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What artery does the cystic artery come off of?
Right hepatic a.
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Triangle of Calot
Cystic duct, CBD, liver edge
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Blood supply to CBD
Right hepatic artery, GDA
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Parasympathetic innervation of gallbladder
Vagus (anterior/left trunk)
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Sympathetic innervation of gallbladder
T7-T10
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Drug that contracts the sphincter of Oddi
Morphine
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Drug that relaxes the sphincter of Oddi
Glucagon
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Normal pancreatic duct size
<4mm
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Invagination of epithelium of the wall of the GB formed from increased GB pressure
Rokitansky-Aschoff sinuses
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Biliary ducts that go directly into the GB from the liver
Ducts of Luschka
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Factors that increase bile excretion (3)
CCK, secretin, vagal input
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Factors that decrease bile excretion (3)
Somatostatin, VIP, sympathetic stimulation
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Essential functions of bile (3)
Fat soluble vitamin absorption, bilirubin excretion, cholesterol excretion
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% of bile salts lost in stool
5-10%
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Location of active resorption of conjugated bile salts (and proportion absorbed by this method)
Terminal ileum (50%)
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Location of passive resorption of nonconjugated bile salts (and proportion absorbed by this method)
Small intestine (45%) and colon (5%)
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Breakdown product of conjugated bilirubin in the gut; gives stool brown color
Stercobilin
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Breakdown product of conjugated bilirubin in gut; yellow
Urobilin
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Enzyme that synthesizes cholesterol
HMG coA reductase
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Cause of gallstones in obese people
Overactive HMG coA reductase
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Cause of gallstones in thin people
Underactive 7-alpha-hydroxylase
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Most common type of gallstone found on ultrasound
Nonpigmented stones
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Gallstones caused by stasis, calcium nucleation by mucin glycoproteins, and increased water absorption from GB
nonpigmented stones
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Most common type of gallstone worldwide (ex: US)
Pigmented stones
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Gallstones caused by solubilization of unconj bili with precipitation of calcium
Pigmented stones
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Gallstones caused by hemolytic disorders or cirrhosis, chronic TPN or ileal resection
Black stones
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Type of stone primarily found in CBD
Brown stones
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GB wall distension and inflammation caused by obstruction of cystic duct by stones
Cholecystitis
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Most common organisms in suppurative cholecystitis (3)
E. coli, klebsiella, enterococcus
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Findings of acute cholecystitis (3)
Gallstones, GB wall thickening, pericholecystic fluid
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If GB cannot be seen on HIDA, then . . .
Cystic duct is probably obstructed; need cholecystectomy
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Impaired GB excretion despite adequate stimulation by CCK
Biliary dyskinesia
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Indications for preop ERCP (6)
Jaundice, cholangitis, pancreatitis, inc bilirubin, inc AST/ALT, CBD stone
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% of patients who have a retained stone after cholecystectomy
5
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Transient cystic duct obstruction caused by gallstone passage
Biliary colic
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Causes of pneumobilia (3)
Previous ERCP, cholangitis, erosion of biliary system into duodenum (gallstone ileus)
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Causes of acalculous cholecystitis (4)
Severe burns, prolonged TPN, trauma, major surgery
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Gas in GB wall secondary to C. perfringens
Emphasematous gallbladder disease
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Fistula between GB and duodenum causing SBO
Gallstone ileus
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Treatment of CBD injury after lap chole
Hepaticojejunostomy (if >50% circumference injury); primary repair (if <50% circumference)
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Treatment of bile leak
ERCP/stent if small injury, hepaticojejunostomy if large injury
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Most important cause of late postoperative biliary strictures
Ischemia
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UGI bleed, jaundice, RUQ pain + Fistula between biliary system and hepatic artery
Hemobilia
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Most common cancer of biliary tract
GB adenocarcinoma
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Gallbladder type that increases risk of GB cancer
Porcelain gallbladder
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Treatment of porcelain GB
Cholecystectomy
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Treatment of stage I GB cancer
Cholecystectomy
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Treatment of stage II GB cancer
Cholecystectomy + segment IV and V resection + regional lymphadenectomy
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Risk factors for cholangiocarcinoma (7)
C. sinesis infection, typhoid, PSC, UC, choledochal cyst, chronic bile duct infection, congenital hepatic fibrosis
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Cholangiocarcinoma in upper 1/3 of bile duct; usually unresectable
Klatskin tumor
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Fusiform or saccular dilation of extrahepatic ducts
Type I choledochal cyst
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Totally intrahepatic cystic disease of bile ducts
Type V choledochal cyst (Karoli?s disease)
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Autoimmune disease with beading of bile ducts on ERCP; can lead to portal HTN and hepatic failure
PSC
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Drug to decrease pruritic symptoms in liver disease (2)
Cholestyramine, urodeoxycholic acid (UDCA)
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Autoimmune disease caused by anti-mitochondrial antibodies that can lead to liver failure
PBC
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Charcots triad
RUQ pain, fever, jaundice
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Reynold?s pentad
Charcot?s triad + mental status changes and shock
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Most common organisms causing cholangitis
E. coli, Klebsiella
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Late complications of cholangitis (2)
Abscess, stricture
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Most common cause of shock after lap chole (2: early AND late)
Hemorrhagic (from clip falling off) and septic (from CBD clip/cholangitis)
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Thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus
Adenomyomatosis
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Benign neuroectoderm tumor of GB
Granular cell myoblastoma
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Speckled cholesterol deposits on GB wall
Cholesterolosis
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Treatment of GB polyp
Cholecystectomy
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Compression of common hepatic duct by a stone in the infundibulum of GB
Mirizzi syndrome
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