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DVG Gallbladder
Gallbladder questions from de Virgilio
52
Medical
Professional
11/19/2013

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Term
Triad of hemobilia
Definition
UGI bleeding (hematemesis), RUQ pain, and jaundice
Term
Underlying lesion of hemobilia
Definition
arterial psuedoaneurysm with connection to the biliary tree
Term
Proposed etiology of choledochal cysts
Definition
anamalous pacreaticobiliary duct jxn whereby there is a long course from the jxn to the ampula
Term
Most common type of choledochal cyst
Definition
Type I: fusiform dilation of the bile duct
Term
Main reason to treat and method of treatment of choledochal cysts
Definition
malignant degeneration and by a biliary enteric bypass
Term
Purpose of routine IOC and alternative
Definition
Prevent CBD transection and obtaining a clean critical view
Term
Management of small lateral CBD injury vs a transection
Definition
Repair a small lateral injury by closing the dochotomy over a t-tube
Repair CBD transection with a biliary-enteric bypass either immediately (if recognized intra-op) or delayed; if delayed, must drain hepatic ducts.
Term
Gallbladder functions
Definition
1) actively absorbs Na and Cl; passively absorbs water
2) epithelial cells secrete mucus, glycoproteins and acidifies bile to make calcium salts more soluble
3) Stimulated to contract by vagal innervation
Term
5 yr survival of gallbladder cancer
Definition
~5%
Term
Managment of gallbladder cancer
Definition
# if in situ or T1 (not extending into perimuscular CT or invading the liver) and has negative margins: CCY alone
# if invades the peri-muscular CT or liver (T2-T4): radical CCY (IVb and V segmentectomies, hepatoduodenal lymphadenectomy
Term
Post-operative management of cholangiocarcinoma
Definition
5-FU
Term
What is a Klatskin Tumor and various subtypes
Definition
Perihilar cholangiocarcinomas
Type I: limited to the common hepatic duct
Type II: involve the bifurcation the R and L hepatic ducts
Type III: enter the secondary right (IIIa) or secondary left (IIIb) intrahepatic ducts
Term
Treatment for Klatskin Tumor
Definition
Type I and II: resection of extrahepatic biliary tree, portal lympadenectomy and B/L hepatico-j's
Type III: lobectomy or hemi-hepatectomy to achieve negative margins
Distal CBD tumor: Whipple
Unresectable dz: 5FU +/- mitomycin C and doxorubicin
Term
Epidemiology of emphasemytous cholecystitis
Definition
# Predominantly elderly diabetic men
# gangrene present in 75%
# perforation in 25%
Term
Bacteria involved in emphysematous cholecystitis
Definition
Clostridia welchii
E. Coli
Enterococcus
Klebsiella
Term
Components of bile
Definition
Bile Salts- 80%; phospholipids-15%; and cholesterol- 5%
Term
Pneumobilia
Definition
Gallstone ileus
Term
Management of fistula in gallstone ileus
Definition
takedown and repair in young and healthy; interval repair in elderly
Term
Aschoff-Rokitansky sinuses
Definition
THe sinuses created when, as a result of the atrophy of the mucosa in chronic cholecystitis, the mucosa potrude into the muscular coat creating the sinuses
Term
Pathophys of acalculus cholecystitis
Definition
Low flow state to the GB -> marked GB distension -> bile stasis 2/2 to lack of contraction (many pts on TPN);
Term
Signs of Acalculous Cholecystitis
Definition
1. Fever
2. Leukocytosis
3. RUQ pain
4. elevated bili and alk phos
5. Thickened GB on US w/o stones
6. nonvisualization of the GB on HIDA
Term
2 types of stones
Definition
Cholesterol or Pigment (Brown or Black)
Term
What are black gall stones and where do they form?
Definition
hemolytic disorder (hereditary spherocytosis and sickle cell) and in the GB
Term
What are brown gall stones and where to they form?
