aC) Biliary Tract O. Joe Hines, Meredith J. Sorensen, Uretz J. Oliphant, and Saad Shebrain Diseases of the gallbladder and bile duets are common in the adult population of North America, These conditions ean be life threatening and may require a detailed understanding in order to effectively wiage patients, Approximately 15% of adults have gallstones, and more than 800,000 cholecystectomies ate performed annually in the United States, accounting for more than $5 billion in health care costs. Accurate clinical assessment, including pertinent history and accurate physical examination, yields valuable information. about the diagnosis of common diseases of the biliary tract. Laboratory tests are helpful in distinguishing. among various eauses of jaundice, and imaging studies play a pivotal role in confirming the diagnosis of biliary tract disease, To mini ize the risk of iatrogenic injury, the surgeon must possess the skills to recognize common variations in the anatomy of the biliary tract and to perform careful disection of the vital structures during surgery. This dictum was rcemphasized in zecent years with the meteoric rise in the popularity of laparoscopic cholecystectomy, which has replaced open cholecystectomy as the preferred operation for most patients with gallstone disease ANATOMY ‘The origin of the biliary tee isan outgrowth from the foregut. Thrce buds fom this diverticulum become the liver, ential pancreas, nd gallbladder. Utimately, the gallbladder is located in the right upper quadrant (RUQ) of the abdomen under the anstomic division ofthe right and left lobes ofthe liver. Normally itis « 90%, with a ‘complication rate of approximately 5% to 10% (eg, pancreatitis, duodenal perforation, and bleeding) Endoscopic intraluminal lithotripsy ean be used to breale up large stones. The fragments can then pass spontaneously or be removed with ERCP and sphincterotomy. If the stones cannot be removed by these methods, an open procedure is necessary Acute Biliary (Gallstone) Pancreatitis Pancreatitis is commonly caused by gallstones (40% of cases, more in women) and alcohol (4084, more in men). When caused by gallstones it is ealled gallstone or biliary pancreatitis. This occurs because of transient or persistent obstruction of the pancreatitis duct, usually at the ampulla of Vater, by « large stone of the ‘passage of small stones and biliary shudge. Patients with acute pancreatitis present with acute upper abdominal pin, often radiating to the back with tenderness usually in the upper abdomen. Severe cases may present with peritoneal signs, simulating other causes of an acute abdomen, Nausea, vomiting, and a low-grade fever are frequent, as ate tachycardia and hypotension secondary to hypovolemia, Severity of acute pancreatitis can be predicted on the basis of clinical, laboratory, and radiologic risk factors. Some of these can be performed on. admission to assist in a triage of patients (eg, Ranson exteria), whereas others ean be obtained only afier the first 48 to 72 hours or later. Management of patients with acute biliary pancreatitis includee initial resuscitation and supportive care, with correction of fluid deficits and electrolyte derangements, Once the acute episode of pancreatitis hae resolved, the gallbladder should be removed as expeditiously as possible to avoid recurrent pancreatitis, Ifthe pancreatitis is mild to moderate in severity, a lapatoseopie cholecystectomy ‘can be performed safely, often within the first 48 to 72 hours of admission, By this time, the abdominal pain has largely resolved and the serum amylase level is returning to normal. Without a cholecystectomy, as many a5 60% of patients will experience recurrent gallstone pancreatitis within 6 months, A longer delay may be justified in patients who have had severe pancreatitis and in whom local inflammation or systemic illness ccontraindicates surgery. In these cases, ERCP with endoscopic sphincterotomy may reduce the incidence of recurrent pancreatitis to between 2% and 5% over 2 years. An IOC should always be performed at the time of the cholecystectomy to confirm thatthe bile duct is fee of stones Antibiotics are added for severe pancreatitis and for the management of septic complications. If seute cholecystitis was present, an interval cholecystostomy may be required, Emergent ES with stone extraction ray be lifesaving in come patients with severe biliary pancreatitis. It should be used when a patient with ‘pancreatitis is known to have gallstones, when a high suspicion of choledocholithiase is present, and when the 462normal resuscitative efforts clinical course does not improve within 24 to 36 hours wi Gallstone Tes Gallstone ileus (mechanical bowel obstruction caused by a gallstone) accounts for «196 of all cases of