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Surgery > Medbear Gall Bladder > Flashcards

Medbear Gall Bladder Flashcards

1
Q

Describe the anatomy of the gall bladder based on the following:

Anatomical areas
Location
Duct

A
  • Gall bladder is divided into 4 anatomical areas: Fundus, Body, Infundibulum and Neck
  • It is a pear-shaped sac
  • Lies beneath segment 4 and 5
  • Lined by SIMPLE COLUMNAR EPITHELIUM (It lacks muscularis mucosa and submucosa)
  • Surface is covered by peritoneal serosa

It consists of
1. Common Hepatic Duct (~4cm) -> fusion of right and left hepatic duct
2. Cystic Duct (~4cm) - variation exists
3. Common Bile Duct (~10cm) -> no distinct muscle layer (So, no peristalsis)

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2
Q

State the boundaries for triangle of Calot

A

Lateral = Cystic duct
Medial = Common bile duct
Superior = Liver

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3
Q

Explain bilirubin metabolism

A

In complete biliary obstruction or severe intrahepatic cholestasis -> conjugated bilirubin leaks out and appears in urine -> Giving tea-colored urine and clay-colored stool (due to lack of formation of UROBILINOGEN)

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4
Q

State the composition of bile

A
  • Water
  • Phospholipids, electrolytes
  • Bile salts - cholic acid, chenodeoxycholic acid
  • Bile pigments - conjugated bilirubin
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5
Q

State the (4) functions of the gall bladder

A
  • Reservoir for bile
  • Concentration of bile -> active absorption of water, NaCl and HCO3 by mucus membrane of the gall bladder -> prevent gall bladder from being distended
  • Secretion of mucus
  • Gall bladder contraction stimulated by cholecystokinin (CCK), mediated by CHOLINERGIC VAGAL NEURONS

CCK half life = 2-3 minutes

Increase bile excretion - CKK, secretin, vagal input

Decrease bile excretion - somatostatin, sympathetic stimulation

Bile is normally neutral pH (But, increase in protein shifts bile to become acidic)

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6
Q

Define jaundice

A
  • It is defined as yellow pigmentation of the skin and eyes due to excess bilirubin in the circulation
  • Clinically detected if serum bilirubin levels >40 micromol/L
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7
Q

State Courvoisier’s law

A

In patients with a palpable enlarged gall bladder and painless jaundice, the cause is unlikely to be stone - malignancy until proven otherwise

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8
Q

What are the (5) exception that Courvoisier’s law doesn’t apply?

A
  • Mirizzi’s syndrome - stones in the Hartmann’s pouch
  • Double impaction - stones occluding cystic duct and distal CBD
  • Oriental cholangiohepatitis - ductal stones form secondary to liver fluke infestation
  • Congenital choledochal cyst
  • Common hepatic duct obstruction
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9
Q

State the cause of obstructive jaundice based on the following:

Commonest cause
Painful obstructive jaundice
Painless obstructive jaundice

A

Commonest causes = gallstones, tumour, hepatitis

Painful obstructive jaundice = choledocolithiasis (+/- cholangitis), strictures, hepatic cause

Painless obstructive jaundice = PERIAMPULLARY TUMOUR

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10
Q

Give 3 differentials for post-operative jaundice

A
  • Retained CBD stones
  • Post-op biliary leak
  • Injury to CBD +/- stricture formation
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11
Q

Define cholelithiasis

A

Refers to the presence of stone in the gall bladder

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12
Q

List the types of stones present in cholelithiasis with its corresponding incidence

A
  1. Cholesterol stone (85%)
  2. Pigment stone (15%)
    - Black (sterile) gall stones -> Hard
    - Brown (infected) gall stones -> Soft
    - Mixed
    - Biliary sludge
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13
Q

Describe on cholesterol gallstones based on the following
1. Radiolucent or radio-opaque
2. Risk factors
3. Pathophysiology

A
  • Radiolucent
  • Associated with 4F (Fat, Female, Forty, Fertile - estrogenic influence)

Pathophysiology:
- Increased cholesterol secretion in bile
- Decreased emptying of the gallbladder

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14
Q

Describe on black (sterile) gallstones based on the following:
1. Radiolucent or radio-opaque
2. Composed of
3. Pathophysiology

A
  • Radio-opaque
  • Composed of calcium salts (hard, speculated and brittle)

Pathophysiology:
- Increased secretion of bilirubin conjugates into bile
- Gallbladder hypomotility
- Decreased bilirubin solubilizes and bile stasis

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15
Q

Describe on brown (infected) gallstones based on the following:
1. Radiolucent or Radio-opaque
2. Composed of
3. Pathophysiology

A
  • Radio-opaque -> formed in intra and extra-hepatic duct
  • Composed of calcium salts and bacterial cell bodies

Pathophysiology:
- Infection - Enteric bacteria (E.coli, Klebsiella)
- Biliary stasis

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16
Q

What is biliary sludge?

