Hydrops

Impacted stone at cystic duct leads to bile reabsorption and increased mucus production - thus white or clear bile

treatment - cholecystectomy

Gallbladder Polyp

Indications for surgery - symptomatic polyp, polyp with gallstones, > 1cm, age > 50

Cholesterolosis or Strawberry Gallbladder

accumulation of cholesterol in macrophages leading to deposition on surface of gallbladder

benign condition - does not need resection

Choledochal cyst

Type I: fusiform cyst (most common)
Type II: diverticulum of common bile duct
Type III: choledochocele (intraduodenal portion of CBD)
Type IVa: intra- and extrahepatic cysts
Type IVb: only extrahepatic cysts
Type V: Caroli’s Disease (only intrahepatic cysts)
Treatment: Hepaticojejunostomy (type I); diverticulectomy (type II); excision / sphincteroplasty (type III); OLT (types IV & V) to reduce malignancy risk

Gallstones

Cholesterol stones - due to cholesterol insolubilization secondary to stasis - cholecystectomy

Pigmented stones

    brown - bacteria (usually E.coli) or parasite infection, composed of calcium bilirubinate, need biliary drainage procedure (sphincteroplasty)

    black - associated with hemolytic disorder, ileal resection, chronic TPN - cholecystectomy

Chronic Cholecystitis

associated with recurrent symptomatic cholelithiasis or biliary colic

Aschoff-Rokitansky sinuses = epithelium or mucosa protrudes into muscular layer

Bile

Consists of bile salts (80%), phospholipids (15%), and cholesterol (5%)

Primary Bile salts - cholic acid and chenodeoxycholic acid

Secondary bile salts - lithocholate and deoxycholate

Sterobilin - conguated bilirubin breakdown product - gives stool brown color

Urobilin - conjugated bilirubin breakdown product - gets reabsorbed in blood and delivery to kidney, secreted in urine, gives yellow color

Emphysematous Cholecystitis

Question: what is classical seen on imaging? treatment?
Answer: Air in gallbladder wall - urgent cholecystectomy

Cholangiocarcinoma

Type I - CHD only

Type II - confluence of right and left hepatic ducts

Type IIIa - right secondary

Type IIIb - left secondary

Type IV - involve both right and left hepatic ducts

Type V - involve CBD

Treatment - Type I-IV = resection of entire extrahepatic biliary tree with hepatic resection if necessary, Type V - Whipple

Sclerosing Cholangitis

Inflammatory strictures leading to recurrent biliary infection and malignancy

Associated with ulcerative colitis - colectomy does not change sclerosing cholangitis

Treatment = liver transplant

Gallbladder Carcinoma

Question: treatment of gallbladder cancer
Answer:

If T1 (not into perimuscular connective tissue) - then no additional surgery

If T2-4 - then radical cholecystectomy (segment IVb and V and hepatoduodenal ligament lymphadenopathy) with post op radiation therapy

Acalculous Cholecysitis

QUESTION: What is the primary cause of acalculous choleysitis and management?
ANSWER: bile stasis; percutaneous cholecystostomy tube and doesn't need interval cholecystectomy

Gallstone Ileus

QUESTION: What is the most common location gallstone ileus obstruction? Management?
ANSWER: Terminal ileum - enterotomy and remove stone with closure, only remove gallbladder if stable and minimal inflammation, otherwise leave gallbladder