Hepato-biliary surgery

Question 1

Across the many different anatomical variations, arteries can do what?

Answer 1

go/lie pretty much anywhere they want

Question 2

What is the most common disease/ surgical problem of the Gallbladder?

Answer 2

Gallstone disease

Question 3

What is Cholesterolosis in the gallbladder? and how does the mucosa appear?

Answer 3

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

Question 4

with Gallbladder polyps, at what size should a polyp be removed?

Answer 4

a polyp bigger than 1cm should not stay there. 0-0.5 cm is good.

Question 5

true or false? you can have gallstones without gallbladder disease

Answer 5

true

Question 6

What is a gallstone made up of?

Answer 6

most commonly it is mixed cholesterol and pigment

or you can get cholesterol and pigment ones on their own

Question 7

Risk factors for gallstones

Answer 7

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

Question 8

how does a patient present with gallstones (7)

Answer 8

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

Question 9

What is Choledocho-lithiasis

Answer 9

gallstone in the common bile duct

Question 10

difference between primary and secondary choledocho-lithiasis?

Answer 10

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

Question 11

what disease can choledocho- lithiasis cause in the pancreas

Answer 11

acute pancreatitis

Question 12

what is obstructive jaundice and what are some symptoms of it?

Answer 12

painful effect of choledocho-lithiasis

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

Question 13

what is Charcot’s triad?

Answer 13

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)

Question 14

Investigations carried out for gallstones? (5)

Answer 14

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

Question 15

Management of gallstones: non-operative (2) and operative methods (7)

Answer 15

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

Question 16

what is the gold standard surgery option for gallbladder removal?

Answer 16

Laparoscopic (camera) cholecystectomy +/- OTC (on table cholangiography

Question 17

what is a cholecystostomy?

Answer 17

a hole or opening is created in the gallbladder and a catheter is inserted in order to drain the gallbladder

Question 18

management of bile duct stones

Answer 18

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

Question 19

what is endoscopic retrograde cholangiopancreatography? and when can it be done

Answer 19

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

Question 20

Name 2 congenital diseases of the biliary tract?

Answer 20

Congenital biliary atresia - narrow, blocked or absent bile duct

Choledochal cysts - cystic dilatation of bile ducts

Question 21

what can benign biliary strictures be caused by

Answer 21

iatrogenic - due to medical examination or treatment

gallstone related

inflammatory - pyogenic, parasitic, pancreatitis, HIV

Question 22

mirizzi syndrome

Answer 22

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

Question 23

What is primary sclerosing cholangitis?

Answer 23

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

Question 24

Cholangiocarcinoma

Answer 24

rare cancer of the bile ducts
chances increases with age

risk factors - Primary sclerosing cholangitis, congenital cystic disease, biliary-enteric draining , carcinogens

Question 25

Intrahepatic cholangiocarcinoma

Answer 25

intrahepatic:-

• rare
• increasing findings
• 3 main types are mass forming, peri-ductal and intra-ductal
• surgery is the only option for it

Question 26

presentation of cholangiocarcinoma (3)

Answer 26

obstructive jaundice
itching
non-specific symptoms

Question 27

investigations carried out for cholangiocarcinoma

Answer 27

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

ERCP, Cholangioscopy and Cytology

Question 28

Management of cholangiocarcinoma

Answer 28

surgical - only curative option

palliative - surgical bypass, stenting (percutaneous vs endoscopic), chemo, Photodynamic therapy (PDT), liver transplant - not standart

Question 29

How does Photodynamic therapy work?

Answer 29

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

Question 30

gallbladder cancer general info

Answer 30

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

Question 31

What does the term peri-ampullary tumours mean

Answer 31

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

Question 32

treatment options for ampullary tumours

Answer 32

ampulla - an opening into the duodenum

endoscopic excision (removal)
trans-duodenal excision

pancreatico-duodenectomy