HPB

Question 1

Hydatid cyst causative agent

Answer 1

Echinococcus granulosus

Question 2

Focal modular hyperplasia

Answer 2

Focal nodular hyperplasia is benign
Biopsy is only needed if there is doubt about the diagnosis

Question 3

Risk of injury to CBD in lap chole

Answer 3

CBD injury with laparoscopic cholecystectomy = 0.3-0.7%

Question 4

HCC mets

Answer 4

Lungs most comman
Then lymphatic spread

Question 5

Pancreatic division

Answer 5

In classic pancreatic divisum the Duct of Santorini drains via the minor papilla and the duct of Wirsung drains via the major papilla

Question 6

Risk factors for pancreatic fistulas

Answer 6

• Pancreatic fistula are the single biggest cause of morbidity following pancreatic resection
• Incidence is approximately 15%, risk lower in distal pancreatectomy
•Clinically significant fistula will have amylase three times the serum amylase level and will give rise to symptoms such as fever and tachycardia
• Risk of fistula is increased if there is a soft pancreas (22%), age over 70 years, long period of jaundice (rather than severity), coronary artery disease and blood loss over 1doomi

Question 7

How many liver segments need to remain post resection

Answer 7

2 segments on the ipsilateral size correlate approximately to 20-30% of liver volume.

Good outcome when >20% left if underlying problems >40%

Question 8

Liver regeneration time

Answer 8

4-6months

Question 9

Main duct IPMN

Answer 9

Lesions which are between 20-30 mm are considered moderate risk and should be further evaluated using US and blood tests for CEA and CA19-9. Percutaneous biopsy is not generally performed.

Question 10

IPMN histology

Answer 10

Main duct - usually pancreatic-bilary differention

Branching ducts - usually gastric foveolar

Question 11

Gallbladder polyps

Answer 11

Malignancy more likely in >1cm

Question 12

Gb cancer

Answer 12

• Represents 2% of all cancers
  • Up to 90% cases associated with gallstones
  • A polyp - carcinoma sequence does not apply in the gallbladder
  • Malignancy is more likely in a gallbladder polyp larger than 1cm diameter
  • 60% are located in the fundus
  • 6% of patients with porcelain gallbladder will be associated with malignancy
  • Treatment of T1 (mucosal disease) is by open cholecystectomy and regional nodal sampling
  • T2-T3 disease is managed by formal resection of segments IVb and V
  • Overall survival is less than 10% at 5 years.

Question 13

Hepatic cystadenomas

Answer 13

Up to 10% of cystadenomas are malignant and distinguishing between benign and malignant disease (even on biopsy is difficult). Surgical resection is therefore recommended. Note that in the question, cross sectional imaging has already suggested the diagnosis.

Question 14

IPMN follow up

Answer 14

Concerning features: enhancing nodule <5mm, elevated ca19.9 increase in growth to >5mm over 2 years

If cystic lesion <1cm thrn CT/MRI every 2 hrs
If >3cm follow up EUS/MRI every 3-6months

Question 15

IPMN malignancy risk

Answer 15

Main duct - 60-100%
Side duct 25%

Question 16

Main duct IPMN resection

Answer 16

Mutal nodule
Main duct involvement
Malignant cells on cytology
>40mm

Question 17

Side branch resection

Answer 17

Criteria for resecting branching duct IPMN:
The presence of jaundice, cytology positive for high-grade dysplasia or cancer, the presence of a contrast-enhancing mural nodule (>5mm) or solid mass should be considered as absolute indications for surgery

Question 18

What percentage of procelain gallbladders are associated with cancer

Answer 18

6%

Question 19

CBD stones

Answer 19

Brown pigment stones have the highest incidence of being located in the CBD. They are also the most prone to infective complications. Black pigment stones are more closely associated with an underlying metabolic disorder.

Question 20

Location of cholangiocarcinomas

Answer 20

Most are located in the peri hilar region. The region between the upper border of the pancreas and the ampulla of vater is the next most common site.

Question 21

What percentage of patients with gallstones and normal CBD diameter and LFTs will have CBD stones

Answer 21

In patients aged less than 55 years with normal CBD on USS and normal LFT’s the incidence of CBD stones is 5%.

Question 22

Tpn and gallstones

Answer 22

TP is more typically associated with pigment rather than cholesterol gallstones.

Question 23

Hepatocellular adenoma

Answer 23

• 90% develop in women in their third to fifth decade
• Linked to use of oral contraceptive pill
• Lesions are usually solitary
• They are usually sharply demarcated from normal liver although they usually lack a fibrous capsule
• On ultrasound the appearances are of mixed echoity and heterogeneous texture.
On CT most lesions are hypodense when imaged prior to administration of IV contrast agents
• In patients with haemorrhage or symptoms removal of the adenoma may be required
• Asymptomatic adenomas >5cm are usually excised
• Adenomas in males are likely to be smaller but have a greater risk of malignant transformation
- Risk of rupture is greater infesions larger than 5cm and those which are exophytic.
Mortality rates from spontaneous rupture are 5-10%.

Question 24

Gallstone pancreatitis in pregnancy

Answer 24

Cholecystectomy performed in the second trimester is the safest option and that which is associated with the lowest morbidity for mother and child.

Question 25

Abx post surgery in acute cholecystitis

Answer 25

Nil required

Question 26

Biliary stents

Answer 26

Metallic stents now useable in respectable disease

Question 27

Side branch IPMN

Answer 27

Follow up of BD-IPMN is required as progression of disease is expected in about 10–15% of patients during 3 to 5 years of follow up. Surveillance should also include the entire pancreatic gland because of an increased risk of new-onset cancer. Initially, MRI in 6 months should be performed. Absence of worrying features at follow up and slow or no growth may allow for annual MRI surveillance