24- Hepatobiliary Explains Flashcards
What is the global ranking of hepatocellular carcinoma as a cause of cancer deaths?
Hepatocellular carcinoma is the second leading cause of cancer deaths globally.
What is the survival rate for hepatocellular carcinoma?
Unfortunately, the incidence of hepatocellular carcinoma approximates the death rate, resulting in few long-term survivors.
How many cases of hepatocellular carcinoma are reported annually?
Up to 750,000 cases of hepatocellular carcinoma are reported annually.
Who is at the highest risk for developing hepatocellular carcinoma?
Hepatocellular carcinoma occurs most commonly in individuals with chronic hepatitis and established liver cirrhosis.
What is a recognized risk factor for hepatocellular carcinoma in an otherwise healthy liver?
The presence of adenomas in an otherwise healthy liver is a recognized risk factor for hepatocellular carcinoma.
How should individuals with chronic hepatitis and liver cirrhosis be screened for hepatocellular carcinoma?
Individuals with chronic hepatitis and liver cirrhosis should be closely screened for the development of hepatocellular carcinoma with serum AFP testing and liver ultrasound every 6-12 months.
What are the diagnostic criteria for hepatocellular carcinoma?
Rising AFP levels and a liver ultrasound showing a nodule greater than 1cm in diameter make hepatocellular carcinoma much more likely, and further evaluation with MRI scanning is recommended.
What is the Barcelona Clinic Liver Classification used for?
The Barcelona Clinic Liver Classification system is used to categorize the extent of the disease, guide treatment decisions, and predict prognosis for hepatocellular carcinoma.
What are the key factors to consider when determining the ideal treatment for hepatocellular carcinoma?
When determining the ideal treatment modality for hepatocellular carcinoma, the key factors to consider are disease extent, functional state of the liver, and overall patient condition.
What is the aim in diagnosing hepatocellular carcinoma?
The aim is to avoid unnecessary percutaneous biopsy. Radiologically, on CT, the classical feature of hepatocellular carcinoma is a suspicious lesion that is highlighted during the arterial phase with washout during the venous phase, reflecting the hypervascularity of the lesions.
What are the features and treatment options for Stage 0 hepatocellular carcinoma?
Features: Single lesion (less than 2cm), normal portal pressures. Treatment: Resection (40-70% survival).
What are the features and treatment options for Stage A hepatocellular carcinoma?
Features: Single nodule greater than 3cm or multiple nodules (no more than 3), Child Pugh A/B. Treatment: Radiofrequency ablation if associated disease, transplantation if no associated disease (up to 70% survival in some cases).
What are the features and treatment options for Stage B hepatocellular carcinoma?
Features: Multiple nodules, Child Pugh A/B. Treatment: Transarterial chemoembolization (usually with doxorubicin) (26% survival at 3 years).
What are the features and treatment options for Stage C hepatocellular carcinoma?
Features: Advanced tumors, invasion of portal vein, Child Pugh A/B. Treatment: Sorafenib (usually survive 10.7 months).
What are the features and treatment options for Stage D hepatocellular carcinoma?
Features: Child Pugh stage C, advanced tumors. Treatment: Best supportive care (less than 6 months survival).
What are the recommended treatment options for hepatocellular carcinoma in selected patients?
In selected patients, the best outcomes are achieved with surgical resection or transplantation (when surgical resection is not possible). Anatomical resections with minimum 2cm margins provide the best outcomes.
What is the role of adjuvant chemotherapy in hepatocellular carcinoma treatment?
At present, there is no evidence to recommend treatment with adjuvant chemotherapy.
What is sorafenib and what is its role in hepatocellular carcinoma treatment?
Sorafenib is an oral multi-tyrosine kinase inhibitor. It is the only drug currently demonstrated to extend survival in individuals with advanced hepatocellular cancer. It improves median survival from 7 months to 10 months.
What is the prevalence of gallstones in women and men?
Up to 24% of women and 12% of men may have gallstones.
