C h a p t er

Gallbladder & Bile Ducts

1

Stars (*) represent previously asked and important questions

SURGICAL ANATOMY Bile is produced by the liver and is transported via the extrahepatic ducts to the gallbladder, where it is concentrated and released in response to humoral and neural control. Anatomy of bile ducts z The extrahepatic bile ducts consist of the right and left hepatic ducts, the common hepatic duct, the cystic duct, and the common bile duct. The common bile duct enters the second portion of the duodenum to open at Ampulla of Vater* through a muscular structure, the sphincter of Oddi*. z The left hepatic duct is longer* than the right and has a greater propensity for dilatation* as a consequence of distal obstruction. z The two ducts join to form a common hepatic duct, close to their emergence from the liver. z The common hepatic duct is 1 to 4 cm in length* and has a diameter of approximately 4 mm. z The common hepatic duct is joined at an acute angle by the cystic duct (from the gallbladder) to form the common bile duct. z The common bile duct is about 7 to 11 cm in length* and 5 to 10 mm in diameter. z In general, the normal diameter of the common bile duct as determined by ultrasound is <6 mm, by ERCP <10 mm, and by intraoperative extraluminal measurements <12mm*. The valves of Heister* are mucosal folds in the cystic duct. Despite their name, they have no valvular function. The CBD can be divided into 3 parts: z The upper third (supraduodenal portion) passes downward in the free edge of the hepatoduodenal ligament, to the right of the hepatic artery and anterior to the portal vein*. z The middle third (retroduodenal portion) of the common bile duct curves behind the first portion of the duodenum. z The lower third (pancreatic portion) curves behind the head of the pancreas in a groove, or traverses through it and enters the second part of the duodenum. There, the main pancreatic duct (of Wirsung) frequently joins it. The common bile duct runs obliquely downward within the wall of the duodenum for 1 to 2 cm before opening on a papilla of mucous membrane (ampulla of Vater).

12 Chapter 1 Gallbladder & Bile Ducts

Right hepatic duct

Left hepatic duct Portal vein

Common hepatic duct Cystic duct Common bile duct

Lesser omentum

Hartmann’s pouch

Hepatic artery

Gall bladder

Accessory pancreatic duct Main pancreatic duct Transverse colon

Second part of duodenum Extrahepatic billiary system

Sphincter of Oddi z The Sphincter of Oddi is a thick coat of circular smooth muscle that controls

the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the duodenum.

z It consists of 3 sphincters:

1. at the end of the bile duct (sphincter choledochus) 2. at the end of the pancreatic duct (pancreatic sphincter) 3. around the ampulla (sphincter ampullae)

Sphincter of oddi

Chapter 1 Gallbladder & Bile Ducts 13 Controversy!! zz Bailey and Love (26/e p1119) is of the opinion that Sphincter of Oddi is composed of 4 sphincters i.e. (1) Superior choledochal sphincter; (2) inferior choledochal sphincter; (3) pancreatic sphincter; (4) ampullary sphincter zz But following books mention only 3 sphincters: ŠŠ Gray’s Anatomy ŠŠ BDC Anatomy ŠŠ Sabiston Surgery (18/e p1472) ŠŠ Sleisenger and Fordtran's Gastrointestinal and Liver Disease (9/e chapter 63) ŠŠ Diseases of the Gallbladder and Bile Ducts Pierre-Alain Clavien (2/e p10) ŠŠ Moore’s Anatomy (5/e p287) zz We could find no book apart from Bailey, mentioning 4 sphincters.

Vascular supply of biliary tract z As opposed to the liver, where most perfusion comes from portal venous flow, the entire biliary tree is supplied solely by the arterial anatomy. This anatomic arrangement makes it particularly susceptible to ischemic injury at the intrahepatic and extrahepatic levels. z The inferior bile duct, below the level of the duodenal bulb, receives its perfusion from tributaries of the posterosuperior pancreaticoduodenal and gastroduodenal arteries*. The small branches coalesce to form the two vessels that run along the common bile duct at the 3 and 9 o’clock positions*. z The superior common bile duct, from the duodenal bulb to the cystic duct, and common hepatic ducts receive their blood supply from the right hepatic and cystic arteries*. Anatomy of Gallbladder z A gall bladder has got following parts - the fundus, the body, infundibulum & the neck. Š Hartmann's pouch* is a small recess projecting posteromedially from the wall of the infundibulum. Š The infundibulum is an area of tapering between the gallbladder body and neck. z Hartmann's pouch is a common site for stone impaction but stones impacted here do not obstruct the gall bladder outflow and hence do not cause mucocele. Instead stones impacted in Hartmann's pouch are known to cause Mirizzi syndrome*. z GB is covered by the serosa except where it is embedded in the liver. z GB wall lacks a muscularis mucosa and submucosa *. z Mucosa contain crypt of Luschka* z Normal capacity of the gallbladder is 30–50 mL*

supply: The gallbladder is supplied by the cystic artery*, which is usually (95% of the time) a branch of the right hepatic artery that passes behind the cystic duct. Caterpillar turn or Moynihan’s hump*: It is most dangerous anomaly in arterial supply of gall bladder, where in a hepatic artery takes tortuous course on the front of the origin of the cystic duct. This tortuosity is known as ‘caterpillar turn’ or moynihan’s hump. This variation is a cause of many problems during cholecystectomy. z Lymphatics: The lymphatic vessels of the gall bladder drain into the cystic lymph node of lund*. The cystic lymph node lies at the angle between the cystic duct and common hepatic duct. z Arterial

14 Chapter 1 Gallbladder & Bile Ducts Calot’s Triangle* It is an area bound by z common hepatic duct (medially), z cystic duct and gall bladder (laterally), and z liver margin (superiorly) This is a very important land mark during cholecystectomy. Functions of the gallbladder include: z Storage of bile z Concentration of bile 5-10 times* The absorption of water and electrolytes by the gallbladder mucosa results in a 10-fold increased concentration of lipids, bile salts, and bile pigments compared with hepatic bile.

Liver

Commo hepatic duct Calot’s Triangle Neck of gall bladder

Common bile duct

Cystic duct

Phrygian cap z This is the most common anomaly of the gallbladder z Created by an infolding of a septum between the body and the fundus z GB functions normally, and this anomaly is not an indication for cholecystectomy

CHOLEDOCHAL CYST (Biliary cysts) A choledochal cyst is an isolated or combined congenital dilatation of the extrahepatic or intrahepatic biliary tree. Classification of Choledochal cyst* Type I

ŠŠ a type I cyst is characterized by fusiform dilatation* of the bile duct. ŠŠ this is the most common* type

Type II

a type II cyst appears as a diverticulum* protruding from the wall of the CBD.

Type III

a type III cyst is dilatation of the biliary tract within the duodenum; also k/a choledochocele

Type IV

Type IV A multiple dilatation of the intrahepatic and extrahepatic bile ducts. Type IV B multiple dilatation involving only the extrahepatic bile ducts.

Type V

consists of multiple dilatation of the intrahepatic bile ducts; also known as Carolis disease*.

Chapter 1 Gallbladder & Bile Ducts 15

Todani’s classification of choledochal cysts z Choledochal

cysts are seen to be frequently associated with an anomalous junction of the pancreatic and biliary duct* (more than 90%). In APBDJ, the junction of the CBD with the pancreatic duct is >1 cm proximal to the ampulla. This results in a long common channel that may allow free reflux of pancreatic secretions into the biliary tract, leading to inflammatory changes, increased biliary pressure, and cyst formation. z Clinical Presentation Š more common in females* than in males (4:1) Š typically choledochal cysts present in children beyond the toddler age group. Š the classical triad presents only in a minority of patients; it consists of y abdominal pain y jaundice y abdominal mass Š If the disorder is left undiagnosed, patients may develop cholangitis or pancreatitis. Cholangitis may lead to the development of cirrhosis and portal hypertension. z Complications caused by choledochal cyst Š recurrent cholangitis* Š pancreatitis Š gall stones Š cirrhosis with portal hypertension Š portal vein thrombosis with resultant portal hypertension Š cyst rupture with biliary peritonitis (very rarely) Š malignancy z Diagnosis Š ERCP* is the most reliable investigation but is invasive

16 Chapter 1 Gallbladder & Bile Ducts Š

MRCP is the best noninvasive investigation

z Treatment*

Cholecystectomy + Cyst excision with reconstruction via a biliary-enteric Roux-en-Y anastomosis is the treatment of choice for all choledochal cysts except type III (choledochocele) and intrahepatic cysts of type IV & type V (Caroli's disease) Š Treatment of type III (Choledochocele) y Endoscopic sphincterotomy y cyst excision Š Treatment of intrahepatic cysts of type IV & V Š if the intrahepatic cysts are localized, hepatic lobe is resected Š if the intrahepatic cysts are diffuse only effective treatment is liver transplantation. z Choledochal cyst is a risk factor for the following cancers* Š biliary tree (most common) Š gall bladder Š pancreas Š liver Š duodenum Š

A cystojejunostomy (anastomosis between cyst and jejunum) is not indicated* because this leads to (i) Recurrent cholangitis and (ii) Risk of biliary tract malignancy in choledochal cyst

Magnetic resonance cholangiopancreaticography image reveals long common channel (APBDJ) (arrows) and associated Todani type IVA choledochal cysts with intrahepatic extrahepatic components. CBD - common bile duct, MPD - main pancreatic duct.

Type V Choledochal cyst (Caroli’s disease) In the given CT image, multiple intrahepatic cysts are noted. Some of them show dots within them;these are portal veins surrounded by dilated intrahepatic bile ducts. The veins are actually not within the ducts, but on CT sections they appear to be within them, hence known as central dot sign. Central dot sign is characteristic of Caroli disease or Type V choledochal cyst.

ANOMALOUS JUNCTION OF THE PANCREATIC AND BILIARY DUCT z APBJ is defined as a junction between the pancreatic and bile ducts and is located outside of the duodenal wall. z In APBDJ, the junction of the CBD with the pancreatic duct is >1 cm proximal to the ampulla. z This results in a long common channel that may allow free reflux of pancreatic secretions into the biliary tract, leading to inflammatory changes, increased biliary pressure, and cyst formation. z APBDJ Š Š Š Š

is seen to be associated with gallbladder cancer gallbladder adenomyomatosis cholangiocarcinoma pancreatitis*

BILIARY ATRESIA z Biliary atresia (BA) is a progressive, idiopathic, fibro-obliterative disease of the extrahepatic biliary tree* that presents

Chapter 1 Gallbladder & Bile Ducts 17 with biliary obstruction exclusively in the neonatal period progresses in untreated cases toward hepatic fibrosis, cirrhosis, and end-stage liver failure*. z Presently, there is no medical therapy to reverse the obliterative process* z It’s the most common* cause of surgical jaundice in newborn period. z It is also the most common indication for liver transplantation* in children z The clinical picture is that of severe obstructive jaundice during the first month of life, with pale, acholic stools. z A few infants with biliary atresia have increased incidence of other associated abnormalities, such as the polysplenia, intestinal malrotation, and intraabdominal vascular anomolies. z It

Classification The inflammatory destruction of bile ducts has been classified in three main types depending on the proximity of the obstruction. Type I: Atresia limited to the CBD Type II: Atresia of common hepatic duct Type III: Atresia of right and left hepatic duct Pathology The salient features of biliary atresia z inflammation and fibrosing stricture of the hepatic or common bile ducts z periductular inflammation of intrahepatic bile ducts, and z progressive destruction of the intrahepatic biliary tree. z marked bile ductular proliferation with inspissated bile (bile plugs)* z parenchymal cholestasis z inflammatory destruction of intrahepatic ducts leads to Š paucity of bile ducts* Š absence of edema or bile ductular proliferation on liver biopsy. Investigations Biliary atresia is difficult to clearly differentiate from other conditions of neonatal jaundice (particularly neonatal hepatitis). Following investigations are used to evaluate an infant suspected of biliary atresia Laboratory studies z Elevation in serum conjugated bilirubin (>2 mg/dL) z Mild or moderate elevations in serum aminotransferases z Disproportionately increased GGTP. Ultrasound z The first investigation of choice. Š The main utility of the ultrasound is to exclude other anatomic causes of cholestasis (ie, choledochal cyst, choledocholithiasis) Š In biliary atresia the gallbladder is either absent or small and irregular shaped. Š The absence of a gallbladder* is highly suggestive of the diagnosis of biliary atresia. However, the presence of a gallbladder does not exclude the diagnosis of biliary atresia because in approximately 10% of biliary atresia patients, the distal biliary tract is patent and a gallbladder may be visualized, even though the proximal ducts are atretic. Š Triangular cord sign*: The triangular cord sign is a triangular or tubular echogenic cord of fibrous tissue seen in the porta hepatis at ultrasonography and is relatively specific in the diagnosis of biliary atresia. Š Gallbladder ghost triad is a term used on ultrasound studies when there is a combination of three gallbladder features on biliary atresia: Š atretic gallbladder, length less than 19 mm Š irregular or lobular contour Š lack of smooth/complete echogenic mucosal lining with an indistinct wall Scintigraphy using technetium-99m (99mTc) iminodiacetate (DISIDA) z This radionuclide is taken up by the liver and excreted through bile. z If it appears in the intestine extrahepatic bile duct patency is ensured and the diagnosis of biliary atresia is excluded. z If it does not appear in the intestine, the diagnosis of biliary atresia can be presumed. Liver biopsy z Percutaneous liver biopsy findings might potentially distinguish between biliary atresia and other sources of jaundice such as neonatal hepatitis. Thus liver biopsy can provide most reliable discriminatory evidence.

18 Chapter 1 Gallbladder & Bile Ducts Intraoperative cholangiogram z Intraoperative cholangiogram is the gold standard* in the diagnosis of BA. z Whenever the investigations point towards extrahepatic biliary atresia, surgical exploration is warranted and an intraoperative cholangiography performed to confirm the diagnosis and see the severity. Surgical treatment of biliary atresia z Portoenterostomy or Kasai's operation* is the surgery of choice. The purpose of this procedure is to facilitate the flow of bile into the intestine. It is based on the observation that the fibrous tissue at the porta hepatitis invests microscopically patent biliary ductules that in turn communicates with the intrahepatic ductal system. Transecting this fibrous tissue, opens these channels and establishes bile flow into a surgically constructed intestinal conduit, using a Roux-en-Y limb of jejunum. z Liver transplantation is done in those, who fail to respond to Portoenterostomy. Prognosis z Even if bile flow is established and cholestasis improves, many patients will have slowly progressive liver disease despite undergoing the Kasai procedure, and the majority of patients with BA will ultimately require liver transplantation. z Thus, the vast majority of individuals with BA will eventually require liver transplantation. In the current era, at least 60 to 80 percent of patients with BA will eventually require liver transplantation. GALLSTONES

Types of Gallstones

Cholesterol

Pure cholesterol 10%

Pigment

Mixed 70%

Black pigment stones 15-20%

Brown pigment stones 15-20%

These are western data. According to SRB’s Surgery Mixed stones are 90%. (Note that Bailey writes that in Asia 80% are pigment stones, which I have consulted with Professors in surgery and told not to be true for India.) z They usually occur as

single large stones with smooth surfaces.

z

Yellow in color.

z These are cholesterol

stones that contain variable amounts of bile pigments and calcium, but are always >70% cholesterol by weight. z These stones are usually multiple, of variable size, and may be hard and faceted or irregular, mulberry-shaped, and soft. z Colors range from whitish yellow and

green to black.

Pigment stones are caused by precipitation of concentrated bile pigments, the breakdown products of hemoglobin. z composed of either pure

calcium bilirubinate or polymer-like complexes with calcium and mucin glycoproteins z they are more common in patients with z chronic hemolytic states (eg. hereditary spherocytosis, sickle cell disease) z mechanical prosthesis like heart valves. z liver cirrhosis z Gilbert's syndrome z Cystic fibrosis

z are composed of calcium

salts of unconjugated bilirubin with varying amounts of cholesterol and protein (eg. calcium bilirubinate, calcium palmitate and calcium sterate) z are typically found in Asia. z Brown stones are rare in gallbladder. They form in bile duct and are related to bile stasis and infected bile.

Chapter 1 Gallbladder & Bile Ducts 19 Pathogenesis of Cholesterol gall stones Bile salts and phospholipids in bile keep cholesterol in solution by the formation of micelles. an excess of cholesterol relative to bite salts and phospholipids allows cholesterol to form crystals and such bile is called Lithogenic* or super-saturated bile. There are three elements necessary for the formation of cholesterol gall stones 1) Lithogenic bile 2) Nucleation and 3) Stasis or gall bladder hypomotility

lithogenic bile

stasis

Nucleation

All three are necessary for cholesterol stone formation.

A) Lithogenic (stone-forming) bile z Cholesterol is insoluble in water (water is major constituent of bile, 85-95%). It is made soluble by bile acids and phospholipid - lecithin which form micelles with cholesterol z so any mechanism which increases the cholesterol in bile or decreases the bile acids (salts) or lecithin makes the bile supersaturated or lithogenic. If to such a bile, the other two elements i.e. nucleation and stasis are provided, the cholesterol in solution precipitates to form cholesterol crystals which grow to form cholesterol stones. z Factors which increase biliary cholesterol Š obesity* Š high calorie and cholesterol rich diet* Š clofibrate therapy* z Factors which decrease bile acids Š primary biliary cirrhosis* Š oral contraceptive pills* Š genetic factors y a mutation in CYP7A1 gene* which results in deficiency of enzyme cholesterol 7α-hydroxylase. It results in impaired hepatic conversion of cholesterol to bile acids, thus it increases the cholesterol/bile acid ratio. Š decreased/impaired enterohepatic circulation of bile acids: Š ileal disease* Š ileal resection* Š cholestyramine, colestipol (bile acid sequestrants) therapy. Š deoxycholate z Factors which decrease biliary lecithin Š a mutation in MDR3 gene leads to defective phospholipid (lecithin) secretion into bile. B) Nucleation z Nucleation refers to the process by which cholesterol monohydrate crystals form and agglomerate to become macroscopic crystals. z Formation of cholesterol stones requires either an excess of pronucleating factors or a deficiency of antinucleating factors. z Mucin and certain non-mucin glycoproteins (and infection according to Bailey & love) appear to be pronucleating factors, while apolipoproteins AI and AII and certain other glycoproteins appear to be antinucleating factor. C) Stasis or gall bladder hypomotility z stones would not be able to form if the gall bladder emptied all supersaturated or crystal containing bile completely. z Gall bladder hypomotility is caused by Š prolonged parenteral nutrition* Š fasting* Š pregnancy* Š drugs such as octreotide Š oral contraceptive pills* Š surgery, burns

20 Chapter 1 Gallbladder & Bile Ducts Predisposing factors for cholesterol gall stone formation are* 1. Demographic/genetic factors a. Prevalence highest in North American Indians, Chilean Indians and Chilean Hispanics, greater in Northern Europe and North America than in Asia, lowest in Japan; familial disposition; hereditary aspects. 2. Obesity a. Normal bile acid pool and secretion but increased biliary secretion of cholesterol 3. Weight loss a. Mobilization of tissue cholesterol leads to increased biliary cholesterol secretion while enterohepatic circulation of bile acid is increased 4. Female sex hormones a. Estrogens stimulate hepatic lipoprotein receptors, increases uptake of dietary cholesterol, and increase biliary cholesterol secretion b. Natural estrogens, other estrogens, and oral contraceptives lead to decreased bile salt secretion and decreased conversion of cholesterol to cholesteryl esters. 5. Increasing age a. Increased biliary secretion of cholesterol, decreased size of bile acid pool, decreased secretion of bile salts. 6. Gallbladder hypomotility leading to stasis and formation of sludge a. Prolonged parenteral nutrition b. Fasting c. Pregnancy d. Drugs such as octreotide 7. Clofibrate therapy a. Increased biliary secretion of cholesterol 8. Decreased bile acid secretion a. Primary biliary cirrhosis b. Genetic defect of the CYP7A1 gene 9. Decreased phospholipid secretion a. Genetic defect of the MDR3 gene 10. Miscellaneous a. High-calorie, high-fat diet b. Spinal cord injury Predisposing factors for pigment gallstone formation* 1. Demographic/genetic factors: Asia, rural setting 2. Chronic hemolysis 3. Alcoholic cirrhosis 4. Pernicious anemia 5. Chronic biliary tract infection, parasite infections (Escherichia coli, Ascaris lumbricoides, Clonorchis sinensis) 6. Increasing age 7. Ileal disease, ileal resection or bypass 8. Cystic fibrosis

Predisiposing factor for cholestrol gall stone Mnemonic [Chowmein] C - Clofibrate therapy, Cholestyraaiine H - Hyper elimenetation, High calory, High fats O - Obesity, OCP, Octeotide W - Weight loss M - Mutation (MDR-3, CYP7, A1) E - Estrogen I - Ileal resection, Increased age N - Total parental Nutrition (TPN)

Chapter 1 Gallbladder & Bile Ducts 21 Effects and complications of gall stones are: In Gall bladder:

In Bile ducts

In the intestine

• Silent Stones • Acute cholecystitis • Chronic cholecystitis • Mucocele • Empyema • Perforation • Cholecysto-enteric fistula • Gangrene • Carcinoma

• Obstructive Jaundice • Cholongitis • Acute Pancreatitis

• Acute intestinal obstruction (‘Gall Stone ileus’)

ACUTE CHOLECYSTITIS z Acute cholecystitis is related to gallstones in 90–95%* of cases. z Characteristic triad: RUQ pain + Fever + Leukocytosis * z A fat, fertile, flatulent, female of forty [5 ‘f ’]* is the classical sufferer from symptomatic gall stone. Etiopathogenesis z Obstruction of the cystic duct leading to biliary colic is the initial event in acute cholecystitis. z Mostly the gallstone dislodges, and the inflammation will gradually resolve. z In the most severe cases, this process can lead to ischemia and necrosis of the GB wall (5–10%)*. Clinical Features z RUQ pain of much longer duration than biliary colic, is the MC symptom* z common symptoms: Fever, nausea, and vomiting. z Physical examination: RUQ tenderness and guarding are usually present inferior to the right costal margin, distinguishing the episode from simple biliary colic. z A mass (gallbladder and adherent omentum) is occasionally palpable* z Murphy’s sign*: Inspiratory arrest with deep palpation in the RUQ in acute cholecystitis (also known as Naunyn’s sign) z Boa’s sign*: Hyperesthesia below right scapula in acute cholecystitis z A mild leukocytosis is usually present (12,000–14,000 cells/mm 3 ). z Mild elevations in serum bilirubin (>4 mg/dL), ALP, transaminases, and amylase may be present.

