BILIARY SYSTEM AND PANCREAS – TCAR EXAM WITH VERIFIED QUESTION AND ANSWER
What segments of the liver does the gallbladder lie underneath? - ANSWER IV and V
What artery is the cystic artery a branch of? - ANSWER Right hepatic artery in the Triangle of Calot
What are the borders of the Triangle of Calot? - ANSWER Lateral: cystic duct
Medial: CBC
Superior: liver
What is the blood supply of the hepatic and common bile duct? What is the surgical significance? -
ANSWER Right hepatic artery branches lateral
GDA branches medial
Supply at the 9 and 3 o'clock positions, longitudinal blood supply must be considered when performing
sphincterotomy
What percentage of the population has an aberrant right hepatic artery? - ANSWER 1%
What is the consequence of injury to the aberrant right hepatic artery located in the Triangle of Calot? -
ANSWER ischemia to liver segments VI and VII causing fever, pain, increased LFTs, liver abscess
Where do the cystic veins drain? - ANSWER right branch of portal vein and then into the liver
Where are the lymphatics draining the gallbladder found? - ANSWER right side of the CBD
What is the innervation of the gallbladder? - ANSWER parasympathetic left vagus anterior trunk
sympathetic splanchnic and celiac ganglions (T7-T10)
,What is the mucosa of the gallbladder comprised of? What layer does the gallbladder NOT possess? -
ANSWER Columnar epithelium
No submucosa
What medication contracts the sphincter of Oddi? Relaxes? - ANSWER Contracts: morphine
Relaxes: glucagon
What is the normal size of the CBD? - ANSWER < 8 mm (< 10 mm after cholecystectomy)
What is the normal thickness of the gallbladder wall? - ANSWER < 4 mm
What is the normal diameter of the pancreatic duct? - ANSWER < 4 mm
Where is the highest concentration of CCK and secretin cells located? - ANSWER Duodenum
What are Rokitansky-Aschoff sinuses? - ANSWER invagination of epithelium into muscle layers of the
gallbladder wall formed from increased gallbladder pressure - harmless
What are the small accessory bile ducts that course along the gallbladder fossa but don't actually drain
into the gallbladder called? Where do they most commonly originate and drain? - ANSWER Ducts of
Luschka
Originate in the right lobe of the liver and drain into the extra-hepatic bile ducts most commonly
What is the best test to diagnose a leaking Duct of Luschka? - ANSWER HIDA
What percentage of people have an aberrant posterior right hepatic duct? Where does it come from? -
ANSWER 1% comes from segments VI or VII
What three things increase bile secretion? - ANSWER CCK
,Secretin
Vagal input
What three things decrease bile excretion? - ANSWER VIP
Somatostatin
Sympathetic input
What stimulates constant, tonic contraction of the gallbladder? - ANSWER CCK
What is the function of bile? - ANSWER Fat soluble vitamin absorption and essential fatty acids
Bilirubin excretion
Cholesterol excretion
What is the concentration of sodium, chloride, bile salts, and cholesterol in bile? - ANSWER The
gallbladder concentrates bile by active resorption of sodium and water Na/K ATPase
Hepatic bile vs. gallbladder
Na 140-180 vs 225-375
Cl 50-100 vs. 1-10
Bile salts 1-50 vs. 250-350
Cholesterol 50-150 vs. 300-700
What is the size of the bile salt pool and how many times a day does it cycle? - ANSWER 6 gm
Cycles 6x/day
What percentage of bile salts are lost in stool? - ANSWER 10% (90% are reabsorbed
How are bile salts reabsorbed? - ANSWER Active resorption of conjugated bile acids in the terminal
ileum (45%, Na/K ATPase)
Passive resorption of non-conjugated bile acids in small intestine (40%) and colon (5%)
, When is postprandial emptying of gallbladder bile maximum? - ANSWER 2 hours (80% emptied)
Which cells secrete bile? - ANSWER Bile canilicular cells
Hepatocytes
What is the origin of the color of bile? - ANSWER Conjugated bilirubin
What is the cause of the color of stool? - ANSWER Stercobilin - breakdown product of conjugated
bilirubin in the gut
What is the cause of the yellow color of urine? - ANSWER Urobilin - breakdown product of conjugated
bilirubin in the gut that is then reabsorbed and released in urine
Why can there be formation of gallstones after a terminal ileum resection? - ANSWER Malabsorption of
bile acids
What percentage of the US population has gallstones? - ANSWER 10%
What percentage of gallstones are radiopaque on xray? - ANSWER 10%
Most common type of gallstone in the US - ANSWER Cholesterol (nonpigmented) stone
Why are cholesterol stones called secondary stones? - ANSWER Form almost exclusively in the
gallbladder itself
Pathophysiology of the development of cholesterol stones - ANSWER Too much cholesterol or too little
bile salts with stasis or incomplete emptying
Mucin glycoproteins in bile also promote calcium nucleation and act as a nidus for stone formation
