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