Gallbladder and Liver Flashcards
Cholangiocarcinoma - classification
according to the tumor’s location-
- Proximal (klatskin- dilation of intrahepatic bile-ducts).
- Bifurcation.
- Distal.
Biopsy in Cholangiocarcinoma
- Not reliable in the presence of jaundice.
2. Is indicated in patients who are not a candidates for surgical treatment.
Drainage of the bile duct prior to surgery in case of Cholangiocarcinoma?
Is performed in patients with DISTAL tumor and bilirubin > 10.
- ERCP.
- If unsuccessful - PTBD (percutaneous transhepatic biliary drainage).
Proximal (Klatskin) Cholangiocarcinoma Tx.
Surgery: Hepatodudenostomy.
Contraindications for surgery in Cholangiocarcinoma
- Liver mets to more than two lobes of liver.
- Involvement of more than two secondary bile ducts.
- Non hepatic mets.
- Involvement of the portal vein.
- Bilateral involvement of lobar hepatic artery.
Portal vein pyelophlebitis
Acquired through ascending infection from the GIT.
Diverticulitis and appendicitis - most common causes.
Others: pancreatitis, IBD, PID, omphalitis.
Caroli disease
Ectasia of the intrahepatic bile ducts.
Bile duct injury after cholecystectomy - symptoms
- Leak from darinage.
- Jaundice.
- Elevated ALP.
- Fever.
- Abdominal pain
Bile duct injury after cholecystectomy - Tx.
- Antibiotics, drainage, and cholangiography.
- followed by stenting and surgery for reconstructions of the biliary tree.
- If occurs during cholecystectomy- proceed to laparotomy.
Gallbladder cancer - Tx.
- Radical cholecystectomy- includes lymph nodes (periportal, hepatoduodenal and right celiac), cystic duct, sometimes common bile duct, resection of 2cm of liver bed, and resection of the portal area.
* Indicated in case of: vascular, lymph or perineural involvement.
T1B Gallbladder cancer without vascular, lymph or perineural involvement - Tx.
Simple cholecystectomy
Septic shock + emphysematous cholecystitis (due to gas forming organism) - Tx.
Emergent cholecystectomy
Indications for elective cholecystectomy in asymptomatic patients
- Hemolytic anemia.
- Increased risk for gallbladder cancer: porcelain gallbladder, stone >2.5cm, long common segment of bile and pancreatic ducts.
- Bariatric surgery.
- Prior to organ transplantion.
Charcot triad
- Fever
- RUQ pain
- Jaundice.
Associated with acute cholangitis.
Reynold’s pentad
Charcot triad + shock (hypotension) + altered mental status.
Acute Cholengitis Tx.
- Unstable patient (e.g. shock): fluids + broad-spectrum AB, followed by ERCP (remove obstruction + papila-sphincterotomy).
- Stable patient- ERCP.
Cullen sign
Periumbilical echimosis, associated with hemoperitoneum (e.g. hemorrhagic pancreatitis).
Rovsing sign
Pain at McBurney point when compressing the LLQ
Primary biliary cirrhosis
- Painless obstructive jaundice.
- Narrowing of bile ducts.
- AMA positive.
Dx. & Tx. - ERCP, Ursodeoxycholic acid.
Gallbladder- normal size
Length: 7-10 cm
Diameter: 3-4 cm
Ascending cholangitis - common pathogens
E. coli > Klebsiella > Enterococcus > Enterobacter > Pseudomonas > Citrobacter.
Acalculous cholecystitis in critically ill patient (e.g. ICU) - Tx.
Percutaneous cholecytostomy = percutaneous drainage of the gallbladder.
PTBD - percutaneous transhepatic biliary drainage
Is indicated in case that the obstruction is located inside the liver.
Amebic liver abscess
- Caused by entameba histolytica.
- Anamnesis- travel to endemic area (africa, jordan). 3. Presentation- RUQ pain, diarrhea, fever, NO jaundice. 4. US- single cyst in the periphery, with peripheral enhancement.
- Tx.- non-surgical, with metronidzole 750mg orallyx3 for 10 days, luminal agent- paromomycin.
Echinococcal liver cyst
Imaging: Hydatid cyst with daughter cysts, septa or calcifications.
Tx.
1. Primarily treated surgically (avoid rupture due to anaphylaxis).
2. Albendazole.
3. PAIR (percutaneous aspiration, injection, reaspiration).
Pyogenic liver abscess
- Classic presentation: fever, jaundice and RUQ.
2. Tx. : Percutaneous drainage.
MELD score
- Bilirubin.
- INR.
- Cr.
- Na level.
Objective score, reflects the likelihood for mortality within 3 moths while waiting for liver transplantation.
Child-Pugh score
- Bilirubin.
- PT (INR).
- Albumin.
- Ascites.
- Encephalopathy.
Quantifies the operative risk in cirrhotic patients.
Liver adenomas
- Woman with OCP: stop OCP and follow-up.
- Pregnant women: resection because the course is unpredictable during pregnancy.
- Active Hemorrhage: angio-embolization is indicated.
- Symptomatic adenoma: removal is indicated.
Hepatic FNH (focal nodular hyperplasia)
- Usually less than 5cm.
- incidental finding.
- Imaging: enhanced during ARTERIAL phase with central fibrotic scar.
- DDx: liver adenoma, HCC.
- There is no need to stop OCP.
- Asymptomatic patients: with definitive diagnosis- no further workup. If definitive diagnosis cannot be made- resection.
- Symptomatic: radiological follow-up. If grows or unresolving symptoms-resection.
Liver Hemangioma
- Usually smaller than 5cm.
- Imaging: Peripheral enhancement and centripetal filling.
- Clinical course of hemangioma is benign, only significant size will be excised.
- complication: Kasabach-Merrit syndrome.
Kasabach-Merrit syndrome
- Type of consumptive coagulopathy, associated with liver hemangioma.
- Thrombocytopenia and coagulopathy due to PLT & coagulation factors overuse.
HCC - indications for resection
Resection is indicated in patients that do not fulfil the Milan criteria and do not have portal hypertension + child-Pugh A.
HCC - indications for TACE (trans-arterial chemoembolization)
TACE is indicated in patient with preserved liver function, multinodular disease, without vascular invasion.
HCC- indications for ablation
Ablation is indicated in patient with tumor > 3cm and multiple comorbidities.
Surgery in cirrhotic patients
Child-Pugh A+B >> correct ascites and coagulopathy, then operate. Child-pugh C >> postpone surgery until improve class or cancel. Surgery is CI at this stage.