What percentage of patients who undergo surgery for gallstones will have stones in the common bile duct?
12% of patients who undergo surgery for gallstones will have stones in the common bile duct.
What is the most common composition of gallstones?
The majority of gallstones are of mixed composition (50%), with pure cholesterol stones accounting for 20% of cases.
How does the etiology of common bile duct stones differ between the Western and Eastern parts of the world?
In the West, most common bile duct stones result from migration. In the East, a higher proportion of stones arise de novo in the common bile duct.
What are the classical symptoms of gallstones?
The classical symptoms of gallstones include colicky right upper quadrant pain that occurs after eating.
When are the symptoms of gallstones usually the worst?
The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.
What are the standard diagnostic tests for suspected gallstones?
The standard diagnostic workup for suspected gallstones includes abdominal ultrasound and liver function tests.
What percentage of patients with stones in the bile duct will have abnormal liver function test results?
60% of patients with stones in the bile duct will have at least one abnormal result on liver function tests.
60% of patients with stones in the bile duct will have at least one abnormal result on liver function tests.
The options for imaging when stones are suspected in the bile duct are magnetic resonance cholangiography and intraoperative imaging.
When is preoperative magnetic resonance cholangiography a better option than intraoperative imaging?
Preoperative magnetic resonance cholangiography is a better option than intraoperative imaging when the surgeon is unsure about proceeding with bile duct exploration and making therapeutic decisions.
What are the features of biliary colic?
Colicky abdominal pain, worsens after eating, especially after fatty foods.
What is the recommended management for biliary colic?
If imaging shows gallstones and the history is compatible, laparoscopic cholecystectomy is recommended.
What is the recommended management for acute cholecystitis?
Imaging (ultrasound) and cholecystectomy (ideally within 48 hours of presentation).
What are the features of acute cholecystitis?
Right upper quadrant pain, fever, positive Murphy’s sign on examination, occasionally mildly deranged liver function tests (especially if Mirizzi syndrome is present).
What are the features of gallbladder abscess?
Usually prodromal illness and right upper quadrant pain, swinging pyrexia, patient may be systemically unwell, generalized peritonism is not present.
What is the recommended management for gallbladder abscess?
Imaging with ultrasound +/- CT scanning, ideally surgery (subtotal cholecystectomy may be needed if Calot’s triangle is hostile). In unfit patients, percutaneous drainage may be considered.
What are the features of cholangitis?
Patient severely septic and unwell, jaundice, right upper quadrant pain.
What is the recommended management for cholangitis?
Fluid resuscitation, broad-spectrum intravenous antibiotics, correction of any coagulopathy, early endoscopic retrograde cholangiopancreatography (ERCP).
What are the features of gallstone ileus?
Patients may have a history of previous cholecystitis and known gallstones, small bowel obstruction (may be intermittent).
What is the recommended management for gallstone ileus?
Laparotomy and removal of the gallstone from the small bowel. The enterotomy should be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with.
What are the features of acalculous cholecystitis?
Patients with intercurrent illness (e.g., diabetes, organ failure), patient is systemically unwell, gallbladder inflammation in the absence of stones, high fever.
What is the recommended management for acalculous cholecystitis?
If the patient is fit, cholecystectomy is recommended. If the patient is unfit, percutaneous cholecystostomy may be considered.
What is the management approach for asymptomatic gallstones?
Asymptomatic gallstones, which rarely cause symptoms (less than 2% per year), may be managed expectantly.
What is the treatment of choice for symptomatic gallstones?
The treatment of choice for symptomatic gallstones is cholecystectomy, typically performed laparoscopically.
What is the alternative treatment option for very frail patients with symptomatic gallstones?
For very frail patients, there may be a role for selective use of ultrasound-guided cholecystostomy.
During the cholecystectomy procedure, what additional diagnostic tests may be performed by some surgeons?
Some surgeons may routinely perform intraoperative cholangiography or laparoscopic ultrasound to confirm anatomy or exclude common bile duct (CBD) stones.
