- •Dedication
- •Editors and Contributors
- •Foreword
- •Preface
- •Contents
- •PREPARING FOR THE SURGERY CLERKSHIP
- •SURGICAL NOTES
- •COMMON ABBREVIATIONS YOU SHOULD KNOW
- •RETRACTORS (YOU WILL GET TO KNOW THEM WELL!)
- •SUTURE MATERIALS
- •WOUND CLOSURE
- •KNOTS AND EARS
- •INSTRUMENT TIE
- •TWO-HAND TIE
- •COMMON PROCEDURES
- •NASOGASTRIC TUBE (NGT) PROCEDURES
- •CHEST TUBES
- •NASOGASTRIC TUBES (NGT)
- •FOLEY CATHETER
- •CENTRAL LINES
- •MISCELLANEOUS
- •THIRD SPACING
- •COMMON IV REPLACEMENT FLUIDS (ALL VALUES ARE PER LITER)
- •CALCULATION OF MAINTENANCE FLUIDS
- •ELECTROLYTE IMBALANCES
- •ANTIBIOTICS
- •STEROIDS
- •HEPARIN
- •WARFARIN (COUMADIN®)
- •MISCELLANEOUS AGENTS
- •NARCOTICS
- •MISCELLANEOUS
- •ATELECTASIS
- •POSTOPERATIVE RESPIRATORY FAILURE
- •PULMONARY EMBOLISM
- •ASPIRATION PNEUMONIA
- •GASTROINTESTINAL COMPLICATIONS
- •ENDOCRINE COMPLICATIONS
- •CARDIOVASCULAR COMPLICATIONS
- •MISCELLANEOUS
- •HYPOVOLEMIC SHOCK
- •SEPTIC SHOCK
- •CARDIOGENIC SHOCK
- •NEUROGENIC SHOCK
- •MISCELLANEOUS
- •URINARY TRACT INFECTION (UTI)
- •CENTRAL LINE INFECTIONS
- •WOUND INFECTION (SURGICAL SITE INFECTION)
- •NECROTIZING FASCIITIS
- •CLOSTRIDIAL MYOSITIS
- •SUPPURATIVE HIDRADENITIS
- •PSEUDOMEMBRANOUS COLITIS
- •PROPHYLACTIC ANTIBIOTICS
- •PAROTITIS
- •MISCELLANEOUS
- •CHEST
- •ABDOMEN
- •MALIGNANT HYPERTHERMIA
- •MISCELLANEOUS
- •OVERVIEW
- •CHOLECYSTOKININ (CCK)
- •SECRETIN
- •GASTRIN
- •SOMATOSTATIN
- •MISCELLANEOUS
- •GROIN HERNIAS
- •HERNIA REVIEW QUESTIONS
- •ESOPHAGEAL HIATAL HERNIAS
- •PRIMARY SURVEY
- •SECONDARY SURVEY
- •TRAUMA STUDIES
- •PENETRATING NECK INJURIES
- •MISCELLANEOUS TRAUMA FACTS
- •PEPTIC ULCER DISEASE (PUD)
- •DUODENAL ULCERS
- •GASTRIC ULCERS
- •PERFORATED PEPTIC ULCER
- •TYPES OF SURGERIES
- •STRESS GASTRITIS
- •MALLORY-WEISS SYNDROME
- •ESOPHAGEAL VARICEAL BLEEDING
- •BOERHAAVE’S SYNDROME
- •ANATOMY
- •GASTRIC PHYSIOLOGY
- •GASTROESOPHAGEAL REFLUX DISEASE (GERD)
- •GASTRIC CANCER
- •GIST
- •MALTOMA
- •GASTRIC VOLVULUS
- •SMALL BOWEL
- •APPENDICITIS
- •CLASSIC INTRAOPERATIVE QUESTIONS
- •APPENDICEAL TUMORS
- •SPECIFIC TYPES OF FISTULAS
- •ANATOMY
- •COLORECTAL CARCINOMA
- •COLONIC AND RECTAL POLYPS
- •POLYPOSIS SYNDROMES
- •DIVERTICULAR DISEASE OF THE COLON
- •ANATOMY
