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HBP > Biliary > Flashcards

Biliary Flashcards

1
Q

Define the different types of choledochal cyst

1) Type 1
2) Type 2
3) Type 3
4) Type 4
5) Type 5

A

1) fusiform / saccular dilation of the bile duct
2) supraduodenal extrahepatic diverticulum
3) choledochocele in intraduodenal CBD
4)
a) dilations in intrahepatic + extrahepatic
b) dilations in extra hepatic
5) dilations in intrahepatic. (Caroli’s)

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2
Q

Bismuth classification (bile duct injury)
Type 1
Type 2
Type 3
Type 4
Type 5

A
  1. CBD +/- CHD, >2cm from confluence
  2. proximal CHD < 2cm from confluence
  3. hilar, no residual CHD, confluence preserved
  4. complete hilar transection, no communication between L and R
  5. Aberrant RHD + hilar injury
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3
Q 
Strasberg classification (bile duct injury) 
ABCD E1,2,3,4,5
A

A. cystic duct leak
B. Abberant RHD occlusion
C.Abberant RHD transection w/o ligation
D.lateral injury to CBD (<50% circumference
E1. CBD injury > 2cm from confluence
E2. CBD injury <2cm form confluence
E3 high CBD injury
E4 no R/L communication
E5. CBD + R aberrant duct injury

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4
Q

Causes of Jaundice

1) Prehepatic
2) Hepatic
3) Post-hepatic /Obstructive

A

1) hemolysis (thalassemia, G6PD), Gilbert’s, spherocytosis
2)hepatitis, late-stage cirrhosis, HCC with cirrhosis, drugs (alcohol, anti-TB, lipid-lowering)
3)
Intrahepatic: sepsis, scleorsing cholangitis, PBC
Extrahepatic: stone, MBO, pancreatitis, mirizzi, recurrent cholangittis, benign stricture, choledochal cysts

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5
Q

Causes of Malignant Biliary Obstruction

A

Ca head of pancreas
Malignant porta hepatic LN
CA ampulla
Cholangiocarcinoma
CA duodenum
CA gallbladder
HCC
Lymphoma
LN met (cholangioCA, Ca GB, pancreas, distal stomach)

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6
Q

Blood supply of common bile duct

A

Retroduodenal, branch of GDA (3OC =)
Right hepatic artery (9OC)

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7
Q

Courvoisier’s Law

A

The presence of a palpable gallbladder in a painless jaundice patient, unlikely to be due to gallstone

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8
Q

Enterohepatic circulation of bilirubin

A

unconjugated bilirubin in blood -> enter hepatocytes -> conjugated by glucuronic acid -> excreted to small intestines -> turned into urobiliogen by bacterial proteases -> 90% excreted in faces, 10% enter portal vein, excreted in kidney

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9
Q 
Csendes classification (mirizzi syndrome 
Type 1,2,3,4
A

Type 1: extrinsic compression of CHD
Type 2: cholecysto-choledochal fistula, less than 1/3 circumference
Type 3: fistula <2/3 circumference
Type 4: > 2/3 circumference

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10
Q

McSherry classification
Type 1a, 1b, 2

A

Type 1a: compression over CHD
Type 1b: obliteration CHD
Type 2: cholecysto-choledochal fistula

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11
Q

Indications for ERCP

A

Therapeutic:
-stone removal, stent insertion, sphincterotomy, lithotripsy
Diagnostic:
-cholangiogram, brush cytology
Management of local complications

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12
Q

Complications of ERCP

A

General:
respiratory depression from benzodiazepines
arrhythmia due to buscopain
Papillotomy bleeding
Pancreatitis
Sepsis
Perforation
Stent complications

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13
Q

T staging for Gallbladder Cancer

A

T1a: lamina propria
T1b: muscular layer
T2: perimuscular layer , not beyond serosa
T3: perforate serosa, into adjacent organs
T4: invade two organs

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14
Q

N staging for Gallbladder Cancer

A

N1: LN along cystic duct, CBD, hepatic artery, portal vein (basically portal hepatis)
N2: periaortic, peri-caval, SMA/celiac trunk

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15
Q

Definition of extended cholecystectomy

A

Cholecystectomy + wedge resection of 2 cm of GB bed

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16
Q

Risk factors for gallbladder cancer

A

Female
Obesity
Multiparity
Porcelain GB
Chronic infection with salmonella
Adenomatous GB > 1cm
Choledochal cyst

17
Q

Indication for lymph node dissection in gallbladder cancer

A

T1b or higher

18
Q

Proper lymph node dissection in ca gallbladder

A

all lymph nodes of the porta hepatis and hepatoduodenal ligaments (including cystic duct, CBD, hepatic artery and portal vein)

19
Q

Cholangiocarcinoma perihilar classification

A

Bismuth Classification:
Type 1: below confluence
Type 2: confluence, not involving left or right
Type 3: occluding CHD with
a: involving right
b: involving left
Type 4: multi-centric OR bilateral intrahepatic involvement OR involving confluence both ducts

20
Q

Risk factors for cholangiocarcinoma

A

Age
Chronic intraductal gallstone
Choledochal cysts
Bile duct adenoma / biliary papillomatosis
Liver flukes
Chronic typhoid carrier

21
Q

Classification of cholangiocarcinoma

A

Intrahepatic 6%
Perihilar 67%
Distal 27%

22
Q

Indication of unresectable disease in cholangiocarcinoma

A

Portal vein invasion
Extensive liver involvement
Inadequate residual liver volume

23
Q

Distal cholangiocarcinoma regional lymph nodes

A

Same as head of pancreas:
common bile duct
common hepatic artery
portal vein
anterior/posterior pancreaticoduodenal nodes
nodes along right lateral wall of SMA

24
Q

Perihilar cholangiocarcinoma regional lymph nodes

A

Hilar
Cystic duct
Choledochal
Portal
Hepatic arterial
Posterior pancreaticoduodenal
*distal to hepatodudoenal ligament =distant met

25
Q

Intrahepatic cohlangiocarcionma regional lymph nodes

1) Left
2) Right

A

Left:
inferior phrenic
hilar (CBD, HA, PV, CD)
gastrohepatic
Right:
hilar
periduodenal
peripancreatic

26
Q

Charcot’s triad

A

*biliary obstruction
upper abdominal pain
fever
jaundice

27
Q

Reynold’s pentad

A

Upper abdominal pain
Fever
Jaundice
Hypotension
Confusion

28
Q

Strasberg Type A

A

Leakage from the cystic duct stump or minor hepatic ducts draining the liver bed

29
Q

Strasberg Type B

A

Occlusion of the biliary tree, most commonly the aberrant right hepatic duct

30
Q

Strasberg Type C

A

Transection without ligation of the aberrant right hepatic duct

31
Q

Strasberg Type D

A

Lateral injury to a major bile duct

32
Q

Criteria for resectability of cholangiocarcinoma

A

Traditional criteria:

  • Absence of retropancreatic and paraceliac nodal metastasis or distant liver metastasis
  • Absence of invasion to portal vein and hepatic artery ( in some centers, en bloc resection)
  • Absence of extrahepatic adjacent organ invasion
  • Absence of disseminated disease
33
Q

Management based on Bismuth-Corlette classification for Klatskin tumors

A

Type 1 + 2: bile duct resection + HJ + regional lymphadenectomy

Type 3: hepatic lobectomy + regional lymphadenopathy

Type 4: multiple hepatic segment resection with portal vein resection vs palliative

34
Q

What is the surgical option for distal cholangiocarcinoma?

A

Pancreaticoduodenectomy (Whipple operation, usually pylorus preserving)

HBP (5 decks)

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