Gall Bladder Flashcards
1
Q
CHARCOT’s Triad
INTERMITTENT FJP
A
Seen in ACUTE CHOLANGITIS
INTERMITTENT
PAIN
JAUNDICE
FEVER
2
Q
REYNOLDS TRIAD
🧠⚡CASH⚡
A
Seen in Acute Suppurative CHOLANGITIS
✨ CHARCOT’s triad
✨ Altered Mental Status
✨ SHock
3
Q
Choledocholithiasis
A
Stones in the CBD
90% from Gall bladder
10% originate in CBD
4
Q
IOC FOR CHOLEDOCHOLITHIASIS
A
MRCP
5
Q
IOC FOR CBD MICROLITHS
A
Endoscopic Ultrasound
6
Q
🧑🏻⚕️ Clinical Features for Choledocholithiasis
A
✨ Asymptomatic
✨ Acute CHOLANGITIS- CHARCOT’s triad and Reynolds Triad
✨ Obstructive Jaundice
7
Q
MANAGEMENT: CBD AND GALL STONE DETECTED BEFORE SURGERY
A
ERCP+ Sphincterotomy
F/b after few days
Laparoscopic Cholecystectomy
8
Q
Indicators of CBD Stone in presence of GB stone:
A
ALP ⬆️⬆️
H/o Jaundice
USG: CBD >10mm diameter
9
Q
Management: CBD Stone+GB Stone detected during surgery
A
Laparoscopic Cholecystectomy + Laproscopic Exploration of CBD
If ❌⬇️
Open exploration of CBD
{Exploration=make Cut in the CBD LONGITUDINAL ➡️ REMOVE THE STONES}
⬇️
Insert T-TUBE in CBD (to decompress the bile duct)
⬇️
Insert dye after 7-10days
⬇️
No residual stones➡️ Remove T tube
10
Q
ERCP
Has EEExtra benefits
A
Both Diagnostic and Therapeutic
MRCP- only diagnostic
11
Q
Bismuth Classification used for:
A
Bile Duct Injury
12
Q
Bile Duct Injury classifications:
A
Bismuth Classification
Strasberg classification
13
Q
Bismuth Corlette classification used for
🧠⚡BC ⚡
A
Biliary Strictures
Cholangiocarcinoma
14
Q
Strasberg A and B
A
15
Q
Strasberg C,D,E
STRASBERG E= BISMUTH CLASSIFICATION
A
Strasberg E: CBD involvement
16
Q
How ERCP is DONE?
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATICOGRAPHY
A
Side Viewing Duodenoscope is used
Dye is injected that delinates the anatomy of the biliary tree
17
Q
MC COMPLICATION OF ERCP
2ND MC COMPLICATION
A
ERCP induced Pancreatitis MC
Duodenal Perforation
18
Q
Sphincterotomy with ERCP DONE @ which position
A
11o’clock position incision➡️remove the CBD stones
NEVER DONE AT 3O’clock and 9O’clock
19
Q
BURHENNE METHOD
A
To remove stones present in CBD via T-Tube
Inject Dye after 7-10 days➡️T-Tube Cholangiogram➡️Stone present➡️Retain T tube for (3-4weeks)➡️Tract is formed⬇️
Remove the stone 🪨 through the tract
20
Q
Maximum size of stone that can be removed by ERCP
A
1.5cm
21
Q
CBD STONES AFTER CHOLECYSTECTOMY: TYPES
A
RESIDUAL STONE 🪨: IF PRESENTS WITHIN<2YRS
RECURRENT STONE 🪨: IF PRESENTS after>2yrs
22
Q
Causes of Recurrent CBD stones
ACC
A
Ascariasis
Clonorchis infection
primary CBD stone
Cholangitis
23
Q
MANAGEMENT OF POST CHOLECYSTECTOMY CBD STONES
A
ERCP+SPHINCTEROTOMY
⬇️IF FAILS
TRANSDUODENAL SPHINCTEROTOMY
⬇️IF FAILS
SUPRADUODENAL CHOLEDOCHOTOMY
(Longitudinal incision in CBD and remove stones)
24
Q
SUTURING ADVICE FOR CBD INCISION
A
Absorbable sutures only (Vicryl/PDS)
Knots outside the lumen
25
Why Transverse Incision not given to CBD?
