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absite biliary
| Question | Answer |
|---|---|
| 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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