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What segments of the liver does the gallbladder lay under?
IV and V
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Where does the cystic artery branch from? What does it go 'through'?
The cystic artery branches off the R hepatic artery
It goes through the triangle of Calot (cystic duct [lateral], common bile duct [medial], liver [superior])
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Whats is the 'longitudinal blood supply'?
The Right hepatic (lateral) and retroduodenal branches of the gastroduodenal artery (medial) supply to the hepatic and common bile duct (9- and 3- o'clock positions when performing ERCP); considered longitudinal blood supply.
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Where do cystic veins drain to?
Cystic veins drain in to the right branch of the portal vein and into the liver
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Where are lymphatics in relation to the common bile duct?
lymphatics are on the right side of the common bile duct
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Where are parasympathetic fibers from?
parasympathetic fibers are from the left (anterior) trunk of the vagus
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Where are sympathetic fibers from and what do they course through?
sympathetic fibers from T7-T10 coursing through splanchnic and celiac ganglions
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Describe the histology of the gallbladder wall?
Gallblader has no submucosa; mucosa is columnar epithelium
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Which parts of the biliary tree do not have peristalsis?
Common bile duct and hepatic duct do not have peristalsis
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How does the gallbladder normally fill?
Gallbladder normally fills by contraction of sphincter of Oddi at the ampulla of Vater
- * Morphine- contracts the sphincter of Oddi
- * Glucagon- relaxes the sphincter of Oddi
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What are the normal sizes of:
- CBD
- gallbladder wall
- pancreatic duct
- CBD- <8mm (<10mm after cholecystectomy)
- Gallbladder wall <4mm
- Pancreatic duct <4mm
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What happens to total bile acid pools after cholecystectomy?
after cholecystectomy, total bile acid pools decrease
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Where are the highest concentrations of CCK and secretin cells?
The highest concentration of CCK and secretin cells are in the duodenum
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Rokitansky-Aschoff sinuses
invagination of the epithelium of the wall of the gallbladder; formed from increased gallbladder pressure
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Ducts of Luschka
biliary ducts that go directly from the liver into the gallbladder; can leak after a cholecystectomy
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Bile excretion regulation:
- Increase bile excretion:
- 1) CCK
- 2) Secretin
- 3) Vagal input
- Decrease bile excretion:
- 1) VIP
- 2) Somatostatin
- 3) Sympathetic stimulation
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Gallbladder contraction:
CCK causes constant, steady tonic contraction
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Essential Functions of bile:
- 1. Cholesterol excretion
- 2. Bilirubin excretion
- 3. Absorb fat soluble vitamins
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How does the gallbladder form concentrated bile?
The gallbladder forms concentrated bile by active resorption of Na and water
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How large is the bile salt pool?
How often does it cycle in a day?
- Bile salt pool is 5-7g.
- It cycles 4-8 times/day
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How much bile salt is lost in stool?
Where and how much is resorbed?
- Small amount (5-10%) of bile salts are lost in stool.
- - active resorption of conjugated bile acids occurs in the terminal ileum (50%)
- - Passive resorption of nonconjugated bile acids can occur in the small intestine (45%) and colon (5%)
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When and what percentage is postprandial emptying maximum?
postprandial emptying maximum at 2 hours (80%)
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What is bile secreted by?
