Hepatobiliary Surgery Flashcards
How does Acute Cholecystitis Classically Present?
[Gallstone obstruct cystic duct]
- HPI – RUQ pain, Fever, N&V
- PMH – Gallstone disease
- PE – Murphy’s+, TGR+, Distended GB [30%]
How does Acute Cholangitis Classically Present?
[Gallstone/Stricture/MBO → stasis → infection → CBD inflammation]
HPI
- Charcot’s Triad [RUQ pain, Fever, Jaundice]
- Obstructive Jaundice [Tea-coloured urine, Pale stool, Pruritus]
- Infection [Fever, Chills & Rigors]
- N&V
PMH – Gallstone disease, Biliary surgery, Known CA
PE – Reynald’s Pentad [Hypotension, Confusion], Murphy’s-, TG+R-
What are features of biliary colic?
- Biliary colic is NOT a true colic – instead of waxing/waning, it is constant RUQ pain
- Radiation → R Scapula/Shoulder
- Associated → N&V, Abdominal distension
Define Murphy’s Sign
Inspiratory arrest during deep palpation of the RUQ
What is the Courvoisier’s Law?
If the gallbladder is palpable in patient with painless jaundice, the cause is unlikely to be gallstone disease
What investigations would you order in suspected cholecystitis/cholangitis?
- Bloods – CBC, Septic workup, LFT, Amylase, RFT [dehydration & pre-surgical baseline], PT/APTT
- Urine – Bilirubin and Urobilinogen
- Imaging – AXR [IO, aerobilia, pigmented stones], Biliary US, ERCP/PTC
Is bilirubin in urine conjugated or unconjugated?
- All bilirubin in urine is CONJUGATED
- Unconjugated bilirubin is bound to albumin ∴not filtered in kidney
How would you manage a patient with Acute cholecystitis?
- Fluid resuscitation – correct electrolyte imbalance, hydration, NBM
- Empirical antibiotics
- Analgesics prn
- Definitive treatment – Cholecystectomy / Cholecystostomy + Elective -ectomy
How would you manage a patient with Acute cholangitis?
- Fluid resuscitation – correct electrolyte imbalance, hydration, NBM
- Empirical antibiotics
- Analgesics prn
- Biliary Decompression
- 24-48h after stabilisation
- Methods
- ERCP Sphincterotomy/Sphincteroplasty + Extraction + Stenting
- Nasobiliary Drain [external drain]
- PTBD or Surgery [ECBD] if ERCP fails
- Definitive Treatment – Elective Cholecystectomy + ECBD
Endoscopic Sphincterotomy vs Sphincteroplasty
Sphincterotomy – Dis = Risk of bleeding & perforation, Sphincter function los
Sphincteroplasty
- Adv – Preserves sphincter function
- Dis – X extract large stones, ↑risk of pancreatitis
What are the commonest organisms causing Cholangitis and Treatment?
Bacteria
- Gram-ve bacteria – Klebsiella, Enterococcus, E. coli
- Anaerobes [Bacteroides]
- Tx – 3rd gen Cephalosporin [Ceftriaxone] + Metronidazole
- Augmentin also acceptable
Parasites
- Endemic in Asian countries
- Transmission by ingesting raw fish
- Organisms - Clonorchis sinensis, Ascaris
- May cause cholangitis, IHD stone, pancreatitis, CC
- Dx - stool exam
- Tx - Praziquantel [CS] and Mebendazole [A]
Boundaries of the Calot’s Triangle and Significance
- Superior – Inferior border of the liver
- Lateral – Cystic duct
- Medial – Common hepatic duct
-
Significance
- Centre of triangle contains Lund’s LN
- Cystic artery traverses the triangle; both cystic artery & duct clipped before proceeding with cholecystectomy
Cholecystectomy – Laparoscopic or Open?
- Laparoscopic preferred – Shorter hospital stay, less pain, better cosmesis
-
Conversion to open [5% risk] due to
- Previous upper abdominal surgery [adhesions ++]
- Cholecystitis [on-going infection]
- Complicated anatomy
Cholecystectomy – Early or Delayed?
- Urgent [immediate; in patients not responding to treatment]
-
Early [within 48-72h]
- Adv – ↓Hospital Stay; Avoid readmission
- Dis – ↑Chance of operative & septic complications
-
Delayed [conservative management → interval surgery in 8-12wks]
- Adv – Avoid misdiagnosis
- Dis – Risk of interval complications requiring readmission
- [NO significant differences in early vs delayed in mortality, conversion rates, bile duct injury]
Indications for Cholecystostomy
- Approach – Percutaneous or Open; Catheter under US guidance → drain GB
- Followed by elective cholecystectomy 4-6wks later
- Indications
- Unfit for surgery [haemodynamically unstable, moribund]
- Early surgery difficult/risky [extensive GB inflammation]
Non-surgical means of stone treatment
- Shockwave lithotripsy
- Medical – UDCA [9mo intensive tx → lifelong maintenance]
- Liver diet
[All treatments retaining GB = 50% recurrence in 5yrs]
Pros and Cons of Hepatobiliary Ultrasound
Pros
- No ionising radiation
- Cheap and Portable
- Sensitive and accurate for detecting
- Bile duct (intra & extra-hepatic) dilatation [>0.6cm diameter]
- Gallstones [>95% accuracy for stones >0.1cm]
- US guided intervention can be performed
Cons
- Operator dependent
- Visualisation can be impeded
- Pneumobilia
- Previous Operations [Abdominal scar, Surgical clips, Ileus]
US Features of Cholecystitis
- Pericholecystic Fluid
- Thickened Gallbladder Wall [>3mm; ∵oedema]
- Sonographic Murphy’s Sign
- Gallstones with Acoustic Shadowing [mobile & echogenic]
What are the modalities of Cholangiography?