22 Chapter 1 Gallbladder & Bile Ducts Diagnosis z USG: IOC for diagnosing acute cholecystitis* z HIDA scan: Gold standard* for diagnosing acute cholecystitis No filling of GB with the radiotracer ( 99m Tc-HIDA) after 4 hours indicates an obstructed cystic duct* A normal HIDA scan excludes acute cholecystitis* . Management of Acute cholecystitis z IV fluids, analgesics and antibiotics are given initially in a pt. presenting with acute cholecystitis. z Cholecystectomy is the definitive treatment. z Timing of Cholecystectomy: Early cholecystectomy performed within 2 to 3 days of presentation is preferred over interval or delayed cholecystectomy that is performed 6 to 10 weeks after initial medical therapy. Several studies have shown that unless the patient is unfit for surgery, early cholecystectomy is done as it provides a definitive treatment in one hospital admission & quicker recovery time. z Laparoscopic cholecystectomy* is the preferred approach z Conversion to open cholecystectomy is made if the inflammation prevents adequate visualization of important structures. The conversion rate to open cholecystectomy is higher in the settings of acute cholecystitis than with chronic cholecystitis. z If a patient presents late, after 3 to 5 days of illness, or in unfit for surgery, he is treated with analgesics, antibiotics and laparoscopic cholecystectomy is scheduled for approximately 2 months later. But if the patient fails to respond to initial medical therapy he would then need a surgical intervention. Laparoscopic cholecystectomy could be attempted, but the conversion rate is high and some prefer to go directly for an open cholecystectomy. For those unfit for surgery, a percutaneous cholecystostomy or an open cholecystostomy under local analgesia can be performed. z Acute cholecystitis may progress to complications like empyema of the gall bladder, emphysematous cholecystitis, or perforation of the gall bladder despite antibiotic therapy. z Emergency cholecystectomy is the procedure of choice for these complications, if the patient can safely withstand an anesthetic. Laparoscopic cholecystectomy could be attempted, but the conversion rate to open procedure is high and some prefer to go directly for an open cholecystectomy. Occasionally, the inflammatory process obscures the structures in the triangle of Calot, making dissection and ligation of the cystic duct unsafe. In these patients, partial cholecystectomy, cauterization of the remaining gall bladder mucosa, and drainage avoid injury to the CBD. If a patient is too unstable to tolerate a surgery, percutaneous cholecystostomy (or an open cholecystostomy) under local analgesia can be performed to drain the gall bladder. Delayed cholecystectomy can then be done once the inflammation has resolved.

CHRONIC CHOLECYSTITIS It is chronically inflamed, thickened gallbladder, due to recurrent attacks of biliary colic, which only temporarily occlude the cystic duct and do not cause acute cholecystitis. Clinical Features Pain in right hypochondrium, may be colicky, or persistent. Pain occurring after ingestion of a fatty meal, is classic for biliary colic These attacks of pain generally last a few hours. Pain lasting longer than 24 hours or when associated with fever suggests acute cholecystitis. Investigation USG is the investigation of choice.

U/S image showing GB stones as echogenic lesions with acoustic shadow within the anechoic gallbladder

Treatment Elective laparoscopic cholecystectomy is the treatment of choice. Contraindications* to Laparoscopic cholecystectomy Absolute

Relative

Suspicion of Gallbladder cancer Inability to tolerate general anesthesia# Peritonitis with hemodynamic compromise Previous abdominal surgery Pregnancy Refractory coagulopathy Morbid obesity Cholangitis Severe comorbidities Cirrhosis with portal hypertension Severe cardiopulmonary disease Cholecystoenteric fistula # The inability to tolerate general anesthesia is considered an absolute contraindication by some authors, but successful laparoscopic cholecystectomy under spinal anesthesia has been reported

Chapter 1 Gallbladder & Bile Ducts 23 First laparoscopic cholecystectomy was performed by Eric Muhe* in 1982

GALLSTONE ILEUS z Gallstone ileus refers to mechanical intestinal obstruction resulting from the passage of a large gallstone into the bowel lumen. The stone enters the duodenum* through a cholecystoenteric fistula. z Most of these fistulae occur in older patients and may be caused by inflammation in the gallbladder or simply pressure necrosis. z The most common site of stone impaction is in the distal ileum*. Classically, there is impaction about 60 cm proximal* to the ileocaecal valve. z The patient may have recurrent attacks as the obstruction is frequently incomplete or relapsing as a result of a ball-valve effect. z The characteristic radiological sign of gallstone ileus is Rigler’s triad*, comprising: z small bowel obstruction, z pneumobilia and z an atypical mineral shadow on radiographs of the abdomen. Treatment z Exploration and enterotomy* are required to relieve the obstruction. z A longitudinal incision is made on the antimesenteric border of the ileum, a few centimeters proximal to the impacted stone. The stone can then be milked back through the enterotomy. The site of impaction is at risk for ischemia and pressure necrosis, with eventual perforation. Therefore, any suggestion of nonviability of this region should mandate resection. z The remainder of the small intestine should be inspected, because approximately 10% of patients will have multiple large stones that have passed through the fistula. z Although some surgeons advocate surgical treatment of the biliary enteric fistula at the same setting, the intense inflammatory process in the right upper quadrant may complicate the cholecystectomy and duodenal repair. In addition, because most of these patients are older, their overall physiologic status may not permit fistula repair in the emergent setting. A second operation later can be considered to avoid the possibility of future biliary complications. z One-stage repair should generally be performed in healthy patients without severe inflammatory changes in the right upper quadrant. BOUVERET’S SYNDROME z Duodenal obstruction due to gallstones, usually in the bulb is known as Bouveret’s syndrome *. z It is treated by duodenostomy or pyloroplasty *. MUCOCELE OF THE GALL BLADDER z It is one of the complications of Gall stones. z Caused due to obstruction of the stone at the neck of the bladder. z In course of time the bile is absorbed and replaced by the mucus secreted by the Gall bladder epithelium. Due to this the Gall bladder may because distended and palpable. Treatment z The t/t is early cholycystectomy. z If early t/t is not done following complications can occurŠ Empyema Š Perforation Š Gangrene GALLBLADDER EMPYEMA GB empyema results from progression of acute cholecystitis with persistent cystic duct obstruction to superinfection* of the stagnant bile with a pus-forming bacterial organism. Clinical Features Š Fever, toxicity. Š Pain and tenderness in right hypochondrium. Š Tender, smooth, globular, gallbladder is palpable in right hypochondrium to the right of the right rectus muscle.

24 Chapter 1 Gallbladder & Bile Ducts Treatment Emergency surgical intervention* with antibiotic coverage is required as soon as the diagnosis is suspected. Cholecystectomy—an emergency procedure. Often initially cholecystostomy* is done, with either Foley’s or Malecot’s catheter kept in situ. Later after 3-6 weeks, cholecystectomy is done. INDICATIONS OF CHOLECYSTECTOMY IN ASYMPTOMATIC GALLSTONES*. 1) Large stone, >3 cm in diameter (because of increased risk of malignancy). 2) Multiple small stones (more chances of passing into CBD and causing obstruction) 3) Stone associated with polyp 4) Calcified gall bladder (Porcelain gall bladder). 5) Congenitally anomalous gall bladder. 6) Gall stones with diabetes (because emphysematous cholecystitis is common in diabetics with gall stones) 7) Immuno compromised patients (because complication rate is high) 8) Transplant patients (because they are on immuno suppressants) 9) Sickle cell disease 10) Total parenteral nutrition 11) No immediate access to health care facilities (eg, missionaries, military personnel, peace corps workers, relief workers) Š

Few authorities are now also recommending routine cholecystectomy in all young patients with silent stones.

MEDICAL THERAPY FOR GALL STONE z Medical therapy for gall stone dissolution utilizes two bile acids Š Ursodeoxycholic acid (UDCA)* Š Chenodeoxycholic acid (CDCA)* [Note Harrison mentions only Ursodeoxycholic acid. CMDT mentions both UDCA and CDCA] z Mechanism Š they inhibit HMG-CoA reductase, the rate limiting enzyme for cholesterol biosynthesis, thus decrease cholesterol saturation of bile. Š they cause dispersion of cholesterol from the stones by physio-chemical means Prerequisites for medical t/t of gall stones*

Drawbacks of Medical therapy

1) 2) 3) 4)

z low rates of complete resolution

Radioluscent stones Size <10 mm in diameter Functioning gall bladder Non acute symptoms.

[Davidson, & Harrison, say - the stone size to be < 15 mm.] Harrison writes that highest success rates are achieved with floating, radioluscent stones less than 5 mm in size.

z high recurrence rate z not cost-effective (expensive drug has to be taken for

upto 2 years)

z need for maintenance therapy to prevent recurrence.

Medical dissolution is effective only for cholesterol gall stones (not for pigment stones)

ACALCULOUS CHOLECYSTITIS z In acalculous cholecystitis, there is acute inflammation of gallbladder without gallstones. z The clinical course is more fulminant than in acute calculous cholecystitis. z In over 50% of cases of acalculous cholecystitis an underlying explanation is not found. z Acalculous cholecystitis typically develop in critically ill patients* in the ICU. Patients on parenteral hyperalimentation* with extensive burns*, sepsis*, major operations, multiple trauma or prolonged illness with multiple organ system failure* are at risk for developing acalculous cholecystitis. Other precipitating factors include Š vasculitis Š obstructing adenocarcinoma of the gall bladder Š diabetes mellitus* Š torsion of the gall bladder Š unusual bacterial infections of the gall bladder (eg. Leptospira, Streptococcus, Salmonella, or Vibrio cholera), and

Chapter 1 Gallbladder & Bile Ducts 25 parasitic infestation of gallbladder. cholecystitis may also be seen with a variety of other systemic disease processes Š sarcoidosis* Š syphilis* Š cardiovascular disease Š actinomycosis* Š tuberculosis* z Clinical manifestation Š is indistinguishable from those of calculuos cholecystitis, however, the setting of cholecystitis in severe underlying illness is characteristic of acalculous cholecystitis. z Ultrasonography is the diagnostic test of choice. U/S & CT examinations show a large, tense, static gallbladder without stones and with evidence of poor emptying over a prolonged period. z A HIDA scan can be useful and will show nonvisualization of the gallbladder, but it is a less sensitive test with high falsepositive rates in patients who are fasting, on total parenteral nutrition, or have liver disease. z Management Š The complication rate of acalculous cholecystitis is more than calculous cholecystitis. If untreated, rapid progression to gangrene and perforation* may occur. Š Acalculous cholecystitis requires urgent intervention*. Š Percutaneous ultrasound or CT guided cholecystostomy* is the treatment of choice for these patients, as they are unfit for surgery. Š If the diagnosis is uncertain, percutaneous cholecystostomy is both diagnostic and therapeutic. About 90% of patients will improve with the percutaneous cholecystostomy. However, if they do not improve, other steps, such as open cholecystostomy or cholecystectomy, may be required. Š If needed cholecystectomy can be done after the patient has recovered from the underlying disease. Š

z Acalculous

GALLBLADDER POLYPS, CHOLESTEROLOSIS AND ADENOMYOMATOSIS Classification of gallbladder polyps z Gallbladder polypoid lesions can be categorized as benign or malignant. z The benign lesions have been further subdivided into neoplastic or non­neoplastic (pseudotumors). z The most common benign neoplastic lesion is an adenoma*. Others like leiomyomas and lipomas are rare. z The most common benign non­neoplastic lesions (pseudotumors) are cholesterol polyps* (the presence of which is referred to as "cholesterolosis"), followed by adenomyomas (the presence of which is referred to as "adenomyomatosis"). z Cholesterolosis and adenomyomatosis are mucosal abnormalities of the gallbladder. They have been referred to as "hyperplastic cholecystosis", to differentiate them from inflammatory conditions such as acute cholecystitis, since they lack inflammatory features but exhibit features of hyperplasia

Polyps of Gallbladder

Benign

z z

z z

Neoplastic Adenoma is MC Others like leiomyomas lipomas and fibromas are very rare.

Cholestrol polyps (Cholestrolosis)

Malignant Adenocarcinoma is MC Other types very rare

Non-neoplastic (Pseudotumers)

Adenomyomas (Adenomyomatosis)

Inflammatory polyps

26 Chapter 1 Gallbladder & Bile Ducts Cholesterolosis and cholesterol polyps z Cholesterolosis or cholesterol polyps is characterized by the accumulation of lipids* (triglycerides, cholesterol precursors, and cholesterol esters) in the mucosa of the gallbladder wall. z In about two­thirds of cases, these nodular deposits are less than 1 mm in diameter. The nodules in the remaining one­third of cases are larger and polypoid in appearance (polypoid form). z The lipid accumulation creates yellow deposits that are generally visible to the naked eye. The appearance of the yellow deposits on a background of hyperemic mucosa led to the description of this finding as a "strawberry gallbladder"*. z It is a benign condition that is usually diagnosed incidentally during cholecystectomy or on ultrasonography. However, in some patients it can lead to Cholesterolosis: Ultrasound of the gall symptoms and complications similar to those caused by gallstones. bladder shows multiple, echogenic, nonz Cholesterol stones* are found in large no of the cases (approx half )*. mobile foci without posterior shadowing, z Treatment located in the wall Cholecystectomy is indicated in symptomatic cholesterolosis or when cholelithiasis is present*.

Cholesterolosis (strawberry gallbladder)

Adenomyomatosis z Adenomyomatosis is an abnormality of the gallbladder characterized by overgrowth of the mucosa, thickening of the muscle wall, and intramural diverticula or sinuses termed as Rockitansky-Aschoff sinuses*. z These sinuses may contain cholesterol crystals. z The presence of cholesterol crystals in theses sinuses can result in “ring down”, “V-shaped”,or “comet-tail” artifacts* on ultrasound. z The abnormality can be diffuse, segmental (annular), or localized to the fundus of the gallbladder. z In the localized type, the cystic structure forms a nodule, usually in the fundus, that projects into the lumen giving the appearance of a polyp on ultrasonography Adenomyomatosis: Ultrasound showing GB z It has no malignant potential*. wall thickening with ‘comet tail artefacts’ arrow z Treatment Cholecystectomy is indicated in symptomatic adenomyomatosis or when cholelithiasis is present*. Adenomas z Adenomatous polyps of the gallbladder are the most common benign tumors of the gallbladder but, unlike their colonic counterpart, are rare (adenocarcinoma is more common than adenomas) z Polyps of the gallbladder are typically incidental findings detected during radiologic imaging of the abdomen. Their significance is related to their potential for malignancy z The most useful predictive feature for malignancy is the size of the polyp. z Polyps larger than 2 cm are almost always malignant and, in many cases, the cancer is advanced (hence extended cholecystectomy is indicated in polyps larger than 2 cm size) z Polyps 1 to 2 cm in size are regarded as possibly malignant.

Chapter 1 Gallbladder & Bile Ducts 27 Management of polyps z Cholecystectomy is done for polyps which are Š symptomatic or Š associated with risk factors for malignancy Risk factors * associated with malignancy in gall bladder polyps z Size greater than 10 mm z Old age (>60 years). z Coexistence of gall stones z A documented increase in size z

Polyps smaller than 10 mm that are asymptomatic and without associated risk factors may be safely observed with follow-up imaging.

XANTHOGRANULOMATOUS CHOLECYSTITIS z Xanthogranulomatous cholecystitis is a rare inflammatory disease of the gallbladder characterized by a focal or diffuse destructive inflammatory process, with accumulation of lipid laden macrophages, fibrous tissue, and acute and chronic inflammatory cells. z Its importance lies in the fact that it is a benign condition that may be confused with carcinoma of the gallbladder. z Difference from chronic cholecystitis: while chronic cholecystitis is usually regarded as a benign condition with questionable clinical significance, xanthogranulomatous cholecystitis is an active and destructive process that can lead to significant morbidity as the inflammatory process usually extends into the gallbladder wall and adjacent structures. Pathogenesis z The pathogenesis of xanthogranulomatous cholecystitis is thought to be related to extravasation of bile into the gallbladder wall from rupture of Rokitansky-Aschoff sinuses or by mucosal ulceration. This event incites an inflammatory reaction in the interstitial tissue, whereby fibroblasts and macrophages phagocytose the biliary lipids in bile, such as cholesterol and phospholipids leading to the formation of xanthoma cells. z Gallstones may have an important role in the pathogenesis, since they appear to be present in all patients*. z The mucosal surface may be ulcerated and cross sections through the wall reveal xanthogranulomatous foci, which appear as yellow nodules or plaques. These yellowish foci may extend into adjacent structures, such as the liver, duodenum, transverse colon, and omentum. z Microscopically, the xanthogranulomatous foci are composed of abundant lipid laden macrophages, fibroblasts, and inflammatory cells. z The lipid laden macrophages are of two morphological types: rounded foamy macrophages and spindle-shaped cells with more granular cytoplasm and elongated nuclei. z Other findings include the presence of cholesterol clefts, lipid droplets, hemosiderin deposits, and extravasated bile. Diagnosis z The diagnosis is usually made by histological examination* of the resected gallbladder. It may not be possible to distinguish xanthogranulomatous cholecystitis from gallbladder cancer based upon clinical, radiographic, or laboratory testing. Treatment z Patients with xanthogranulomatous cholecystitis should undergo cholecystectomy to confirm the diagnosis, relieve symptoms and exclude gallbladder cancer. z Open cholecystectomy* is preferred in most patients due to dense fibrosis, extensive local inflammation, and concerns of possible coexistent malignancy. z A complete resection of adjacent xanthogranulomatous tissue should be attempted, even if this includes resection into the hepatic bed. EMPHYSEMATOUS CHOLECYSTITIS z Emphysematous cholecystitis is a rare entity caused by secondary infection of the gallbladder wall with gas-forming organisms. z It is more common in men (usually fifth to seventh decade) and diabetic patients*. z Gallstones are present in about one-half of patients. Infecting organisms

28 Chapter 1 Gallbladder & Bile Ducts z Most

common organism -------------- Clostridium welchii*. organisms that may be isolated include Escherichia coli, staphylococci, streptococci, Pseudomonas, and Klebsiella.

z Other

Clinical and diagnosis z Like other patients with acute cholecystitis, patients with emphysematous cholecystitis usually present with right upper quadrant pain, nausea, vomiting, and low-grade fever. z Rarely, crepitus in the abdominal wall adjacent to the gall bladder may be detected and if present is an important clue to the diagnosis. z The diagnosis occasionally can be made by simple abdominal radiographs, but more often it is diagnosed on US or CT scan Management z Emphysematous cholecystitis often heralds the development of gangrene, perforation, and other complications. z Patients should receive intravenous antibiotics to include coverage for Clostridium species, followed by emergent cholecystectomy.

Emphysematous cholecystitis (A) Plain-film radiograph showing air in the lumen and wall of the enlarged gallbladder(arrows). (B) Computed tomography of the abdomen, showing an air–liquid level in the lumen (thin arrow) and gas in the wall (thick arrows) of the gallbladder.

MIRIZZI SYNDROME Mirizzi syndrome is defined as biliary obstruction secondary to cholecystitis*. (note that some books also define it as ‘common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or Hartmann's pouch of the gallbladder ‘) Type I mirizzi syndrome

Type II mirizzi syndrome

An impacted stone in the gallbladder infundibulum or cystic duct can compress the bile duct, usually at the level of the common hepatic duct.

A stone can erode from the gallbladder or cystic duct into the common hepatic duct, resulting in a cholecystocholedochal fistula.

Clinical Patients are seen with symptoms of acute cholecystitis but with the additional finding of hyperbilirubinemia and elevated alkaline phosphatase. Management Laproscopic approach is not recommended as it results in high conversion rate and high complication rates. Open cholecystectomy* is the gold standard for treatment when this condition is identified preoperatively. In the acute setting, the biliary obstruction often resolves after cholecystectomy and resolution of the inflammatory process. If inflammation has obliterated the triangle of Calot, a partial cholecystectomy with removal of any stones may be all that is possible and usually resolves the condition.

Chapter 1 Gallbladder & Bile Ducts 29 MIRIZZI Type I

MIRIZZI Type II

GALLBLADDER CARCINOMA Risk factors* for Ca Gall bladder are: i) Gall stones Š approximately 90% of patients with Ca GB have gall stones Š size of the stone has a direct relationship with development of carcinoma, the risk is ten times more for larger stones (3 cm in diameter) than for stones less than 1 cm in diameter. Š the risk is higher with symptomatic than asymptomatic stones. ii) Adenomatous gall bladder polyps (particularly polyps larger than 10 mm) iii) Calcified (porcelain) gallbladder* iv) Choledochal cyst v) Estrogens vi) Anomalous pancreaticobiliary duct junction vii) exposure to carcinogens (azotoulene, nitrosamine) viii) Typhoid carriers ix) Sclerosing cholangitis x) Cholecystoenteric fistula (Ref: S. Das Sx 3/e, p 919) xi) Ulcerative colitis (Ref: S. Das Sx, 3/e, p 920) Š ASI Surgery mentions two other risk factors 1) chemicals used in rubber industry 2) use of adulerated mustard cooking oil in India. Clonorchis sinensis is liver fluke acquired by ingestion of raw or inadequately cooked fresh water fish and is well known to be a risk factor for Cholangiocarcinoma. It also has association with GB ca. Š Š Š

Š

Adenocarcinoma is the most common type of Ca G.B. (~80-90%) Patients may present with jaundice, though less commonly. Common presenting symptoms are Š abdominal discomfort Š right upper quadrant pain Š nausea & vomitting Less common presenting symptoms are Š jaundice Š weight loss Š anorexia Š ascites Š abd. mass.

