Gallbladder Flashcards

Question

Describe choledocholithiasis

Answer 1

-Stones in the common bile duct -Primary bile duct stones are rare but can develop within the common bile duct many years after a cholecystectomy and are sometimes related to biliary sludge arising from dysfunction of the sphincter of Oddi. -In Far Eastern countries, primary common bile duct stones are thought to follow bacterial infection secondary to parasitic infections -Bile duct obstruction and may be complicated by cholangitis due to secondary bacterial infection, sepsis, liver abscess and biliary stricture.

Answer 2

-Asymptomatic, may be found incidentally by operative cholangiography at cholecystectomy, -May manifest as recurrent abdominal pain with or without jaundice. -The pain is usually in the right upper quadrant, and fever, pruritus and dark urine may be present. -Rigors may be a feature; jaundice is common and usually associated with pain. -Physical examination may show the scar of a previous cholecystectomy; if the gallbladder is present, it is usually small, fibrotic and impalpable.

Answer 3

-LFTs show a cholestatic pattern and there is bilirubinuria. -If cholangitis is present, the patient usually has a leucocytosis. -Obstruction to the common bile duct is transabdominal ultrasound =dilated extrahepatic and intrahepatic bile ducts, together with gallbladder stones -EUS is extremely accurate at identifying bile duct stones. -MRCP is non-invasive and is indicated when intervention is not necessarily mandatory (e.g. the patient with possible bile duct stones but no jaundice or sepsis).

Answer 4

-Cholangitis= analgesia, IV fluids and broad-spectrum antibiotics (cefuroxime and metronidazole) -Blood cultures -Urgent decompression of the biliary tree and stone removal. -ERCP with biliary sphincterotomy and stone extraction is the treatment of choice and is successful in about 90% of patients. -Confirmed by intraoperative cholangiography.

Answer 5

-Uncommon tumour, females + 70 years. -90% adenocarcinomas; the remainder are anaplastic or, rarely, squamous tumours. -Gallstones present in 70–80% of cases -Calcified gallbladder= high risk of malignant change/ gallbladder polyps over 1 cm in size =increased risk of malignancy =Preventative cholecystectomy -Chronic infection with Salmonella, especially in areas where typhoid is endemic, is also a risk factor.

Answer 6

-Diagnosed incidentally and is found in 1–3% of gallbladders removed at cholecystectomy for gallstone disease. -Repeated attacks of biliary pain and, later, persistent jaundice and weight loss. -A gallbladder mass may be palpable in the right hypochondrium. -LFTs show cholestasis, and porcelain gallbladder may be found on X-ray. -The tumour can be diagnosed by ultrasonography and staged by CT.

Answer 7

-Surgical excision but local extension of the tumour beyond the wall of the gallbladder into the liver, lymph nodes and surrounding tissues is invariable and palliative management is usually all that can be offered. -Survival is generally short, death typically occurring within 1 year in patients presenting with symptoms.

Answer 8

-Uncommon tumour that can arise anywhere in the biliary tree, from the intrahepatic bile ducts (20–25% of cases) and the confluence of the right and left hepatic ducts at the liver hilum (50–60%) to the distal common bile duct (20%). -Associated with gallstones, primary and secondary sclerosing cholangitis, Caroli's disease and choledochal cysts -Primary sclerosing cholangitis carries a lifetime risk of CCA of approximately 20%, -Chronic biliary inflammation appears to be a common factor in the development of biliary dysplasia and cancer that is shared by all the predisposing causes.

Answer 9

-Obstructive jaundice. -About 50% of patients also have upper abdominal pain and weight loss. -CT and MRI but can be difficult to confirm in patients with sclerosing cholangitis. -Serum levels of the tumour marker CA19-9 are elevated in up to 80% of cases, although this may occur in biliary obstruction of any cause. -In the setting of biliary obstruction, ERCP may result in positive biliary cytology. -Endoscopic ultrasound–fine needle aspiration (EUS-FNA) of bile duct masses is sometimes possible

Answer 10

-Surgically in about 20% of patients, which improves 5-year survival from less than 5% to 20–40%. -Surgery involves excision of the extrahepatic biliary tree with or without a liver resection and a Roux loop reconstruction. -However, most patients are treated by stent insertion across the malignant biliary stricture, using endoscopic or percutaneous transhepatic techniques. -Combination chemotherapy is increasingly used and palliation with endoscopic photodynamic therapy has provided encouraging results.

Answer 11

-Nearly 40% of all adenocarcinomas of the small intestine arise in relationship to the ampulla of Vater and present with pain, anaemia, vomiting and weight loss. -Jaundice may be intermittent or persistent.

Answer 12

-The diagnosis is made by duodenal endoscopy and biopsy of the tumour but staging by CT/MRI and EUS is essential. -Ampullary carcinoma must be differentiated from carcinoma of the head of the pancreas and a CCA because these last two conditions both have a worse prognosis. -Imaging may show a ‘double duct sign’ with stricturing of both the common bile duct and pancreatic duct at the ampulla and upstream dilatation of the ducts. -EUS is the most sensitive method of assessing and staging ampullary or periampullary tumours.

Answer 13

-Curative surgical treatment can be undertaken by pancreaticoduodenectomy and the 5-year survival may be as high as 50%. If resection is impossible, palliative surgical bypass or stenting may be necessary.