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76 Cards in this Set
- Front
- Back
Composition of bile solutes.
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- bile salts (67%): cholates, chenodeoxycholates, deoxycholates, lithocholates, ursodeoxycholates
- phospholipids (22%) - cholesterol (4%) - protein (4.5%): secreted to conjugate drugs - bilirubin (0.3%) |
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Compostion of bile secreted by hepatocytes.
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- 97% water
- 3% solutes |
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What are some functions of gall bladder?
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- concentrate bile by 5-10 fold: active absorption of eletrolytes, waters follows sodium
- release bile when stimulated by CCK (I cell in duodenum and jejunum) in response to lipid and protein in small intestine. |
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Where are most of secreted bile (95%) salts reabsorbed?
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ileum
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What is a very sensitive screen for gall bladder calculi?
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ultrasound
- can detect stones as small as 2-3mm diameter |
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What is ERCP useful for?
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- directly visualize bile ducts
- inject dye into pancreatic and extrahepatic bile ducts - take biopsies - place stents to relieve obstructions |
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What imaging step is required after cholecystectomy?
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Intraoperative cholangiogram
- make sure there is no left over gall stone in common bile duct |
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Name three general categories of congenital gall bladder anomalies.
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- cystic diseases
- extrahepatic biliary atresia - anatomic variants |
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What are some classes of cystic diseases of bile ducts (5)?
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- choledochal cyst: dilation of common bile duct
- diverticulum of bile duct - choledochocele: cysts protrudes into duodenum - multiple cysts (caroli disease) - fusiform cysts: intra- and extra- hepatic |
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What is this cystic disease of gall bladder?
- dilations of common bile ducts |
choledochal cyst
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What is this cystic disease of gall bladder?
- cysts attached to common bile duct |
diverticulum
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What is this cystic disease of gall bladder?
- cysts protrudes into duodenum |
choledochaocele of intraduodenal bile duct
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What is this cystic disease of gall bladder?
- multiple intrahepatic cysts |
caroli disease
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What is this cystic disease of gall bladder?
- intra- and extra-hepatic cysts |
fusiform cysts
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What are some complications of cystic disease?
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- obstruction
- perforation -> bile peritonitis - ascending cholangitis (caroli disease) - hepatic abscess - secondary biliary cirrhosis - carcinoma (rare) |
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What is a common complication associated with caroli disease?
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ascending cholangitis
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What is this gall bladder disease?
- complete obstruction od bile flow due to destruction/absence of all or part of extrahepatic bile ducts |
extrahepatic biliary atresia
- neonatal jaundice (conjugated) - 10% surgically curable. others need liver transplant |
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Treatment for extrahepatic atresia.
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- 10% surgically curable
- others need liver transplant |
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Describe the morphology of early sequalae of extrahepatic biliary atresia.
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- inflammation and/or necrosis of bile duct cells
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Describe the morphology of late sequalae of extrahepatic biliary atresia.
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- fibrosis/obliteration of bile duct -> biliary cirrhosis
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Name some anatomic variations of gall bladder (3).
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- hourglass gallbladder
- double and bilobed gallbladder - aberrant locations of gall bladder: intrahepatic gallbladder, and left sided gallbladder. |
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Name some anatomic variations of bile ducts (3).
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- abnorsmally long
- accessory hepatic ducts - low fusion of hepatic ducts -> double common bile duct |
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What is this anatomic variation of gallbladder?
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Hourglass gallbladder
- septation |
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Definition: stones in gallbladder.
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cholelithiasis
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Definition: stones in common bile duct.
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choledocholithiasis
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Three varieties of gallstones.
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- pure cholesterol: 10%
- pure pigment (calcium bilirubinate): 10% - mixed: 80% |
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What percentage of all gallstones contain cholesterol?
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90%
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What percentage of all gallstones contain pure cholesterol?
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10%
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What makes up the pure pigment gallstone?
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Calcium bilirubinate
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Pathogenesis of gallstone.
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- deficient bile salts or excess cholesterol -> cholesterol supersaturation -> crystals
- gallbladder hypomotility and hypersecretion of mucus -> accretion of crystals - calcium salts + cholesterol crystals => stone |
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Which gender has more risk for cholesterol containing gallstones?
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premenopausal women
- estrogen promotes uptake and synthesis of cholesterol by hepatocytes (OCP and pregnancy) |
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What are some risk factors for cholesterol containing gallstones?
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- native american, inductrialized societies
- elderly - premenopausal women - estrogen - obesity - hypercholesterolemia - family history - GI disorder that interferes with bile salt reabsorption in ileum (Crohn's) |
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What are some risk factors for pure pigment gallstones?
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disorders with elevated unconjugated bilirubin in bile
- hemolytic syndromes - disease or removal of ileum - bacterial infection of biliary tree (E coli): beta-glucuronidase convert conjugated yo unconjugated bilirubin - parasitic infection: clonorchis, ascaris lumbricoides |
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How does bacterial infection such as E. coli cause pure pigment stones of gallbladder?
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beta-glucuronidase convert conjugated yo unconjugated bilirubin
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People who had ileum removal is at risk for what gallbladder conditions?
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gall stones
- less bile salts in bile |
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What are some complications of gallstones?
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- common bile duct obstruction
- biliary colic - acute cholecystitis with sepsis - acute pancreatitis (obstriction of pancreatic duct) - gallstone ileis: fistula from gallbladder to small bowel - Mirizzi syndrome: stone in bile duct causing stricture |
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What is this complication of gallstones?
- fistula from gallbladder to small bowel |
gallstone ileus
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What is this complication of gallstones?