TRANSVERSE cuts heals to form STRICTURES
26
MIRRIZI SYNDROME
MIRRI=MARRY=Adhered=BANDH jana
GB becomes adherent to CBD dt inflammation. GB Stone 🪨 presses against CBD
27
CSENDES CLASSIFICATION USED FOR
CSENDes= Send= NUDES=WIFE=MARRY
MIRRIZI SYNDROME
28
C/F of MIRRIZI SYNDROME
Obstructive Jaundice
Acute Cholecystitis- Charcots Triad and Reynolds triad
29
MANAGEMENT OF MIRRIZI SYNDROME
Laproscopic Cholecystectomy
Partial Cholecystectomy: in pts whose GB IS DENSELY ADHERENT to CBD
30
Complication/Presentation of GALL STONES x12
🧠⚡ A⁴C²E--M²G²⚡
1. Asymptomatic/ Incidental detection
2. Acute Cholecystitis
10. Acute Cholangitis
11. Acute Pancreatitis
5. Chronic Cholecystitis
9. Choledocholithiasis
6. Emphysematous Cholecystitis
3. Mucocele nd EMPYMA
4. MIRRIZI syndrome
7. Gallstone ileus
12. GB Cancer
31
MurPhy's Sign
Abrupt CEASE of Breathing d/t Pain
Seen in Acute Cholecystitis
PT winces in pain when pressed in the Rt Hypochondrium
32
Boa's Sign
riB
Hyperesthesia in region of 12th RIB
33
Sonogrophic MurPhy's sign
Seen in ACUTE CHOLECYSTITIS
Focal tenderness when compressed by Sonographic probe
34
IOC FOR GB STONES / ACUTE CHOLECYSTITIS/ CHRONIC CHOLECYSTITIS
USG
35
IOC FOR
STAGING GB CANCER
STAGING LIVER CANCER
STAGING BILE DUCT CA
STAGING PANCREAS CA
CT SCAN
36
MERCEDES BENZ SIGN
Xray finding in RADIO-OPAQUE GB STONES
TRIRADIATE STONES
CENTER OF GALL STONE CONTAINS RADIOLUCENT GAS
37
SEAGULL SIGN
Xray finding in RADIO-OPAQUE GB STONE
BIRADIATE GALL STONES
38
TOKYO CONSENSUS GUIDELINES FOR
ACUTE CHOLECYSTITIS
39
TOKYO 🗼 Consensus Guidelines
Grade 2 DANGEr ⚡
Duration of symptoms>72 hrs
Abscess(pericholecystic/hepatic)
Neutrophils and WBC>18000/MM3
Gangrenous Cholecystitis
Emphysematous Cholecystitis
40
MANAGEMENT OF ACUTE CHOLECYSTITIS
41
Rokitansky Aschoff Sinuses seen in HPE of
✨ Chronic Cholecystitis
✨ Adenomyomatosis- benign condition with hypertrophy of mucosal epithelium
42
Chronic Cholecystitis
⭐ USG
⭐ MANAGEMENT
⭐ USG- WALL ECHO SHADOW (WES) SIGN
⭐ Management- Laproscopic Cholecystectomy
43
Emphysematous
➡️ Cholecystitis C=C
➡️ PyElonephritis
..CDE..