A
  • Microlithiasis suspended in bile
  • Can be visualized on US scan
  • Sludge is a pre-stone condition

20% of biliary sludge will disappear

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17
Q

Describe the biliary colic symptoms of cholelithiasis using SOCRATES

A

Site = Epigastric (70%) or RHC pain

Onset = usually occurs within hours of eating a meal

Character = waxing and waning character

Radiation = inferior angle of scapula or tip of right shoulder

Timing = distinct attack lasting 30 minutes to several hours

Associated symptoms =
- Patient gets better after vomiting
- Bloating, abdominal distension
- Back pain, LUQ pain

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18
Q

List the complicated conditions of cholelithiasis (In the gallbladder)

A
  • Hydrops of gall bladder
  • Acute calculous cholecystitis -> acute gangrenous cholecystitis / empyema of the gallbladder
  • Porcelain gallbladder / chronic cholecystitis -> Increase risk of gall bladder cancer
  • Gallbladder cancer
  • Mirizzi’s syndrome
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19
Q

List the complicated conditions of cholelithiasis (In the common bile duct)

A

CHOLEDOCHOLITHIASIS leading to
- Obstructive jaundice
- Ascending cholangitis
- Secondary biliary cirrhosis
- Gallstone pancreatitis

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20
Q

List the complicated conditions of cholelithiasis (In the gut)

A
  • Cholecystoenteric fistula formation -> Intestinal obstruction/gallstone ileus
  • BOUVERET SYNDROME -> GOO (rare)
  • Gallstone dyspepsia (non-ulcer dyspepsia) - fatty food intolerance, dyspepsia, flatulence
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21
Q

State the triad of gallstone ileus

A
  • Gastric/small bowel dilatation
  • Pneumobilia (Presence of gas in the biliary system)
  • Intraluminal gallstone on CT
22
Q

State what you would see on abdominal X-ray for gallstone ileus

Hint = RIGLER’S TRIAD

A

RIGLER’S TRIAD
- Distended small bowel loops
- Air in the biliary tree
- Radio-opaque stone in the right lower quadrant (rare)

23
Q

Which is the most common site of obstruction for gallstone ileus?

A

Terminal ileum (2 feet proximal to ileocecal valve)

24
Q

What imaging studies would you order for a case of cholelithiasis?

A
  • Plain abdominal X-ray
  • US scan (Investigation of choice) -> Shows strong echogenic rim around the stone + posterior acoustic shadowing
  • MRCP
  • ERCP -> If therapeutic indication is needed

ERCP
1. Stone removal (using FOGARTY-BALLOON CATHETER or DORMIA WIRE BASKET)
2. Sphincterotomy
-> to relieve obstruction or facilitate removal of stone
3. Stenting

25
Q

What is the management for patient who are asymptomatic in a case of cholelithiasis?

A
  • No surgery indicated unless patient has indications
  • Dietary modifications (avoid fat and large meals)
  • Counsel patient about symptoms

Indication for surgery:
1. Increased risk of malignancy
2. Chronic hemolytic disease

26
Q

What are the indications for surgery in symptomatic cholelithiasis patient?

A
  • Abdominal pain with US proven sludge/stones/cholesterolosis/adenomyomatosis
  • Recurrent attacks
  • Typical biliary colic symptoms
  • Pain radiating to the back
  • Positive response to simple analgesics
27
Q

What is the definitive treatment for symptomatic cholelithiasis patient?

A

Elective laparoscopic cholecystectomy

28
Q

State the 5 criterias for a normal cholangiogram

A
  • Normal intrahepatic ducts
  • No filling defects
  • Smooth common bile duct
  • No strictures/narrowing of the common bile duct
  • Good and free flow of contrast into duodenum
29
Q

Define acute calculous cholecystitis

A

It is defined as inflammation of the gallbladder

30
Q

Explain about the pathophysiology of acute calculous cholecystitis

A
  • Obstruction of cystic duct by gallstone or biliary sludge
  • Increased intraluminal pressure within the gallbladder
  • Compromise blood supply and lymphatic drainage
  • Mucosal ischemia and necrosis

Also, trauma caused by gallstones -> stimulates prostaglandin -> mediates inflammation

31
Q

On physical examination, what are the positive findings for a case of acute cholecystitis?

