Hepatobiliary Surgery JC063: RUQ Pain, Jaundice And Fever: Cholecystitis And Cholangitis, Imaging Of GI System

Question 1

***Hepatobiliary system pathologies

Answer 1

1. Liver
2. Gallbladder
   - **Gallstones
   - **Acute cholecystitis
   - GB cancer
3. CBD
   - **CBD stones
   - **Acute cholangitis
   - ***Cholangiocarcinoma / Bile duct cancer
4. CHD
   - ***Klatskin tumour
   - RPC
5. Pancreas
   - **Acute pancreatitis
   - **CA ampulla of Vater
   - ***Pancreatic head cancer

Biliary tract: Gallbladder, CBD (below cystic duct), CHD (above cystic duct)

RUQ pain + Fever: Pathologies along Bile duct +/- Gallbladder

Common pathologies in HB surgery:
- Stones
- Tumours

Question 2

***Gallstones

Answer 2

• Hard, pebble-like deposits form inside GB
• Small as sand / Large as golf ball

Epidemiology:
- 12% men
- 24% women
- 10-30% symptomatic (mostly ***asymptomatic, incidental findings)

Types:
1. Cholesterol stone
- most common
- ∵ imbalance between phospholipid, bile salt, cholesterol in composition of stones

2. Pigment stone
   - usually in patients with haematological disorders
   - ∵ too much bilirubin in bile (∵ ***haemolysis)

**Risk factors:
1. **4Fs: Female, Middle age, Obesity, Fertile
2. **Estrogen (↑ cholesterol production in the liver)
3. OC pills
4. **Pregnancy (∵ hormonal changes, impair hormonal control of GB contraction)
5. Rapid weight loss in obese patient (∵ liver releases extra cholesterol into the bile)
6. **Use of Fibrates (↓ synthesis of bile acid —> easier for cholesterol to precipitate)
7. **Prolonged TPN (∵ induce cholestasis —> precipitation of bile)
8. **Ileal resection / jejunoileal bypass (induces enterohepatic circulation of bilirubin and doubles the secretion rate of bilirubin into the bile) (web: increased spillage of malabsorbed bile acids into the colon where they solubilize unconjugated bilirubin and promote its absorption and thereby increase the rate of bilirubin secretion into the bile)
9. Ileal disease (Crohn’s disease)
10. Spinal cord injury
11. Vagotomy / Previous gastrectomy (∵ dissection in surgery divide nerve supplying GB)
12. **DM (∵ peripheral neuropathy affect contractility of GB)
13. **Haemolytic anaemia, Haemolytic disorders e.g. **Thalassaemia (∵ ↑ Bilirubin deposition)
14. ***Cirrhosis
15. BM transplant / Solid organ transplant

Clinical features:
1. **Epigastric / RUQ pain
2. Fat intolerance (bloating sensation / pain onset after fatty meal)
3. **Fever
4. ***Jaundice (if obstruct bile duct)

Question 3

***Gallstones: Investigations + Treatment

Answer 3

Investigations:
1. ***Liver USG (1st line)
2. CT scan

Management:
**NO indication if asymptomatic no matter how big stone is
1. **Laparoscopic cholecystectomy
- 4 ports
- single port (subumbilical port)

2. ***Percutaneous transhepatic cholecystostomy (PTHC)
   - needle puncture through abdominal wall into GB —> drain bile
   - transhepatic: safest route is going through liver into GB (∵ if not go through liver then directly go into GB, bile may leak into peritoneal cavity —> bile peritonitis)
   - if not fit for surgery (e.g. elderly)

Question 4

CBD stone + Gallstone

Answer 4

4 different treatment strategies:
1. **Preoperative ERCP (prone position) —> **Cholecystectomy
- most common

2. Laparoscopic cholecystectomy + Laparoscopic exploration of CBD
   - advantage: only 1 operation with 2 procedures
3. Laparoscopic cholecystectomy + on-table ERCP (supine position, more challenging)
   - uncommon, usually in ***emergency setting
   - ERCP need to distend bowel —> may obstruct view of laparoscope
4. Cholecystectomy —> Post-op ERCP
   - uncommon
   - if ERCP fail then need to go to OT again (i.e. troublesome)