-
ERCP – Endoscopic Retrograde Cholangiopancreatography
* Complications – Pancreatitis, Perforation - MRCP - Magnetic Resonance CP
- PTC – Percutaneous Transhepatic Cholangiography
- Gradually replaced by MRCP
- Complications – Bleeding, Hepatic injury
- T-Tube Cholangiogram – after Cholecystectomy + ECBD → look for residual stone
When is CT indicated for acute cholecystitis?
- Suboptimal Ultrasound [e.g. obscured by scar]
- Complications [GB perforation, Pericholecystic abscess, Empyema]
What parameters are in Child-Pugh Score?
- Albumin – N= 35-50; 1+ = >35; 2+ = 28-35; 3+ = <28
- Bilirubin – N= >20; 1+ = <34; 2+ = 34-51; 3+ = >51
- Clotting [INR] – N=<1.5; 1+ = <1.7; 2+ = 1.7-2.2; 3+ = >2.2
- Distension – 1+ = None; 2+ = Mild; 3+ = Moderate
- Encephalopathy – 1+ = None; 2+ = Grade 1-2; 3+ = Grade 3-4
- Interpretation
- Child A – 5-6pts; 1/2yr Mort = 100%; 85%
- Child B – 7-9pts; 1/2yr Mort = 80; 57%
- Child C – 10-15pts; 1/2yr Mort = 45%; 35%
What is the underlying pathophysiology of cirrhosis-induced portal hypertension?
- Portal Hypertension due to 2 main factors
- ↑Resistance to portal flow – architectural distortion [fibrosis & regenerative nodules occlude sinusoids in the liver]
- ↑Portal blood flow ∵splanchnic vasodilatation [∵↑NO bioavailability in cirrhosis]
How can cirrhosis lead to upper GI-bleeding?
- Gastro-oesophageal varices [∵Portal hypertension]
- Peptic Ulcer Disease [∵↓hepatic metabolism of gastrin → ↑Gastrin = ↑HCl]
- Portal hypertensive gastropathy
- ↑Bleeding tendency [∵↓Production of clotting factors]
What are the management modalities for variceal bleeding?
- Management of ACTIVE variceal bleeding
- PROPHYLAXIS to prevent further bleeding
- CHRONIC management
How would you manage a patient presenting with ACTIVE variceal bleeding?
- Stabilise – Monitor vital signs + Initiate active fluid resuscitation
- A – Protect airway if encephalopathy
- B – Nasal cannula + supplemental O2
- C – BP & HR + 2x large bore IV catheters → initiate 1L N/S fast
- D – Decompress
- NEVER use a NGT in suspected varices
- Monitor – U/O [Foley’s], CVP [Swan-Ganz]
- Basic investigations
- T&S + Transfusions [packed RBC/Platelets/Clotting factors] → target Hb 7g/dL
- Bloods – CBC, L/RFT, PT/aPTT
- Pharmacological treatment [HAPK]
- Target Bleeding – UGI haemostasis [Omeprazole] + Correct coagulopathy [Vit K]
-
Target Pathophysiology
- Antibiotic prophylaxis – ↓SBP and re-bleeding risk with Ciprofloxacin or Ceftriaxone
- Portal pressure – ↓Portal pressure using splanchnic vasoconstrictors [Octreotoide, Somatostatin, Terlipressin]
- Temporary measures – Control bleeding while awaiting definitive treatment
-
Sengstaken-Blakemore tube → Balloon tamponade effect
- Temporary measure in case of uncontrollable bleeding
- Consists – Gastric and Oesophageal; Balloon and Opening
- Precautions
- Must protect airway first
- Maximum 24hrs – temporarily deflate after 12hrs to prevent pressure necrosis
- Definitive treatment
-
Endoscopic
- Band ligation – preferred as ↑effect and ↓complications
- Injection sclerotherapy
- Emergency Shunt Surgeries – X ideal LT preventive measure
- [ONLY use in refractory bleeding NOT controlled by pharmacological and endoscopic means]
- TIPS [Transhepatic intrahepatic Porto-systemic Shunt]
- Splenorenal Shunt [Prox. (splenectomy involved) and Dist.]
- Portocaval, Mesocaval shunts
What are the prognostic factors predicting risk of re-bleeding?
[Previous Child Forrest Site Size]
- Previous – Previous bleeds [70% will re-bleed after first episode; most cases re-bleed within 48hrs]
- Child – ↑Child-Pugh Score = ↑Risk
- Forrest – ESRH [longitudinal streaks, discrete (Cherry) red spots, blood blisters (haematocysts), erythema]
- Site – GEJ ↑commonly bleed ∵fewest supportive tissue
- Size – ↑Size = ↑Bleed
What is the mechanism of action of Lactulose in preventing HE?
- Osmotic laxative – ↓enteric transit time → ↓time for bacterial production of ammonia
- Create Acid Medium – Lactulose → Lactose + Galactose by gut fermenters → Lactose to lactic acid → acid medium → X ammonia absorption by ionising it
