GB & the extrahepatic biliary system Flashcards
1
Q
What is Cantle’s line?
A
It’s a vertical plane running from the gallbladder fossa anteriorly, to the inferior vena cava posteriorly, divides the liver into right and left lobes.
2
Q
What are the anatomic areas of the gallbladder?
A
- Fundus
- Body
- Infundibulum
- neck
3
Q
What is hartmann’s pouch/infundibulum of the gallbladder?
A
It’s a mucosal out pouching that it’s present at the junction of the neck and the cystic duct.
4
Q
How does the gallbladder differs histologically from the rest of the GI tract?
A
It lacks a muscularis mucosa and submucosa.
5
Q
Where can the cystic artery be found ?
A
Within the hepatocystic triangle ( Triangle of calot)
6
Q
What are the boundaries of hepatocystic triangle ( Triangle of calot) ?
A
- Cystic duct.
- Common hepatic duct.
- Inferior edge of the liver.
7
Q
How long and how wide is the common hepatic duct?
A
1-4 cm long
4 mm in diameter.
8
Q
How long and how wide is the common bile duct?
A
7-11 cm long.
5 - 10 mm in diameter.
9
Q
What is the composition of bile ?
A
Organic:
- bile acid
- cholesterol
- phospholipids
- Lecithin
- bile pigment (bilirubin from Hb breakdown)
- protein.
Inorganic:
- Na
- Cl
- K
- HCO3
- Ca
- Mg
10
Q
What is the pathway of cystic artery ?
A
Arises from right hepatic artery, passes posterior to common hepatic duct (CHD), superior to the cystic duct CD, and through the Calot triangle.
11
Q
How much bile is produced in a normal adult consuming an average diet?
A
500 - 1000 mL.
12
Q
What are the sonographic features of acute cholecystitis?
A
- Thickened gallbladder wall.
- Pericholecystic fluid.
- Sludge in the gallbladder.
- Local tenderness with direct pressure by US probe over the funds of the gallbladder (sonographic Murphy’s sign).
13
Q
When to consider an abnormal gallbladder ejection fraction ?
A
Ejection fraction < 35 %
14
Q
What are the risk factors of cholelithiasis ?
A
- Pregnancy
- Non - HDL hyperlipidemia.
- Crohn’s disease.
- Hereditary spherocytosis.
- Sickle cell anemia
- Thalassemia
- Surgeries that ulter the normal neural or hormonal regulation of the biliary tree: terminal ileal resection and gastric or duodenal surgery.
- Rapid weight loss following bariatric surgery or lifestyle changes.
- Somatostatin analogues.
- Estrogen - containing oral contraceptives
- Being a woman.
- Having a first degree relative having cholelithiasis.
15
Q
What are the complications of gallstones?
A
- Acute cholecystitis.
- Choledocholithiasis.
- Cholangitis.
- Gallstone pancreatitis.
- Gallstone ileus.
- Gallbladder stones.
16
Q
What are the indications of prophylactic cholecystectomy in asymptomatic patients ?
A
- Patients who will be isolated from medical care for an extended period of time.
- Patients with increased risk of gallbladder cancer.
- The presence of porcelain gallbladder (absolute indication).
17
Q
How do you classify gallbladder stones?
A
By their cholesterol content:
- Cholesterol stones.
- Pigment stones: Black or Brown.
18
Q
What is the amin phospholipid in bile ?
A
Lecithin
19
Q
Which gallbladder stones are radiopaque and which are radiolucent and why ?
A
- Cholesterol stones are usually radiolucent (only if it contained high calcium carbonate it will be radiopaque).
- Pigment stones has high calcium content so usually it’s radiopaque.
20
Q
Brown gallbladder stones usually related to which organisms?
A
- Escherichia coli.
- Parasite: Ascaris lumbricoides (round worms).
- Parasite: Clonorchis sinensis (liver fluke).
21
Q
What is the cause of biliary colic ?
A
A stone obstructs the cystic duct, resulting in a progressive increase of tension in the gallbladder wall as it contracts in response to a meal.
22
Q
What is biliary colic?
