Week 3.6 - Hepato-Biliary Surgery

Question 1

What are 7 presentations of gallstones?

Answer 1

ABE DA PJ
- asymptomatic most commonly
- biliary colic
- empyema
- dyspepsia
- acute cholecystitis
- perforation
- jaundice

Question 2

what is choledocho-lithiasis?

Answer 2

gallstones in common bile duct.
- primary starts in bile duct
- secondary starts in cystic duct.

Question 3

What are bile stones made of?

Answer 3

in uk mix of cholesterol and pigments. in rest of world usually either fully cholesterol or fully pigment.

Question 4

What are risk factors for gallstones?

Answer 4

• women
• age
• contraceptive pills and parity

Question 5

What is biliary colic?

Answer 5

recurring epigastric pain radiating to shoulder with nausea and vomiting, comonly following eating fatty foods

Question 6

What signs do you see in acute cholecystitis?

Answer 6

colic pain. increased WBC, temp, CRP

Question 7

Who do you see empyema in as a presentation of gallstones?

Answer 7

diabetics - have neuropathy so cant detect pain so turn up in worse condition

Question 8

what is a risk of choledocho-lithiasis?

Answer 8

• may get stuck in ampulla and cause pancreatitis

Question 9

When do bilestones become apparent?

Answer 9

usually during cholecystectomy.

Question 10

What signs does choledocholithiasis (bilestones) cause?

Answer 10

• obstructive jaundice
• dark urine
• pale stool
• pruritis
• steatorrhea

Question 11

How do you investigate gallstones and why?

Answer 11

• LFT’s - ALP, AST, ALT for obstruction
• amylase and lipase for pancreatitis
• WBC count- may raise suspicion of acute cholecystitis or cholangitis

Question 12

What are different screening tests for gallstones? (4)

Answer 12

• ultrasound gold standard
• EUS small stones
• HIDA shows gallbladder function
• CT rule out cancer, perforation, infection

Question 13

How do you manage gallstones? inc. non-op (2) and op (5)

Answer 13

• asymptomatic nothing
• non-operative is dissolution and lithotripsy to dissolve and break down
• open cholecystectomy, mini cholecystectomy, laparoscopic cholecystectomy (gold standard), NOTES, cholecystostomy

Question 14

How do you manage bile duct stones?

Answer 14

• if asymptomatic and no harm, leave it
• if cystic duct, do laparoscopic trans-cystic CBD exploration
• if elsewhere, do laparoscopic exploration of bile duct. allows retreival of stones

Question 15

What are the benign biliary tract diseases? (5)

Answer 15

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• PSC
• iatrogenic bile duct injuries
• choledochal cysts
• biliary atresia
• biliary enteric fistula

Question 16

What is biliary atresia?

Answer 16

babies born with absence of bile duct. treat with reconstruction.

Question 17

What is Choledochal cysts ?

Answer 17

congenital enlargements of bile ducts in different locations - type 1-6. recommended that bile duct removed and reconstruction done due to risk of cancer.

Question 18

What is iatrogenic bile duct injuries?

Answer 18

injury acquired during cholecystectomy - not closed off bile duct properly

Question 19

What is PSC?

Answer 19

autoimmune - finds dilatation of ducts in different areas, causing fibrosis and strictures - risk of cholangiocarcinoma.

Question 20

What is biliary enteric fistula?

Answer 20

gallbladder may perforate into and form fistula with small intestine, stomach, colon or common bile duct following inflammation. stones can pass and block various parts of GIT. needs surgery.

Question 21

What are the malignant tumours? (4)

Answer 21

called cholangiocarcinoma
- intrahepatic
- extrahepatic
- gallbladder
- ampullary

Question 22

what are risk factors for cholangiocarcinoma?

Answer 22

• PSC,
• age 80,
• congenital disease like choledochal cysts,
• biliary enteric drainage,
• hepatolithiasis
• carcinogens

Question 23

What is intrahepatic cholangiocarcinoma?

Answer 23

• cancer in the liver hilum,
• mass around duct or in duct.
• surgery to treat.
• if metastasises treat jaundice with stent

Question 24

What is gallbladder cancer?

Answer 24

presentation usually too late and unsuitable for surgery so treat depending on stage. palliatively can treat jaundice. stent, chemo, radiotherapy

Question 25

What is ampullary cancer?

Answer 25

tumour starts as benign polyp. from lining of duodenum or ampulla. if possible remove using pancreatico-duodenoscopy if high dysplasia.

Question 26

What is FAP?

Answer 26

genetic condition presenting with many polyps in colon. at early age do colonoscopy to avoid cancer. in 40’s develop duodenal polyps - low survival of 50/60.

Question 27

What does extrahepatic cholangiocarcinoma present as?

Answer 27

obstructive jaundice typically. non-specific cancer symptoms. check if metastasised to determine treatment. radiology and labs to diagnose. stent if not resectable.