A
  • General -> ill-looking, lying still
  • Mild jaundice
  • Vitals -> febrile, tachycardia

Abdomen
- RHC tenderness with guarding
- Murphy’s sign POSITIVE
- Boas’s sign (Hyperaesthesia below the right scapula)
- Palpable gallbladder (30%)

Hyperaesthesia -> Hypersensitivity in your sense of touch

32
Q

What features of acute cholecystitis can be seen on Ultrasound HBS?

A
  • Thickened gallbladder wall
  • Sonographic Murphy’s positive
  • Pericholecystic fluid (edema of gallbladder wall)
  • Presence of gallstones in the biliary system
  • Contracted gallbladder (from chronic gallstone disease)
33
Q

What are the features of grade 2 or moderate acute cholecystitis?

A
  • Elevated total white >18k
  • Palpable tender mass in RUQ
  • Duration of complaints >72hrs
  • Marked local inflammation
34
Q

What are the features of grade 3 or severe acute cholecystitis?

A

Associated with ORGAN DYSFUNCTION

35
Q

What guideline do we use to diagnose a case of acute cholecystitis?

A

2013/2018 TOKYO GUIDELINES

36
Q

List the conservative, definitive and alternative treatment of acute cholecystitis

A

Conservative
- Assess patient’s vitals and resuscitate the patient if needed
- Septic workup
- Analgesia
- Empirical IV antibiotics -> IV CEFTRIAXONE & METRONIDAZOLE
- NBM - bowel rest
- Careful monitoring for signs of failure of conservative management

Definitive -> LAPAROSCOPIC CHOLECYSTECTOMY KIV OPEN

Alternative/Immediate treatment -> PERCUTANEOUS CHOLECYSTECTOMY (TRANS-PERITONEAL & TRANS-HEPATIC)
- Indications:
1. Patient who are not fit for surgery
2. When early surgery is difficult due to extensive inflammation, gangrenous gallbladder with thin wall
- Bile cultures should be obtained and sent for culture
- Keep cholecystectomy tube till mature fistula tract is formed

37
Q

What 4 factors determine the timing of cholecystectomy?

A
  • Timing of presentation
  • Severity of illness
  • Response to resuscitation and antibiotic therapy
  • Logistical consideration (Availability of OT, surgeon etc…)
38
Q

List (5) complications of acute cholecystitis.

A
  • Hydrops
  • Empyema
  • Emphysematous cholecystitis
  • Gangrene and perforation
  • Cholecystoenteric fistula
  • Gallstone ileus
39
Q

State (4) risk factors for acute acalculous cholecystitis

A
  • Critically ill patients
  • Sepsis with hypotension
  • Extensive burns, multiple trauma
  • Patients on total parenteral nutrition -> lead to biliary stasis
40
Q

State the clinical presentation of acute acalculous cholecystitis

A
  • Insidious onset
  • GB necrosis, gangrene and perforation

Higher rates of GANGRENOUS CHOLECYSTITIS (31%)

41
Q

Define choledocholithiasis

A

Presence of gallstones in the CBD

42
Q

State 2 standard of care approaches for choledocholithiasis

A
  1. ERCP sphincterotomy and stone removal -> Laparoscopic cholecystectomy
  2. Common bile duct exploration (CBDE)
43
Q

What are the indications for ERCP with sphincterotomy and stone removal?

A
  • Pre-op for ductal clearance before surgery
  • Patients who are not fit for surgery
  • Prior cholecystectomy
  • Post-op for ductal clearance
44
Q

List the (4) therapeutic procedure that an ERCP would offer

A
  • Sphincterotomy
  • Stone extraction
  • Stricture dilatation
  • Stenting
45
Q

Classify perforation from ERCP based on STAPFER CLASSIFICATION

A
46
Q

Define Mirizzi’s syndrome

A
  • Common hepatic duct obstruction secondary to extrinsic compression from an impacted gallstone in the cystic duct or infundibulum of the gallbladder
47
Q

List the US findings in a case of Mirizzi’s syndrome

A
  • Dilatation of biliary system above the level of gallbladder neck
  • Presence of stone impacted in gallbladder neck
  • Abrupt change to normal diameter of common duct below the level of the stone
48
Q

Classify Mirizzi’s syndrome based on Csendes classification.

A
49
Q

State the management of Mirizzi’s syndrome.

A

Grade 1 = Laparoscopic cholecystectomy

Grade 2 - 4 = Open cholecystectomy with CBD exploration

50
Q

Define cholangitis

A

A life-threatening ascending bacterial infection of the BILIARY TREE, associated with partial or complete obstruction of the ductal system

51
Q

State (5) etiology of cholangitis

A
  • Choledocholithiasis (28-70%)
  • Benign biliary strictures
  • Malignancy
  • Foreign bodies/previous instrumentation (ERCP)
  • Others - Mirizzi’s syndrome

Surgery (13 decks)

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