Hepatobiliary MCQs In patients aged less than 55 years with normal CBD on USS and normal - PowerPoint Presentation

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Hepatobiliary MCQs

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In

patients aged less than 55 years with normal CBD on USS and normal LFT's the incidence of CBD stones is 5%.

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Common bile duct stones

In the West CBD stones typically originate in the gallbladder and migrate into the CBD. Primary CBD stones may develop de novo and underlying parasitic infections are a recognised precipitant. In

those patients with normal CBD on USS and normal LFTs the incidence of CBD stones at the time of cholecystectomy is unlikely to exceed 5% and is the rationale for not performing OTC as a

routine.

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Common bile duct

stones: DiagnosisUSS: Not sensitive – why ?Intra-operative cholangiogramCT scanERCPMRCPEndoscopic Ultrasound (EUS)Laparoscopic Ultrasound

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Aetiology

Most benign bile duct strictures are the result of iatrogenic injury during surgery. The commonest cause of malignant strictures is pancreatic cancer. Most of the benign biliary strictures following injury during cholecystectomy go unrecognized at the time of surgery (as many as 75% of cases).

Presentation

after more than 5 years may occur in 30% of cases; therefore, a history of recent or past cholecystectomy should be sought in all cases.

Other

causes of strictures

include:

P

rimary

S

clerosing

C

holangitis (strictures

, beading, and irregularities of the intrahepatic and extrahepatic bile

ducts).

Abdominal radiotherapy

HIV

/ AIDS,

liver

transplantation, trauma

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Treatment of biliary strictures

Treat cholangitis (iv antibiotics & fluids)Biliary decompression, usually via ERCP. Non-resectable malignant strictures are best palliated with metallic stent insertion. Treatments for benign strictures include

stents / endoscopic dilatation

or surgical

bypass e.g. hepatico-jejunostomy.

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Management of acute pancreatitis – some rules

Antibiotics have

no role

for non infected acute pancreatitis.

ERCP

should be performed

early

(<72hrs)

in

those with gallstone related biliary

obstruction

Sphincterotomy

should generally be performed irrespective of whether stones are found, if the attack is severe and gallstones the aetiology.

All

patients with gallstone pancreatitis who are fit enough should undergo cholecystectomy once medically stable either during the index admission or within 2 weeks of it. Imaging of the bile duct should be performed pre or peri operatively.

Patients with >30% necrosis and symptoms should undergo radiologically guided FNA and culture of the areas, this is to allow conservative management of non infected cases.

Patients with

infected necrosis

should generally undergo surgical debridement and closed lavage systems.

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Pancreatitis

Pancreatitis is one of the most common serious complication of ERCPTransient rise in pancreatic amylase may be noted in up to 75% of patients undergoing the procedure. The

incidence is approximately 3.5%.

Reducing

the risk of pancreatitis

Administration of indomethacin

Temporary pancreatic duct stents

Wire guided cannulation

Risk factors for post ERCP pancreatitis

Normal bilirubin

Young age

Pancreatic duct injection

Precut sphincterotomy

Balloon dilatation of sphincter

Sphincter of Oddi dysfunction

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Other complications of ERCP

BleedingOccurs most often following sphincterotomy and is intra luminalOccurs in 1.3% of cases

Severe haemorrhage has an incidence of less than 1 in 1000

Perforation

Occur in 0.6% - 1% of cases

Both malignancy and pre cut access increase the risk of perforation

Cholangitis

Occurs in 1% of cases

Incidence may be reduced by use of antibiotics when an obstructed duct is not completely cleared

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Pancreatic

divisumMost common congenital anomaly of the pancreas (7% of population)Occurs as a result of a failure of the dorsal and ventral pancreatic buds to fuse antenatallyMost cases are asymptomatic. Where symptoms do occur they may be the result of raised pancreatic pressures

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Liver metastasis from colorectal cancer

70% of patients with metastatic colorectal cancer will have disease that is confined to the liver. Detection is usually made using CT scanning. Hypoattentuating on CT. Only

15% of patients will have disease that is surgically resectable.

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Liver metastasis from colorectal cancer

FOLFOX 4 chemotherapy regime is standard (oxaliplatin, fluorouracil and folinic acid).Given prior to liver resection. A

regime lasting 3 months is usually

favored

Recurrence is seen in up to 60% of patients undergoing surgical resection of liver metastasis.

Usually

within the first 1-2 years.

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Stents for resectable pancreatic CA

Both benign and malignant biliary obstruction may be treated by placement of stents. These may be either plastic tubes or self expanding metallic stents.

The

use of routine preoperative biliary drainage in the setting of pancreatic cancer with biliary obstruction is controversial.

Prospective

studies have shown that complications related to preoperative biliary drainage using endoscopic placement of traditional plastic endoprostheses increase the overall morbidity compared to pancreaticoduodenectomy alone.

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Abdominal Emergencies Pregnancy

Cholecystectomy performed in the second trimester is the safest option and that which is associated with the lowest morbidity for mother and child.Appendicitis

is the most common non obstetric cause of abdominal pain in pregnancy resulting in laparotomy and the foetal loss rate approaches 35%. Because of diagnostic uncertainty the perforation rate is 55% (hence the high rate of foetal loss)

.

Biliary disease

is also common in pregnancy and gallstones may form as a complication of biliary stasis (progesterone causes reduced gallbladder contraction).

Acute

cholecystitis

– surgery in

the second

trimester

is usually advised

.

Pancreatitis

may occur in the pregnant women (1 in 1000). The two most common causes are gallstones and hypertriglyceridaemia.

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Hydatid cysts

Hydatid cysts are endemic in Mediterranean and Middle Eastern countries. They are caused by the tapeworm parasite Echinococcus granulosus. An outer fibrous capsule is formed containing multiple small daughter cysts.

These

cysts are allergens which precipitate a type 1 hypersensitivity reaction.

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Hydatid

cystsUp to 90% cysts occur in the liver and lungsCan be asymptomatic, or symptomatic if cysts > 5cm in diameterMorbidity caused by cyst bursting, infection and organ dysfunction (biliary, bronchial, renal and cerebrospinal fluid outflow obstruction)In biliary

rupture

there may be the classical triad of; biliary colic, jaundice, and urticaria

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Hydatid

cystsIn fit patients with hydatid disease the best option is generally surgical excision. During the operation the operating field is draped with drapes impregnated with hypertonic saline to minimise the dangers associated with cyst spillage. Options range from peeling off the endocyst layer from the exocyst layer, with marsupialisation of the cyst cavity. Peripherally sited lesions may be considered for formal resection.

Medical

therapy with mebendazole may be used to provide peri-operative cover.

There is no role for percutaneous treatment

.

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Pancreatic

injury in splenectomyThe tail of the pancreas lies adjacent to the hilum of the spleen and is thus vulnerable to injury. Injury to the pancreatic tail may cause a pancreatic fistula.

Initial

management is easier if a drain was placed at the time of surgery.

In

most cases distal pancreatic fistulae will heal with conservative management and nutritional support.

The

use of TPN

to reduce pancreatic

stimulation may be beneficial and considered at an early stage.

Decompression of the pancreas with ERCP, sphincterotomy and stent insertion may be beneficial for very high output fistula.

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Blood

supply to bile duct60% from gastroduodenal artery

40

% from the hepatic artery

The bile duct has an axial blood supply which is derived from the cystic and right hepatic

arteries.

Unlike

the liver there is no contribution by the portal vein to the blood supply of the bile duct.

Damage

to the hepatic artery during a difficult cholecystectomy is a recognised cause of bile duct strictures.

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