Definition
Associated with parasytic infections and bacteria in the bile; they are formed within the bile ducts
Term
Important risk factors for GB cancer
Definition
1. Female gender (2-3x more common than males)
2. Native American
3. Large gall stones
4. Carcinogens: azotoluene, nitrosamines
5. Calcified GB: only in selective mucosal calcification
Term
Most common presentation of bile duct stricture
Definition
cholangitis
Term
Most common location of iatrogenic bile duct strictures
Definition
Common hepatic duct distal to the confluence of the R and L hepatic ducts
Term
Most common cause of benign bile duct strictures and mechanism of injury
Definition
Iatrogenic injury during CCY; aggressive dissection near CBD
Term
W/u for painless jaundice
Definition
LFTs, RUQ US (dilated ducts proximal to stricture), CT scan (for massses), ERCP with endoscopic ultrasound (brushings for cytology)
Term
Management of benign focal stricture of bile duct
Definition
Biliary-enteric bypass (more invasive) vs. stening (risk of obstructing)
Term
Types of choledochal cysts
Definition
I: dilation of either the entire common hepatic duct and CBD or a segment
II: diverticula that project from the CBD wall
III: in the intraduodenal portion of the CBD
IVa: multiple dilations of intrahepatic and extrahepatic biliary tree
IVb: multiple dilations of only the extrahepatic duct
V: dilations of the intrahepatic biliary tree (Caroli Dz)
Term
Caroli Dz
Definition
Dilations of the intrahepatic biliary tree (type V choledochal cysts)
Term
Strawberry GB and management
Definition
Liver hypersecretion of cholesterol -> excessive accumulation of cholesterol esters with in the lamina propria of the GB -> phagocytosis by macrophages in the mucosa gives it strawberry-like appearance; no surgery necessary
Term
Adenomyomatosis and management
Definition
hypertrophic smooth muscle bundles and the in growth of the mucosal glands into the muscle layer; no surgery necessary
Term
Jaundice with absent urobilinogen in the urine
Definition
Biliary obstruction
Term
Effect of biliary obstruction on stool
Definition
Less bilirubin enters urobilinogen is made, less stercobilin in made and stool appears pale
Term
Indications for pre-Whipple biliary drainage and stenting
Definition
Cholangitis or intractable pruritis
Term
Risks a/w pre-Whipple biliary drainage
Definition
Wound infection and pancreatic fistula
Term
Indications for CCY when polyp is found on US
Definition
1. symtomatic polyp
2. polyp a/w gallstones
3. polyp > 10 mm
4. age older than 50
Term
Types of polypoid lesions of the GB
Definition
- pseudo polyps (cholesterol polyps, adenomyomatosic polyps, inflammatory) multiple, pedunculated and small (< 10mm) are benign
- Adenomas/adenocarcinomas (larger than 10 mm)
Term
Factors a/w with a higher conversion rate from lap to open
Definition
1. ASA class 2. GB wall > 4mm 3. previous surgery 4.Advanced age 5. male gender
Term
Longer hepatic duct and one more likely to be dilated in presence of distal obstruction
Definition
Left hepatic duct
Term
Percentage of people in which the CBD and pancreatic duct unite outside the duodenal wall and traverse the wall as one duct
Definition
0.75
Term
Source and location of CBD blood supply
Definition
Right hepatic and GDA; runs in the 3 and 9 o'clock positions
Term
Method of repair of a bile duct injury
Definition
If small and longitudinal injury in large CBD or hepatic duct -> primary repair over a t-tube; if transverse, RNY hepatico-jej; if distal CBD, can do choledochal duodenostomy
Term
Pathogenesis, natural hx and management of hydrops of the GB
Definition
a stone becomes impacted in cystic duct w/o acute chole, bile within GB is absorbed, but the GB epithelium continues to secrete mucus eventually leading to a GB distended with mucinous material (hydrops); possible GB wall edema and perforation; Cholecystectomy to avoid complications
Term
Percentage of gallstones that are pure cholesterol
Definition
0.1
Term
Percentage of gallstones that are radio-opaque
Definition
0.15
Term
Cause and source of pigment in pigment gallstones
Definition
Hemolysis which leads to a build up of calcium bilirubinate
Term
Difference b/w brown and black pigmented gallstones
Definition
Both are pigment stones but brown stones are a/w bacterial and parasytic infxs
Term
Cholangiohepatitis AKA pyogenic cholangitis:
# presentation
# pathogenesis
# natural hx
# management
Definition
# Fever + RUQ pain + jaundice + elevated WBC + ALP and tbili with dilated CBD, intrahepatic ducts, multiple strictures and stones on MRCP
# Bacteria deconjugate bilirubin in the biliary tree which precipitates as sludge which combines with dead bacteria to form brown stones; Stones usually harbor parasite egg (Clonorchis sinensis, Opisthorchis viverrini and Ascaris lumbricoides);
# Recurrent cholangitis, liver abscesses, structures, liver failure and increased risk of cancer
# ERCP + transhepatic cholangiography, eventually may need biliary-enteric bypass
Term
Benefit of early ( within 24 hrs of admission) vs. late lap chole
Definition
Same conversion to open rates, same complication rate, bile duct injury rate, and mortality;
Early lap choles have shorter hospital stays
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