1. Gallbladder and Extrahepatic Biliary System
Chapter 32 Schwartz’s

2. 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

3. Anatomy

4. Anatomy
The cystic artery which supplies the gallbladder is usually a branch of what artery?

5. 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

6. Anatomy
What are the boundaries of the Triangle of Calot?

7. Anatomy What are the boundaries of the Triangle of Calot?
Cystic duct, common hepatic duct, liver margin

8. Anatomy
Name the mucosal folds found in the cystic duct adjacent to the gallbladder neck.
Extra credit: do they have any valvular function?

9. Anatomy
The Spiral Valves of Heister, and no they do not have any valvular function.

10. Anatomy
The arterial supply to the bile ducts is derived from which 2 major arteries and is oriented in what clock positions???

11. 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)

12. 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

13. 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

14. 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

15. 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

16. Anatomy Ducts of Luschka
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

17. 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

18. Physiology Stimulates Gallbladder Contraction
Stimulates Gallbladder Relaxation
CCK
Atropine
Parasympathomimetics
VIP
Vagus Nerve
Splanchnic Sympathetic Activity
Antral distention of stomach
Somatostatin

19. 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

20. 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
All of them are!!!

21. Physiology Which of the following is not a major component of bile?
Cholesterol
Bile Salts
Lecithin
Budweiser

22. Physiology Which of the following is not a major component of bile?
Cholesterol
Bile Salts
Lecithin
Budweiser

23. 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

24. Imaging
True or False: Ultrasound will show stones in the gallbladder with a sensitivity and specificity of >90%.

25. Imaging
True or False: Ultrasound will show stones in the gallbladder with a sensitivity and specificity of >90%.
TRUE

26. Imaging
True or False: MRCP has 95% sensitivity and 89% specificity at detecting choledocholitiasis .

27. Imaging
True or False: MRCP has 95% sensitivity and 89% specificity at detecting choledocholitiasis.
TRUE

28. 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…..

29. 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.

30. 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

31. Surgical Treatment
Is prophylactic cholecystectomy routinely indicated in patients with asymptomatic gallstones?

32. Surgical Treatment
Is prophylactic cholecystectomy routinely indicated in patients with asymptomatic gallstones? NO

33. 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

34. 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!

35. 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?

36. 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

37. PEG
What do you call this?

38. 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.

39. Surgical Tx of Gallstones
26 yo G1P0 presents to ED with symptomatic gallstones refractory to medical management, dietary modifications.
Is lap chole safe???

40. Surgical Tx of Gallstones
26 yo G1P0 presents to ED with symptomatic gallstones refractory to medical management, dietary modifications.
Is lap chole safe???
YES
Chapter says lap chole safe in second trimester

41. 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

42. Murphy’s Sign
An inspiratory halt upon deep palpation of the R subcostal area, characteristic of acute cholecystitis

43. 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

44. 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

45. 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

46. Acute Cholecystitis Tx
IV fluids, pain meds, Antbx (cover gram neg aerobes and anaerobes, 3rd gen cephalosporin)
Cholecystectomy is definitive tx
Earlier the better!