Biliary Flashcards
Acute cholecystitis presentation and work up
RUQ pain
LFTs, CBC
RUQ US/ HIDA if need EF of gallbladder
What is the normal size of the CBD and gallbladder wall
8mm
4mm
Gallstone ileus
presentation, work up and treatment
RUQ pain or epigastric pain, sx of obstruction (nausea, vomiting, constipation)
Xray/US/CT: pneumobilia, stone in ileum, SBO with small bowel dilation and air fluid levels
Treatment:
high risk patients: enterolithotomy alone
low risk patient: enterolithotomy, cholecystectomy with biliary-enteric fistula closure
optional CBD exploration
what is primary choledocholitiasis
occurs in setting of bile stasis (patient with cystic fibrosis or hepatic artery injury such as after transplant)
what is secondary choledocholithiasis
results from passage of stones from GB to CBD
what are the complications of choledocholithiasis
- acute pancreatitis
- acute cholangitis
What is Charcot’ triad and Reynold’s pentad
charcots
- fever, RUQ pain and jaundice
Reynold’s
- fever, RUQ pain and jaundice with hypotension and altered mental status
what is the treatment for symptomatic choledocholithiasis with high risk of CBD stones
ERCP with stone removal followed by elective cholecystectomy
OR
cholecystectomy with intraoperative CBD exploration or post op ERCP
What is managment of patient with acute cholangitis with evidence of biiary obstruction and acute pancreatitis
preoperative ERCP with stone removal
who are the patients at high risk of CBD stone
- cbd stone found on US
- acute cholangitis
- TB >4mg/dL and a dilated CBD >6mm (with in situ gb or 8mm s/p chole)
who is at intermediate risk of CBD stone
- abnormal liver biochemical tests
- age >55
- dilated CBD on ultrasound or cross-sectional imaging
management of patient with intermediate risk of CBD stone
- MRCP or EUS
- if positive can do pre-op ERCP or chole with IOC
- can go straight to OR and do IOC or intraoperative U/S
managment of CBD stone s/p cholecystectomy
- mrcp or eus
what are the gallbladder cancer TNM
- T1 invades lamina propria or muscular layer
- T1a invade LP
- T1b invades muscle
- T2
- T2a tumor invades perimuscular connective tissue without involvement of serosa
- T2b invades perimuscular tissue on hepatic side without extension to liver
- T3 perforates serosa and/or directely invades liver and/or one other adjacent organ.
- T4 invades main portal vein or heptic a. or two or more extrahepatic organs
N1 1-3
N2 > or =4
if for whatever reason you try to do CBD exploration and encounter stones you cannot extract, what do you do?
choledochoJ or choledochoD
How do you stage Gallbladder ca
CT C/A/P
can also get MRI abd with contrast (eval liver parenchyma and bile duct)
staging laparoscopy with lap U/S
what makes gallbladder ca unresectable
- liver mets
- peritoneal mets
- malignant ascites
- tumor involvemet of paraaortic, pericaval, SMA and or celiac a. LN’s
- extensive involvement of hepatoduodenal ligament by tumor or LN’s
- encasement or occlusion of major vessels (hepatic a. or portal vein)
surgical treatment of gallbladder sx
- T1a cholecystectomy
- T1b extended chole
- T2 extended chole
- T3 extended chole with en bloc resection of involved organ (can also do radical sx like major
describe lap cholecystectomy
- pre-op T/S, pre-op abx
- 10mm trochar at umbilicus, Hasson technique
- 3 other trochars at RUQ and epigastrium
- grasp infundibulus of gallbladder and push it back caudad
- the cystic duct is dissected and clipped and cut
- the cystic artery is dissected and clipped and cut
- gallbladder is removed off liver bed with cautery
- remove the gallbladder with specimen bag
describe lap CBD exploration
- make incision in cystic duct after clipping it for cholecystectomy
- insert cholangiogram catheter into cystic duct and flush
- can place fogarty catheter to retrieve stones
- can use basket device
- can use choledochoscope
describe open CBD exploration
- kocher incision, bookwalter for retraction
- cholecystectomy with IOC
- kocher maneuver
- use left hand to bring up CBD, place stay sutures, low vertical incision on CBD
- use latex catheter to flush and then look
- if palpable stones, use stone forceps to remove
- use choledochoscopy to look both distal and proximal. can also use it or t-tube cholangiogram to assure the duct is clear and the ampulla is patent