Management of GB carcinoma The appropriate management for gallbladder cancer depends on the stage of cancer. Let’s first see the TNM staging for gallbladder cancer.

30 Chapter 1 Gallbladder & Bile Ducts TNM staging of Gallbladder cancer [According to AJCC Cancer Staging Manual, 7th Edition] Primary tumor (T) T0

No evidence of primary tumor

Tis

Carcinoma in situ

T1

Tumor invades lamina propria or muscle layer T1a

Tumor invades lamina propria

T1b

Tumor invades muscle layer

T2

Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver

T3

Tumor perforates the serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ or structure, such as the stomach, duodenum, colon, or pancreas, omentum or extrahepatic bile ducts

T4

Tumor invades main portal vein or hepatic artery, or invades multiple extrahepatic organs or structures

Regional lymph nodes (N) NX

Regional lymph nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Metastases to nodes along the cystic duct, common bile duct, hepatic artery, and/or portal vein

N2

Metastases to periaortic, pericaval, superior mesenteric artery, and/or celiac artery lymph nodes

Distant metastasis (M) MX

Distant metastasis cannot be assessed

M0

No distant metastasis

M1

Distant metastasis

Stage grouping Stage 0

Tis

N0

M0

Stage I

T1

N0

M0

Stage II

T2

N0

M0

Stage IIIA

T3

N0

M0

Stage IIIB

T1-3

N1

M0

Stage IVA Stage IVB

T4 Any T Any T

N0-1 N2 Any N

M0 M0 M1

z For

stage Ia: T1a staged tumors (tumors confined to lamina propria): Š These tumors are recognized incidentally at the time of pathologic review. No further t/t is needed. Simple cholecystectomy* is sufficient for them. Š In laparoscopic cholecystectomy, recurrent cancer has been seen at the port site. Hence all port sites should be excised*. Š Patients with preoperatively suspected gallbladder cancer should undergo open cholecystectomy to minimize the chances of tumor dissemination. T1b staged tumors (tumors invading muscular layer): Š Invasion of the muscular layer allows access to lymphatics and vessels. For T1b staged tumors, an extended cholecystectomy* is indicated, as these tumors have been reported to recur after simple cholecystectomy.

z For Š

stage Ib, II, selected stage III tumors: These are managed by extended cholecystectomy*. [This includes lymphadenectomy of the cystic duct, pericholedochal, portal, right celiac, and posterior pancreatoduodenal lymph nodes. Obtaining an R0 resection should be the goal of surgery and results in an improved survival compared with patients who have remaining microscopic or macroscopic disease. Adequate clearance of the pericholedochal lymph nodes may be facilitated by resection of the common bile duct, but common duct resection is not always necessary; in those cases in which the cystic duct stump margin is positive for malignancy, common duct resection with Roux-en-Y reconstruction is mandatory. Extension into the hepatic parenchyma is common, and extended cholecystectomy should incorporate at least a 2-cm margin beyond the palpable or sonographic extent of the tumor. For smaller tumors, this goal can be achieved with a wedge resection of the liver. For larger tumors, an anatomic liver resection (extended right hepatectomy) may be required to achieve a histologically negative margin.]

Chapter 1 Gallbladder & Bile Ducts 31 z Stage

IV tumors: Should be treated with appropriate palliation as indicated. z No randomized data have demonstrated improved survival with either chemotherapy or radiation and its use depends on case to case basis. Š

z Treatment Š Š Š

after incidental finding* of gallbladder cancer on pathologic review: Patients with T1a tumors (tumor invades lamina propria) do not further benefit from re-resection if the gallbladder was removed intact and should be observed only. In laparoscopic cholecystectomy, recurrent cancer has been seen at the port site. Hence all port sites should be excised. A radical re-resection (after a complete staging including laparoscopy demonstrating resectability) is highly recommended for patients with incidental gallbladder carcinoma stage T1b (tumor invades muscle layer) or greater.

z Treatment Š

after incidental finding* of gallbladder cancer at surgery: After incidental finding of gallbladder cancer at surgery staging has to be performed intraoperatively and extended cholecystectomy including en bloc hepatic resection and lymphadenectomy with or without bile duct excision has to be considered depending on resectability and expertise of the surgeon.

Prognosis: z The prognosis of gall bladder cancer is very bad. Š Most patient have unresectable disease at the time of diagnosis Š the 5 yr survival for all patients with gall baldder cancer is less than 5%, with a median survival of 6 months. Š Only the T1 stage disease treated with cholecystectomy has good prognosis (85 to 100% 5 yr. survival rate). “The median survival associated with unresectable gallbladder cancer is less than 6 months.”- Maingot’s 5 yr survival rates after resection in resectable GB carcinomas T1

85-100%

T2

80-90%

T3

15-63%

T4

2-25%

PORCELAIN GALLBLADDER z Porcelain GB is characterized by extensive calcification of GB wall*. z The term porcelain gallbladder has been used to emphasize the blue discoloration and brittle consistency of GB wall at surgery*. z Most porcelain GB (90%) are associated with gallstones*. z Patients are usually asymptomatic and the condition is usually found incidentally on plain abdominal radiographs, sonograms or CT images. z High frequency association (approx 20%) is with GB adenocarcinoma*. Treatment z Prophylactic cholecystectomy in all patients* with porcelain GB ( due to high incidence of development of carcinoma GB)

Porcelain gallbladder: Calcification of gallbladder wall

Porcelain gallbladder: CT scan showing calcified gallbladder wall

32 Chapter 1 Gallbladder & Bile Ducts CHOLEDOCHOLITHIASIS (stone in common bile duct) Approximately 6-12%* of patients with cholelithiasis, are found to have stone in common bile duct. CBD stones can be of two types

CBD stones

Secondary ŠŠ formed within the gall bladder and migrate down the cystic duct to CBD ŠŠ more common type* ŠŠ usually are cholesterol stone*

ŠŠ ŠŠ ŠŠ ŠŠ

Primary formed per primam in the CBD usually of the brown pigment type more common in Asian population the surgical significance of primary CBD stone is that they are the product of two conditions that must be corrected in treating these stones i. bile duct stasis* and ii. infection*

Clinical presentation of a CBD stone Choledochal stones may be silent and often are discovered incidentally. They may cause incomplete or complete obstruction, or they may manifest with cholangitis or gallstone pancreatitis. Symptoms z Asymptomatic z Symptoms due to obstruction: Š biliary colic (abd. pain is usually intermittent and often associated with nausea & vomiting) Š jaundice z Symptoms due to cholangitis - may present with fever, pain or jaundice z Symptoms due to pancreatitis Laboratory findings z due to biliary obstruction ↑ serum alkaline phosphatase ↑ serum gamma glutamyl transpeptidase ↑ serum bilirubin mildly elevated SGOT & SGPT (AST & ALT) z if cholangitis is associated ↑ WBC count markedly elevated SGOT & SGPT

MRCP image showing dilated IHBR (intrahepatic biliary radicals) and CBD till lower end with a meniscus sign in its distal end suggestive of choledocholithiasis

Imaging investigations z Ultrasound is the first investigation for suspected cholelithiasis or choledocholithiasis Š it can document the presence of gallstones, will demonstrate dilated ducts but demonstration of cause and site of obstruction is difficult. Š A dilated common bile duct on ultrasonography in a patient with gallstones, jaundice, and biliary pain is highly suggestive of common bile duct stones. z MRCP is the best non-invasive investigation. z ERCP is the gold standard for diagnosing CBD stones. It has the advantage of providing a therapeutic option at the time of diagnosis. Management of CBD stones z The mainstay of the management of choledocholithiasis is removal of the common bile duct stone either endoscopically or surgically. z There are usually 3 clinical situations in which CBD stones can be found: A. Before cholecystectomy

Chapter 1 Gallbladder & Bile Ducts 33 B. At the time of cholecystectomy C. After cholecystectomy z If the stone is detected before or after cholecystectomy, then ERCP stone extraction is the method of choice. z The choice of treatment for patients with choledocholithiasis found during surgery includes intraoperative ERCP, intraoperative common bile duct exploration (laparoscopic or open), and postoperative ERCP. ERCP performed at a later time during the same hospitalization is standard in most practice settings. CBD Stone

Detected/Suspected prior to cholecystectomy

Detected after cholecystectomy

Detected/Suspected at time of cholecystectomy on intraop cholangiogram

ERCP

Negative

Positive

Lap cholecystectomy

ERCP sphincterotomy and stone extraction

Followed by lap cholecystectomy

Retained

Recurrent

ERCP sphincterotomy & stone extraction

ERCP sphincterotomy & stone extraction

If fails and a T-tube has been left in place

Stone removed through T-tube tract

If expertise and instrumentation for lap exploration of CBD available

If expertise and instrumentation for lap exploration of CBD NOT available

Laparoscopic stone retrieval through the cystic duct or choledochotomy

Complete cholecystectomy and post the patient for ERCP stone extraction

Note that: z For elderly (>70 yrs), poor risk patients with both gallstones and CBD stones, ERCP stone extraction can be the sole treatment with no need for asymptomatic gallstones. They do not need a cholecystectomy, as only about 15% will become symptomatic from their gallbladder stones, and such patients can be treated as the need arises by a cholecystectomy. z Endoscopic

sphincterotomy is difficult in Large gall stones (> 1.5 cm) Š Multiple stones that are impacted Š Stone location proximal to a stricture Alternative approaches to these situations include mechanical lithotripsy, electrohydraulic or laser lithotripsy, and extracorporeal shock wave lithotripsy. “Mechanical lithotripsy is the most commonly used and simplest means of fragmenting large bile duct stones or when a significant discrepancy between the stone size and the diameter of the exit passage exists.” In mechanical lithotripsy a large strong basket is used to trap and crush the stone. z In patients for whom ERCP is not available, not possible secondary to anatomic considerations, or not successful, an alternative method of cholangiography and nonsurgical therapy is percutaneous transhepatic cholangiography (PTC) followed by transhepatic methods of stone removal. z In the rare instances where the biliary system cannot be cleared of stones nonoperatively, surgical duct exploration is considered. Š

34 Chapter 1 Gallbladder & Bile Ducts ERCP with sphincterotomy and stone extraction is the management of choice for CBD stones. In sphincterotomy the sphincter is incised at 11’O clock* position to avoid injury to the pancreatic duct.

T-TUBE z When the CBD is explored through a choledochotomy (either during laparoscopic or open operation) a T-tube is usually left in the duct. z A cholangiogram is taken after 7-10 days* postoperatively. If it comes out to be normal the T-tube is removed. z If any residual stone is discovered on these post-op cholangiograms, the T-tube is left in place for 4-6 weeks for the tract to mature. The stones are then removed percutaneously through the mature tract (known as Burhenne technique)*. z Alternatively the retained stone can be removed through endoscopic route.

This is an AP/PA supine T-tube cholangiogram image. The biliary tree is outlined with contrast medium.

CHOLANGITIS Acute cholangitis is an ascending bacterial infection in association with partial or complete obstruction of the bile ducts. Causes of cholangitis z Gall stones are the most common cause* of obstruction in cholangitis. z Other causes are Š benign & malignant strictures Š parasites Š instrumentation of the ducts and indwelling stents Š partially obstructed biliary enteric anastomosis z Most common organisms cultured from bile in patients with cholongitis include Š Escherichia coli* Š Klebsiella pneumoniae Š Streptococcus faecalis Š Enterobacter Š Bacteroides fragilis Clinical presentation z Presentation of Cholangitis may range from a mild, intermittent, and self-limited disease to a fulminant, potentially lifethreatening septicemia. z Gallstone-induced cholangitis is typically seen in old females*. z Most common presentation is Charcot’s triad* i.e. Š Fever Š Pain (epigastric or right upper quadrant) Š Jaundice

Chapter 1 Gallbladder & Bile Ducts 35 z The Š Š Š

illness may progress to Reynold’s pentad* i.e. Charcot’s triad plus Septicemia (septic shock) Mental status change

Imaging investigations z Ultrasound is the first investigation* it can document the presence of gallstones, will demonstrate dilated ducts but demonstration of cause and site of obstruction is difficult. z MRCP is the best non-invasive investigation. z ERCP is the gold standard* for diagnosing CBD stones. It has the advantage of providing a therapeutic option at the time of diagnosis. z PTC can be done where ERCP is not available Management of Cholangitis z The initial management is IV antibiotics + Fluid resuscitation. z The obstructed bile duct is drained as soon as the patient is stabilized z Few patients will not respond to antibiotics and fluid resuscitation, and will require emergency biliary decompression. z Methods of biliary decompression* a) ERCP with sphincterotomy and stone extraction Š it is the procedure of choice*, Š early endoscopy allows not only diagnosis by cholangiography and direct visualization of the ampulla but also permits biliary decompression by sphincterotomy and stone extraction. Š If the stones cannot be removed, a nasobiliary catheter or stent is inserted to decompress the biliary tract. b) Percutaneous transhepatic route (PTC) Š PTC is performed if Š the endoscopic procedure has failed or not available. Š if the obstruction is more proximal or perihilar. Š if there is a stricture in a biliary enteric anastomosis. c) Surgical biliary decompression Š Surgical biliary decompression is indicated when neither ERCP nor PTC is possible. This emergency operation consists of decompression of CBD with a T-tube. z Definitive operative therapy should be deferred until the cholangitis has been treated. BILE DUCT STRICTURE z Benign bile duct stricture can have numerous causes. z However the most common cause is operative injury during cholecystectomy*. z The incidence of CBD injury is more with laparoscopic cholecystectomy than open cholecystectomy. * Bile duct stricture

Bengin ŠŠ Operative injury (most commonly laparoscopic cholecystectomy*) ŠŠ CBD stones* ŠŠ Acute cholangitis ŠŠ Cholecystolithiasis (Mirizzi's syndrome) ŠŠ Sclerosing cholangitis ŠŠ Recurrent pyogenic cholangitis ŠŠ Post-transplantation strictures ŠŠ Biliary-enteric anastomosis ŠŠ Congenital – biliary atresia ŠŠ Radiotherapy

Malignant ŠŠ ŠŠ ŠŠ ŠŠ

Cholangiocarcinoma Pancreatic head carcinoma Ampullary carcinoma Metastasis to liver or biliary tract

36 Chapter 1 Gallbladder & Bile Ducts z Bile

duct stricture that goes unrecognized or improperly managed may lead to recurrent cholangitis, secondary biliary cirrhosis, which may lead into portal hypertension. Less commonly, they may present with jaundice without evidence of infection.

Classification system of biliary strictures: Bismuth classification* (see below) Management of benign strictures Treatment depends on the location of the stricture. Percutaneous or endoscopic dilatation and/or stent placement. (It gives good results in more than one half of patients.) Surgery with Roux-en-Y choledochojejunostomy or hepaticojejunostomy is management of choice with good or excellent results in 80% to 90% of patients. BILE DUCT INJURY z Most commonly (80%) during cholecystectomy* z Laparoscopic >> Open cholecystectomy* z Less common iatrogenic causes are: biliary injury is associated with common bile duct exploration, division or mobilization of the duodenum during gastrectomy, and dissection of the hepatic hilum during liver resections. Causes of bile duct injury during lap cholecystectomy z Visual misperception i.e. failure to identify structures before ligating or dividing them (most common cause*, approx 97%) Ref: Sabiston z Surgical inexperience z Inflammation in the porta z Variable biliary anatomy z Aggressive attempt at hemostasis Bismuth and Strasberg classification systems* z Bismuth and Strasberg classification systems are the most widely used classification systems for iatrogenic bile duct injury. z Bismuth classification is the traditional classification system. It originated from the era of open surgery and is based on the location of the lesion in relation to the hepatic duct bifurcation. It does not encompass the whole spectrum of injuries that are possible. Bile duct injury during laparoscopic cholecystectomy tends to be more severe than those with open cholecystectomy. Strasberg’s classification made Bismuth’s classification much more comprehensive by including various other types of extrahepatic bile duct injuries. z Bismuth classification is primarily based on the length of remaining bile duct and does not include bile leaks from the cystic duct stump or the liver bed; it also neglects lateral injuries to the bile duct and isolated occlusion of the right hepatic duct. These shortcomings have been taken care of in the Strasberg classification system. Strasberg classification TypeA

Cystic duct leaks or leaks from small ducts in the liver bed Bile leak from a minor duct still in continuity with the CBD. In most cases the leaks occur from the cystic duct or from the liver bed. The two injuries are combined because their presentation and management are almost identical.

TypeB

Injury to sectoral duct (commonly aberrant right hepatic duct) with consequent obstruction In about 2% of patients the cystic duct enters the right hepatic duct rather than the CBD-CHD junction. The right duct then joins the main ductal system. Such an aberrant duct has a similar appearance to a cystic duct at the point where it joins the main duct and is in danger of being mistaken for the cystic duct or cystic artery and divided.

TypeC

Injury to sectoral duct with consequent bile leak Transection without ligation of the aberrant right hepatic ducts with drainage of bile into the peritoneal cavity.

TypeD

Lateral injuries to major bile ducts

TypeE

Circumferential injury/ Stricture of Major bile ducts (Subdivided as per Bismuth’s classification into E1 to E5). These injuries involve circumferential injury of one or more main bile ducts as described by Bismuth. Type E injuries cause ‘separation’ of hepatic parenchyma from the lower ducts and duodenum. This separation is usually the result of resection or ablation with cautery. This is the most serious type of bile duct injury and is associated with the greatest morbidity and mortality.

Chapter 1 Gallbladder & Bile Ducts 37 Bismuth’s classification (Type E of Strasberg classification) Type1 (E1)

Low CHD stricture, with a length of the common hepatic duct stump of >2 cm

Type2 (E2)

Proximal CHD stricture-hepatic duct stump <2 cm

Type3 (E3)

Hilar stricture, no residual CHD, but the hepatic ductal confluence is preserved

Type4 (E4)

Hilar stricture, with involvement of confluence and loss of communication between right and left hepatic duct

Type5 (E5)

Involvement of aberrant right sectoral hepatic duct with concomitant stricture of the CHD

Strasberg Classification

Diagnosis Only about 25% of major bile duct injuries (common bile duct or hepatic duct) are recognized at the time of operation. More than half of patients with biliary injury will present within the first postoperative month. The remainder will present months or years later, with recurrent cholangitis or cirrhosis from a remote bile duct injury.

38 Chapter 1 Gallbladder & Bile Ducts In the early postoperative period, patients present either with progressive elevation of liver function tests due to an occluded or a stenosed bile duct, or with a bile leak from an injured duct. Imaging An ultrasound or a CECT are the first investigations to show the bile collection (biloma) in the GB area or free fluid (bile) in peritoneal cavity. They are also the first investigations to demonstrate the dilated part of the biliary tree proximal to the stricture. HIDA (hepatobiliary iminodiacetic acid) scanning* can demonstrate bile leakage noninvasively but typically does not have the sensitivity to define the specic anatomic site of injury. (Ref: Maingot) PTC (percutaneous cholangiogram)* delineates ductal system proximal to the stricture. In addition to delineating the anatomy, a percutaneous biliary drainage catheter should be placed at the time of PTC to decompress the biliary tree, and treat cholangitis and control the biliary leak. ERCP An endoscopic cholangiogram demonstrates the anatomy distal to the injury and may allow the placement of stents across a stricture to relieve an obstruction MRCP is the best non invasive investigation for stricture*. It demonstrates biliary anatomy both proximal and distal to the injury. Management The management of bile duct injuries depends on the type, extent, and level of injury, and the time of its diagnosis. Management of the Bile Duct Injury Recognized at the Time of Cholecystectomy If a major injury is discovered and an experienced biliary surgeon is not available, an external drain and, if necessary, transhepatic biliary catheters are placed, and the patient is transferred to a referral center. If a bile leak is recognized by an experienced surgical team, then early conversion to an open laparotomy and prompt cholangiography should be performed. Cholangiography will define the proximal anatomy to ensure that all hepatic ducts are accounted for and included in the reconstruction. REPAIR OPTIONS Injury to isolated hepatic ducts < 3 mm or those draining a single hepatic segment

can be safely ligated

Injury to isolated hepatic ducts > 4 mm or those drain several segments or an entire lobe

need to be reimplanted (anastomosed to Roux-en-Y jejunum loop)

small partial lateral bile duct injury

can be managed with placement of a T tube through the small injured site as it were a formal choledochotomy

More extensive lateral bile duct injury

T tube should be placed through a separate choledochotomy and the injury closed over the T-tube end to minimize the risk of subsequent stricture formation

Major bile duct injuries such as transection of the common hepatic or common bile duct

usually requires a biliary enteric anastomosis with a jejunal loop. Either an end-to-side Roux-en-Y choledochojejunostomy or, more commonly, a Roux-en-Y hepaticojejunostomy

z if over 2 cm of healthy common hepatic duct is preserved

Roux-en-Y choledochojejunostomy

z if less than 2 cm of healthy CHD is preserved but

Roux-en-Y hepaticojejunostomy

z injuries that completely separate the right and left systems

separate right and left biliary enteric anastomoses

z E5 type of injury

Roux­en­Y hepaticojejunostomy with trans­anastomotic stents

z if there is no or minimal loss of ductal length

a duct-to-duct repair may be done over a T tube that is placed through a separate incision (this management is highly controversial as many say that it mostly leads to stricture hence better avoided)

(i.e. E1 type of injury)

communication between right and left duct is preserved (E2 and E3 type of injury)

(E4 type of injury)