Question 5

Gallstones: ***Complications

Answer 5

1. ***Mucocele of GB
   - ∵ bile accumulation —> GB distended —> mucus formation from GB epithelium
2. ***Empyema of GB
   - bile / mucus becomes infected when accumulation
3. ***GB gangrene / rupture
   - grossly distended GB —> thinned out GB wall —> venous gangrene —> rupture wall —> bile peritonitis
4. ***Acute cholecystitis
   - Pain + Fever + N+V
5. ***Acute cholangitis
   - Charcot triad: Pain + Fever + Jaundice
   - Reynold’s pentad (Ascending cholangitis): Pain + Fever + Jaundice + Hypotension + Confusion
6. ***Acute pancreatitis
7. **Cholecystoduodenal fistula
   - a chronic process: distended GB —> touching duodenum —> GB stone erode into duodenum —> potential IO (i.e. **Gallstone ileus) / if fistula is blocked —> cholecystitis
   - usually in elderly patients
8. Liver abscess

Question 6

***Acute cholecystitis

Answer 6

Acute inflammation of GB

Causes:
- ***Obstruction of cystic duct
- Complication of gallstone disease
- Chemical inflammation e.g. bacterial infection

Clinical features:
1. RUQ pain
2. Fever
3. ***N+V
4. NO tea-colour urine (NO Charcot triad!!!)

Question 7

***Treatment of Acute cholecystitis

Answer 7

1. **Cholecystectomy
   - open / **laparoscopic
   - delayed / early
2. **Cholecystostomy
   - drainage of GB
   - open / **percutaneous (PTHC)
   - indications: **high surgical risk, **haemodynamically unstable, difficult cholecystectomy anticipated

Question 8

Pros and Cons of Laparoscopic approach

Answer 8

Pros:
- less pain
- shorter hospital stay
- faster recovery
- better cosmesis

Cons:
- **technically demanding
- **higher conversion rate
- ***more serious complications

Question 9

Early vs Delayed surgery

Answer 9

Early surgery (within 48-72 hours):
- high chance of success + low conversion rate
- avoid urgent operation
- **avoid recurrent symptom
- avoid readmission
- **shorter hospital stay
- ***safe without ↑ risk of complications

Delayed surgery (conservative treatment / interval surgery in 8-12 weeks):
- **avoid misdiagnosis
- **easier dissection
- less septic complications
- less serious complications

Question 10

***Acute cholangitis

Answer 10

Clinical features:
**Charcot triad:
1. RUQ pain
2. Fever
3. **Jaundice (Tea-colour urine)
***Reynolds’ pentad (Ascending cholangitis):
4. Confusion
5. Shock / Hypotension

Causes:
1. ***Bile duct obstruction
- Stones
- Tumour
- Benign stricture

2. ***Bacteria in bile
   - Gram -ve rods
   - Enterococcus
   (- Anaerobes)

Question 11

***Treatment of Acute cholangitis

Answer 11

Treatment (記: Fast, Fluid, Antibiotic, ERCP / ECBD):
Conservative
1. **Keep patient fast
2. **IV fluid
3. ***IV antibiotics
- Cefuroxime
- Metronidazole
- Piperacillin + Tazobactam

Invasive
1. **ERCP +/- **Biliary stenting
- potential complications: perforation, bleeding from papillotomy, pancreatitis
- relative CI for ERCP: ***altered GI anatomy e.g. Billroth 2 gastrectomy, Roux-en-Y

2. Surgical decompression by exploration of CBD (ECBD)
   - indications:
   —> failure of endoscopic drainage
   —> deterioration despite endoscopic drainage
   - open approach for emergency cases
   - laparoscopic approach in selected elective cases

Question 12

Recurrent Pyogenic Cholangitis (RPC)

Answer 12

Definition:
- Repeated attacks of **bacterial infection of biliary tract
- as a result of **stones / **strictures in bile ducts (esp. in **intrahepatic segments)

Clinical features:
- Charcot triad: Pain + Fever + Jaundice (***same as Cholangitis)
- But repeated episodes (e.g. 3-4 times in 1 year)

Other names:
- Hong Kong disease
- Oriental cholangiohepatitis
- Primary cholangitis
- Intrahepatic cholelithiasis

Causative organism:
- ***Clonorchis sinesis —> liver fluke / flatworm

Epidemiology:
- rare in western countries (↑ incidence in Asian migrants)
- common in SE Asia
- young + lower socio-economic groups
- no gender preponderance

Pathogenesis:
Entry of bowel organisms (**Clonorchis sinesis) into bile ducts
—> Inflammation in the portal triad
—> Necrosis of hepatocytes
—> **Cholangiohepatitis
—> **Fibrosis + **Cholangitis + **Abscess formation
—> **Bilirubinate stones (infected bile becomes insoluble precipitate from a supersaturated solution) + ***Stricture formation (lead to repeated cholangitis)

