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Oral Boards > Biliary > Flashcards

Biliary Flashcards

1
Q

Sx Chole in Pregnancy note?

A
  • Note- Increased gallstone formation
    • controversial timing
    • However new recommendations surgery anytime be causes recurrence rates 92, 64, 44% and complications are higher and if cholangitis, gallstone panc developed could be fatal for the fetus, preterm etc
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2
Q

Sx Chole in Pregnancy DDx?

A
  • DDx-RUQ pain- PUD, pancreatitis, pyelonephritis, HELLP, acute fatty liver, hepatitis
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3
Q

Sx Chole in Pregnancy choledochlithiasis suspected?

A
  • if choledocholithiasis suspected

- ERCP, MRCP not well establish effects on fetus

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4
Q

Sx Chole in Pregnancy treatment?

A
  • Treatment
    • OB c/s fetal monitoring >24 wks viable fetus,
      • preop and postom monitoring fetal HR and uterine activity
    • left lateral decubitus
    • hasson entry based on location of fundal height
    • keep pressures
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5
Q

Acute cholecystitis note?

A
  • Note-5-10% biliary colic will develop acute cholecystitis in a year
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6
Q

Acute cholecystitis ddx?

A
  • Note-5-10% biliary colic will develop acute cholecystitis in a year
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7
Q

Acute cholecystitis HPI?

A
  • Note-5-10% biliary colic will develop acute cholecystitis in a year
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8
Q

Acute cholecystitis diagnosis?

A
  • CBD stones not always suggested on US but dilated CBD >8mm suggests
    • HIDA false positives in setting of chronic cholecystitis, non visual of GB in 60 min dx.
    • cholecystokinin or morphine to stimulate contraction increases accuracy of HIDA in dx acute chole
    • use EF to dx dyskinesia
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9
Q

Acute cholecystitis treatment? Conversion? Critical ill? What to do considering removal of tube? Hydrops? when subtotal?

A
  • Ideally operate within 48 hrs of sx onset should be “urgent”; cooling off doesn’t help makes it harder with chronic fibrous scarring
  • lap ass w decrease hospital stay, quicker return to work, less pain
  • open chole with hostile abdomen, known aberrant anatomy, significant inflammation, or can’t tolerate pneumoperitoneaum, suspect GB cancer
  • conversion- fail to progress, bleeding uncontrolled, inability to define relevant anatomy,
  • Cholecystostomy tube, perc drain or cut down for decompensated cardiac failure, unstable angina, sever chronic lung dz, critical ill patients with MOF or septic shock
  • remains indefinitely esp for patients with limited life exp, or serves as a bridge
  • any trial of tube removal need to do contrast study prior to confirm a patent duct
  • Higher chance of conversion with the cholecystectomy after tube placement -chronic inflame, fibrosis around calots triangle
  • hydrops need to needle decompress
  • lateral retraction helps open the triangle separating cystic duct from CHD
  • subtotal - when can’t obtain critical view in select cases- top down and transect at level of the neck or infundibulum and remove remaining stones and oversew with absorbable suture and leave drains
  • if really bad just leave a cholecystostomy tube placed laparoscopically
  • prior abdominal surgical scars just go in different area likely left subcostal
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10
Q

Acute cholecystitis postop?

A
  • persistent pain, fever or hyperbilirubenima check for retained stones, leak, injury.
  • check US for biliary dilation and fluid collection and CT possible ERCP (sten, sphincterotomy) perc drains
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11
Q

Acute cholecystitis clean kills?

A
  • ordering HIDA with EF
  • not doing IOC with unsure anatomy
  • performing subtotal cholecystectomy laparoscopically
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12
Q

Choledocholithiasis treatment? Options when lack of availibility?

