cholecystectomy, 5) bariatric operations b/c of high incidence of gallstones associated with obesity and during rapid wt loss.
BILIARY–Rush
In patients with which of the following conditions is early elective cholecystectomy for symptomatic gallstones not indicated?
A. Elderly B. Diabetes C. Child Pugh C D. TPN induced gallstones E. Chronic renal failure
C
Certain medical conditions are considered to be higher risk for morbidity and mortality from gallstone disease.
Complications of cholelithiasis, such as sepsis, perforation, and choledocholithiasis, more frequently develop in elderly patients. They also have higher mortality during emergency operations. Elective cholecystectomy can be performed safely in elderly and is recommended for symptomatic patients. A
Diabetic patients may also be at increased risk, particularly if emergency intervention is requires and should therefore be considered for early elective chole.
Gallstones develop in a high proportion of patients maintained on long term TPN and reports suggest that complications, emergency operations, and mortality are more frequent. Early chole is indications
Chole is indicated for patient with chronic renal failure, particularly if they are candidates for renal transplant.
Patients with hepatic cirrhosis have higher morbidity and mortality rates related to cholecystectomy, especially with hepatocellular dysfunction and portal HTN. Chole should be approached with great caution in these circumstances and is usually reserved for patients with complications of cholelithiasis or for patients with substantial symptoms and less advanced hepatic disease (child pugh A).
BILIARY–Rush
A patient with abdo pain has a CCK-stimulated hepatibiliaty iminodiacetic acid (HIDA) scan that demonstrated 25% gallbladder emptying. U/S of the gallbladder is normal. What is true regarding cholecystectomy in this situation?
A. Chole is not indicated b/c persistent or recurrent symptoms are likely
B. Chole is indicated only if duodenal drainage yields cholesterol crystals or bilirubinate granules
C. Chole can alleviate symptoms in most patients if the pain is episodic and located in the RUQ
D. Chole improves symptoms in most patients regardless of the location or characteristics of pain
E. When compared with operations on patients with gallstones, there is a greater change that lap chole will need to be converted to open
C
When symptoms are atypical or when US does not identify any abnormality, further evaluation is necessary to determine whether chole is warranted. Other dx must be excluded and additional investigations may include EGD, CT, ERCP, GI contrast studies and colonoscopy
Cholecystokinin stimulated cholescintigraphy can be useful for identifying patients who may have symptoms as a result of motility disorders of the gallbladder. Test does not always reliably predict the long term outcome of chole. If symptoms are more typical of biliary origin and findings on CCK scintigraphy are abnormal (<30% ejection), data suggest that most patients (>70%) can benefit from chole. Histologic abnormalities of the gallbladder are found in a reasonable number of these patients. If the symptoms are less typical, results of chole cannot be expected to be as favourable even though emptying is abnormal. Additional tests such as repeat U/S or duodenal drainage with CCK cholecystography may be useful
BILIARY–Rush
Lap chole is most strongly contraindicated in which of the following situations?
A. Pregnancy B. Prev upper abdominal surgery C. Known CBD stone D. COPD E. Gallbladder cancer
E
Most contraindications are relative, and in fact the laparoscopic approach is preferred when possible in certain situations that were initially considered contraindications (e.g. acute chole, choledocholithiasis, obesity).
There are patients for whom the potential physiologic consequences of CO2 pneumoperitoneum are more important but the presence of underlying disease itself does not prohibit a lap chole. Lap chole may be more beneficial in the post op course.
Pregnancy is not a contraindication with appropriate precautions, although the physiologic effects on the fetus are not completely known.
The strongest contraindication currently involves patients with suspected or known gallbladder cancer because of the risk of dissemination
BILIARY–Rush
Most major bile duct injuries during lap chole occur in patients under which of the following circumstances?
A. Acute chole B. Gallstone pancreatitis C. Choledocholithiasis D. Elective chole E. Conversion of a lap --> open
D
There are several risk factors for bile duct injury during lap chole.
Pathological include severe acute or chronic inflammation. Statistical correlation between rate of duct injury and presence of acute cholecystitis. Bleeding is implicated as a factor predisposing to duct injury during open or lap chole. Injuries are sometimes attributed to the anomalous anatomy of the bile ducts. More often than not, such anomalies are simply common anatomic variants that the surgeon must recognize to prevent injury. The surgeon’s experience is a risk factor.
