Lecture 17 Hepato-Biliary Surgery

Question 1

What are the functions of the gall bladder

Answer 1

• Bile reservoir

* Concentrates bile

Question 2

When is bile secreted and what causes it

Answer 2

After a meal

CC

Question 3

What is Cholesterolosis

Answer 3

Change in gall bladder wall due to excess cholesterol

Question 4

Name Gallstone diseases

Answer 4

Cholesterolosis

Polyps

Question 5

What compositions can gallstones be

Answer 5

Mixed
Cholesterol
Pigment

Question 6

What are the risk factors for gallstones

Answer 6

• Age
• Gender
• Parity + OCP (4F)- Fat, Female, Forty, fertile
• Cholesterol: obesity, ileal disease, cirrhosis, cystic fibrosis, DM, TPN, heart transplant, delayed GB emptying, clofibrate, long-term low-fat diet
• Pigment (far east): M=F, haemolytic anaemia, bile infection (e-coli, Bacteroides)

Question 7

What is the presentation of someone who has gallstones

Answer 7

• Asymptomatic
• Dyspeptic symptoms (flatulence)
• Biliary colic (pain causes by a gallstone temporarily blocking the cystic duct)
• Acute cholecystitis
• Empyema
• Perforation
• Jaundice (Mirrizi’s Syn.)
• Gallstone Ileus

Question 8

What is Choledocho-lithiasis

Answer 8

Common bile duct stones

Question 9

What signs and symptoms comes with gall stones in the common bile duct

Answer 9

Obstructive jaundice
Pain
Dark urine
Pale stule
Pruritus
Steatorrhea

Question 10

Why does a blockage in the common bile duct cause jaundice

Answer 10

When the bile ducts become blocked, bile builds up in the liver, and jaundice (yellow colour of the skin) develops due to the increasing level of bilirubin in the blood

Question 11

How is bilirubin formed

Answer 11

Formed by the breakdown of red blood cells and the liver helps excrete it

Question 12

What is ascending cholangitis

Answer 12

Charcot’s triad

Infection of the bile duct in the liver

Question 13

What are the symptoms of ascending cholangitis

Answer 13

Jaundice
Fever
Rigors
RUQ abdominal pain

Question 14

Investigations for gallbladder disease

Answer 14

•	Blood tests: 
–	LFT’s: AST, ALT, ALP
–	Amylase, Lipase
–	WCC
•	USS
•	EUS
•	Oral cholecystography
•	CT scan
•	Radio iso-tope scan (HIDA)
•	IV cholangiography
•	MRCP (Magnetic resonance cholangiopancreatography)
•	PTC (Percutaneous transhepatic cholangiography)- 
•	ERCP (Endoscopic retrograde cholangiopancreatography)

Question 15

Treatment

Answer 15

• Open cholecystectomy- large incision
• Mini-cholecystectomy- small incision under the rib
• Laparoscopic cholecystectomy +/- OTC “Gold Standard” – 4 incisions are made and a laparoscope with a camera is used with instruments to remove gall bladder
• Subtotal Cholecystectomy

Question 16

Name a benign biliary tract disease

Answer 16

Biliary atresia

Question 17

What is primary sclerosing Cholangitis

Answer 17

inflammation and scarring of the bile ducts which normally allow bile to drain from the gallbladder (autoimmune disease)

Question 18

What are the types of Cholangiocarcinoma

Answer 18

Intrahepatic or extra hepatic
Mass like
Periductal
Intra-ductal

Question 19

Presentation of cholangiocarcinoma

Answer 19

• Obstructive jaundice
• Itching
• None-specific symptoms

Question 20

What are the investigations for Cholangiocarcinoma

Answer 20

• Radiology: USS, EUS, CT, MRA, MRCP, PTC, Angiography, FDG PET
• ERCP, Cholangioscopy and Cytology

Question 21

Management of Cholnagiocarcinoma

Answer 21

•	Surgical: only potential curative option
Palliative:
•	Surgical bypass
•	Stenting (Percutaneous vs Endoscopic)
•	Palliative radiotherapy
•	Chemotherapy
•	PDT
•	liver transplant (not standard)

Question 22

What are Ampullary Tumours

Answer 22

cancer between the bile duct and small opening that enters into the first portion of the small intestine, known as the duodenum

Question 23

Treatment options for ampullary tumours

Answer 23

Endoscopic excision
Transduodenal excision
Pancreatico-duodenectomy