Hepato-biliary surgery

Question 1

what is the function of the gallbladder

Answer 1

Bile reservoir

Concentrates bile

Secretes after meal
- CCK

Question 2

name some benign conditions of the gallbladder

Answer 2

gallstones
cholesterosis
GB polyps

Question 3

what is the composition of gallstones

Answer 3

Mixed(>50% cholesterol) make up 80%

other 20%:
Cholesterol
Pigment

Question 4

what are risk factors for gallstones

Answer 4

Age
Gender
Parity + OCP (4F)

Cholesterol: obesity, ileal disease, cirrhosis, cystic fibrosis, DM, TPN, heart transplant, delayed GB emptying, clofibrate, long-term low-fat diet

Pigment (far east): M=F, haemolytic anaemia, bile infection (e-coli, Bacteroides)

Question 5

how do gallstones present

Answer 5

Asymptomatic

Dyspeptic symptoms (flatulent dyspepsia)

Biliary colic - stretch pain – foregut pain in upper abdomen – nausea, vomiting, radiating to shoulder

Acute cholecystitis

Empyema

Perforation

Jaundice (Mirrizi’s Syn.) - from stone stuck in neck of gallbladder, perforated gall bladder

Gallstone Ileus

Question 6

what is choledocholithiasis

Answer 6

the present of gallstones in the common bile duct

Question 7

how can choledocholithiasis present

Answer 7

Incidental at cholecystectomy

Post-cholecystectomy pain

Pain, jaundice, dark urine, pale stool, pruritus, steatorrhoea

Question 8

what can choledocholithiasis cause

Answer 8

Obstructive jaundice (painful)

acute pancreatitis

ascending cholangitis

Question 9

what are the investigations for gallstones

Answer 9

Blood tests:
LFT’s: AST, ALT, ALP
Amylase, Lipase
WCC

USS
EUS
Oral cholecystography
CT scan
Radio iso-tope scan (HIDA)

IV cholangiography
MRCP
PTC
ERCP

Question 10

what is the non-operative management for gallstones

Answer 10

Dissolution

Lithotripsy

Question 11

what is the operative management for gallstones

Answer 11

Open cholecystectomy

Mini-cholecystectomy

Laparoscopic cholecystectomy +/- OTC “Gold Standard”

Single port cholecystectomy

NOTES cholecystectomy

Cholecystostomy

Subtotal Cholecystectomy

Question 12

what is the management of common bile duct stones

Answer 12

Expectant treatment (incidental)

Lap trans-cystic CBD exploration

Lap exploration of CBD

Open exploration of CBD

ERCP

• Pre-op
• Intra-op
• Post-op

Transhepatic stone retrieval

Question 13

what are the types of benign biliary tract disease

Answer 13

congenital

• atresia
• choledochal cysts

benign biliary stricture

• iatrogenic
• gallstone related (Mirrizis)
• inflammatory

Question 14

what are the different tumours that can cause jaundice

Answer 14

Cholangiocarcinoma:

• Intrahepatic 6%
• Extrahepatic
• Gallbladder Cancer
• Ampullary Cancer

Cancer of the Head of Pancreas

Question 15

what are risk factors for cholangiocarcinoma

Answer 15

PSC (strong association)

Congenital cystic disease

Biliary-enteric drainage

Thorotrast (contrast)

Hepatolithiasis

Carcinigens: aflatoxins, etc

Question 16

what are the three types of cholangiocarcinoma

Answer 16

mass forming
peri-ductal
intra-ductal

Question 17

what is the treatment for cholangiocarcinoma

Answer 17

surgery the only potential curative option

palliative - including surgical bypass, stunting, radiotherapy, chemotherapy

Question 18

what is the presentation of cholangiocarcinoma

Answer 18

Obstructive jaundice
Itching
None-specific symptoms

Question 19

what investigations can be done for cholangiocarcinoma

Answer 19

Lab

Radiology: USS, EUS, CT, MRA, MRCP, PTC, Angiography, FDG PET

ERCP, Cholangioscopy and Cytology

Question 20

what does the treatment for gall bladder cancer depend on

Answer 20

stage of cancer

Question 21

what are the two types of ampullary tumours

Answer 21

adenoma

adenocarcinoma

Question 22

what are the treatment options for ampullary tumours

Answer 22

Endoscopic excision
Trans-duodenal excision
Pancreatico-duodenectomy