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absite biliary

triangle of Calot contains cystic artery, boundary of liver superior, cystic duct lateral, and CBD medial
what does cystic artery nml come off R hep a
nml dimensions of CBD, GB wall, pan duct 8, 4, 4
what are accessory biliary ducts called, why impt ducts of luschka, can leak s/p lap chole
how does GB fill cxn of Sphincter of Oddi (doesn't have its own peristalsis)
what causes GB to contract? Spincter of Oddi to contract/relax? CCK; morhpine; glucagon
what increases biliary excretion CCK, secretin (both duo), vagal
what decreases biliary excretion VIP, somatostatin, sympathetic
what's stercobilin breakdown product of conjug bili in gut giving stool its brown color
where is conjugated bili resorbed terminal ileum
how does HMGCoA reductase relate to gallstones HMGCoA reductase turns HMGCoA into cholesterol, then 7alpha hydroxylase turns into bile acids; in obese ppl stones are due to overactive HMGCoA reductase, in thin due to underactive reductase
fxns of bile (3) fat soluble vitamin absorption, bilirubin excretion and cholesterol excretion
2 main types of gallstones and pts nonpigmented (MC, fat, fertile, malabsorb, cf); pigmented incl black (in GB, due to incrsd bili load, decrsd hep fxn, bile stasis, ie hemolytic dz, cirrhosis, ileal resxn, TPN (stasis), ileal resxn); brown (ducts, infxn in Asian E Coli)
1ry v 2ry gallstones if formed in duct considered 2ry
differentiating cholelithiasis v choledocholithiasis cholelithiasis-stone in cystic duct, colicky pain, no murphy no incrsd bili or WBC; choledocho incrsd bili, jaundice but no F or WBC
dx choledocho ERCP
tx choledocho v cholelithiasis choledocho-ERCP w sphincterotomy and stent; cholelithiasis do chole only if recurrent
differentiating cholecystitis and choledocho cholecystits-GB distension and wall inflamm 2/2 stones w incrsd WBC and AlkP, but not incrsd bii, Murphys, pain for days v cholelithiasis; choledocho has incrsd bili
differentiating cholecystitis and cholangitis cholangitis has jaundice, F, WBC whereas cholecystitis only low F, minor incrs WBC and no incrs bili
mgmt cholangitis emergent decompression of biliary tree w ERCP/PTC
mgmt cholecystitis iV Abx and pain, then cholecystectomy
mgmt choledocholith ERCP w sphincterotomy and stent
what is Charcot's triad RUQ pain, F, jaundice (cholangitis)
MC organisms cholangitis E Coli, Klebsiella
air in biliary system MC due to ERCP and sphincterotomy; Bac infxn of bile, usu from portal system, highest incidence from post op stricture (usu E Coli polymicrobial)
which pts at risk for acalculous cholecystits surgery, TPN, burns/trauma
cause of emphysematous GB dz, organism, tx gas in GB wall in DM 2/2 C perfringens, hi risk of perf so emergent cholecystectomy
where/how does gallstone ileus occur fistula bw GB and duo causes obstruction in terminal ileum, seen in elderly and see air in biliary tree
tx gallstone ileus enterotomy prox to obstruction, pull out stone, resect the fistula and cholecystectomy
mgmt CBD injury if <50% circumference 1ry repair, otherwise hepaticojejunostomy
if N/V or jaundice s/p lap chole U/S to look for bile leak (can perQ drain). If bilious fluid ERCP w sphincterotomy and stent if leak of cystic duct remnant
shock s/p lap chole (2 causes) hemorrhage from clip falling off cystic a, or late septic shock from clip on CBD leading to cholangitis
if stricture s/p lap chole on CBD, do ERCP and stent strictured area
causes of CBD strictures MC after lap chole, isch is impt in late post op, also 2/2 chronic pancreatitis commonly seen in chronic EtOH
Mgmt porcelain GB? procelain GB w high risk of cancer, should get chole
when is lap chole contraindicated (need to do open) GB adeno (bc high risk of tumor implants at trocar sites)
focal bile duct stenosis and no h/o biliary surgery in older person, think BD cancer (cholangiocarcinoma)
RF cholangiocarcinoma PSC (MC), UC, choledochal cyst, clonorchus infxn from hong kong
types of cholangiocarcinoma and tx upper 1/3 (Klatskin) MC unresectable and worst px; middle 1/3 hepaticojejunostomy; lower 1/3 whipple
types of pts who get choledochal cysts, types female asian, usu extrahep fusiform dilation
tx choledochal cyst hepaticojejunostomy and chole bc risk of cholangiocarcinoma
PSC assoc w what, pt types usu men 40-50 assoc w UC
ERCP of PSC shows bead like strictures intra and extrrahep ducts
mgmt PSC transplant, also cholestyramine and urodeoxycholic acid (decrs pruritis and bile acids respectively)
PBC: pt type, key serology, tx seen in women, assoc w scleroderma, no incrsd risk of cancer; anti mito Abs, tx Txp
indications for chole for asympt gallstones liver trxp or gastric bypass
Mirrizzi syndrome compression of c hep duct by extrinsic (stone in cystic duct)
Created by: ehstephns
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