C=clostridium
E=E coli
EC seen in D(Diabetes and immunosuppression)
44
Emphysematous Cholecystitis Clinical Features
Pain Fever Sepsis CREPITUS
GAS IN GALL BLADDER
45
Pneumobilia
🧠⚡SUPER GAS⚡
Air in the biliary tree
✨ SUrgery (Biliary/Enteric)
✨ Pancreatitis chronic
✨ Emphysematous Cholecystitis
✨ R-CP- ERCP
✨ GAllstone ileus
✨ Sphincterotomy/incompetent sphincter
46
HeMOBilia
SandBlOOM Syndrome
Melena
Obstructive Jaundice
Biliary Colic
47
Obstructed GB
⭐ MUCUS Accumalates➡️MUCOcele➡️ infection➡️Empyma
⭐ TRANSUDATE Accumalates ➡️ HYDROPS
48
DIFFERENCE BETWEEN
CHOLELITHIASIS
CHOLEDOCHOLITHIASIS
ACUTE CHOLECYSTITIS
ACUTE CHOLANGITIS
CHOLELITHIASIS- PAIN ✔️
CHOLEDOCHOLITHIASIS- PAIN ✔️ Jaundice ✔️
ACUTE CHOLECYSTITIS- PAIN✔️PYREXIA✔️
ACUTE CHOLANGITIS- PAIN ✔️ PYREXIA ✔️ Jaundice ✔️
49
IOC: Gall Stone Ileus
🧠⚡CEIl ⚡
CECT
50
IOC FOR MIRRIZI SYNDROME
MRCP(Magnetic Resonance CHOLANGIOPANCREATICOGRAPHY)
51
BOUVERET SYNDROME
Seen in Gall stone Ileus
Stone leads to Gastric Outlet obstruction
C/F: Distension
Obstipation
Pain 😢
Nausea and Vomiting 🤮
52
RIGLERS TRIAD SEEN IN
POS
XRAY ABDOMEN IN GALLSTONE ILEUS
✨ Pneumobilia
✨ Obstructive gall stone in RT ILIAC FOSSA
✨ Small Intestinal Obstruction features- dilated bowel loops & Air-fluid levels
53
Management of Gall Stone Ileus
MEC-RA
54
SAINTS TRIAD
1st and Last Letter: SD²
Stones(gall stones)
Diverticulosis of Colon
Diaphragmatic Hiatal Hernia
55
Limitation of USG in Biliary Tract Pathology
Difficulties in identifying DISTAL CBD STONES
⬇️
DISTAL PART OF CBD IS COVERED BY DUODENUM, BOWEL GAS HINDERS ITS visualization
56
Use of PTC in Hepatobiliary pathology
Used when Endoscopic or Surgical procedures are 🚫 CONTRAINDICATION
⬇️
Both Diagnostic amd Therapeutic
57
ERCP is good for detection of CBD Stones, but NOT USED?
Highly Invasive
⬇️
Used only for Therapeutic interventions
58
Which investigation are best for detection of CBD Stones?
MRCP
MRI
59
Absolute 🚫 CONTRAINDICATION of LAPAROSCOPIC CHOLECYSTECTOMY
1. Unable to Tolerate General Anaesthesia
2. Refractory Coagulopathy
3. Gall Bladder Carcinoma
60
Relative 🚫 CONTRAINDICATION of LAPAROSCOPIC CHOLECYSTECTOMY
1. Diffuse Peritonitis
2. Previous upper abdominal surgery with EXTENSIVE ADHESIONS
3. Severe Cardiopulmonary Disease
4. Morbid Obesity
5. Pregnancy
6. Cholangitis
7. Cirrhosis & (OR) Portal HTN
8. Cholecystenteric Fistula
61
Prerequisites for MEDICAL therapy in CHOLELITHIASIS
1. Functional GALL BLADDER
2. Radiolucent stones
3. Stones < 10 mm
4. Cholesterol stones
62
Which Gall stones are RESPONSIVE to MEDICAL THERAPY?
