Term
| What is the basic anatomical organization of the gallbladder |
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Definition
Stores and Concentrates BIle!
Pear-shaped organ that arises from diverticulum at the hepatic duct (which originally originates from duodenum) and lies on inferior surface of liver
1) Fondus
2) Body
3) Neck- Hartmann's pouch empties into cystic duct
**multiple anatomical variations** |
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Term
| Describe the 3-layer histology of the gallbladder wall. |
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Definition
1) Mucosa- simple columnar cells with microvilli
- folded into ridges that flatten with distention
2) Muscularis propria- smooth muscle (circular and longitudinal)
3) Serosa |
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Term
| What is the blood supply of the gallbladder? |
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Definition
1) Cystic artery off of right hepatic artery (ischemic cholangopathy)
- lies in Calot's triangle, formed by the inferior border of the liver, cystic duct and common hepatic duct.
**RHA comes from PHA, which comes from common hepatic artery off of celiac trunk**
2) NO cysten vein (small tributaries drain into portal vein) |
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Term
| What are the functions of secreted bile and how is it regulated? |
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Definition
Bile is composed of water/electrolytes, BA, phospholipids, cholesterol and bile pigments
Functions
1) Digestion and absorption of fat in small bowel
2) Elimination of endogenous chemicals (cholesterol and bile) and exogenous chemicals (Phenothiazines and heavy metals)
Regulation (Depends on resistance in gallbladder and sphincter of Oddi)
1) During fasting, GB is distensible and sphincter remains closed (STORED)
2) During eating, CCK causes GB contraction and sphincter relaxation (Flow into duodenum) |
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Term
| How and where are bile acids synthesized? How does this relate to the action of Cholestyrmaine, Colestipol and Colesevelam? |
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Definition
Major component of bile
1) Synthesized from cholesterol in liver (major elimination pathway for cholesterol)
- Cholic acid and Chonodeoxycholic acids are primary
2) Bile acid sequesterants bind BA in intestine and prevent enterohepatic re-circulation (usually 95%), thereby causing more production of BA from cholesterol in liver and REDUCING CHOLESTEROL and LDL (synergistic with statins) |
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Term
| How would you diagnose sphincter of oddi dysfunction (SOD) and how might it manifest? |
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Definition
1) Manometry (ERCP)
- Type 1= biliary pain with dilated CBD and abnormal LFTs 2X
- Type 2= biliary pain + either LFTs or dilated CBD
- Type 2= biliary pain
2) Biliary pain and idiopathic acute recurrent pancreatitis (IARP) |
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Term
| What are the major causes of Bile acid malabsorption? |
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Definition
Ileal disease is common
See Diarrhea and Steatorrhea, as well as Oxalate kidney stones (fat + calcium)
1) Crohn's****
2) Ileal resection
3) Ileal bypass
4) Radiation enteritis |
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Term
| What is the primary bile pigment and how is it formed and metabolized? |
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Definition
1) Bilirubin formed from Hg splitting derived from Senescent RBCs
2) Unconjugated form bound to albumin and taken to liver, where it is glucouronidated by Glucuronyl-transferase
3) Conjugated bilirubin is water soluble and can be secreted into bile, which is then fed into the small intestine |
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Term
| What are the major causes of Unconjugated and Conjugated Hyperbilirubinemia? |
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Definition
1) Unconjugated
- Increased production (Hemolysis)
- Decreased conjugation (Gilbert syndrome and Crigler Najjar)
2) Conjugated
- Hepatocellular dysfunction (CLD, drugs)
- Intrahepatic cholestasis (Amyloid, Sarcoid, CF)
- Extrahepatic cholestasis (Obstruction)
- Hereditary (DJ syndrome, Rotor syndrome) |
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Term
Patient presents with RUQ pain, fever, and leukocystosis.
On PE, you gently place you hand below the costal margin in the mid clavicular line on his right side and ask him to breathe in (he winces).
What is going on? |
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Definition
Acute Calculous Cholecystitis (inflammation of GB due to persistent obstruction) with characteristic symptoms and (+) Murphy sign.
Worry about fistula, gangrene, rupture, ect. |
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Term
| What are the 4 primary risk factors of gallbladder cancer? |
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Definition
90% adenocarcinoma (RARE)
1) Gallstones (the larger the worse)
2) Porcelain GB (intramural calcifications from cholecystitis)
3) GB polyps
4) Salmonella Typhi |
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Term
| Describe the basic structure of the biliary tree. |
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Definition
All biliary system is tall columnar epithelium EXCEPT terminal bile duct.