A
  • NPO, IVF, ABX
  • ERCP decompression of CBD
    • If unavailable then IOC and stone removal lap or open (if IOC done via the cystic duct you don’t have to suture the duct but it limits the size of stones retrieved)
    • choledochotomy, IOC stones removed and placement of T-tube duct closed around it
    • if unable to remove it then try choledochoduodenostomy or a RNY HJ
    • If impacted at ampulla perform transduodenalsphincteroplasty with incision at 11 o’clock
  • Laparoscopic cholecystectomy
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13
Q

Bile duct injury goals?

A

Control sepsis, drain collection, and secure drainage and ongoing assessment

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14
Q

Bile duct injury DDx?

A
  • DDx-bowel injury, UTI, SSI, lack of bowel fxn return ominous sign, hemorrhage (24hrs), retained stone (days to weeks) duct injury
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15
Q

Bile duct injury SI?

A
  • Si- jaundice, cholangitis, pancreatitis’ - total bill may just be slightly elevated incomplete transection with free leak cuz
  • mark total bill increase should raise suspicion of vascular injury
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16
Q

Bile duct injury dx?

A
  • dx- US, CT, HIDA, ERCP, PTC
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17
Q

Bile duct injury imaging?

A
  • HIDA
    • Dx extra of bill drainage and demo failure of bile to enter duodenum from liver
  • CTA to define vascular leak dual phase
  • MRCP to define strictures
  • ERCP best to define and tx
    • stent and sphinterotomy for cystic duct leaks or small accessory ducts Bismuth Type A
    • incomplete transections may be bridged c stent and determine need for surgical intervention only with time
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18
Q

Bile duct injury immediate treatment?

A
  • ERCP best to define and tx
    • stent and sphinterotomy for cystic duct leaks or small accessory ducts Bismuth Type A
    • incomplete transections may be bridged c stent and determine need for surgical intervention only with time
  • PTC is next - if ERCP unable to determine extent of injury like a CBD ligation so place a transhepatic biliary drain to decompress and often place perc drains to control leak
  • cholangiograms need to inspect all liver segments to be visualized and if not get a PTC dx and tx
  • Bismuth Type E -complete disruption of biliary enteric continuity- majority will require PTC to define injury and tx and later hepaticoj
  • fluid collection is collected by perc drain -gram stain, culture then give ABX
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19
Q

Bile duct injury CBD exploration description?

A
  • CBD exploration
    • Right subcostal incision
    • IOC
    • if small stones give glucagon and flush and pass fogarty #4
    • if persist perform Kocher maneuver trace cystic duct to CBD and aspirate
    • place 5-0 vicryl suture as stay suture and make a 1.5cm longitudinal incision in the duct
    • flush it with salon via a 10 Fr red rubber catheter
    • place flexible choledochoscope and pass 4 fr fogarty or use a basket to retrieve stones
    • leave a T tube
    • perform a completion IOC to ensure stones are gone
    • repeat cholangiogram in 3 weeks
      • if retained stones wait another 3 weeks and try to extract via the tube,
      • if normal then remove T-tube
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20
Q

Bile duct injury intraoperative recognition? Type of injury?

A
  • Intraoperative recognition of biliary injury
    • dont open if you are not prepared for the dissection and reconstruction cuz will worsen the situation
    • if no expert is available place a closed suction drain and txfr to a high volume center
    • Type A injury (cystic duct leak or a liver bed leak)
      • suture ligate and close suction drainage is adequate
    • Type D injury (lateral injury to major duct)
      • closure of the defect over a T-tube and close suction drainage should be done
      • if avulsion of cystic duct same as above
      • more than >50% circumfrential injury or complete transection of the duct then RNY HJ
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21
Q

Bile duct injury postop recognition early?

A
  • Post operative recognition early
    • PTC/ERCP c stent
    • perc drainage, abx, and wait 6-8 weeks for inflammation to go down before repair
    • Type B (clipped aberrant right hepatic duct)
      • RNY HJ or hepatic resection if an anastomosis isn’t possible
    • Type C (leaking cut end of right aberrant hepatic duct
      • small
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22
Q

Bile duct injury RNY HJ description? Postop?