Canalicular cells (20%) and hepatocytes (80%)
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Color of bile:
The color of bile is mostly due to conjugated bilirubin
Stercobilin- the breakdown product of conjugated bilirubin in gut; gives stool brown color
Urobilin- breakdown product of conjugated bilirubin in gut; some gets reabsorbed and released in urine
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Cholesterol and bile acid synthesis:
1. HMG-CoA--> (HMG CoA reductase) --> Cholesterol--> (7 alpha hydroxylase) --> bile acids
2. HMG CoA reductase - rate-limiting step in cholesterol synthesis
3. Stones in obese people - overactive HMG CoA reductase
4. Stones in thin people- underactive 7-alpha-hydroxylase
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Gallstones:
- 1) occur in 10% of the population; most asymptomatic
- 2) Only 10% of gallstones are radiopaque
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Nonpigmented stones:
- Increased cholesterol insolubilization; caused by:
- 1) stasis
- 2) calcium nucleation by mucin glycoproteins
- 3) increased water resorption from gallbladder
- 4) decreased lecithin and bile acids
- found almost exclusively in the gallbladder
Most common type of stone found in US (75%)
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Pigmented Stones:
- 1) most common worldwide, 25% of stones in US
- 2) caused by solubilization of unconjugated bilirubin with precipitation of calcium bilirubinate and insoluble salts
- 3) Dissolution agents do not work on pigmented stones (mono-octanoin)
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Black Stones
- Can be caused by:
- 1) hemolytic disorders
- 2) cirrhosis
- 3) patients on chronic TPN
- 4) patients with ileal resection
- 2) Important factors for development of these stones:
- 1- increased bilirubin load
- 2- decreased hepatic function
- 3- bile stasis
4) almost always form in gallbladder
5) Tx: cholecystectomy
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Brown Stones:
- 1) primary CBD stones, formed in ducts
- 2) Infection causing deconjugation of bilirubin
- 3) Increased in Asians
- 4) E. coli most common- produced beta-glucuronidase, which deconjugates bilirubin, causing formation of calcium bilirubinate
- 5) need to check for ampullary stenosis, duodenal diverticula, and abnormal sphincter of Oddi
- 6) most commonly form in the bile duct (are primary common bile duct stones)
- 7) Almost all patients with primary stones need a biliary drainage procedure- sphincteroplasty 90% successful
- 8) cholesterol stones and black stones found in the CBD are considered secondary common bile duct stones
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Cholecystitis
- 1) caused by obstruction of the cystic duct by a gallstones
- 2) results in gallbladder wall distention and wall inflammation
- 3) Symptoms: RUQ pain, referred pain to the right shoulder and scapula, nausea/vomiting, loss of appetite
- 4) Attacks frequently after a fatty meal and pain is persistent (unlike biliary colic)
- 5) Murphy's sign- patient resists deep inspiration with deep palpation to the RUQ secondary to pain
- 6) Alkaline phosphatase and WBC are frequently elevated
- Suppurative cholecystitis- associated with frank purulence in the gallbladder--> can be associated with sepsis & shock
- Most common organisms in cholecystitis:
- -E. coli
- -klebsiella
- -enterococcus
- Stone risk factors:
- 1) >40
- 2) female
- 3) obesity
- 4) pregnancy
- 5) rapid weight loss
- 6) vagotomy
- 7) TPN (pigmented stones)
- 8) ileal resection (pigmented stones)
- Ultrasound
- 1) 90% sensitive for picking up stones--> hyperechoic focus, posterior shadowing, movement of focus with changes in position
- 2) best initial evaluation test for jaundice or RUQ pain
- 3) Findings suggestive of acute cholecystitis- gallstones, gallbladder wall thickening (>4mm), pericholecystic fluid
- 4) Dilated CBD (>8mm) suggests CBD stone and obstruction
- HIDA Scan
- 1) technetium taken up by liver an excreted in the biliary tract
- 2) If gallbladder cannot be seen, it is secondary to cystic duct obstrution by stone--> needs cholecystectomy
- 3) If <25% of gallbaldder volume excreted after CCK over 2 hours--> biiary dyskinesia; although not totally occluded, the excretion is reduced.
- 4) 50% of these patients benefit from cholecystectomy
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Indications for preop ERCP (signs that a common bile duct stone is present):
- 1- jaundice
- 2- cholangitis
- 3- gallstone pancreatitis
- 4- increased bilirubin (can also be due to primary liver disease)
- 5- signficantly increased AST/ALT (can also be due to primary liver disease)
- 6-stone in CBD on ultrasound.
<5% of patients undergoing cholecystectomy will have a retained CBD stone --> 95% of these cleared with ERCP
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Whats the treatment for cholecystitis?