- •ANAL CANCER
- •ANATOMY
- •TUMORS OF THE LIVER
- •ABSCESSES OF THE LIVER
- •HEMOBILIA
- •ANATOMY
- •PHYSIOLOGY
- •PATHOPHYSIOLOGY
- •DIAGNOSTIC STUDIES
- •BILIARY SURGERY
- •OBSTRUCTIVE JAUNDICE
- •CHOLELITHIASIS
- •ACUTE CHOLECYSTITIS
- •ACUTE ACALCULOUS CHOLECYSTITIS
- •CHOLANGITIS
- •SCLEROSING CHOLANGITIS
- •GALLSTONE ILEUS
- •CARCINOMA OF THE GALLBLADDER
- •CHOLANGIOCARCINOMA
- •MISCELLANEOUS CONDITIONS
- •PANCREATITIS
- •PANCREATIC ABSCESS
- •PANCREATIC NECROSIS
- •PANCREATIC PSEUDOCYST
- •PANCREATIC CARCINOMA
- •MISCELLANEOUS
- •ANATOMY OF THE BREAST AND AXILLA
- •BREAST CANCER
- •DCIS
- •LCIS
- •MISCELLANEOUS
- •MALE BREAST CANCER
- •BENIGN BREAST DISEASE
- •CYSTOSARCOMA PHYLLODES
- •FIBROADENOMA
- •FIBROCYSTIC DISEASE
- •MASTITIS
- •BREAST ABSCESS
- •MALE GYNECOMASTIA
- •ADRENAL GLAND
- •ADDISON’S DISEASE
- •INSULINOMA
- •GLUCAGONOMA
- •SOMATOSTATINOMA
- •ZOLLINGER-ELLISON SYNDROME (ZES)
- •MULTIPLE ENDOCRINE NEOPLASIA
- •THYROID DISEASE
- •ANATOMY
- •PHYSIOLOGY
- •HYPERPARATHYROIDISM (HPTH)
- •PARATHYROID CARCINOMA
- •SOFT TISSUE SARCOMAS
- •LYMPHOMA
- •SQUAMOUS CELL CARCINOMA
- •BASAL CELL CARCINOMA
- •MISCELLANEOUS SKIN LESIONS
- •STAGING
- •INTENSIVE CARE UNIT (ICU) BASICS
- •INTENSIVE CARE UNIT FORMULAS AND TERMS YOU SHOULD KNOW
- •SICU DRUGS
- •INTENSIVE CARE PHYSIOLOGY
- •HEMODYNAMIC MONITORING
- •MECHANICAL VENTILATION
- •PERIPHERAL VASCULAR DISEASE
- •LOWER EXTREMITY AMPUTATIONS
- •ACUTE ARTERIAL OCCLUSION
- •ABDOMINAL AORTIC ANEURYSMS
- •MESENTERIC ISCHEMIA
- •MEDIAN ARCUATE LIGAMENT SYNDROME
- •CAROTID VASCULAR DISEASE
- •CLASSIC CEA INTRAOP QUESTIONS
- •SUBCLAVIAN STEAL SYNDROME
- •RENAL ARTERY STENOSIS
- •SPLENIC ARTERY ANEURYSM
- •POPLITEAL ARTERY ANEURYSM
- •MISCELLANEOUS
- •PEDIATRIC IV FLUIDS AND NUTRITION
- •PEDIATRIC BLOOD VOLUMES
- •FETAL CIRCULATION
- •ECMO
- •NECK
- •ASPIRATED FOREIGN BODY (FB)
- •CHEST
- •PULMONARY SEQUESTRATION
- •ABDOMEN
- •INGUINAL HERNIA
- •UMBILICAL HERNIA
- •GERD
- •CONGENITAL PYLORIC STENOSIS
- •DUODENAL ATRESIA
- •MECONIUM ILEUS
- •MECONIUM PERITONITIS
- •MECONIUM PLUG SYNDROME
- •ANORECTAL MALFORMATIONS
- •HIRSCHSPRUNG’S DISEASE
- •MALROTATION AND MIDGUT VOLVULUS
- •OMPHALOCELE
- •GASTROSCHISIS
- •POWER REVIEW OF OMPHALOCELE AND GASTROSCHISIS
- •APPENDICITIS