If CBD stones are found during the procedure, what are the treatment options?
The options for treatment include early endoscopic retrograde cholangiopancreatography (ERCP) within a day or two after surgery or immediate surgical exploration of the bile duct.
What is the preferred approach if CBD stones are found during the procedure and ERCP is not necessary?
If ERCP is not necessary, the preferred approach is transcystic exploration, which adds minimal morbidity and results in faster recovery.
What should be taken into consideration when exploring small ducts during the procedure?
Exploration of ducts smaller than 8mm is challenging and should be avoided.
What are the risks associated with ERCP?
The risks of ERCP include bleeding (0.9%, rising to 1.5% if sphincterotomy is performed), duodenal perforation (0.4%), and cholangitis (1.1%).
What is the recommended management for small gallstones measuring less than 5mm?
Small stones measuring less than 5mm can be safely left, as most will pass spontaneously.
What has traditionally been used for the diagnosis of acute pancreatitis?
Traditionally, hyperamylasemia with amylase levels elevated three times the normal range has been utilized for the diagnosis.
What are the limitations of using amylase for diagnosis?
Amylase may give both false positive and negative results, and serum lipase is considered more sensitive and specific.
Do serum amylase levels correlate with disease severity?
No, serum amylase levels do not correlate with disease severity.
What are the differential causes of hyperamylasemia?
Hyperamylasemia can be caused by acute pancreatitis, pancreatic pseudocyst, mesenteric infarct, perforated viscus, acute cholecystitis, and diabetic ketoacidosis.
What scoring systems are used to assess the severity of pancreatitis?
The Glasgow, Ranson, and APACHE II scoring systems are commonly used for assessing the severity of pancreatitis.
What are some features that may predict a severe attack of pancreatitis within 48 hours of admission?
Features that may predict a severe attack within 48 hours of admission include clinical impression of severity, body mass index >30, pleural effusion, APACHE score >8.
What are some features that may predict a severe attack of pancreatitis 24 hours after admission?
Features that may predict a severe attack 24 hours after admission include APACHE II >8, Glasgow score of 3 or more, persisting multiple organ failure, CRP >150.
What are some features that may predict a severe attack of pancreatitis 48 hours after admission?
Features that may predict a severe attack 48 hours after admission include Glasgow score of >3, CRP >150, and persisting or progressive organ failure.
What is the role of nutrition in the management of pancreatitis?
There is reasonable evidence to suggest that the use of enteral nutrition does not worsen the outcome in pancreatitis. Feeding helps prevent bacterial translocation from the gut, which can contribute to the development of infected pancreatic necrosis.
Do UK surgeons commonly administer antibiotics to patients with acute pancreatitis?
Yes, many UK surgeons administer antibiotics to patients with acute pancreatitis.
Is there strong evidence to support the use of antibiotics in acute pancreatitis?
No, there is very little evidence to support the use of antibiotics in acute pancreatitis.
What does a recent Cochrane review suggest about the use of Imipenem in patients with established pancreatic necrosis?
A recent Cochrane review highlights the potential benefits of administering Imipenem to patients with established pancreatic necrosis to prevent the progression to infection.
What are the concerns regarding the administration of antibiotics in mild attacks of pancreatitis?
There are concerns that administering antibiotics in mild attacks of pancreatitis will not affect the outcome and may contribute to antibiotic resistance and increase the risks of antibiotic-associated diarrhea.
What is the recommended surgical approach for patients with acute pancreatitis due to gallstones?
Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy.
What is the recommended surgical approach for patients with an obstructed biliary system due to stones?
Patients with an obstructed biliary system due to stones should undergo early endoscopic retrograde cholangiopancreatography (ERCP).
What is the recommended approach for patients with extensive necrosis where infection is suspected?
Patients with extensive necrosis where infection is suspected should usually undergo fine-needle aspiration (FNA) for culture.
What can a careful history and examination help determine in cases of jaundice?
