Classification of cholangiocarcinomas
intrahepatic
extra hepatic
- upper duct
- distal CBD
Bismuth classification I: below confluence II: reaching confluence IIIA/B: conflu + R/L hepatic duct IV: multicentric/ confluence + both hepatic ducts
RF for cholangiocarcinoma
- Chronic cholestasis - prolonged inflammation
- PSC (a.w UC)
- parasitic infx
- hepatolithiasis
- viral hepatitis - Fibro-polycystic liver dz
- Caroli syndrome: diffuse intrahepatic ductal ectasia
- congenital hepatic fibrosis
- choledochal cyst
Types of periampullary tumours
- sign
pancreatic head
cholangioca (lower CBD)
periampullary duodenum CA
ampulla of vater CA
Thomas sign: silver stools
Causes of biliary strictures
- Iatrogenic
- lap cholecystectomy
- other sx: gastrectomy, hepatic resection
- ERCP - Inflammatory
- PSC
- recurrent pyogenic Cholangitis - Others;
- recurrent gall stones, pancreatitis, RT, parasites
- trauma - congenital:
biliary atresia
RF for acalculous cholecystitis
- v ill pt (ICU)
- sepsis w hypotension
- immunosuppression (HIV)
- major trauma, burns
- DM
- salmonella typhi infx
- prolonged NBM, TPN use
(high risk for perf and gangrene)
Differentiate biliary colic from acute cholecystitis
biliary colic:
- transient obstruction to cystic duct
- intermittent pain, post prandial, epigastric, visceral pain
acute cholecystitis
- bac infection
- pain of longer duration, localised to RHC
RF for gallbladder CA
- age
- chronic cholecystitis, cholelithiasis, calcification of gallbladder (porcelain gallbladder)
- mirizzi syndrome
Cholangitis Causes
choledocholithiasis
- benign strictures (instrumentation)
- CA (Panc, biliary)
- foreign body, parasites
- PSC, choledochal cyst, mirizzi
Cholangitis common causative org
gram neg bac and anerobes - klebsiella, e coli, enterobacter, enterococcus
normal CBD size
5mm normal in 50s
6mm in 60s and so on
when to do operative vs ERCP removal of stones
op:
- stone large >25mm
- intrahepatic
- large number
- impacted stone
- dual pathology
- tortuous duct
- previous bilroth (unsuitable anatomy)
ERCP
- not surgical candidates
- prev cholecystectomy
- acute cholangitis
US findings of acute cholecystitis
- thickened gallbladder wall (>3/4mm)
- sonographic murphy positive
- pericholecystic fluid
- presence of gallstone in biliary system
- contracted gallbladder (chronic gallstone dz)
Cx of cholecystectomy
Procedure:
- injury to bile duct, hepatic artery, bowel
- un-retrieved gallstone spillage - abscess, fistula
- retained stones in CBD
- incisional hernia
- post cholecystectomy syndrome
Post:
- reflux dz, biliary gastritis
- ab pain, diarrhoea (fat intolerance)
Lap risks: - conversion to open - injury: biliary system - spilled bile: peritonitis, sepsis GA: allergy, pneumonia, stroke, MI, death Gen: bleed, wound infx, DVT, PE
Cx of cholecystitis
- hydrops
- empyema
- gangrene/ perforation
- cholecystoenteric fistula
- gallstone ileus - SB IO at terminal ileum (2 feet proximal to ileocecal valve)
- emphysematous gb
timing of cholecystectomy
Emergency
- complicated acute cholecystitis (gangrene/ necrosis, perf/ emphy)
- progressive signs and symptoms (high fever, hemo instability, intractable pain in spite of best supportive care)
ASAI/II: within first 3 days
ASAIII-V: non sx, biliary drainage first then elective sx if possible
Types of gallstones
- Causes
- Cholesterol (85%)
- radiolucent
a. inc cholesterol secretion in bile [- fat, female, forty, fertile (estrogenic - preg, OCP)]
b. decreased emptying in gb [ca, preg, tpn, fasting, truncal vagotomy] - Pigment stones (15%): radioopaque - calcium salts
- black (sterile)
[inc bilirubin secretion: chronic hemolysis, cirrhosis, CLD, TPN, gb stasis]
- brown (infx)
[klebsiella infx, billiary stasis] - Mixed
- Biliary sludge
renal colic vs biliary colic
biliary colic = not true colic, no pain free intervals, but wax and wane. often wake pt from slp, few hr post meal
renal colic = pain free intervals
Features of normal cholangiopancreatogram
- n intrahepatic ducts
- no filling defects
- smooth CBD
- no stricture/ narrowing of CBD
- good and free flow of contrast into duodenum
US feature of gallstone
strong echogenic rim and stone with posterior acoustic shadowing
Cx of ERCP
procedure = pancreatitis, infx (cholecystitis, Cholangitis), hemorrhage, perf
Sedation = hypoTN, resp depression, N&V
Fatality
non sx gallstone tx
shockwave lithotripsy
- only for cholesterol stone
not for: >3stones, large, non fx GB, cx of gallstones
bile salt therapy (chemodissolution): LT PO bile acid - reduce hepatic synthesis of cholesterol/ cholesterol secretion
liver diet: mod carbohydrates, low fat and cholesterol, high fibre
aerobilia causes
- recent biliary instrumentation:
- incompetent sphincter of oddi
- biliary enteric sx anastomosis: whipple
- spont biliary-enteric fistula: cholecystoduodenal mainly - gall stone ileus
- infx: cholangitis, emphysematous cholecystitis, liver abscess, rupture hydatid cyst
Portal venous gas causes
- alt in bowel wall: ischemic bowel, necrotic/ ulcerated CRC, IBD, PUD
- bowel luminal distention: endoscope, IO
- intra ab sepsis
- others: pneumatosis intestinalis
Calot triangle
minimise bile duct injury in lap cholecystectomy
- cystic art anteriorly
- cystic duct laterally
- CHD medially
- LN in middle (Lund’s node)