No convincing evidence that duct injury is more frequent during cases involve lap management of CBD stones, possible b/c these procedures are performed by more experienced surgeons.
Most major bile duct injuries during lap chole have occurred in elective and otherwise uncomplicated cases.
Despite the presence or absence of risk factors, the primary problem resulting in duct injury is misidentification of anatomy. Mistaking a major bile duct for the cystic duct and clipping and cutting it.
Obtain the critical view of safety by dissecting the base of the gallbladder off the liver for an adequate distance to visualize the cystic plate and to verify that the only structures entering the gallbladder are the true cystic duct and cystic artery.
Intraoperative bileduct imaging with cholangiography or lap u/s can aid in discerning anatomy. If cystic duct cannot be conclusively identified, surgeon must resort to alternative approaches such as lap subtotal chole, conversion to open or termination of procedure.
BILIARY–Rush
Surgeon encounters difficulty during an elective lap chole in a healthy 25 y.o. F and converts to open. The 4 mm common hepatic duct has been transected 1 cm below the bifurcation. Which of the following procedures is the most appropriate?
A. Duct to duct repair over a T tube B. Duct to duct repair without a stent C. Roux en y hepaticojejunostomy D. Heapticoduodenostomy E. Ligation of duct and placement of drain
C
When transection or resection injury of extrahepatic biliary tree is discovered at time of chole, surgeon must make careful decisions
Repair at the time is preferable, provided the surgeon is adequately experienced in performing such a repair. Evidence indicates that a most primary repairs by the initial operating surgeon have failed, this necessitating repeated operations and other interventions. Initial repair of a major duct injury has the best chance for long term success
Less experienced surgeon should not anastomoses a small bile duct but instead drains should be placed and transfer made to tertiary care center.
If repair at that time is appropriate, the standard reconstruction for this type of injury is Roux-en-Y hepaticojej. Duct to duct repair usually fails in this situation. Hepaticoduodenostomy is not recommended at this level
BILIARY–Rush
How would a bile duct injury involving a transection of the common hepatic duct less than 1 cm from the confluence be classified?
A. Bismuth type 1 B. Bismuth type 2 C. Bismuth type 3 D. Bismuth type 4 E. Bismuth type 5
B
The Bismuth classification of bile duct injuries and strictures describes the level of injury in relation to the bifurcation of the main right and left hepatic ducts.
Type 1 = 2 cm or more of the CHD is preserved below the bifurcation
Type 2 = Less than 2 cm remains
Type 3 = Reaches bifurcation with preservation of continuity between the right and left ducts
Type 4 = Destruction of hepatic duct confluence with separation of right and left hepatic ducts
Type 5 = Separate inserting R sectors duct with or without injury to the common duct
BILIARY–Rush
On the second post op day following elective lap chole, a 40F complains of nausea and abdo pain. Exam shows a temp of 37.8, HR 100, mild abdo distension and moderated RUQ tenderness. Which of the following would next be appropriate?
A. Administration of IV Abx B. MRCP C. HIDA D. ERCP E. PTC
C
Serious delays in post op dx of bile duct injuries can compound problems. Should be investigated promptly when clinical course suggests anything other than anticipated recovery. Primary concern is development of bile leak, which occurs in 1-2% of patients. Other problems, such as, retained stone or intestinal injury, can occur although less frequently.
HIDA shows ongoing bile leak and is often the most reasonable initial investigation after patient is examined. US or CT can demonstrate fluid collections or intrahepatic bile duct dilation. If a fluid collection is seen, percutaneous aspiration can determine whether the fluid is bile. If a bile leak is confirmed, cholangiography is necessary to establish site of leakage and determine therapy. ERCP is generally first choice and many be all necessary for bile leaks that originate from lateral injuries, the cystic stump or gallbladder fossa. PTC is necessary fro complete anatomic definition in patients with transection or resection injuries or injuries to sectoral hepatic ducts that may not be in continuity with the rest of the extrahepatic bile ducts. MRCP is not an initial diagnostic exam but can be useful for delineation of bile duct anatomy in complex situations