A
It refers to the postprandial right upper quadrant or epigastric pain.
23
Q
What is chronic cholecystitis?
A
It is a chronic noninfectious inflammation of the gallbladder wall.
24
Q
What do you call the formation of intramural diverticula or sinus tracts in the gallbladder?
A
Rokitansky–Aschoff sinuses (entrapped epithelial crypts).
25
What is the chief symptom associated with symptomatic cholelithiasis ?
Biliary colic
26
Where does usually the biliary colic pain radiates?
To the right upper back or between the scapula.
27
In gallstone patient who present with atypical symptoms, what are the other DDx you should think off, especially if they're having upper abdominal pain ?
- Peptic ulcer disease.
- Gastroesophageal reflux disease.
- Herpes zoster.
- Abdominal wall hernias.
- Inflammatory bowel disease.
- Diverticular disease.
- Pancreatitis.
- Liver disease.
- Renal calculi
- Pleuritic pain.
- Cardiac pain.
28
When there is an impacted stone in the cystic duct without cholecystitis, this will result in a condition called: ... ?
Hydrops of the gallbladder (Mucocele)
29
What are the complications of hydrous of the gallbladder (gallbladder mucocele)?
- Edema of the gallbladder wall.
- Inflammation.
- Infection.
- Perforation.
30
What is the standard diagnostic test for gallstones?
Abdominal ultrasound as is it noninvasive and highly sensitive.
31
What is Cholesterolosis?
Cholesterolosis is caused by the accumulation of cholesterol in macrophages in the gallbladder lamina propria, either locally or as polyps.
32
Strawberry gallbladder is the classic studded macroscopic appearance of which condition?
Cholesterolosis
33
At which trimester does laparoscopic cholecystectomy
| is preferred to be done in pregnant patients with symptomatic gallstones ?
Second trimester.
34
What is Emphysematous cholecystitis ?
It is an acute infection of the gallbladder wall caused by gas-forming organisms (eg, Clostridium or Escherichia coli).
35
What are the difference between biliary colic and acute cholecystitis in clinical manifestations?
Biliary colic:
- Relapsing and remitting pain in the RUQ or epigastrium.
- Radiate to the right back or inter scapular area.
Acute cholecystitis:
- Pain never subside.
- Associated with fever, anorexia, nausea and vomiting.
- Patient may refuse to move as the inflammatory process creates focal peritonitis.
36
What is Murphy's sign ?
An inspiratory arrest with deep palpation in the right subcostal area, which is characteristic of acute cholecystitis.
37
How are the labs in a patient with acute cholecystitis ?
- Leucocytosis: mild to moderate (high in complicated acute cholecystitis).
- Elevation of serum bilirubin
- Mild elevation of alkaline phosphatase.
- Mild elevation in Amylase.
- Mild elevation in Transaminase
38
What is Mirizzi's syndrome ?
It is a mechanical hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder
39
What are the DDx of acute cholecystitis ?
- Peptic ulcer disease.
- Pancreatitis.
- Appendicitis.
- Hepatitis.
- Perihepatitis ( Fitz- Hugh - Curtiz syndrome).
- Myocardial ischemia.
- Pneumonia
- Pleuritis.
- Herpes zoster involving the intercostal nerve.
40
What is the sensitivity and specificity of ultrasound in acute cholecystitis ?
70% to 90%
41
What is the treatment of acute cholecystitis ?
- IV fluid.
- Broad spectrum antibiotic ( covers gram negative enteric organisms and anaerobes).
- Analgesia.
- Cholecystectomy is the definitive treatment.
42
What is the best timing of performing laparoscopic cholecystectomy in patients with acute cholecystitis ?
Early cholecystectomy (within 72 hours of onset of illness) is preferred over delayed cholecystectomy (performed 6 -8 weeks after initial medical treatment.
43
How do you deal with acute cholecystitis patients who are medically unfit for surgery ?
- Treat with antibiotics.
- Biliary decompression with cholecystostomy tube placement.
- When they recover remove the tube once the track is mature ( approximately 4 weeks) and a cholangiography through it shows a patent cystic duct.
