Hepato-Biliary Surgery

Question 1

Function of the Gallbladder

Answer 1

Bile Reservoir
Removes water to concentrate bile
Secretes bile salts after a mile (CCK)

Question 2

Name common diseases of the gallbladder

Answer 2

Gallstone Disease (cholelithiasis)
Gallbladder Polyps
Cholesterosis - change in the galbladder wall due to cholesterol build up

Question 3

Presentation for Gallstones

Answer 3

Asymptomatic 
Flatulent Dyspepsia
Biliary Colic 
Acute cholecystitis 
Empyema - pus-pilled pockets 
Perforation
Jaundice
Gallstone Illeus - small bowel obstruction, gallstone in the small intestine.

Question 4

Risk Factors for Gallstones

Answer 4

Obesity.
Low Fibre, High calorie, high fat diet
Pregnancy
Rapid Weight loss
Prolonged fasting 
Sedentary lifestyle

Older Age.
Woman > Men
Genetics

Question 5

What is Cholecystitis?

Answer 5

Inflammation of the gallbladder. Usually occurs when drainage is blocked (gallstone)

Question 6

What is choledocholithiasis? Presentation?

Answer 6

Presence of gallstones in the common bile dict. If stuck may cause infection, biliary cirrhosis and pancreatitis.

It may present with abdominal pain, jaundice, fever, loss of appetite, nausea, vomiting and pale stools.

Causes obstructive jaundice,

Question 7

What are the different gallstone variations?

Answer 7

Cholesterol Gallstones - Yellow. Caused by bile that contains too much cholesterol, bilirubin and not enough bile salts

Pigment Gallstones. Occurs in cirrhosis, biliary tract infections.

Question 8

What is a cholecystectomy?

Answer 8

Surgical Removal of the gallbladder.

Question 9

What is the difference between primary and secondary choledocholithiasis?

Answer 9

Primary - Stones formed within the biliary tree

Secondary - stones ejected from the gallbladder.

Question 10

Presentation of obstructive jaundice

Answer 10

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

Question 11

Investigations for Gallstones

Answer 11

Blood Tests - LFTS (AST, ALT, ALP) Amylase, Lipase and WCC.
USS, EUS, Oral cholecystopgraphy (oral=iodine contrast pill).
CT
Radio isotope scan (HIDA - scintography)
IV cholangiography (iodine dye)
MRCP/ERCP
PTC

Question 12

Management of Gallstones

Answer 12

Non-operative treatment: Dissolution or Lithotripsy.

Operative Treatment
Open/Mini/Laparascopic/Subtotal
/NOTES Cholecystectomy.

Question 13

What is Lithotripsy?

Answer 13

High energy shock waves passed though the body to break down gallstones. ESWL (extracorporeal shock wave lithotripsy).

Question 14

Management of Common Bile Duct stones (CBD)

Answer 14

Laparoscopic exploration.
ERCP
Trans-hepatic stone retrieval

Question 15

Name other Biliary Tract Disease

Answer 15

Congenital - Biliary Atresia, choledochal cysts.

Benign Biliary Stricture - iatrogenic, inflammatory, gallstone related

Question 16

Describe Mirrizi’s Syndrome

Answer 16

Common hepatic duct obstruction from extrinsic compression from an impacted stone in the cystic duct or the neck of the gallbladder.

Question 17

Malignant causes of Jaundice?

Answer 17

Cholangiocarcinoma - Bile Duct Cancer. Surgery is only treating

Extrahepatic (67% Hilar, 27% distal)
Gallbladder Cancer, Ampullary Cancer.
Cancer of the head of the pancreas.

Question 18

Presentation and investigation of cholangiocarcinoma

Answer 18

Presents with obstructive jaundice, itching, non specific.

Investigations - USS, EUS< CT, MRA, MRCP, PTC, angiography, FDG PET

Managment - surgical only potential curative option or palliative care (stenting, radiotherapy, chemotherapy, pancreaticoduodenal transplantation.