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Gallbladder and Extrahepatic Biliary System. Chapter 32 Schwartz’s. Why Should You Care?. Lap Chole = frequent 2 nd year case Anatomy can be tricky Complications can be very bad!

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why should you care
Why Should You Care?
  • Lap Chole = frequent 2nd year case
  • Anatomy can be tricky
  • Complications can be very bad!
  • Even if you don’t do this type of surgery, your friends and family may have this type of surgery and come to you for info/advice
anatomy1
Anatomy
  • The cystic artery which supplies the gallbladder is usually a branch of what artery?
anatomy2
Anatomy
  • The cystic artery which supplies the gallbladder is usually a branch of what artery?
    • The Right Hepatic Artery (90% of the time)
    • Course can vary, usually in triangle of Calot
    • Divides into posterior and anterior branches at neck of gallbladder
anatomy3
Anatomy
  • What are the boundaries of the Triangle of Calot?
anatomy4
Anatomy
  • What are the boundaries of the Triangle of Calot?
    • Cystic duct, common hepatic duct, liver margin
anatomy5
Anatomy
  • Name the mucosal folds found in the cystic duct adjacent to the gallbladder neck.
  • Extra credit: do they have any valvular function?
anatomy6
Anatomy
  • The Spiral Valves of Heister, and no they do not have any valvular function.
anatomy7
Anatomy
  • The arterial supply to the bile ducts is derived from which 2 major arteries and is oriented in what clock positions???
anatomy8
Anatomy
  • The arterial supply to the bile ducts is derived from which 2 major arteries and is oriented in what clock positions???
    • Gastroduodenal and Right Hepatic Arteries, in the 3:00 and 9:00 positions (medial and lateral walls)
slide12

Ruggero Oddi

Described the Sphincter of Oddi while a student

Francis Glisson identified the sphincter 2 centuries

earlier

Inflammation of the sphincter of Oddi is called

odditis

anatomy9
Anatomy
  • The classic description of the extrahepatic biliary tree and its arteries applies only in:
    • A. two thirds of patients
    • B. half of patients
    • C. one third of patients
anatomy10
Anatomy
  • The classic description of the extrahepatic biliary tree and its arteries applies only in:
    • A. two thirds of patients
    • B. half of patients
    • C. one third of patients
anatomy11
Anatomy
  • Name the small ducts which drain directly from the liver into the body of the gallbladder, and are a potential source of biloma post cholecystectomy
anatomy12
Anatomy
  • Name the small ducts which drain directly from the liver into the body of the gallbladder, and are a potential source of biloma post cholecystectomy
    • Ducts of Luschka
anatomy13
Anatomy
  • Replaced Right: Right Hepatic Artery off the SMA; 20% of patients; can course anterior to common duct
  • Cystic Artery can arise from the Left Hepatic, Common Hepatic, GDA, or SMA; 10% of patients
physiology1
Physiology
  • Which of the following factors are asscoiated with increased risk of gallstone development?
    • A. Obesity
    • B. Pregnancy
    • C. Crohn’s disease
    • D. Terminal ileal resection
    • E. Gastric surgery
    • F. Sickle Cell Disease
physiology2
Physiology
  • Which of the following factors are asscoiated with increased risk of gallstone development?
    • A.Obesity
    • B. Pregnancy
    • C. Crohn’s disease
    • D. Terminal ileal resection
    • E. Gastric surgery
    • F. Sickle Cell Disease
physiology3
Physiology
  • Which of the following is not a major component of bile?
    • Cholesterol
    • Bile Salts
    • Lecithin
    • Budweiser
physiology4
Physiology
  • Which of the following is not a major component of bile?
    • Cholesterol
    • Bile Salts
    • Lecithin
    • Budweiser
gallstone fun facts
Gallstone Fun Facts
  • In Western countries, Cholesterol stones are the most common type of gallstones
  • Pigment stones are black or brown b/c of Ca bilirubinate; often d/t hemolytic disorders
  • Brown stones usually d/t bacterial infection caused by bile stasis
  • Black/brown stones more common in Asia
imaging
Imaging
  • True or False: Ultrasound will show stones in the gallbladder with a sensitivity and specificity of >90%.
imaging1
Imaging
  • True or False: Ultrasound will show stones in the gallbladder with a sensitivity and specificity of >90%.
  • TRUE
imaging2
Imaging
  • True or False: MRCP has 95% sensitivity and 89% specificity at detecting choledocholitiasis .
imaging3
Imaging
  • True or False: MRCP has 95% sensitivity and 89% specificity at detecting choledocholitiasis.
  • TRUE
imaging4
Imaging
  • Your patient, a retired chemist/anatomy teacher, is suspected of having a bile leak following a laparoscopic cholecystectomy. Your team decides to order a HIDA scan, and the patient wants to know what the test is and how it works. Please explain…..
hida scan
HIDA Scan
  • ‘Biliary Scintigraphy’; gives anatomic/fxnal info. 99mTechnetium-labeled derivatives of dimethyl iminodiacetic acid (HIDA) IV, cleared by Kupffer cells,excreted in bile. Liver uptake detected w/in 10min. GB, bile ducts, duodenum seen in 60min in fasted pt.
hida scan1
HIDA Scan
  • Acute Cholecystitis=non-visualized GB w prompt filling of CBD & duodenum
  • False positives in pts w GB stasis/critically ill/TPN
  • Absent duo filling=obstruction at ampulla
surgical treatment
Surgical Treatment
  • Is prophylactic cholecystectomy routinely indicated in patients with asymptomatic gallstones?
surgical treatment1
Surgical Treatment
  • Is prophylactic cholecystectomy routinely indicated in patients with asymptomatic gallstones?
  • NO
surgical treatment2
Surgical Treatment
  • Is prophylactic cholecystectomy routinely indicated in patients with asymptomatic gallstones?
  • NO
  • Advisable for elderly diabetics, pts isolated from medical care, pts w increased risk of GB CA
  • Porcelain GB is indication for cholecystectomy
surgical treatment of gallstones
Surgical Treatment of Gallstones
  • Approx 3% of a’sxmatic pts become sx’matic per year
  • Complicated gallstone dz develops in 3-5% of sx’matic pts per year
  • Over 20 yr period, two thirds of a’sxmatic pts w gallstones remain sx free!
surgical tx of gallstones
Surgical Tx of Gallstones
  • A 45 yo WF presents to the ED with biliary colic for the second time in 2 weeks, repeat RUQ U/S shows no stones but sludge in the GB. Is cholecystectomy indicated in this pt?
surgical tx of gallstones1
Surgical Tx of Gallstones
  • A 45 yo WF presents to the ED with biliary colic for the second time in 2 weeks, repeat RUQ U/S shows no stones but sludge in the GB. Is cholecystectomy indicated in this pt?
  • Yes!
  • 2 or more occasions of pain/sludge
  • Cholesterolosis/adenomyomatosis/granulo-matous polyps indication if causing sx’s
slide37