A careful history and examination can often provide clues about the underlying cause of jaundice.
What are the treatment options for patients with infected necrosis?
Patients with infected necrosis can undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends on local expertise.
What can liver function tests help determine in cases of jaundice?
Liver function tests can help classify jaundice as pre-hepatic, hepatic, or post-hepatic.
What are the typical liver function test patterns for pre-hepatic jaundice?
In pre-hepatic jaundice, bilirubin levels are normal or high, ALT/AST levels are normal, and alkaline phosphatase levels are normal.
What are the typical liver function test patterns for hepatic jaundice?
In hepatic jaundice, bilirubin levels are high, ALT/AST levels are elevated (often very high), and alkaline phosphatase levels are elevated but seldom to very high levels.
What are the typical liver function test patterns for post-hepatic jaundice?
In post-hepatic jaundice, bilirubin levels are high to very high, ALT/AST levels are moderately elevated, and alkaline phosphatase levels are high to very high.
What is a specific feature to address in the history of post-hepatic jaundice?
In post-hepatic jaundice, the stools are often pale in color.
What are the typical features and pathogenesis of gallstones?
Typical features of gallstones include a history of biliary colic or episodes of cholecystitis. The pathogenesis involves small gallstones that can pass through the cystic duct. In Mirizzi syndrome, the stone may directly compress the bile duct, leading to cholecystitis with jaundice.
What are the typical features and pathogenesis of pancreatic cancer?
Pancreatic cancer typically presents as painless jaundice with a palpable gallbladder (Courvoisier’s Law). It occurs due to direct occlusion of the distal bile duct or pancreatic duct by the tumor. In some cases, nodal disease at the portal hepatis may be the cause, resulting in a normal-caliber bile duct.
What are the typical features and pathogenesis of cholangitis?
Cholangitis is usually obstructive and presents with Charcot’s triad of symptoms: pain, fever, and jaundice. It is caused by ascending infection of the bile ducts, often by E. coli, and occurs in a pool of stagnant bile.
What are the typical features and pathogenesis of TPN-associated jaundice?
TPN-associated jaundice usually follows long-term use and is painless with non-obstructive features. It is often due to hepatic dysfunction and fatty liver, which can occur with prolonged TPN usage.
What are the typical features and pathogenesis of bile duct injury?
Bile duct injury can have a sudden or gradual onset and usually presents as obstructive jaundice. It often occurs during a difficult cholecystectomy when the anatomy in Calot’s triangle is not properly appreciated. In severe cases, the bile duct may be excised leading to rapid postoperative jaundice. Bile duct stenosis can also occur due to clips or diathermy injury, causing a more insidious presentation.
What are the typical features and pathogenesis of cholangiocarcinoma?
Cholangiocarcinoma presents with a gradual onset and an obstructive pattern. It occurs due to direct occlusion by the disease itself and can also be caused by extrinsic compression by nodal disease at the porta hepatis.
What are the typical features and pathogenesis of jaundice in a septic surgical patient?
Jaundice in a septic surgical patient usually presents with hepatic features. It is a combination of impaired biliary excretion and the effects of drugs such as ciprofloxacin, which can cause cholestasis.
What are the typical features and pathogenesis of jaundice in metastatic disease?
Jaundice in metastatic disease presents with a mixed hepatic and post-hepatic pattern. It is a combination of liver synthetic failure in the late stages and extrinsic compression of intrahepatic structures by nodal disease and anatomical compression earlier on.
What is the most commonly used first-line test for evaluating the liver and biliary tree?
Ultrasound
What information can be obtained from an ultrasound of the liver and biliary tree?
Bile duct caliber, presence of gallstones, visualization of pancreatic masses and other lesions
Which imaging test is preferred when pancreatic neoplasia is suspected?
Pancreatic protocol CT scan
Which imaging test is often preferred for liver tumors and cholangiocarcinoma?
MRI/MRCP
Are PET scans routinely used as a first-line test?
