Gen surg: gallbladder - cholangitis, cholecystitis, biliary colic, cancer

Question 1

What are the RF for gallbladder carcinoma??

Answer 1

Hx of gallstones or chronic cholecystitis

Porcelain gallbladder
Smoking
Obesity
Primary sclerosing cholangitis
UC/crohns colitis
Oestrogens
Occupational exposure

Question 2

How does gallbladder carcinoma present?

Answer 2

Usually presents late with vague symptoms of abdo pain

Question 3

A patient comes in with jaundice, upon investigation, the cause is post- hepatic. What are your ddx?

Answer 3

acute cholangitis, cholecystitis, bile duct strictures, obstructive choledocholithiasis, external compression from extra- billiard tumour, pancreatic tumour, primary biliary cirrhosis and primary sclerosing cholangitis

Question 4

What conditions increase risk of anal carcinoma?

Answer 4

HPV, Chrons, HIV

Question 5

What are the symptoms of gallstone disease?

Answer 5

Can be asymptomatic
RUQ pain
Biliary colic
Nausea
Vomitting
Pale urine
Dark stools
Fever
Jaundice

Question 6

What are the risk factors of gallstone disease?

Answer 6

Fair, fat, forty, family history, fertile
Poor diet
Oral contraceptives
Pregnancy
Malabsorption
Ethnicity- Native American and hispanic

Question 7

What is biliary colic?

Answer 7

Stone is temporarily obstructing the neck of the gall bladder, impeding drainage

Question 8

What is the most likely picture of LFTs when a patients presents with biliary colic?

Answer 8

Raised ALP, raised bilirubin

Question 9

What is the first line investigation for patients who have suspected gallstone disease?

Answer 9

Ultrasound (trans abdominal)- helpful in identifying any gallstones in the gallbladder, gallstones in the ducts, bile duct dilatation, acute cholecystitis (thicken GB wall, or sludge in the gallbladder with fluid around the gallbladder)

Question 10

What is the indication of MRCP in suspected gallstone disease?

Answer 10

Investigate further if ultrasound doesn’t show the presence of stones, but there is dilatation of the bile duct or raised bilirubin which suggests obstruction

Question 11

What is acute cholecystitis?

Answer 11

Gallstone blocking the cystic duct or neck of the gallbladder causing the gallbladder to become inflamed.

Question 12

What are the signs and symptoms of acute cholecystitis?

Answer 12

Pain in the RUQ
Fever
Nausea
Vomiting
Tachycardia and tachypnoea
Murphy’s sign positive

Question 13

What is Murphy’s sign?

Answer 13

Hand on the RUQ and apply pressure, ask patient to take a deep breath in, the gallbladder will move downwards and come in contact with your hand and cause pain for the patient.

Question 14

What is the first line investigation for acute cholecystitis?

Answer 14

Abdo ultrasound showing thickened gallbladder wall, stones or sludge in gallbladder, fluid around the gallbladder

Question 15

What is the management of acute cholecystitis?

Answer 15

Conservative includes, Nil by mouth, Co-amoxiclav +/- metronidazole, antiemetics

Laproscopic cholecsytectomy is performed usually during the acute admission (within 72 hours) and sometimes delayed by 6-8 weeks to allow for the inflammation to subside

Question 16

What is acute cholangitis?

Answer 16

Biliary outflow obstruction and infection
Due to gallstone which fully stops bile flow, causing stasis and then infection
ERCP, infection introduced

Question 17

What is Charcot’s triad?

Answer 17

Presentation of acute cholangitis
RUQ pain
Fever
Jaundice

Question 18

What are the most common organisms causing acute cholangitis?

Answer 18

Escherichia coli
Klebsiella species
Enterococcus species

Question 19

How would a patient with acute cholangitis behave on examination?

Answer 19

Confused
RUQ tenderness
Jaundice
Hypotension
Tachycardic

Question 20

Why is acute cholangitis a surgical emergency?

Answer 20

Due to the risk of sepsis and septicaemia

Question 21

What would investigations find in acute cholangitis?

Answer 21

FBC- leukocytosis
LFTs-elevated ALP +/- GGT & bilirubin
blood cultures - not always positive

ultrasound buliary tract - duct dilation

Question 22

How is acute cholangitis managed?

Answer 22

risk of sepsis- fluid resuscitation, routine bloods,
blood cultures, broad spectrum Abx
(co-amoxiclav + metronidazole)

definitive managment:
endoscopic biliary decompression using ERCP
cholecystectomy maybe required if
gallstones the underlying cause

Question 23

What is a cholangiocarcinoma?