Characteristics of RPC:
1. Infection

2. ***Stricture formation
   - more common in left main hepatic duct / segmental ducts
   - main duct strictures usually short-segment
   - intrahepatic strictures usually long-segment
   - proximal dilatations behind strictures
3. ***Stone formation
   - soft, muddy, easily crumbled —> hard to pass out, instead crumbles —> sand / sludges cause more blockage —> repeated cholangitis

Question 13

Investigations of RPC

Answer 13

1. ***Liver USG
2. CT
3. ***MRI
   - enhancement of ductal walls on contrast enhanced T1 weighted images
   - T2 weighted images
   —> Bile: high intensity
   —> Stones: signal void
   —> Good for showing ductal dilatation
4. **ERCP
   - ductal dilatation
   - **“arrowhead” configuration (∵ stricture of intrahepatic ducts (尖頭形狀))
   - irregular contour + strictures (beaded apperance)
   - stones
5. Percutaneous transhepatic cholangiogram (PTC)

Question 14

***Treatment of RPC

Answer 14

記: Fast, Fluid, Antibiotic, ERCP / ECBD

Acute attack (Same as Acute cholangitis)
1. Conservative treatment
- **IV antibiotics (2nd gen Cephalosporin)
- **Rehydration
- Analgesics

2. Aggressive treatment
   - Fluid resuscitation
   - IV antibiotics
   - ***Urgent biliary decompression (radiologically (PTBD) / endoscopically (ERCP) / laparotomy (surgical exploration))
3. Non-operative approach
   - **ERCP + Insertion of **Endoprosthesis
4. Operative approach
   - ***Exploration of CBD
   - Drainage of pus + infected bile
   - Removal of stones within CBD

Common pathogens:
- **E. coli
- **Klebsiella spp.
- Pseudomonas
- Anaerobes

Definitive (prevent recurrence):
1. **Remove biliary ductal stones + Drain infected bile
2. **Enlarge / Bypass strictures (to facilitate biliary drainage)
3. **Provide adequate biliary drainage
4. **Provide permanent percutaneous access to biliary tract

Surgical options:
1. ***Hepaticojejunostomy
- allow passage of bile, sludges, stones into small bowel
- ↓ time of bile in biliary tract —> ↓ chance of stone formation —> ↓ RPC

2. **Hepaticojejunostomy with a cutaneous stoma (i.e. Hepaticocutaneous jejunostomy)
   - provide percutaneous route for future stone removal via **choledochoscopy (∵ cannot perform ERCP anymore after dividing bile duct)
3. **Hepaticojejunostomy + **Hepatectomy
   - for destroyed liver segment
   - for intrahepatic strictures / stones
   - for multiple liver abscess
   - for Cholangiocarcinoma

Outcomes:
Short term outcomes:
- immediate stone clearance: 90%
- final stone clearance: 98%
- 10% had concomitant Cholangiocarcinoma

Long term outcomes:
- stone recurrence: 9%
- 5-year survival
—> with Cholangiocarcinoma: 9% (i.e. ***Malignant transformation)
—> without Cholangiocarcinoma: 93%

Question 15

***Management of RPC

Answer 15

Definitive treatment:
1. ***Removal of stones + strictures
- remove stones
- dilate stricture
- hepatectomy

2. Prevent recurrence by improving bile drainage
   - bilio-enteric bypass (***Hepaticojejunostomy)
3. Provide access for treatment of recurrence
   - hepaticojejunostomy with ***cutaneous stoma (allow removal of stone in case of recurrence of stricture)

Question 16

Complications of RPC

Answer 16

1. ***Liver abscess
2. Choledochoduodenal fistula
3. ***Acute pancreatitis
4. ***Portal vein thrombosis (∵ bile duct just in front, inflammation of bile duct —> affect portal vein as well) (vs Pancreatitis: Splenic vein thrombosis)
5. ***Biliary cirrhosis (Cirrhosis secondary to biliary pathology, liver becomes atrophic, deranged LFT)
6. ***Cholangiocarcinoma

Question 17

Cholangiocarcinoma

Answer 17

• 2% of all cancers
• risk factor: advanced age (disease of elderly)
• peak incidence: 70-80 yo

