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Sabiston Biliary System Notes

Sabiston Biliary System Notes

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Published by svidrillion
Notes from Sabiston's Biliary system chapter 55
Notes from Sabiston's Biliary system chapter 55

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Published by: svidrillion on Dec 02, 2012
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07/05/2013

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 ANATOMYThree places the common bile duct may join the pancreatic duct 
 in the wall of the duodenum 
 within the pancreas prior to insertion into the duodenal wall 
 may enter the duodenum separately from the pancreatic duct
 Parts of the gallbladder: neck,
infundibulum with Hartmann’s pouch, body, fundus
 Gallbladder capacity 30 - 60 mL of bileWhere the gallbladder attaches the liver, Glisson's capsule does not formCystic duct length 1
 –
5 cmCommon bile duct>8mm is dilatedSpiral valves of Heister: folds of mucosa oriented in a spiral pattern to keep gallstones fromentering the common bile ductHepatic parenchyma segments based on hepatic venous drainage and portal inflowThree major hepatic veins drain into the inferior vena cava
 –
The entire biliary tree is supplied solely by the arterial anatomy
 –
In most cases the right hepatic artery passes posterior to the common hepatic duct to supplythe right lobe of the liver The cystic artery normally arises from the right hepatic artery Although variable, the cystic artery generally lies superior to the cystic duct and is usuallyassociated with the lymph node (Calot's node)Bile ducts generally my superior to the corresponding portal veinsThe left duct drains segments II, III and, IV, IVaThe right duct drains segments V, VI, VII, and VIIIRight duct is short, left duct is longPHYSIOLOGY
bile
excretes toxins
plays critical role in the absorption of most lipidsvagal activity, gastrointestinal hormone secretin and cholecystokinin all induce mobilesecretionCholecystokinin is secreted by intestinal mucosaBilirubin is the breakdown products of hemoglobin and myoglobinThe gallbladder is efficient at absorbing water and concentrating bile componentsWith absorption of sodium chloride and water across the gallbladder epithelium bile isconcentratedFasting state causes increase in tonic activity of sphinceter of Oddi
 
 IMAGING
Hepatic Iminodiacetic Acid scan (H I DA)
Biliary scintigraphy used to evaluate the physiologic secretion of Bile
Failure to fill the gallbladder two hours after injection demonstrates obstruction of thecystic duct
Call bladder function can be determined by a HIDA scan because the injection
cholecystic kinin during scan will document physiological injection the gallbladder 
Triple phase CT: arterial phase, portal venous face, delayed phase
Indications for intraoperative cholangiography:
pain at the time of operation
abnormal hepatic function panel
Anomalous or confusing biliary anatomy
inability to perform ERCP following cholecystectomy
dilated biliary tree
preoperative suspicion ofColey Delco lithiasisERCP or PTC (percutaneous transhepatic cholangiography) prophylactic antibiotics equals first or second generation cephalosporin or flouroquinoloneGALLSTONESIn US 70% of gallstones are calcium and cholesterol
Increased gallbladder stone formation
impaired gallbladder emptying
prolonged fasting
TPN use
post Vagotomy
Somatostatin analoguesBlack stones: hemolytic conditions and cirrhosisBrownstones: occur within the biliary tree20 to 30% of patients with asymptomatic gallstones will develop symptoms within 20 yearsRapid weight-loss favors stone formation
Nonoperative treatments of Cholelithiasis
oral salt therapy
contact dissolution
extracorporeal shockwave Lithotripsy Acute Vs. Chronic Cholecystitis Acute:Pain lasting longer than 2 hours or when associated with fever suggests acute cholecystits Acute = inflammation with edema and subserosal hemorrhageTenderness and positive
Murphy’s sign
 
Biliary colic (no inflammatory process, and thus no tenderness or Murphy’s sign)
  Acute Calculous Cholecystitis:Most common organisms:Gram negative aerobes Anaerobes
 
Gram positive aerobesTx:NPOIVFParenteral antibiotics (broad-spectrum)Cholecystectomy:Within one weekToo much intraoperative inflammation: partial cholecystectomy (transecting gallbladder atinfundibulum with cauterization of remaining mucosa)Cholecystostomy tube: allows for 3-6 months of medical optimization before operation
Choledocholithiasis:
Primary (arising in the duct)
Most commonly brown stones
More common in Asian populations
Associated with bacterial infection of bile duct
Secondary (passing from the gallbladder)
Most common in US
 
“Retained common duct stones” when found within 2 years of cholecystectomy
 
Symptoms
Biliary colic
obstructive jaundice (dark urine, scleral icterus, lightening of stools), fever, RUQ
pain (Charcot’s triad)
 
 
Charcot + hypotension and metnal status changes (Reynold’s p
entad)
Findings
>8mm CBD
Tests
ERCP
75% clearance of stones on first try, 90% on repeat tries
MRI
>90% sensitive, 100% specific
1488
Treatment
ERCP as above
Common bile duct exploration (lap or open)
Impacted stone at ampulla
Nondilated biliary tree
Transduodenal sphincterotomy
Dilated biliary tree
Cholodochoenterostomy
Choledochoduodenostomy
Preserves endoscopic access
Can create sump syndrome
Roux-en-Y choledochojenjunostomy
Difficult to access endoscopically
Gallstone pancreatitis
Stone passing into CBD and temporarily blocking pancreas outflow
Stone usually passes spontaneously
Lap chole to prevent repeat episode of gallstone pancreatitis is warranted
Can do it during the same hospitalization just prior to discharge
Biliary dyskinesia

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