- 1- cholecystectomy
- 2- cholecystostomy tube can be placed in patients who are very ill and cannot tolerate surgery
- - when a patient is subsequently able to tolerate surgery, cholecystectomy is performed
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ERCP
- 1) best treatment for late common bile duct stone
- 2) sphincterotomy allows for removal of stone
- 3) grasper and other tools can then be used to remove the stone
- 4) Risks: bleeding, pancreatitis, perforation
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Biliary Colic-
- 1) transient cystic duct obstruction caused by passage of gallstone
- 2) resolves in 4-6 hours
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Air in the biliary system:
- 1) most commonly occurs with previous ERCP and sphincterotomy
- 2) can also occur with cholangitis or erosion of the biliary system into the duodenum (i.e. gallstone ileus)
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Bacterial infection of bile
- 1) dissemination from portal system is usual route.
- 2) can also get retrograde infection from bacteria in duodenum
- 3) highest incidence of positive bile cultures occurs with postoperative strictures (usually E. coli, often polymicrobial)
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Acalculous Cholecystitis
- 1) thickened wall, RUQ pain, incresased WBCs
- 2) occurs most commonly after severe burns, prolonged TPN, trauma, or major surgery
- 3) primary pathology is bile stasis (narcotics, fasting), leading to distention and ischemia
- 4) Also have increased viscosity secondary to dehydration, ileus, transfusions
- 5) ultrasound shows sludge, gallbladder wall thickening, and pericholecystic fluid
- 6) HIDA scan is positive
- 7) Treatment: cholecystectomy, percutaneous drainage if patient is too unstable.
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Emphysematous Gallbladder Disease
- 1) gas in gallbladder wall
- 2) can see on plain film
- 3) increased in diabetics; usually secondary to clostridium perfringens
- 4) Symptoms: severe, rapid-onset abdominal pain, nausea, vomiting, and sepsis
- 5) perforation more common in these patients
- 6) Tx: emergent cholecystectomy; percutaneous drainage if patient is too unstable.
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Gallstone ileus:
- 1) fistula between gallbladder and duodenum that releases stone, causing small bowel obstruction; elderly.
- - can see pneumobilia (air in the biliary system) on plain film
- 2) Terminal Ileum- most common site of obstruction
- 3) Treatment: remove stone with enterostomy proximal to obstruction; perform cholecystectomy and fistula resection if patient can tolerate it.
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Common bile duct injuries:
- 1) most commonly occur after laparoscopic cholecystectomy
- 2) intraoperative cholangiography does not prevent injuries; may limit severity; increased early diagnosis of injury
- 3) in 10% of patients, the right posterior duct (from segement 6 or 7) enters the common bile duct seperately
- 4) Risk of injury with cholecystectomy (confused for cystic duct)
- 5) if >2mm, will need to open and perform hepaticojejunostomy
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Intraoperative CBD injury:
if less than 50% the circumference of the common bile duct, can probably perform primary repair; in all other cases, will likely need hepaticojejunostomy or choledochojejunostomy
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Persistent nausea and vomiting or jaundice following laparoscopic cholecystectomy
- 1) Ultrasound to look for fluid collection
- -if fluid collection present, may be bile leak--> percutaneous drain into the collection
- - if fluid is bilious, get ERCP --> sphincterotomy and stent if due to cystic duct remnant leak, small injuries to hepatic or common bile duct, or a leak from duct of Luschka.
- - larger lesions (i.e. complete duct transection) will require hepaticojejunostomy or choledochojejunostomy
- - if fluid collection not present and the hepatic ducts are dilated, likely have a completely transected common bile duct.
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How are anastomotic leaks following transplantation or hepaticojejunostomy usually handled?