Clinical presentation:
- **Painless jaundice (differentiate cancer vs stones), **Tea-colour urine (early sign, very sensitive), Pale stool (later)
- RUQ pain
- ***Hepatomegaly
- Fever (depend on whether bile get infected or not)
- LOW
- LOA

Bismuth classification:
- classified according to tumour location along Y-shaped biliary tree
- type 1-4
- clinical implication: dictate operation needed

Question 18

Investigations of Cholangiocarcinoma

Answer 18

1. **ERCP (best imaging quality + **therapeutic: stenting / brush cytology) + CT —> best assessment of biliary system
2. MRCP
3. ***CT (hypodense in arterial phase vs HCC: hyperdense in arterial phase)

Question 19

***Treatment of Cholangiocarcinoma

Answer 19

Curative:
- **Bile duct excision + **Hepatectomy + ***Hilar LN clearance (important for staging) + Bile duct reconstruction

Outcome:
- 1 year survival: 60.3%
- 3 year survival: 29.4%
- 5 year survival: 22.0%

Palliative:
- Radiotherapy
- Chemotherapy
- ***Metallic stenting / Surgical bypass

Question 20

Acute pancreatitis

Answer 20

Clinical features:
1. Characterised by sudden onset **epigastric / RUQ pain with radiation to **back (∵ retroperitoneal organ)
- Pain can be so severe / generalised that mimic signs of **generalised peritonitis due to perforated viscus
2. **N+V
3. High fever (uncommon but often implies complications already occurred e.g. necrotising pancreatitis)

Causes (**GET SMASHED):
- **Gallstones
- **Ethanol
- Trauma
- Steroid
- Mumps
- Autoimmune
- Scorpion venom
- **Hyperlipidaemia
- ERCP
- Drugs

Question 21

Complications of Acute pancreatitis

Answer 21

記: Pseudocyst, Abscess, Peritonitis, Shock

1. **Pseudocyst
   - cystic collection lined by non-epithelial wall ∵ disruptions of the pancreatic duct due to pancreatitis or trauma followed by **extravasation of pancreatic secretions
2. Infected pseudocyst
   - fluid within cyst infected
3. ***Necrotising pancreatitis
   - ∵ severe inflammation
4. ***Haemorrhagic pancreatitis
   - ∵ trigger systemic inflammatory reaction response —> derangement in clotting profile —> diffuse haemorrhage inside peritoneal cavity, fatal
5. Pleural effusion
   - ∵ transdiaphragmatic lymphatic blockage or pancreaticopleural fistulae
6. Ascites
   - ∵ pseudocyst leak through a fistula
7. ***Splenic vein thrombosis
   - ∵ peripancreatic inflammation
8. ***Peritonitis
9. ***Abscess

(8. Pseudoaneurysm: may cause acute bleeding
9. Fistula)

Question 22

***Treatment of Acute pancreatitis

Answer 22

1. Conservative treatment
   - Nutritional support (**Fast + TPN)
   - **IV antibiotics
2. ***Necrosectomy
   - if clinical deterioration / evidence of infected necrosis
   - approach: endoscopic / open

Question 23

Hepatectomy

Answer 23

Indication:
- For destroyed liver segment
- Intrahepatic strictures / stones
- Multiple liver abscess
- ***Cholangiocarcinoma

Question 24

Portal vein embolisation

Answer 24

• technique used before hepatic resection to increase the size of liver segments that will remain after surgery
• indicated for future left lateral section ***<30% estimated total liver volume
• estimated total liver volume is calculated by ***Urata formula that takes body height + body weight into consideration

Question 25

Pancreatic cancer

Answer 25

• Highly lethal cancer even if resectable
• Peak age of onset: >60
• Early cancer is usually ***asymptomatic
• Clinical presentation often indicates advanced diseases

Clinical features:
- Obstructive jaundice (if pancreatic head)

Question 26

Treatment of Pancreatic cancer

Answer 26

**Whipple operation (aka **Pancreaticoduodenectomy):
- medically fit for major surgery but age is not a contraindication
- localised disease
- free from metastasis
- ***no tumour involvement in SMA

Curative treatment
1. Radical pancreaticoduodenectomy (Whipple)
- excision of pancreatic head
- excision of duodenum
- excision of CBD
- partial excision of stomach

2. Reconstruction to restore GI tract continuity (3 anastomoses)
   —> Pancreas, Bile duct, Stomach
   - Pancreatojejunostomy
   - Hepaticojejunostomy
   - Gastrojejunostomy

Palliative treatment
1. **Double bypass + Celiac axis block
- Gastrojejunostomy
- Hepaticojejunostomy
2. **Metallic stenting
3. Radiotherapy
4. Chemotherapy

