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Gallbladder and biliary system 2019 absite
- 1. Gallbladder and Biliary System ABSITE REVIEW 2019
- 3. Most common duct anomaly? Right sectoral ducts draining directly into the CBD
- 4. Arterial anomalies “Replaced”: substitute for the normal one “Accessory”: in addition to the normal one Replaced right hepatic: from the SMA Replaced left hepatic: from the LEFT Gastric A.
- 6. CBD size Normal: 4-6mm Add 1mm per decade over 50 years of age Enlarges after cholecystectomy
- 7. Bile facts Daily amount: 600 to 1,000mL Primary bile acids: Cholic & Chenodeoxycholic acids Synthesized in the liver by what enzyme?: 7-alpha-hydroxylase Conjugated with what amino acids? Glycine or Taurine Reabsorption occurs where?: Terminal ileum Bilirubin is a breakdown product of?: Biliverdin (from heme)
- 8. Syndromes Elevated unconjugated Bili after stress? Gilbert Disease Elevated Conjugated Bili? Dubin-Johnson Syndrome (secretion) Rotor Syndrome (storage)
- 9. Gallstones (8-15% of the population) Cholesterol stones: imbalance of cholesterol, lecithin, and bile acids Black pigment stones: hemolysis, long-term TPN Brown pigment stones: infections, parasites. Usually form within the bile ducts
- 10. Cholecystitis Ultrasound (most commonly used, 97% sensitivity for stones) - GB wall thickening (>3mm) - Pericholecystic fluid - Distention - Murphy’s sign - Mobile gallstones HIDA (MOST SENSITIVE for CHOLECYSTITIS) Acalculous cholecystitis: RFs- fasting, critical illness, TPN, trauma, hyperalimentation
- 11. Cholangitis Charcot Triad: fever, jaundice, RUQ pain Reynold pentad: add hypotension and mental status changes Bugs: E. coli >> Enterococcus >> Klebsiella >> Proteus >> Pseudomonas >> Enterobacter Treatment? - EMERGENT BILIARY DECOMPRESSION (ERCP or PTC)
- 12. Choledocholithiasis Dx: MRCP, ERCP, IOC DX pre-op? >> ERCP DX intraop? >> - Glucagon and flush with saline - CBD exploration, saline, fogarty balloon, basket, choledochoscope, close over a T-tube if open
- 13. Mirizzi syndrome
- 14. Galbladder polyps Indications to operate: 1. symptoms 2. size >1cm 3. increasing size 4. family history of GB cancer 5. PSC
- 15. Gallbladder Histology/ Cancer Mucosa Muscularis propria Serosa NO SUBMUCOSA!!!!!!!!!!! Bottom Line: if it invades the muscularis (T1b) or deeper, you must resect segments IVB and V and do a regional lymph node dissection
- 16. Lap chole post-op complications Patient in shock? - Return to OR for bleeding Persistent nausea, vomiting, pain, or jaundice? - Ultrasound - Fluid collection? – Drain it. HIDA may help visualize leak, as will ERCP - Bilious fluid?- ERCP and stent to seal the leak No fluid, but dilated hepatic ducts - Worry about transected CBD
- 17. CBD injury after Lap Chole Injury <50% circumference: end-to-end repair of duct Injury >50% circumference, left or right duct: Hepaticojejunostomy reconstruction
- 18. Gallstone ileus S/S of bowel obstruction Elderly patients Pneumobilia on imaging (50%) Treatment? - Ex-lap, removal of stone through proximal enterotomy, exploration of entire length of bowel, cholecystectomy
- 19. Cholangiocarcinoma Typically painless jaundice Dx: ERCP, EUS, brushings, CT Tx: resection, and reconstruction depending on location of tumor
- 20. Choledochal cysts Types 1,2,4: resect & reconstruct Type 3: transduodenal cyst excision Type 5: Liver transplant *Surgery due to risk of future malignancy
- 21. Primary Sclerosing Cholangitis Associated with UC Multifocal bile duct strictures Risk of cholangiocarcinoma Tx: Liver transplant
- 22. Primary Biliary Cirrhosis Cholestasis >> Cirrhosis >> Portal HTN Tx: transplant