Liver Biliary Tract

Question 1

What is the Biliary Tract?

Answer 1

The excretory conduit for the liver. Composed of the:
-Hepatic Ducts (collect bile from the liver)
-Common Hepatic Duct (R and L together)
-Gallbladder (bile reservoir)
-Cystic duct (joins gallbladder to the Common Bile Duct)
-Common Bile Duct (terminates in the duodenum via the Sphincter of Oddi)

Question 2

Where is the gallbladder located?

Answer 2

-Attached to the Liver
-Shallow fossa between R&L lobes of liver
-Drains into the cystic duct

Question 3

What is contained in the gallbladder?

Answer 3

30-50 mL of bile
-Bilirubin
-Cholesterol
-Bile salts
-Lecithin
-Water
-Electrolytes

Question 4

What is Cholecystokinin (CCK)?

Answer 4

Secreted from duodenum in response to food ingested.

Question 5

What are the 3 functions of Bile?

Answer 5

-Emulsify & assist in absorption of amino acids & fat
-Excretory pathway for bilirubin, drugs & toxins
-Maintain duodenal alkalization

Question 6

What is the arterial blood supply to the gallbladder?

Answer 6

-Cystohepatic triangle: Cystic artery, Right hepatic artery, and cystic node.
-Very careful dissection: risk of cutting hepatic artery
-Rapid transfuser available

Question 7

What is Cholecystitis?

Answer 7

Inflammation of the cystic duct.
-Due to stone or obstruction.

Question 8

What is Cholelithiasis?

Answer 8

The presence or production of gallstones
-Hydrophobic cholesterol crystals due to fatty diet
-Calcium bilirubinate leads to cirrhosis and hemolytic anemia

Question 9

What are the S/Sx of Cholelithiasis?

Answer 9

-Severe, midepigastric pain
-Radiates to abdomen
-Vomiting
-HIDA Scan

Question 10

What is a HIDA scan?

Answer 10

-Radionuclide scan
-Hepatoiminoacetic acid
-Acid usually taken up & stored in gallbladder.
-Inject dye to see where stone is obstructing

Question 11

What is the treatment for Cholelithiasis?

Answer 11

-Oral/ IV agents
-Extracorpeal shock-wave lithotripsy
-Choledochocystotomy
-Creation of drainage conduit for common bile duct
-First go for ERCP for a stent to relieve back pressure in common bile duct
-Open vs laparoscopic surgery (Cholecystectomy)

Question 12

When is Open Cholecystectomy indicated?

Answer 12

-Necrotic, perforated gallbladder
-Inflammation
-Morbidly obese (can’t get trocars down enough)
-Previous surgery: adhesions

Question 13

Describe Laparoscopic Cholecystectomy

Answer 13

-3-5 abdominal wall punctures
-CO2 insufflation
-Reverse T-berg
-Cystic duct/ artery isolated and clipped
-Removal of GB
-Irrigation
-Hemostasis

Question 14

What are the anesthetic considerations for Cholecystectomy?

Answer 14

-Preop: Dehydrated, N/V. Usually young, female, and obese
-N2O
-ETT
-Insufflation: Monitor airway pressures and watch for bradycardia
-Intra-op decompression of the stomach: risk of reflux, better view of structures
-Loss of hemostasis
-Relative hypercarbia
-CO2 embolism (rare)

Question 15

What is the treatment for a Sphincter of Oddi spasm?

Answer 15

-Glucagon (1 mg IVP. Onset = 45 seconds)
-Narcan: start small (20 mcgs)
-NTG (5-10 mcgs)