Fiser Chapter 32 BILIARY SYSTEM Flashcards Preview

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Gallbladder function

Stores bile

Concentrates bile by active resorption of NaCl and water (has more sodium, bile salts, and cholesterol than hepatic bile; hepatic bile has more chloride)

Postprandial emptying (maximum at 2 hours)

Cholecystectomy -> decreased total bile salt pools


45yo man with UC presents with jaundice, fatigue, pruritis, weight loss, and RUQ pain

Primary sclerosing cholangitis: associated with UC, pancreatitis, DM

Multiple strictures throughout hepatic ducts (string of beads)

Leads to portal HTN, hepatic failure (progressive fibrosis of intrahepatic and extrahepatic ducts) -> cirrhosis, cholangiocarcinoma

Tx: PTC tube drainage, choledochojejunostomy or balloon dilatation of dominant strictures may provide symptomatic relief, cholestyramine to decrease bile acids and pruritis, UDCA (ursodiol) to decrease bile acids and improve liver enzyms; LIVER TXP EVENTUALLY NEEDED FOR MOST; Colon resection does NOT help PSC


Cholangitis dx

Elevated AST/ALT, bilirubin, alk phos, WBC

US shows dilated CBD (> 8 mm, > 10 mm after cholecystectomy) if d/t biliary obstruction


GB wall normal size

< 4 mm


Pigmentes stones

Most common worldwide

1. Calcium bilirubinate stones: from increased bilirubin load, decreased hepatic function, and bile stasis -> solubilization of unconjugated bilirubin with precipitation; dissolution agents (monooctanoin) do NOT work

2. Black stones: Hemolytic disorders, cirrhosis, ileal resection (loss of bile salts), chronic TPN; tx cholecystectomy if symptomatic


Cholecystitis most common organisms

E coli (#1), Klebsiella, Enterocococcus


Biliary colic

Transient cystic duct obstruction caused by passage of gallstone



Patient with sepsis following lap chole

1. Fluid resuscitation, stabilize
2. US to look for dilated intrahepatic ducts or fluid collection (cystic duct leak versus transection)
3. Could also be cholangitis


Charcot's triad

RUQ pain, fever, jaundice

Reynaud's pentad: altered mental status and shock


Diabetic with severe rapid-onset abdominal pain, nausea, vomiting, sepsis, gas in gallbladder wall on plain film

Emphysematous gallbladder disease: risk of perforation

Usually d/t clostridium perfringens
Tx: emergent cholecystectomy, percutaneous drainage if unstable


Enterohepatic circulation

1. Bile secreted by hepatocytes (80%) and bile canalicular cells (20%); broken down in gut to stercobilin (makes stool brown); reabsorbed

2. Terminal ileum: active resorption of conjugated bile salts; Small intestine (45%) and colon (5%): passive resorption of non-conjugated bile salts

3. Absorbed bile gets converted to urobilinogen and eventually urobilin, which is released in urine (yellow color)


Drugs that affect sphincter of Oddi

Morphine: contracts (why meperidine used to be used)

Glucagon: relaxes


Cholesterol and bile acid synthesis

HMG CoA -> (HMG CoA reductase) -> cholesterol -> (7-alpha-hydroxylase) -> bile salts (acids)

HMG CoA reductase is rate limiting step in cholesterol synthesis


Shock after lap chole causes

First 24 hours: hemorrhagic shock from clip that fell off cystic artery

After 24 hours: septic shock from accidental clip on CBD with subsequent cholangitis


Gallstone risk factors





Rapid weight loss


TPN (pigmented stones)

Ileal resection (pigmented stones)


Most sensitive test for cholecystitis

CCK-CS test (cholecystokinin cholescintigraphy), also uses HIDA scan (technetium taken up by liver and excreted in biliary tract)

Indications for cholecystectomy afterward:
-GB not seen (stone in cystic duct)
-Take >60 min to empty (chronic cholecystitis)
-EF < 40% (biliary dyskinesia)


Cystic vein

Drain into R branch of portal vein


Best treatment for late CBD stone

ERCP (sphincterotomy allows for removal of stone)

Risks: bleeding, pancreatitis, perforation


Most common cause of positive bile cultures

Postoperative strictures, usually E coli, or polymicrobial


Longitudinal blood supply of hepatic and common bile ducts

Right hepatic artery (9 oclock on ERCP), gastroduodenal artery retroduodenal branches (3 oclock on ERCP)


Pancreatic duct normal size

< 4 mm


Rokitansky-Aschoff sinuses

Epithelial invaginations in GB wall, formed from increased gallbladder pressure


Patient with sepsis, cholangitis, and jaundice

Bile duct stricture: cancer until proven otherwise (unless history of pancreatitis or biliary surgery)

Dx: MRCP to define anatomy, look for mass -> ERCP with brush biopies

Tx: if d/t ischemia or chronic pancreatitis -> choledochojejunostomy (best long-term solution), otherwise if cancer then appropriate workup


Todani classification of choledochal cysts

I: saccular or fusiform dilatation of a portion or whole CBD

II: isolated diverticulum from CBD

III: right by duodenum

IV: multiple (extrehepatic +/- intrahepatic)

V: intrahepatic (if multiple intrahepatic, is Carroli's disease)


Cystic artery anatomy

Branches off right hepatic artery

Found in triangle of Calot (cystic duct latera, CBD medial, liver superior)


Most common route of bacterial infection of bile

Dissemination from portal system (NOT retrograde through sphincter of ODD)


Benign neuroectoderm tumor of gallbladder

Granular cell myoblastoma: can occur in biliary tract with signs of cholecystitis

Tx: cholecystectomy


CBD normal size

< 8 mm (< 10 mm after chole)


Causes of bile duct strictures

-Ischemia after lap chole (most important cause)

-Chronic pancreatitis

-Gallbladder cancer

-Bile duct cancer


Indications for asymptomatic cholecystectomy

Patients undergoing liver transplant, or gastric bypass procedure (if stones are present)