intestinal obstruction, It is an uncommon complication that results from a gallstone eroding through the wall of the gallbladder into the adjacent bowel (usually duodenum), creating a cholecystoenteric fistula. The stone migrates until it lodges in the narrowest portion of the small bowel, just proximal to the ileocecal valve Patients present with symptoms of bowel obstruction and air in the biliary te. Te occurs more commonly in women than in men (3.5:1 ratio). A history of biliary colic or gallstone disease is common, Patients present with the clinical picture (symptoms and signs) of small intestinal obstruction including nausea, vomiting, abdominal pain, and distension. Occasionally, the intermittent nazure of the obstruction inthe early stages (before impaction of the stone) often results in delay in the diagnosis Plain radiographs of the abdomen show findings of small intestinal obstruction and may show air in the biliary wee. Occasionally, «large stone has sufficient calcium to be seen in the intestine, Ultrasonography is useful in documenting gallstones. CT with oral contrast is the preferred diagnostic test, because it ean demonstrate ai in the biliary tee, a biliary-enteric fistula, the site of obstruction, and the obstructing stone. ‘The CT sean in Figure 16-6 shows a stone in distal small bowel, with proximal bowel distension, distal bowel collapse, and gas in the gallbladder. igus 16-6 This computed tomography sean shows a stone in the distal small bowel, with proximal bowel distension, distal bowel collapse, and gas inthe gallbladder. Gallstone ileus is managed initially as a small bowel obstrvetion, and this includes the placement of a 463nasogastric tebe for decompression of the obstruction and intravenous hydration. This should be followed by exploratory laparotomy (or laparoscopy) and removal of the obstructing gallstone by milking it back co an enterotomy made in healthy intestine Figure 16-7. The entire bowel should be searched diligently for ather stones, Many of these patients are elderly and will not tolerate prolonged operations, but in a few select pitients who are otherwise healthy, cholecystectomy and definitive correction ofthe intemal stl may also be performed. 8 "gue 167 Gallstone ileus. A, Intraoperative photo ofa gallstone in the small intestine causing an obstruction B, The gallstone after removal ‘Table 16-1 summarizes the common chnical syndromes and complications that can result from cholelithiasis, TABLE 16-1 Summary of the Common Clinical Syndromes That Result from Cholelithiasis and the ‘Complications of Cholelithiasis Syndrome Enology ndings Bain coe “Transient te dct plodes of wpper abdominal pain cisenction ‘Nospecie pie dings 464re hoes (Ara cletis ‘Const serene RUQ pan lente en Morphy sign Rebound tnderne Leakocytons Mild pettiness ‘Usound:colelchias, wth or without other sgn of blader inlaumaton IDA san: nonveualiation of glbladder Choledochotians “Histay of abdominal uo, jana light stool, darkurine eg ‘Ulrasoun: colelhits with lated ducts CT, MRC, PTC, ERCP—ductal nes ‘Acute cholangic| Tnfected ieseptcemia History ume as choledchottis but acutely pet wih shdominal pai, jaundice, eer, chilly; nay ao have ypatenion sod changin enotion Gn sce muppursive clang) Stone impactedinthe CRD ‘Suture ofthe CD (previous biliary sarge) “Tomer sbtrstng th: CRD (epeclly afi snares dleguetc procedure dha might have seded the bie with bute) Laboratory findings: meat choledacholchias, pat erated white ood call count ‘Ueasound tame at chledocholihians, bu gallbladder may have tren smved psi if th etilogy iat Minera ‘Aa pace ey pees a el -aliaon ough the back ee eee eet etree ae ‘Tenderness, gotdingio upper bomen marhely elevated sera ed , CT scan, MRC cholelihiass, with or without Gatcone ew Ctecstentee sta dey debated patent ‘Verylage gallstones) Incomplete bowel abortion Stone bstuctingitestine Radiograph shows Bowel bsrution (sully distal sal bowel) (aly dive eam) May show arbi te nd may ee age tone obretig ‘Uasound: stone in gallbladder and iin bin tee CPeallotthe sore (CBD, common ble hut: CT, computed omegraphy: ERCP, enna rergreecaensopanceteraphy, HIDA, bepatbiry inode iran bry nm: MIRC, mae reunancecaniegraph, PTC peraaneus rapa caanioram: RUD right npr pret GALLBLADDER CANCER Gallbladder cancer is the most common cancer of the biliary tract and the sith most common cancer of the GI tract. The incidence peaks at the seventh decade of life, with a 3:1 female-to-male ratio, ‘There are a number of risk factors for gallbladder cancer, Gallstones are the most common tisk factor, Up to 75% of patients with thie gallbladder cancer are noted to have cholelithiasis. Patents with gallbladder polyps 1.5 em 465or geeater in diameter have 2 46% to 70% prevalence of cancer, An