Chapter 1 Gallbladder & Bile Ducts 39 Management of the Bile Duct Injury Recognized after Cholecystectomy z Post operatively patients present with leakage of bile or with bile duct stricture. z Leakage may manifest as bilious drainage into a subhepatic drain placed at the time of operation or bilious drainage from a surgical incision. Without a site for external drainage, bile leakage can present as a biloma, whether sterile or infected, or with biliary ascites. z Patients with bile duct stricture usually present with either progressive elevation of liver function tests or cholangitis. Post Cholecystectomy bile leak z It occurs due to slipping of ligature from the cystic duct or bile duct injuries which go unrecognized at the time of surgery. z Initial investigation of these patients includes U/S or CT (preferably CT) for detection of any fluid collection. z Any biliary collection or subhepatic abscess should be promptly drained. z Minor collection, after percutaneous drainage, needs no further treatment, if the patient improves. The output from the drain is monitored and if not resolved even after 5-6 days, endoscopic sphincterotomy and stenting is done. This usually resolves the leak. z In the presence of any major leak, jaundice, signs of cholangitis, the patient should be investigated with an ERC (or PTC) to establish the presence, extent and severity of bile duct injury. z Management of Cystic duct bile leaks Š can be managed by endoscopic sphincterotomy and stenting (the principle behind is that if the bile is allowed to flow through the normal tract, any fistulous communication would heal spontaneously) Management of bile duct injuries z the basic approach is biliary decompression, either by endoscopic sphincterotomy & stenting or by transhepatic catheters z Some fistulas may close spontaneously by biliary decompression z For the major injuries (like complete transection of CBD or hepatic ducts) not responding, definitive repair is done. But definitive repair is delayed 6 to 8 weeks until acute inflammation has resolved. z Before definitive repair cholangiography is done to clearly delineate the biliary anatomy. For this either ERCP or PTC is done. z For patients with bile duct continuity, ERCP may be possible, but PTC is generally more useful. z Definitive repair includes Š Roux-en-Y choledochojejunostomy or Š hepaticojejunostomy z Self-expanding metal or plastic stents, placed either percutaneously or endoscopically across the stricture, can provide temporary drainage and, in the high-risk patient, permanent drainage of the biliary tree. z All patients with biliary leak should be well nourished and kept free of infection with use of broad spectrum antibiotics. Most common bile duct injury is ----- complete transection of the CBD* This "classic" injury occurs when the CBD is mistaken for the cystic duct

CHOLANGIOCARCINOMA z Risk factors for Choangiocarcinoma* Š Primary sclerosing cholangitis Š Choledochal cyst Š Ulcerative colitis Mnemonic 5C's Š Clonorchis sinensis inf. Š Chronic typhoid carriers z Other risk factors Š Hepatolithiasis Š Biliary enteric anastomosis Š Liver flukes Š Dietary nitrosamines Š Exposure to thorotrast, dioxin Most common site of cholangiocarcinoma is at – hepatic duct bifurcation* (60-80 %) Perihilar cholangiocarcinomas are also known as Klatskin tumors*. z Cholangiocarcinoma

are rare tumors arising from biliary epithelium. arise anywhere along the biliary tree, but about 2/3 are located at the hepatic duct bifurcation* (perihilar chol they are known as Klatskin tumors*)

z Can

40 Chapter 1 Gallbladder & Bile Ducts z Most

common type is adenocarcinoma* (~95%) MC gene mutation: K-ras >p16 (KRAP-16)* z The average age of presentation is between 50 and 70 years*. z The male to female ratio is 1.3:1 z Morphologically, they are divided into nodular (the most common type), scirrhous*, diffusely infiltrating, or papillary. z They are markedly desmoplastic* with production of dense collagenous stroma. z Cholangiocarcinomas are rarely bile stained, because differentiated bile duct epithelium of cholangicarcinoma does not synthesize bile. z Anatomically, they are divided into distal, proximal, or perihilar tumors (most common)*. z Intrahepatic cholangiocarcinomas occur, but they are treated like hepatocellular carcinoma, with hepatectomy when possible. z Perihilar cholangiocarcinomas, also referred to as Klatskin tumors, are further classified based on anatomic location by the Bismuth-Corlette classification. z

Bismuth-Corlette classification for perihilar cholangiocarcinoma Type I

tumors are confined to the common hepatic duct, without involving the bifurcation (main biliary confluence)

Type II

tumors involve the bifurcation (main biliary confluence) without involvement of the secondary intrahepatic ducts (i.e. without involvement of secondary biliary confluence)

Type III

Type IIIa and IIIb tumors extend into the right and left secondary intrahepatic ducts, respectively. Type IIIa – tumor extending upto right secondary biliary confluene. Type IIIb – tumor extending upto left secondary biliary confluence.

Type IV

tumors involve both the right and left secondary intrahepatic ducts (i.e. bilateral secondary biliary confluence involved)

Bismuth-Corlette classification of perihilar cholangiocarcinoma RHD, right hepatic duct, LHD, left hepatic duct, HDC hepatic duct confluence z Most

common presentation is painless jaundice*. symptoms are- Pruritus, mild right upper quadrant pain, anorexia, fatigue, and weight loss, symptoms of cholangitis. z Distant metastasis seen in one third* of the patients. z MC site of metastasis: Lung or mediastinum, liver and peritoneum. z The tumor marker most commonly used to aid the diagnosis of cholangiocarcinoma is --- CA 19-9* (it has a sensitivity of 79% and specificity of 98% if the serum value is >129 U/mL) z Raised CA19-9 is a poor prognostic factor* in cholangiocarcinoma. z Other

Imaging investigations z The initial tests are usually ultrasound or CT scan z Investigation of choice is –MRI* z A perihilar tumor causes dilatation of the intrahepatic biliary tree, but normal or collapsed gallbladder and extrahepatic bile ducts distal to the tumor. Distal bile duct cancer leads to dilatation of the extra- and intrahepatic bile ducts as well as the gallbladder. (Note that dilated bile duct along with collapsed contracted GB is thus suggestive of CBD calculus and dilated bile duct and dilated GB suggestive of malignant etiology)

Chapter 1 Gallbladder & Bile Ducts 41 Management z Surgical excision is the only potentially curative treatment for cholangiocarcinoma and is done for those having no signs of metastasis or locally unresectable disease. z However, many patients have advanced disease at the time of diagnosis. Therefore, palliative procedures aimed to provide biliary drainage to prevent liver failure and cholangitis are often the only therapeutic options. z There is not much role for adjuvant chemotherapy or adjuvant radiotherapy. z Patients with distal cholangiocarcinoma are more likely to have resectable disease and improved prognosis compared to perihilar cholangiocarcinoma. Curative surgical resection of Choalangiocarcinoma For curative resection, the location and local extension of the tumor dictates the extent of the resection Perihilar tumors involving the bifurcation or proximal common hepatic duct (Bismuth-Corlette type I or II)

local tumor excision with portal lymphadenectomy + cholecystectomy + CBD excision + bilateral Roux-en-Y hepaticojejunostomies

Perihilar tumors involving the right or left hepatic duct (Bismuth-Corlette type IIIa or IIIb)

Same as above + right or left hepatic lobectomy

Distal bile duct tumors

pylorus-preserving pancreatoduodenectomy (Whipple procedure)

Palliative measures z Palliative measures are done in unresectable ,metastatic or recurrance disease z Palliative measures include expandable metal stents, drainage catheters, or surgical bypass procedures Prognosis z Most patients with perihilar cholangiocarcinoma present with advanced, unresectable disease. z Patients with unresectable disease have a median survival between 5 and 8 months. z The most common causes of death are hepatic failure and cholangitis. z The overall 5-year survival rate for patients with resectable perihilar cholangiocarcinoma is between 10% and 30%. z Best prognosis is for distal cholangiocarcinoma. These are more likely to have resectable disease. The overall 5-year survival rate for resectable disease is 30% to 50%. Criteria of un-resectability in Hilar Cholangiocarcinoma (till now asked only in MCh entrance examinations) z Hepatic duct involvement up to secondary radicals bilaterally* (Bismuth type IV) z Atrophy of one lobe with contralateral involvement of secondary biliary radicals* z Encasement or occlusion of the main portal vein proximal to its bifurcation* z Atrophy of one lobe with encasement of contralateral portal vein branch* z Histologically proven metastasis to N2 lymph nodes* z Liver, lung or peritoneal metastasis

PRIMARY SCLEROSING CHOLANGITIS (PSC) z is a fibrosing cholangitis of bile ducts leading to inflammatory strictures and obliteration of both intrahepatic and extrahepatic ducts with dilatation of preserved segments. z It’s a progressive disease eventually resulting in secondary biliary cirrhosis. z Its of Unknown etiology Š association is seen with HLA-B8, -DR3, -DQ2 and -DRw52A. z Its seen to be associated with ulcerative colitis* and occasionally Crohn's disease (Ulcerative colitis seen in approx 2/3rd of patients of PSC) z Other diseases associated with PSC Š Riedel's thyroiditis Š Retroperitoneal or mediastinal fibrosis Š Pseudotumor of orbit z PSC is a risk factor for Cholangiocarcinoma* Š 10 to 20% of patients with PSC develop cholangiocarcinoma Š Cholangocarcinoma can present at any time during the disease process and does not correlate with the extent of sclerosing cholangitis.

42 Chapter 1 Gallbladder & Bile Ducts z Morphology

Robbins writes - "PSC is a fibrosing cholangitis of bile ducts, with a lymphocytic infiltrate, progressive atrophy of the bile duct epithelium, and obliteration of the lumen. The concentric periductal fibrosis around the affected ducts ("onion skin fibrosis")* is followed by their disappearance leaving behind a solid cord-like fibrous scar. In between areas of progressive stricture, bile ducts become ectatic and inflamed, presumably the result of downstream obstruction. As the disease progresses, the liver becomes markedly cholestatic, culminating in biliary cirrhosis much like that seen with primary and secondary biliary cirrhosis." z Clinical Picture Š Mean age of presentation is 30 to 45 yrs. Š M : F ratio - 2 : 1 Š Usual presentation is intermittent jaundice*, fatigue, weight loss, pruritus* and abdominal pain. Š Asymptomatic patients may come to attention because of persistent elevation of serum alkaline phosphatase. Š Clinical course is highly variable with cyclic remissions and exacerbations. some may remain asymptomatic for years, others may progress very rapidly to sec. biliary cirrhosis and liver failure. z The clinical presentation and increased alkaline phosphatase and bilirubin levels may suggest the diagnosis, but Endoscopic retrograde cholangiography is the definitive investigation*. ERC shows multiple dilatation and strictures involving both intrahepatic and extrahepatic ducts. Š MRCP* is the best non-invasive investigation. It is less sensitive than ERCP for intrahepatic ducts. z Treatment Š there is no known effective medical treatment. Š Liver transplantation* is the only option Š

Primary Sclerosing Cholangitis: Endoscopic retrograde cholangiopancreatography shows multiple intrahepatic bile duct strictures and beading.

PRIMARY BILIARY CIRRHOSIS z Believed to be an autoimmune etiology, leading to progressive destruction of intrahepatic bile ducts* z More common in females* z Associated with autoimmune disorders (CREST, Sicca syndrome, Autoimmune thyroiditis, Renal tubular acidosis)* . Pathology z Florid duct lesion is characterized by lymphocytic or granulomatous bile duct infiltration*. z In the setting of positive AMA, the florid duct lesion is essentially diagnostic*. Clinical Features z Most patients are asymptomatic, pruritus is the commonest and earliest symptom*. z Pruritus precedes jaundice in PBC* z Jaundice, fatigue, melanosis* (gradual darkening of exposed areas of skin), deficiency of fat soluble vitamins due to

Chapter 1 Gallbladder & Bile Ducts 43 malabsorption. and xanthelesmas* due to protracted elevation of serum lipids.

z Xanthomas

Laboratory findings z Increased ALP, hyperlipidemia and positive antimitochondrial antibody*. Treatment z Cholestyramine is mainstay of treatment of pruritus* . z Ursodeoxycholic acid is associated with significant delay to time of transplantation*. z Transplantation in PBC may also be indicated for intolerable lethargy or intractable pruritus*. Prognosis z Serum bilirubin is the best guide to prognosis* . RECURRENT PYOGENIC CHOLNGITIS (OR CHOLANGIOHEPATITIS) z Cholangiohepatitis is caused by bacterial contamination (commonly E. coli, Klebsiella species, Bacteroides species, or Enterococcus faecalis) of the biliary tree, and often is associated with biliary parasites such as Clonorchis sinensis*, Opisthorchis viverrini, and Ascaris lumbricoides. z Bacterial enzymes cause deconjugation of bilirubin, which precipitates as bile sludge. z The sludge and dead bacterial cell bodies form brown pigment stones*. z These stones are formed throughout the biliary tree and cause partial obstruction that contributes to the repeated bouts of cholangitis. z Biliary strictures form as a result of recurrent cholangitis and lead to further stone formation, infection, hepatic abscesses, and liver failure (secondary biliary cirrhosis). z It is endemic to the Orient (middle east)*. z M = F z Most frequent in the third and fourth decades of life. Symptoms z The patient usually presents with pain in the right upper quadrant and epigastrium, fever, and jaundice. z Recurrence of symptoms is one of the most characteristic features of the disease. z The episodes may vary in severity but, without intervention, will gradually lead to malnutrition and hepatic insufficiency. Imaging z Ultrasound is the first investigation: it will detect stones in the biliary tree, pneumobilia from infection due to gas-forming organisms, liver abscesses, and, occasionally, strictures. z Diagnosis is usually made by a combination of CT or MRCP with ERCP and PTC z MRCP is the non invasive investigation of choice. Management z Acute attack is managed as in cholangitis, hepatic abscesses may be drained, and emergent decompression of the biliary tree is done in septic patients z Definitive operative treatment is almost always required. z The goals of surgical therapy are threefold: (1) remove all stones; (2) bypass, enlarge, or resect the strictures; and (3) provide adequate biliary drainage. Roux-en-Y hepaticojejunostomy* with a subcutaneous afferent limb (Hudson loop*) is a safe and effective way to provide access to the biliary tree for stone extractions. z Occasionally, resection of involved areas of the liver may offer the best form of treatment. HEMOBILIA z Hemobilia is defined as bleeding into the biliary tree from an abnormal communication between a blood vessel and bile duct. Causes of hemobilia: a) Trauma (most common) Š iatrogenic trauma is the most common cause (includes interventional radiological procedures, percutaneous liver biopsy, percutaneous transhepatic biliary drainage, operations on gallbladder and bile duct)

44 Chapter 1 Gallbladder & Bile Ducts Š blunt trauma is more common cause than penetrating trauma b) Gall stones c) Vascular pathologies - aneurysms, angiodysplasias, hemangiomas. d) Uncommon causes Š Malignant tumors of liver, biliary tree, gall bladder, pancreas Š parasitic infection Š heaptic abscess Š cholangitis Š acalculus cholecystitis

Clinical presentation z Classical triad consists of Š Upper abdominal pain (biliary colic) Š Obstructive jaundice (obstruction by blood clots) Š Upper gastrointestinal haemorrhage Š hematemesis Š melena Diagnosis Š Diagnosis of hemobilia is typically made on upper endoscopy with findings of bleeding from the ampulla of vater. Š Arterial angiography is the investigation of choice as it will reveal the source of bleeding in about 90% of cases. Management Š Minor hemobilia can be managed conservatively. Š For major hemobilia transarterial embolization (TAE) is first line of therapy. Š Surgery is indicated when TAE has failed, it consists of: Š ligation of bleeding vessels, excision of aneurysms, or nonselective ligation of a main hepatic artery. BILHEMIA z Bilhemia is an extremely rare condition z Bile flows into the bloodstream either through the hepatic veins or portal vein branches* Etiology z High intrabiliary pressure, exceeding that of the venous system (CBD stone)* z Gallstones eroding into the portal vein z Accidental or iatrogenic trauma Clinical Features z Rapidly increasing jaundice, marked direct hyperbilirubinemia (without elevation of hepatocellular enzymes) and septicemia* . z The condition can be fatal secondary to embolization of large amounts of bile into the lungs*. z Most often, bile flow is low, and the fistula spontaneously closes*. Diagnosis z ERCP is investigation of choice (diagnostic and therapeutic)* Treatment z Treatment is directed at lowering intrabiliary pressures either through stents or sphincterotomy* VANISHING BILE DUCT SYNDROME z The vanishing bile duct syndrome and adult bile ductopenia are rare conditions in which there are a decreased numbers of bile ducts seen in liver biopsy specimens. z The histologic piιture is similar to that in primary biliary cirrhosis z Causes of vanishing bile duct syndrome. Š Chronic rejection after liver transplantation Š Graft versus-host disease after BM transplantation Š Sarcoidosis Š Drugs like Chlorpromazine Š Idiopathic

Chapter 1 Gallbladder & Bile Ducts 45 Causes of Pneumobilia zz zz zz zz zz

Previous biliary surgeries such as ERCP with sphincterotomy, Papillotomy, choledochojejunostomy Gallstone ileus Fistula between gallbladder or CBD and bowel Emphysematous cholecystitis Suppurative cholangitis

Healthy gallbladder has z greenish blue or sea green colour z thin and elastic wall z can be emptied by squeezing

COURVOISIER’S LAW z In obstruction of the common bile duct is due to a stone, distention of gallbladder seldom occurs; the organ usually is shriveled*. z In obstruction from other causes, distention of gallbladder is common. z If there is no disease in the gallbladder and the obstruction is due to cancer of ampulla, pancreas or bile duct, then gallbladder will be distended*. Exceptions to Courvoisier’s Law z Double impaction of stones* i.e. one in the cystic duct and other in CBD. z Oriental cholangiohepatitis* z Pancreatic calculus obstructing the ampulla of Vater* SUMP SYNDROME z Particulate matter, stones, and food debris accumulate and stagnate in the distal, “blind” end of the common duct; this is known as Sump syndrome* z Sump syndrome occurs after choledochoduodenostomy*. z Management Š Endoscopic management, consisting of sphincterotomy with or without balloon dilation of the anastomosis* Š Conversion to end-to-end Roux-en-Y choledochojejunostomy or hepaticojejunostomy is preferred surgical procedure. BILIARY FISTULA Biliary fistulas are of 2 types: External biliary fistula z External fistulas are more common and are often caused by iatrogenic injury after operations, invasive procedures, or trauma involving the biliary tract. Etiology Š Bile leakage from the cystic duct remnant Š Difficult cases of open cholecystectomy Š Central hepatectomy and caudate resection Internal Biliary fistula z Internal fistulas are spontaneous, rare, and occur without a significant collection of bile. z MC biliary-enteric fistulas is Cholecystoduodenal fistulas (72–80%) followed by cholecystocolic fistulas (8-12% ) z Most cholecystoduodenal fistula are asymptomatic. Etiology Š Calculous biliary tract disease (90%)* Š Duodenal ulcer (6%) Š Neoplasm, trauma, parasitic infestation, and congenital anomalies (4%) WHITE BILE z "White bile" is the colorless fluid occasionally found in biliary system proximal to an obstruction.

46 Chapter 1 Gallbladder & Bile Ducts z It

is double misnomer: It is neither white nor bile. is mucous secreted by the lining of biliary tree. z It signifi es severe obstruction due to stone (impacted in the CBD), or carcinoma head of pancreas or periampullary region. z It is on table finding during surgery. z It means liver is unable to secrete bile due to raised intraductal pressure, and so can anticipate hepatic failure. z Indicates a poor prognosis. z It



Chapter 1 Gallbladder & Bile Ducts 47 Gallbladder

10.

Saccular diverticulum of extrahepatic bile duct in choledochal cyst is classified as: (COMED 09) a) Type I b) Type II c) Type III d) Type IV

1.

The gall bladder is capable of distending.....ml.: a) 10 (PGI 88) b) 20 c) 40 d) 50

11.

2.

Bile is concentrated in the gall bladder to....... times: a) 5 (PGI 88) b) 10 c) 20 d) 50

Clinical features of choledochal cyst in adult are: a) Pain, lump and intermittent jaundice (UPSC 04) b) Pain, fever and intermittent jaundice c) Pain, lump and prgressive jaundice d) Pain, fever and progressive jaundice

12.

True about choledochal cyst is: a) Always extrahepatic b) T/t is cystojejunostomy c) Excision is ideal t/t d) Drainage is t/t of choice

(Manipal 06)

(AIIMS SEP 96)

3.

Sentinel node of gall bladder is: a) Virchow’s nodes b) Iris nodes c) Clouquet node d) Lymphnode of lund

13.

4.

Best investigative modality for gall bladder: (PGI 85) a) OCG b) PTC c) Ultrasound d) Intravenous cholangiogram

Not true regarding choledochal cyst: (AIIMS NOV 95) a) Epigastric mass b) Jaundice c) Pain in abdomen d) Cystojejunostomy is t/t of choice

14.

Graham Cole test refers to: (AIIMS 81, AP 89) a) Oral cholecystography b) Intravenous cholangiography c) Pre-operative cholangiography d) Post-operative cholangiography e) Tomography

In case of choledochal cyst, bile diversion into the small intestine is not done because of the risk of: a) Malignancy (AIIMS JUNE 01) b) Pancreatitis c) Recurrent Cholangitis d) Gall stones

15.

Not true about choledochal cyst is: (AIIMS MAY 09) a) Associated with anomalous junction of the pancreatic and biliary duct. b) Type 2 is most common c) Surgical removal is the treatment of choice d) If ruptures can cause biliary peritonitis

16.

Choledochal cyst develops due to: (NBE/DNB pattern) a) Iatrogenic b) Stenosis of sphincter c) Congenital d) Dysfuntion of long circular fibers

5.

6.

7.

8.

Which is Not required for visualisation of gall bladder in oral cholecystography: (AIIMS NOV 95, AI 97) a) Functioning liver b) Motor mechanisms of gall bladder c) Patency of cystic duct d) Ability to absorb water The substance used in OCG is: (PGI 87, KERALA 88) a) Iapanoic acid b) Sodium diatrozite c) Meglumine iodothalamate d) Biligraffin e) Dianosil Dye used in IV cholangiography is: a) Diansoil b) Conray c) Biligraffin d) Myodil

(PGI 86)

Biliary atresia 17.