- Elective laparoscopic cholecystectomy can be scheduled within 4-6 weeks if their medical fitness recovered.
- If they are still unfit but there is complications of acute cholecystitis then damage control surgery is Unavoidable.
44
Which type of stones usually found in primary CBD stones and in secondary CBD stones?
In primary CBD stones: Brown pigment type.
| In secondary CBD stones: Cholesterol stones.
45
What are the causes of biliary stasis that leads to the development of primary CBD stones ?
- Biliary stricture.
- Papillary stenosis.
- Tumors.
- Other secondary stones.
46
How much is the diameter of a dilated common bile duct (CBD) ?
> 8 mm in diameter.
47
Wha is the sensitivity and specificity of MRCP in detecting choldocholithiasis ?
sensitivity : 95%
| specificity : 89%
48
What is the sensitivity and specificity of Endoscopic ultrasound in detecting choldocholithiasis ?
sensitivity : 95 %
| specificity : 97%
49
What is the treatment for a patient with a symptomatic gallstones and suspected common bile duct stones?
Bile duct clearance and cholecystectomy.
Either:
- Preoperative ERCP followed by surgery.
- Intra-operative cholangiogram and common bile duct exploration.
50
What do you call a bile duct stone that was left in place at the time of surgery or diagnosed shortly after the cholecystectomy ?
Retained stone.
51
What do you call a bile duct stone that was diagnosed months or years after cholecystectomy ?
Recurrent stones.
52
How does retained or recurrent bile duct stones best treated ?
Endoscopically:
- A generous sphincterotomy
- Mature T-tube tract (4 weeks). And under fluoroscopic guidance the stone can be retrieved with a basket or a balloon.
- Or by Percutaneous Transhepatic Cholecystostomy PTC/
53
What is the definition of acute cholangitis ?
It is an ascending bacterial infection associated with partial or complete obstruction of the bile ducts.
54
What is the most common cause of obstruction in cholangitis ?
Gallstones .
55
What are the causes of obstruction in cholangitis ?
- Gallstones (most common).
- Primary sclerosing cholangitis.
- Benign and malignant strictures.
- Parasites.
- Instrumentation of the duct.
- Indwelling stent.
- Biliary enteric anastomoses.
56
What is the most common organisms cultured from bile on patients with cholangitis ?
- E.coli
- Klebsiella pneumoniae.
- Streptococcus faecalis
- Enterobacter.
- Bacteriodes fragilis.
57
What is the Charcot's train ?
It is the classic symptoms of cholangitis:
- Fever
- Epigastric or RUQ pain
- Jaundice.
58
What is Reynold's Pentad ?
Cholangitis with septic shock:
- Fever
- Jaundice.
- RUQ pain
- Septic shock
- Altered mental status
59
What are the labs manifestation in acute cholangitis?
- Leucocytosis.
- Hyperbilirubinemia
- Elevation of alkaline phosphatase and transaminase.
60
What could be the findings in ultrasound in patients with cholangitis?
- Presence of gallstones.
- Demonstrate dilated ducts.
- Possibly pinpoint a site of obstruction.
61
What is the initial treatment of patients with cholangitis ?
- Broad spectrum IV antibiotics that covers both enteric and anaerobes.
- Fluid resuscitation.
- Rapid biliary decompression (ERCP and sphincterotomy).
62
What are the alternatives of ERCP in patients with acute cholangitis ?
- PTC
- EUS
- Surgical drainage.
63
Why does cholecystectomy tubes are not indicated in the acute management of cholangitis ?
Because the primary source of the infection is extrinsic to the gallbladder.
64
What is the mortality rate of acute cholangitis ?
5 %
65
When should elective cholecystectomy performed in a patient with acute cholangitis that is causes by gallstones?
6 weeks after the resolution of their cholangitis.
66
What is the mechanism by which obstruction of the pancreatic duct lead to pancreatitis ?
The exact mechanism is unknown, but it may be related to increased ductal pressures causing leakage of pancreatic enzymes into the glandular tissue.
67
How to manage gallstone pancreatitis ?
Initial management: Supportive:
- Bowel rest.