Question 27

Post-op course of Whipple operation

Answer 27

• 2 latex drains (to monitor pancreatic leakage)
• drain output + appearance
• drain fluid + amylase on day 1, 3, 5
• pancreatic drain in some cases
• ***Broviac catheter
• ***Parenteral nutrition

Pancreatic fistula / leak:
- amylase concentration >3x ULN of normal serum amylase level

Question 28

Role of imaging

Answer 28

1. Obstructive vs Non-obstructive
2. Delineate site of obstruction
3. Identify possible complications
4. Offer minimally invasive interventions

Question 29

Imaging modalities in biliary tract

Answer 29

1. Plain AXR
2. ***USG (best modality, 1st line investigation for biliary diseases)
3. Cholangiography
4. CT (reserved for complicated cases)
5. MRI (reserved for complicated cases)

Question 30

1. Plain AXR

Answer 30

Abnormalities seen:
1. Calcified gallstones (10-20%)
- opposite to renal stones

2. **Pneumobilia (Air in biliary tree)
   - e.g. **post-ERCP with sphincterotomy, **duodenal fistula, **ampulla damage by stone —> i.e. no sphincter to stop gas going in
3. ***Air in gallbladder wall (e.g. infection)
   - looks like gas under diaphragm (DDx: pneumoperitonitis)
4. Soft tissue mass
   - ***Abscess
5. Bowel dilatation
   - could be due to ***Ileus secondary to infection or gallstones / SBO

Question 31

2. USG

Answer 31

Normal USG anatomy:
1. Gallbladder wall **<3 mm thick
2. CBD **<6 mm diameter (however, will enlarge as aging)
3. Intrahepatic duct: difficult to see

Abnormalities seen:
1. Gallstones, CBD stones
- mobile (roll patient)
- echogenic with acoustic shadowing: **Comet tail sign (∵ US hits stone —> reflects back —> **hypoechoic shadow)
- >95% accuracy in detecting gallstones >0.1 cm
- DDx: polyp

2. Gallbladder wall edema
   - GB wall >3 mm
   - due to **inflammation
   - can be due to non-specific / systemic causes:
   —> hepatitis (inflammation spread to GB)
   —> perforated peptic ulcer
   —> pyelonephritis
   —> CHF (∵ ascites)
   —> nearby inflammation
   —> ↓ albumin (∵ ascites)
   —> tumour (tend to be **focal thickening)
3. ***Pericholecystic fluid
   - suggest inflammation of GB
4. Dilated IHD / Ductal stone
   - differentiate from portal vein: use a Doppler (should show bloodflow vs no bloodflow in IHD)
5. Liver abscess
6. ***Acute cholecystitis
   - Gallstones
   - Gallbladder wall >3mm
   - Distended GB
   - Pericholecystic fluid
   - Murphy’s sign

Advantages:
- no ionising radiation
- cheap, safe, portable, quick (experienced operators) —> available in most settings
- **GB evaluation (Gallbladder itself, wall thickening, stones)
- sensitive + accurate for **Intra + ***Extrahepatic bile duct dilatation
- image guided intervention

Disadvantages:
- operator dependent
- things can impede visualisation:
1. **Pneumobilia (∵ air reflects US)
2. **Soft pigmented stones (difficult to see)
3. Previous operation (impair contact between probe and abdominal wall)
- abdominal scar
- surgical clips
- drainage tube (∵ air within)
- duodenal gas
- ileus (∵ air within)

Question 32

3. Cholangiography

Answer 32

• Direct / Indirect introduction of contrast medium into ductal system
• Can be invasive
• Ionising radiation

1. ***ERCP
   - direct cannulation of CBD via scope
   - diagnostic (cytology + microbiology) + therapeutic
   - possible complications: pancreatitis, perforation
2. **PTC (percutaneous transhepatic cholangiogram)
   - mostly **replaced by MRCP
   - performed as a pretreatment roadmap (∵ ERCP may not see biliary tree if have Klatskin tumour)
   - possible complications: vascular / organ injuries, bile leak causing ***bile peritonitis
3. ***T-tube cholangiogram
   - performed after cholecystectomy and exploration of CBD to look for residual stone

(4. MRCP)