anomalous junetion of the panereaticobiliary duct has been noted in approximately 10% of patents with gallbladder cancer. Another risk. factor for gallbladder cancer isa porcelain gallbladder, which is characterized by calcification ofthe gallbladder ‘wall, Carcinoma associated with porcelain gallbladder has been estimated at approximately 20%. Prophylactic cholecystectomy is generally recommended for a inding of gallbladder wall calcification on imaging studies. Other risk factors include primary sclerosing cholangitis, gallbladder infection with F cali and/or Salmonella species, and exposure to certain industrial solvents and toxins ‘Thirty percent of these tumors are diagnosed incidentally during cholecystectomy, and cancer is found in 03% to 196 of all cholecystectomy specimens, Symptorns of early-stage disease are often liectly caused by gallstones rather than the cancer. ‘The most common presenting symptom is RUQ pain similar to previous episodes of biliary colic but more persistent. Patients with more advanced eancer have vague RU pain, ‘weight loss, and malaise. Jaundice is present in approximately 50% of such patients because these cancers tend co spread early through direct extension into the liver and adjacent steuetures in the porta hepatis causing bility obstruction, and by metastasizing to the regional lymph node. Physical examination may show a mass in the RUQ.of the abdomen, which may not be recognized as a rncoplasm if the patient has acute cholecystitis, Suggestive ultrasound findings inelude thickening or irregularity of the gallbladder, a polypoid mass, or ilfuse wall caleiication indicative of porcelain gallbladder. CT scan and MRCP accurately identify the extent of disease and are important imaging modalities to evaluate for metastatic disease, The correct diagnosis is made preoperatively in only 1096 of cases Early and mucosal adenocarcinoma confined to the gallbladder wall is often identified after routine laparoscopic cholecystectomy. Because the overall 5-year survival rate i as high as 80%, cholecystectomy alone ‘with negative resection margins (including the cystic duct margin) is adequate therapy. Patients with a preoperative suspicion of gallbladder cancer should undergo open cholecystectomy. Larger tumors abutting or _growing into the liver parenchyma are treated with a liver wedge resection of the gallbladder fossa and a regional lymphadenectomy, Advanced tumors may require a formal liver resection, Porta hepatis lymphadenectomy lacks the standardization associated with other abdominal Iymphadenectomice because of the proximity of vital steuctures and the oxgan's lack of a mobile mesentery. Moreover, despite radical approaches, the 5-year survival rate remains poor («59% at 5 years) unless the cancer is detected incidentally a 4 small focus within a gallbladder remaved for symptomatic stone disease. BILE DUCT MALIGNANCIES Cancer of the bile ducts, called cholangiocarcinoma, accounts for approximately 39 of all GI malignancies. Anatomically, cholangiocarcinomas are classified as intrahepatic ( ising proximal to the bifurcation ofthe left and sight hepatic duets) and extrahepatic. Extrahepatic cholangiocarcinoma is further divided into pesihilar (including the confluence of the left and right hepatic ducts to the insertion of the cystic duct into the CBD) and distal segments (Eom the insertion of the cystic duet into the common duet to the ampulla of Vater) Extrahepatic cholangiocarcinoma ie by far the most common, with 50% of cases having peribilar disease and 40% of cases having distal segment disease, Intrahepatic eholangiocarcinoma represents only about 10% of all. 466bile duct malignancies Bile duct cancer occu with equal fequency in both sexes, usualy affeting individuals berween 50 and 70 yours of age. As with gallbladder cancer, chronic inlammatory processes often precede the development of overt malignancy. The risk of bile duet malignancy is significantly higher in patients with PSC (which is strongly associated with ulcerative colts). Other risk factors inchide choledachal cysts, infection with the parasitic liver Nukes Opisehrcisexverrini or Clonorehs sinensis, toxic exposures, chronic liver disease, obesity, and genetic disorders (specifically, Lynch syndrome and biliary papillomatosis). Approximately one-third of patients with bile det eareinoma have associated gallstones. Many cholangioearcinoma patients do not have a specifiers factor. Histologically, the lesions are usually mucin-producing adenocarcinomas. In general, bile duct cancers ae slow-growing, locally advanced tumors that rarely metastasize to distant sites, However, because of the anatomic relationships ofthe extrahepatic duct tothe liver, portal vein, and hepatic artery, curative resection of these