Hepato-Biliary Surgery Flashcards
In what quadrant in the gall bladder in?
Right hypochrium
How is the gall bladder peritonised?
Intraperitoneal
Name different parts of the gallbladder
Fundus, body and neck
Name three function of the gall bladder
- Bile Reservoir
- Concentrated bile
- Secretes bile after meal: stimulated by CCK
Name three common pathologies of the gallbladder
• Gallstones
Other:
• Cholesterosis
• GB polyps
What is cholesterosis?
A change in the gallbladder wall due to excess cholesterol
What is the composition of gallstones?
- Mixed (>50% cholesterol)
- Cholesterol
- Pigment
Name four risk factors for formation of gallstones
- Female
- Parity (no. of times pregnant) + oral contraceptive pill (OCP)
- Cholesterol
- Pigment: haemolytic anaemia, bile infection (e. coli)
What is the presentation of gallstones?
- Asymptomatic
- Dyspeptic symptoms (flatulent dyspepsia)
- Biliary colic
- Acute cholecystitis
- Empyema (not treated perforate peritonitis)
- Perforation
- Jaundice (Mirrizi’s syndrome)
- Gallstone Ileus
List the investigations used for gallstones
• Blood tests: o LFTs: AST, ALT, ALP o Amylase, lipase • USS • EUS • Oral cholecystography • CT • Radio isotope scan • MRCP • PTC* • ERCP*
*not used to diagnose as risk of perforation and infection high
What is an ERCP?
A bendable, lighted tube (endoscope) placed through your mouth and into your stomach and duodenum
What is PTC investigation?
Percutaneous transhepatic cholangiography -
this procedure is similar to the ERCP and takes X-ray images of the bile duct
What are the three different types of treatment options used for gallstones?
- Asymptomatic -> no treatment
- Non-operative
- Operative
What are the non-operative options used to treat gallstones?
- Dissolution – only palliative as if young then have to have meds all of life
- Lithotripsy – ultrasound shock waves break stones into smaller particles
What are operative options used to treat gallstones?
• Laparoscopic cholecystectomy +/- OTC (on-table cholangiogram)
- Open cholecystectomy
- Mini-cholecystectomy
- Single port cholecystectomy
- NOTES cholecystectomy
- Cholecystectomy
What is the management of common bile duct stones?
- Expectant treatment
- Lap trans-cystic CBD exploration
- Lap exploration of CBD
- Open exploration of CBD
- ERCP: pre-op, intra-op, post-op
- Transhepatic stone retrieval
What are congenital benign biliary tract disease?
- Biliary atresia
* Choledochal cysts
Name causes of benign biliary strictures
• Iatrogenic • Gallstone related (Mirrizi’s) • Inflammatory: o Pyogenic o Parasitic o PSC o Pancreatitis o HIV
Name two malignant tumour which cause jaundice
- Cholangiocarcinoma
* Cancer of the Head of Pancreas
Name risk factors for cholangiocarcinoma
- Primary Sclerosing Cholangitis
- Congenital cystic disease
- Biliary-enteric drainage
- Thorotrast
- Hepatolithiasis
- Carcinogens: aflatoxins
What are the main types of cholangiocarcinoma?
- Intrahepatic
- Extrahepatic (commonest): hilar and distal
- Gallbladder cancer
- Ampullary cancer
What are the three types of intrahepatic cholangiocarcinoma?
- Mass forming
- Peri-ductal
- Intra ductal
Surgery is only option
Describe the presentation of cholangiocarcinoma
- Obstructive jaundice
- Itching
- Non-specific symptoms
What investigations are used for cholangiocarcnoma
- Radiology: USS, EUS, CT, MRS, MRCP, PTC, angiography, FCG PET
- ERCP, cholangioscopy and cytology
Describe the management of cholangiocarcinoma
Surgical: only potential curative option
Palliative: • Surgical bypass • Stenting • Radiotherapy • Chemotherapy • PDT (activating drug by light source to kill cancer cells) • Liver transplant (rare)
What are treatment options for ampullary tumours
- Endoscopic excision
- Trans-duodenal excision
- Pancreatico-duodenectomy
