Hepato-Biliary Surgery Flashcards by Annie Caldwell

What is the commonest condition of the gallbladder?

Gallstones

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What is an important risk factor for developing gallbladder cancer?

Polyps

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Definition of cholesterolosis

Gallbladder wall changes due to excess cholesterol

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What appearance does the gallbladder have in cholesterolosis?

Strawberry gallblader

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What % of gallstones are symptomatic?

10-30%

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What are gallstones made up of?

Mixed stones
Cholesterol
Pigment

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What % of mixed stones make up all gallstones?

80%

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What % do cholesterol and pigment stones make up of gallstones?

20%

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Risk factors for gallstones

Age
Gender
Parity + OCP = the 4Fs

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Risk factors for cholesterol gallstones

obesity 
ileal disease
cirrhosis
CF
DM
TPN
heart transplant 
delayed GB emptying
clofibrate 
long term low fat diet

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Risk factors for pigment gallstones

Haemolytic anaemia
Bile infection
- E coli
- Bacteroides

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Presentation of gallstones

Asymptomatic 
Dyspeptic symptoms (flatulent dyspepsia)
Bloating after eating 
Biliary colic 
Acute cholecystitis 
Empyema / perforation 
Jaundice
Gallstone ileus

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What is biliary colic?

Pain typically after having a meal / early hours of morning after dinner
Upper abdomen
Often also nausea and vomiting

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Where is the pain in acute cholecystitis?

Right upper quadrant

Can be quite tender

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What does perforation of the gallbladder result in?

Free gas in the abdomen due to the hole

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What is Mirrizi’s syndrome?

Stone stuck in the neck of the gallbladder obstructing the common hepatic duct - resulting in jaundice

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What is gallstone ileus?

Stone climbs into the bile duct and duodenum

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Definition of choledocho-lithiasis

Gallstones in the common bile duct

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Presentation of choledocho-lithiasis

Obstructive jaundice
- pain 
- jaundice
- dark urine
- pale stool 
- pruritis 
- steatorrhoea 
Acute pancreatitis 
Ascending cholangitis
Rigors
Fever

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What is charcots triad?

Rigors
Fever
Ascending cholangitis

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Investigations for gallstones

LFTs; AST, ALT, ALP
Amylase, Lipase
WCC
USS
EUS
Oral cholecystography 
Radio isotope cscan 
IV cholangiography 
MRCP 
PTC
ERCP

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What is the first line investigation of gallstones?

USS

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Treatment of gallstones

Dissolution
Lithotripsy
Surgery
- cholecystectomy

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What is a cholecystostomy?

Drainage of the gallbladder

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What does ERCP stand for?

Endoscopic Retrograde Cholangio-Pancreatography

Examples of congenital benign biliary tract diseases

Biliary atresia | Choledochal cysts

Causes of a benign biliary stricture

``` Iatrogenic Gallstone related (Mirrizi's) Pyogenic Parasitic PSC Pancreatitis HIV ```

What is biliary atresia?

Bile duct or cystic duct have failed to form

What do choledochal cysts carry the risk of? What is the lifetime risk of this?

Cancer malformation | Lifetime 10% cancer risk

What classification is used for iatrogenic bile duct injuries?

Strasberg classification

What does PSC stand for?

Primary sclerosing cholangitis

What is a biliary enteric fistula?

Fistula between gallbladder and organs that surround it

What is a cholangiocarcinoma?

Bile duct cancer

Types of cholangiocarcinoma

``` Intrahepatic 6% Extrahepatic - hilar 67% - distal 27% Gallbladder cancer Ampullary cancer ```

How common is gallbladder cancer?

Very rare

What is the peak age for a cholangiocarcinoma?

80 y/o

Risk factors for cholangiocarcinoma

``` PSC Congenital cystic disease Biliary enteric drainage Thorotrast (contrast) Hepatolithiasis Carcinogens e.g. aflatoxins ```

What does a cholangiocarcinoma have the strongest association with?

PSC

Types of intra hepatic cholangiocarcinoma

Mass forming Peri ductal Intra ductal

Presentation of cholangiocarcinoma

Obstructive jaundice Itching Non -specific symptoms (not feeling right)

Investigations for cholangiocarcinoma

``` USS EUS CT MRA MRCP PTC Angiography FDG PET ```

What would be raised in cholangiocarcinoma?

Bilirubin | Phosphates

Treatment of cholangiocarcinoma

Surgery | Palliative

What do 90% of gallbladder cancers have?

Existing gallstones

Prognosis of gallbladder cancer

Very poor | Aggressive

Types of ampullary tumours

Adenoma | Adenocarcinoma

Treatment of ampullary tumours

Endoscopic excision Trans duodenal excision Pancreatico-duodenoectomy

Function of the gallbladder

Bile reservoir Concentrates bile Secretes after meal (CKK)

What does ERCP stand for?

Endoscopic retrograde cholangiopancreatography

What is ERCP for?

Procedure to see the pancreatic and bile ducts

What % of ERCP are done for gallstones?

85%

What % of ERCP are done for malignancy?

25%

What does MRCP stand for?

Magnetic resonance cholangiopancreatography

What does a MRCP show?

MRI for the biliary tree

What is done in ERCP?

Travels to second part of the duodenum, to ampulla and sphinter of oddi, then cannulate, which will pass the stone out

What does EUS show?

Walls Bile ducts Any stones

What is the spinchter of oddi?

An area where the pancreatic duct and common bile duct empty into the duodenum

What happens if there is a stone proximal to the pancreatic duct?

Digestive enzymes build up in the pancreas These eat the pancreas Causes acute pancreatitis

Functions of the biliary system

Drain waste products from liver into duodenum | Help in digestion with the controlled release of bile

Function of bile

Breaks down fats and vitamins during digestion | Carry away waste

What is bile made up from?

Waste products Cholesterol Bile salts

What is the ratio of cholesterol to bile salts in gallstones? What happens If this ratio is disturbed?

1 : 25 | Gallstones are formed

What hormone does the gallbladder respond to at mealtimes?

CCK

Why is bile stored in the gallbladder normally?

So that the bile does not constantly drip into the duodenum when there is no food present

Complications of gallstones

``` Cholecystitis Cholestasis Jaundice Cholangitis Pancreatitis Billiary cirrhosis ```

What would fluroscene show in the biliary tree and why?

If obstruction or strictures | These areas would not fill as well

Pathology of cholecystitis

Inflammation of the gallbladder | Due to stone in the exit of the gallbladder or if it enters the cystic duct

What is cholestasis?

Stoppage of bile flow from the liver to the duodenum

Pathology of cholestasis

Stone blocking the common bile duct

What is cholangitis?

Inflammation of the bile ducts outside of the liver due to bacterial infection of stagnant bile

How does pancreatitis occur as a complication of gallstones?

Stone blocking the pancreatic duct or the spinchter of oddi

What can cholangitis lead to?

Hepatitis

Pathology of biliary cirrhosis

Inflammation and obstruction of the bile ducts inside the liver Leads to liver cirrhosis As obstructs other liver cells

What would gallstone ileus show on an AXR?

SBO and air in the biliary tree