The Liver and Biliary Tree

Question 1

Ultrasound

Answer 1

Non-invasive so the first imaging investigation of choice in biliary or pancreatic disease.

Question 2

Computerised Tomography

Answer 2

Particularly if carried out on a helical or multi-slice scanner provides good views. It is useful for diagnosing and staging suspected tumours and identifying severity of pancreatitis.

Question 3

Magnetic Resonance Imaging

Answer 3

Non-invasive - useful for imaging the bile and pancreatic ducts– this is known as magnetic resonance cholangiopancreatography (MRCP).

MRI is also used for assessment of malignant tumours.

Question 4

Endoscopic Ultrasound

Answer 4

An ultrasound transducer on the end of an endoscope – provides good images of the pancreas, bile duct and gallbladder.

It is safer than ERCP particularly with regard to pancreatitis.

Question 5

ERCP

Answer 5

Endoscopic retrograde cholangiopancreatography – a side viewing endoscope is passed into the duodenum – the bile or pancreatic ducts can be cannulated and sphincterotomy and stone extraction is also possible.

Complications can include acute pancreatitis, bleeding, perforation and cholangitis.

Question 6

Percutaneous transhepatic cholangiography

Answer 6

Percutaneous access to the biliary tract is mainly used in patients with a hilar obstruction or where ERCP has failed to relieve the biliary obstruction.

Question 7

Liver or Pancreatic Biopsy

Answer 7

If the patient has a liver or pancreatic tumour which is suspicious of malignancy biopsy is not usually necessary and may risk causing peritoneal metastases.

Liver biopsy is used for parenchymal disease e.g. cirrhosis and pancreatic biopsy when the diagnosis is uncertain.

Question 8

Gallstones - Bile and Types of Stones

Answer 8

Bile contains cholesterol, bile pigments (from broken down haemoglobin) and phospholipids. If the concentrations vary different stones may form:

• Pigment stones - <10% - small and irregular stones caused by haemolysis.
• **Cholesterol stones - **75% - large, often solitary stones caused by being female, age or obesity.
• **Mixed stones - **may contain calcium salts, pigment and cholesterol.

Question 9

Gallstones - Epidemiology and Risk Factors

Answer 9

• Epidemiology – gallstones affect 8% of patients over the age of 40 although 90% are asymptomatic.
• Predisposing factors – female sex (3 times more common), obesity, age (10% of >50 year olds and 30% of >70 year olds), haemolytic anaemia, hyperlipidaemia, Crohn’s disease and pregnancy.
• Amirand’s triangle – increased cholesterol and decreased lecithin and bile salts increase the risk.

Question 10

Gallstones - Complications

Answer 10

Can occur in the:

• Gallbladder - biliary colic, acute or chronic Cholecystitis, empyema, mucocoele, carcinoma or Mirizzi’s syndrome
• Bile ducts - obstructive jaundice, pancreatitis or cholangitis.
• Gastrointestinal tract - gallstone ileus.

Question 11

Acute Cholecystitis - Definition

Answer 11

Follows stone or sludge impaction in the neck of the gallbladder which may cause continuous epigastric or right upper quadrant pain (can be referred to the right shoulder), vomiting, fever, local peritonism or a gallbladder mass.

The main difference from biliary colic is the **inflammatory component - **local peritonism, fever and a raised white cell count.

If the gallstone moves into the **common bile duct **obstructive jaundice and cholangitis (infection of the bile duct) may also occur.

Question 12

Acute Cholecystitis - Phlegmon and Murphy’s Sign

Answer 12

• Phlegmon – a RUQ mass of inflamed adherent omentum and bowel which may be palpable.
• Murphy’s sign – lay 2 fingers over the right upper quadrant and ask the patient to breathe in. This causes pain and arrest of inspiration as an inflamed gallbladder impinges on your fingers. However the test can only be called positive if the same action in the LUQ does not cause pain.

Question 13

Acute Cholecystitis - Investigations

Answer 13

• Bloods – FBC (raised WCC), U+Es, LFTs, and amylase.
• Ultrasound - thick wall and shrunken gallbladder, pericholecystic fluid, stones or dilated common bile duct if >6mm.
• HIDA cholescintigraphy - a radioisotope scan – HIDA is taken up by the liver and excreted in the bile – if the cystic duct is patent it will effectively fill the gallbladder excluding cholecystitis. It can be useful if diagnosis is still uncertain following an ultrasound although rarely performed.

Question 14

Acute Cholecystitis - Management

Answer 14

Keep nil by mouth, give pain relief, IV fluids, antibiotics e.g. 1.5g cefuroxime IV TDS and consider cholecystectomy within 72 hours – laparoscopic if definitely no perforation.

