HPB Flashcards
What are the types of Choledochal cysts?
5 types
1) Dilatation of CBD (80-90%)
2) Cystic diverticulum of CBD
3) Arising from duodenal CBD at ampulla
4) Cystic dilatations of both intra- and extra-hepatic biliary tree
4a) L/R HD and CBD (15%) L»R
4b) CHD and CBD
5) Cystic dilatation of intrahepatic biliary tree only
Malignancy risk 1/4 8% –> 2% with treatment
2/3/5 5% –> c.0% with treatment
What is the eponymous name for a type 5 Choledochal cyst?
Caroli’s disease
What type Choledochal cyst is found with Caroli’s disease?
Type 5
How are choledochal cysts managed?
Usually with complete duct excision/reconstruction
Risk of pancreatitis, cholangitis, stricture, malignancy (6-30%, usually type 1/4a)
Infants also need early excision due to risk of liver fibrosis (<1month)
Risk of biliary malignancy persists after excision
Type 4 may need hepatectomy or liver transplant, others can usually be managed with Roux-en-y
What are some characteristics associated with Choledochal cysts?
F:M = 4:1
Increased risk with anomalous pancreaticobiliary duct union (APBDU) or long common channel >10mm due to risk of enzyme reflux
80% present in childhood
What is Mirrizzi Syndrome?
Compression of common hepatic duct by gallstone/gallbladder
Csendes classfication
1) Extrinsic compression
2)Involvement of <1/3 CBD circumference
3) Involvement of 1/3-2/3 CBD circumference
4) Complete destruction of CBD wall
5) Any + fistula
Is HCC more common in Men or Women?
Men.
Less risk with PBC
Screen with USS and AFP
In which patients with CRLM should ablative therapies be offered?
Only in those not suitable for liver resection.
-Selective internal radiation therapy (SIRT) is not recommended at present outside of research programmes
What adjunctive treaments should be given to patients undergoing surgery for CRLM?
Combination chemotherapy –> higher DFS and prob OS
What complications can occur after RFA for CRLM?
Bleeding, biliary tree injury, sepsis in 9%
What factors are most prognostic of severe pancreatitis at presentation?
APACHE II>8
Obesity
What factors are most prognostic of severe pancreatitis at 48hrs?
Glasgow score ≥3
CRP >150
Persistent organ failure
What proportion of cases of pancreatitis are classified as idiopathic?
<20%
What proportion of cases of pancreatitis are related to gallstones and alcohol?
35% and 25% respectively
What is the primary means of improving pain control in patients with chronic pancreatitis?
Alcohol abstinence
What is the effect of beta blockade on bleeding prophylaxis for varices?
Reduction from 25-15% over 24 months, with no difference in overall mortality.
Following bleeding reduction of 7% mortality
What are the classification systems for CBD Injury?
Strasberg (A:E)
Bismuth (1:5)
What is the Strasberg classification for BDI?
A - cystic duct/liver bed leak
B - partial ligation of biliary tree (mostly aberrant right hepatic)
C - partial transection of biliary tree not communicating with CBD
D - lateral injury of biliary system without loss of continuity
E - Ligation/division of biliary tree
How does the Bismuth classification integrate with the Strasberg system?
Subdivides Strasberg E
E1 - CHD >2cm
E2 - CHD<2cm
E3 - hilum at confliuence
E4 - above hilum
E5 - Hilar injury + Strasberg C
What is the incidence of cancer in a porcelain gallbladder?
6-10%
In which patients with gallbladder polyps should Lap Chole be performed?
≥10mm or symptomatic
How should <1cm GB polyps be followed up?
If ‘high risk’ (Age >50, PSC, Indian, Sessile)
<6mm - US at 6months then annually
6-9mm - Cholecystectomy
Otherwise
<6mm US at 1,3,5 years
6-9mm - US 6 months then annually
If increases by 2mm or more –> cholecystectomy
EAES guidelines
What is the survival for patients undergoing potentially curative resection for cholangiocarcinoma?
25-40% at 5 years.
Chemoradio resistant
What are some characteristic findings of PSC?
