Benign Biliary Disease 1 Flashcards
1
Q
Gb stones types
A
Classified into two major subtypes
1- Cholesterol
2- Pigment stones
2
Q
More than 70% of gallstones in the United States are formed by precipitation of
A
Cholesterol and Calcium
3
Q
Pigment stones can be divided into
A
Black stones :
» hemolytic conditions and cirrhosis
» from concentration of bilirubin, they are found almost exclusively in the gallbladder.
Brown stones :
» Found in the bile ducts and are thought to be secondary to infection
4
Q
Four major factors explain most gallstone formation:
A
- supersaturation of secreted bile
- concentration of bile in the gallbladder
- crystal nucleation
- gallbladder dysmotility.
5
Q
What predispose patients to cholesterol stones
A
High concentrations of cholesterol and lipid in bile secretion from the liver
6
Q
increased hemoglobin processing is seen in most patients with
A
pigment stones
7
Q
What causes Crystal Formation
A
- cholesterol precipitates out into crystals when the concentration in the gallbladder vesicles exceeds the solubility of cholesterol
- Crystal formation is further accelerated by pronucleating agents, including glycoproteins and immunoglobulins.
8
Q
abnormal gallbladder motility can increase stasis in the gallbladder, Examples ?
A
- Increased stone formation can be seen in conditions associated with impaired gallbladder emptying
such as in
» prolonged fasting states
» use of total parenteral nutrition
» after vagotomy
» use of somatostatin analogues.
9
Q
What percentage of Asymptomatic Gb Stones turned into Symptomatic
A
- Only 20% to 30% of patients with asymptomatic stones will develop symptoms within 20 years
- approximately 1% of patients with asymptomatic stones develop complications of their stones before onset of symptoms
10
Q
Indications for Prophylactic Cholecystectomy
A
- hemolytic anemias, such as sickle cell anemia
» Cholecystitis can precipitate a crisis - calcified gallbladder wall (porcelain)
- large (>2.5 cm) gallstones
- long common channel of bile and pancreatic ducts
» all have a higher risk of gallbladder cancer
11
Q
Nonoperative Treatment of Cholelithiasis
A
- Oral bile salt therapy
- Cannulation of the gallbladder and infusion of organic solvent
- Extracorporeal shock wave lithotripsy.
> > for whom general anesthesia presents a prohibitively high risk
12
Q
When can you use Extracorporeal shock wave lithotripsy
A
- Used in patients with single stones 0.5 to 2 cm in size.
lower recurrence rate
approximately 20%,
13
Q
Biliary Colic Vs Cholecystitis ?
A
Pain lasting longer than 24 hours or associated with fever suggests acute cholecystitis
14
Q
When is Observing the case appropriate ?
A
- Mild symptoms
» They have a low rate of complications from gallstones (1%–3%/year)
» observation and dietary and lifestyle changes are appropriate in this population. - Severe or recurrent symptoms have a higher rate of complications of the disease (7%/year)
» elective laparoscopic cholecystectomy is warranted
15
Q
Process of Acute Calcular Chole
A
Blockage of Cystic Duct by stone
Then Inflammation Then gangrenous then emphysematous cholecystitis
16
Q
What about biliary colic or chronic chole
A
cystic duct blockage in temporary and recurrent
17
Q
Mirizzi syndrome
A
> > inflammation or a stone in the gallbladder neck leads to inflammation of the adjoining biliary system, with obstruction of the common hepatic duct.
18
Q
CT is less sensitive than ultrasound for the diagnosis of acute cholecystitis. True or False?
A
True
19
Q
MC Organisms in Acute Chole
A
> > gram-negative aerobes are the most common organisms found in acute cholecystitis,
20
Q
Early Vs Delayed Lap Chole in Acute Chole
A
early in the disease process (within the first week), the operation can be performed laparoscopically with equivalent or improved morbidity, mortality, and length of stay as well as a similar conversion rate to open cholecystectomy
21
Q
With substantial inflammation, what can you do ?
A
partial cholecystectomy
> > transecting the gallbladder at the infundibulum with cauterization of the remaining mucosa, is acceptable to avoid injury to the CBD.
22
Q
Patient with high operative Risk ?
A
percutaneously placed cholecystostomy tube should be considered.
23
Q
Patient with Percutaneous drainage, when to do the operation ?
A
- Delayed cholecystectomy 3 to 6 months after medical optimization.
- In patients with cholecystostomy tubes, when fluoroscopy shows a patent cystic duct, the cholecystostomy tube can be removed and the decision for cholecystectomy determined by the patient’s ability to tolerate surgical intervention.