A
  • RNY HJ
    • Right subcostal incision, LOA
    • careful portal dissection-mobiize duodenum, omentum and hepatic flexure away from porta
    • “Anteriorly only “ dissection of the hepatic duct (avoids further dissection behind the duct and disrupt blood supply) cuz RHA is often right behind the hepatic duct
    • lower the portal plate to allow exposure of hepatic duct bifurcation (incise liver parenchyma to get above the hepatic duct bifurcation can do bluntly minimize cautery if bleed pack and come back to it at the end of case after anastomosis )
    • create retrocolic RNY to ruq via transverse mesocolon to right of the mesocolon (most direct route) may have to really do a good LOA to get better extension
    • broad biliary enteric anastomosis using PDS interrupted (can also take seromuscular bites of jejunum and tack to the GB fossa or portal plate to relieve tension)
    • closed suction drainage
    • avoid stents can cause further trauma
    • 15% will develop strictures and can manage by perc transheptic dilation and stunting without the need for further OR revision-remove catheter at 3 weeks postop after study showing a patent anastomosis
    • check LFTs 3-6 mo for 2 yrs and then annually
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23
Q

Post-Cholecystectomy Syndrome etiology?

A
  • s/p laparoscopy cholecystectomy for a calculous comes back with similar RUQ complaints
  • Etiology
    • Non-biliary - reflux esophagitis, PUD, Pancreatitis, IBS
    • Biliary- CBD stone or stricture, Oddi sphincter stenosis or spasm, Biliary dyskinesia
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24
Q

Post-Cholecystectomy Syndrome hpi?

A
  • HPI- ETOH usage, pain, jaundice, anxiety
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25
Q

Post-Cholecystectomy Syndrome labs?

A
  • Labs- LFT, amylase lipase
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26
Q

Post-Cholecystectomy Syndrome test?

A
  • Test- upper endoscopy, ERCP
    • CT Abdomen
    • RUQ US
    • HIDA scan
27
Q

Post-Cholecystectomy Syndrome surgery?

A
  • Surgery
    • ERCP shinchterotomy if needed with objective findings
      • delayed empyting CBD on HIDA >2 hrs
      • CBD >12 mm on US
      • inability of experienced GI to cannulate ampul - surgical transduodenal sphincteroplasty
      • reproduction of pain by injecting NS to the CBD
      • elongated cystic duct with impacted stone in it
28
Q

Post-Cholecystectomy jaundice etiology and HPI?

A
  • usually uneventful surgery patient returns one week later
  • HPI
    • Pain, fever, dark urine, clay-colored stools
  • Causes
    • Cystic duct leak, CBD leak, liver bed leak, CBD clipped, retained stone, pancreatitis
29
Q

Post-Cholecystectomy Jaundice diagnosis?

A
  • Diagnosis
    • CBC, LFTs, AXR, Broad spectrum antibiotics
    • RUQ US or CT (show biliary dilation, CBD dilation, stones, fluids)
    • HIDA (CBD is occluded or not)
30
Q

Post-Cholecystectomy Jaundice treatment?

A
  • upper endoscopy, ERCP
    • CT Abdomen
    • RUQ US
    • HIDA scan
31
Q

Post-Cholecystectomy Jaundice occluded CBD treatment? cant get it out its impacted in the ampulla?

A
  • Occluded CBD (dilated duct, HIDA suggestive)
    • ERCP determine location of obstruction and possibly remove retained stone
    • If fails or clip across CBD suspected go to OR exploration and repair of CBD (T-tube or choledocho-jejunonstomy)
      • RUQ incision along the costal margins
      • expose porta hepatis, find CBD, aspirate it with 22 g to confirm
      • make a vertical 2 cm incision
      • give patient glucagon
      • forcibly flush the duct with saline on an olive tip followed by serial passes c #4 fogarty passes into duodenum
      • pass choledochoscope down to ensure the duct is clear
    • If you can’t get it out its impacted in the ampulla
      • transduodenal and do a sphincterotomy to extract stone
      • Still can’t remove it
        • close duodenum in two layers
        • hepaticojejunostomy
        • If unstable leave a T-Tube and get out
32
Q

Post-Cholecystectomy Jaundice biloma?

