SR 54 - Biliary Tract Flashcards
Which is the proximal and which is the distal bile duct?
Proximal is close to the liver
What is in Calot’s triangle?
Calot’s nodes
What are the small ducts that drain bile directly into the gallbladder from the liver?
Ducts of Luschka
What artery is at risk during cholecystectomy?
Right hepatic artery
close to cystic artery and Calot’s triangle
What is the name of the valves of the gallbladder?
Spiral valves of Heister
Where is the infundibulum of the gallbladder?
Near the cystic duct
Where is the fundus of the gallblader?
At the top end of the gallbladder
What are the boundaires of the triangle of Calot?
Cystic duct
Common hepatic duct
Cystic artery (newer - liver edge)
What is the source of alkaline phosphatase?
Bile duct epithelium
Thus, elevated in duct obstruction
What is in bile?
Cholesterol
Lecithin (phospholipid)
Bile acids
Bilirubin
What does bile do?
Emulsifies fats
Where is bile absorbed?
Terminal ileum
What stimulates gallbladder emptying?
CCK
Vagal input
What is the source of CCK?
Duodenal mucosal cells
What stimulates the release of CCK?
Fat, protein, AA and HCl in duodenum
and antral stretch
What inhibits release of CCK?
Trypsin
Chymotrypsin
What are the actions of CCK?
Gallbladder emptying
Opening of ampulla of Vater
Slowing of gastric emptying
Pancrease acinar cell growth and release of exocrine products
What level of bilirubin does a patient become jaundiced?
> 2.5
Where is the first anatomical location that you see evidence of jaundice?
Under the tongue
With good renal function, how high can bilirubin go?
Rarely >20
Signs and symptoms of obstructive jaundice?
Jaundice Dark urine Clay-color stools (acholic stools) Pruritis Loss of appetite Nausea
What causes itching in obstructive jaundice?
Bile salts in teh dermis
Define Klastkin’s tumor
Cholangiocarcionma of bile duct at the junction of the right and left hepatic ducts
Define Biliary colic
Pain from gallstones
RUQ, epigastrum or right subscapular region
Lasts minutes to hours
Often postprandial, especially with fatty foods
Define Biloma
Intraperitoneal bile fluid collection
Initial diagnostic studry for evaluation of billary tract?
US
Define ERCP
Endoscopic retrograde cholangiopancreatography
Define PTC
Percutaneous transhepatic cholangiogram
Define IOC
Intraoperative cholangiogram (to rule out choledocholithiasis)
Define HIDA/PRIDA scan
Radioisotope study
Isotope is concentrated in the liver and secreted into bile
Demonstrates cholecystitis, bile leak or CBD obstruction
How often will plain x-ray film see gallstones?
10-15%
What is the Kocher incision?
Right subcostal incision
What is a sphincterotomy?
Cut through the sphinchter of Oddi to allow passage of gallstones from the CBD
AKA papillotomy
How do you treat post-op biloma after a lap-chole?
Percutaneous drain bile collection
ERC with placement of biliary stent
What is the treatment of major CBD injury after lap chole?
Choledochoejunostomy
DDx of proximal bile duct obstruction?
Cholangiocarcinoma Lymphadenopathy Metastatic tumor Gallbladder carcinoma Sclerosing cholangitis Gallstones Tumor embolus Parasites Postsurgical stricture Hepatoma Benign bile duct tumor
DDx of distal bile duct obstruction?
Choledocholithiasis (gallstones) Pancreatic carcinoma Pancreatitis Ampullary carcinoma Lymphadenopathy Pseudocyst Postsurgical stricture Ampulla of Vater dysfunction/stricture Lyphoma Benign bile duct tumor Parasites
Initial study of choice for obstructive jaundcce?
US
Labs associated with obstructive jaundice?
Elevated alk-phos
Elevated bilirubin
+/- elevated LFTs
Risk factors for cholelithiasis?
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
What are black stones made of?
Calcium bilirubinate
Cirrhosis, hemolysis
What are brown stones made from?
Biliary tract infections
Complications of gallstones?
Acute cholecystitis Choledocholithiasis Gallstone pancreatitis Gallstone ileus Cholangitis
Possible complications of lap-chole?
Common bile duct injury
Right hepatic duct/artery injury
Cystic duct leak
Biloma
Indications for cholecystectomy in asymptomatic patient?
Sickle-cell disease
Calcified gallbladder*
Child
What are indications for IOC?
Jaundice Hyperbilirubinemia Gallstone pancreatitis (Resolved) Elevated alkaline phosphatase Choledocholithiasis on ultrasound To define anatomy
How do you manage choledocholithiasis?
ERCP with papillotomy and basket/balloon retrieval of stones
Laparoscopic trancystic duct or trans common bile duct retrieval
Open common bile duct exploration
What medication may dissolve cholesterol gallstones?
Chenodeoxycholic acid
Ursodeoxycholic acid
Major feared complication of ERCP?
Pancreatitis
Signs and symptoms of acute cholecystitis?
Unrelenting RUQ pain/tenderness Fever Nausea/vomiting Painful, palpable gallbladder (33%) Postiive MUrphy's signs Right subscapular pain Epigastric discomfort
Complications of acute cholecystitis?
Abscess Perforation Choledocholithiasis Cholecysteneric fistula formation Gallstone ileus
Labs associated with acute cholecystitis?
