HBP surgery Flashcards
Borders of Calot’s triangle
Medial - common hepatic duct
Inferior - cystic duct
superior - inferior surface of liver
Contents of Calot’s triangle
Right hepatic artery
cystic artery
lymph node of Lund
What are the ducts of luschha?
The small ducts draining bile from the liver directly into the gallbladder
What artery is susceptible to injury in a cholecystectomy?
Right hepatic
Why dark urine with obstructive jaundice?
Increased conj bilirubin in serum is water soluble and is excreted in urine
Need to visualise biliary tract. Imaging of choice?
US - trans abdominal or endoscopic
ERCP
define obstructive jaundice
Jaundice ( hyperbilirubinaemia >2.5) from obstruction of bile flow to the duodenum
most common type of gallstones
Cholesterol stones 75%
pigmented 25%
What proportion of people with gallstone disease are asymptomatic?
80%
Imaging for suspected choledocholithiasis
MRCP
Imagine for gallstone cholecystitis / biliary colic / acute cholecystitis
US
Indications for cholecystectomy in asymptomatic patients
Sickle cell disease
Calcified / porcelain GB because risk of carcinoma
Child
Complication of ERCP
5% risk of pancreatitis
Management of choledocholithiasis
ERCP w papillotomy + balloon retrieval of stones
Murphy’s +ve
Acute cholecsystitis
not usually choledocholithiasis
Risk factors for calculus cholecystitis
Prolonged fasting TPN Trauma Multiple transfusions Dehydration Prolonged post-op or ICU
Most common cause of cholangitis
Choledocholithiasis
What is Charcot’s Triad?
S&S of cholangitis
- fever / chills
- RUQ pain
- Jaundice
Reynolds Pentad
Charcots + altered mental status + shock
Management of cholangitis
non suppurative - IVFluids + abx suppurative - IV fluids + abs + decompression ERCP w/ papillotomy PTC with catheter drainage Lap w/ T tube placement
Most common type of gallbladder cancer
Adenocarcinoma
Prognosis of GB carcinoma
if T1 and early resection 95% 5yr survival
but most are asymptomatic and present late as unresecable so <5% 5yr survival
Importance of spread of GB cancer to the muscluaris / serosa
tx will be radical cholecystectomy + wedge resection of overlying liver + lymph node disection ± chemo/radio tx
Needed for definitive diagnosis of acute cholecystitis
All three of
A. local signs of inflammation ( RUQ pain / mass/ Murphys)
B. Systemic signs of inflammation ( fever, CRP, WCC)
C. image findings
timing of cholecystectomyoperation
early 24-72hrs
delayed 6-12wks
Classic site for gallstone ileus to obstruct
gallstone ileus is most common in ?
Ileocaecal valve
women >70yrs
Air in biliary tract on abdo Xray is…
Gallstone ileus
Signs of gallstone ileus on xray
gallstone in bowel
air in biliary tract
small bowel distension
air fluid levels
CT findings of gallstone ileus
Air in biliary tract
SBO
± gallstone in the bowel
What type of IBD is most commonly associated with sclerosing cholangitis
Ulcerative colitis
complications / sequelae of sclerosis cholangitis
cirrhosis + liver failure
10% develop cholangiocarcinoma
How does sclerosis cholangitis manifest
Often asymptomatic
but may present as obstructive jaundice w. weight lots and fatigue
Beads on a string dx
sclerosis cholangitis seen with PTC or ERCP with contrast
management options for sclerosing cholangitis
- Resection of extra hepatic bile ducts + hepatoenteric anastomosis
- Transplant if dx is primarily intra-hepatic or cirrhosis
- Endoscopic balloon dilations
