Hepato-billary pancreatic Flashcards
% of patient’s undergoing cholecystectomy who have gallstone in CBD
10%
Cholecystitis mx
Hot laporascopic cholecystectomy
Within 24-48 hours after presenting
Calot triangle
Common hepatic duct
Liver
Gallbladder
Contains right hepatic artery and cystic arteryand lymph Lund
Mirzziri syndrome
Obstruction of the common bile duct or common hepatic duct by external compression from multiple impacted gallstones or a single large impacted gallstone in Hartman’s pouch
Mx of cholecystitis with mikzziri syndrome
Operative cholecystostomy- draining gallbladder
Post cholecystectomy, bile in drain what do you do
ERCP
cystic stump leak can be managed with ERCP , sphincterotomy and stent.
AFP increased and USS shows suspicious lesion on liver, next steps?
Liver MRI
What biliary problem can Crohns cause
Bile salts are absorbed in the terminal ileum. When this process is impaired as in Crohns the patient may develop gallstones, if these pass into the CBD then obstructive jaundice will result.
Patient with pancreatitis- necroses and infected- drainage failed- what next?
Necrosectomy
Obstructive jaundice mx
ERCP
Gallstone ileus mx
Remove glasstone via proximally sited terminal ileal enterotomy and decompress small bowel
Leave gallbladder in situ
If hepatocellular adenoma seen on MRI- mx
Resection
Mx of large pancreatic pseudocyst that does not resolve on its self and causing symptoms
Elective cystogastrostomy
Damage to bile duct during cholecystectomy
Place in drain and close wounds
Glasgow scoring for pancreatitis
P a02 < 60 mmHg
A ge > 55 years
N eutrophils > 15 x 10/l
C alcium < 2 mmol/l
R aised urea > 16 mmol/l
E nzyme (lactate dehydrogenase) > 600 units/l
A lbumin < 32 g/l
S ugar (glucose) > 10 mmol/l
> 3 positive criteria indicates severe pancreatitis.
Courvoisiers law
Painless jaundice in association with a smooth right upper quadrant mass is typical of distal biliary obstruction secondary to pancreatic malignancy
After cholecystectomy a patient is found to have a bile leak. An ERCP is performed and leakage is noted from the cystic duct. mx?
Sphincterotomy and stent in common BD
Cut sphincter at oddi
Difficult cholecystectomy due to poor visualisation of calots what do you do
Cholecystostomy
Severe abdo pain after ERCP - ddx and mx
Could be pancreatitis or perf of deuodenum
CT abdo
Mild pancreatitis with gallstones
Cholecystectomy once attack settles
Acalculous cholecystitis
Most common in DM
RUQ pain, septic
No stones on USS
Microscopic assessment of the cholecystitic gallbladder
Aschoff-Rokitansky sinuses are the result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the gallbladder wall.
Imaging that can be used for pancreatitis
CT with contrast
Cholangitis and ERCP fails- mx?
Percutaneous transhepatic cholangiogram and drain
Most sensitive blood test for pancreatitis
lipase
Lesion in liver after cirrhosis
In patients with cirrhosis the presence of a lesion >2cm is highly suggestive of malignancy. The diagnosis is virtually confirmed if the AFP is >400ng/mL.
Surgical workup for cholecystectomy
LFT and diameter of CBD
Cholangitis Tx
ERCP and stent
Hartmann’s pouch
Diverticulum at fungus of gallbladder
How Mirizzi syndrome causes poor visualisation of clots triangle
In Mirizzi syndrome the gallstone becomes impacted in Hartmans pouch. Episodes of recurrent inflammation occur and this causes compression of the bile duct. In severe cases this then progresses to fistulation. Surgery is extremely difficult as Calots triangle is often completely obliterated and the risks of causing injury to the CBD are high.
Gallstone in distal CBD cannot be removed what is next option?
choledochoduodenostomy
Most sensitive sign on US for cholecystitis
Sono Murphy sign with cholethiasis
Intramural, intraluminal and extraluminal CBD obstruction
IM- strictures
IL- stones
EL- carcinomas, porta hepatic LN
Gallbladder wall if cholecysitic on US
Thick >3mm