Which of the following are histopathological features of Extra hepatic Biliary Atresia: (PGI JUNE 01) a) Bile lakes b) Hepatocyte ballooning degeneration c) Marked bile duct proliferation d) Fibrosis of hepatic duct e) Parenchymal cholestasis

18.

The gold standard for the definitive diagnosis of the extrahepatic biliary atresia is: (AIIMS NOV 02) a) Peroperative cholangiography. b) Hepatobiliary scintigraphy. c) Alkaline phosphatase level. d) Liver biopsy.

19.

Better prognostic factor for operation of biliary duct

Choledochal cyst 9.

Most common type of choledochal cyst? (APPG 08) a) Type 1 b) Type 2 c) Type 3 d) Type 6

48 Chapter 1 Gallbladder & Bile Ducts (PGI JUNE 01)

obstruction in newborn are: a) No passage of bile b) Size of ductule > 200 micron c) Weight of baby > 3 kg d) Preterm baby e) Age of 8 weeks

b) 20% c) 30% d) 40% 29.

Color of pure cholesterol stone is: (NBE/DNB pattern) a) Pale yellow b) Dark yellow c) Black d) Green

Gall stones : Pathogenesis 20.

Commenest type of gallstone is: a) Pigment (Kerla 87, NBE/DNB pattern) b) Cholesterol c) Mixed d) All are equally common

30.

Gall stones do not contain: a) Oxalate b) Cholestrol c) Phosphate d) Carbonate

21.

Lithogenic bile has the following properties: (AI 96) a) ↑Bile and cholesterol ratio b) ↓Bile and cholesterol ratio c) Equal bile and cholesterol ratio d) ↓Cholesterol only

31.

22.

Stone formation in Gall bladder is enhanced by all expect: (AI 96) a) Clofibrate therapy b) Ilial resection c) Cholestyramine therapy d) Vagal stimulation

Which of the following factors in bile juice is responsible for preventing the precipitation of cholesterol and formation of gallstones- (PGI June 05) a) High alkaline condition b) High concentration of bicarbonates c) Bile salts d) Bile pigments

23.

Gall blader stone formation in influenced by A/E: a) Clofibrate therapy (AI 98) b) Hyperalimentation c) Primary biliary cirrhosis d) Hypercholesterolemia

(JIPMER 81, AMU 86)

Gall stones : Symptoms, complications & management 32.

Gall stones: (ORISSA 98) a) Are about twice as common in men as in women b) There is an increased incidence of stones in diabetics c) About 80-90% of gall stones are radio-opaque d) Are usually more than 50 mm in diameter

33.

Gallstones may be complicated by which among the following: (PGI DEC 01) a) Pancreatitis b) Choledocholithiasis c) Acute cholecystitis d) Carcinoma stomach e) Carcinoma pancreas

(AIIMS NOV 93)

24.

Incidence of gall stone is high in: a) Partial hepatectomy b) Ileal resection c) Jejunal resection d) Subtotal gastrectomy

25.

True statement about gall stones are All/EXCEPT: (AIIMS NOV 99) a) Lithogenic bile is required for stone formation b) May be associated with carcinoma gall bladder c) Associated with diabetes mellitus d) More common in males between 30 - 40 years of age

34.

The following are complications of gallstone EXCEPT- (UPSC-II 09) a) Hemobilia b) Cholangitis c) Biliary enteric fistula d) Acute pancreatitis

26.

Which among the following does not lead to pigment gallstones: (PGI JUNE 99) a) TPN b) Clonorchis sinensis c) Hemolytic anemia d) Alcoholic cirrhosis

35.

The commonest site of obstruction in Gall stone ileus is: (AI 94, 99) a) Proximal ileum b) Distal ileum c) Ileocecal junction d) Transverse colon

27.

The predominant constituent of the pale yellow gall stones in the gall bladder is: (Comed 07) a) Mucin glycoprotein b) Calcium carbonate c) Cholesterol d) Calcium phosphate

36.

Most common site of gall stone impactation is: a) Duedenojejunal junction (AI 97) b) Proximal to iliocaecal junction c) Distal to iliocaecal junction d) Colon

28.

Radio-opaque gall stones (JIPMER, NBE/DNB pattern) a)) 10%

37.

The most common site of intestinal obstruction in gallstone ileus is: (AIIMS May 05, AI 04) a) Duodenum

Chapter 1 Gallbladder & Bile Ducts 49 b) Jejunum c) Ileum d) Sigmoid colon 38.

Internal fistula is most common between gall bladder and: (AIIMS JUNE 93) a) Colon b) Duodenum Ist Part c) Jejunum d) Transverse colon

46.

Treatment of chronic cholecystitis: (PGI DEC 2000) a) Cholecystectomy b) Choledochocystectomy c) Choledochocytostomy d) Conservative

47.

A 69 year old male patient having coronary artery disease was found to have gall bladder stones while undergoing a routine ultrasound of the abdomen. There was no history of biliary colic or jaundice at any time. What is the best treatment advice for such a patient for his gallbladder stones: a) Open cholecystectomy (NBE/DNB pattern, AIIMS b) Laparoscopic cholecystectomy Nov 03, AI 03) c) No surgery for gallbladder stones d) ERCP and removal of gallbladder stones

39.

Investigation of choice in gall bladder stone is: a) USG (KERALA 94) b) X-ray abdomen c) OCG d) Intravenous cholangiogram

40.

The treatment of gall stone ileus is: (PGI JUNE 99) a) Cholecystectomy alone b) Removal of obstruction c) Cholecystectomy, closure of fistula and removal of stone by enterotomy d) Cholecystectomy with closure of fistula

48.

Elective cholecystectomy is contra-indicated in – a) DM (NBE/DNB pattern) b) Congenital haemolytic anemia c) Bariatric surgery d) End stage liver disease

49.

The treatment of choice for a mucocele of gall bladder is: (AIIMS JUNE 04) a) Aspiration of mucous b) Cholecystectomy c) Cholecystostomy d) Antibiotics and observation

Which of the following drug is used for medical treatment of gall stones- (NBE/DNB pattern) a) Clemastine fumarate b) Mizolastine c) Lovastatin d) Ursodeoxycholic acid

50.

True about gall stones: (PGI DEC 02) a) More common in female b) Gall stones, haitus hernia, CBD stones form Saints triad c) Limely bile precipitated d) Lithotripsy always done

In which condition, medical t/t of gall stone is indicated: (AIIMS NOV 96, AI 98) a) Stone is < 15 mm size b) Radio opaque stone c) Calcium bilirubinate stone d) Non functioning gall bladder.

51.

The treatment of choice for silent stones in Gall bladder is : (AI 97) a) Observation b) Chenodeoxy cholic acid c) Cholecytectomy d) Lithotripsy

52.

A 50-year-old diabetic patient with asymptomatic gallstone (>3 cm) will be best treated by: a) Early surgery (UPSC-II 09) b) Bile salt treatment c) ESWL d) Waiting till it becomes symptomatic

53.

Ursodeoxycholic acid is a : a) Urinary stone dissolving drug b) Thrombolytic drug c) Gall stone dissolving drug d) Antifibrinolytic

54.

Investigation of choice in acute cholecystitis a) OCG (PGI Dec 2005) b) HIDA scan c) USG d) CT

41.

42.

43.

“Limey bile” is: (Karnataka 94) a) Present in the CBD b) Thin and clear c) Toothpaste like emulsion in the gall bladder d) Bacteria richs

44.

Which of the following is not an indication for cholecystectomy (AIIMS MAY 05) a) 70-year-old male with symptomatic gallstones b) 20-year-old male with sickle cell anaemia and symptomatic gallstones c) 65-year-old female with a large gallbladder polyp d) 55-year-old with an asymptomatic gallstone

45.

A 45 year old female presents with symptoms of acute Cholecystitis. On USG there is a solitary gallstone of size 1.5 cm. Symptoms are controlled with medical management. Which of the following is the next most appropriate step in the management of this patient? a) Regular follow up (All India 08) b) IV Antibiotics c) Laparoscopy cholecystectomy immediately d) Open cholecystectomy immediately

(PGI JUNE 95)

50 Chapter 1 Gallbladder & Bile Ducts 55.

In a patient of acute cholecystitis, referred pain to the shoulder is k/a (NBE/DNB PATTERN) a) Murphy’s sign b) Gray Turner sign c) Boa’s sign d) Cullen’s sign

56.

Which one of the following statements is incorrect in regard to stones in the gallbladder? a) Pigment stones are due to increased excretion of conjugated bilirubin b) Are considered a risk factor for the development of gallbladder carcinoma c) 10% of gallstones are radio-opaque d) A mucocele of the gallbladder is caused by a stone impacted in Hartmann’s pouch

57.

58.

59.

A patient has a surgical cause of obstructive jaundice. He is advised USG. All of the following can be detected on USG, except: (AIIMS NOV 12) a) Biliary tree obstruction b) Peritoneal deposits c) Gall bladder stones d) Ascites A 50 year old lady with history of jaundice in the past has presented with right upper quadrant abdominal pain. Examination and investigations reveal chronic calculous cholecystitis. The liver functions tests are within normal limits and on ultrasound examination the common bile ducts is not dilated. Which of the following will be the procedure of choice in her: a) Laparoscopic cholecystectomy (J & K 05) b) Open choledocholithotomy with CBD exploration c) ERCP± cholecystectomy followed by laparoscopic cholecystectomy d) Laparoscopic cholecystectomy followed by ERCP ± choledocholithotomy Laproscopic cholecystectomy is largely preferred for all of the following reasons to conventional laparotmy EXCEPT : (SGPGI 04) a) Decrease pain b) Decresed incidence of bile duct injuries c) Smaller scar d) Decreased stay in hospital

60.

Which of the following is contraindication to laparoscopic cholecystectomy: (NBE/DNB pattern) a) Refractory coagulopathy b) Obstructive pulmonary disease c) End stage liver disease d) All of the above

61.

Contra indication for Laproscopic cholecystectomy is all except : (KERALA 95) a) Shrunken liver b) Previous laprotomy c) Emphysema d) Morbid obesity

62.

A 88 years male patients presented with end stage

renal disease with coronary artery block and metastasis in the lungs. Now presents with acute cholecystitis, patient’s relatives need treatment to do something: (UP 08) a) Open cholecystectomy b) Tube cholecystostomy c) Laparoscopic cholecystectomy d) Antibiotics then elective cholecystectomy 63.

Bleeding adjacent to the “Triangle of Calot” should be controlled by: (MHPGMCET 2009) a) Pressing the artery manually b) Blind clipping c) Kocher’s artery forceps d) Stitching Acalculous Cholecystitis

64.

Acalculous cholecystitis is caused by: (PGI DEC 01) a) Diabetes mellitus b) Total parenteral nutrition c) Tuberculosis d) Anemia e) Malignancy

65.

All of the following are causes of acalculous cholecystitis: (NBE/DNB pattern) a) Prolonged TPN b) Major operations c) Schistosomiasis d) Bile duct stricture

66.

Acalculous cholecystitis can be seen in all the following conditions except: (AIIMS Nov. 2005) a) Enteric fever b) Dengue haemorrhagic fever c) Leptospirosis d) Malaria

67.

Acalculus cholecystitis caused by: a) DM b) TPN c) Leptospirosis d) Estrogen therapy

68.

Which of the following statements about acalculous cholecystitis is incorrect ? (DELHI PG Mar. 09) a) Manifestation of disturbed microcirculation in critically ill patient b) Prolonged parenteral nutrition can be causative c) It is life threatening condition d) Cholecystectomy is not indicated

(PGI DEC 06)

Gallbladder Polyps, Cholesterolosis & Adenomyomatosis 69.

Strawberry gallbladder is seen in: a) Gangrene of gallbladder b) Porcelain gall bladder c) Adenomatosis d) Cholesterosis

(JIPMER 81)

Chapter 1 Gallbladder & Bile Ducts 51 70.

71.

Cholesterosis is: (KARNATAKA 94) a) Disease of defective metabolism of choline b) Concerned with epithelial tumours of brain c) Diffuse depositon of cholesterol in mucosa of gall bladder d) Disease concerned with obstructive jaunidce On abdominal ultrasound gall bladder shows diffuse wall thickening with hyperechoic nodules at neck and comet tail artifacts. The most likely diagnosis will be: a) Adenomyomatosis (AIIMS May 11, Nov 08) b) Adenocarcinoma of gall bladder c) Xanthogranulomatous cholecystitis d) Cholesterol crystals (UPSC-II 09)

72.

Consider the following: 1) Cholesterosis 2) Adenomyomatosis 3) Polyposis 4) Cholelithiasis



To which of the above does cholecystoses refer to: a) 1, 2 and 3 b) 1 and 3 only c) 2, 3 and 4 d) 1 and 3 only

73.

Risk factors for malignant change in an asymptomatic patient with a gall bladder polyp on ultrasound include all of the following, Except: a) Age > 60 years (AIIMS May 11; All India 09) b) Rapid increase in size of polyp c) Size of polyp > 5 mm d) Associated Gall stones

d) Transitional cell ca 78.

Factors associated with gall bladder ca (PGI June 05) a) Chronic cholesterol stone b) Hyperlipidemia c) Chronic gall bladder disease d) Hepatitis e) Porcelain gall bladder

79.

Commonest association seen in carcinoma gall bladdera) Peritoneal deposits (AIIMS 91) b) Duodenal infiltration c) Secondaries liver d) Cystic node involvement

80.

Laparoscopic cholecystectomy done in a patient with cholelithiasis. Pathology report shows adenocarcinoma with invasion of muscle layer. CT was normal. Further t/t is: (AIIMS NOV 09) a) Wait and regular follow up b) Wedge hepatic resection with lymph node dissection c) Excise all port sites d) Radiotherapy

81.

In a male after laparoscopic cholecystectomy, specimen is sent for histopathology which shows carcinoma gallbladder stage T1a. Appropriate management is: (AIIMS NOV 08) a) Conservative and follow up. b) Extended cholecystectomy c) Excision of all port sites d) Radiotherapy

82.

A 40 year old woman has undergone a Cholecystectomy. The histopathology reveals that she has a 3 cm adenocarcinoma in the body of the gallbladder infiltrating upto the serosa. Which of the following further management would you advise her: a) Chemotherapy (AIIMS NOV 04) b) Radiotherapy c) Radical Chlolecystectomy d) Follow up with regular ultrasound examinations

83.

Survival in unresectable GB ca is? a) 4-6 months b) 8-10 months c) 1 yr d) 12-24 months

84.

Regarding Ca gallbladder: (PGI JUNE 02) a) Squamous cell ca is the most common b) Present with jaundice c) Good prognosis d) Gallstones predispose e) 65% survival after surgery

85.

Organism associated with fish consumption and also causes carcinoma gallbladder: (AIIMS Nov 10) a) Gnathostoma b) Anglostrongyloidosis cantonensis c) Clonorchis sinensis d) H. dimunata

Gall Bladder Carcinoma 74.

All of the following are risk factors for carcinoma gall bladder, EXCEPT: (AIIMS JUNE 04) a) Typhoid carriers b) Adenomatous gall bladder polyps c) Choledochal cysts d) Oral contraceptives

75.

Association of carcinoma gall bladder with gall stones is about: (PGI 85) a) 50% b) 70% c) 90% d) 20%

76.

77.

Precancerous lesion of gall bladder is (AIIMS JUNE 98) a) Porcelain gall bladder b) Mirrizi syndrome c) Cholesterosis d) Acalculous Cholecystitis Commonest type of ca gallbladder with gall stones is: a) Adenocarcinoma (AIIMS NOV 95) b) Anaplastic carcinoma c) Sq. cell carcinoma

(AIIMS May 11)

52 Chapter 1 Gallbladder & Bile Ducts Choledocholithiasis

d) Convert it to open cholecystectomy & remove CBD stone

86.

Normal length of CBD is: a) 2 cm b) 3 cm c) 5 cm d) 7 cm

(NBE/DNB pattern)

94.

87.

A gall stone gets impacted most commonly in which part of common bile duct: (JIPMER 87) a) Supraduodenal b) Retroduodenal c) Ampulla of vater d) Common hepatic duct

The treatment of choice for an 8 mm retained common bile duct (CBD) stone is: (AIIMS May 05, Nov 03) a) Laparoscopic CBD exploration (NBE/DNB pattern) b) Percutaneous stone extraction c) Endoscopic stone extraction d) Extracorporeal shock wave lithotripsy

95.

Which one of the following statement is incorrect regarding stone in the common bile duct? a) Can present with Charcot’s triad (All India 2006) b) Are suggested by a bile duct diameter > 6 mm of ultrasound. c) ERCP, sphincterotomy and balloon clearance is now the standard treatment d) When removed by exploration of the common bile duct the T-tube can be removed after 3 days

(AIIMS JUNE 98)

88.

Not a feature of CBD stone: a) Pain b) Fever c) Jaundice d) Septic shock

89.

What is more appropriate for diagnosis of CBD stones: (PGI JUNE 97) a) Ultrasonography b) ERCP c) O C G d) IV cholangiography

96.

Absolute indication for choledochotomy : a) Gallstone ileus (PGI June 2006) b) Gallstone pancreatitis c) Fever d) Jaundice e) Palpable CBD stone

90.

Ramu, presents with recurrent attacks of cholelithiasis, U/S examination shows a dilated CBD of 1 cm. The next line of management is: a) ERCP (AIIMS JUNE 01) b) PTC c) Cholecystostomy d) Intravenous cholangiogram

97.

Sphincterotomy of sphincter of Oddi is performed at which position: (NBE/DNB pattern) a) 3’O clock b) 6’O clock c) 9’O clock d) 11’O clock

91.

Best treatment modality for common bile duct stone is: a) Endoscopic sphincterotomy (AIIMS NOV 94) b) Observation c) Chenodeoxycholic acid d) Percutaneous removal

92.

93.

A patient having multiple Gall stones and shows 8 mm dilation and 4 stones in CBD, best treatment modalities are: (PGI DEC 02) a) Cholecystectomy with choledocholithotomy at same setting b) ESWL c) Cholecystectomy and wait for ERCP d) Sphincterotomy and then cholecystectomy e) Cholecystectomy and after 14 days sphincterotomy done Surgeon with less experience of laparoscopic choelcystectomy while doing lap surgery found some stone in common bile duct. What should he ideally do? (AIIMS NOV 11) a) Open cholecystectomy with choledocoduodenostomy b) Lap exploration of CBD and removal of stone c) Lap CBD extraction through the cystic duct

Cholangitis (PGI DEC 02)

98.

CBD stone may present with: a) Increased bilirubin b) ↑WBC count c) ↑ liver enzymes d) Fever with rigors e) Hepatomegaly

99.

Which of the following occurs in Charcot’s triad: a) Pain abdomen (PGI DEC 01, PGI DEC 03) b) Fever and chills c) Jaundice d) Shock e) Pruritus

100. ‘Charcot’ triad’ is: a) Fever, pain, vomiting b) Fever, stone, jaundice c) Fever, pain, jaundice d) Gall stone, vomiting, jaundice

(AI 95, AI 96)

101. Which of the following is not a component of Reynolds' Pentad in toxic cholangitis ? a) Right upper quadrant pain (DELHI PG Mar. 09) b) Confusion c) Septic shock

Chapter 1 Gallbladder & Bile Ducts 53 d) Markedly elevated transaminases 102. Most common cause of cholangitis: (AIIMS JUNE 94) a) Viral infection b) CBD stone c) Surgery d) Amoebic infection 103. A patient of post-cholecystectomy biliary stricture has undergone an ERCP three days ago. Following this she has developed acute cholangitis. The most likely organism is- (All India 2006) a) Escherichia coli b) Bacillus fragilis c) Streptococcus viridians d) Pseudomonas aeruginosa 104. Which of the following statements is true regarding cholangitis: (PGI DEC 01) a) Increased leucocyte count b) Increased transaminases c) Increased bilirubin d) Increased alkaline phosphatase e) Association with fever and chills 105. The most common cause of suppurative cholangitis is: a) Stone in common bile duct (UP 97) b) Cancer of the ampulla of vater c) Choledochal cyst d) Empyema of gall bladder 106. A 50 year old woman presented with history of recurrent episodes of right upper abdominal pain for the last one year. She presented to casualty with history of jaundice and fever for 4 days. On examination, the patient appeared toxic and had a blood pressure of 90/60 mmHg. She was started on intravenous antibiotics. Ultrasound of the abdomen showed presence of stones in the common bile duct. What would be the best treatment option for her: a) ERCP and bile duct stone extraction (AIIMS NOV 03) b) Laparoscopic cholecystectomy c) Open surgery and bile duct stone extraction d) Lithotripsy Post cholecystectomy biliary injury/ Strictures 107. Causes of bile duct strictures are: a) Bile duct carcinoma b) Chronic pancreatitis c) Acute pancreatitis d) Trauma e) CBD stone

(PGI DEC 08)

108. Most common cause of biliary stricture is: a) CBD stone (NBE/DNB pattern, AIIMS June 94) b) Trauma c) Asiatic cholangitis d) Congenital

109. According to Strasberg classification, lateral CBD injuries are classified as: (JIPMER GIS 2011) a) Type B b) Type C c) Type D d) Type E 110. According to Bismuth Strasberg classification of bile duct injury, causing occlusion of abranch of biliary tree would be which type? (MHSSMCET 2010) a) Type A b) Type B c) Type C d) Type D 111. In Bismuth/ Strasberg classification system cystic blow out is classified as: (All India 2010) a) Type A b) Type B c) Type C d) Type D 112. A 40 year old patient has undergone an open cholecystectomy. The procedure was reported as uneventful by the operating surgeon. She has 100 ml of bile output from the drain kept in the gallbladder bed on the first post operative day. On examination she is afebrile and anicteric. The abdomen is soft and bowel sounds are normally heard. As an attending physician, what should be your best possible advice- a) Order an urgent endoscopic retrograde cholangiography and biliary stenting b) Urgent laparotomy (AIIMS NOV 03) c) Order an urgent hepatic imino diacetic acid scintigraphy (HIDA) d) Clinical observation 113. On 7th postoperative day after laparoscopic cholecystectomy, pt. developed rt. upper abdominal pain and 10 cm X 8 cm collection. Treatment consists of: (PGI DEC 03) a) Immediate laparotomy b) Percutaneous drainage c) Laparotomy & surgical exploration of bile duct and T tube insertion d) Laparoscopic cystic duct ligation and percutaneous drain e) Roux-en-Y loop hepatojejunostomy 114. On 5th postoperative day after laparoscopic cholecystectomy, a 50 years old lady presented with rt. upper quadrant pain with fever and 12 cm subhepatic collection on CT and ERCP shows cystic duct leak. The best management is: (PGI JUNE 03) a) Immediate laparotomy b) Percutaneous drainage of fluid c) Laparotomy and surgical exploration of bile duct and T-tube insertion d) Laparoscopic cystic duct ligation & percutaneous

54 Chapter 1 Gallbladder & Bile Ducts drain e) Roux en loop hepatojejunostomy 115. 5 days after CBD surgery there is a small leak. What will be the best T/t: (AIIMS JUNE 98) a) Ultrasound guided drainage b) ERCP and stenting c) Re-exploration and hepatojejunostomy d) Re-exploration and primary repair. 116. The initial investigation of choice for a post cholecystectomy biliary stricture is: (AIIMS May 05) a) Ultrasound scan of the abdomen b) Endoscopic cholangiography c) Computed tomography d) Magnetic resonance cholangiography 117. Regarding bile duct injuries following cholecystectomy which of the following statement is false: (AIIMS Nov 2005) a) The incidences following open cholecystectomy is in the range of 0.2 to 0.3% b) The incidence rate following Laparoscopic cholecystectomy is three times higher than the rates following open cholecystectomy c) Untreated cases may develop secondary biliary cirrhosis d) Routine use of ‘open’ technique of laparoscopic port insertion has resulted in a decline in the incidence of post laparoscopic cholecystectomy bile duct injuries. 118. Biliary stricture developing after Laparoscopic cholecystectomy usually occurs at which part of the common bile duct? (All India 2006) a) Upper b) Middle c) Lower d) All sites with equal frequency 119. After exploration of common bile duct, the T- Tube is removed on which of the following days: (KARNAT 96) a) 3 postop.day b) 4 postop. day c) 12 postop.day d) 6 postop day Cholangiocarcinoma 120. Which of the following does not predispose to cholangiocarcinoma: (AI 96, AIIMS Feb 97) a) Ulcerative colitis b) Clonorchis sinensis c) Choledochal cyst d) Chronic pancreatitis 121. All of the following are known predesposing factors for cholangiocarcinoma except: (AI 97) a) CBD stones b) Clonorchis sinensis c) Ulcerative colitis d) Primary sclerosing cholangitis

122. An increased incidence of cholangiocarcinoma is seen in all of the following except: (AI 03) a) Hydatid cyst of liver b) Polycystic disease of liver c) Sclerosing cholangitis d) Liver flukes 123. Risk factor for cholangiocarcinoma all except: a) Chronic typhoid carrier (AIIMS NOV 09) b) Chronic ulcerative colitis c) Parasitic infestation d) Choledocholithiasis 124.