with ERCP and stents
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Sepsis Following laparoscopic cholecystectomy
- 1) Fluid resuscitation and stabilize patient
- 2) May be due to complete transection of the CBD and cholangitis--> get ultrasound to look for dilated intrahepatic ducts or fluid collections
- 3) If no fluid collections but bile ducts are dilated --> get ERCP and try to stent the strictured area
- 4) If that fails, place a PTC tube
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Common bile duct or hepatic duct strictures
- 1) Most commonly occur after laparoscopic cholecystectomy
- 2) Ischemia is the most important cause of late postoperative biliary strictures
- 3) Can also be caused by chronic pancreatitis or stricture of a biliary enteric anastomosis
- 4) Diagnosis- ERCP will show stricture; U/S will likely show dilated hepatic ducts
- 5) Symptoms: sepsis, cholangitis, jaundice
- 6) Treatment:
- - ERCP with sphincterotomy and possible stent placement to decompress; PTC tube if that fails
- - for lesions that cause early symptoms (<7days)- hepaticojejunostomy
- - for lesions that cause later symptoms (>7days)- hepaticojejunostomy 6-8 weeks after injury
- - acute injuries are unlikely to be treated sufficiently with ERCP, sphincterotomy, and stent (need to make sure these late injuries do not represent Ca- get brushings)
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Hemobilia
- 1) fistula between bile duct and hepatic arterial system (most commonly)
- 2) patients classically present with UGI bleed, jaundice, and RUQ pain
- 3) Most commonly occurs with trauma (50% of all cases), infections, primary gallstones, aneurysms, and tumors
- 4) Diagnosis: angiogram
- 5) Treatment: angiogram and embolization first; operation if that fails.
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Gallbladder Adenocarcinoma:
- 1) rare; most common cancer of the biliary tract
- 2) four times more common than bile duct Ca; most have stones
- 3) Liver is the most common site of metastasis
- 4) Porcelain gallbladder- risk of gallbladder Ca (10-20%) --> these patients need cholecystectomy
- 5) 1st spreads to segments IV and V; 1st nodes are the cystic duct nodes (right side)
- 6) Symptoms: jaundice 1st, then RUQ pain
- 7) If limited to mucosa (stage I), cholecystectomy is all that is needed
- - this scenario usually occurs as an incidental finding following laparoscopic cholecystectomy
- 8) If into the muscle (stage II), need wide resection around liver bed at segments IV and V (2-3 cm margins), regional lymphadenectomy, including portal triad; may need whipple, lobectomy, or resection of the CBD.
- -90% of patients present with stage IV disease
- 9) High incidence of tumor implants in trocar sites when discovered after laparoscopic cholecystectomy
- 10) laparoscopic approach contraindicated for gallbladder Ca
- 11) 5%- 5year survival overall
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Bile Duct Cancer (Cholangiocarcinoma)
1) occurs in elderly males
- 2) risk factors:
- 1- C. sinensis infection
- 2- typhoid
- 3- ulcerative colitis
- 4- choledochal cysts
- 5- sclerosing cholangitis
- 6- congenital hepatic fibrosis
- 7- chronic bile duct infection
- 3) Symptoms:
- early- painless jaundice most common; can also get cholangitis
- late- weight loss, anemia, pruritis
4) Persistent increase in bilirubin and alkaline phosphatase
5) Diagnosis: ERCP 1st, MRI may help define the lesion (these tumors can be hard to find)
6) Invades contiguous structures early
7) discovery of a focal bile duct stenosis in patients without a history of biliary surgery or pancreatitis is highly suggestive of bile duct Ca
- 8) Klatskin tumors-
- upper 1/3
- - most common type, worst pronosis, usually unresectable
- Middle 1/3- hepaticojejunostomy
- Lower 1/3- whipple
- 9) Palliative stenting for unresectable disease
- 10) overall 5yr survival rate- 20%
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Choledochal cysts:
- 1) female gender, asia, japan
- 2) 90% extrahepatic; 15% cancer risk
- 3) Older patients have episodic pain, fever, jaundice, cholangitis
- 4) most are type I- fusiform or saccular dilation of extrahepatic ducts (very dilated)
- 5) infants can have symptoms similar to biliary atresia
- 6) possibly caused by abnomal reflux of pancreatic enzymes during development secondary to bad angle of insertion
- 7) occurs during uterine development
- 8) Treatment: cyst excision with hepaticojejunostomy and cholecystectomy
- 9) Type IV cysts are partially intrahepatic and Type V (Caroli's disease) are totally intrahepatic--> will need partial liver resection
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Primary Sclerosing Cholangitis:
