Gallbladder and Liver

Question 1

Cholangiocarcinoma - classification

Answer 1

according to the tumor’s location-

1. Proximal (klatskin- dilation of intrahepatic bile-ducts).
2. Bifurcation.
3. Distal.

Question 2

Biopsy in Cholangiocarcinoma

Answer 2

1. Not reliable in the presence of jaundice.

2. Is indicated in patients who are not a candidates for surgical treatment.

Question 3

Drainage of the bile duct prior to surgery in case of Cholangiocarcinoma?

Answer 3

Is performed in patients with DISTAL tumor and bilirubin > 10.

1. ERCP.
2. If unsuccessful - PTBD (percutaneous transhepatic biliary drainage).

Question 4

Proximal (Klatskin) Cholangiocarcinoma Tx.

Answer 4

Surgery: Hepatodudenostomy.

Question 5

Contraindications for surgery in Cholangiocarcinoma

Answer 5

1. Liver mets to more than two lobes of liver.
2. Involvement of more than two secondary bile ducts.
3. Non hepatic mets.
4. Involvement of the portal vein.
5. Bilateral involvement of lobar hepatic artery.

Question 6

Portal vein pyelophlebitis

Answer 6

Acquired through ascending infection from the GIT.
Diverticulitis and appendicitis - most common causes.
Others: pancreatitis, IBD, PID, omphalitis.

Question 7

Caroli disease

Answer 7

Ectasia of the intrahepatic bile ducts.

Question 8

Bile duct injury after cholecystectomy - symptoms

Answer 8

1. Leak from darinage.
2. Jaundice.
3. Elevated ALP.
4. Fever.
5. Abdominal pain

Question 9

Bile duct injury after cholecystectomy - Tx.

Answer 9

1. Antibiotics, drainage, and cholangiography.
2. followed by stenting and surgery for reconstructions of the biliary tree.
3. If occurs during cholecystectomy- proceed to laparotomy.

Question 10

Gallbladder cancer - Tx.

Answer 10

1. Radical cholecystectomy- includes lymph nodes (periportal, hepatoduodenal and right celiac), cystic duct, sometimes common bile duct, resection of 2cm of liver bed, and resection of the portal area.
   * Indicated in case of: vascular, lymph or perineural involvement.

Question 11

T1B Gallbladder cancer without vascular, lymph or perineural involvement - Tx.

Answer 11

Simple cholecystectomy

Question 12

Septic shock + emphysematous cholecystitis (due to gas forming organism) - Tx.

Answer 12

Emergent cholecystectomy

Question 13

Indications for elective cholecystectomy in asymptomatic patients

Answer 13

1. Hemolytic anemia.
2. Increased risk for gallbladder cancer: porcelain gallbladder, stone >2.5cm, long common segment of bile and pancreatic ducts.
3. Bariatric surgery.
4. Prior to organ transplantion.

Question 14

Charcot triad

Answer 14

1. Fever
2. RUQ pain
3. Jaundice.
   Associated with acute cholangitis.

Question 15

Reynold’s pentad

Answer 15

Charcot triad + shock (hypotension) + altered mental status.

Question 16

Acute Cholengitis Tx.

Answer 16

1. Unstable patient (e.g. shock): fluids + broad-spectrum AB, followed by ERCP (remove obstruction + papila-sphincterotomy).
2. Stable patient- ERCP.

Question 17

Cullen sign

Answer 17

Periumbilical echimosis, associated with hemoperitoneum (e.g. hemorrhagic pancreatitis).

Question 18

Rovsing sign

Answer 18

Pain at McBurney point when compressing the LLQ

Question 19

Primary biliary cirrhosis

Answer 19

1. Painless obstructive jaundice.
2. Narrowing of bile ducts.
3. AMA positive.
   Dx. & Tx. - ERCP, Ursodeoxycholic acid.