Reveresed portal venous flow and early portal hypertension
After sphincterotomy and balloon trawl, how frequent is recurrent cholecystitis (elderly)?
80% no further episodes
What is the second most common manifestation of MEN-1
Gastrinoma (after Parathyroid)
What is Budd-Chiari syndrome?
Occlusion of hepatic veins, presenting with pain, hepatomegaly and ascites
May be associated with OCP use or thrombophilic tendencies
Treat with TIPPS
Who should receive screening for HCC?
Cirrhotic patients (any cause) Should have 6 monthly USS +/- AFP (unless Hep B then def AFP)
Which patients with pancreatic cysts should be referred for resection?
1) Obstructive jaundice with cystic lesions in head
2) Enhancing solid component in cyst
3) Main pancreatic duct ≥10mm
Consider FNAC if more information needed + CEA assay
Which patients should have surveillance for pancreatic cancer?
- Hereditary pancreatitis and a PRSS1 mutation
- BRCA1/2, PALB2/CDKN2a mutations with 1+ FDR
- Peutz Jaegers syndrome
-Consider with 2 FDR or Lynch syndrome
Screen with MRI/MRCP/EUS
In hereditary pancreatitis offer pancreatic CT
What nutritional support is required for patients with pancreatic cancer?
Pancreatin (creon)
When should patients receive neoadjuvant therapy for pancreatic cancer?
For borderline resectable, as part of a trial.
However the recent PREOPANC trial suggests that NACRT is beneficial regardless
What adjuvant treatment is recommended for pancreatic cancer?
Gemcitabine and capecitabine
What vessels influence resectability of a pancreatic adenocarcinoma?
Arteries - CHA, SMA, CA
Veins - SMV, PV
What defines a borderline resectable pancreatic tumour?
Arterial
1)Head
- Contact with CHA
- Contact with SMA≤180d
2)Body
Contact with CA≤180 or ≥180 without aorta or GDA
Venous
- Contact with SMV/PV >180d SMV/PV but reconstructable
- Contact with IVC
What defines a locally advanced/irresectable pancreatic tumour?
Arterial
1) Head - SMA/CA >180
2) Body - SMA/CA >180 or aortic involvement
Venous
Unreconstructable SMV/PV
In which pancreatic cystic neoplasm is Ca19-9 useful?
IPMN where there is suspicion of malignant transformation
What tests should be sent at EUS FNA for PCN?
CEA + Cytology/KRAS/GNAS and Lipase levels
Cannot differentiate between MCN/IPMN
What factors make IPMN at high risk of progression to malignancy?
-Jaundice
-Enhancing mural nodule ≥5mm
-MPD ≥10mm
High risk
MPD5-9.9, Cyst ≥40mm or enlarging ≥5mm per year increased risk
How should patients with IPMN be followed up?
6 monthly for 1 year then annually
What threshold of main duct dilatation should be take as an indication for surgery?
Absolute indication at >10mm, probably >5mm in either MD-IPMN or MT-IPMN if fit or other risk factor
Malignancy rate of 30-90%
Which size of mucinous cystic neoplasm should undergo surgical resection?
≥40mm or symptomatic or risk factors (mural nodule) or jaundice
What is the rate of malignancy transformation of serous cystic neoplasm?
0% this is benign - follow up for 1 year only and discharge
What factors increase the risk of a pancreatic fistula following Whipples?
Soft remnant (22%)
Age >70
Jaundice for long period (not severity)
CAD or EBL>1000ml
Preoperative CRT decreases the risk!
There may be a lower rate with pancreaticogastrostomy, but this is controversial. Stents and octreotide conflicting data
What is the risk of a pancreatic fistula after Whipple?
15% (lower for distal panc)
What is the most common cause of Haemobilia?
Trauma
Triad of pain, UGI bleed and jaundice
What is the optimal treatment of T2-3 GB cancer?
Formal resection of sections IVb and V
For T1 - open cholecystectomy and regional LN sampling
What future liver volume is required for resection in healthy patients?
> 20%.