lesions is the exception rather than the rule. (Common symptoms relate to local growth resulting in biliary obstruction, This leads to jaundice, prusitus dark wine, and clay-colored stools. Other common presenting symptoms include weight loss, abdominal pain, and fever, cholangitis is rare. In contrast tothe fluctuating jaundice chat ie often seen in patents with common duet caleui, the jaundice associated with bile duct cancers is progressive. On physical examination, hepatomegaly may be found. A palpable, nontender gallbladder in a jaundiced patient (Courvosier sign) indicates that the ste of the obstructing tumor is distal tothe junetion of the este duct with the common uct, although this finding is not specific ta bile duct malignancy. Distal cholangiocarcinomas presenting in ¢his manner thus mimie he symptoms of pancreatic tumors. Laboratory studies show a typical picture of cholestasis and biliay obstruction, Initial studies should include measurement of fractionated bilirubin, ALP, and serum aminotansferses. Abdominal ultrasound is ‘ypicilly the most helpful inital radiographie study. Although the cancer itielf may not be visualized, ductal dilatation in the absence of stones suggests the diagnosis. Follow-up with CT or MRI is helpful in determining the extrahepatic extent of the tumors and providing information about the reseetailty and invasion of adjacent structures. PTC and ERCP are very helpful in demonstrating lesions, assessing intraductal tumor extent, and obtaining cytologic specimens. PT is particularly use for evaluation of the proximal lesions and establishing antegrade acess for stenting these lesions Prognosis for cholangiocarcinoma is poor, witha S-year survival of only 5% to 1096, Surgery provides the only possibilty for cure, but achieving tumor-fice margins can be challenging, and local recurrence is common. The surgical approach depends on the location of the lesion. Intrahepatic cholangiocarcinomas are ‘ypicilly treated with liver resections, but negative margins ae achieved in «30% of patonts. [resection isnot possible, the tumor may be traversed with a guide wire and a stent passed through it to relieve the biliary obstruction, Perhilar tumors, also eilled Klatskin tumors, ae best treated by sesection and Rouwt-en-Y Ihepaicojejunostomy, often with the addition ofa hepatic resection. ‘The 5-year survival rate afer resection of ‘middle-third lesions is approximately 10%, If esection is not possible the bile duct may be stented with an ‘endoscopic or transhepatic approach. ‘The operation of choice for distal CBD tumors is the Whipple procedure, which involves reseeting the distal CBD, including the tumor, the pancreatic head, and the duodenum, Three anastomoses, connecting the pancreatic remnant, the hepatic duct, and the proximal GI 467tract in sequence to a mobilized length of jejunum, must be performed after the resection, The 5-year survival rate after a Whipple procedute for a lesion of the distal third of the CBD is approximately 12% to 25%. If distal lesions are unresectable, palliation can be achieved through a surgical bypass or biliary stent, CONGENITAL CHOLEDOCHAL CYSTS Very uncommonly, cystic enlargements of the bile ducts occur that are thought to be congenital. These are ‘more frequent in females (4:1 female-to-male ratio) and among the Asian population, Patients may present as asymptomatic after an imaging study performed for other reasons, or in the late teens or early 20s with pain and jaundice and rarely an upper abdominal mass, Choledochal eysts are best evaluated by CT sean initially anatomy further delineated by MRC or ERCP. Generally, itis recommended that these cysts bbe resected to address symptoms and the associated risk of bile duct cancer (20- to 30-fold increase risk over and the speci the general population). Following resection, a Roux-en-Y hepaticojejunostomy is performed to reestablish bile flow. Continued follow-up af these patients is important because anastomotic structures ean occur, and patients should be surveyed for malignancy. BILE DUCT INJURY AND STRICTURE ‘The majority of bile duct strctutes result ftom latrogenic injury during an operative procedure. The bile duct is capecially susceptible to this because of a limited blood supply and no redundancy. Approximately 75% of injuries occur during simple cholecystectomy and involve division of the bile duct and its vasculature close t0 the liver, This underscores the impor nce of recognizing the anatomic variations of the bikary tree correctly and proceeding in a cautions, systematic fashion even during routine cholecystectomy. Injures can involve the common duct, the hepatic duct, or the left and right hepatic duets, Although low, the incidence of bile duct injuries associated with