Increased WBC
Slight elevation in alk-phos
Slight elevation in LFTs, amylase, T. bili
Signs of acute cholecystitis on US?
Thickened gallbladder wall (>3mm) Pericholecystic fluid Distended gallbladder Gallstones present/cystic duct stone Sonographic Murphy's sign
Treatment of acute cholecystitis?
IVF
Antibiotics
Cholecystectomy
What percentage of patients have an accessory cystic artery?
10%
Why would you open the gallbladder in the operating room?
Looking for cancer
To determine anatomy
What is acute acalculous cholecystitis?
Acute cholecystitis without gallstones
Due to bile stasis
Risk factors for acalculous cholecystitis?
Prolonged fasting TPN Trauma Multiple transfusions Dehydration Prolonged post-op or ICU setting
Diagnostic tests for acalculus cholecystitis?
US
HIDA (non-filling)
Management of acalculus cholecystitis?
Cholecystectomy Cholecystomy tube (if unstable)
What is cholangitis?
Bacterial infection of the biliary tract
Associated with obstruction
What are common causes of cholangitis?
Choledocholithiasis Stricture (post-op) Neoplasm (ampullary carcinoma) Extrinsic compression (pseudocyst, pancreatitis) Instrumentation of the bile ducts Biliary stent
Most common cause of cholangitis?
Gallstones in the CBD
Signs and symptoms of cholangitis?
Charcot’s triad - Fever/chills, RUQ pain, jaundice
Reynold’s pentad - Alterted mental status, Shock
Labs associated with cholangitis?
Increased WBCs, bilirubin, alk-[hos
Positive blood cultures
Most common organisms with cholangitis?
G- (E. coli, Klebsiella, Psuedomonas, Enterobacter, Proteus, serratia)
G+ (enterococci)
Anarobes - less common (B. fragilis)
Fungi - rare (Candida)
Management of nonsuppurative cholangitis?
IVF
Antibiotics
Definitive treatment treatment later (lap-chole, ERCP)
Managment of suppurative cholangitis?
IVF
Antibiotics
Decompression - ERCP with papillotomy; PTC with catheter drainage; laparotomy with T-tube placement
What is sclerosing cholangitis?
Mulitple inflammatory fibrou thickening of bile duct walls resulting in biliary strictures
What is the natural history of sclerosing cholangitis?
Progressive obstruction leading to eventual cirrhosis and liver failure
10% develop cholangiocarcinoma
Major risk factor for sclerosing cholangitis?
IBD - 66% ulcerative colitis
Signs and symptoms of sclerosing cholangitis?
Obstructive jaundice
Complications of sclerosing cholangitis?
Cirrhosis
Cholangiocarcinoma
Cholangitis
Obstructive jaundice
How do you diagnose sclerosing cholangitis?
Elevated Alk-phos
PTC/ERCP revealing ‘beads on a string’ appearance on contrast study
How do you manage sclerosing cholangitis?
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
What is gallstone ileus?
Small bowel obstruction from large gallstone (>2.5cm) that has eroded through the gallbladder and into the duodenum/small bowel
What is the classic site of obstruction in gallstone ileus?
Ileocecal valve
Flextures, brim of the pelvis
Classic findings of gallstone ileus?
Air in hepatic bile ducts
SBO with air fluid levels
Gallstone in ileocecal valve
Signs/symptoms of gallstone ileus?
SBO - distention, vomiting, hypovolemia, RUQ pain
What is carcinoma of the gallbladder?
Malignant neoplasm
Most are adenocarcinoma
Risk factors for gallbladder carcinoma?
Gallstones
Porcelain gallbladder
Cholecysenteric fistula
What percentage of patients with a porcelain gallbladder have gallbladder cancer?
50%
Symptoms of gallbladder cancer?
Biliary colic Weight loss Anorexia Asymptomatic until late May present as acute cholecysitis
What are the signs of gallbladder cancer?
Jaundice (invasion of CBD compression by LNs)
RUQ mass
Palpable gallbladder (late)
Management of gallbladder cancer that is confined to the mucousa?
Cholecystectomy
Managment of gallbladder cancer confided to muscularis/serosa?
Radial cholecystectomy
Main complicatio of a lap chole for gallbladder cancer?
Trocar site tumor implants
if the diagnosis is know presurgery - do an open approach
What is cholangiocarcinoma?
Malignancy of extrahepatic or intrahepatic ducts
Adenocarcinoma
Signs and symptoms of cholangiocarcinoma?
Biliary obstruction (aundice, pruritis, dark urine, clay-colored stools, cholangitis)
Most common location for cholangiocarcinoma?
Proximal bile duct
What are the risk factors for cholangiocarcinoma?
Choledochal cysts UC Thorotrast contrast dye (1950s) Sclerosing cholangitis Liver flukes (clonorchiasis) Toxin exposures (i.e. Agent orange)
What is hydrops of the gallbladder?
Complete obstruction fo teh cystic duct
Filling of the gallblader with fluid from gallbladder mucosa
What is Gilbert’s syndrome?
Error in liver bilirubin uptake and glucuronyl transferase resulting in hyperbilirubinemia
What is Courvoisier’s gallbladder?
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)
What is Mirizzi’s syndrome?
Common hepatic duct ostruction due to extrinsic compression from a gallstone impacted in the cystic duct
