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Surgical Recall > SR 54 - Biliary Tract > Flashcards

SR 54 - Biliary Tract Flashcards

1
Q

Which is the proximal and which is the distal bile duct?

A

Proximal is close to the liver

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2
Q

What is in Calot’s triangle?

A

Calot’s nodes

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3
Q

What are the small ducts that drain bile directly into the gallbladder from the liver?

A

Ducts of Luschka

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4
Q

What artery is at risk during cholecystectomy?

A

Right hepatic artery

close to cystic artery and Calot’s triangle

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5
Q

What is the name of the valves of the gallbladder?

A

Spiral valves of Heister

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6
Q

Where is the infundibulum of the gallbladder?

A

Near the cystic duct

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7
Q

Where is the fundus of the gallblader?

A

At the top end of the gallbladder

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8
Q

What are the boundaires of the triangle of Calot?

A

Cystic duct
Common hepatic duct
Cystic artery (newer - liver edge)

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9
Q

What is the source of alkaline phosphatase?

A

Bile duct epithelium

Thus, elevated in duct obstruction

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10
Q

What is in bile?

A

Cholesterol
Lecithin (phospholipid)
Bile acids
Bilirubin

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11
Q

What does bile do?

A

Emulsifies fats

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12
Q

Where is bile absorbed?

A

Terminal ileum

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13
Q

What stimulates gallbladder emptying?

A

CCK

Vagal input

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14
Q

What is the source of CCK?

A

Duodenal mucosal cells

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15
Q

What stimulates the release of CCK?

A

Fat, protein, AA and HCl in duodenum

and antral stretch

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16
Q

What inhibits release of CCK?

A

Trypsin

Chymotrypsin

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17
Q

What are the actions of CCK?

A

Gallbladder emptying
Opening of ampulla of Vater
Slowing of gastric emptying
Pancrease acinar cell growth and release of exocrine products

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18
Q

What level of bilirubin does a patient become jaundiced?

A

> 2.5

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19
Q

Where is the first anatomical location that you see evidence of jaundice?

A

Under the tongue

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20
Q

With good renal function, how high can bilirubin go?

A

Rarely >20

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21
Q

Signs and symptoms of obstructive jaundice?

A 
Jaundice
Dark urine
Clay-color stools (acholic stools)
Pruritis
Loss of appetite
Nausea
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22
Q

What causes itching in obstructive jaundice?

A

Bile salts in teh dermis

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23
Q

Define Klastkin’s tumor

A

Cholangiocarcionma of bile duct at the junction of the right and left hepatic ducts

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24
Q

Define Biliary colic

A

Pain from gallstones
RUQ, epigastrum or right subscapular region
Lasts minutes to hours
Often postprandial, especially with fatty foods

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25
Q

Define Biloma

A

Intraperitoneal bile fluid collection

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26
Q

Initial diagnostic studry for evaluation of billary tract?

A

US

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27
Q

Define ERCP

A

Endoscopic retrograde cholangiopancreatography

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28
Q

Define PTC

A

Percutaneous transhepatic cholangiogram

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29
Q

Define IOC

A

Intraoperative cholangiogram (to rule out choledocholithiasis)

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30
Q

Define HIDA/PRIDA scan

A

Radioisotope study
Isotope is concentrated in the liver and secreted into bile
Demonstrates cholecystitis, bile leak or CBD obstruction

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31
Q

How often will plain x-ray film see gallstones?

A

10-15%

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32
Q

What is the Kocher incision?

A

Right subcostal incision

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33
Q

What is a sphincterotomy?

A

Cut through the sphinchter of Oddi to allow passage of gallstones from the CBD
AKA papillotomy

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34
Q

How do you treat post-op biloma after a lap-chole?

A

Percutaneous drain bile collection

ERC with placement of biliary stent

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35
Q

What is the treatment of major CBD injury after lap chole?

A

Choledochoejunostomy

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36
Q

DDx of proximal bile duct obstruction?

A 
Cholangiocarcinoma
Lymphadenopathy
Metastatic tumor
Gallbladder carcinoma
Sclerosing cholangitis
Gallstones
Tumor embolus
Parasites
Postsurgical stricture
Hepatoma
Benign bile duct tumor
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37
Q

DDx of distal bile duct obstruction?

A 
Choledocholithiasis (gallstones)
Pancreatic carcinoma
Pancreatitis
Ampullary carcinoma
Lymphadenopathy
Pseudocyst
Postsurgical stricture
Ampulla of Vater dysfunction/stricture
Lyphoma
Benign bile duct tumor
Parasites
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38
Q

Initial study of choice for obstructive jaundcce?

