Gallbladder and extrahepatic biliary system
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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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Gallbladder and extrahepatic biliary system

Gallbladder and Extrahepatic Biliary System

Chapter 32 Schwartz’s


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


Anatomy

Anatomy


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)


Gallbladder and extrahepatic biliary system

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


Physiology

Physiology


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


Gallbladder and extrahepatic biliary system

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


Gallbladder and extrahepatic biliary system

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


Gallbladder and extrahepatic biliary system

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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