Hepato-Biliary Surgery

Question 1

What are the sommon diseases of the gall bladder?

Answer 1

• Gallstones (Cholelithiasis)
• Cholesterosis (cholesterol in cells lining gallbladder wall)
• GB Polyps

Question 2

What are the types of gall stones?

Answer 2

Some are all cholesterol
Some are all pigments
Most are mixed

Question 3

What are the risk factors for gall strones?

Answer 3

Age
Female
High cholesterol (e.g. obese)
Pigment conditions (e.g. bile infection or haemolytic anaemia)
Female sex hormones e.g. OCP, hormone replacement

Remmeber 5Fs (Fat Female Fertile Forty Fair) but don’t say them to patients its derogatory man

Question 4

How can gallstones present?

Answer 4

• Asymptomatic
• Biliary Colic (RUQ or epigastric pain)
• Sometimes nausea, heatburn, dyspepsia & flatulence
• Jaundice if in the CBD or impacted in the neck of the cystic duct (Mirrizis syndrome)

Question 5

What is gallstone ileus?

Answer 5

Gallstones become stuck in the narrowest part of the ileum

Question 6

What is choledocho-lithiasis?

Answer 6

Lithiasis = Formation of stones in the body
Chole - in gall bladder
Choledoco - In biliary ducts

So basically stones forming or collecting in the bile ducts. Can cause obstructive jaundice, acute pancreatitis and ascending cholangitis

Question 7

What is mirrizis syndrome?

Answer 7

A gallstone impacted in the cystic duct/neck of gallbladder

Results in obstruction jaundice

Question 8

What investigations are there for gall stones?

Answer 8

LFTs, Amyase, Lipase, WCC
Ultrasound/Endoscopic ultrasound
CT scan
MRCP

Question 9

What treatment is there for gall stones?

Answer 9

If asymptomatic just leave them

Non-operative:

• Dissolution (bile acid therapy)
• Lithotripsy (shock waves)

Operative:
- Laparascopic Cholecystectomy +/- on table cholangiography

For common bile duct stones: (Indicated by a dilated CBD on US, Elevated liver or pancreatic enzymes & biliary colic)
- ERCP +/- adjunct lithotripsy or stenting

Question 10

List some benign biliary tract disease?

Answer 10

Congenital:

• Biliary Atresia
• Choledochal Cysts (congenital cystic dilatation of bile ducts)

Benign Biliary stricture:

• Iatrogenic
• Gallstone related (mirrizis syndrome)
• Inflammatory stricture

Biliary Enteric Fistula

Question 11

Jaundice can be caused by tumours, what kind?

Answer 11

Cholangiocarcinoma
 - Intrahepatic
 - Extrahepatic (hilar or distal)
 - Gallbladder
 - Ampullary
Cancer of the head of the pancreas

Question 12

What are the types of cholangiocarcinoma?

Answer 12

Mass Forming
Peri-ductal
Intra-ductal

Question 13

How does a cholangiocarcinoma present?

Answer 13

• Non-specific systemic symptoms
• Pruritis
• Obstructive Jaundice

Question 14

What investigations are there for cholangicarcinoma?

Answer 14

• Lab Tests
• Radiology (US, CT)
• ERCP

Question 15

Management of a cholangiocarcinoma?

Answer 15

Curative:
- Surgery

Palliative:

• Surgical bypass or stenting (percutaneous/endoscopic)
• Palliative radiotherapy or chemo

Question 16

Whats the prognosis for gall bladder cancer?

Answer 16

Very poor as rarely caught until very advanced.

Only good if caust early incidentally in gallstones

Question 17

What inherited condition is associated with ampullary tumours?

Answer 17

FAP (Familial Adenomatous Polyposis)

Question 18

What are the treatment options for ampullary tumours?

Answer 18

Endoscopic Excision
Trans-duodenal excision
Pancreatico-duodenectomy (removes fucking everything)