Question 33

4. CT

Answer 33

• rarely required
• cross-sectional display of intra-abdominal organs

Abnormalities seen:
1. Gallstones
- **appear black (∵ contain cholesterol rather than Ca, **hypodense structure)
2. Perfusion abnormality (i.e. non-uniform enhancement of liver e.g. portal vein thrombosis)
3. Wall edema
4. Ductal stones
5. Dilated IHD / bile duct
6. **Emphysematous cholecystitis (air within GB ∵ air-producing organism) (needs urgent treatment)
7. Pneumobilia
8. Liver abscess
9. Liver cirrhosis
10. **HCC
- Solitary hypervascular mass
- **Cirrhosis (irregular border)
- **Ascites
- **Varices (distended vessels)
11. **Acute pancreatitis
- assessment + staging of pancreatitis (scoring based on CT findings)
- assessment of complications

Advantages:
- not limited by gas, clips, drainage tubes
- detects other abnormalities apart from dilated ducts, stones
- surgical planning, staging, look for complications

Disadvantages:
- **not that useful in visualising biliary tree
- ionising radiation
- IV contrast injection related complications
- **not sensitive for cholangitis
- relatively expensive
- not portable

Indications:
1. Suboptimal US
2. Complications e.g. GB perforation with pericholecystic abscess, empyema
3. Evaluation of other abdominal organs / pelvis for other pathology
4. CT-guided interventions

Question 34

5. MRI

Answer 34

**MR cholangiopancreatography (MRCP):
- heavily T2-weighted sequence to see water —> “pseudo-contrast” appearance
- **no contrast required
- non-invasive
- ***3D image

Abnormalities seen:
1. Pericholecystic fluid
2. Wall edema
3. Pericholecystic inflammation

Advantages:
- no ionising radiation
- **true multi-planar images
- better contrast resolution than CT
- **tissue characterisation
- MR abdomen / **MRCP (gold standard for **biliary tree visualisation)

Disadvantages:
- ***inferior spatial resolution than CT (∵ thicker cuts 3-5 mm)
- longer scanning time (20 mins vs 3 mins for CT)
- limited availability and accessibility (∵ expensive)
- require patient cooperation
- claustrophobic
- difficult to tell stone vs air bubble
- medical implants CI e.g. pacemakers, cochlear implants

Indication:
1. Unsuccessful ERCP
2. ERCP contraindicated (∵ previous gastric / bypass operation)
3. Evaluation of other abdominal pathology needed

Question 35

SpC Interactive tutorial: Gallstone and Acute cholangitis
Gallstones

Answer 35

• 12% population
• 10% men + 25% women >60 yo

Types:
1. Cholesterol stones
- Pure
- Mixed

2. Pigment stones (decomposition of Hb)
   - Black stones
   - Brown stones

Risk factors for Cholesterol stones:
1. Fair (White Caucasians)
2. Female
3. Fat
4. Fertile
5. Forty

Symptoms of gallstones:
1. Asymptomatic
2. **Biliary colic
3. **Complications

Natural history:
- 70-80% of all patients with gallstones develop symptoms
- Development of symptoms: 1-2% per year
- Initial presentation with complications: <5%
- Recurrent symptoms: 60-70% in 2 years
- Major complications: 1-2% per year

Question 36

Investigations of gallstones

Answer 36

1. AXR (detect kidney stones 70%, gallstone 30%)
2. ***USG
3. CT
4. MRI
5. Nuclear medicine
6. ERCP / Cholangiography (filling defect)

USG:
- Acoustic shadow
- Turn the patient —> stone move to dependent area

Question 37

Cholecystectomy

Answer 37

Indications for **asymptomatic gallstones:
1. **Calcified gallbladder (Porcelain gallbladder) (by any imaging e.g. AXR, USG, CT) —> Risk of gallbladder cancer
2. Young patients with **chronic haemolytic disease (e.g. sickle cell disease, thalassaemia)
3. Patients on **long-term TPN

Indications for ***symptomatic gallstones:
1. Control symptoms
2. Prevent complications

Surgery: Gold standard for symptomatic gallstone
- Patient selection: Acceptable operative risk
- Mortality (elective) <0.5% (<65: <0.05%, >80: up to 5%)
- Morbidity: 5-10% (e.g. skin infection, bile duct / vascular injury)
- Disability: weeks

Laparoscopic cholecystectomy:
Advantages:
- Lesser pain
- Better cosmesis
- Early return of GI function
- Shorter hospital stay (can be performed as day surgery)
- Shorter recuperation

Disadvantages:
- Bile duct injury (0.4-0.8%)
- Conversion rate (3-8%) (esp. in patients with previous infection)

