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MBBS Surgery > Biliary > Flashcards

Biliary Flashcards

1
Q

Classification of cholangiocarcinomas

A

intrahepatic
extra hepatic
- upper duct
- distal CBD

Bismuth classification
I: below confluence
II: reaching confluence
IIIA/B: conflu + R/L hepatic duct
IV: multicentric/ confluence + both hepatic ducts
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2
Q

RF for cholangiocarcinoma

A
  1. Chronic cholestasis - prolonged inflammation
    - PSC (a.w UC)
    - parasitic infx
    - hepatolithiasis
    - viral hepatitis
  2. Fibro-polycystic liver dz
    - Caroli syndrome: diffuse intrahepatic ductal ectasia
    - congenital hepatic fibrosis
    - choledochal cyst
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3
Q

Types of periampullary tumours

- sign

A

pancreatic head
cholangioca (lower CBD)
periampullary duodenum CA
ampulla of vater CA

Thomas sign: silver stools

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4
Q

Causes of biliary strictures

A
  1. Iatrogenic
    - lap cholecystectomy
    - other sx: gastrectomy, hepatic resection
    - ERCP
  2. Inflammatory
    - PSC
    - recurrent pyogenic Cholangitis
  3. Others;
    - recurrent gall stones, pancreatitis, RT, parasites
    - trauma
  4. congenital:
    biliary atresia
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5
Q

RF for acalculous cholecystitis

A
  • v ill pt (ICU)
  • sepsis w hypotension
  • immunosuppression (HIV)
  • major trauma, burns
  • DM
  • salmonella typhi infx
  • prolonged NBM, TPN use

(high risk for perf and gangrene)

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6
Q

Differentiate biliary colic from acute cholecystitis

A

biliary colic:

  • transient obstruction to cystic duct
  • intermittent pain, post prandial, epigastric, visceral pain

acute cholecystitis

  • bac infection
  • pain of longer duration, localised to RHC
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7
Q

RF for gallbladder CA

A
  • age
  • chronic cholecystitis, cholelithiasis, calcification of gallbladder (porcelain gallbladder)
  • mirizzi syndrome
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8
Q

Cholangitis Causes

A

choledocholithiasis

  • benign strictures (instrumentation)
  • CA (Panc, biliary)
  • foreign body, parasites
  • PSC, choledochal cyst, mirizzi
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9
Q

Cholangitis common causative org

A

gram neg bac and anerobes - klebsiella, e coli, enterobacter, enterococcus

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10
Q

normal CBD size

A

5mm normal in 50s

6mm in 60s and so on

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11
Q

when to do operative vs ERCP removal of stones

A

op:

  • stone large >25mm
  • intrahepatic
  • large number
  • impacted stone
  • dual pathology
  • tortuous duct
  • previous bilroth (unsuitable anatomy)

ERCP

  • not surgical candidates
  • prev cholecystectomy
  • acute cholangitis
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12
Q

US findings of acute cholecystitis

A
  • thickened gallbladder wall (>3/4mm)
  • sonographic murphy positive
  • pericholecystic fluid
  • presence of gallstone in biliary system
  • contracted gallbladder (chronic gallstone dz)
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13
Q

Cx of cholecystectomy

A

Procedure:

  • injury to bile duct, hepatic artery, bowel
  • un-retrieved gallstone spillage - abscess, fistula
  • retained stones in CBD
  • incisional hernia
  • post cholecystectomy syndrome

Post:

  • reflux dz, biliary gastritis
  • ab pain, diarrhoea (fat intolerance)
Lap risks:
- conversion to open 
- injury: biliary system
- spilled bile: peritonitis, sepsis
GA: allergy, pneumonia, stroke, MI, death
Gen: bleed, wound infx, DVT, PE
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14
Q

Cx of cholecystitis

A
  • hydrops
  • empyema
  • gangrene/ perforation
  • cholecystoenteric fistula
  • gallstone ileus - SB IO at terminal ileum (2 feet proximal to ileocecal valve)
  • emphysematous gb
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15
Q

timing of cholecystectomy

A

Emergency

  • complicated acute cholecystitis (gangrene/ necrosis, perf/ emphy)
  • progressive signs and symptoms (high fever, hemo instability, intractable pain in spite of best supportive care)

ASAI/II: within first 3 days
ASAIII-V: non sx, biliary drainage first then elective sx if possible

