Biliary

Question 1

When you see a pulsating mass on the lateral aspect of the CBD; what do you need to watch out for?

Answer 1

A replaced right hepatic artery coming off of the SMA

Question 2

What hormone is primarily responsible for GB contraction/stimulation

Answer 2

CCK

Question 3

What cutoff number can you begin to see scleral icterus?

Answer 3

> 2.5 mg/dL

Question 4

Charcots triad vs Reynolds’ Pentad:

Answer 4

Triad: Fever, RUQ, jaundice

Pentad: + hypotension, AMS

Question 5

Most common type of bacteria found in the biliary tree?

Answer 5

E.coli» Kleb»>Enterobacter

Question 6

BIsmuth-Strasburg classification of bile duct injuries?

Answer 6

Question 7

A beading or chain of lakes pattern on imaging makes you think of what disease?

Answer 7

PSC

Multifocal dilations and strictures of intra/extra-hepatic bile ducts

Question 8

Biliary cysts are rare (choledochal cysts); what causes them?

Answer 8

Anomalous biliary-pancreatic junction

Question 9

Todani classification of choledochal cysts;

Answer 9

Question 10

What is the most common choledochal cyst?

Answer 10

Type I; fusiform dilatation of extrahepatic biliary tree

Question 11

Type IV and V choledochal cysts?

Answer 11

IVa; cysts both intra/extra hepatic
IVb; cysts extrahepatic only

V; Carollis dx—> intrahepatic ducts only

Question 12

Adenomyomatosis of the GB:

Answer 12

Question 13

Primary risk factor for GB cancer?

Answer 13

Gallstones

> 3 cm stones carry an increased risk

Question 14

Treatment for a 10 mm gallbladder polyp?

Answer 14

Cholecystectomy; do it open to prevent potential spillage

Question 15

Tx for T1a GB cancer after cholecystectomy?

Answer 15

Tumor invades lamina propria; but does not invade the muscle layer

CCY should suffice

Question 16

GB cancer that extends to the muscularis propria is stage T1b, what is the treatment?

Answer 16

after cholecystectomy, if margin is positive at cystic duct and path comes back for adenocarcinoma, need to remove segments IVB, V, portal lymphadenectomy, Roux-en-y reconstruction

Question 17

T1a GB cancer involves what?

Answer 17

Only lamina propria

Tx is CCY

Question 18

Double duct sign?

Answer 18

DIlation of CBD and pancreatic duct

Normally due to pancreatic head tumors; periampullary tumors

Question 19

Hepatocystic and Calot’s triangle;

Answer 19

Question 20

Layers of the GB and how it relates to GB cancer;

Answer 20

Question 21

Choledochal cysts:

Answer 21

Question 22

Rigler’s triad?

Answer 22

Seen in gallstone ileum

***pneumobilia + SBO + gallstones

Question 23

Bismuth classification of cholangiocarcinoma:

Answer 23

Question 24

What s a normal future liver remnant for someone with no medical problems?

Answer 24

FLR 20-25% is needed

Cirrhotic need a FLR >40%

30% for pts with steatohepatitis or moderate chemotherapy exposure

Question 25

A replaced right hepatic artery is commonly seen coming off the SMA, where is it located?

Answer 25

Seen in 11% of pts
Commonly encountered posterior to cystic duct during lap chole, medial aspect of Calot’s triangle

Question 26

Screening for someone with diagnosed PSC?

Answer 26

MRI/MRCP every 6-12 months
Annual CA 19-9
Annual RUQ US
Colonoscopy every 1-2 years

Question 27

Staging and treatment of GB cancer;

Answer 27

Question 28

We have hemobilia post-cholecystectomy, how do we diagnose and treat?

Answer 28

Angiography

Trans-arterial embolization is first line treatment for hemobilia

Question 29

Adjuvant chemotherapy after resection for gb cancer?

Answer 29

May be helpful; need bigger studies

Radiation is not routinely given post-surgery; no data on it

Question 30

What is bile made of?

Answer 30

Bile salts
Water
Cholesterol
Lecithin

Question 31

Based on the makeup of bile; what ratio of bile salts, cholesterol and lecithin needed to form micelles and not cholesterol stone formation:

Answer 31

High bile salts, low cholesterol, low lecithin ratio

Question 32

Greatest risk factor for cholangiocarcinoma?

Answer 32

PSC

Question 33

Among asymptomatic pts with cholelithiais; what % progress to be symptomatic?

Answer 33

1-2 %/year

Question 34

Tx for T3/T4 GB cancer that invades the serosa or grows or the liver without mets?

Answer 34

Completion extended right hepatectomy needed (segments 4-8)

Question 35

Recurrence of gallstone ileus?

Answer 35

5-10%

Often due to missed stones in the small bowel at the index operation

Question 36

Cholecystectomy and taking down the fistula should be performed in which patients with gallstone ileus at the first operation?

Answer 36

If they;’re low risk; ASA class I/II

ASA Class III/IV merit a two stage operation

Question 37

Biliary intraepithelial neoplasm>

Answer 37

Pre-malignant lesion for cholangiocarcinoma

It has no clinical implications when found on surgical margins

Question 38

Bismuth Collette classification for perihilar cholangiocarcinoma”

Answer 38

Type I; tumor involves common hepatic duct
Type II: tumor extends to hepatic duct confluence
Type IIIa: hepatic duct confluence and right hepatic duct
Type IIIb; hepatic duct confluence and left hepatic duct
Type IV: extends to bifurcation of both right and left hepatic ducts

Question 39

Bouveret syndrome?

Answer 39

GOOD 2/2 gallstone at pylorus or proximal duodenum

Question 40

Bile duct injury rate during lap chole?

Answer 40

<0.5%

Question 41

Bile duct injuries are classified according to:

Answer 41

Strassfburg classification A-D

25% of bile duct injuries will be identified intra-op
>50% present within first month after surgery

Question 42

Tx for T1b GB cancer?

Answer 42

Remove segments IVB and V

Resect CBD, portal lymphadenectomy, Roux-en-y reconstruction

Question 43

Highest positive predictive value for choledocholithiasis?

Answer 43

Total bilirubin

Question 44

Tx of hemobilia?

Answer 44

Angiography—-> transarterial embolization