Cholesterol stones
⭐ Pigment stones are NOT RESPONSIVE
63
Which patients can be given MEDICAL THERAPY for CHOLELITHIASIS
1. Symptomatic patients without COMPLICATIONS
2. NORMAL Gall Bladder Function ➕ Patent cystic duct
64
💊💉 MANAGEMENT RECURRENT CHOLEDOCHOLITHIASIS after CHOLECYSTECTOMY
Long term UDCA
65
Position of PATIENT in LAPAROSCOPIC CHOLECYSTECTOMY
Reverse TRENDELENBURG Position
Head end UP, Foot end DOWN
66
Traditional LAPROSCOPIC CHOLECYSTECTOMY
1. Infraumbilical Port: Camera
2. Epigastric Port: Maryland Dissector
3. Right HYPOCHONDRIAL: Blunt Grasper
4. Lumber Port: Toothed Grasper
67
SILS
Meaning
Single Incision LAPROSCOPIC Surgery
LAPROSCOPIC CHOLECYSTECTOMY via SINGLE INFRAUMBILICAL PORT
68
Position of SURGEON & ASSISTANT in LAPAROSCOPIC CHOLECYSTECTOMY
Left Side
69
⚡⚡ MOST COMMON COMPLICATION of SILS
Umbilical Hernia risk ⬆️
70
Surgery to Perform if it is DIFFICULT to DISSECT the CALOT'S TRIANGLE
🎯 FUNDUS FIRST CHOLECYSTECTOMY
🎯 RETROGRADE CHOLECYSTECTOMY
71
⚡⚡ MOST COMMON COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY
Right SHOULDER TIP PAIN
(because of retained CO2)
Others:
1. Hemorrhage
2. Injury to Bile Ducts
3. Conversion to Open Surgery
4. Residual CBD Stones
5. Strictures in CBD or BILIARY TREE
6. Residual CBD Stones
7. Post CHOLECYSTECTOMY syndrome
72
Frozen CALOT
73
MOYNIHAN'S hump
(OR)
CATERPILLER Hump
RIGHT HEPATIC ARTERY can have a TORTUOUS COURSE & can LIE in HEPATOCYSTIC TRIANGLE
⬇️
Hemorrage Occurs During CHOLECYSTECTOMY
74
Causes of Post CHOLECYSTECTOMY syndrome
Cholecystitis like features, even after CHOLECYSTECTOMY
⭐ Retained CBD stones
⭐ Biliary Dyskinesia
⭐ Sphincter of ODDI Dysfunction
75
INCISION in OPEN CHOLECYSTECTOMY
Kocher INCISION
Right SUBCOSTAL Incision
76
💊💉 MANAGEMENT of BILIARY INJURY identified during SURGERY
1. Partial INJURY in BILE DUCT: Repair Injury using NON-ABSORBABLE SUTURES (OR) T-tube
2. Complete TRANSECTION but NO LOSS of Segment: ANASTAMOSE over T-tube
3. Complete TRANSECTION with LOSS of Segment: Roux en Y Hepatico-duodenostomy/Jejunostomy
77
🧑🏻⚕️ Clinical Features: Bile leak after CHOLECYSTECTOMY
1. Abdominal pain
2. Fever
3. ⬆️ Leucocytes
4. Jaundice
5. Features of Sepsis
78
🩺 IOC for BILE LEAK
MRCP > ERCP
QBANK: ERCP is BEST in POST-CHOLECYSTECTOMY BILE LEAKS
⬇️
BECAUSE BOTH DIAGNOSTIC & THERAPEUTIC
79
💊💉 MANAGEMENT BILE LEAK patient PRESENTS within 2 DAYS of CHOLECYSTECTOMY
Re-Explore & REPAIR
80
💊💉 MANAGEMENT BILE LEAK patient PRESENTS after 2 DAYS of CHOLECYSTECTOMY
USG guided PIGTAIL CATHETER to Drain Collection (BILIOMA)
⬇️
ERCP ➕ STENT Placement
81
⚡⚡ MOST COMMON BILE DUCT INJURY
Type A STRASBERG
⬇️
Cystic Duct Leaks from SMALL DUCTS in Liver Bed
82
Type C STRASBERG
Leak from an ABBERENT RIGHT HEPATIC DUCT
83
Risk Factors for GALL BLADDER Cancer
🧠⚡S²P²AM ⚡
1. Stones (GB Stones)
2. Salmonella typhi carriers
3. Porcelain Gall Bladder
6. Polyps GB
4. APBDJ (Abnormal pancreatico-biliary duct junction)
5. Metal Contamination
6. Choledochal cyst
7. Cholecysto-enteric fistula (Gall Stone ileus)
8. Estrogen
9. Ulcerative colitis
84
APBDJ ⬆️ ⬆️ the RISK of
1. Gall Bladder Cancer
2. Cholangiocarcinoma
85
APBDJ ⬆️ ⬆️ the RISK of
1. Gall Bladder Cancer
2. Cholangiocarcinoma
86
Why GANGETIC BED is ENDEMIC for GB Cancer?