- stone in bile ducts causing stricture |
Mirizzi syndrome
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Is medical treatment useful in gallstones?
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only for pure cholesterol stones
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How to treat gallstones?
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- medicine for pure cholesterol stones
- surgery: laproscopic, open cholecystectomy, ERCP |
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What is this gallbladder disease?
- intermittent pain, recently worse RUQ pain - fever, leukocytosis - palpable dilated gallbladder - jaundice |
acute cholecystitis
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Pathogenesis of acute cholecystitis.
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- 90% calculous
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What are some treatments for acute cholecystitis?
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- 25% require risky surgery because of pain, stones or sepsis
- others: antibiotics followed by elective surgery |
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What is this gallbladder disease?
- intermittent nausea, belching, discomfort - epigastric or RUQ pain - symptoms worse after meals (fatty or large meals) "flatulent dyspepsia" |
chronic cholecystitis
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What is this gallbladder disease?
gross - stones and thickened wall micro - hyperplasia of fibromuscular layer |
chronic cholecystitis
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What are some variants of typical chronic cholecystitis?
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- Porcelain gallbladder: lithiasis gradually erode mucosa, leaving a leathery wall
- hydrops: stone obstructing cystic duct -> watery fluid in lumen - mucocele: stone obstructing cystic duct -> thick mucoid fluid in lumen |
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What is this gallbladder disease?
- leathery thicj all and eroded mucosa - stone found at orifice of cystic duct |
porcelain gallbladder (variant of chronic cholecyctitis)
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What is this gallbladder disease?
- watery fluid in lumen - stone obstructing cystic duct |
hydrops variant of chronic cholecystitis
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What is this gallbladder disease?
- thick mucoid fluid in lumen - stone obstructing cystic duct |
mucoid variant of chronic cholecystitis
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Name some non-neoplastic disorders of the gallbladder.
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- cholesterolosis
- cholesterol polyps - diverticular disease - torsion - metaplasia (gastric type) and dysplasia |
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What is this gallbladder disease?
- accumulation of lipid laiden macrophages in lamina propria |
cholesterolosis
- diffuse linear streaks in mucosa |
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What is this gallbladder disease?
- accumulations of cholesterolosis |
cholesterol polyps
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What is this gallbladder disease?
- diffuse mural thickening with cysts in the wall - cysts lined by normal columnar epithelium embedded within fibromuscular layer |
diverticula: localized adenomyomatous hyperplasia type
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Name the 2 types of diverticular diseases of the gallbladder.
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- diffuse type: adenomyomatosis
- localized type: adenomyomatous hyperplasia |
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Pathogenesis of diverticular disease of gallbladder.
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pulsion diverticulum
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Torsion of the gallbladder leads to _____.
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ischemia -> necrosis (urgent surgery to avoid rupture with bile peritonitis
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Neoplastic or non-neoplastic gallbladder disease?
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non-neoplastic
- metaplasia (gastric type) due to chronic inflammation |
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Neoplastic or non-neoplastic gallbladder disease?
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non-neoplastic
- dysplasia due to chronic inflammation |
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Are gallbladder neoplasms common?
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NO!
but if one has one, it is more likely to be malignant. |
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Benign neoplasm of the gallbladder. (4)
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- papillary adenoma
- heterotopias: gastric, pancreatic - non-epithelial neoplasms: lipoma, fibroma - adenomyomatous hyperplasia (diverticulum) |
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What is this gallbladder disease?
gross - soft, polypoid, exophytic lesion protruding into lumen micro - papillary frons of epithelium supported by fibrovascular stroma - no invasion of wall |
papillaty adenoma
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Which type of gross appearance is this gallbladder carcinoma?
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diffusely infiltrating (70%)
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Which is more common?
carcinoma of the gallbladder or carcinoma of the bile duct |
carcinoma of the gallbladder
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What is the observation of the correlation between gallstone and gallbladder carcinoma?
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- 80-90% gallbladder carcinoma have gallstones
- 0.5% patients with gallstones develop carcinoma |
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3 microscopic features of gallbladder carcinomas. Which one is most common?
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- adenocarcinoma in situ (5%)
- invasive adenocarcinomas (90%) - squamous cell carcinoma or mixed (5%) |
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What is the clinical presentation of gallbladder carcinoma?
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- often late and invading liver with regional/distant metastases
- poor prognosis: 5-10% 5 yr survival |
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What is the most common site of carcinoma of bile ducts?
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1. ampula
2. common bile duct 3. hepatic duct 4. junction hepatic and common duct (Klatskin tumor) |
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What is this called?
- carcinoma at the junction of hepatic and common bile duct |
Klatskin tumor
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What is this biliary disease?
- obstructive jaundice - predisposition: gallstones, parasitic infections, sclerosing cholangitis, chronic ulcerative colitis |
- carcinoma of bile ducts
- stones in common bile duct * need to differentiate |
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How to surgically treat carcinoma of bile duct?
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Whipple procedure for lesion <2cm big
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Inflammation of the Bile ducts?
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Cholangitis
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Causes of cholangitis is depending on what type of diseases?
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-ductal strictures
-parasitic infestation -bacterial infection -stones -neoplasm |
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Stones in the CBD
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Choledocholithiasis
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Majority of the stones have migrated from the gallbladder is usually associated with calculous cholecystitis
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Choledocholithiasis
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Primary areas for obstruction
Intrapancreatic Suprapancreatic porta hepatis |
Extrahepatic biliary obstruction
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What three conditions that called the majority of biliary obstruction at the level of the distal duct and causes extrahepatic duct to be entirely dilated?
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Pancreatic carcinoma
Choledocholithiasis Chronic pancreatitis with stricture formation |