For patients with significant liver disease this is 40%
If less than this, can conduct portal vein embolisation to induce enlargement of normal liver
What is the most common cause of benign biliary stricture?
Cholecystectomy, up to 75% unrecognised and 30% >5 years post surgery
What proportion of cases of PSC are associated with IBD?
70%
What are the principle risks of ERCP?
Bleeding 1%
Duodenal perforation 0.4%
Cholangitis 1.1%
Pancreatitis 3.5%
What is the most common composition of gallstones?
Mixed
20% Cholesterol
TPN can result in pigment stones
How are Hydatid cysts best treated?
Usually with surgery after instillation of mebendazole.
Care must be taken to avoid rupture which can cause a Type 1 hypersensitivity/ anaphylaxis
Echinococcus granulosus
How is pancreatic drainage affected by pancreatictic divisum?
The Duct of Santorini drains via the minor papilla and the duct of Wirsung drains via the major papilla
7% prevalence
What is the normal thickness of the GB wall?
<3mm
What medications can reduce the risk of post ERCP pancreatitis?
Indomethacin and possibly diclofenac
What are the risk factors for post ERCP Pancreatitis?
Normal bilirubin
Young age
Pancreatic duct injection
Precut sphincterotomy
Balloon dilatation of spinchter
SOD
What is a contraindication to TACE for HCC?
Portal vein thrombosis.
Sorafenib is useful in cases of irresectable disease.
What is the Barcelona Clinic Liver Classification for HCC?
Stage 0, A,B,C,D
What is the recommended treatment for Hepatocellular Adenomas?
If >5cm or symptomatic or male –> resection
Rupture risk >5cm –> 10% mortality
What is the recommended treatment for hepatic cyst adenomas?
Resection (10% malignant, cannot distinguish)
Most common R>L lobe 85% Female, 95% mucinous
What is the incidence of CBD stones with normal duct size and LFTs and age <55
5%
What is the minimum number of liver segments that must be preserved in liver resection?
2 contiguous
What are risk factors for pancreatic adenocarcinoma?
Smoking + ETOH ++
DM
Gallstones and cholecystectomy
Chronic pancreatitis (5% over 20 years)
What is the most common type of Choledochal cyst?
Type 1 - fusiform dilatation of CBD
What is the Todani classification?
Choledochal cysts
Type 1 - fusiform CBD (most common)
Type 2 - CBD diverticulum
Type 3 - Choledochocele (at ampulla)
Type 4 - type 1 extending to IHDs (second most common)
Type 5 - intrahepatic cystic disease (Carolis disease)
What is the risk of tumour seeding with HCC?
2.7%
What is the most common site of metastasis with HCC?
Lung (direct to IVC) > LN
When is a Kasai procedure used?
Congenital biliary atresia
Which type of gallstone is most frequently found in the CBD?
a Brown pigment stone
How does a Hydatid cyst classically present?
Triad of jaundice, pain and urticarial rash
How quickly does the liver regenerate following resection of sections 2/3
4-6months
How quickly does the liver regenerate following resection of sections 2/3
4-6months
What is the characteristic imaging finding for Focal nodular hyperplasia?
Stellate scar (70%)
Usually distinguished from Liver cell adenoma on MRI - iso or hypointense on T1 and iso or hyperintense on T2
What neoadjuvant treatment is given for CLRM?
Consideration of excision of primary tumour if symptomatic
FOLFOX +/- Cetuximab/Bevacizumab
What are the typical features of HCC on CT (3)?
1) Arterial enhancement
2) Rapid washout on porto-venous/delayed phase
3) Heterogenous appearance of tumour
What are the common causes of liver abscess?
Appendicitis, biliary, diverticulitis,
rarely tumours (consider colonoscopy)
How can a cholangiocarcinoma be differentiated from a HoP tumour on USS?
in Hilar cholangio (Klatskin) there is only intrahepatic biliary dilatation (not extra hepatic)
What proportion of PNETs are functioning?
10%
What is the incidence of R1/2 resection in Cholangiocarcinoma?
25%
How much bile is produced daily?
500-1500ml/day