- IVF
- Pain control
In mild and self-limited pancreatitis:
- Cholecystectomy on the same admission once the symptoms are resolved clinically.
In severe pancreatitis :
- ERCP with sphincterotomy and stone extraction (only if supportive management failed).
68
Define gallstone ileus.
Gallstone ileus occur when a large gallstone erodes through the wall of the gallbladder directly into the intestine via a choledochoenteric fistula.
69
What is Bouveret syndrome ?
Refers to a gastric outlet obstruction secondary to impaction of a gallstone in the pylorus or proximal duodenum. Thus, it can be considered a very proximal form of gallstone ileus.
70
What is the most sensitive and specific imaging in gallstone ileus?
CT.
| US may be limited due to extensive bowel gas
71
What is the management of gallstone ileus ?
- Relive intestinal obstruction
- Stone removal:
* In very proximal obstruction: use endoscopy.
* In distal obstruction: surgical enterolithotomy open/laparoscopic. (removal of stone through enterotomy.
- Pursuing cholecystectomy and/or choledochoenteric fistula closure at the time of the enterolithotomy or later is still a topic of debate.
72
What does pyogenic mean ?
Involving or relating to the production of pus.
73
What is cholangiohepatitis ?
It is a recurrent pyogenic cholangitis (RPC) is characterized by a recurrent syndrome of bacterial cholangitis that occurs in association with intrahepatic pigment stones and intrahepatic biliary obstruction.
74
In which decades does cholangiohepatitis mostly occurs ? and affects which gender the most ?
It occurs in the 3rd and 4th decades of life. and affects both sexes equally.
75
Name the most common organisms that causes cholangiohepatitis.
Bacteria:
- E. coli
- Klebsiella species.
- Bacteroides species.
- Enterococcus faecalis
Parasites:
- Clonorchis sinensis.
- Opisthorichis viverrini
- A lumbricoides.
76
What is the common clinical presentation of cholangiohepatitis?
- Pain in RUQ or epigastrium
- Fever
- Jaundice.
77
What are the features of abdominal ultrasound in a patient with a cholangiohepatitis ?
An ultrasound may detect:
- Stones in the biliary tree.
- Pneumbilia )from infection by gas- forming organisms.
- Liver abscess.
- Strictures.
- Thickening of the gallbladder (20%).
78
What is the long term goal therapy in treating cholangiohepatitis?
To extract stones and debris and relieve strictures.
79
When we should consider poor prognosis in cholangiohepatitis ?
When hepatic insufficiency has developed.
80
What is the aim of a cholecystectomy tube ?
It is used to be placed into the gallbladder to compress and drain a distended, inflamed, hydropic, or purulent gallbladder.
81
What is a PTC ?
Percutaneous Transhepatic Cholecystostomy tubes are a pigtail catheters inserted percutaneously under ultrasound guidance.
The catheter is inserted over the a guide wire that has been passed through the abdominal wall, the right lobe of the liver, and into the gallbladder.
82
What should you do before the removal of a percutaneous trans hepatic cholecystostomy ?
You should confirm that the cystic duct is patent by a tube cholangiogram.
83
When was the first successful open cholecystectomy performed and by who ?
In 1987, by a German surgeon Carl Langenbuch.
84
When was laparoscopic cholecystectomy first introduced and by who ?
In 1987, by Philippe Mouret in France.
85
What is the treatment of choice in a symptomatic gallstones and complication of gallstone diseases?
Laparoscopic cholecystectomy
86
what are the absolute contraindications to laparoscopic cholecystectomy?
- Hemodynamic instability.
- Uncontrolled coagulopathy.
- Frank peritonitis.
- Patients with COPD or congestive heart failure (EF<20%) as they might not tolerate the increased intra-abdominal pressures.
87
What are the situations that the conversion of laparoscopic cholecystectomy to open cholecystectomy may be necessary ?
- Unable to tolerate pneumoperitoneum.
- Complications occur that cannot be fixed laparoscopically.
- Important anatomy structures cannot be clearly identified.
- No progress in made over a set period of time.
88
What is the mortality rate for laparoscopic cholecystectomy ?