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16
Q

Types of gallstones

- Causes

A
  1. Cholesterol (85%)
    - radiolucent
    a. inc cholesterol secretion in bile [- fat, female, forty, fertile (estrogenic - preg, OCP)]
    b. decreased emptying in gb [ca, preg, tpn, fasting, truncal vagotomy]
  2. Pigment stones (15%): radioopaque - calcium salts
    - black (sterile)
    [inc bilirubin secretion: chronic hemolysis, cirrhosis, CLD, TPN, gb stasis]
    - brown (infx)
    [klebsiella infx, billiary stasis]
  3. Mixed
  4. Biliary sludge
17
Q

renal colic vs biliary colic

A

biliary colic = not true colic, no pain free intervals, but wax and wane. often wake pt from slp, few hr post meal

renal colic = pain free intervals

18
Q

Features of normal cholangiopancreatogram

A
  • n intrahepatic ducts
  • no filling defects
  • smooth CBD
  • no stricture/ narrowing of CBD
  • good and free flow of contrast into duodenum
19
Q

US feature of gallstone

A

strong echogenic rim and stone with posterior acoustic shadowing

20
Q

Cx of ERCP

A

procedure = pancreatitis, infx (cholecystitis, Cholangitis), hemorrhage, perf
Sedation = hypoTN, resp depression, N&V
Fatality

21
Q

non sx gallstone tx

A

shockwave lithotripsy
- only for cholesterol stone
not for: >3stones, large, non fx GB, cx of gallstones

bile salt therapy (chemodissolution): LT PO bile acid - reduce hepatic synthesis of cholesterol/ cholesterol secretion

liver diet: mod carbohydrates, low fat and cholesterol, high fibre

22
Q

aerobilia causes

A
  • recent biliary instrumentation:
  • incompetent sphincter of oddi
  • biliary enteric sx anastomosis: whipple
  • spont biliary-enteric fistula: cholecystoduodenal mainly - gall stone ileus
  • infx: cholangitis, emphysematous cholecystitis, liver abscess, rupture hydatid cyst
23
Q

Portal venous gas causes

A
  • alt in bowel wall: ischemic bowel, necrotic/ ulcerated CRC, IBD, PUD
  • bowel luminal distention: endoscope, IO
  • intra ab sepsis
  • others: pneumatosis intestinalis
24
Q

Calot triangle

A

minimise bile duct injury in lap cholecystectomy

  • cystic art anteriorly
  • cystic duct laterally
  • CHD medially
  • LN in middle (Lund’s node)
25
Q

risk factors of viral hepatitis

A

travel hx, seafood ingestion, fam hx, blood transfusions, drug abuse, needle sharing, needle stick injuries, sexual contact

26
Q

Positive lab findings in pre-hepatic jaundice

A

raised LDH, reticulocytes
dec haptoglobin

other ix: PBF, direct combo, stool OCP, malaria

27
Q

Causes of pre-hepatic jaundice

A

Gilbert syndrome (AR, deficiency of uridine diphosphate glucuronosyltransferase)

Hemolytic anemia
- Inherited: thal, G6PD, spherocytosis, sickle cell
- Acquired:
> infx: malaria
>autoimmune: SLE
> HUS (Hemo anemia, ARF, thrombocytopenia)

28
Q

AST>ALT

ALT>AST

A
  1. Toxins (AST in mito), ratio >2 suggests alcoholic liver disease
  2. Viral (ALT in cytoplasms)
29
Q

Congenital causes of jaundice

A

dec/absent activity of UGT (unconj hyperBr)

  • Gilbert syndrome
  • Crigler Najjar 1&2

impaired biliary excretion (conj hyperBr)

  • Dubin johnson
  • Rotor
30
Q

Causes of hepatic jaundice

A

Infx: viral Hep A/B, EBV, CMV, TB

AI: AIH, SLE
Drug: phenytoin, paracet
Causes of cirrhosis
Inherited causes

31
Q

Causes of post hepatic jaundice

A

Intraluminal: gallstones, parasites

Mural:

  • biliary strictures: ERCP, chronic inflame from gallstones, pancreatitis
  • PBC, PSC
  • Cholangitis
  • Choledochal cyst
  • Distal cholangioCA

Extraluminal:

  • HOP, Periampullary CA
  • mirizzi
  • portal hepatitis LN

others:
intrahepatic: drugs, hepatitis, cirrhosis
biliary atresia
drugs

MBBS Surgery (18 decks)

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