Hepato-Biliary Surgery

Question 1

What types of conditions can occur in the gallbladder?

Answer 1

Gallstones
Cholesterosis
Gallbladder polyps (which can develop into cancer)

Question 2

What are the risk factors for gallstones?

Answer 2

Age
Gender
Parity
Cholesterol 
Pigment

Question 3

What are the signs of gallstones?

Answer 3

Asymptomatic
Dyspeptic symptoms
Biliary colic
Acute cholecystitis
Empyema
Perforation
Jaundice
Gallstone ileus

Question 4

What are the investigations for gallstones?

Answer 4

Bloods (LFTs, AST, ALT, ALP, amylase, lipase, WCC)
Ultrasound
EUS
Oral cholecystography
CT scan
Radio isotope scan (HIDA)
IV cholangiography
MRCP
PTC
ERCP

Question 5

What are the non-operative treatments for gallstones?

Answer 5

Dissolution

Lithotripsy

Question 6

What are the operative treatments for gallstones?

Answer 6

Open cholecystectomy
Mini-cholecystectomy
Laparoscopic cholecystectomy +/- OTC
Single port cholecystectomy
NOTES cholecystectomy (through stomach)
Cholecystostomy
Subtotal cholecystectomy

Question 7

What are congenital benign biliary tract diseases?

Answer 7

Biliary atresia

Choledochal cysts

Question 8

What are benign biliary stricture caused by?

Answer 8

Iatrogenic
Gallstone related
Inflammatory (pyogenic, parasitic, PSC, pancreatitis, HIV)

Question 9

What is primary sclerosing cholangitis (PSC)?

Answer 9

Autoimmune disease that causes inflammation which results in scarring in bile duct = strictures
Some strictures can turn into cancer

Question 10

What is a biliary-enteric fistula?

Answer 10

When the gallbladder connects to another structure (e.g. duodenum, small bowel)

Question 11

What malignant tumours would cause jaundice?

Answer 11

Cholangiocarcinoma (intrahepatic 6%, extrahepatic 94%, gallbladder cancer, ampullary cancer)
Cancer of the head of pancreas

Question 12

What are the risk factors for cholangiocarcinoma?

Answer 12

PSC
Congenital cystic disease
Biliary-enteric drainage
Thorotrst
Hepatolithiasis
Carcinogens

Question 13

What are the 3 types of intrahepatic cholangiocarcinoma?

Answer 13

Mass forming
Peri-ductal
Intra-ductal

Question 14

What is the treatment for intrahepatic cholangiocarcinoma?

Answer 14

Surgery

Question 15

What is type 1 cholangiocarcinoma?

Answer 15

Tumour is below the right and left hepatic ducts

Question 16

What is type 2 cholangiocarcinoma?

Answer 16

Tumour is at the right and left hepatic ducts

Question 17

What is type 3a cholangiocarcinoma?

Answer 17

Tumour is occluding the common hepatic and right hepatic ducts

Question 18

What is type 3b cholangiocarcinoma?

Answer 18

Tumour occluding common hepatic and left hepatic ducts

Question 19

What is type 4 cholangiocarcinoma?

Answer 19

Tumour occluding both right and left hepatic ducts

Question 20

What is type 5 cholangiocarcinoma?

Answer 20

Tumours are multicentric

Question 21

What are the clinical signs of cholangiocarcinoma?

Answer 21

Obstructive jaundice
Itching
Non-specific symptoms

Question 22

What investigations are done for cholangiocarcinoma?

Answer 22

Radiology: USS, EUS, CT, MRA, MRCP, PTC, angiography, FDG PET
ERCP, cholangioscopy and cytology

Question 23

What is the management of cholangiocarcinoma?

Answer 23

Surgical: only potential curative option
Palliative:
- surgical bypass
- stenting
- palliative radiotherapy/chemotherapy
- PDT
- liver transplant (not standard)

Question 24

What is the prognosis for gallbladder cancer?

Answer 24

Poor unless detected early (rare)

Treatment depends on stage

Question 25

What are the treatment options for ampullary tumours?

Answer 25

Endoscopic excision
Trans-duodenal excision
Pancreatico-duodenectomy