PEG

What do you call this?

emphysematous gallbladder
Emphysematous Gallbladder
  • Persistent obstruction>2ndary bacterial infxn>gas forming organisms involved>see gas in GB lumen/wall of GB
  • GB can perforate, form cholecystoenteric fistula, lead to gallstone ileus, cause intrahepatic abscess, peritonitis, etc.
surgical tx of gallstones2
Surgical Tx of Gallstones
  • 26 yo G1P0 presents to ED with symptomatic gallstones refractory to medical management, dietary modifications.
  • Is lap chole safe???
surgical tx of gallstones3
Surgical Tx of Gallstones
  • 26 yo G1P0 presents to ED with symptomatic gallstones refractory to medical management, dietary modifications.
  • Is lap chole safe???
  • YES
but does it really work doc
But does it really work doc?
  • Approx. 90% of pts with typical biliary sx’s (epigastric/ruq pain, N/V episodes) and stones are sx free post-cholecystectomy
  • Pts w atypical sx’s or dyspepsia (flatulence, belching, bloating, dietary fat intolerance) have less favorable results
murphy s sign
Murphy’s Sign
  • An inspiratory halt upon deep palpation of the R subcostal area, characteristic of acute cholecystitis
mirizzi s syndrome
Mirizzi’s Syndrome

Obstruction of the bile ducts by severe pericholecystic inflammation secondary to impaction of a stone in the infundibulum of the GB that mechanically obstructs the bile duct

slide44
DDx???
  • 55 yo WF presents with 10 hours of RUQ pain radiating to back, +N/V, similar prior episodes lasted only a few hours and resolved completely. Started suddenly after fatty meal.
  • Temp 101.9, otherwise VSS
  • Guarding in RUQ, +Murphy’s Sign
  • WBC# 15, LFT’s WNL
slide45
DDx
  • Acute Cholecystitis
  • Peptic Ulcer (w or w/o perforation)
  • Pancreatitis
  • Appendicitis
  • Hepatitis
  • Perihepatitis (Fitz-Hugh-Curtis Syndrome)
  • Myocardial Ischemia
  • Intercostal Nerve Herpes Zoster
  • Pneumonia
  • Pleuritis
acute cholecystitis tx
Acute Cholecystitis Tx
  • IV fluids, pain meds, Antbx (cover gram neg aerobes and anaerobes, 3rd gen cephalosporin)
  • Cholecystectomy is definitive tx
  • Earlier the better!
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