< 0.1 %
89
How do you position a patient in laparoscopic cholecystectomy procedure ? and where does the surgeon stand ?
- Supine and surgeon stands at the left side of the patient.
| - Split- leg positioning and surgeon stand between the patients legs.
90
What are the techniques used to establish pneumoperitoneum in laparoscopic cholecystectomy procedure ?
- Open technique (Hasson).
- Optical viewing trocar.
- Closed - needle technique (Veress).
91
Where is the typical access region of the abdomen in laparoscopic cholecystectomy procedure ?
Supra-umbilical
| But consider alternate sites if the patient has a previous surgery or scars.
92
What is the next step in laparoscopic cholecystectomy after you established an adequate pneumoperitoneum ?
You insert a 5- or 10- mm trocar in the supreumbilical incision through which a 5- or 10- mm 30 degree laparoscope is introduced.
93
In laparoscopic cholecystectomy, after inserting the laparoscope, how many more ports traditionally is inserted and where ?
3 more ports.
- Epigastrium, 10- or 12- mm port.
- Right midclavicular line, 5- mm port.
- Right flank, 5-mm port.
94
In laparoscopic cholecystectomy , What do you do with the lateral most port ?
The assistant uses a locking instrument to grasp the gallbladder fundus and retract it over the liver edge and upward towards the patient's right shoulder.
95
In laparoscopic cholecystectomy, how can you facilitate the exposure ( I mean what position can help the exposure) ?
Reverse Trendelenburg position with slight tilting of the table to bring the right side up.
96
In laparoscopic cholecystectomy, What is the usage of midclavicular port ?
The surgeon uses a grasper in his left hand to retract the gallbladder infundibulum laterally, and expose the neck of the gallbladder and hepatoduodenal ligament.
In this step you may need to dissect between GB and the momentum, duodenum and colon, using electrocautery, sharp or blunt dissection to reach the infundibulum of the GB.
97
In laparoscopic cholecystectomy, what is the next step after identifying the gallbladder neck and the proximal part of the cystic duct?
Identifying the cystic artery
98
Where is the location of the cystic artery ?
- Parallel to and begin the cystic duct
| - lies behind a prominent lymph node (Lund;s node/ Calot's node).
99
At which point of the laparoscopic cholecystectomy you can perform an intra-operative cholangiogram?
When you identify the 2 and the only 2 structures going into the gallbladder ( the cystic duct and the cystic artery).
100
In laparoscopic cholecystectomy, What is the next step after identifying the cystic duct and the cystic artery ?
Apply 2 clips at the base and one clip on the gallbladder side on both cystic artery and duct.
101
In laparoscopic cholecystectomy, What do you do if the cystic duct is very dilated and too large for clips ?
It's managed by one of :
- Ligation with endoloop.
- Laparoscopic staplers.
- Suture closure.
102
In laparoscopic cholecystectomy, from which incision you should remove the gallbladder ?
Either from the epigastric or umbilical incision with the aid of a retrieval bag.
103
In laparoscopic cholecystectomy, when do you put. drain, and where and which type of drain ?
You place a drain if:
- Gallbladder was severely inflamed or gangrenous.
- Any bile or blood is expected to accumulate.
You place a closed-suction drain through one of the 5- mm ports and left underneath the right liver lobe close to the gallbladder fossa.
104
How to make an incision in open cholecystectomy ?
Either through midline laparotomy or right subcostal incision.
105
What are the boundaries of the triangle of Calot (hepatocystic triangle) ?
- Common hepatic duct.
- Cystic duct
- Liver margin
106
In laparoscopic cholecystectomy, what is the purpose of intraoperative cholangiogram ?
To:
- Evaluate the extra-hepatic bile ducts.
- Identify common bile duct stones.
- Clarify ductal anatomy
107
aparoscopic cholecystectomy, when should selective intra-operative cholangiogram be performed
- When a patient has a history of abnormal liver function tests.
- Pancreatitis.
- Jaundice.
- A large duct and small stones.
- A dilated duct on preoperative ultrasound.
- If preoperative endoscopic cholangiography was unsuccessful.