Question 38

Minimally invasive surgery / Minimally access surgery

Answer 38

1. Endoscopic surgery
2. Laparoscopic surgery
   - Needlescopic surgery (2-3 mm)
   - Single incision laparoscopic surgery
   - Robotic surgery
3. Natural Orifice Transluminal Endoscopic surgery (NOTES) (go from anus, avoid visible wound in abdomen, but dirty wound since puncture colon)

Question 39

***Complications of gallstones

Answer 39

1. Gallbladder (Cystic duct blocked)
   - Acute cholecystitis
   - Mucocele of gallbladder (∵ infection)
   - Carcinoma (∵ chronic inflammation —> fibrosis)
2. Bile duct
   - Obstructive jaundice
   - Acute cholangitis
   - Acute pancreatitis (very distal CBD obstruction)
3. Perforation to other sites
   - Bowel —> Gallstone ileus
   - Liver bed —> Liver abscess
   - CBD —> Mirizzi’s syndrome

Question 40

(Courvoisier’s law)

Answer 40

Painless palpable enlarged gallbladder + Mild jaundice —> unlikely to be caused by gallstones
(Original version: Without painless —> Cholecystitis is an exception)

Gallstone:
Acute —> Distension but have pain
Chronic —> Painless but not palpable (∵ fibrotic shrunken)

Exception (i.e. Stone can cause Painless palpable enlarged gallbladder + Mild jaundice):

1. Double duct stone (Cystic duct stone (not enough to cause pain) + CHD stone (cause jaundice))
2. Mirizzi’s syndrome

Question 41

***Diagnosis of Acute cholecystitis

Answer 41

1. Clinical
2. USG
   - Gallstones
   - Positive Sonographic Murphy’s sign
   - **Gallbladder wall >3mm
   - **Distended gallbladder
   - Pericholecystic fluid
   - Impacted gallstone

***Tokyo guideline 2013:
—> Suspected diagnosis: 1 item in A + 1 item in B
—> Definite diagnosis: 1 item in A + 1 item in B + C
A. Local sign of inflammation
- Murphy’s sign
- RUQ mass / pain / tenderness
B. Systemic signs of inflammation
- Fever
- Elevated CRP
- Elevated WBC
C. Imaging findings
- Characteristics of acute cholecystitis

***Severity grading (Tokyo guideline 2013):
- Grade 1 (mild: not Grade 2/3)
- Grade 2 (moderate: with marked inflammation e.g. WBC elevated, duration >72 hours, abscess, peritonitis)
- Grade 3 (severe: with organ dysfunction)

Question 42

***Management of Acute cholecystitis

Answer 42

Initial: Conservative:
1. NPO
2. **IV fluid
3. **Antibiotic
4. ***Analgesic
5. Blood tests
6. Cross match
7. Monitor BP, Pulse, Temp, Urine output

Surgical treatment:
1. ***Cholecystectomy
- Open / Laparoscopic
- Delayed / Early

2. **Cholecystostomy (drainage of gallbladder)
   - Open / **Percutaneous
   - **Always through Liver (if through peritoneal cavity —> bile peritonitis)
   - Indications:
   —> **High surgical risk
   —> **Haemodynamically unstable
   —> **Difficult cholecystectomy anticipated (e.g. multiple previous abdominal surgery, anticipate 2-3 hours of surgery)

Tokyo guideline 2013:
Grade 1 cholecystitis —> Antibiotics + General supportive care —> **Early LC / Observation
Grade 2 cholecystitis —> Antibiotics + General supportive care —> **Emergency LC / **Delayed or Elective LC / Urgent or Early **GB drainage
Grade 3 cholecystitis —> Antibiotics + **General organ support —> **Urgent or Early ***GB drainage (∵ unfit for surgery) —> Delayed or Elective LC

Question 43

Newer modalities for Gallbladder drainage

Answer 43

Only in high volume institutes by skilled endoscopist

1. Endoscopic transpapillary gallbladder drainage (ETGBD) under ***ERCP (cannulate ampulla —> go into cystic duct)
   - Nasogallbladder drainage (ENGBD) (drainage through nose)
   - Gallbladder stenting (EGBS)
2. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) (stenting direct between gallbladder and duodenum, reserved for older patient with ASA >3)

Question 44

Acute cholangitis

Answer 44

**More sinister than Acute cholecystitis
- ∵ CBD obstructed
—> Increase pressure + Bacteria in CBD
—> **Translocation of bacteria into ***Portal triad (i.e. Portal vein, Hepatic artery)
—> Sepsis