1) Right and Left hepatic ducts form common hepatic duct
2) Common hepatic duct and cystic duct form common bile duct (terminally lined with CUBOIDAL epithelium)
3) Common bile duct and pancreatic duct form Sphincter of Oddi, which empties into the duodenum |
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Term
Patient presents with RUQ pain, fever and jaundice, as well as hypotension and MS changes.
Which is going on and what are the most common pre-disoping factors? |
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Definition
Charcot's triad (really, Reynold's pentad) of Acute cholangitis.
- Usually ascending bacterial infection from duodenum due to stone/stricture.
- Treat with abdominal and biliary decompression. |
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Term
| How do you diagnose the autoimmune condition that causes stricturing of medium size and large ducts in the intrahepatic and extrahepatic biliary tree |
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Definition
PSC- Cholangiogram (MRCP)- beads on string
Found in middle-aged (40) males with IBD (UC >CD) |
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Term
1 year old presents with intermittent abd pain, jaundice
and a RUQ Abd mass.
How do you likely treat? |
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Definition
Choledochal Cysts- Congenital condition involving cystic dilation of the bile ducts
Surgical resection required
5 types (1= extrahepatic and 5= IHD)
Type I: Most common variety (80-90%) involving saccular or fusiform dilatation of a portion or entire common bile duct with normal IHD.
Type V or Caroli’s disease: Cystic dilatation of intra hepatic biliary ducts. |
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Term
| What are the major risk factors for Cholangiocarcinoma? |
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Definition
1) PSC
2) Choledochol cysts
3) Liver fluke
4) CLD (HCV) |
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Term
| What are the important radiographic & endoscopic evaluation techniques for the Gallbladder and Biliary Tree? |
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Definition
US, HIDA and EUS
1) EUS- stone removal
2) HIDA- hepatic iminodiacetic acid, which is injected intravenously and is then taken up selectively by hepatocytes and excreted into bile (if cystic duct is open, it will visualize GB)
**Positive test means cystic obstruction** |
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Term
What is the site of origin, pathogenesis and composition of each of the following types of Gallstones?
1) Cholesterol
2) Black
3) Brown |
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Definition
1) Arises in GB, where physical-chemical pathogenesis produces stones out of cholesterol
2) Arises in GB, where physical-chemical pathogenesis produces stones of Calcium and bilirubin
3) Arises in bile ducts, where infection leads to production of mixed stones. |
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Term
| How do cholesterol gallstones form? |
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Definition
After being released from hepatocytes into bile, Cholesterol is normally solubilized in bile by lecithin (PDC) and bile salts as mixed micelles or vesicles.
As cholesterol carriers become saturated, forming multilaminar vesicles, cholesterol precipitates into crystals that dwell in mucin gel and ultimately form gallstones.
**Facilitated by Prostaglandins, which induce mucin formation** |
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Term
| What are the major risk/protective factors associated with cholesterol gallstone formation? |
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Definition
1) Risk
- Ethnic (Pima indians, chile, Mexican)
- Age/sex (Older women)
- Pregnancy (sludge > gallstones) Post-partum greatest
- Obesity (>30 for women, but decreased from 25-30, relative to 20-25).
- Rapid weight loss
- TPN (sludge > gallstones)
- Estrogen (contraceptives) in women <20
2) Protective
- CCK administration (sludge)
- Ursodiol and ASA (stones)
- Vitamin C in women
- Coffee, veg protein
2) Protection |
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Term
| How can gallstones and sludge be prevented? |
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Definition
1) Stones use Ursodiol and Aspirin (ASA)
2) Sludge use CCK daily |
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Term
| What 3 diseases are associated with the formation of black gallstones? |
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Definition
Formed from unconjugated bilirubin with higher prevalence in sickle cell anemia and chronic liver disease
1) Cirrhosis (dec conj)
2) Hemolytic Anemia (inc bili)
3) Crohn’s involving TI (impaired enterohepatic cycling of bilirubin leading to inc Ca and unconj bili in bile) |
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Term
| What is the pathophysiology of brown pigment gallstone formation? |
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Definition
Patients with h/x of cholangitis get brown stones in bile ducts where biliary tree is exposed to duodenal bacteria
Bacteria break down lecithin to FFA (reduced cholesterol carrier) and conjugated bilirubin to unconjugated bilirubin (increased indirect forming brown pigment), so you get MIXED stones. |
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