Hepatobiliary Surgery

Question 1

name some benign conditions of the gallbladder

Answer 1

> gallstones
cholesterosis
polyps

Question 2

what is the composition of gall stones?

Answer 2

> 80% mixed

> 20% cholesterol, pigment

Question 3

what are the risk factors for gall stones?

Answer 3

> age
> gender (female)
> parity + OCP
> cholesterol
> pigment (Far East)

Question 4

how may patients with gallstones present?

Answer 4

> asymptomatic
> dyspeptic symptoms
> biliary colic (pain in upper abdomen, may be referred to shoulder)
> jaundice
> acute cholecystitis 
> empyema
> perforation
> gallstone ileus

Question 5

what is gallstone ileus?

Answer 5

when the gall stone enters the duodenum and goes through the gi tract until it lodges in the ileum causing obstruction

Question 6

what is acute cholecystitis?

Answer 6

acute inflammation of the gallbladder, touches the peritoneum causing localised tenderness

Question 7

what is choledocholithiasis?

Answer 7

gallstones in the common bile duct

Question 8

what are the signs and symptoms of choledocholithiasis?

Answer 8

> pain
> jaundice
> dark urine
> pale stool
> pruritus
> steatorrhoea

Question 9

what can choledocholithiasis cause?

Answer 9

> acute pancreatitis
ascending cholangitis
obstructive jaundice

Question 10

what investigations would you carry out for gallstones?

Answer 10

> blood tests (LFTs, amylase, lipase, WCC)
USS (or EUS but only for certain patients)
oral cholecystography (no longer used)
CT scan (not good at picking up stones)
MRCP
ERCP or PTC (therapy only now)

Question 11

how would you manage asymptomatic gallstones?

Answer 11

do nothing, due to surgical risk

Question 12

what non-operative treatment is there for gallstones?

Answer 12

> dissolution (break down gallstones using chemicals)

> lithotripsy (US shockwaves which break down stones)

Question 13

what is the “gold standard” surgical treatment for gallstones?

Answer 13

laparoscopic cholecystectomy

Question 14

what operative treatments are there for gallstones?

Answer 14

> open cholecystectomy
> mini chlecysectomy
> laparoscopic cholecystectomy
> single port cholecystectomy
> NOTES (lecturer would not want this one tho)

Question 15

name some congenital biliary tract diseases

Answer 15

> biliary atresia

> choledochal cysts

Question 16

what are the causes of a benign biliary stricture?

Answer 16

> iatrogenic
gallstones
inflammatory

Question 17

what could cause inflammatory benign biliary disease?

Answer 17

> pyogenic
> parasitic
> pancreatitis
> PSC (primary sclerosing cholangitis)
> HIV

Question 18

what malignant tumours can cause jaundice?

Answer 18

> cholangiocarcinoma

> cancer of the head of the pancreas

Question 19

what cholangiocarcinoma’s can you get?

Answer 19

> intra hepatic
extra hepatic
gallbladder cancer
ampullary cancer

Question 20

what are the risk factors for cholangiocarcinoma?

Answer 20

> PSC
> congenital cystic disease
> biliary-enteric drainage
> thorotrast
> hepatolithiasis
> carcinogens

Question 21

name the three types of intra hepatic cholangiocarcinoma

Answer 21

> mass forming
peri-ductal
intra-ductal

Question 22

what is the management for cholangiocarcinoma?

Answer 22

> Only curative option is surgery

> Palliative: surgical bypass, stenting, radiotherapy, chemotherapy, PDT, transplantation (not standard)

Question 23

what is the presentation for cholangiocarcinoma?

Answer 23

> obstructive jaundice
itching
non-specific symptoms

Question 24

what are the investigations for cholangiocarcinoma?

Answer 24

> Lab tests
Radiology: USS/EUS, CT, MRI, MRCP, PTC, angiography, PET scan
ERCP, cholangioscopy, cytology

Question 25

what is the treatment of gallbladder cancer dependent on?

Answer 25

the stage of the cancer

Question 26

what are the treatment options for ampullary tumours?

Answer 26

> endoscopic excision
transduodenal excision
pancreatico-duodenectomy