- 1) men 4-5th decade
- 2) can be associated with:
- - retroperitoneal fibrosis
- - Riedel's thyroiditis
- - ulcerative colitis
- - DM
- 3) Symptoms: fatigue, fluctuating jaundice, pruritis, weight loss, RUQ pain
- -pruritis caused by bile acids
- 4) Diagnosis: ERCP- multiple strictures and dilatations (beaded appearance)
- 5) antimitochondrial antibodies
- 6) Bacterial cholangitis unusual unless biliary tract manipulation has occured
- 7) Does not get better after colon resection for ulcerative colitis
- 8) Leads to portal HTN and hepatic failure (scarring and patching with progressive fibrosis of intrahepatic and extrahepatic ducts
- 9) Can have isolated intrahepatic or extrahepatic duct inflammation and fibrosis
- 10) complications: cirrhosis, cholangiocarcinoma
- 11) Treatment: transplant needed long term for most; PTC tube drainage, choledochojejunostomy may be effective for some; balloon dilatation of dominant strictures may provide some symptomatic relief
- - cholestyramine- can decrease pruritis symptoms (decrease bile acids)
- - UDCA (urodeoxycholic acid)- can decrease symptoms (decrease bile acids) and improve liver enzymes
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Primary Biliary Cirrhosis
- 1) women; medium-sized hepatic ducts
- 2) Cholestasis--> cirrhosis--> portal hypertension
- 3) symptoms-
- -fatigue
- -pruritis
- -jaundice
- -xanthomas
- 4)antimitochondrial antibodies
- 5) No increased risk for cancer
- 6) Treatment: transplantation
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Cholangitis
- 1) Charcot's triad-
- 1- RUQ pain
- 2- fever
- 3- jaundice
2)Reynold's pentad- charcot's triad plus mental status changes and shock
3) Most common organisms- 1) E.coli 2) klebsiella
4) Cholovenous reflux occurs at 20mmHg pressure --> systemic bacteremia
5) Diagnosis: AST/ALT, bilirubin, alkaline phosphatase, and WBC often increase
6) Ultrasound- CBD will be dilated (>8 mm, >10mm after cholecystectomy) on ultrasound if due to obstruction of the biliary system
7) Stricture and hepatic abscess are late complications of cholangitis
8) Renal failure- #1 serious complication, related to sepsis
9) Gallstones are most common etiology
- 10) Other causes-
- 1- biliary strictures (iatrogenic)
- 2- neoplasm
- 3- chronic pancreatitis
- 4- congential choledocal cysts
- 5- duodenal diverticula
10) Treatment: fluid resuscitation, antibiotics
11) Emergent ERCP with sphincterotomy and stone extraction; if ERCP fails, go to PTC tube
12) If PTC tube is infected- change the PTC tube
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Oriental Cholangioheptatitis
1) Asia, recurrent cholangitis from primary CBD stones
- 2) Caused by:
- 1- C. sinesis
- 2- A. lumbridoides
- 3- T. trichiura
- 4- E.coli
3) Treatment: hepaticojejunostomy and antiparasitic medications
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Shock following laparoscopic cholecystectomy
1) early (1st 24hrs)- hemorrhagic shock from clip that fell off cystic artery
2) Late (after 1st 24hrs)- septic shock from accidental clip on CBD with subsequent cholangitis
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Adenomyomatosis
- thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus
- -not premaligannt; does not cause stones, can cause RUQ pain
Treatment: cholecystectomy
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Granular cell myoblastoma
- 1) benign neuroectoderm tumor of the gallbladder
- 2) can occur in biliary tract with signs of cholecystitis
- 3) Treatment: cholecystectomy
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Cholesterolosis
speckled cholesterol deposits on gallbladder wall
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Gallbladder polyps
- 1) >1cm worry about malignancy
- 2) polyps in patients >60 years more likely malignant
- 3) Treatment: cholecystectomy
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Delta bilirubin
- 1) bound to albumin covalently
- 2) half life of 18 days
- 3) may take a while to clear after long-standing jaundice
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Mirizzi Syndrome
compression of the common hepatic duct by a stone in the infundibulum of the gallbladder or inflammation arising from the gallbladder or cystic duct extending to the contiguous hepatic duct, causing stricture and hepatic duct obstruction
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Ceftriaxone
can cause gallbladder sludge and cholestatic jaundice
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Indications for asymptomatic cholecystectomy
in patients undergoing liver TXP or gastric bypass
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