Gallbladder

Question 1

What is the most specific imaging finding to confirm acute cholecystitis?

Answer 1

Ultrasonographic tenderness of the gallbladder (90% specific)

Question 2

Diagnosis of acute cholangitis, which guidelines?

Answer 2

Tokyo guidelines
1. Systemic inflammation (fever, rigors, WCC >10 or <4, CRP >10)
2. Biochemical evidence of cholestasis (bili >34, LFT >1.5x ULN)
3. Imaging (dilatation, evidence of stones/stricture/stent)

One item from each category for definitive diagnosis

Question 3

Primary sclerosing cholangitis: define

Answer 3

A chronic progressive disorder of unknown aetiology, characterised by progressive inflammation, stricturing and fibrosis of medium and large intra- and extrahepatic bile ducts

The majority (up to 90% if biopsies routinely obtained) of patients have ulcerative colitis

Question 4

Mayo risk score for primary sclerosing cholangitis (what does it predict? 5 variables)

Answer 4

Predicts short-term survival of PSC only

Age, albumin, bilirubin, AST, history of variceal bleeding

Question 5

Indications for IOC

Answer 5

Clinical: pancreatitis, cholangitis
Biochemical: raised bilirubin, elevated LFTs suggesting persistent obstruction
Radiological: presence of stones in CBD on pre-op imaging, inability to radiologically clear CBD
Intra-operative: confirmation of anatomy

Question 6

What 5 things are you looking for on IOC?

Answer 6

Presence of cystic duct and CBD
Presence of CHD, confluence and intrahepatic ducts
Flow of contrast into duodenum
Lack of filling defects in distal CBD
CBD that tapers smoothly into duodenum

Question 7

What are the types of gallstones and their risk factors?

Answer 7

Cholesterol stones: an environmental or genetic predisposition to cholesterol supersaturation in bile

Black pigment stones: in patients with haemolytic disorders (eg. the young Greek man); calcium bilirubinate

Brown pigment stones: in patients with infection, eg. liver fluke; Crohns with ileal disease or resection