Answer 23

Cancer of the biliary system

Question 24

What is a Klaskin tumour?

Answer 24

A tumour at the bifurcation of the L and R hepatic duct. It is a slow growing tumour which invades local lymph nodes

Question 25

What are the risk factors for cholangiocarcinoma?

Answer 25

Primary scerlosing cholangitis
UC
Infective causes (liver flukes, HIV, hep)
Airplane and rubber fumes
Congential
Alcohol excess
DM

Question 26

What are the clinical features of cholangiocarcinoma?

Answer 26

usually asymptomatic until later stages
post hepatic jaundice
pruritus
pale stools and dark urine

Less commonly- RUQ pain, early satiety, weight loss, anorexia and malaise

Question 27

How does cholangiocarcinoma present on examination?

Answer 27

Jaundice and cachexia and courvoisiers rule applies

Question 28

What is courvoisiers law?

Answer 28

Palpable gallbladder with painless jaundice–> pancreatic or biliary pathology should be suspected

Question 29

What do you expect to be present on LFTs in a cholangiocarcinoma?

Answer 29

Obstructive jaundice, elevated bilirubin, ALP, y gamma transferase

Question 30

What is the gold standard imaging for cholangiocarcinoma?

Answer 30

MRCP
ERCP can be used to obtain samples

Question 31

What is the most common aim of treatment with cholangiocarcinoma?

Answer 31

Palliative

Question 32

What is the definitive cure of cholangiocarcinoma?

Answer 32

Surgery

Question 33

How do you treat a Klaskin tumour?

Answer 33

Partial hepatectomy and reconstruction of biliary tree

Question 34

What are the palliative treatment options for cholangiocarcinoma?

Answer 34

Stenting- to relieve the obstruction
Bypass surgery- to bypass the obstruction, stenting doesn’t work
Palliative radiotherapy- to prolong survival some chemo agents may be used with radiotherapy

Question 35

What are some conditions that can predispose you to hepatocellular carcinoma?

Answer 35

Viral hep B and c
Hereditary haemochromatosis
Primary biliary cirrhosis

Question 36

What are some risk factors for hepatocellular carcinoma?

Answer 36

Male
Over 70
Fhx liver disease
High alcohol intake
aflatoxin poisoining
smoking
viral hep b and c

Question 37

How do patients with hepatocellular carcinoma present?

Answer 37

Similar to liver cirrhosis
Vague and non-specific symptoms: leathery, weight loss, fatigue, fever
Dull ache in RUQ is uncommon but if present can be suspicious of malignancy

Question 38

What are the examination findings of a patient with hepatocellular carcinoma?

Answer 38

Large, craggy, tender and irregular liver–>v suggestive of malignancy

Question 39

What are the blood abnormalities in a patient with hepatocellular carcinoma?

Answer 39

LFTs deranged
Low platelets and clotting due to liver failure
Alpha fetoprotein should be measure as is raised in 70% of cases, and is good indication of treatment progress

Question 40

What investigative imaging do you use in hepatocellular carcinoma?

Answer 40

US. Mass >2cm, with raised alpha fetoprotein (AFP) is virtually diagnostic of hepatocellular carcinoma

Rising AFP with nodular liver–> MRI

Question 41

What is the name of the staging criteria for hepatocellular carcinoma?

Answer 41

Barcelona Clinic (no need to know the different stages_)

Question 42

When can transplantation be considered in hepatocellular carcinoma?

Answer 42

Milan Criteria is used and needs to be fulfilled:
One lesion less than 5cm or 3 lesions are smaller than 3 cm
No extra hepatic manifestations
No vascular infiltration

Question 43

When would surgery be indicated in a patient with hepatocellular carcinoma?

Answer 43

Good baseline function and no cirrhosis

Question 44

What are the non-surgical treatment options fo hepatocellular carcinoma?

Answer 44

Image guided ablation- low grade tumours
Alcohol ablation

Transarteril chemoembolisation

Question 45

Which organs metastasise to the liver most frequently?

Answer 45

bowel, breast, stomach, pancreas and lung

Question 46

What is a rare but serious complication of gallstone disease?

Answer 46

Gallstone ileus

Question 47

What is gallstone ileus?

Answer 47

Gallstone passing into the intestinal system via a biliary-enteric fistula causing distal obstruction

Question 48

Differentials for RUQ pain?

Answer 48

Biliary colic
Acute cholangitis
Acute cholecystitis