108
What are the types of biliary enteric anastomoses ?
- Choledochodudenostomy.
- Choledochojejunostomy.
- Hepaticojejunostomy.
109
What is the meaning of biliary dyskinesia ?
Disorders affecting the normal motility and function of the gallbladder and sphincter of Oddi,
110
How to diagnose biliary dyskinesia ?
By HIDA scanning , when gallbladder ejection fraction is less than 35 % ( EF < 35 %).
111
What is the definition of Acalculous Cholecystitis ?
It is an acute inflammation of the gallbladder that occurs in the absence of gallstones.
112
Whose at risk of having Acalculous cholecystitis ?
Critically ill patients in the ICU:
- Patients on parenteral nutrition.
- Extensive burns.
- Sepsis.
- Major operations.
- Multiple trauma.
- Prolonged illness with multiple organ system failure.
113
What is the cause of Acalculous cholecystitis ?
the cause is unknown, but the causative factors are:
- Gallbladder distension.
- Bile stasis.
- Ischemia.
114
What i the diagnostic test of choice in Acalculous cholecystitis ? and what are the features found in that test ?
Ultrasonography:
- Distended gallbladder with thickened wall.
- Biliary sludge.
- Pericholecystic fluid.
- Presence or absence of abscess.
115
What is the treatment of Acalculous cholecystitis ?
- Early broad spectrum antibiotics.
- Fluid resuscitation.
- If stable: laparoscopic cholecystectomy.
- If unstable/unfit for surgery : percutaneous cholecystostomy tube (90% of patients improve. And discuss laparoscopic cholecystectomy after recovery (Not strictly required on the absence of gallstones).
116
What is the definition of Choledochal (biliary) cysts ?
It is a congenital cystic dilatations of the extra hepatic and/or intrahepatic biliary tree.
117
What is the clinical triad of Choledochal (biliary) cysts ?
1. Abdominal pain.
2. Jaundice.
3. Palpable mass.
118
What is the study of choice in Choledochal (biliary) cysts?
- US or CT will confirm the diagnosis.
| - ERCP or MRCP are essential to assess the biliary anatomy and to plan the appropriate surgical treatment.
119
What is the risk of having Choledochal (biliary) cysts ?
There is a 20 - 30 fold higher chance of developing cholangiocarcinoma.
120
Classification of Choledochal (biliary) cysts ?
- Type 1: Fusiform or cystic dilation of the extra-hepatic biliary tree.
- Type 2: Saccular diverticulum of an extra-hepatic duct.
- Type 3 : Bile duct dilatation within the duodenal wall (Choledochoceles)
- Type 4 a: Multiple cysts affects both into-hepatic and extra-hepatic bile ducts.
- Type 4 b: Multiple cysts affects extra-hepatic bile ducts only.
- Type 5: Intrahepatic biliary cysts. (Caroli disease).
121
What is Caroli disease ?
It is a intrahepatic biliary cysts, very rare and makes up 1% of choledochal cysts.
122
What is the most common type of Choledochal (biliary) cysts ?
Type 1: Fusiform CBD dilation (Fusiform or cystic dilation of the extra-hepatic biliary tree).
123
Which type of Choledochal (biliary) cysts has the highest risk of malignancy?
Type 1: Fusiform CBD dilation (Fusiform or cystic dilation of the extra-hepatic biliary tree).
Risk > 60 %
124
What is the treatment of type 1 and type 2 Choledochal (biliary) cysts ?
Excision of the cystic dilations in the extra-hepatic biliary tree, including cholecystectomy, with either simple cyst excision or duct resection with Roux-en-Y hepatojejuonostomy is ideal.
125
What is the treatment of Choledochal (biliary) cysts Type3 ?
Pancreaticoduodenectomy.
126
What is the treatment of Choledochal (biliary) cysts Type 4a and type 4b?
Excision of all cystic tissue and reconstruction.
```
IF the liver in type 4b has:
- Intrahepatic stones.
- Intrahepatic stricture.
- Intrahepatic abscess
then do segmental resection of the liver.
```
127
What are the complications of Choledochal (biliary) cysts Type 5?