Question 20

Gallbladder- normal size

Answer 20

Length: 7-10 cm
Diameter: 3-4 cm

Question 21

Ascending cholangitis - common pathogens

Answer 21

E. coli > Klebsiella > Enterococcus > Enterobacter > Pseudomonas > Citrobacter.

Question 22

Acalculous cholecystitis in critically ill patient (e.g. ICU) - Tx.

Answer 22

Percutaneous cholecytostomy = percutaneous drainage of the gallbladder.

Question 23

PTBD - percutaneous transhepatic biliary drainage

Answer 23

Is indicated in case that the obstruction is located inside the liver.

Question 24

Amebic liver abscess

Answer 24

1. Caused by entameba histolytica.
2. Anamnesis- travel to endemic area (africa, jordan). 3. Presentation- RUQ pain, diarrhea, fever, NO jaundice. 4. US- single cyst in the periphery, with peripheral enhancement.
3. Tx.- non-surgical, with metronidzole 750mg orallyx3 for 10 days, luminal agent- paromomycin.

Question 25

Echinococcal liver cyst

Answer 25

Imaging: Hydatid cyst with daughter cysts, septa or calcifications. Tx. 1. Primarily treated surgically (avoid rupture due to anaphylaxis). 2. Albendazole. 3. PAIR (percutaneous aspiration, injection, reaspiration).

Question 26

Pyogenic liver abscess

Answer 26

1. Classic presentation: fever, jaundice and RUQ. | 2. Tx. : Percutaneous drainage.

Question 27

MELD score

Answer 27

1. Bilirubin. 2. INR. 3. Cr. 4. Na level. Objective score, reflects the likelihood for mortality within 3 moths while waiting for liver transplantation.

Question 28

Child-Pugh score

Answer 28

1. Bilirubin. 2. PT (INR). 3. Albumin. 4. Ascites. 5. Encephalopathy. Quantifies the operative risk in cirrhotic patients.

Question 29

Liver adenomas

Answer 29

1. Woman with OCP: stop OCP and follow-up. 2. Pregnant women: resection because the course is unpredictable during pregnancy. 3. Active Hemorrhage: angio-embolization is indicated. 4. Symptomatic adenoma: removal is indicated.

Question 30

Hepatic FNH (focal nodular hyperplasia)

Answer 30

1. Usually less than 5cm. 2. incidental finding. 3. Imaging: enhanced during ARTERIAL phase with central fibrotic scar. 4. DDx: liver adenoma, HCC. 5. There is no need to stop OCP. 6. Asymptomatic patients: with definitive diagnosis- no further workup. If definitive diagnosis cannot be made- resection. 7. Symptomatic: radiological follow-up. If grows or unresolving symptoms-resection.

Question 31

Liver Hemangioma

Answer 31

1. Usually smaller than 5cm. 2. Imaging: Peripheral enhancement and centripetal filling. 3. Clinical course of hemangioma is benign, only significant size will be excised. 4. complication: Kasabach-Merrit syndrome.

Question 32

Kasabach-Merrit syndrome

Answer 32

1. Type of consumptive coagulopathy, associated with liver hemangioma. 2. Thrombocytopenia and coagulopathy due to PLT & coagulation factors overuse.

Question 33

HCC - indications for resection

Answer 33

Resection is indicated in patients that do not fulfil the Milan criteria and do not have portal hypertension + child-Pugh A.

Question 34

HCC - indications for TACE (trans-arterial chemoembolization)

Answer 34

TACE is indicated in patient with preserved liver function, multinodular disease, without vascular invasion.

Question 35

HCC- indications for ablation

Answer 35

Ablation is indicated in patient with tumor > 3cm and multiple comorbidities.

Question 36

Surgery in cirrhotic patients

Answer 36

``` Child-Pugh A+B >> correct ascites and coagulopathy, then operate. Child-pugh C >> postpone surgery until improve class or cancel. Surgery is CI at this stage. ```