24
Q
Retained Stone or Secondary Biliary Stone
A
Retained stones are secondary stones found in bile duct within 2 years of cholecystectomy and occur in 1% to 2% of patients
25
Charcot triad
Charcot triad
>> right upper quadrant pain, fever, and jaundice
septic shock with mental status changes, and hypotension >> Reynolds pentad
26
Finding of choledocholithiasis via intraoperative cholangiogram during cholecystectomy may be managed by
either CBD exploration
or
postoperative ERCP.
The experience of the surgeon with open biliary exploration may be a factor determining which route is chosen
27
When to use PTC
- treat choledocholithiasis in case of
>> unsuccessful ERCP
>> anatomical difficulty for ERCP such as the patients’ post-Roux-en-Y procedures.
- PTC is as effective as ERCP in patients with dilated biliary system with similar complication rate, but less effective in a nondilated biliary tree patient
28
most common causes of failure of ERCP.
- Large stones (usually more than 2.5 cm)
- altered gastric or duodenal anatomy such as Roux-en-Y
- impacted stones
- intrahepatic stones
- multiple stones
29
Gallstone Ileus
- A large stone in the dependent portion of the gallbladder fistulizes into the adjacent duodenum, passing directly into the intestine.
- in older patients
- caused by inflammation
- or simply pressure necrosis.
- The most common site for obstruction is in the terminal ileum
30
imaging findings ?
Plain radiographs
>> air-fluid levels consistent with a small bowel obstruction
>> Pneumobilia
sometimes identified by CT scan
31
Tx ?
- longitudinal incision on the antimesenteric border of the ileum is made a few centimeters proximal to the stone.
- This site of impaction is at risk of perforation, so signs of ischemia may mandate resection.
- The stone is milked back through the enterotomy.
- 10% of patients have multiple large stones, so the remainder of the small intestine should be inspected.
32
do you go for the GB and Fistula same time ?
Although some surgeons advocate surgical treatment of the biliary-enteric fistula at the same setting
the intense inflammatory process in the right upper quadrant may complicate the cholecystectomy and duodenal repair.
33
When to go for One Stage repair ?
- One-stage repair should generally be performed in healthy patients without severe inflammatory changes in the right upper quadrant.
- Enterotomy with removal of the offending stone should suffice for patients with multiple comorbidities
- A second operation for the cholecystectomy can be considered to avoid the possibility of future biliary complications.
34
Acute Acalculous Cholecystitis
The exact mechanism and pathophysiology are poorly understood, but there is a role for bile stasis and gallbladder ischemia
35
RF ?
old age
burns and trauma
prolonged use of total parenteral nutrition
critical illness
immunosuppression
diabetes
36
Tx ?
- cholecystectomy
- or if Old and critical
PTC > then consider Lap chole if imaging still positive
37
Biliary Dyskinesia
- usually a diagnosis of exclusion.
- CCK-stimulated HIDA scan confirm diagnosis
- ejection fraction < than one third at 20 minutes after CCK administration in a patient without stone is considered diagnostic.
- More than 85% of patients show improvement in symptoms after cholecystectomy
- In nonresponders, ERCP with sphincterotomy may prove useful.
38
Sphincter of Oddi Dysfunction
- higher tone and failing to relax
- Pain and recurrent pancreatitis
- suspected in patients with biliary pain and a common duct diameter of more than 12 mm
39
Tx ?
- Sphincter manometry > sphincter pressure higher than 40 mm Hg
- Therapy consists of endoscopic sphincterotomy or transduodenal sphincteroplasty with approximately equivalent results from the two approaches
40
Primary Sclerosing Cholangitis
- Idiopathic and autoimmune process
- associated with ulcerative colitis (in almost 70% of patients) and Riedel thyroiditis
- intrahepatic, extrahepatic, combined, or small ducts disease.
- Progressive , Biliary Cirrhosis , liver failure
41
80% of patients have elevated
perinuclear antineutrophil cytoplasmic antibodies
42
Abnormal liver function tests in a patient observed for inflammatory bowel disease should suggest
PSC.
43
Imaging what will show ?
- multifocal diffuse dilation and stricturing of the intrahepatic and/or extrahepatic biliary trees.
>> “beading” or “chain of lakes” and is characteristic of PSC.
- MRCP is useful in the diagnosis and surveillance of PSC patients, while ERCP is reserved for the treatment of dominant strictures and to exclude malignancy, namely, cholangiocarcinoma
44
Role of Biopsy ?
Liver biopsy
>> onionskin concentric periductal fibrosis
>> periportal fibrosis occurs
>> bridging necrosis
>> biliary cirrhosis.
PSC is associated with cholangiocarcinoma, and distinguishing the strictures of PSC fibrosis from those of cholangiocarcinoma can be challenging.