APBDJ is associated with: (AIIMS GIS 2003) a) Cholangiocarcinoma b) CA GB c) Choledochal cyst d) All of the above

125. Most common site of cholangiocarcinoma? a) Distal biliary duct (AIIMS Nov11, 08) b) Hilum c) Intrahepatic duct d) Multifocal 126. Klatskin tumor is: (JIPMER 2010) a) Merkel cell carcinoma of skin b) Primitive neuroectodermal tumor of chest wall c) Common hepatic duct tumor d) Adenocarcinoma of anal canal 127. Cholangiocarcinoma histologically resembles: a) Sq. cell type (AIIMS 79, DELHI 79, 92) b) Colloid cell type c) Schirrhous type d) Columnar cell type 128. Type II cholangiocarcinoma involves: a) Tumor confined to CHD (NBE/DNB pattern) b) Involvement of bifurcation and not extending further c) Involvement of secondary hepatic ducts on right side d) Involvement of secondary hepatic ducts on left side 129. All are criteria of non-resectability in patients with hilar cholangiocarcinoma except: (JIPMER GIS 2011) a) Hepatic duct involvement upto secondary radicals bilaterally b) Encasement or occlusion of main portal vein proximal to its bifurcation c) Atrophy of one lobe with encasement of contralateral portal vein branch d) Atrophy of one lobe with ipsilateral involvement of secondary biliary radicals Primary sclerosing cholangitis 130. Primary sclerosing cholangitis is likely to be associated with: (JIPMER 2012, 2011) a) Adenocarcinoma of pancreas b) Cholangiocarcinoma c) Hepatocellular carcinoma

Chapter 1 Gallbladder & Bile Ducts 55 d) Adenocarcinoma of gallbladder

d) Hepatitis (PGI DEC 99)

131. “Onion skin” fibrosis of bile duct is seen in: a) Primary biliary cirrhosis (COMEDK 2009) b) Primary sclerosing cholangitis c) Extrahepatic biliary fibrosis d) Congenital hepatic fibrosis

140. All are seen in hemobilia except: a) Shock b) Colicky pain c) Melena d) Jaundice

132. True about primary sclerosing cholangitis are all Except a) fibrosing cholangitis of bile duct (PGI June 05) b) periductal onion skin appearance c) Cirrhosis never occurs d) jaundice seen e) associated with ulcerative colitis

141. Triad of hemobilia includes all, EXCEPT: a) Pain (AIIMS JUNE 93) b) Fever (NBE/DNB pattern) c) G.I. bleeding d) Jaundice

133. All of the following are true for patients of ulcerative colitis associated with primary sclerosing cholangitis, except (AI 05) a) They may develop biliary chrrhosis b) May have raised alkaline phosphatase c) Increased risk of hilar cholangiocarcinoma d) PSC reverts after a total colectomy 134. All are true about PSC except: (AIIMS GIS May 2011) a) Commonly affect 40-45 years of age b) More common in males c) Most patients presents with advanced disease d) Survival after diagnosis is 10–15 years Primary biliary cirrhosis 135. The earliest symptom in primary biliary cirrhosis is: a) Jaundice (COMEDK 2008, 2007) b) Pruritus c) Melanosis d) Vomiting 136. Which is not true about PBC? (APPG 08) a) No increase in risk of hepatocellular carcinoma b) Often asymptomatic c) Elevated IgM d) Positive antimitochondrial antibody 137. Commonest presentation of primary biliary cirrhosisa) Pruritis (AI 98) b) Pain c) Jaundice d) Fever Hemobilia 138. Most common cause of hemobilia is: a) Gall stones (NBE/DNB pattern) b) Blunt trauma c Iatrogenic trauma d Malignancy 139. Causes of Hemobilia are All Excepta) Trauma to Abdomen (AIIMS JUNE 2000) b) Malignancy c) Rupture of hepatic artery aneurysm

142. True regarding hemobilia: (DPG 2007) a) Triad of jaundice, pain, melena b) MC cause- rupture of portal vein into biliary system c) MR angiography is the IOC d) None of the above Miscellaneous 143. Which of the following is true regarding principle of MRCP? (AIIMS Nov 12 ) a) Use of IV Gadolinium contrast agent is used to enhance the biliary radicals and the pancreatic duct b) Contrast agent is instilled percutaneously into the biliary radicals first and then MRI done c) Intraluminal dye is used to create the three dimensional view of the biliary radicals and the pancreatic duct d) Use of heavily T2 weighted images without contrast 144. A 2 month old child presented with white colored stools since 1 month and yellowish discoloration of eyes and urine. She was started on steroids and ursodeoxycholic acid. Blood tests show direct bilirubin of 6 mg%. Which of the following would be the best investigation in this patient to arrive at the diagnosis? a) Ultrasonography b) CT scan c) MRI d) HIDA scan 145. Not true about Xanthogranulomatous cholecystitis is: a) Yellow nodules are seen (NBE/DNB pattern) b) Associated with tuberculosis c) Foam cells are seen d) Confused with carcinoma of gallbladder 146. All of the following are correct regarding emphysematous cholecystitis, except: (NBE/DNB pattern) a) It is caused most commonly by Pseudomonas b) More common in men c) More common in diabetics d) In many cases gallbladder does not contain stone 147. All are component of saint’s triad Except: a) Renal Stones (AIIMS NOV 95) b) Hiatus hernia

56 Chapter 1 Gallbladder & Bile Ducts c) Diverticulosis coli d) Gall stones 148. Features of healthy gallbladder on laprotomy are: a) Typical “sea-green” colored (PGI DEC 2000) b) Wall is thin & elastic c) Cannot be emptied d) Not easily visible 149. Most common surgical cause of obstructive jaundicea) Periampullary carcinoma (NBE/DNB pattern, AIIMS b) Carcinoma gall bladder Nov 94, Nov 96, AI 98, 2000) c) Carcinoma head of pancreas d) CBD stones 150. Pneumobilia is seen in: a) Gallstone ileus b) Mirizzi’s syndrome c) Volvulus d) TPN

(NBE/DNB pattern)

151. In cholangiography CBD stone appears as: a) Meniscus sign (AIIMS JUNE 98) b) Cut off sign c) Slight flow of dye from the sides of stone d) Chain of lake appearance. 152. One is not the feature of obstructive jaundice: a) Pruritis (AIIMS NOV 95) b) Elevated level of S.bilirubin c) Raised alkaline phosphatase d) Raised Urinary urobilinogen 153. Mirizzi syndrome is: (NBE/DNB pattern) a) Pancreatic carcinoma causing CBD obstruction b) GB stone causing cholecystitis c) GB stone invading IVC d) GB stone compressing over CHD 154. Which is not elevated in a child presenting with jaundice, icterus, pruritus & clay coloured stools. a) Gamma glutanyl transpeptidase (AIIMS NOV 11) b) Alkaline phosphatase c) 5'-nucleotidase d) Glutamate dehydrogenase 155. The Gall stone pain is referred to the shoulder through which of the following nerves: [NBE/DNB PATTERN] a) C2-C8 b) T1-T4 c) T8-T12 d) C3-C5 156. Which does not contribute to Enterobillary Fistula: a) Duodenal ulcer (JIPMER 91) b) Gall stones c) Gastric ulcer d) Carcinoma gall bladder 157. An ultrasound examination shows dilated intrahepatic biliary channels with a small gall

bladder. The most likely possibility is: (KARNATAKA 94) a) Gall Bladder stone b) Pancreatic calculus c) Common bile duct stone d) Carcinoma of the head of the pancreas 158. Best suture for common bile duct is: (JIPMER 95) a) Synthetic absorbable synthetic b) Synthetic non-absorbable c) Non-synthetic absorbable d) Non-synthetic non-absorbable 159. A 50-years old male presents with pain upper abdomen, pruritus, jaundice and weight loss, elevated ANA, the likely diagnosis is: (COMEDK 2011) a) Primary sclerosing cholangitis b) Klatskin tumor c) Secondary sclerosing cholangitis d) Choledocholithiasis 160. Pruritus precedes jaundice in: (ILBS 2011) a) Primary biliary cirrhosis b) Secondary biliary cirrhosis c) Primary sclerosing cholangitis d) CBD stone 161.

All of the following are true regarding RPC except: (AIIMS GIS Dec 2010) a) Equal incidence in males and females b) More common in left lobe of liver c) All are pigmented stones d) GB stones are present in >50% cases

162. A patient presents with Abdominal pain, Jaundice and malena. The Diagnosis is: (AI 2000) a) Hemobilia b) Acute cholangitis c) Carcinoma gall bladder d) Acute pancreatitis 163. Best investigation for bilhemia is: (JIPMER GIS 2011) a) ERCP b) MRCP c) CT d) EUS 164. Vanishing bile duct syndrome is seen in: a) Chronic viral hepatitis (PGI JUNE 03) b) Sarcoidosis c) Lymphoma d) Non-cirrhotic portal fibrosis e) Alcoholism 165. Bile ductopenia seen in: a) GVHD b) Alcoholic hepatitis c) Autoimmune hepatitis d) Cirrhosis e) Sclerosing cholangitis

(PGI DEC 03)

166. A patient presenting with H/O diarrhea for several

Chapter 1 Gallbladder & Bile Ducts 57 years with recent onset pruritus & ↑Alkalline Phosphatase, normal SGOT/PT & USG shows no gall stones & biliary tract abnormality, the diagnosis is: a) Hodgkins Lymphoma (PGI JUNE 04) b) Sclerosing cholangitis c) Chronic Hepatitis d) Autoimmune Hepatitis e) Viral Hepatitis 167. The ideal treatment of stenosis of sphineter of Oddi is: a) Transduodenal sphincteroplasty (SGPGI 04) b) Endoscopic sphincterotomy c) Choledochojejunostomy d) Choledochoduodenostmy 168. Sump syndrome occurs most commonly after: a) Cholecystojejujunostomy (COMEDK 2008) b) Choledochoduodenostomy c) Mirizzi’s syndrome d) Choledochojejunostomy

170. Which does not contribute to enterobiliary fistula? (Punjab 2008) a) Gastric ulcer b) Duodenal ulcer c) Carcinoma gallbladder d) Gallstones 171. A young patient develops high grade fever with chills and rigors, mild jaundice and acute pain in the upper abdomen following cholecystectomy. On examination, she was jaundiced, toxic, haemodynamically stable and having vague fullness upper abdomen. What is the most probable diagnosis: (UPSC-II 09) a) Localised collection of bile in peritoneal cavity b) Iatrogenic ligation of common bile duct c) Duodenal injury d) Acute pancreatitis

169. Most common cause of gallbladder fistula is: (DPG 2008) a) Liver abscess aspiration b) Laparoscopic surgery c) Gallstones d) Trauma



58 Chapter 1 Gallbladder & Bile Ducts Gallbladder 1.

Ans. is ‘d’ i.e. 50 [Ref: Schwartz 9/e p1136 (8/e, p1187); Bailey & Love 25/e p1111 (24/e, p1094)] Normal capacity of gallbladder is ------ 30 to 50mL; When obstructed it has the capacity of distend up to---- 300mL

2.

Ans. is ‘a’ i.e. 5 and ‘b’ i.e. 10 [Ref: Bailey & Love 25/e p1112 (24/e, p1095)]

3.

Ans. is ‘d’ i.e., Lymphnode of lund [Ref: Love & Bailey 25/e p1112 (24/e p1094)]

4.

Ans. is ‘c’ i.e. Ultrasound [Ref: Bailey & Love 25/e p1113 (24/e, p1097)]

5.

Ans. is ‘a’ i.e. Oral cholecystography [Ref: Bailey & Love 24/e, p 1093]

6.

Ans is ‘b’ ie Motor Mechanism of Gall bladder [Ref, S. Das text book, 4/e, p 892, Bailey 24/e, p 1095] cholecystography (also known as Grahm Cole test) involves oral administration of a radioopaque compound that is absorbed, excreted by the liver, and passed into the gall bladder. z S. Das writes - “Successful visualisation of gall bladder in oral cholecystography depends on:1) Blood flow to the liver 2) Ability of the liver cells to excrete the dye into the bile (ie functioning liver) 3) Patency of hepatic and cystic duct system. 4) Ability of gall bladder to concentrate the excreted dye (by absorbing water)” z Motor Mechanism of the gall bladder in a requirement for Medical t/t of gall stones. Also know z Oral cholecystography is of no value in patients with Š intestinal malabsorption Š vomitting Š obstructive jaundice, and Š hepatic failure z Oral

7.

Ans. is ‘a’ i.e. Iapanoic acid [Ref: Bailey & Love 24/e, p 1095] z Dye used for z Oral cholecystography - Iopanoic acid z IV cholangiography - Biligrafin, Biligram (ioglycamide), Biliscopin (iotroximate) Also know: Needle used for PTC ------------- Chiba needle*

8.

Ans. is ‘c’ i.e. Biligraffin [Ref: See Revision Notes] Choledochal cyst

9.

Ans. is ‘a’ i.e., Type I [Ref: Schwartz, 9/e p1440 (8/e p1500); Bailey & Love 25/e p1119 (24/e, p1102; 23/e, p974)]

10.

Ans. is ‘b’ i.e., Type II [Ref: Bailey & Love 25/e p1119]

11.

Ans. is ‘c’ i.e. Pain, lump and progressive jaundice

12.

Ans is ‘c’ ie Excision is the ideal t/t [Ref. Schwartz 10/e p 1330 (9/e p1440);Bailey & Love 26/e p 1106 (25/e p1119); Sabiston 10/e p 1503-4; Maingot’s 11/e chapter 34 (10/e p1709)] “The treatment of choledochal cyst is surgical excision followed by biliary-enteric reconstruction. There is no role for internal drainage by cystenterostomy, which leaves the cyst wall intact and leads to the inevitable development of cholangitis. Rarely, choledochal cyst can lead to the development of a biliary tract malignancy. This provides a further rationale for complete cyst excision.” - Schwartz 9/e

13.

Ans is ‘d’ ie Cystojejunostomy is t/t of choice [Ref: See Revision Notes]

14.

Ans is ‘c’ i.e. Recurrent Cholangitis [Ref: Schwartz, 10/e p 1400 (9/e p1440; Maingot’s 12/e p 1034 (11/e chapter 34, 10/e p1709)]

Chapter 1 Gallbladder & Bile Ducts 59 Schwartz writes “There is no role for internal drainage by cystenterostomy, which leaves the cyst wall intact and leads to the inevitable development of cholangitis. Rarely, choledachal cyst can lead to the development of biliary tract malignancy. This provides a further rationale for complete cyst excision.” Š A bypass procedure will lead to strictures and recurrent cholangitis. This can be prevented by complete excision of cyst and reconstruction procedure. Š Though by complete excision we also prevent malignancy (which may occur in future), but this is an added advantage 15.

Ans is b i.e. Type 2 is most common [Ref. Schwartz, 9/e p1440 (8/e p1500); Bailey & Love 25/e p1119 (24/e, p1102; 23/e, p974); Maingot’s 11/e chapter 34 (10/e p1709)] Type I is the most common.

16.

Ans is ‘c’ i.e. Congenital [Ref: See Revision Notes] Biliary atresia

17.

Answer (c, d & e) (c) Marked Bile duct proliferation; (d) Fibrosis of hepatic duct: (e) Parenchymal cholestasis : [Ref: Bailey & Love 26/e p 1104; Robbin’s 8/e p887 (7/e, p933); Schwartz, 9/e p1439 (8/e, p1500); Maingot’s 10/e, p 2117; CSDT 12/e p1192 (11/e, p1334)]

18.

18. Ans is (a) ie., peroperative cholangiograpy [ Ref: Bailey & Love 26/e p 1105; Schwartz, 10/e p 1392 (9/e p1439); Maingot’s 10/e, p 2122; Nelson 18/e p1672 (17/e, p1317)]

19.

Answer (b) Size of ductule > 200 micron; (e) Age of 8 weeks [Ref: CSDT 13/e p1192 (11/e, p1335); Maingot’s 10/e, p 2123, Schwartz, 9/e p1439 (8/e, p1500)] z About prognostic factors for successful outcome of the Kasai operation, we have consulted many books including books on Pediatric Surgery. The maximum information we could get was from CSDT, Maingot’s and Schwartz. z The prognostic factors are: a) Age of operation a better prognosis is achieved with age less than 60 days (8 weeks given in 8th edition of Schwartz). b) Absence of cirrhosis checked by bridging liver fibrosis on biopsy. c) Diameter of bile ductules at the portal plate ductules greater than 150 µm in diameter are associated with good chances of bile drainage (-Maingot 10/e, p 2123) [NMS Surgery writes > 120 µm are associated with good prognosis] d) Establishment of adequate bile flow e) Cholangitic episodes postoperative cholangitic episodes are associated with bad prognosis. Gall stones : Pathogenesis

20.

Ans is ‘c’ i.e. Mixed [Ref: Schwartz 10/e p1318; SRB’s Manual of Surgery]

21.

Ans is ‘b’ i.e., Decreased Bile and cholesterol ratio [Ref: Bailey & Love 26/e p 1106; Schwartz 10/e p 1318; Harrison 17/e p1991 (16/e p1880); Maingot’s 10/e, p 1718] z Bile salts and phospholipids in bile keep cholesterol in solution by the formation of micelles. z An excess of cholesterol relative to bite salts and phospholipids allows cholesterol to form crystals and such bile is called Lithogenic or super-saturated bile.

22.

Ans is ‘d’ i.e., Vagal stimulation [Ref: Bailey 23rd/e p. 975] z Vagal stimulation increases gall bladder motility and thus prevents stone formation. z As described in the notes z Clofibrate - increases biliary cholesterol z Cholestyramine and ileal resection-decrease enterohepatic circulation of bile salts. Š thus they predispose to cholesterol stone formation. z Also know Š Earlier it was thought that truncal vagotomy increased the risk of cholesterol gall stone formation. But recent studies show no increased incidence of gall stone formation following truncal vagotomy. [Ref: Maingot’s 10/e p 1722]

60 Chapter 1 Gallbladder & Bile Ducts 23.

Ans is ‘d’ i.e., Hypercholesterolemia [Ref: See Revision Notes] z Hyperalimentation - decreases gall bladder motility, promotes stasis z Primary biliary cirrhosis - decreases bile salt secretion into bile z Clofibrate therapy - increases biliary cholesterol Š thus these factors predispose to cholesterol stone formation.

24.

Ans. is ‘b’ i.e., Ileal resection [Ref: See Revision Notes] As already explained ileal resection or ileal disease decreases enterohepatic circulation of bile salts (or acids). This decreases the biliary secretion of bile salts, thus increasing the cholesterol bile acid ratio (lithogenic bile).