Heavy Metal Contamination of Water
87
Types of GB Polyps
1. Cholesterol Polyps
2. Adenomatous Polyps
88
Identify
CHOLESTROL POLYPS of GALL BLADDER
-Small
-Multiple
-Pedunculated
89
CHOLESTROL POLYPS of GALL BLADDER
90
Identify
ADENOMATOUS POLYPS of GALL BLADDER
✨ Single
✨ Large
✨ Sessile
✨ Risk of GB CANCER
91
Which GB POLYP ⬆️ Risk of GB CANCER?
Adenomatous POLYPS of GALL BLADDER
92
🌸 TYPES of GB CANCER
Adenocarcinoma
✨ INFILTRATING
✨ NODULAR
✨ PAPILLARY
93
🎯 WORST PROGNOSIS GB CANCER
🎯 BEST PROGNOSIS GB CANCER
🎯 WORST PROGNOSIS GB CANCER
✨ INFILTRATING
🎯 BEST PROGNOSIS GB CANCER
✨ PAPILLARY
94
🧑🏻⚕️ Clinical Features of GB CANCER
1. Abdominal Lump
2. JAUNDICE : VERY LATE
3. Pain
4. Anorexia & Weight Loss
⭐ PYRIFORM SHAPE OF GB is NOT RETAINED
95
⭐ JAUNDICE is VERY LATE FEATURE IN
⭐ JAUNDICE is EARLY FEATURE IN
⭐ JAUNDICE is VERY LATE FEATURE IN
🎯 GB CANCER
⭐ JAUNDICE is EARLY FEATURE IN
🎯 PERIAMPULLARY CANCER
96
1st LYMPH NODE to be affected in GB CANCER
Lymph Node of LUND
97
⚡⚡ MOST COMMON SITE OF DISTANT METASTASIS in GB CANCER
LIVER
98
🩺 IOC for DIAGNOSIS AND STAGING OF GB CANCER
CECT
99
T-STAGING: GB CANCER
🧠⚡T2 is MUSCULARIS PROPRIA in MOST GIT Cancer, except GB Cancer ⚡
🧠⚡Submucosa is ABSENT in GB ⚡
100
N-staging: GB Cancer
🧠⚡Smallest Organ in abdomen: Only 2 subdivisions ⚡
101
M staging of GB CANCER
M0
M1
102
💊💉 MANAGEMENT of GB CANCER
103
💊💉 MANAGEMENT GB Cancer T3 without NODAL or Peritoneal involvement
1. Extended Right Hepatectomy
2. Caudate Lobectomy
3. Lymphadenectomy
104
💊💉 MANAGEMENT of T4 GB Cancer
Palliative Management
1. Jaundice ➡️ Endoscopic Biliary Stenting
2. Pain ➡️
a. Analgesics
b. Percutaneous Necrolysis of celiac ganglion
3. Intestinal Obstruction
✨ Endoscopic Duodenal Wall Stent
105
Strawberry Gall Bladder
Cholestrolosis
106
ASSOCIATIONS of EHBA
1. Situs inversus
2. Preduodenal Portal Vein
3. Cardiac defects
4. Polysplenia
5. Absent IVC
107
🩺 IOC for EHBA
HIDA Scan
108
GOLD STANDARD INVESTIGATION FOR EHBA
Intraoperative Cholangiogram
109
🧑🏻⚕️ Clinical Features of EHBA
Inflammatory Fibrosis of Biliary tree
⬇️
Atresia
⬇️
Cirrhosis
1. Jaundice at BIRTH
2. PRURITIS
3. PALE STOOLS
4. LIVER FAILURE FEATURES
110
TRIAGULAR CORD SIGN seen in
USG of INTRAHEPATIC BILE ATRESIA
111
Types of EHBA
112
💊💉 MANAGEMENT of TYPE I EHBA
Roux en Y Hepaticojejunostomy
113
Identify the Procedure
Roux en Y Hepaticojejunostomy
114
💊💉 MANAGEMENT of TYPE 2 and 3 EHBA
Kasai's procedure
Intestine is connected DIRECTLY to the LIVER
115
Identify
KASAI's procedure
PORTO-ENTEROSTOMY
116
⚡⚡ MOST COMMON CAUSE of LIVER TRANSPLANT in CHILDREN
EHBA
117
⭐ TODANI CLASSIFICATION used for
⭐ MODIFIED ALONSO-LEJ CLASSIFICATION used for