laparoscopic cholecystectomy (0.4% to 0.6%) is about four times higher than that associated with open cholecystectomy. This incidence decreases with individual surgeon experience and is higher in operations performed for acute cholecystitis rather than those performed for biliary coli elective. Unfortunately, many iatrogenic injuries go unrecognized intraoperatively and declare themselves later as 2 subhepatic collection, iatrogenic occlusion, or delayed ctricture formation. When bile duct injury or anomaly is suspected intraoperatively, cholangiography should be performed to elincate the anatomy and suspected injury. Injures to accessory ducts smaller chan 3 min that drain a small amount of liver parenchyma may be ligated. Otherwise the operation should be converted to an open procedure and an operative repair should be performed. Ifthe injury involves <50% of the czcumferenee of ‘the duct, and the duct has not sustained signi ant devascularization, primary repair may be performed. A'T- tube stent is placed and brought out through another location in the common duet to decompress the duct and stent the repair open. In more significant injuries involving >50% of the circumference or with obvious devasculasization, a Roux-en-Y hepaticojeiunostomy or choledochojejunostomy should be performed in order to avoid stricturing of a primary repair. In the ently postoperative period, previously unrecognized bile duct injuties may cause severe abdorninal in, jaundice, drainage of bile from an operatively placed drain or through the wound, signs of acute abdomen, or sepsis, Ultrasonography or CT sean may be obtained to detect or exclude an intra-abdominal bile 468collection, which is called a biloma. Definition ofthe exact location of the ductal injury requires either ERCP or MRCP. A minor leak from an accessory hepatic duct is likely to heal spontaneously and merely requites the placement of a percutaneous drainage catheter in the subhepatic space under CT or ultrasound guidance. Leakage ftom a eystic duct is typically treated with ERCP placement of a stent. If major ductal injury is detected postoperatively, surgical reconstruction will need to be performed but should be delayed while the anatomy is defined, any sepsis resolves, and the local inflammation induced from the bie leak improves, Late development of stricture leads to obstructive jaundice and recurrent cholangitis. Long-standing strictures may result in biliary cirthosis and portal hypertension. Diagnosis of strictures is confirmed by MRC, ERCP, or PTC. Cholangitis should be managed with antibiotics and the stricture treated by bypassing the dilated proximal bile duet to a Roux-en-Y loop of jejunum. In the hands of experienced surgeons, excellent outcome of the operative repair is achieved in 70% to 90% of patients, For high-risk surgical candidates, stenting is an option, BRIEF DESCRIPTION OF SELECTED PROCEDURES, Laparoscopic Cholecystectomy Laparoscopic cholecystectomy has replaced open cholecystectomy as the preferred approach to the ‘management of gallstone disease in most lective and many emergent situations. When performed electvely in an otherwise healthy patient, most procedures can be done as day surgery. Even if the patient har serious comorbidities or if the surgery ie done for acute cholecystitis, postoperative hospital stay is usually only 24 to 48 hours, The main reason patients can undergo this surgery with such a short hospital stay isthe greatly reduced postoperative incisional pain when compared with that of open cholecystectomy. In addition to Lleereased postoperative pain and shorter length of stay, the advantages of the laparoscapie approach are reduced wound and pulmonary complications, and rapid recovery from the procedure with early return to normal activity, ‘The main riske associated with the laparoscopic approach are related to injury to the bile ducts, intestine, and major vessels, usually resulting from blind trocar insertion or the injudicious use of electrocautery. With, greater experience of the operating surgeon, the sis of complications diminishes significantly. If anatomy is obscured because of the pathologie process or technical difficulties encountered with the laparoscopic approach, the laparoscopic procedure must be converted to an open approach. There is some controverty ato whether cholangiography should be performed routinely or selectively at che time of laparoscopic cholecystectomy. Most surgeons utilize a selective approach, If tones are found in the CBD on intraoperative cholangiography, they may be removed laparoscopicaly through the cystic duct or an incision in the CBD. during the same operation depending on surgeon experience. Alternatively, ERCP with stone extraction and sphincterotomy may be performed