Chapter 4: Hepatobiliary Surgery (i)
Jaundice
present when bili >40 mmol/L (normal = 3-17)
Types
prehepatic (haemolytic)
hepatic
post-hepatic (obstructive)
unconjugated (Gilbert's, Crigler-Najjar)
conjugated
Courvoisier's law
Autoimmune liver disease
ANA
AMA
anti-SMA
Gallstone Disease
Cholecystojejunostomy
creating an anastomosis of the CBD to the jejunum to relieve symptoms of biliary obstruction + restore continuity to the biliary tract
done when other interventions fail
can be due to chronic haemolytic disorders, vagotomy, long term TPN
3 components of gallstones = bile pigments, chol, phospholipids
GB secretes bile in response to CCK
Types of gallstone: mixed, pure chol, pure pigment (in haemolysis)
Percutaneous transhepatic cholangiography
radiological technique used to visualise biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken
Common presentations
asymp
biliary colic
acute cholecystitis
empyema (bile becomes purulent)
gangrene
perforation (high pressure + gangrenous wall, +/- peritonitis)
chronic cholecystitis (recurrent pain)
mucocoele
gallstone ileus (due to stone passing throughma biliary-enteric fistula i.e. cholecystoduodenal fistula)
ascending cholangitis
charcot's triad (RUQ, jaundice, fever)
Obstructive jaundice (CBD stone or rarely external compression due to Mirrizi syndrome)
pancreatitis
for non specific sx you should excl IBS (Rome criteria) to prevent post cholecystectomy syndrome
GB pain often radiations to shoulder tip or right scap
MRCP: look for filling defects
US: look for thick oedematous GB wall, duct dilatation, sludge/stones
chemical inflamm but give abx to prevent secondary infection
Murphy's +ve
usually stone in cystic duct so doesn't cause jaundice
no stones in 5%
cholecystectomy can be done during admission or after 6 wks when inflamm has settled
can do percut drainage/cholecystostomy if unfit for cholecystectomy
may be a mass palpable
add hypotension + confusion for Reynold's pentad (higher mortality)
done when ERCP unsucessful