25.

ns is ‘d’ ie. More common in males between 30-40 yrs. of age [Ref. Bailey & love 26/e p 1106 (25/e p1120); Schwartz A 10/e p 1318] z Though Cholelithiasis can occur in both sexes from childhood to the centenarian (people in their 100), it is more common in females. A ‘fat, fertile, flatulent, female of fifty’ is the clinical sufferer from symptomatic gallstones. z Lithogenic bile : is required for the formation of mixed stone and cholesterol stones. Š Bile contain cholesterol, insoluble in water and held in solution by detergent action of bile salts & phospholipids. When there is excess of cholesterol relative to bile salts & phospholipids, cholesterol gets precipitated to form gall stones. Such a bile is termed supersaturated or lithogenic. z Gall stones are associated with Ca gall bladder. In over 95% cases gall stones are found associated with Ca G.B. z Patients with diabetes mellitis, have increased risk of developing gall stones due to Š increased cholesterol level in bile Š reduced bile acid pool Š decreased gall bladder motility - Maingot’s 10/e, p 1722; Chandrasoma Taylor, 3/e, p 666. z Also know Š Percentage of gall stones which are radiopaque ––––® 10%

26.

Answer (A) TPN: [Ref: Harrison 17/e p1993 (16/e, p1882); Bailey & Love, 25/e p1120 (24/e p1103); Maingot’s, 10/e, p 1720, Robbins, 8/e p883 (7/e p929)] In TPN, there is cholesterol and mixed stones due hypomotility of Gallbladder and leading to stasis and biliary sludge.

27.

Ans. is ‘c’ i.e., Cholesterol [Ref: Love & Bailey 25/e p1119-20 (24/e p1103); Schwartz 8/e, p 1196]

28.

Ans. is ‘a’ i.e., 10% [Ref: Sabiston 18 th /e p. 1554] Only about 10-15% gallstones contain enough calcium to render them radioopaque.

29.

Ans is ‘a’ i.e. Pale yellow [Ref: See Revision Notes]

30.

Ans. is ‘a’ i.e. Oxalate [Ref: Bailey & Love 25/e p1120 (24/e, p1103)]

31.

Ans. is ‘c’ i.e., Bile salts. [Ref: Harrison 17/e p1991 (16/e p1880)] Gall stones : Symptoms, complications & management

32.

Ans. is ‘b’ i.e. There is an increased incidence of stones in diabetics [Ref: Maingot’s 10/e, p 1722]

33.

Answer ‘a’ i.e. Pancreatitis; ‘b’ i.e. Choledocholithiasis; ‘c’ i.e. Acute cholecystitis: [Ref: Bailey & Love 26/e p 1107 (25/e p1120)]

34.

34. Ans. is None; Best ans is Hemobilia [Ref : See Revision Notes]

35.

Ans. is ‘b’ i.e., Distal ileum [Ref: Sabiston 19/e p 1500 (18/e p1572); Bailey & Love, 26/e p 1183 (25/e p1190); Maingot’s 10/e, p 1736] z Although Harrison writes the most common site to be the ileocecal valve; Sabiston, Bailey & Maingot’s write ‘distal ileum’ to be the most common site. [Maingot’s and Sabiston are highly reputed books for surgery, and are definitely more reliable than Harrison as far as surgery is concerned] z Maingot writes, z “The site of obstruction is usually the terminal ileum, just proximal to the ileocecal valve. This corresponds to the segment of the intestine with the smallest diameter.” z Bailey & Love write, “classically there is impaction about 60 cm proximal to the ileocecal valve.”

Chapter 1 Gallbladder & Bile Ducts 61 Also know Š the commonest site for gall stone impaction in CBD ––––→ Ampulla of vater. 36.

Ans is ‘b’ i.e., Proximal to Ileocaecal junction [Ref: Bailey & Love, 25/e p1190 (24/e p1194), Maingot’s 10/e, p 1736]

37.

Ans. is ‘c’ i.e. ileum [Ref: Bailey and Love 26/e p1183; Sabiston 19/e p1500]

38.

Ans. is ‘b’ i.e., Duodenum Ist Part [Ref: Schwartz 10/e p 1320; Sabiston 19/e p. 1500;Hamilton Bailey, 10/e, p 432] z Biliary fistula is a complication of gallstone (90% of Biliary fistulas are due to gallstone). z The inflamed gall bladder becomes adherent to adjacent stomach, duodenum, colon and necrosis develops at the site leading to the development of fistulas. z Most common site of fistula is duodenum z 2nd most common site is colon.

39.

Ans. is ‘a’ i.e. USG [Ref: Bailey & Love 25/e p1113 (24/e, p1097)]

40.

Answer ‘b’ i.e. Removal of obstruction: [Ref: CSDT 13/e p559; Bailey & Love, 26/e p 1183 (25/e p1190); Maingot’s 10/e, p 1736, Harrison 17/e p1997 (16/e, p)1886] z The treatment priority should focus on relief of obstruction and not on gall bladder and its fistulous communication. So the procedure of choice is Š Laprotomy with stone extraction. z The gallbladder disease can be dealt on later, which includes cholecystectomy and closure of the fistulous tract. [Note that Sabiston (18/e p1572), differs with the above management. It writes that – “Takedown of the biliary-enteric fistula and cholecystectomy during the same procedure is warranted because recurrent cholecystitis and cholangitis are common. However, in patients with a significant inflammatory process in the right upper quadrant or who are unstable to withstand a prolonged operative procedure, the fistula can be addressed at a second laparotomy.” However the above management is supported by Bailey, Harrison, Maingot’s and CSDT]

41.

Ans. is ‘b’ i.e., Cholecystectomy [Ref: Bailey & Love 26/e p 1099, 1106, 1107, 1108 (24/e p 1106); Harrison 17/e p1996 (16/e p1886)]

42.

Answer is ‘a’ i.e. More common in females:[Ref: Bailey & Love, 25/e p1120 (24/e, p1103); Schwartz 9/e p1142 (8/e, p1194)] z “Women are three times more likely to develop gallstones than men, and first degree relatives of patients with gallstones have a two-fold greater prevalence” - Schwartz, 9/e p1142. z Saint’s Triad consists of: Š gall stones Š diverticulosis of the colon & Š hiatus hernia z Limey Bile [Ref: Harrison 17/e p1997 (16/e, p1886); Bailey & Love 24/e, p 1103] Š in this condition, there is secretion of calcium salts into the lumen of the gallbladder in sufficient concentrations to produce calcium precipitation and diffuse, hazy opacification or a layering effect on plain x-ray Š this limey bile or milk of calcium bile, is usually clinically innocuous, but cholecystectomy is recommended, especially when it occurs in a hydropic gallbladder. z Also see what Bailey & Love write about it z “The condition tends to occur when there is a gradual obstruction of the cystic or common bile duct, for example due to chronic pancreatitis or carcinoma of the pancreas. z Lithotripsy [Ref: Maingot’s 10/e, p 1730; Harrison 16/e, p 1884] Š Though ESWL is highly successful for genitourinary stones, its only of limited value in biliary tract stones.

43.

Ans. is ‘c’ i.e. Toothpaste like emulsion in the gall bladder [Ref: Bailey & Love 24/e, p 1103]

44.

Answer is ‘d’ i.e. 55 year old with an asymptomatic gallstone. [Ref: Harrison, 17/e p1995 (16/e, p1884); Sabiston 18/e p1578 (17/e, p1622). See Revision Notes]

45.

Ans. is ‘c’ i.e. Laparoscopy cholecystectomy immediately [Ref: Schwartz 9/e p1148 (8/e, p1200); Sabiston 19/e p 1488 (18/e, p 1559); Bailey & Love 26/e p1108]

46.

Answer is ‘a’ i.e. Cholecystectomy [Ref: Bailey & Love 26/e p 1108; Schwartz, 9/e p1146 (8/e, p1199)] Laparoscopic cholecystectomy is the treatment of choice for chronic cholecystitis. Patients should be advised to avoid dietary fats and large meals while awaiting surgery. z But diabetic patients with chronic cholecystitis should have a cholecystectomy promptly as they are at higher risk for acute cholecystitis or even gangrenous cholecystitis. z Elective

62 Chapter 1 Gallbladder & Bile Ducts z Pregnant

women with symptomatic gallstones who cannot be managed expectantly with diet modifications can safely undergo laparoscopic cholecystectomy during the 2nd trimester.

47.

Ans. is (c) No surgery for gallbladder stones [Ref.: Bailey & Love 26/e p1108 (25/e p1121); Schwartz Surgery Pretest based on 7/e p 204, Q no. 558]

48.

Ans. is ‘d’ i.e., End stage liver disease [Ref: Schwartz 9 th /e p. 1151] Absolute contraindications for cholecystectomy are uncontrolled coagulopathy and end stage liver disease.

49.

Ans is ‘d’ i.e. Ursodeoxycholic acid [Ref. Harrison, 17/e p1995 (15/e, p1781); CMDT 2009 chapter 16] See below for explanation.

50.

Ans is ‘a’ ie Stone is <15 mm in size [Ref. Schwartz 10/e p 1331; Harrison, 17/e p1995 (15/e, p1781); CMDT 2009 chapter 16]

51.

Ans is ‘a’ i.e., Observation [Ref: Harriosn 15th/e p. 1780 & 14th/e p. 1729, Bailey 23rd/e p. 974]

52.

Ans. is ‘a’ i.e., Early surgery [Ref : Bailey & Love 25/e p1124 & 24/e p1121; Biliary Tract and Pancreas 4/e p479]

53.

Ans. is ‘c’ i.e. Gall Stone dissolving drug [Ref: See Revision Notes]

54.

Ans. is ‘c’ i.e. USG [Ref: Sabiston 19/e p 1487 (17/e, p 1610)] Ultrasound is the investigation of choice for both acute as well as chronic cholecystitis.

55.

Ans is ‘c’ i.e. Boas’ sign [Ref: Stedman’s Medical Eponyms, 2/e p 83] Boas’ sign: In cases of acute cholecystitis pain radiates to the tip of the right shoulder and an area of skin below the scapula is found to be hypersensitive. This is k/a Boas’ sign. Sensitivity is quite less. Also Know: Murphy’s sign: Seen in acute cholecystitis. Murphy’s sign is elicited by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand). If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner’s fingers) and winces with a ‘catch’ in breath, the test is considered positive. In order for the test to be considered positive, the same maneuver must not elicit pain when performed on the left side. Grey Turner & Cullen’s sign: positive in severe necrotizing pancreatitis. Grey Turners sign is bluish discolouration seen at the flanks. Bluish discolouration around the umbilicus is known as Cullen’s sign.

56.

Ans. is ‘d’ i.e. A mucocele of the gallbladder is caused by a stone impacted in Hartmann’s pouch. [Ref: Bailey & Love, 24/e, p 1106; Harrison, 17/e p1996 (16/e, p1886); Gray’s Anatomy, 38/e, p Section 12 Alimentary System] z Mucocele of the gallbladder is caused by a stone impacted in the neck of gallbladder or the cystic duct, not in the Hartmann's pouch. z A gall bladder has got following parts - the fundus, the body, infundibulum & the neck. Š Hartmann’s pouch is a small recess projecting posteromedially from the wall of the infundibulum. Š The infundibulum is an area of tapering between the gallbladder body and neck. z Hartmann’s pouch is a common site for stone impaction but stones impacted here do not obstruct the gall bladder outflow and hence do not cause mucocele. Instead stones impacted in Hartmann’s pouch are known to cause Mirizzi syndrome. Other options: of gallstones (~90%) are radioluscent and hence not visible on x-ray or CT scans. z Gall stones are well known risk factor for GB carcinoma z Pigment stones are formed due to increased excretion of conjugated bilirubin. Infact pigment stones are of 2 types. One is Black pigment stone - this is seen in condition of intravascular hemolysis which lead to increased excretion of conjugated bilirubin. Other is Brown pigment stone - this is formed of unconjugated bilirubin which is derived by deconjugation of conjugated z Majority

Chapter 1 Gallbladder & Bile Ducts 63 bilirubin. 57.

Ans is ‘b’ i.e. Peritoneal deposits [Ref: Grainger Radiology 5/e chapter 34; CSDT 13/e p549; Bailey and love 25/e p113] Ultrasound is the first radiological investigation done to evaluate obstructive or any jaundice. It is both sensitive and specific for diagnosing gallbladder stones and biliary tract dilatation. It is able to detect the level of biliary obstruction and most of other causative pathologies. It is also very sensitive for ascites and even minimal fluid can be detected. Peritoneal deposits could also be detected on USG, but with difficulty. CECT and MR are the preferred investigation for peritoneal deposits in that order.

58.

Ans. is ‘a’ i.e., Laparoscopic cholecystectomy [Ref: See Revision Notes]

59.

Ans. is ‘b’ i.e. Decreased incidence of bile duct injuries [Ref: Schwartz 9/e p1156 (8/e, p1211)]

60.

Ans is ‘d’ i.e. All of the above [Ref: Blumgart’s 5/e p514]

61.

Ans. is ‘a’ i.e. Shrunken liver [Ref: See Revision Notes]

62.

Ans. is ‘b’ i.e., Tube cholecystostomy [Ref: Schwartz 9/e p1151] When patient’s general condition is poor percutaneous catheter cholecystostomy is the preferable t/t.

63.

Ans. a. Pressing the artery manually [Ref: Blumgart 5/e p525] Golden rules to be followed in case of difficult cholecystectomy When the anatomy of Callot’s triangle is not clear, blind dissection should not be done* Bleeding adjacent to the Callot’s triangle should be controlled by pressure and not by clipping or clamping* When there is doubt about the anatomy, a fundus first cholecystectomy dissecting on gallbladder wall down to the cystic duct can be helpful*.

Acalculous Cholecystitis 64.

Ans. (a) Diabetes mellitus (b) Total parenteral nutrition (c) Tuberculosis (e) Malignancy [Ref: Bailey & Love 26/e p 1100; Harrison 17/e p1996 (16/e, p1885); Schwartz 10/e p 1327 (9/e p1154)]

65.

Ans is ‘d’ i.e. Bile duct stricture [Ref: See Revision Notes] Schistosomiasis is a rare cause of acalculous cholecystitis [Ref: following article- Review article cholecystitis without gallstones HPB Surgery

1990, Vol. 2 pp. 83-103 1990 Harwood Academic Publishers GmbH Printed in the United Kingdom; Acute granulomatous schistosomal cholecystitisEur J Gastroenterol Hepatol. 2001 Aug;13(8):1001-3.]

66.

Ans. is ‘d’ i.e. Malaria [Ref: Harrison 17/e p1996 (16/e, p1885) and Internet reference] Dengue and malaria are uncommon causes of acalculous cholecystitis. z But Malaria seems to be more uncommon between the two. z Only two cases have so far been reported which establishes the association between malaria and acalculous cholecystitis. z Both

Dengue and acalculous cholecystitis Š Several cases of acalculous cholecystitis have been reported all over the world in patients with Dengue Š A report published from a Taiwan Hospital has shown that there is definite association between Dengue and acalculous cholecystitis. 67.

Ans. is ‘a’, ‘b’ & ‘c’ i.e. DM, TPN & Leptospirosis [Ref: See Revision Notes]

68.

Ans. is ‘d’ i.e., Cholecystectomy is not indicated [Ref: Sabiston 18/e p1574; Bailey & Love 25/e p1122] Gallbladder Polyps, Cholesterolosis & Adenomyomatosis

69.

Ans. is ‘d’ i.e. Cholesterosis [Ref: Bailey & Love 25/e p1122 (24/e, p1106)]

70.

Ans. is ‘c’ i.e. Diffuse depositon of cholesterol in mucosa of gall bladder [Ref: Bailey & Love 25/e p1122 (24/e, p1106)]

71.

Ans is a i.e. Adenomyomatosis [Ref: Rumack Diagnostic Ultrasound] Repeat from Nov 08

72.

Ans. is ‘a’ i.e., 1, 2 and 3 [Ref : Bailey & Love 25/e p1122 & 24/e p1122]

64 Chapter 1 Gallbladder & Bile Ducts 73.

Ans is C i.e. Size of polyp > 5mm [Ref: Sabiston 18/e p1579] Gall Bladder Carcinoma

74.

Ans. is ‘d’ i.e., Oral Contraceptives [Ref: Schwartz 10/e p 1334 (9/e p1160); Bailey & Love 26/e p 1116; Maingot’s 10/e, p1837 Williams 22/e, p 732, S. Das 3/e, p 919 ] No risk of Ca G.B. has been noted with the use of oral contraceptives

75.

Ans. is ‘c’ i.e. 90% [Ref: See Revision Notes]

76.

Ans is ‘a’ ie Porcelain gall bladder [Ref: Schwartz 9/e p1160 (8/e, p1214); S. Das text book 4/e, p919] “The calcified ‘porcelain’ gallbladder is associated with more than a 20% incidence of gallbladder carcinoma. These gallbladders should be removed, even if the patients are asymptomatic” - Schwartz Surgery

77.

Ans is ‘a’ ie Adenocarcinoma [Ref. S.das text book, 4/e, p 919]

78.

Answer is a, c and e (a) i.e. chronic cholesterol stone; (c) i.e. chronic gall bladder disease; (e) i.e. porcelain gall bladder. [Ref: See Revision Notes] About option ‘c’ i.e. chronic gall bladder disease CMDT 2005 p670 writes “Other risk factors (for GB carcinoma) are chronic infection of the gallbladder with Salmonella typhi, gallbladder polyps over 1 cm in diameter, mucosal calcification of the gallbladder.”

79.

Ans. is ‘c’ i.e. Secondaries liver [Ref: Schwartz 9/e p1161 (8/e, p1214)]

80.

Ans is ‘b’ i.e. Wedge hepatic resection with lymph node dissection [Ref: Sabiston 19/e 1508; Devita, Hellman & Rosenberg’s Cancer 8/e Chapter 39; Annals of Oncology 20 (Supplement 4): iv46–iv48, 2009]

81.

Ans is c i.e. Excision of all port sites [Ref: Sabiston 19/e p 1508 (18/e p1581); Devita, Hellman & Rosenberg’s Cancer 8/e Chapter 39; Annals of Oncology 20 (Supplement 4): iv46–iv48, 2009] z Treatment after incidental finding of gallbladder cancer on pathologic review: Š Patients with T1a tumors (tumor invades lamina propria) do not further benefit from re-resection if the gallbladder was removed intact and should be observed only. Š In laparoscopic cholecystectomy, recurrent cancer has been seen at the port site. Hence all port sites should be excised. Š A radical re-resection (after a complete staging including laparoscopy demonstrating resectability) is highly recommended for patients with incidental gallbladder carcinoma stage T1b (tumor invades muscle layer) or greater. z Treatment after incidental finding of gallbladder cancer at surgery: Š After incidental finding of gallbladder cancer at surgery staging has to be performed intraoperatively and extended cholecystectomy including en bloc hepatic resection and lymphadenectomy with or without bile duct excision has to be considered depending on resectability and expertise of the surgeon.

82.

Ans. is ‘c’ i.e., Radical cholecystectomy [Ref: See Revision Notes]

83.

Ans is ‘a’ i.e. 4-6 months [Ref: Schwartz 10/e p 1335; Maingot’s Abdominal Operations 11/e p927] “The median survival associated with unresectable gallbladder cancer is less than 6 months.”- Maingot’s 5 yr survival rates after resection in resectable GB carcinomas T1

85-100%

T2

80-90%

T3

15-63%

T4

2-25%

84.

Answer (b) Presents with jaundice; (d) Gallstones predispose [Ref: Schwartz9/e p1160 (8/e, p 1214, 1215)]

85.

Ans is c i.e. Clonorchis sinensis [Ref: Harrison 17/e p1330; http://www.ncbi.nlm.nih.gov/pubmed/12483392 http://www.ncbi. nlm.nih.gov/pubmed/3993073] Clonorchis sinensis is liver fluke acquired by ingestion of raw or inadequately cooked fresh water fish. In human body it

Chapter 1 Gallbladder & Bile Ducts 65 lives within bile ducts and causes inflammatory reaction leading to cholangitis, cholangiohepatitis and biliary obstruction. It is well known to be a risk factor for Cholangiocarcinoma. But above mentioned websites from pubmed lists articles showing association between Clonorchis infection and gallbladder carcinoma. Choledocholithiasis 86.

Ans is ‘d’ i.e. 7 cm [Ref: Schwartz 10/e p1310] The common bile duct is about 7 to 11 cm in length and 5 to 10 mm in diameter. The common hepatic duct is 1 to 4 cm in length and has a diameter of approximately 4 mm.

87.

Ans. is ‘c’ i.e. Ampulla of vater [Ref: Oxford Surgery 1/e, p 1229]

88.

Ans is None [Ref. Schwartz 9/e p1149 (8/e, p1203)] z As already explained, septic shock is a feature of Reynold’s pentad z Other three options are well known features of Charcot’s triad

89.

Answer (b) ERCP [Ref: Schwartz 10/e p 1323 (9/e p1149); Maingot’s 12/e p 1022] z USG is the first investigation z MRCP is the best non-invasive investigation z ERCP is the gold standard for diagnosing CBD stones. It has the advantage of providing a therapeutic option at the time of diagnosis.

90.

Ans. is A ie. ERCP [Ref: See Revision Notes] first inv. for any pt. with cholelithiasis or jaundice is U/S. z Next inv. depends on U/S findings, Š If the intrahepatic ducts are dilated without any extrahepatic dilatition then the preferred inv. is −−−® PTC* Š If the dilatation is in CBD −−−® ERCP*. z ERCP may provide direct diagnosis of the distal CBD pathology and may be therapeutic as well for a CBD stone or stricture. z The

91.

Ans. is ‘a’ i.e., Endoscopic sphincterotomy

92.

Answer (d) Sphicterotomy and then cholecystectomy [Ref: Maingot’s 12/e p 1023, 24 (10/e, p 1744)]

93.

