Hepato-billary pancreatic

Question 1

% of patient’s undergoing cholecystectomy who have gallstone in CBD

Answer 1

10%

Question 2

Cholecystitis mx

Answer 2

Hot laporascopic cholecystectomy
Within 24-48 hours after presenting

Question 3

Calot triangle

Answer 3

Common hepatic duct
Liver
Gallbladder

Contains right hepatic artery and cystic arteryand lymph Lund

Question 4

Mirzziri syndrome

Answer 4

Obstruction of the common bile duct or common hepatic duct by external compression from multiple impacted gallstones or a single large impacted gallstone in Hartman’s pouch

Question 5

Mx of cholecystitis with mikzziri syndrome

Answer 5

Operative cholecystostomy- draining gallbladder

Question 6

Post cholecystectomy, bile in drain what do you do

Answer 6

ERCP

cystic stump leak can be managed with ERCP , sphincterotomy and stent.

Question 7

AFP increased and USS shows suspicious lesion on liver, next steps?

Answer 7

Liver MRI

Question 8

What biliary problem can Crohns cause

Answer 8

Bile salts are absorbed in the terminal ileum. When this process is impaired as in Crohns the patient may develop gallstones, if these pass into the CBD then obstructive jaundice will result.

Question 9

Patient with pancreatitis- necroses and infected- drainage failed- what next?

Answer 9

Necrosectomy

Question 10

Obstructive jaundice mx

Answer 10

ERCP

Question 11

Gallstone ileus mx

Answer 11

Remove glasstone via proximally sited terminal ileal enterotomy and decompress small bowel
Leave gallbladder in situ

Question 12

If hepatocellular adenoma seen on MRI- mx

Answer 12

Resection

Question 13

Mx of large pancreatic pseudocyst that does not resolve on its self and causing symptoms

Answer 13

Elective cystogastrostomy

Question 14

Damage to bile duct during cholecystectomy

Answer 14

Place in drain and close wounds

Question 15

Glasgow scoring for pancreatitis

Answer 15

P a02 < 60 mmHg
A ge > 55 years
N eutrophils > 15 x 10/l
C alcium < 2 mmol/l
R aised urea > 16 mmol/l
E nzyme (lactate dehydrogenase) > 600 units/l
A lbumin < 32 g/l
S ugar (glucose) > 10 mmol/l

> 3 positive criteria indicates severe pancreatitis.

Question 16

Courvoisiers law

Answer 16

Painless jaundice in association with a smooth right upper quadrant mass is typical of distal biliary obstruction secondary to pancreatic malignancy

Question 17

After cholecystectomy a patient is found to have a bile leak. An ERCP is performed and leakage is noted from the cystic duct. mx?

Answer 17

Sphincterotomy and stent in common BD

Cut sphincter at oddi

Question 18

Difficult cholecystectomy due to poor visualisation of calots what do you do

Answer 18

Cholecystostomy

Question 19

Severe abdo pain after ERCP - ddx and mx

Answer 19

Could be pancreatitis or perf of deuodenum

CT abdo

Question 20

Mild pancreatitis with gallstones

Answer 20

Cholecystectomy once attack settles

Question 21

Acalculous cholecystitis

Answer 21

Most common in DM

RUQ pain, septic
No stones on USS

Question 22

Microscopic assessment of the cholecystitic gallbladder

Answer 22

Aschoff-Rokitansky sinuses are the result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the gallbladder wall.

Question 23

Imaging that can be used for pancreatitis

Answer 23

CT with contrast

Question 24

Cholangitis and ERCP fails- mx?

Answer 24

Percutaneous transhepatic cholangiogram and drain

Question 25

Most sensitive blood test for pancreatitis

Answer 25

lipase

Question 26

Lesion in liver after cirrhosis

Answer 26

In patients with cirrhosis the presence of a lesion >2cm is highly suggestive of malignancy. The diagnosis is virtually confirmed if the AFP is >400ng/mL.

Question 27

Surgical workup for cholecystectomy

Answer 27

LFT and diameter of CBD

Question 28

Cholangitis Tx

Answer 28

ERCP and stent

Question 29

Hartmann’s pouch

Answer 29

Diverticulum at fungus of gallbladder

Question 30

How Mirizzi syndrome causes poor visualisation of clots triangle

Answer 30

In Mirizzi syndrome the gallstone becomes impacted in Hartmans pouch. Episodes of recurrent inflammation occur and this causes compression of the bile duct. In severe cases this then progresses to fistulation. Surgery is extremely difficult as Calots triangle is often completely obliterated and the risks of causing injury to the CBD are high.

Question 31

Gallstone in distal CBD cannot be removed what is next option?

Answer 31

choledochoduodenostomy

Question 32

Most sensitive sign on US for cholecystitis

Answer 32

Sono Murphy sign with cholethiasis

Question 33

Intramural, intraluminal and extraluminal CBD obstruction

Answer 33

IM- strictures
IL- stones
EL- carcinomas, porta hepatic LN

Question 34

Gallbladder wall if cholecysitic on US

Answer 34

Thick >3mm