postoperatively. Only if these options were not available would the Laparoscopic procedaze be converted to an open CBD exploration to extract the stones. Open Cholecystectomy and CBD Exploration Open cholecystectomy is generally pesformed through a right subcostal incision, After the abdomen is opened, the gallbladder is exposed and the gallbladder is dissected out of the gallbladder fossa, An JOC may 469bbe performed through the eystic duet at any time to define the anatomy and confirm or exclude suspected choledocholithiasis. Both the cystic duct and artery are individually identified and ligated. ‘A common duct exploration ie sometimes performed during a cholecystectomy. Absolute indications for this include a palpable common duet stone and common duet stones visualized on preoperative or IOC. Relative indications include jaundice, acute biliary pancreatitis, ductal dilation, and small gallbladder stones Operative cholangiogram is performed to confirm or exclude stones in the bile duct when only relative indications for bile duct exploration are present “The procedure for open CBD exploration involves mol identify saline using flexible catheters to help flush out stones and debris from the duct. Inflatable balloon catheters are iting the duodenum with a Kocher maneuver, the duet and making a small longitudinal incision in the CBD. Then the lumen is irrigated with ‘passed both proximally and distally in an attempt to extract stones, A small endoscope (choledochoseope) may bbe advanced through the opening and the duct thus careflly visualized both proximally and distally so determine whether residual stones ate present, A vatiety of instruments, including stone forceps and collapsible wire baskets ate available to remove stones that remain impacted and resist removal by the previous maneuvers, All stones, mucus, and debris are removed from the bile duet, and the duct i irxigated with saline ATT tube is then placed in the lumen of the duct, and the opening in the duct is closed around the T tube. A completion cholangiogram is obtained to ensure that no stones remain in the duet and that eonteast flows freely in the duodenum. A closed drainage catheter is often left in the subhepatic space. When there are ‘multiple stones, or the physician believes that there are stones left in the bile due, itis prudent to perform an anastomosis between the bile duct and the GI tract (choledochoduodenostomy or choledochojejunostomy), so that residual stones may pass easily from the duct into the intestine. ‘The peritoneal drainage catheter is removed within 24 to 48 hours after the T tube has been clamped. Drainage of significant amounts of blood o bile requires farther investigation. ‘The typical T tube is let in place for 3 weeks, after which an injection of contrast material inthe radiology department is obtained. If the dye flows freely into the duodenum and demonstrates no filling defects, the T tube may be removed. T tubes are typically pulled after an established track is present (3 to 6 weeks). If there is any concern about interpretation of the cholangiogram, the T tube is left in place for a longer period of time and the x-ray study is repeated, Occasionally, despite thorough common duct exploration, a filling defect is noticed in the postoperative ‘T-tube cholangiogram, indicating a missed or retained stone. In approximately 20% of patients, these stones ‘pass spontancously, especially if they are small. Under such circumstances, the T tube islet in place for 4 t0 6 ‘weeks, and the cholangiogram is repeated. If stones remain, they may be extracted with the use of ERCP techniques. Alternatively, the T-tube tact ean be used to advance a wire basket into the duct under ‘luoroscopy, so that the stones might be retrieved. In the rare circumstances where none of these methods is successful, operative reexploration of the duct is necessary Endoscopic Extraction of CBD Stones ‘Most CBD stones ate removed by ERCP and sphincterotomy. Sphineterotomy of the sphineter of Oddi is performed by a special cautery wire passed through the duodenoscope into the sphincter, The common duct iz then cleased of stones and debris using special balloon catheters or wire baskets also passed through the 470duodenoscope. When performed clectvely, this is usualy an outpatient procedure. Any cougulopathy should bbe conected before the procedure, Ifa stone cannot be extracted, jaundice can be relieved by inserting a stent with one end above the stone and the other in the duodenum. This stent is left in place, providing biliary Aecompression until ERCP extraction can be attempted again or surgical stone removal can be arranged, Potential complications of ERCP with sphincterotomy and stone manipulation are postprocedure pancreatitis, GI bleeding (196 to 298) and duodenal or common duct perforation (0.3%). SUGGESTED READINGS Ayub K, Imada R, Slavin J. Endoscopic retrograde cholangiopancreatography in gallstone-associated acute pancreatitis. Cochrane Database Syst Rev. 2004:18(4):CD008630. da Costa DW, Boesma D, van Santvoort HC, et al. Staged mulidisciplinary step-up management for necrotizing pancreatitis. BrJ Surg. 2014;101(1):265-£79. European Association for the Study of the Liver, EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016;65(1): 146-181, Luu MB, Deziel DJ. Unusual complications of gallstones. Surg Clin North Ams, 2014;94(2):377-394, Chease the best answer for each question. 