Pathogenesis:
1. ***Bile duct obstruction
- Stones
- Tumour
- Benign stricture

2. ***Bacteria in bile
   - Gram -ve rods
   - Enterococcus
   (- Anaerobes)

Question 45

***Diagnosis of Acute cholangitis

Answer 45

1. Clinical
2. ***ERCP
   - diagnostic + therapeutic
3. ***MRCP (MR cholangiopancreatogram)
   - T2 weighted —> high intensity
   - no contrast is required
   - non-invasive

***Tokyo guideline 2013:
—> Suspected diagnosis: 1 item in A + 1 item in B/C
—> Definite diagnosis: 1 item in A + 1 item in B + 1 item in C
A. Systemic inflammation
- Fever / Chills
- Laboratory data of inflammatory response
B. Cholestasis
- Jaundice
- Abnormal LFT
C. Imaging
- Biliary dilatation
- Evidence of etiology (e.g. stone, stricture)

***Severity grading (Tokyo guideline 2013):
- Grade 1 (mild)
- Grade 2 (moderate)
- Grade 3 (severe)

Question 46

***Management of Acute cholangitis

Answer 46

Initial: Conservative:
1. NPO
2. **IV fluid
3. **Antibiotic
4. ***Analgesic
5. Blood tests
6. Cross match
7. Monitor BP, Pulse, Temp, Urine output

Clinical manifestation of failure of conservative treatment:
1. ↑ Temp, Pulse
2. ↓ **BP
3. ↓ **Urine output
4. ↓ Sensorium
5. ↑ Abdominal tenderness, guarding
—> Transfer to ICU if necessary

Treatment for failed conservative treatment:
1. **Biliary decompression + drainage
- **Endoscopic (ERCP) (1st line)
—> Stone extraction: basket / balloon
—> Mechanical lithotripsy (to crush stone)
—> Endoprosthesis (for urgent decompression) (e.g. straight stent, pigtail stent)

• **Surgical exploration of CBD
  —> Failure of medical treatment / Failure of endoscopic drainage (e.g. difficult cannulation / distorted anatomy) / Deterioration despite endoscopic drainage
  —> **T-tube placement
• **Radiologic: Percutaneous transhepatic biliary drainage (PTBD)
  —> External type
  —> External-Internal type: tube go into duodenum (risk of **ascending infection of gut flora into bile duct)

Tokyo guideline 2013:
Grade 1 cholangitis —> Antibiotics + General supportive care —> **Elective Biliary drainage / **Finish course of antibiotics —> **Treatment for etiology if needed (e.g. **Cholecystectomy)
Grade 2 cholangitis —> Antibiotics + General supportive care + **Early Biliary drainage —> Treatment for etiology if needed
Grade 3 cholangitis —> Antibiotics + **General organ support + ***Urgent Biliary drainage —> Treatment for etiology if needed

Question 47

Mirizzi’s syndrome

Answer 47

Gallstone impacted in Cystic duct / Neck of gallbladder —> compression of CHD

Type 1: No fistula present
- Presence of cystic duct
- Obliteration of cystic duct
—> Just need to remove gallbladder + impacting stone

Type 2-4: Fistula present
- Defect smaller than 33% of CBD diameter
- Defect 33-66% of CBD diameter
- Defect >66% of CBD diameter
—> Need to perform reconstruction of fistula (e.g. Hepaticojejunostomy)

Question 48

T-tube placement during Surgical exploration of CBD

Answer 48

• Primary closure of CBD with inflammation —> high risk of leakage —> require T-tube placement
• T-tube induces formation of fibrous tract to skin (~6 weeks) —> Bile drain to skin —> Fibrous tract formed around T-tube serves as a conduit for ***choledochoscopy —> Extraction of residual stone not removed during previous surgical exploration

Purpose:
1. **Decompress bile duct
2. **Prevent bile leakage from suture line into peritoneal cavity
3. **Post-op cholangiogram to check residual stone
4. **Allow access for removal of residual stone

Action after T-tube cholangiogram:
No residual CBD stone after initial surgical exploration
—> Spigot T-tube (i.e. turn off the tap)
—> Fever —> Release spigot —> Re-do cholangiogram for possible CBD stone —> +ve residual stone —> Keep T-tube **6-8 weeks —> Choledochoscopy via fibrous T-tube tract
—> No fever —> Keep T-tube spigot for **4-6 weeks —> Remove T-tube