absite biliary
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| triangle of Calot | contains cystic artery, boundary of liver superior, cystic duct lateral, and CBD medial
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| what does cystic artery nml come off | R hep a
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| nml dimensions of CBD, GB wall, pan duct | 8, 4, 4
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| what are accessory biliary ducts called, why impt | ducts of luschka, can leak s/p lap chole
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| how does GB fill | cxn of Sphincter of Oddi (doesn't have its own peristalsis)
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| what causes GB to contract? Spincter of Oddi to contract/relax? | CCK; morhpine; glucagon
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| what increases biliary excretion | CCK, secretin (both duo), vagal
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| what decreases biliary excretion | VIP, somatostatin, sympathetic
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| what's stercobilin | breakdown product of conjug bili in gut giving stool its brown color
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| where is conjugated bili resorbed | terminal ileum
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| 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
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| fxns of bile (3) | fat soluble vitamin absorption, bilirubin excretion and cholesterol excretion
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| 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)
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| 1ry v 2ry gallstones | if formed in duct considered 2ry
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| 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
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| dx choledocho | ERCP
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| tx choledocho v cholelithiasis | choledocho-ERCP w sphincterotomy and stent; cholelithiasis do chole only if recurrent
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| 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
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| differentiating cholecystitis and cholangitis | cholangitis has jaundice, F, WBC whereas cholecystitis only low F, minor incrs WBC and no incrs bili
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| mgmt cholangitis | emergent decompression of biliary tree w ERCP/PTC
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| mgmt cholecystitis | iV Abx and pain, then cholecystectomy
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| mgmt choledocholith | ERCP w sphincterotomy and stent
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| what is Charcot's triad | RUQ pain, F, jaundice (cholangitis)
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| MC organisms cholangitis | E Coli, Klebsiella
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| 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)
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| which pts at risk for acalculous cholecystits | surgery, TPN, burns/trauma
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| cause of emphysematous GB dz, organism, tx | gas in GB wall in DM 2/2 C perfringens, hi risk of perf so emergent cholecystectomy
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| 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
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| tx gallstone ileus | enterotomy prox to obstruction, pull out stone, resect the fistula and cholecystectomy
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| mgmt CBD injury | if <50% circumference 1ry repair, otherwise hepaticojejunostomy
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| 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
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| 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
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| if stricture s/p lap chole on CBD, do | ERCP and stent strictured area
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| 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
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| Mgmt porcelain GB? | procelain GB w high risk of cancer, should get chole
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| when is lap chole contraindicated (need to do open) | GB adeno (bc high risk of tumor implants at trocar sites)
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| focal bile duct stenosis and no h/o biliary surgery in older person, think | BD cancer (cholangiocarcinoma)
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| RF cholangiocarcinoma | PSC (MC), UC, choledochal cyst, clonorchus infxn from hong kong
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| types of cholangiocarcinoma and tx | upper 1/3 (Klatskin) MC unresectable and worst px; middle 1/3 hepaticojejunostomy; lower 1/3 whipple
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| types of pts who get choledochal cysts, types | female asian, usu extrahep fusiform dilation
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| tx choledochal cyst | hepaticojejunostomy and chole bc risk of cholangiocarcinoma
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| PSC assoc w what, pt types | usu men 40-50 assoc w UC
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| ERCP of PSC shows | bead like strictures intra and extrrahep ducts
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| mgmt PSC | transplant, also cholestyramine and urodeoxycholic acid (decrs pruritis and bile acids respectively)
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| PBC: pt type, key serology, tx | seen in women, assoc w scleroderma, no incrsd risk of cancer; anti mito Abs, tx Txp
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| indications for chole for asympt gallstones | liver trxp or gastric bypass
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| Mirrizzi syndrome | compression of c hep duct by extrinsic (stone in cystic duct)
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