Diseases of the Hepatobiliary System 2

Question 1

Cirrhosis is a major risk factor for what cancer?

Answer 1

hepatocellular carcinoma

Question 2

Is hepatocellular carcinoma (HCC) more common in males or females?

Answer 2

males

Question 3

Why is the incidence of HCC thought to be rising in the UK?

Answer 3

Obesity and alcohol

Question 4

HCC can show geographical variantion based on the prevelance of which infection?

Answer 4

Viral hepatitis

Question 5

what are the 2 clinical features of HCC, when in the disease course do they arise?

Answer 5

Worsening liver function

Weight loss

Question 6

What are the 2 possible surveillance methods for patients with cirrhosis?

Answer 6

1) 6 monthly USS
2) Blood test possibly - raised alpha feto-protein in serum in 75% (less than 50% in non cirrhotic patients and small HCC less than 3cm)

Question 7

What is the macroscopic appearance in HCC, is there just one lesion?

Answer 7

Expansile soft nodule which are often green (bile), this is often multifocal in cirrhosis

Question 8

Well differentiated HCC is likely to produce what?

Answer 8

Bile

Question 9

What are the 2 main differential diagnosis in liver biopsy investigation when unclear diagnosis?

Answer 9

1) benign liver v well differentiated HCC

2) Metastatic carcinoma v poorly differentiated HCC

Question 10

What is the prognosis of HCC?

Answer 10

very poor (less than 1 year) unless diagnosed early - hence surveillance of cirrhosis is v important

Question 11

What are the 2 treatments for confined HCC?

Answer 11

1) surgery is non cirrhotic, small and peripheral

2) Transplant is 1 tumour less than 5 cm or less than 3 less than 3cm

Question 12

What is the 3 treatment options for non resectable (multiple, large, metastasised) HCC?

Answer 12

1) Ablation - radiofrequency
2) Embolisation
3) Chemo - sorafenib

Question 13

What is considered diagnosis HCC early in terms of TMN staging?

Answer 13

pT1 (solitary tumour, no vascular invasion) and pT2 (solitary tumour with vascular invasion or multiple tumours, none more than 5cm in greatest diameter)

Question 14

What is more common, primary liver cancer or metastasis to liver?

Answer 14

Metastasis to liver

Question 15

What metastasis results in few large nodules in liver?

Answer 15

Large bowel

Question 16

What 5 metasases result in multinodular or infiltrative?

Answer 16

1) Lung
2) Pancreas
3) Breast
4) Stomach
5) Melanoma

Question 17

In addition to HCC what is the other primary liver cancer?

Answer 17

Cholangiocarcinoma - and adenocarcinoma arising in the bile ducts

Question 18

What are the 2 classifications of cholangiocarcinoma?

Answer 18

1) intrahepatic - from small intrahepatic ducts

2) perihilar - from large ducts

Question 19

Does intrahepatic cholangiocarcinoma present early or later?

Answer 19

Later - is it mass forming

Question 20

What is the 1 risk factor for intrahepatic cholangiocarcinoma?

Answer 20

Cirrhosis

Question 21

Does perihilar cholangiocarcinoma present early or late?

Answer 21

Early as it causes obstructive jaundice early

Question 22

What are the 2 risk factors for perihilar cholangiocarcinoma?

Answer 22

Bile duct disease:

1) Primary sclerosing cholangitis
2) Liver flukes

Question 23

What are gall stones caused by?

Answer 23

Precipitation of the constituents of bile when it is concentrated in the gall bladder

Question 24

What is the prevelance of gall stones amongst UK adults?

Answer 24

10-20%

Question 25

What are the 3 risk factors for gall stones?

Answer 25

1) Female
2) Obesity
3) Diabetes
ie an imbalance of bile constituents

Question 26

What are the 4 main types of gall stones?

Answer 26

1) Cholesterol stones - yellow/opaque
2) Pigments stones - small, black - in haemolytic anaemia
3) Mixed stones - most comon
4) 10% contain calcium - visible on plain x ray

Question 27

Gallstones predispose to what cancer?

Answer 27

Cancer of the gall bladder

Question 28

Give the 3 inflammatory complications of gall stones?

Answer 28

1) Cholecystitis (inflammation of gall bladder)
2) Pancreatitis
3) Cholangitis (inflammation of bile duct)

Question 29

Why do gall stones lead to biliary colic and jaundice?

Answer 29

Due to obstruction of the bile system

Question 30

Gall stones can cause mucocele, what does this refer to?

Answer 30

Mucous retention cyst in the gall bladder

Question 31

Why can gall stones lead to cholangitis and liver abscesses?

Answer 31

Due to infection of the static bile

Question 32

How can gall stones lead to gall stone ileus?

Answer 32

Due to intestinal obstruction by a gall stone that has entered the gut through a fistulous connection with bladder

Question 33

How common is cholecystectyomy?

Answer 33

1200 per year in leeds

Question 34

What are the 4 indications for cholecystectomy?

Answer 34

1) Pain
2) gall stones
3) Pancreatitis
4) Gall stone polyp - rarely

Question 35

What is acute cholecystisis caused by?

Answer 35

Duct blocked by a stone, initially sterile then becomes infected

Question 36

What are the 2 complications of acute cholecystitis?

Answer 36

1) Empyema

2) Rupture

Question 37

What is the cause of chronic cholecystitis?

Answer 37

Usually caused by small fibrotic stones

Question 38

How do the macroscopic appearances of acute and chronic cholecystitis differ?

Answer 38

Acute - large, swollen, congested, ulcerated

Chronic - fibrosis, rokitansky aschoff sinuses

Question 39

Why are all removed gall bladders examined histologically?

Answer 39

To detect bladder cancer

Question 40

What percentage of gall bladder cancers are known about before surgery?

Answer 40

50%, the other 50% found in routine cholecystectomy

Question 41

What is the associated pre malignant lesion in gall bladder cancer?

Answer 41

Polyp showing dysplasia