Hepato-biliary surgery Flashcards
Across the many different anatomical variations, arteries can do what?
go/lie pretty much anywhere they want
What is the most common disease/ surgical problem of the Gallbladder?
Gallstone disease
What is Cholesterolosis in the gallbladder? and how does the mucosa appear?
There is a buildup of cholesterol esters and they stick to the wall of the gallbladder forming polyps.
‘strawberry gallbladder’ - red with small yellow dots
with Gallbladder polyps, at what size should a polyp be removed?
a polyp bigger than 1cm should not stay there. 0-0.5 cm is good.
true or false? you can have gallstones without gallbladder disease
true
What is a gallstone made up of?
most commonly it is mixed cholesterol and pigment
or you can get cholesterol and pigment ones on their own
Risk factors for gallstones
age
gender 9:1 - f:m
cholesterol - obesity, cirrhosis, CF, diabetes, heart transplant
pigment - m=f, haemolytic anaemia (more blood in stools), bile infection like e.coli
how does a patient present with gallstones (7)
asymptomatic 70%
dyspeptic symptoms eg flatulent dyspepsia
biliary colic - most common
acute cholecystitis - actual gallbladder becomes enflamed not just colic part
empyema - extreme of cholecystitis - common in diabetic patients due to numbed pain senses
perforation - can be fatal
jaundice
What is Choledocho-lithiasis
gallstone in the common bile duct
difference between primary and secondary choledocho-lithiasis?
primary - stones form directly in the common bile duct
secondary - originally form in the gallbladder but move to the CBD through cystic duct - more common
what disease can choledocho- lithiasis cause in the pancreas
acute pancreatitis
what is obstructive jaundice and what are some symptoms of it?
painful effect of choledocho-lithiasis
Pain, jaundice, dark urine, pale stool, pruritus, steatorrhoea
what is Charcot’s triad?
combination of:-
- jaundice
- fever, usually with rigors
- right upper quadrant abdominal pain
It occurs as a result of ascending cholangitis (an infection of the bile duct)
Investigations carried out for gallstones? (5)
blood tests - liver function test, aspartate aminotransferase - liver damage, lipase, amylase, FBC including white cell count
ultrasound - most common
endoscopic ultrasound
CT scan
oral cholecystography - x ray of gallbladder
Management of gallstones: non-operative (2) and operative methods (7)
Asymptomatic – do nothing
Non-operative treatment: Dissolution of gallstone using acid or Lithotripsy - uses shock waves to break up gallstones - they then pass through urine
Operative:
Laparoscopic (camera) cholecystectomy +/- OTC “Gold Standard”
Cholecystectomy - Mini, single port, NOTES (vaginal catheter), total or sub-total
Cholecystostomy
what is the gold standard surgery option for gallbladder removal?
Laparoscopic (camera) cholecystectomy +/- OTC (on table cholangiography
what is a cholecystostomy?
a hole or opening is created in the gallbladder and a catheter is inserted in order to drain the gallbladder
management of bile duct stones
Lap trans-cystic CBD exploration
Lap exploration of CBD
Open exploration of CBD
endoscopic retrograde cholangiopancreatography either pre, intra or post operation
transhepatic stone retrieval - removal of stones with putting instrument through the liver to reach the bile ducts
what is endoscopic retrograde cholangiopancreatography? and when can it be done
a procedure that enables you to examine the pancreatic and bile ducts
An endoscope is placed through your mouth and into your stomach and duodenum
can either be done pre, intra or post operatively
Name 2 congenital diseases of the biliary tract?
Congenital biliary atresia - narrow, blocked or absent bile duct
Choledochal cysts - cystic dilatation of bile ducts
what can benign biliary strictures be caused by
iatrogenic - due to medical examination or treatment
gallstone related
inflammatory - pyogenic, parasitic, pancreatitis, HIV
mirizzi syndrome
common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder
Patients can present with jaundice, fever, and right upper quadrant pain
What is primary sclerosing cholangitis?
long-term progressive disease of the liver and gallbladder characterised by inflammation and scarring of the bile ducts
has potential to turn into cancer - need to monitor
Cholangiocarcinoma
rare cancer of the bile ducts
chances increases with age
risk factors - Primary sclerosing cholangitis, congenital cystic disease, biliary-enteric draining , carcinogens
Intrahepatic cholangiocarcinoma
intrahepatic:-
- rare
- increasing findings
- 3 main types are mass forming, peri-ductal and intra-ductal
- surgery is the only option for it
presentation of cholangiocarcinoma (3)
obstructive jaundice
itching
non-specific symptoms
investigations carried out for cholangiocarcinoma
Lab
Radiology: USS, EUS, CT, MRA, MRCP, PTC, Angiography, FDG PET
ERCP, Cholangioscopy and Cytology
Management of cholangiocarcinoma
surgical - only curative option
palliative - surgical bypass, stenting (percutaneous vs endoscopic), chemo, Photodynamic therapy (PDT), liver transplant - not standart
How does Photodynamic therapy work?
a treatment that uses a drug, called a photosensitiser or photosensitising agent, and a particular type of light.
When photosensitisers are exposed to a specific wavelength of light, they produce a form of O2 that kills nearby cells
gallbladder cancer general info
rare - 2-5% of GI cancers
90% of patients with GC have existing gallstones
aggressive, poor prognosis unless caught early. Usually incidental finding through having gallstones
treatment depends on stage
What does the term peri-ampullary tumours mean
a varied group of neoplasms arising from the head of the pancreas, the distal common bile duct and the duodenum -
can have adenomas or adenocarcinomas under this umbrella term
treatment options for ampullary tumours
ampulla - an opening into the duodenum
endoscopic excision (removal) trans-duodenal excision
pancreatico-duodenectomy