45
Tx ?
- Ursodeoxycholic acid
( Not Sure if Prevent Progression )
- In the symptomatic patient, endoscopic therapy, consisting of balloon dilation of the dominant strictures, has been shown to alleviate pruritus, to reduce likelihood of cholangitis
- But Surgery can complicate future transplant
46
Does proctocolectomy affect PSC ?
does not appear to affect biliary disease progression or survival in patients with both ulcerative colitis and PSC.
47
PSC and Cholangiocarcinoma , To transplant ? or no ?
Although the development of cholangiocarcinoma in a PSC liver is generally considered a contraindication to transplantation
some centers have shown excellent survival rates, up to 70% at 5 years, for patients with limited hilar disease who undergo a neoadjuvant protocol of chemotherapy and radiation followed by transplantation
48
Intrahepatic strictures
usually a result of cholangiohepatitis and/or ischemic events
49
Chronic pancreatitis
- cause strictures in the intrapancreatic portion of CBD and are usually long (2–4 cm) with gradually tapered narrowing
50
Stricturing at the middle portion of CBD
usually associated with a gallbladder process.
The most common reason is iatrogenic and post cholecystectomy
51
Mirizzi syndrome Tx
- These patients often have a cystic duct parallel to common hepatic duct and an impacted gallstone in the neck or cystic duct.
- The resultant inflammation can cause a cholecystocholedochal fistula.
- The treatment of Mirizzi syndrome is cholecystectomy, which may require repair of the common duct; when a large fistula exists, a choledochojejunostomy may be necessary
52
Long-standing choledocholithiasis also can cause fibrosis and stricture, Tx ?
- ERCP with sphincterotomy
- balloon dilation
- stent placement
>> Endoscopic and percutaneous therapy can provide long-term success in more than 50% of patients.
>> When unsuccessful, surgical management with anastomosis of the biliary tree to a Roux-en-Y jejunal limb has success rates of up to 90%.
53
Type I choledochal cyst
- is the most common form and involves only the extrahepatic biliary tree with a fusiform dilation
54
Type II cysts
appear as a saccular diverticulum off the CBD and may be mistaken for an accessory gallbladder
55
Type III cysts
appear as a cystic dilation of the intramural CBD, within the wall of the duodenum, and are also known as choledochoceles
56
Type IVa and IVb
Cysts involving the intrahepatic and extrahepatic biliary tree are known as type IVa
with type IVb being multiple cysts limited to the extrahepatic biliary tree
57
Type V cysts
Caroli disease
involve the intrahepatic ducts only.
Type V cysts may be solitary but usually occur diffusely in all segments
58
Etiology for Type 1 and 4
- the anomalous pancreatobiliary junction (APBJ)
- the pancreatic duct and biliary tree fuse to form a common channel before passage through the duodenal wall
- seen in up to 90% of patients with choledochal cysts, but almost exclusively in types I and IV.
- allows pancreatic secretions to reflux into the biliary tree
59
What about 2 and 3 ?
Types II and III almost never present with APBJ and are associated with minimal risk of malignancy.
60
MC Symptom Of Biliary Cyst ?
Jaundice
61
the diagnosis of a choledochal cyst is usually suspected in
- CT
- further classified by MRCP or ERCP.
- distal bile duct is difficult to evaluate by MRCP
>> so ERCP is more useful for defining the distal biliary tree and pancreaticobiliary junction.
62
What complications might happen ?
Liver Cirrhosis
Cholangiocarcinoma
63
In type 1 malignancy can be seen in ?
malignancy has been seen in the nondilated intrahepatic biliary tree in type I choledochal cysts.
64
Type I cysts
>> treated by complete surgical excision, cholecystectomy, and Roux-en-Y hepaticojejunostomy.
>> The proximal extent of resection should continue to the nondilated biliary tree and may require anastomosis to the left and right hepatic ducts.
>> The distal duct is oversewn, with care taken not to injure the pancreatic duct.
65
Type II cysts
should be excised entirely.
66
Type III cysts
approached transduodenally.
Because the pathogenesis of type III cysts is not clear and almost always does not involve APBJ, endoscopic drainage may suffice.
In the setting of duodenal or biliary obstruction, transduodenal excision or sphincteroplasty can be performed
67
Type IV cysts
- affecting only the extrahepatic bile ducts are managed similarly to type I cysts, with excision and hepaticojejunostomy.
- Those with intrahepatic extension involving only one lobe can be treated with partial hepatectomy and reconstruction.
68
Caroli Tx
Surgical treatment of Caroli disease ranges from resection if the disease is unilobar to liver transplantation when diffuse disease is detected.