CHOLEDOCHAL CYST
118
⭐ TODANI CLASSIFICATION
🧠⚡ 123 EDC ⚡
🧠⚡A for “And or Additional” and B for “Bunch” ⚡
Type I: Entire CBD dilated
Type II: Diverticulum
Type III: Choledochocele (Intraduodenal portion of CBD)
Type IV: Extrahepatic + Intrahepatic
Type IVa: Both intrahepatic AND extrahepatic cysts
Type IVb: Multiple extrahepatic cysts only
Type V: Intrahepatic cysts only (Caroli’s disease)
Type VI: Dilatation of CYSTIC DUCT
119
Choledochocele
Dilatation of INTRADUODENAL Part of CBD
120
CAROLI'S disease
Intrahepatic cysts only
121
🩺 IOC of CHOLEDOCHAL CYST
MRCP
122
🧑🏻⚕️ Clinical Features of CHOLEDOCHAL CYST
1. Lump
2. Jaundice
3. Pain
123
CHOLEDOCHAL CYST ⬆️ ⬆️ the RISK of
✨ CHOLANGIOCARCINOMA
✨ JAUNDICE (Ineffective drainage of Bile)
124
💊💉 MANAGEMENT of CHOLEDOCHAL CYST
🧠⚡Liver Transplant if INTRAHEPATIC Dilatation⚡
Type 1: Roux-en-Y Hepaticojejunostomy
Type2: Roux-en-Y Hepaticojejunostomy
(OR) Cut DIVERTICULUM ➕ Repair CBD
Type 3: ERCP ➕ Sphincterotomy
Type 4a: LIVER TRANSPLANT
Type 4b: KASAI Procedure
Type 5: LIVER TRANSPLANT
125
CHOLANGIOCARCINOMA: ASSOCIATIONS
🧠⚡ 8Cs⚡
C-Caroli's disease
C-Choledochal cyst
C-Colitis (ulcerative colitis)
C-Cholangitis (sclerosing)
C-Clonorchis sinensis
C-Congenital Hepatic Fibrosis
C-C/c typhoid carrier state
C-Carcinogens like rubber,automotive factories
126
⚒️ RISK FACTOR for CHOLANGIOCARCINOMA
1. Obesity
2. DM
3. HBV & HCV
4. CHOLEDOCHAL CYST
5. APBDJ
6. THOROTRAST
7. 1° SCLEROZING CHOLANGITIS
127
Autoimmune condition MORE COMMON in MEN
1° SCLEROZING CHOLANGITIS
128
Antibodies in 1° SCLEROZING CHOLANGITIS
1. Anti-Smooth Muscle
2. Anti-Nuclear ANTIBODY
129
ASSOCIATION of 1° SCLEROZING CHOLANGITIS
1. IBD
2. HLA B8 & DR3
3. Riedel's thyroiditis
4. Retroperitoneal Fibrosis
130
MRCP Appearance of 1° SCLEROZING CHOLANGITIS
Beaded Appearance
131
Extra-INTESTINAL Manifestations of IBD that DO NOT RESOLVE AFTER COLECTOMY
1. 1° SCLEROZING CHOLANGITIS
2. Ankylosing Spondylitis
132
COURVOISIER'S LAW
133
🩺 IOC of 1° SCLEROZING CHOLANGITIS
MRCP
134
⭐ BISMUTH-CORLETTE CLASSIFICATION used for
⭐ BISMUTH CLASSIFICATION used for
⭐ BISMUTH-CORLETTE CLASSIFICATION used for
🎯 Perihilar Tumour (CHOLANGIOCARCINOMA)
⭐ BISMUTH CLASSIFICATION used for
🎯 BILE DUCT INJURY
135
⭐ BISMUTH-CORLETTE CLASSIFICATION
136
💊💉 MANAGEMENT of RESECTABLE CHOLANGIOCARCINOMA
✨ Tumour @ DISTAL CBD: Whipple's procedure
✨ Tumour @ SUPRADUODENAL CBD: Hepatico-jejunostomy
✨ Tumour @ HIGH-UP CBD: KASAI'S Procedure
⬇️
⬇️
CHEMOTHERAPY
GEMCITABINE-Based
137
💊💉 MANAGEMENT of UNRESECTABLE CHOLANGIOCARCINOMA
Palliative MANAGEMENT
-Manage Jaundice
✨ ERCP & STENTING
✨ PTBD
-CHEMO
Gemcitabine
138
Marker used for PROGRESSION of CHOLANGIOCARCINOMA