Ans is ‘d’ i.e. Convert it to open cholecystectomy and remove CBD stone [Ref: Bailey & Love 26/e p 1111; Schwartz 10/e p 1325; Maingot’s 10/e, p 1744] CBD stone detected at the time of laparoscopic cholecytectomy

If expertise and instrumentation for laparoscopic exploration of CBD is available Laparoscopic stone retrieval through the cyst duct or choledochotomy

If expertise and instrumentation for laparoscopic exploration of CBD is not available

ERCP stone extraction during the same operation

Complete# the op. and post the pt. for ERCP stone extraction

Convert the operation to open procedure and remove CBD stone

# ERCP stone extraction after cholecystectomy is the procedure of choice

94.

Ans. is ‘c’ i.e. Endoscopic stone extraction [Ref: Bailey & Love 26/e p 1112; Schwartz, 9/e p1148 (8/e, p1201)] z Post cholecystectomy stones are defined as two types : z Retained - if the stones are diagnosed shortly after cholecystectomy. z Recurrent - if they are diagnosed months or years later. “Both the retained and recurrent stones are best treated endoscopically”- Schwartz

66 Chapter 1 Gallbladder & Bile Ducts 95.

Ans. is ‘d’ i.e. When removed by exploration of the common bile duct the T-tube can be removed after 3 days [Ref: Bailey & Love 26/e p 1104, 1112; Maingot’s 12/e p 1082; CSDT 13/e p563 (11/e, p615)] z When the CBD is explored through a choledochotomy (either during laparoscopic or open operation) a T-tube is usually left in the duct. z A cholangiogram is taken after 7-10 days postoperatively. If it comes out to be normal the T-tube is removed.

96.

Ans. is ‘e’ i.e. Palpable CBD stone [Ref: Bailey & Love, 25/e p1124 (24/e, p1108); internet sites; Blumgart’s Surgery of the Liver & Biliary tract, 3/e, p 739] During open cholecystectomy there are certain traditional indications for choledochotomy. These are: Indications for choledochotomy during open cholecystectomy Absolute indications (high suspicion of CBD calculi) a) b) c) d)

palpable CBD stone jaundice with cholangitis demonstration of stones by intraoperative cholangiography dilatation of CBD > 12 mm

Relative indications (low suspicion of CBD calculi) a) b) c) d) e)

jaundice without cholangitis h/o pancreatitis dilated CBD when on aspiration bile is white a dilated cystic duct

In laparoscopic cholecystectomy, the only indication of laproscopic choledochotomy is when transcystic duct exploration is not possible. 97.

Ans is ‘d’ i.e. 11’O clock [Ref: Sabiston 19/e p1494] The sphincter is incised at 11’O clock position to avoid injury to the pancreatic duct. The pancreatic duct usually enters at 5 o’clock on the ampulla Cholangitis

98.

Ans. (a) Increased bilirubin; (b) ↑ WBC count ; (c) ↑ liver enzymes; (d) Fever with rigors: [Ref: Schwartz 10/e p 1321 (9/e p1148), Maingot’s 12/e p 1007 (10/e, p1740)]

99.

Ans. (a) Pain abdomen (b) Fever and chills; (c) Jaundice: [Ref: Schwartz, 9/e p1149 (8/e, p1203); Bailey & Love, 25/e p1125 (24/e, p1109)]

100. Ans. is ‘c’ i.e., Fever, Pain, Jaundice [Ref: Bailey & Love, 25/e p1125 (24/e, p1109)] 101. Ans. is ‘d’ i.e., Markedly elevated transaminases [Ref: Sabiston 18/e p1553] 102. Ans. is ‘b’ i.e., CBD Stone [Ref: Schwartz 9/e p1149 (8/e, p1203)] 103. Ans. is ‘a’ i.e. Escherichia coli [Ref: Schwartz 10/e p 1323 (9/e p1149);Maingot’s 12/e p 1021; Sabiston, 17/e, p 1601] 104. Answer is (a) Increased leucocyte count, (b) Increased transaminases, (c) Increased bilirubin, (d) Increased alkaline phosphatase, (e) Association with fever and chills: [Schwartz 9/e p1148 (8/e, p1200), Maingot’s 12/e p 1021 (10/e, p 1740)] 105. Ans. is ‘a’ i.e. Stone in common bile duct [Ref: Schwartz, 9/e p1149 (8/e, p1203)] 106. Ans. is (a) i.e. ERCP and bile duct stone extraction [Ref. Schwartz 10/e p 1323 (9/e p1149), Maingot’s 12/e p 1023 (10/e, p 1749)] Post cholecystectomy biliary injury/ Strictures 107. Ans is a (Bile duct carcinoma), b (Chronic pancreatitis), d (Trauma), & e (CBD stone) [Ref: Schwartz 10/e p 1331; Maingot’s 12/e p 1037; Sabiston 18/e p1577; Gallbladder and biliary tract diseases By Nezam H. Afdhal p844; S. Das Textbook of Surgery 3/e p917; Bailey and Love 25/e p1127]

Chapter 1 Gallbladder & Bile Ducts 67 108. Ans. is ‘b’ i.e., Trauma [Ref: Schwartz, 9/e p1156 (8/e, p1211)] “Benign bile duct strictures can have numerous causes. However, the vast majority are caused by operative injury, most commonly by Laparoscopic cholecystectomy.” - Schwartz 109. Ans. c. Type D 110. Ans. b. Type B 111. Ans is ‘a’ i.e. Type A [Ref: Maingot’s 12/e p 1041] 112. Ans. is (d) i.e. Clinical observation [Ref: Oxford Textbook of Surgery 1/e, p 1237; Textbook of liver and biliary surgery by William C. Meyer’s 1990 edition, p 375] z 100 ml. of Bile output from the patient on the 1st postop. day without any other abnormality is of no clinical significance, so does not warrant any action from the surgeon. But remember if passing of 100 ml of bile continues for 5-6 days then it is considered abnormal. It denotes bile duct injury. z Oxford textbook of Surgery writes “Even after a straightforward cholecystectomy there may be a little bile in the drain the following day.” z Textbook of Liver and Biliary Surgery writes “A small amount of biliary drainage following cholecystectomy should cause no alarm because it usually disappears within 1 or 2 days. However, excessive biliary draingae through the wound or drain site, jaundice, sepsis, or a combination of these events early in the post op. period should suggest a bile duct injury, as should copious biliary drainage for more than a few post-op days”. 113. Ans (b) Percutaneous drainage [Ref: Bailey & Love 26/e p 1111; Maingot’s 10/e, p 1893, Textbook of Liver & Biliary Surgery by William C. Meyer 1990 ed., p 374-377; Blumgart’s Surgery of the Liver & Biliary tract 3/e, p 911, Sabiston, 19/e p 1495, 96 (17/e, p 1624)] “Subhepatic abscesses or localized biliary collections require prompt drainage.” - Textbook of Liver & Biliary Surgery 114. Ans : (b) i.e. percutaneous drainage of fluid [Ref: See Revision Notes] 115. Ans is ‘a’ i.e. Ultrasound guided drainage [Ref. See Revision Notes] For small leaks percutaneous drainage is done; most small leaks would resolve. If clinically or radiographically the leak continues ERCP with stenting is done. 116. Ans. is ‘ d’ i.e. ie Magnetic resonance cholangiography [Ref: Sabiston 19/e p 1496 ] The initial investigation of choice for a post cholecystectomy stricture would be an MRCP. It is a non-invasive modality and provides high resolution images of the entire biliary tree. “PTC is the imaging method of choice for most postoperative biliary strictures, but expertise with this is not available at all centers. ERCP may be easier to obtain in a patient with a biliary stricture and cholangitis who requires urgent cholangiography and biliary decompression. However, ERCP is only useful in patients with bile duct continuity.”- Sabiston 18/e p1569

An ultrasound or a CT can also be used as initial study but an MRCP would be better, as it would provide better anatomic information about the location and the degree of stricture. 117. Ans. is ‘d’ i.e. Routine use of ‘open’ technique of laparoscopic port insertion has resulted in a decline in the incidence of post laparoscopic cholecystectomy bile duct injuries [Ref: Sabiston 18/e p1563 (17/e, p 1612, 1613, 1624); Schwartz, 10/e p 1332 (9/e p1158); Maingot’s 10/e, p 251] Use of ‘open’ technique of laproscopic part insertion has resulted in reduction of vascular and bowel injuries, not bile duct injuries z The process of laproscopy begins with creation of pneumoperitoneum, which is achieved by two methods Š closed technique with Veress needle or Š Open minilaprotomy technique (using Hasson’s canula) z Closed technique - in this classical technique a special hollow insufflation needle (Veress needle) is inserted blindly into the peritoneal cavity through a supraumblical incision. z Open technique - in the open technique the umbilical fascia and peritoneum are incised under direct vision in the manner of a minilaprotomy. z Open technique has resulted in reduction of trocar induced vascular and bowel injuries. 118. Ans. is ‘a’ i.e. Upper [Ref: Maingot’s 1039, 1041; Various gastrosurgery journals] Most common duct injuries occur when the CBD or CHD or rt hepatic duct is mistaken to be the cystic duct and ligated and/or divided. Most common site involved is upper CBD.

68 Chapter 1 Gallbladder & Bile Ducts 119. Ans. is ‘c’ i.e. 12 postop.day [Ref: Farquharson’s Textbook of Operative Surgery 9/e, p 328] A T-tube cholangiogram is taken on the 7th to 10th post-op day to ensure there are no retained stones. If the cholangiogram is normal, the T-tube is clamped. Removal of the T-tube will depend on the material from which it is made, as this will determine the length of time for a track to form. If it is latex rubber, the T-tube can be removed at 10-14 days, but if it silastic it should be left for 3-4 weeks before removal. Following removal of the T-tube, there may be a small bile leak that persists for 1-2 days.” Cholangiocarcinoma 120. Ans is ‘d’ i.e., Chronic pancreatitis [Ref: Bailey & Love 26/e p 1115; Schwartz 10/e p 1735 (9/e p1162)] 121. Ans is ‘a’ i.e., CBD stone [Ref: Harrison 17/e p585 (16/e, p536; 15/e p590)] 122. Ans. is ‘a’ i.e., Hyadatid cyst of liver [Ref: Oxford text book of oncology p. 1213] Polycystic disease of liver is a predisposing factor for cholangiocarcinoma [Ref: Oxford text book of oncology] 123. Ans is ‘d’ i.e. Choledocholithiasis [Ref: See Revision Notes] 124. Ans. d. All of the above [Ref: Sabiston 19/e p1504] 125. Ans is b i.e. Hilum [Ref: Bailey & Love 26/e p 1114; Sabiston 18/e p1582; Schwartz 9/e p1162 (8/e p1215)] “About two-thirds of cholangiocarcinomas are located in the perihilar location” - Schwartz 126. Ans. c. Common hepatic duct tumor 127. Ans. is ‘c’ i.e. Schirrhous type 128. Ans is ‘b’ i.e. Involvement of bifurcation and not extending further [Ref: See Revision Notes] 129.

Ans. d. Atrophy of one lobe with ipsilateral involvement of secondary biliary radicals Primary sclerosing cholangitis

130. Ans. b. Cholangiocarcinoma 131. Ans. b. Primary sclerosing cholangitis 132. Answer is ‘c’ i.e. Cirrhosis never occurs [Ref: Bailey & Love 26/e p 1113; Schwartz 9/e p1155 (8/e, p1210); Robbins, 8/e p869 (7/e, p915)] 133. Answer is ‘d’ i.e. PSC reverts after a total colectomy [Ref: Bailey & Love 26/e p 1146; Schwartz 9/e p1156 (8/e, p1211); previous questions] z Schwartz writes “In patients with associated ulcerative colitis, the course of each disease seems independent of each other. Colectomy for the colitis makes no difference to the course of primary sclerosing cholangitis.” z Ulcerative colitis is seen in about 2/3 of patients with sclerosing cholangitis, but the converse is not true. The prevalence of PSC in ulcerative colitis patients in only about 4%. Also know Š Smoking is associated with decreased risk of both ulcerative colitis & primary sclerosing cholangitis !!! 134. Ans. c. Most patients presents with advanced disease Primary biliary cirrhosis 135. Ans. b. Pruritus 136. Ans. is ‘a’ i.e., No increase in risk of HCC [Ref: Harrison 17/e p581 p1974, 1975] 137. Ans is ‘a’ i.e., Pruritus [Ref: Bailey & Love 26/e p 1078, 79; Harrison 17/e p1974 (16/e, p1860; 15/e p1757)] Harrison writes “Most patients with Primary biliary cirrhosis are asymptomatic, and the disease is initially detected on the basis of elevated serum alkaline phosphatase levels during routine screening. Often the earliest symptom is pruritus, which may be either generalized or limited initially to the palms and soles. In addition fatigue is commonly a prominent early symptom. After several months or years, jaundice and gradual darkening of the exposed areas of the skin (melanosis) may ensue.”

Chapter 1 Gallbladder & Bile Ducts 69 Hemobilia 138. Ans is ‘c’ i.e. Iatrogenic trauma [Ref: See Revision Notes] 139. Ans is ‘d’ ie Hepatitis (Ref. Sabiston 18/e p1515 (17/e, p1561; 16/e, p 1056); Maingot’s 10/e, p 300) 140. Answer (a) Shock [Ref: See Revision Notes] 141. Ans. is ‘b’ i.e., Fever [Ref: See Revision Notes] 142. Ans. a. Triad of jaundice, pain, melena Miscellaneous 143. Ans is ‘d’ i.e. Use of heavily T2 weighted images without contrast [Ref: Grainger & Allison’s Diagnostic Radiology, 5/e Chapter 36 The Biliary System] No contrast material is used in MRCP. It is performed with the use of heavily T2-weighted MR pulse sequences. On heavily weighted T2 sequences, stationary or slow-flowing fluid within the bile and pancreatic ducts appear very bright relative to the low signal intensity produced by adjacent solid tissues. Magnetic resonance cholangiopancreatography (MRCP) z Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive technique for evaluating the intrahepatic and extrahepatic bile ducts and the pancreatic duct. z Unlike conventional endoscopic retrograde cholangiopancreatography (ERCP), MRCP does not require contrast material to be administered into the ductal system. Thus, the morbidity associated with endoscopic procedures and contrast materials is avoided. However, MRCP does not currently allow any intervention to be performed, such as stone extraction, stent insertion, or biopsy. z The technique is performed with the use of heavily T2-weighted MR pulse sequences. These had the effect of making stationary or slow-flowing fluid within the bile and pancreatic ducts to appear very bright relative to the low signal intensity produced by adjacent solid tissues. z Pulse sequences used in MRCP are RARE (rapid acquisition with relaxation enhancement) and HASTE (half-Fourier acquisition single-shot turbo spin-echo) z MRCP has established role in the investigation of many biliary disorders, serving as a non-invasive alternative to endoscopic retrograde cholangiopancreatography (ERCP). 144. Ans is ‘d’ i.e. HIDA scan [Ref: Nelson 18/e chapter 353; uptodate.com] The child in the question is having cholestatic jaundice. In contrast to unconjugated hyperbilirubinemia, which can be physiologic, cholestasis (conjugated bilirubin elevation of any degree) in the neonate is always pathologic and prompt differentiation is imperative to treat the conditions to avoid further damage to the liver. Most common causes of neonatal cholestasis Biliary atresia Idiopathic neonatal hepatitis Infectious hepatitis Alpha-1-antitrypsin deficiency Alagille syndrome Progressive familial intrahepatic cholestasis Parenteral nutrition-associated

Here in this infant having cholestasis with acholic stools, the diagnosis of biliary atresia has to be confirmed or ruled out promptly as success of surgical intervention (hepatoportoenterostomy, the Kasai procedure) diminishes progressively with older age at surgery. HIDA scan would be the investigation of choice to differentiate biliary atresia from other non obstructive causes. “Hepatobiliary scintigraphy with technetium-labeled iminodiacetic acid derivatives is used to differentiate biliary atresia from nonobstructive causes of cholestasis. The hepatic uptake of the agent is normal in patients with biliary atresia, but excretion into the intestine is absent. Although the uptake may be impaired in neonatal hepatitis, excretion into the bowel will eventually occur.” - Nelson

145. Ans is ‘b’ i.e. Associated with tuberculosis [Ref: article: Xanthogranulomatous cholecystitis by Shyam Varadarajulu, MD] 146. Ans is ‘a’ i.e. It is caused most commonly by Pseudomonas Ref: Blumgart 5/e p492; article “Acute cholecystitis: Pathogenesis, clinical features, and diagnosis” by Salam F Zakko, MD, FACP It is caused most commonly by gas forming organisms such as Clostridium welchii.

70 Chapter 1 Gallbladder & Bile Ducts 147. Ans is ‘a’ ie Renal stones [Ref. Bailey & love, 23/e, p 975] Saints triad Saints triad includes z Gall Stone z Diverticulosis of the colon z Hiatus hernia

148. Answer is (a) Typical “sea-green” colored; (b) Wall is thin & elastic: [Ref: Bailey & Love 26/e p 1097; Op.Surgery by S. Das 4/e, p 340] z “That the gallbladder is diseased is known by the change in its hue from greenish blue to yellowish white (due to thickening of its wall and deposition of subserous fat) and the presence of adhesions. The gallbladder is now palpated carefully for calculi. Inability to empty the gallbladder by squeezing suggests an obstruction in the cystic duct by a calculus.” - S. Das Op. Surgery Healthy Gallbladder A healthy gallbladder has z greenish blue or sea green colour z thin and elastic wall z can be emptied by squeezing.

149. Ans. is ‘d’ i.e., CBD Stones Most common surgical cause of obstructive jaundice is choledocholithiasis 150. Ans is ‘a’ i.e. Gallstone ileus [Ref: Bailey and Love 26/e p1183; Sabiston 19/e p1500] Pneumobilia is seen in gallstone ileus as the fistula that permitted the stone to pass into the duodenum allows air into the gallbladder and biliary tree. 151. Ans is a ie Meniscus sign [Ref. Sutton, 6/e, p971, figure 33.35] 152. Ans is d ie Raised urinary urobilinogen [Ref: Chatterjea Shinde, 4/e, p 481] z Urobilinogen is produced by the action of ileal and colonic bacteria on conjugated bilirubin in the intestines. z It is absorbed and excreted in bile and urine z Thus any condition which decreases the bile excretion into intestine, decreases urinary urobilinogen z Urinary urobilinogen is a useful tool for distinguishing possible causes of jaundice. z Urinary urobilinogen is increased Š when production of bilirubin is greatly increased (eg with hemolysis) Š when the hepatic uptake and excretion of urobilinogen is impaired (eg in hepatocellular diseases) z Urinary urobilinogen is decreased in Š cholestasis or extrahepatic biliary obstruction (obstructive jaundice) 153. Ans is ‘d’ i.e. GB stone compressing over CHD [Ref: Blumgart 5/e p493] 154. Ans. is ‘d’ i.e. Glutamate dehydrogenase [Ref: Harrison 18/e p2529 (17/e p1925 16/e, p1815)] Repeat from Nov 06 z Jaundice, icterus, clay coloured stools, pruritus, all suggest cholestatic jaundice z These three enzymes are usually elevated in cholestasis 1. Alkaline phosphatase 2. 5’-nucleotidase 3. Gamma glutanyl transpeptidase 155. Ans is ‘d’ i.e. C3-C5 Gallstone disease may refer pain to the right shoulder tip (k/a Kehr’s sign). This is because, an inflamed gallbladder irritates the diaphragm which is supplied by the phrenic nerv (C3-C5). These cervical nerve roots, also provide sensory supply to the right shoulder through supraclavicular nerves. Hence the gallbladder pain is referred to the right shoulder through the C3-C5 nerve roots. 156. Ans. is ‘c’ i.e. Gastric ulcer 157. Ans. is ‘c’ i.e. Common bile duct stone [Ref: Bailey & Love 24/e, p 1109] In Ca Head of Pancreas, GB will also be distended.

Chapter 1 Gallbladder & Bile Ducts 71 158. Ans. is ‘c’ i.e. Non-synthetic absorbable [Ref: Surgery of Liver & Biliary Tract by Blumgart 2/e] 159. Ans. a. Primary sclerosing cholangitis 160. Ans. a. Primary biliary cirrhosis 161. Ans. d. GB stones are present in >50% cases [Ref: Sabiston 19/e p1501] 162. Ans. is ‘a’ i.e., Hemobilia [Ref: Sabiston 19/e p 1170, 1467 (18/e p1515)] 163. Ans. a. ERCP [Ref: Sabiston 19/e p1469; Blumgart 5/e p1843-1844; Shackelford 7/e p1488] 164. Ans. b. Sarcoidosis [Ref: Harrison 18/e (table 42-3 & chapter 42 (17/e p265)] 165. Ans: (a) GVHD [Harrison 17/e p265 (16/e, p243)] 166. Ans. (b) Sclerosing cholangitis [Ref: See Revision Notes] This patient having inflammatory bowel disease (history of diarrhea for several years) now presenting with pruritus and ↑ alkaline phosphatase points towards the diagnosis of Primary sclerosing cholangitis. 167. Ans. is ‘b’ i.e. Endoscopic sphincterotomy Schwartz 9/e p1156; Sabiston 18/e p1562; Maingot’s 11/e chapter 39] 168. Ans. b. Choledochoduodenostomy [Ref: SRB’s Manual of Surgery 4/e p694; Blumgart 5/e p632] 169. Ans. c. Gallstones [Ref: Blumgart 5/e p645-669] 170. Ans. a. Gastric ulcer [Ref: Blumgart 5/e p644-657] 171. A ns. is ‘a’ i.e., Localised collection….. [Ref: Sabiston 18/e p1568, 1572 fig. 54.19] “Bile leaks commonly present shortly after cholecystectomy (within 1 week) with right upper quadrant pain, fever, chills, and hyperbilirubinemia. Bile leak or bile peritonitis should be considered in any patient with persistent bloating or anorexia more than a few days after laparoscopic cholecystectomy.”- Sabiston 17/e p1572 “Jaundice may indicate absorption of bile from an intraabdominal collection following a biliary leak or mechanical obstruction of the CBD” - Harrison 17/e p1997 