- liver cirrhosis
- Liver failure
which may require liver transplantation.
128
Define Primary Sclerosing Cholangitis (PSC).
It is an uncommon disease characterized by inflammatory strictures involving the intrahepatic and extrahepatic biliary tree.
129
What are the causes of secondary sclerosis cholangitis?
- Bile duct stones.
- Acute cholangitis.
- Previous biliary surgery.
- Toxic agents.
130
What is the pathogenesis of Primary Sclerosing Cholangitis (PSC) ?
Not clear, but the following were suggested to play a role in the pathogenesis:
- Autoimmune reactions.
- Chromic low grade bacterial or viral infection.
- Toxic reactions.
- Genetic factors.
131
What are the autoimmune diseases that are commonly associated with Primary Sclerosing Cholangitis (PSC) ?
- Ulcerative colitis.
- Riedel's thyroiditis.
- Retroperitoneal fibrosis.
132
Which Human Leukocyte antigen haplotypes are usually found in patients with autoimmune diseases including Primary Sclerosing Cholangitis (PSC) ?
- HLA- B8
- HLA- DR3.
- HLA- DQ2.
- HLA- DRw52A.
133
What are the symptoms and signs of Primary Sclerosing Cholangitis (PSC) ?
- Intermittent jaundice.
- Fatigue
- Weight loss.
- Pruritus.
- abdominal pain.
- Elevated liver function test.
134
How to confirm the diagnosis of Primary Sclerosing Cholangitis (PSC) ?
By ERCP:
| revealing multiple dilatations and strictures (beading) of the intra- and extra- hepatic biliary tree.
135
Why liver biopsy is important in patients with Primary Sclerosing Cholangitis (PSC) ?
To determine the degree of hepatic fibrosis and the presence of cirrhosis. And to evaluate for the development of complications such as strictures and cancers.
136
What is the treatment of Primary Sclerosing Cholangitis (PSC) ?
No known curative treatment. Medical management is largely supportive.
Surgical Mx:
- In patients without cirrhosis or significant hepatic fibrosis:
Resection of the extrahepatic biliary tree and hepaticojejunostomy.
- In patients with advanced liver disease:
Liver transplantation is the only option. (There is a 10-20% chance of recurrence).
137
What are the causes of bile duct strictures ?
1. Operative injury ( usually during cholecystectomy) (MOST COMMON).
2. Fibrosis due to chronic pancreatitis.
3. Common bile duct stones.
4. Acute cholangitis.
5. Biliary obstruction due to cholecystolithiasis (Mirizzi's syndrome).
6. Sclerosing cholangitis.
7. Cholangiohepatitis.
8. Strictures of a biliary- enteric anastomosis.
138
What are the complications of bile duct strictures that are unrecognized or managed improperly?
- Portal hypertension.
- Recurrent cholangitis.
- Secondary biliary cirrhosis.
139
What is the treatment of bile duct strictures ?
Percutaneous or endoscopically dilatation and/or stent placement.
- In persistent or complex strictures: surgical resection and reconstruction with Roux - en - Y choledochojejunostomy or hepaticojejunostomy.
140
What is the treatment of choice in gallbladder injuries?
Cholecystectomy
141
When does extra-hepatic ducts injuries occur ?
- Iatrogenic:
* Cholecystectomy (most common).
* Common bile duct exploration.
* Division or mobilization of the duodenum during gastrectomy.
* Dissection of the hepatic hilum during liver resection.
- Rarely, penetrating trauma.
142
What are the factors associated with bile ducts injuries during laparoscopic cholecystectomy ?
- Obesity.
- Acute / chronic inflammation.
- Surgical technique.
- Anatomic variation.
- Inadequate exposure (common)
- Failure to correctly identify structures before ligating or dividing them (common).
143
What are the complications of bile duct injuries ?
- Leaks
| - Obstruction related to stricture.
144
What is biloma ?
Fluid collection in the gallbladder fossa.
145
What are the co-morbidities associated with bile ducts repair ?
- Cholangitis.
- External biliary fistula.
- Bile leak.
- Subhepatic and subphrenic abscess.
- Hemobilia