If surgery is delayed relapse occurs in 18% and may be associated with more complications.

Question 15

Chronic Cholecystitis - Definition and Differential

Answer 15

There is chronic inflammation ± colic which leads to ‘flatulent dyspepsia’. Symptoms include vague abdominal discomfort, distension, nausea, flatulence and fat intolerance.

If symptoms persist – consider hiatus hernia, IBS, peptic ulcer, relapsing pancreatitis or tumour.

Question 16

Chronic Cholecystitis - Investigation and Management

Answer 16

• Investigations – ultrasound to image the stones and assess dilation of the common bile duct.
• Management – cholecystectomy and if ultrasound shows a dilated CBD with stones an ERCP (endoscopic retrograde cholangiopancreatography) and sphincterotomy before surgery.

Question 17

Biliary Colic

Answer 17

Gallstones are symptomatic – pain is caused by gallbladder muscle spasms against a stone stuck in the neck of the gallbladder (Hartmann’s pouch) or the cystic duct.

There is continuous epigastric or right upper quadrant pain (can radiate to the back) which can be severe causing patients to be sweaty, pale and tachycardic.

There may also be nausea, vomiting and in some cases jaundice. Patients are unable to lie still on the bed (unlike acute cholecystitis where patients lie very still).

Management – give analgesia, rehydrate, keep NBM, ultrasound and elective cholecystectomy.

Question 18

Obstructive Jaundice with CBD Stones

Answer 18

If LFTs are worsening perform an ERCP with sphincterotomy ± biliary trawl or cholecystectomy or open surgery with CBD exploration may be required.

Question 19

Chalangitis

Answer 19

Infection of the bile duct causing right upper quadrant pain, jaundice and rigors (Charcot’s triad).

Treat with antibiotics - 1.5g Cefuroxime IV TDS and 500mg Metronidazole IV TDS.

Question 20

Gallstone Ileus

Answer 20

A stone erodes through the gallbladder into the duodenum and may then obstruct the terminal ileum.

Abdo x-ray shows air in the common bile duct (pneumobilia), small bowel fluid levels and a visible gallstone.

Treatment is removal of the stone via enterotomy.

Question 21

Mucocoele

Answer 21

An obstructed gallbladder fills with mucus secreted by the walls.

Question 22

Silent Gallstones

Answer 22

Perform elective surgery on those with sickle cell or the immunosuppressed.

Question 23

Mirizzi’s Syndrome

Answer 23

A stone in the gallbladder presses on the bile duct causing jaundice.

Question 24

Cholecystectomy - Procedure

Answer 24

An open cholecystectomy is only indicated in difficult cases or when a laproscopic procedure has failed.

The gallbladder is dissected off the liver, the cystic artery and cystic duct are then identified, ligated and divided (there is no cystic vein).

Great care is taken to not damage the bile duct.

Question 25

Lap Chole - Advantages and Disadvantages

Answer 25

• Advantages – attributable to smaller wounds used for laparoscopic ports – less postoperative pain, less chance of wound infection, reduced postoperative chest complications and an earlier mobilisation and discharge from hospital as well as earlier return to work.
• Disadvantages – need for special equipment and training, loss of tactile feedback, the potential for tumour implantation at port sites if an incidental malignancy is found and complications are more difficult to deal with e.g. haemostasis where the blood obscures the field of vision.

Question 26

Lap Chole - Contraindications

Answer 26

Suspected malignancy, patients with a bleeding disorder or portal hypertension.

Multiple adhesions may make laparoscopy more difficult but not impossible.

Question 27

Cholecystectomy - General Complications

Answer 27

The increased intra-abdominal pressure when the pneumoperitoneum is created can lead to a decreased venous return and hence cause strain to the heart and lungs.

Rarely a CO2 embolism can occur which causes hypoxia and have a rapid reduction in cardiac output.

Question 28

Cholecystectomy - Specific Complications

Answer 28

Bleeding from the cystic or hepatic artery may be more difficult to deal with laparoscopically.

The incidence of common bile duct injury is equal in both procedures but may be more difficult to recognise in laparoscopic procedures.

Instrumental injury e.g. thermocoagulation of tissues with diathermy dissection used in laparoscopic surgery.

Question 29

Gallbladder Carcinoma

Answer 29

Relatively rare malignancy and unfortunately most cases are advanced at presentation. It is associated with long standing gallstones, polyps or calcification of the gallbladder. The last 2 associations (polyp >1cm) are indications for cholecystectomy.

If gallbladder carcinoma is suspected pre-operatively an open procedure should be performed and a retrieval bag used to prevent reoccurrence at laparotomy port sites.

A second operation involving resection of the gallbladder bed of the liver, the extra hepatic biliary tree and radical hilar lymphadenectomy is later performed.