Serum CA 19-9
139
⚡⚡ MOST COMMON SITE OF DISTANT METASTASIS IN CHOLANGIOCARCINOMA
Liver
140
Cause of HEMOBILIA
Arterial Bleeding
✨ Trauma
✨ Iatrogenic
🎯 Post ERCP
🎯 Post PTBD
✨ Bloom Syndrome
141
Quincke's TRIAD seen in
🧠⚡JUP Quickly!! ⚡
1. Jaundice
2. Upper GI hemorrhage MELENA
3. Pain
142
🩺 IOC of HEMOBILIA
CT Angiography
143
💊💉 MANAGEMENT of HEMOBILIA
Self Resolving
⬇️
⬇️
Trans-Arterial Embolization
144
BILHEMIA
Fistula BETWEEN Vein & Biliary Tree
⬇️
Bile leaking into Blood Stream
145
🩺 IOC for BILHEMIA
CT Angiography
146
💊💉 MANAGEMENT of BILHEMIA
ERCP & Stent the FISTULA or EMBOLIZATION
147
ABERNETHY MALFORMATIONS
Congenital Portosystemic shunts
148
🩺 IOC of ABERNETHY MALFORMATIONS
CT ANGIOGRAPHY
149
💊💉 MANAGEMENT of TYPE 1 ABERNETHY MALFORMATIONS
💊💉 MANAGEMENT of TYPE 2 ABERNETHY MALFORMATIONS
💊💉 MANAGEMENT of TYPE 1 ABERNETHY MALFORMATIONS
🎯 TRANSPLANT
💊💉 MANAGEMENT of TYPE 2 ABERNETHY MALFORMATIONS
🎯 EMBOLIZATION
150
⚡⚡ MOST COMMON SITE OF STRICTURE FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY
⚡⚡ MOST COMMON SITE OF STRICTURE FOLLOWING OPEN CHOLECYSTECTOMY
⚡⚡ MOST COMMON SITE OF STRICTURE FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY
🎯 COMMON HEPATIC DUCT
⚡⚡ MOST COMMON SITE OF STRICTURE FOLLOWING OPEN CHOLECYSTECTOMY
🎯 COMMON BILE DUCT (CBD)
151
💊💉 MANAGEMENT of BILHEMIA
ERCP & STENT the FISTULA (OR) EMBOLIZATION
152
⚡⚡ MOST COMMON BILE LEAK AFTER CHOLECYSTECTOMY IS FROM
Cystic Duct
💊💉 MANAGEMENT
Biliary Ensoprosthesis (STENT)
153
Types of Gall Stones
✨ Pigment
🎯 Brown
🎯 Black
✨ Cholesterol
✨ Mixed
154
⚡⚡ MOST COMMON Gall Stone Overall
⚡⚡ MOST COMMON Gall Stone in ASIA
⚡⚡ MOST COMMON Gall Stone Overall
🎯 Mixed
⚡⚡ MOST COMMON Gall Stone in ASIA
🎯 Pigment stones
155
⚒️ RISK FACTOR for GALL STONE FORMATION
1. Lithogenic Bile
2. Stasis
3. Nucleation
156
Lithogenic Bile
⬆️ Cholesterol & ⬇️ Bile acids & ⬇️ Lecithin
🧠⚡OCC, ⬇️ Bile Acids: BOCE ⚡
⬆️ Cholesterol
🎯 Obesity
🎯 Cholesterol Rich Diet
🎯 Clofibrate therapy
⬇️ Bile acids
🎯 1° Biliary Cirrhosis
🎯 OCPs
🎯 CYP7A1 gene mutation
🎯 Enterohepatic circulation impaired
✨ Ileal disease
✨ Ileal resection
✨ Cholestyramine
✨ Colestipol
⬇️ Lecithin
🎯 MDR3 gene mutation
157
✨ Normal Bile Acids to Cholesterol ratio in Bile
✨ Ratio below which Gall Stones are precipitated
✨ Normal Bile Acids to Cholesterol ratio in Bile
🎯 25:1
✨ Ratio below which Gall Stones are precipitated
🎯 13:1
158
Nucleation Factors for GALL STONEA
1. Mucin
2. Non Mucin Glycoprotein
3. Infection
✨ Clonorchis
✨ Cholangitis
✨ Ascariasis
159
Anti-nucleation Factors for Gall Stones
Apolipoprotein A1
Apolipoprotein A2
160
Causes of GALL BLADDER HYPOMOTILITY