What segments of the liver does the gallbladder lie underneath? - ANSWER IV and V
What artery is the cystic artery a branch of? - ANSWER Right hepatic artery in the Triangle of Calot
What are the borders of the Triangle of Calot? - ANSWER Lateral: cystic duct
Medial: CBC
Superior: liver
What is the blood supply of the hepatic and common bile duct? What is the surgical significance? -
ANSWER Right hepatic artery branches lateral
GDA branches medial
Supply at the 9 and 3 o'clock positions, longitudinal blood supply must be considered when performing
sphincterotomy
What percentage of the population has an aberrant right hepatic artery? - ANSWER 1%
What is the consequence of injury to the aberrant right hepatic artery located in the Triangle of Calot? -
ANSWER ischemia to liver segments VI and VII causing fever, pain, increased LFTs, liver abscess
Where do the cystic veins drain? - ANSWER right branch of portal vein and then into the liver
Where are the lymphatics draining the gallbladder found? - ANSWER right side of the CBD
What is the innervation of the gallbladder? - ANSWER parasympathetic left vagus anterior trunk
sympathetic splanchnic and celiac ganglions (T7-T10)
,What is the mucosa of the gallbladder comprised of? What layer does the gallbladder NOT possess? -
ANSWER Columnar epithelium
No submucosa
What medication contracts the sphincter of Oddi? Relaxes? - ANSWER Contracts: morphine
Relaxes: glucagon
What is the normal size of the CBD? - ANSWER < 8 mm (< 10 mm after cholecystectomy)
What is the normal thickness of the gallbladder wall? - ANSWER < 4 mm
What is the normal diameter of the pancreatic duct? - ANSWER < 4 mm
Where is the highest concentration of CCK and secretin cells located? - ANSWER Duodenum
What are Rokitansky-Aschoff sinuses? - ANSWER invagination of epithelium into muscle layers of the
gallbladder wall formed from increased gallbladder pressure - harmless
What are the small accessory bile ducts that course along the gallbladder fossa but don't actually drain
into the gallbladder called? Where do they most commonly originate and drain? - ANSWER Ducts of
Luschka
Originate in the right lobe of the liver and drain into the extra-hepatic bile ducts most commonly
What is the best test to diagnose a leaking Duct of Luschka? - ANSWER HIDA
What percentage of people have an aberrant posterior right hepatic duct? Where does it come from? -
ANSWER 1% comes from segments VI or VII
What three things increase bile secretion? - ANSWER CCK
,Secretin
Vagal input
What three things decrease bile excretion? - ANSWER VIP
Somatostatin
Sympathetic input
What stimulates constant, tonic contraction of the gallbladder? - ANSWER CCK
What is the function of bile? - ANSWER Fat soluble vitamin absorption and essential fatty acids
Bilirubin excretion
Cholesterol excretion
What is the concentration of sodium, chloride, bile salts, and cholesterol in bile? - ANSWER The
gallbladder concentrates bile by active resorption of sodium and water Na/K ATPase
Hepatic bile vs. gallbladder
Na 140-180 vs 225-375
Cl 50-100 vs. 1-10
Bile salts 1-50 vs. 250-350
Cholesterol 50-150 vs. 300-700
What is the size of the bile salt pool and how many times a day does it cycle? - ANSWER 6 gm
Cycles 6x/day
What percentage of bile salts are lost in stool? - ANSWER 10% (90% are reabsorbed
How are bile salts reabsorbed? - ANSWER Active resorption of conjugated bile acids in the terminal
ileum (45%, Na/K ATPase)
Passive resorption of non-conjugated bile acids in small intestine (40%) and colon (5%)
, When is postprandial emptying of gallbladder bile maximum? - ANSWER 2 hours (80% emptied)
Which cells secrete bile? - ANSWER Bile canilicular cells
Hepatocytes
What is the origin of the color of bile? - ANSWER Conjugated bilirubin
What is the cause of the color of stool? - ANSWER Stercobilin - breakdown product of conjugated
bilirubin in the gut
What is the cause of the yellow color of urine? - ANSWER Urobilin - breakdown product of conjugated
bilirubin in the gut that is then reabsorbed and released in urine
Why can there be formation of gallstones after a terminal ileum resection? - ANSWER Malabsorption of
bile acids
What percentage of the US population has gallstones? - ANSWER 10%
What percentage of gallstones are radiopaque on xray? - ANSWER 10%
Most common type of gallstone in the US - ANSWER Cholesterol (nonpigmented) stone
Why are cholesterol stones called secondary stones? - ANSWER Form almost exclusively in the
gallbladder itself
Pathophysiology of the development of cholesterol stones - ANSWER Too much cholesterol or too little
bile salts with stasis or incomplete emptying
Mucin glycoproteins in bile also promote calcium nucleation and act as a nidus for stone formation