A
  • CT guided perc drainage (cultures and gram stain)
    • Then GI ERCP to stent leak and determine if it is cystic or common duct
    • If unavailable then PTCA
    • If cystic duct is leaking leave drain and the CBD stent and follow
      • most close in 1-2weeks
33
Q

Post-Cholecystectomy Jaundice CBD injury?

A
  • cool down, drainage, come back in 4-6 weeks to repeat ERCP
  • If continues to leak need to repair over a T-tube or do a choledocho-j explore the porta and dissect above clips
  • if patient is septic need to go in sooner
34
Q

Post-Cholecystectomy Jaundice ducts of luschka?

A
  • Drain biloma
  • ensure no distal obstruction
  • may need to return to OR to suture/ligate
35
Q

Post-Cholecystectomy Jaundice abdomen is scarred down?

A

If abdomen is scarred down and can’t dissect out anything then locate the CBD by aspirating with 25 g needle an do a side to side choledochojejunostomy

36
Q

Cholangitis charcots triad? Reynolds?

A
  • Charcots Triad- fever,pain, jaundice Reynolds-add MS changes and hypotension
37
Q

Cholangitis dx?

A
  • Dx- US, CT, MRCP not necessary but identify etiology of obstruction
38
Q

Cholangitis admission?

A
  • Admit- IVF, app ABX send cx first GNB and anaerobes, HD monitoring and prompt biliary decompression
  • if responds well to ABX there is no HD instability then ok to CT or MRCP to elicit cause
39
Q

Cholangitis septic?

A
  • However if appears septic needs urgent decompression by endoscopic, percutataenous, surgical
40
Q

Cholangitis what if ERCP not available?

A
  • However if appears septic needs urgent decompression by endoscopic, percutataenous, surgical
  • Urgent decompression within 24-48hrs should be dictated by patients response to IVF and ABX more urgent if patient doesn’t respond
  • ERCP uses mod deep sedation and is associated with decrease rate of postop mech ventilation and death as opposed to traditional open bile duct exploration
  • If not available then perc drain transhepatic drainage and surgical decompression (good approach if intrahepatic ducts are dilated provides a good targetP
41
Q

Cholangitis surgery RNY GB?

A
  • Surgery if RNY GB or where other specialist not available
    • CBD exploration and t-tube placement (avoid in CBD >5mm or really inflamed field then just do a cholecystostomy tube for biliary drainage
      • dome down tech until calots triangle id
      • cystic artery is ligated and perform a cholecystectomy
      • only the anterior surface (3 and 9 o’clock blood supply) ok to aspirate 22 g needle, to confirm avoid lateral dissection cuz of blood supply
      • choledochotomy 1-2 cm distal to the cystic duct insertion on the CBD
      • two separate 4-0 suture placed on either side anteriorly and with a 15 blade
      • CBD or T tube (unstable) depends on patients status
      • simple irrigation with a small bore red rubber catheter mobilized the stones out the choledochotomy and advance catheter prox and distally ( may use a biliary fogarty (ballon tip cath))
      • avoid rigid instruments
      • Choledochoscope to ensure clearance
      • difficult stones retrieved with wire baskets placed through the scope
      • once cleared a t-tube is placed in the setting of cholangitis use a 14F gutter t-tube and closed with a absorbable suture over the t tube and brought through the abdominal wall
      • completion t-tube cholangiogram to confirm clearance and closure
      • leave also a closed suction drain catheter
42
Q

Cholangitis postop?

A
  • Postop
    • If a t-tube was left leave it to gravity in the acute setting
    • after discharge get a contrast study to confirm clearance and patency usually 2-3 weeks after insertion, decision can be made to internalize biliary drainage (cap the T-tube) and get another study in 4-6 weeks and tube is removed if OK
43
Q

Acalculus Cholecystitis scenario?