1. TPN (prolonged)
2. Octreotide
3. OCPs
4. Pregnancy
5. Post Vagotomy
6. Fasting (prolonged)
7. Burns (massive)
161
Why USG is 🩺 IOC for GB STONE
1. Superficial location of Gall Bladder
2. Absence of overlying Bowel Gas
162
USG for GB Stones is NOT USEFUL in
1. Excess Body Fat
2. Intraluminal Bowel Gas
3. Operator dependent
163
Post Acoustic Shadow is seen with which Stones
GB Stone
Kidney Stone
164
USG Findings of GB STONE
1. Post Acoustic Shadow
2. GB wall thickening
3. Pericholecystic Fluid ➕
165
Surgical Intervention in ASYMPTOMATIC GB STONE is done in
🧠⚡S²P²M: BED C²⚡
1. Salmonella carrier
2. Stone ≥ 3cm
3. Porcelain GB with stone (Calcification of wall of Gall Bladder)
4. Polyp with stone
5. Multiple small stone
6. Bariatric Surgery
7. Endemic zone of GB cancer
8. DM
9. Choledochal cyst
10. Choledocholithiasis
11. Transplant or Immunosuppression therapy
166
Abdominal X-Ray is useful in which biliary pathologies
1. Calcified Gall Stones
2. Emphysematous Cholecystitis
3. Porcelein GB
4. Limey Bile
5. Gall Stone ileus
167
Use of HIDA / DIDA / DISDA
✨ Confirmation of Suspected Acute Cholecystitis
✨ Acalculous Cholecystopathy
168
HIDA scan
Hepatobiliary Imino Diacetic Acid Scan
169
DIDA / DISDA Scan
Di-isopropyl Imino Diacetic Acid Scan
Dynamic Tc99m DIDA Cholescintigraphy
170
LIMEY Gall Bladder
Opacified GALL BLADDER
✨ Toothpaste lile substance is filled within the gall bladder containing Calcium Phosphate & Calcium Carbonate
171
Congenital Anomalies of the Gall Bladder
1. Absence of Gall Bladder
2. Phrygian Cap
3. Double (OR) Triple Gall Bladder
4. Mobile (OR) Floating (OR) Mesenteric Gall Bladder
5. Long Cystic Duct with Low Insertion of Cystic Duct into CBD
6. Absent CYSTIC DUCT
7. Accessory Cholecystohepatic duct (Duct of Luschka)
8. Cystic artery originates from Hepatic artery
9. Tortuous Right Hepatic Duct ➡️ Moynihan's HUMP
10. Double CYSTIC Duct
172
Causes of OBSTRUCTIVE JAUNDICE (OR) Surgical JAUNDICE
1. Congenital
✨ EHBA
✨ CHOLEDOCHAL Cyst
2. Inflammatory
✨ Ascending Cholangitis
✨ Sclerosing Cholangitis
3. Infective
✨ Ascariasis
✨ Clonorchis
4. Obstructive
✨ CBD STONE
✨ Structures in CBD
5. NEOPLASTIC
✨ Periampullary cancer
✨ Ca Head of Pancreas
✨ Cholangiocarcinoma
✨ Klatskin tumour
6. Extrinsic compression by Lymph nodes
173
Causes of Cholangitis
1. Choledocholithiasis
2. Biliary stricture
3. Neoplasm
4. Post ERCP
5. Others
✨ Pseudocyst of pancreas
✨ chronic Pancreatitis
✨ Biliary Parasitic Infection
174
Uses of ERCP
1. Gold standard for CBD Stone Removal
2. Stenting for inoperable Tumours
3. ENDOSCOPIC basketting & stone retrieval
4. Biopsy
5. Preoperative Bile Drainage
6. Sphincter of Oddi Dysfunction