No, they are not routinely used as a first-line test
What test may be necessary if MRCP fails to provide adequate information?
ERCP
Is ERCP an invasive procedure?
Yes, it is invasive
What should be the priority in the management of jaundice?
Relief of jaundice
What should be screened for and addressed in patients with jaundice?
Clotting irregularities
What is the treatment approach for inserting a stent in patients with malignancy?
Metal or plastic stents
What are the characteristics of plastic stents?
Cheap, easy to replace, prone to displacement and blockage
What are the characteristics of metal stents?
More expensive, less prone to displacement and blockage, may compromise surgical resection
What is an alternative strategy when stenting has failed in patients with bile duct/pancreatic head malignancy?
Percutaneous drainage via a transhepatic route
What is the main problem with temporary percutaneous transhepatic drains?
Propensity to displacement, which may result in a bile leak
What is the required treatment for bile duct injury?
Surgery to repair the defect
What treatment should be given to patients with cholangitis?
High dose broad spectrum antibiotics via the intravenous route
What surgical procedure is necessary if the bile duct has been inadvertently excised?
Hepatico-jejunostomy
What treatment options are available for gallstones?
Removal by ERCP and cholecystectomy
What should be performed if there is doubt about the efficacy of ERCP in gallstone management?
Operative cholangiogram and bile duct exploration
What should follow soon after antibiotic treatment in patients with cholangitis?
Biliary decompression
What are the typical features of gallstones?
History of biliary colic or episodes of cholecystitis
What type of history and symptoms are associated with obstructive gallstones?
Obstructive history and test results
What are the typical characteristics of gallstones in most cases?
Small calibre gallstones that can pass through the cystic duct
What are the typical features of cholangitis?
Obstructive symptoms and Charcot’s triad (pain, fever, jaundice)
What is the pathogenesis of cholangitis?
Ascending infection of the bile ducts, usually caused by E. coli and occurring in stagnant bile
What is Mirizzi syndrome?
A condition where a gallstone compresses the bile duct directly, leading to jaundice
What are the typical features of pancreatic cancer?
Painless jaundice with a palpable gallbladder (Courvoisier’s Law)
What causes jaundice in TPN-associated jaundice?
Hepatic dysfunction and fatty liver due to long-term TPN usage
What are the common causes of bile duct injury?
Difficult laparoscopic cholecystectomy, excision of the bile duct, or bile duct stenosis due to clips or diathermy injury
What is the pathogenesis of cholangiocarcinoma?
Direct occlusion by the disease and extrinsic compression by nodal disease at the porta hepatis
What are the typical features of biliary disease in a septic surgical patient?
Hepatic features
What causes biliary features in a septic surgical patient?
Impaired biliary excretion and drugs such as ciprofloxacin causing cholestasis
What are the features of biliary disease in metastatic disease?
Mixed hepatic and post-hepatic symptoms
What causes the features of biliary disease in metastatic disease?
Liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intrahepatic structures (earlier)
What is the incidence of open conversion following cholecystectomy?
Less than 1%
Is there a possibility of selection bias in the reported cases of open conversion?
Yes, as the data covers an early period in laparoscopy, there may be an element of selection bias in the cases chosen for laparoscopic surgery
What is the main cause of bile leaks after cholecystectomy?
Leakage from biliary radicles or cystic stump leaks
How are many patients with a cystic stump leak managed?
They can be managed with ERCP, sphincterotomy, and stent placement
What is the incidence of bile leaks as a complication of cholecystectomy?
Around 1%
What is the commonest cause of bile duct injury?
Cholecystectomy
What is the reported incidence range of bile duct injuries after cholecystectomy?
0.3-0.7%
What is the recommended management for bile duct injuries during cholecystectomy?
Reconstruction of the bile duct
What should be done if the operating surgeon is not experienced in bile duct reconstruction?
The area should be drained, and the patient should be transferred to an HPB (hepatobiliary and pancreatic) unit
Who are more likely to develop hepatocellular adenoma?
