60a Liver tumours + biliary

Question 1

What are the risk factors for hepatocellular carcinoma? (5)

Answer 1

Cirrhosis.
Male >> Female.
Alcohol.
Obesity.
Viral hepatitis.

Question 2

How are cirrhotic patients monitored? (2)

Why?

Answer 2

6 month ultrasound scan.
Raised alpha feto-protein. (very large to secrete this).
HCC usually too large once symptomatic to treat.

Question 3

What are the macroscopic features of hepatocellular carcinoma? (3)

Answer 3

Expansile soft nodules (green due to bile).
Often multifocal if cirrhosis.
Often involves portal vein.

Question 4

What is the diagnostic microscopic feature of hepatocellular carcinoma?

Answer 4

Bile production.

Question 5

How is hepatocellular carcinoma treated, criteria? (3)

Answer 5

Surgery (if non-cirrhotic, small, peripheral).
Transplant (1 tumour under 5cm or 3 under 3cm).
If not: ablation, embolisation, chemo.

Question 6

What is the TNM staging for hepatocellular carcinoma?

Answer 6

1. no vascular invasion.
2. tumours invade vasculature, or multiple tumours less than 5cm.
   3a. Multiple, anymore than 5cm.
   3b. Anything involving major branch of hepatic or portal vein.
3. Invades other organs (other than gall bladder), or perforates visceral peritoneum.

Question 7

What is the prognosis of hepatocellular carcinoma?

Answer 7

Less than 1 year unless spotted early.

Question 8

Which is more common, 1o liver cancer or mets?

Answer 8

Mets.

Question 9

Which cancers metastasise to the liver? (1, 5)

Answer 9

Few large nodules - large bowel.

Multi nodular: Lung, Pancreas, Breast, Stomach, Melanoma

Question 10

What is a cholangiocarcinoma?

Answer 10

Adenocarcinoma arising from bile ducts.

Question 11

How does intrahepatic cholangiocarcinoma behave? (3).

Risk factors?

Answer 11

Peripheral, mass forming, presets late.

Cirrhosis.

Question 12

How does perihilar cholangiocarcinoma behave?

Risk factors? (2)

Answer 12

In large ducts: causes obstructive jaundice early.

Primary sclerosing cholangitis, Liver flukes.

Question 13

What does bile contain? (6)

Answer 13

Bile salts
Phospholipids
Cholesterol
Bilirubin
Calcium salts
Mucin

Question 14

Who do gallstones occur in?

Answer 14

female, obesity, diabetes

“fair, fat, female, forty”

Question 15

What are the main types of gallstones? (3)

Appearance?

Answer 15

Cholesterol – yellow, opalescent,
Pigment – small black, in haemolytic anaemia
Mixed stones (most common)

Question 16

What are the complications of gallstones? (7)

Answer 16

Cholecystitis 
Mucocele
Increased gallbladder cancer risk.
Jaundice
Cholangitis and liver abscesses
Pancreatitis.
Gallstone ileum (entered into gut through  fistulous connection with the gallbladder)

Question 17

What is cholecystitis?

Answer 17

Inflammation of the gall bladder.

Question 18

Cause of acute cholecystitis?
Features? (4)
Complications? (2)

Answer 18

Stone blocks duct, 2o infection.
Large, swollen, congested, ulcerated.
Empyema + rupture.

Question 19

Cause of chronic cholecystitis?

Histological features? (2)

Answer 19

Small gall stones.

Fibrosis, Rokitansky Aschoff sinuses.

Question 20

What are the indications for a cholecystectomy? (4)

Answer 20

Pain.
Gallstones.
Pancreatitis.
Gall bladder polyp (rare).