A

US

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39
Q

Labs associated with obstructive jaundice?

A

Elevated alk-phos
Elevated bilirubin
+/- elevated LFTs

40
Q

Risk factors for cholelithiasis?

A 
Female, fat, forty, fertile
Oral contraceptives
Bile stasis
Chronic hemolysis
Cirrhosis
Infection
Native American
Rapid weight loss/gastric bypass
Obesity
IBD
Terminal ileal resection
TPN
Vagotomy
Advanced age
Hyperlipidemia
Somatostatin therapy
41
Q

What are black stones made of?

A

Calcium bilirubinate

Cirrhosis, hemolysis

42
Q

What are brown stones made from?

A

Biliary tract infections

43
Q

Complications of gallstones?

A 
Acute cholecystitis
Choledocholithiasis
Gallstone pancreatitis
Gallstone ileus
Cholangitis
44
Q

Possible complications of lap-chole?

A

Common bile duct injury
Right hepatic duct/artery injury
Cystic duct leak
Biloma

45
Q

Indications for cholecystectomy in asymptomatic patient?

A

Sickle-cell disease
Calcified gallbladder*
Child

46
Q

What are indications for IOC?

A 
Jaundice
Hyperbilirubinemia
Gallstone pancreatitis (Resolved)
Elevated alkaline phosphatase
Choledocholithiasis on ultrasound
To define anatomy
47
Q

How do you manage choledocholithiasis?

A

ERCP with papillotomy and basket/balloon retrieval of stones
Laparoscopic trancystic duct or trans common bile duct retrieval
Open common bile duct exploration

48
Q

What medication may dissolve cholesterol gallstones?

A

Chenodeoxycholic acid

Ursodeoxycholic acid

49
Q

Major feared complication of ERCP?

A

Pancreatitis

50
Q

Signs and symptoms of acute cholecystitis?

A 
Unrelenting RUQ pain/tenderness
Fever
Nausea/vomiting
Painful, palpable gallbladder (33%)
Postiive MUrphy's signs
Right subscapular pain
Epigastric discomfort
51
Q

Complications of acute cholecystitis?

A 
Abscess
Perforation
Choledocholithiasis
Cholecysteneric fistula formation
Gallstone ileus
52
Q

Labs associated with acute cholecystitis?

A

Increased WBC
Slight elevation in alk-phos
Slight elevation in LFTs, amylase, T. bili

53
Q

Signs of acute cholecystitis on US?

A 
Thickened gallbladder wall (>3mm)
Pericholecystic fluid
Distended gallbladder
Gallstones present/cystic duct stone
Sonographic Murphy's sign
54
Q

Treatment of acute cholecystitis?

A

IVF
Antibiotics
Cholecystectomy

55
Q

What percentage of patients have an accessory cystic artery?

A

10%

56
Q

Why would you open the gallbladder in the operating room?

A

Looking for cancer

To determine anatomy

57
Q

What is acute acalculous cholecystitis?

A

Acute cholecystitis without gallstones

Due to bile stasis

58
Q

Risk factors for acalculous cholecystitis?

A 
Prolonged fasting
TPN
Trauma
Multiple transfusions
Dehydration
Prolonged post-op or ICU setting
59
Q

Diagnostic tests for acalculus cholecystitis?

A

US

HIDA (non-filling)

60
Q

Management of acalculus cholecystitis?

A 
Cholecystectomy
Cholecystomy tube (if unstable)
61
Q

What is cholangitis?

A

Bacterial infection of the biliary tract

Associated with obstruction

62
Q

What are common causes of cholangitis?

A 
Choledocholithiasis
Stricture (post-op)
Neoplasm (ampullary carcinoma)
Extrinsic compression (pseudocyst, pancreatitis)
Instrumentation of the bile ducts
Biliary stent
63
Q

Most common cause of cholangitis?

A

Gallstones in the CBD

64
Q

Signs and symptoms of cholangitis?

A

Charcot’s triad - Fever/chills, RUQ pain, jaundice

Reynold’s pentad - Alterted mental status, Shock

65
Q

Labs associated with cholangitis?

A

Increased WBCs, bilirubin, alk-[hos

Positive blood cultures

66
Q

Most common organisms with cholangitis?

A

G- (E. coli, Klebsiella, Psuedomonas, Enterobacter, Proteus, serratia)
G+ (enterococci)
Anarobes - less common (B. fragilis)
Fungi - rare (Candida)

67
Q

Management of nonsuppurative cholangitis?