1. The blood supply tothe gallbladder isa branch of the |A, gastroduodenal artery B. proper hepatic artery fight hepatic artery D. sight gastric artery E, superior mesenteric artery 2. Bile consists of ‘A. alluen, bile acids, tglycerides 1B, bile acids, triglycerides, phospholipids ©. albumen, cholesterol, bile acids D, bile acid, lecithin, cholesterol , lipopotysaccharid, bile acid albumen 3, Which laboratory esults would be most consistent with biliary obstruction from choledocholithiasis? ‘A, normal ALP and high total bilirubin B. high AST and high total bilirubin © high AST and high ALT D. normal ALP and normal ALT. am. high total bilirubin and high ALP. 4, 60-year-old male who is status post open repair of abdominal aortie aneurysm rupture has been. inthe intensive care unit for the past 2 weeks since on a ventilator with total parenteral nutrition. He is responsive and able to communicate, He complains of upper abdominal pain that he locates, in the RUQepigasteie area, White blood cell count is now 12,500 and the ALP, AST, and ALT are elevated. The total bilirubin is normal. The best test to use to diagnose this patients condition A. CT sean of abdomen B. HIDAsean ©. ultrasound of the RUQ. D. MRCP E, abdominal series 5, A 72-year-old man comes to the clinic because his wife noticed that his eyes are yellow. Recently, hhe has found that his urine ie dark and his stools light in color. He alzo has a diminished appetite bout otherwise is feeling well without other complaints. His past medical history is unremarkable He smoked cigarette for 30 years but quit 15 years ago. On examination, he is afebrile and hie vital signs are normal. He is deeply jaundiced and when examining the abdomen, a nontender smooth globular mass is found in the RUQ The rest of hie examination is normal. Which of the following is the most likely diagnosis in this patient? ‘A. Bie duct cancer B. Choledocholihiasis C. Choledochal eyst D. Biliary stricture E, Gallstones Answers and Explanations 1. Answer: ‘The eystic artery isa branch of the right hepatic artery. The cystic artery branches into an anterior and posterior branch before joining the gallbladder. Both of these branches will require ligation when performing a cholecystectomy. For more information on this topic, please see the section on Anatomy. 2. Answer: D ‘The three components of ble (bile aids, lecithin, and cholesterol) ate normally balanced, but when one ‘component of bile ie present in a higher concentration, the formation of gallstones (cholesterol, bile, mixed) can occur. For more information on this topic, please see the section on Pathogenesis of Gallstones (Cholelithiasi) 3. Answer: Patients with choledocholithiasis can present with biliary obstruction revulting in a high total bilirubin, 4nand ALP. AST and ALT are more likely clevated in the case of liver inflammation like hepatitis Patients with biliary obstruction can have an elevated AST and ALT alone, but the ALP and total bilirubin values are relatively more elevated. For more information on this topic, please see the section on Laboratory Test. 4. Answer: © ‘The presentation is consistent with possible cholecystitis. This clinical presentation is typical for acaleulous cholecystitis in asic patient who has been NPO. A HIDA scan in ths situation would have a high false-positive rate because the patient is NPO. A CT sean would not be as definitive as ultrasound bbut would be the test of choice if you were considering other possible etiologies. MRCP and an abdominal series would not be helpful. For more information on this topi, please see the section on. Imaging Stuies, 5. Answer: A When a patient presents with jaundice and acholie stols, a bile duct obstruction is likely present. Galltones alone do not cause a bile duct obstruction. The ather diagnoses listed may be associated with ‘obstructed jaundice. Given the patient's age and the presentation along with a distended gallbladder (Courvoisiee sign), the most ikely diagnosis i a pancreaticobilisry malignancy. For more information on ‘this topic, please see the section on Bile Duet Malignancies. 473