A
  • Scenario- inpatient s/p CABG, Aortic surgery, TPN, NPO, and in the ICU
44
Q

Acalculus Cholecystitis HPI?

A
  • HPI- Fevers, RUQ pain, High WBC, increased LFTs
45
Q

Acalculus Cholecystitis Dx?

A
  • RUQ US (thickened GB wall, fluid, no stones)
  • HIDA not a good choice in patient with acute inflammation and NPO (can be negative in the absence of cystic duct obstruction)
    • OK to use on a patient with biliary dyskinesia with EF healthy young patient
46
Q

Acalculus Cholecystitis Tx?

A
  • ABX
    • optimize
    • if can tolerate surgery then laparoscopic cholecystectomy
    • Critical ill- IR percutaneous trans-hepatic cholecystectomy tube under US or CT guidance (95-100% successful)
      • if not available then open cholecystostomy tube at bedside under local anesthetic
47
Q

Primary Sclerosing Cholangitis etiology?

A
  • rare, h/o UC, cholangitis, cirrhosis
48
Q

Primary Sclerosing Cholangitis PE?

A
  • PE- jaundice or have stigmata or cirrhosis
49
Q

Primary Sclerosing Cholangitis dx?

A
  • LFT
  • ERCP (show stricture) note intra and extra hepatic disease
  • Liver biopsy determine stage of disease
    • stage 1 portal inflammation
    • stage 2 portal and peri-portal inflammation
    • stage 3 bridging fibrosis
50
Q

Primary Sclerosing Cholangitis tx?

A
  • medical tx is ineffective (ex anti-inflam, immunosuppressive worthless)
  • Ursodeoxycholic acid relieves sx and decreases LFTs but not progression
  • Non op
    • balloon dilation (help sx but not stop progression)
    • Percuateneous stenting can help dissection of the hepatic ducts during operation
  • Operation
    • without intrahepatic disease
      • near total ductal excision and a hepatic-jejunostomy over silastic stents with PDS and a retro colic RNY
      • closed suction drainage
      • can delay transplant
      • if patient has cirrhosis then needs transplant
51
Q

Choledochal Cyst scenario?

A
  • Younger patient
52
Q

Choledochal Cyst H&P?

A
  • RUQ pain, Jaundice, acute pancreatitis, acute cholangitis, biliary cirrhosis
53
Q

Choledochal Cyst Dx?

A
  • US and CT
  • ERCP is diagnostic and clearly defines the anatomy of the cyst, location of pancreatic duct and can be tx if sphincterotomy or stent
  • MRCP clearly defines the biliary tree
54
Q

Choledochal Cyst type?

A
  • Type 1 choledochal cyst MC cystic, fusiform saccular extrahepatic biliary dilation
  • Type 2 mixed type 1 and 2 fusiform dilation of the extra hepatic biliary tree in combo c separate diverticulum, mid portion of the CBD c cystic duct entering right of the diverticulum
  • Type 3 choledochocele dilation of extra hepatic intraduodenal biliary tree
  • Type 4 intrahepatic and extrahepatic intraduodenal biliary tree
  • Type 5 (caroli dz) intrahepatic biliary cyst
55
Q

Choledochal Cyst treatment? different types?

A
  • Treatment (malignant potential)
    • surgical if possible
    • if too close to the portal vein, then a portion must be left behind
    • Type 1 - cyst excision or choledocho-j
    • Type 2- cyst require excision and primary closure over a T-tube
    • Type 3 - requires cyst excision (leaving intrahepatic portion) and choledocho-j or hepatico-j (malignant potential is low)
    • Type 4 - cyst are treated with lobectomy and RNY hepatic-jejunostomy if intrahepatic or diffuse then they need transplant, excise all extra hepatic cyst and do RNY HJ
    • Type 5 cyst - get actigall to reduce biliary sludge and reduce stasis, can do lobectomy of localized dz in one lobe or txp for diffuse dz in bilateral lobes
    • Note on surgery-
      • surgery can be tedious b/w cyst and PV
      • may be safer to enter the cyst and try to develop subserosal plane or a at least submucosal plane and leave the outer layer of the cyst wall in situ and the intrapancreatic portion of the CBD is also left alone
  • MC complication is strictures
56
Q

Biliary Cancer HPI?