Women in their third to fifth decade
Are hepatocellular adenomas usually solitary or multiple?
Usually solitary
What is hepatocellular adenoma linked to?
Use of oral contraceptive pill
How are hepatocellular adenomas demarcated from normal liver?
Usually sharply demarcated, although they lack a fibrous capsule
What are the ultrasound appearances of hepatocellular adenomas?
Mixed echogenicity and heterogeneous texture
When is removal of hepatocellular adenoma required?
In patients with hemorrhage or symptoms
What are the CT findings of hepatocellular adenomas prior to administration of contrast agents?
Hypodense lesions
What is the recommended management for asymptomatic adenomas larger than 5cm?
Excision
Do adenomas in males have a higher or lower risk of malignant transformation compared to females?
Higher risk of malignant transformation
What are the risk factors for rupture in hepatocellular adenomas?
Lesions larger than 5cm and those that are exophytic
What are the mortality rates from spontaneous rupture of hepatocellular adenomas?
5-10%
What can be used to treat both benign and malignant biliary obstruction?
Placement of stents
What are the two types of stents that can be used?
Plastic tubes or self-expanding metallic stents
Where can stents be placed?
Percutaneously, at ERCP, or through open surgery (less commonly)
What are the complications associated with pancreatic stents?
Blockage, displacement, and complications related to the method of insertion
What are the characteristics of metallic stents?
Expensive, embed in surrounding tissues, rare displacement, and rare blockage
What are the characteristics of plastic stents?
Cheap, do not usually embed, common displacement, and common blockage
What is the most common benign tumor of mesenchymal origin in the liver?
Haemangioma
What is the incidence of haemangiomas in autopsy series?
8%
Can cavernous haemangiomas be large in size?
Yes, they may be enormous
How do haemangiomas appear clinically?
Reddish-purple hypervascular lesions
How are haemangiomas typically separated from normal liver tissue?
By a ring of fibrous tissue
What are the ultrasound characteristics of haemangiomas?
They are typically hyperechoic
What are peripancreatic fluid collections?
Fluid collections that occur in or near the pancreas and lack a wall of granulation or fibrous tissue
Why is aspiration and drainage of peripancreatic fluid collections usually avoided?
Because it may precipitate infection
What can peripancreatic fluid collections develop into?
Pseudocysts or abscesses
What are pseudocysts?
Collections of organized peripancreatic fluid that may or may not communicate with the ductal system and are walled by fibrous or granulation tissue
When do pseudocysts typically occur after an attack of acute pancreatitis?
4 weeks or more
What imaging modalities are used to investigate pseudocysts?
CT, ERCP, MRI, or Endoscopic USS
How long can symptomatic pseudocysts be observed before considering treatment?
Up to 12 weeks, as up to 50% may resolve
What is pancreatic necrosis?
Necrosis involving both the pancreatic parenchyma and surrounding fat
What are the treatment options for symptomatic pseudocysts?
Endoscopic or surgical cystogastrostomy or aspiration
When is early necrosectomy recommended?
Only when compelling indications for surgery exist, as it is associated with a high mortality rate
What are the complications of pancreatic necrosis directly linked to?
Extent of parenchymal necrosis and extent of overall necrosis
How should sterile necrosis be managed initially?
Conservatively
What might be performed if infection is suspected in necrotic tissue?
Fine needle aspiration sampling, although false negatives may occur
What can be a better guide to surgery in necrotic pancreatitis?
Extent of sepsis and organ dysfunction
What is a pancreatic abscess?
An intraabdominal collection of pus associated with the pancreas, typically resulting from infected pseudocysts
How are pancreatic abscesses usually managed?
Placement of percutaneous drains
What can cause hemorrhage in pancreatitis?
Infected necrosis involving vascular structures, which can result in de novo hemorrhage or occur during surgical necrosectomy
What is Grey Turner’s sign?
Identification of retroperitoneal hemorrhage
