Part two - biliary

Question 1

What types of gallbladder polyps are there?

Answer 1

BENIGN

• Cholesterol polyps - 60%
• Adenomyomas - 25%
• Inflammatory polyps - 10%
• Adenoma - 4%
• Miscellaneous - 1%
• —Lipoma
• —Leiomyoma
• —Fibroma…

MALIGNANT

• Adenocarcinoma - 80%
• Miscellaneous - 20%
• —Mucinous cystadenoma
• —SCC
• —Adenocanthoma

Question 2

Define extended cholecystectomy

Answer 2

Cholecystectomy with a rim of liver tissue

Question 3

Complications of ERCP

Answer 3

Pancreatitis 5%
Perforation & bleeding perforation and migration (rare)

Increased risk in young females

Question 4

Classification of choledochal cysts

Answer 4

Todani Classification - 1977
1 - Extrahepatic saccular/fusiform - 50%
2 - Diverticular out pouching of CBD - <1%
3 - Distal CBD (intraduodenal) choledochocele - 10%
4a - Multiple intra- and extrahepatic cysts - 30%
4b - Multiple extra-hepatic cysts - within 30% above
5 - Multiple intra-hepatic cysts with hepatic fibrosis - 10%

Question 5

Aetiology of choledochal cysts

Answer 5

Common channel theory

Usually separate ducts but when common the only control is by the common channel sphincter with increased reflux of pancreatic juice into bid duct resulting in cystic dilatation and increased ductal pressure and abnormal sphincter of Oddi function.

Question 6

Define Mirizzi syndrome

Answer 6

Obstruction of the biliary tree due to extrinsic compression from a gallstone impacted in the gallbladder neck /Hartmann’s pouch/cystic duct

Question 7

McSherry classification of Mirizzi syndrome

Answer 7

Type I - Compression

Type II - Erosion

Question 8

Csendes classification of Mirizzi syndrome

Answer 8

Type I - External compression only
Type II - Erosion < 1/3 of bile duct circumference
Type III - Erosion up to 2/3 of bile duct circumference
Type IV - Complete destruction of bile duct wall

Question 9

Pathogenesis of choledochal cysts

Answer 9

APBJ = abnormal pancreaticobiliary junction = pancreaticobiliary malfunction or malunion

Long common channel -> reflux of pancreatic juice into biliary tree -> damage to epithelium and cyst formation

Question 10

Courvoisier’s law

Answer 10

In the presence of a non-tender palpable gallbladder, painless jaundice is unlikely to be caused by gallstones

Question 11

Blood supply to CBD

Answer 11

A plexus around the duct:

• Posterior superior PDA
• Cystic artery
• +/- GDA
• +/- hepatic artery

If dividing the CBD do it as high as possible as most of the blood supply comes from below

Question 12

Complications of ERCP

Answer 12

Pancreatitis - 4%
Bleeding - 1%
Perforation - 1%
Ascending biliary infection - 1%
Death <1%

Question 13

Complications of MRCP

Answer 13

Nephrogenis fibrosing dermopathy in patients with severe renal disease.

Rare condition resulting in tightened, swollen skin. Predominantly affects the skin, but abnormal fibrosis of the internal organs may also occur, which is then often called nephrogenic systemic fibrosis.

Question 14

Calot’s triangle

Answer 14

Cystic duct
Cystic artery
Common hepatic duct

One of the conditions of the critical view of safety

Question 15

Critical view of safety

Answer 15

1. Calot’s triangle dissected
2. Lowest part of GB separated from cystic plate
3. Only two structures seen entering gallbladder

Question 16

Hepatocystic triangle

Answer 16

Inferior edge of liver
Cystic duct
Common hepatic duct

Right hepatic artery runs through it

Question 17

Renyold’s pentad

Answer 17

Charcot’s triad for cholangitis + hypotension and confusion for suppurative cholangitis