- •INTUSSUSCEPTION
- •MECKEL’S DIVERTICULUM
- •NECROTIZING ENTEROCOLITIS
- •BILIARY TRACT
- •TUMORS
- •PEDIATRIC TRAUMA
- •OTHER PEDIATRIC SURGERY QUESTIONS
- •POWER REVIEW
- •WOUND HEALING
- •SKIN GRAFTS
- •FLAPS
- •SENSORY SUPPLY TO THE HAND
- •CARPAL TUNNEL SYNDROME
- •ANATOMY
- •MISCELLANEOUS
- •NOSE AND PARANASAL SINUSES
- •ORAL CAVITY AND PHARYNX
- •FACIAL FRACTURES
- •ENT WARD QUESTIONS
- •RAPID-FIRE REVIEW OF MOST COMMON CAUSES OF ENT INFECTIONS
- •THORACIC OUTLET SYNDROME (TOS)
- •CHEST WALL TUMORS
- •DISEASES OF THE PLEURA
- •DISEASES OF THE LUNGS
- •DISEASES OF THE MEDIASTINUM
- •DISEASES OF THE ESOPHAGUS
- •ACQUIRED HEART DISEASE
- •CONGENITAL HEART DISEASE
- •CARDIAC TUMORS
- •DISEASES OF THE GREAT VESSELS
- •MISCELLANEOUS
- •BASIC IMMUNOLOGY
- •CELLS
- •IMMUNOSUPPRESSION
- •OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
- •MATCHING OF DONOR AND RECIPIENT
- •REJECTION
- •ORGAN PRESERVATION
- •KIDNEY TRANSPLANT
- •LIVER TRANSPLANT
- •PANCREAS TRANSPLANT
- •HEART TRANSPLANT
- •INTESTINAL TRANSPLANTATION
- •LUNG TRANSPLANT
- •TRANSPLANT COMPLICATIONS
- •ORTHOPAEDIC TERMS
- •TRAUMA GENERAL PRINCIPLES
- •FRACTURES
- •ORTHOPAEDIC TRAUMA
- •DISLOCATIONS
- •THE KNEE
- •ACHILLES TENDON RUPTURE
- •ROTATOR CUFF
- •MISCELLANEOUS
- •ORTHOPAEDIC INFECTIONS
- •ORTHOPAEDIC TUMORS
- •ARTHRITIS
- •PEDIATRIC ORTHOPAEDICS
- •HEAD TRAUMA
- •SPINAL CORD TRAUMA
- •TUMORS
- •VASCULAR NEUROSURGERY
- •SPINE
- •PEDIATRIC NEUROSURGERY
- •SCROTAL ANATOMY
- •UROLOGIC DIFFERENTIAL DIAGNOSIS
- •RENAL CELL CARCINOMA (RCC)
- •BLADDER CANCER
- •PROSTATE CANCER
- •BENIGN PROSTATIC HYPERPLASIA
- •TESTICULAR CANCER
- •TESTICULAR TORSION
- •EPIDIDYMITIS
- •PRIAPISM
- •ERECTILE DYSFUNCTION
- •CALCULUS DISEASE
- •INCONTINENCE
- •URINARY TRACT INFECTION (UTI)
- •MISCELLANEOUS UROLOGY QUESTIONS
- •Rapid Fire Power Review
- •TOP 100 CLINICAL SURGICAL MICROVIGNETTES
- •Figure Credits
- •Index
364 Section II / General Surgery
C h a p t e r 54 |
Biliary Tract |
ANATOMY |
|
|
|
Name structures 1 through 8 (below) of the biliary tract:
Which is the proximal and which is the distal bile duct?
What is the name of the node in Calot’s triangle?
What are the small ducts that drain bile directly into the gallbladder from the liver?