A

IVF
Antibiotics
Definitive treatment treatment later (lap-chole, ERCP)

68
Q

Managment of suppurative cholangitis?

A

IVF
Antibiotics
Decompression - ERCP with papillotomy; PTC with catheter drainage; laparotomy with T-tube placement

69
Q

What is sclerosing cholangitis?

A

Mulitple inflammatory fibrou thickening of bile duct walls resulting in biliary strictures

70
Q

What is the natural history of sclerosing cholangitis?

A

Progressive obstruction leading to eventual cirrhosis and liver failure
10% develop cholangiocarcinoma

71
Q

Major risk factor for sclerosing cholangitis?

A

IBD - 66% ulcerative colitis

72
Q

Signs and symptoms of sclerosing cholangitis?

A

Obstructive jaundice

73
Q

Complications of sclerosing cholangitis?

A

Cirrhosis
Cholangiocarcinoma
Cholangitis
Obstructive jaundice

74
Q

How do you diagnose sclerosing cholangitis?

A

Elevated Alk-phos

PTC/ERCP revealing ‘beads on a string’ appearance on contrast study

75
Q

How do you manage sclerosing cholangitis?

A 
Hepatoenteric anastomosis (if extrahepatic ducts are pimarily involved) and resection of extrahepatic ducts due to risk of cholangiocarcinoma
Transplant (primarily intrahepatic or cirrhosis)
Endoscopic ballon dilation
76
Q

What is gallstone ileus?

A

Small bowel obstruction from large gallstone (>2.5cm) that has eroded through the gallbladder and into the duodenum/small bowel

77
Q

What is the classic site of obstruction in gallstone ileus?

A

Ileocecal valve

Flextures, brim of the pelvis

78
Q

Classic findings of gallstone ileus?

A

Air in hepatic bile ducts
SBO with air fluid levels
Gallstone in ileocecal valve

79
Q

Signs/symptoms of gallstone ileus?

A

SBO - distention, vomiting, hypovolemia, RUQ pain

80
Q

What is carcinoma of the gallbladder?

A

Malignant neoplasm

Most are adenocarcinoma

81
Q

Risk factors for gallbladder carcinoma?

A

Gallstones
Porcelain gallbladder
Cholecysenteric fistula

82
Q

What percentage of patients with a porcelain gallbladder have gallbladder cancer?

A

50%

83
Q

Symptoms of gallbladder cancer?

A 
Biliary colic
Weight loss
Anorexia
Asymptomatic until late
May present as acute cholecysitis
84
Q

What are the signs of gallbladder cancer?

A

Jaundice (invasion of CBD compression by LNs)
RUQ mass
Palpable gallbladder (late)

85
Q

Management of gallbladder cancer that is confined to the mucousa?

A

Cholecystectomy

86
Q

Managment of gallbladder cancer confided to muscularis/serosa?

A

Radial cholecystectomy

87
Q

Main complicatio of a lap chole for gallbladder cancer?

A

Trocar site tumor implants

if the diagnosis is know presurgery - do an open approach

88
Q

What is cholangiocarcinoma?

A

Malignancy of extrahepatic or intrahepatic ducts

Adenocarcinoma

89
Q

Signs and symptoms of cholangiocarcinoma?

A

Biliary obstruction (aundice, pruritis, dark urine, clay-colored stools, cholangitis)

90
Q

Most common location for cholangiocarcinoma?

A

Proximal bile duct

91
Q

What are the risk factors for cholangiocarcinoma?

A 
Choledochal cysts
UC
Thorotrast contrast dye (1950s)
Sclerosing cholangitis
Liver flukes (clonorchiasis)
Toxin exposures (i.e. Agent orange)
92
Q

What is hydrops of the gallbladder?

A

Complete obstruction fo teh cystic duct

Filling of the gallblader with fluid from gallbladder mucosa

93
Q

What is Gilbert’s syndrome?

A

Error in liver bilirubin uptake and glucuronyl transferase resulting in hyperbilirubinemia

94
Q

What is Courvoisier’s gallbladder?

A

Palpable, nontender gallbladder
Associated with cancer of the head of teh pancreas
Able to distend due to lack of scaring (versus obstruction associated with gallstones)

95
Q

What is Mirizzi’s syndrome?

A

Common hepatic duct ostruction due to extrinsic compression from a gallstone impacted in the cystic duct

Surgical Recall (32 decks)

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