A
  • HPI- similiar to Sx cholelithiasis
57
Q

Biliary Cancer PE?

A

normal

58
Q

Biliary Cancer Dx?

A
  • after cholecystectomy report comes back
    • US suggest cancer include
      • mass >1cm
      • calcified GBW
      • discontinuous wall layers
      • loss of interface b/w the GB and liver
59
Q

Biliary Cancer treatment? stages?

A
  • T-stage
    - Tis- insitu ca
    - T1-tumor invade lamina propria (A) or muscle layers(B)
    - T2- tumor invades perimuscular connective tissue, no extension beyond series or into liver
    - T3- Tumor perforates serosa (Visceral peritoneum) or directly invades the liver and or one other adj organ or structure (stomach, duo, colon, pancreas, omentum, extra hepatic biliary ducts)
    - T4- Tumor invades main portal vein or hepatic artery, or invades two or more extra hepatic organ or structures
    • Tis and T1a - simple cholecystectomy is enough
    • T1b and T2 lesions- resection of the tumor , 2 come the gallbladder fossa and lymphadenectomy is done
      • lymphadenectomy consists of
      • dissection of LN beds in portal hepatic, gastroduodenal ligament, gastrohepatic ligament,
      • kocher maneuver with removal of LN along posterior duodenum
    • T3 and T4
      • metastatic dz should be r/o with laparoscopy in before laparotomy
      • tumor should be resected if it can’t be completely removed no survival benefit for debulking
      • if any adjacent organs are involved (colon, stomach, duodenum) should be resected with negative margins
      • large segments of liver (segments 4-8) may need resection if involved
      • Most important factor survival resection of tumor c negative margins preferably greater than 2 cm
      • Para-arotic LN involvement contraindication to operation
60
Q

Extrahepatic Biliary Cancer RF?

A
  • RF-PSC, Choledochocyst, xrt, clonorchis
61
Q

Extrahepatic Biliary Cancer HPI?

A
  • HPI- painless jaundice, weight loss, fatigue, abdominal pain, biliary colic
62
Q

Extrahepatic Biliary Cancer Dx?

A
  • PTC and ERCP c bx and washings best way
    • r/o non-malignant cases like choledocholithiasis, extrinsic compression from LN at portal (CCA, BCA, or lymphoma) and PSC
  • CT scan
    • visualize extent of tumor r/o vascular invasion or LN and distant mets,
    • also location of tumor proximal, middle or distal
  • MRI or angio
    • assess vessel invasion
    • unresectable if multi-focal hepatic dz, portal vein involvement or hepatic artery involvement
63
Q

Extrahepatic Biliary Cancer tx? proximal, middle, distal?

A
  • use laparoscopy check LN involvement, liver mets, peritoneal mets, extension of tumor
  • if not resectable then drain the biliary system with either a stent via ERCP/PTC or biliary-enteric anastomosis
  • Proximal tumors (klatskin)
    • distal to proximal dissection
    • en bloc resection to include cholecystectomy
    • resect to healthy right and left ducts
    • resect caudate lobe if needed
    • RNY HJ
  • Middle lesions
    • resect GB and CBD to intra pancreatic portion and hepatic ducts
    • create RNY HJ
  • Distal lesions or intrahepatic extension
    • Whipple
64
Q

Extrahepatic Biliary Cancer palliative?

A
  • Palliative therapy
    • biliary drainage and prevent cholangitis
    • PTC catheters changed out every 3 months or with malfunction
    • unresectable cancer 10 months survival
    • no adjuvant tx

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