1.Intrahepatic ducts
2.Left hepatic duct
3.Right hepatic duct
4.Common hepatic duct
5.Gallbladder
6.Cystic duct
7.Common bile duct
8.Ampulla of Vater
Proximal is close to the liver (bile and the liver is analogous to blood and the heart; they both flow distally)
Calot’s node
Ducts of Luschka
Which artery is susceptible |
Right hepatic artery, because of its |
to injury during |
proximity to the cystic artery and Calot’s |
cholecystectomy? |
triangle |
What is the name of the |
Spiral valves of Heister |
valves of the gallbladder? |
|
Where is the infundibulum |
Near the cystic duct |
of the gallbladder? |
|
Where is the fundus of the |
At the end of the gallbladder |
gallbladder? |
|
|
|
Chapter 54 / Biliary Tract 365 |
What is “Hartmann’s pouch”? |
Gallbladder infundibulum |
|
What are the boundaries of |
The 3 C’s: |
|
the triangle of Calot? |
1. |
Cystic duct |
|
2. |
Common hepatic duct |
|
3. |
Cystic artery |
|
|
3 |
2
1
“Dr. Blackbourne, are you absolutely sure that the Triangle of Calot includes the cystic artery and not the liver edge?”
PHYSIOLOGY
Yes, look up Gastroenterology, 2002; 123(5):1440
What is the source of |
Bile duct epithelium; expect alkaline |
alkaline phosphatase? |
phosphatase to be elevated in bile duct |
|
obstruction |
What is in bile? |
Cholesterol, lecithin (phospholipid), bile |
|
acids, and bilirubin |
What does bile do? |
Emulsifies fats |
What is the enterohepatic |
Circulation of bile acids from liver to gut |
circulation? |
and back to the liver |
Where are most of the bile |
In the terminal ileum |
acids absorbed? |
|
What stimulates gallbladder |
Cholecystokinin and vagal input |
emptying? |
|
What is the source of |
Duodenal mucosal cells |
cholecystokinin? |
|
What stimulates the release |
Fat, protein, amino acids, and HCl |
of cholecystokinin? |
|
366 Section II / General Surgery |
|
What inhibits its release? |
Trypsin and chymotrypsin |
What are its actions? |
Gallbladder emptying |
|
Opening of ampulla of Vater |
|
Slowing of gastric emptying |
|
Pancreas acinar cell growth and release |
|
of exocrine products |
PATHOPHYSIOLOGY |
|
|
|
At what level of serum total bilirubin does one start to get jaundiced?
Classically, what is thought to be the anatomic location where one first finds evidence of jaundice?
With good renal function, how high can the serum total bilirubin go?
What are the signs and symptoms of obstructive jaundice?
What causes the itching in obstructive jaundice?
Define the following terms: Cholelithiasis
2.5
Under the tongue
Very rarely, 20
Jaundice Dark urine
Clay-colored stools (acholic stools) Pruritus (itching)
Loss of appetite Nausea
Bile salts in the dermis (not bilirubin!)
Gallstones in gallbladder
Cholethiasis
7 0 ‘
f r
h
Chapter 54 / Biliary Tract 367
Choledocholithiasis |
Gallstone in common bile duct |
rf h
‘07
Gallstone in common bile duct
Cholecystitis Inflammation of gallbladder
|
h |
|
|
r |
|
|
f |
|
|
‘ |
|
|
0 |
|
|
7 |
Stone |
|
|
|
|
|
in neck |
|
Inflammation |
|
Cholangitis |
Infection of biliary tract |
|
Cholangiocarcinoma |
Adenocarcinoma of bile ducts |
|
Klatskin’s tumor |
Cholangiocarcinoma of bile duct at the |
|
|
junction of the right and left hepatic |
|
|
ducts |
|
Biliary colic |
Pain from gallstones, usually from a stone |
|
|
at cystic duct: The pain is located in the |
|
|
RUQ, epigastrium, or right subscapular |
|
|
region of the back; it usually lasts minutes |
|
|
to hours but eventually goes away; it |
|
|
is often postprandial, especially after |
|
|
fatty foods |
|