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Surgery for Finals: Biliary Disorders Dr. Lily Wenyi Cai FY1Social Medias Case 1 Question Which of the following enzyme is directly responsible for bilirubin formation? A. Heme oxygenase B. Cytochrome P450 reductase C. Biliverdin reductase D. Glucuronyltransferase UDP E. Unsure Case 1 Question Which of the following enzyme is directly responsible for bilirubin formation? A. Heme oxygenase B. Cytochrome P450 reductase C. Biliverdin reductase D. Glucuronyltransferase UDP E. Unsure Case 1 Bilirubin Metabolism Unconjugated Haem 1. Formation of bilirubin Bilirubin Heme a. Reticuloendothelial cells (in the spleen) oxygenase breaks red cells into haem and globin Glucuronyl l b. Haem is broken down to form bilirubin r transferase l Biliverdin L t Biliverdin Conjugated l reductase 2. Bilirubin conjugation Bilirubin t R a. Unconjugated bilirubin binds to albumin in Bilirubin the bloodstream b. Conjugation takes place in the liver Bile duct 3. Bilirubin excretion a. Bacteria in the gut converts bilirubin into urobilinogen (urine) and stercobilin (stool) Glucuronic acid GI tract b. 20% of urobilinogen is reabsorbed into the removed by blood and enters the enterohepatic Conjugated bacteria Urobilinogen Bilirubin circulation Stercobilin Case 2 Question Which of the following stimulate bile secretion? A. Trypsin B. Cholecystokinin C. Secretin D. Gastrin E. GIP Case 2 Question Which of the following stimulate bile secretion? A. Trypsin B. Cholecystokinin C. Secretin D. Gastrin E. GIP Case 2 Digestive enzymes ● Presence of fatty acids and amino acids in the small intestine triggers CCK secretion into the blood. ● Circulating CCK stimulates the pancreas to increase the secretion of digestive enzymes and causes sphincter of Oddi to relax ● CCK causes gallbladder to contract to release bileCase 2 Digestive enzymes Site of production Functions Trypsin Pancreas - Trypsinogen as precursor - A proteolytic enzyme that helps with digestion - Release is stimulated by amino acids Gastrin Antrum of stomach and peptides in stomach - Stimulates stomach motility and acid release CCK Small intestine - Amino acids and fatty acids in the small intestine - Relaxes sphincter of Oddi - Stimulates gallbladder contraction - Stimulates pancreatic enzyme secretion - Stimulates pancreatic secretions Secretin Small peptide GIP Small intestine - Release is stimulated by glucose and fats in small intestine - Stimulates insulin secretion by pancreas Case 3 Question The following conditions/ procedures increase the risk of gallstone formation, except for which one? A. Sickle cell disease B. Ulcerative colitis C. Ileal resection D. Familial hypercholesterolaemia E. G6PD deficiency Case 3 Question The following conditions/ procedures increase the risk of gallstone formation, except for which one? A. Sickle cell disease B. Ulcerative colitis C. Ileal resection D. Familial hypercholesterolaemia E. G6PD deficiency Case 3 Risk factors of gallstone formation Certain conditions predispose to gallstone formation. Conditions that increase cell turnover - Chemotherapy; cancer Conditions that increase red cell turnover - Sickle cell disease(acquired & congenital) Conditions that causes an excess of gallstone components - High cholesterol; lesch-nyhan syndrome Conditions that disrupts the enterohepatic circulation - Crohn’s (terminal ileitis) Case 4 Question 45 year old woman presents to A&E with constant RUQ pain. She said the pain came on 1-2 hours after dinner and since then, the pain has been constant. PMH: known gallstones, AF; DH: Apixaban Blood results Hb 135; WCC 15.7; CRP 60; ALT 150; ALP 300; Bilirubin 50 What is the most appropriate management? A/ Patent A. Discharge alone B/ E/ B. Discharge with oral antibiotics RUQ pain Sats 96% OA C. Admit and start IV antibiotics RR 22 Murphy’s sign positive D. Admit, start IV antibiotics and requests USS +/- MRCP C/ D/ No rebound HRBP 125/73lar GCS 15 tenderness E. Admit, start IV antibiotics and CRT 2 seconds PEARL plan for ERCP HS I + II + 0 Temp 38.0 Case 4 Question 45 year old woman presents to A&E with constant RUQ pain. She said the pain came on 1-2 hours after dinner and since then, the pain has been constant. PMH: known gallstones Blood results Hb 135; WCC 15.7; CRP 60; ALT 150; ALP 300; Bilirubin 50 What is the most appropriate management? A/ Patent A. Discharge alone B/ E/ B. Discharge with oral antibiotics RUQ pain Sats 96% OA C. Admit and start IV antibiotics RR 22 Murphy’s sign positive D. Admit, start IV antibiotics and requests USS +/- MRCP C/ D/ No rebound HRBP 125/73lar GCS 15 tenderness E. Admit, start IV antibiotics and CRT 2 seconds PEARL plan for ERCP HS I + II + 0 Temp 38.0 Case 4 Choledocholithiasis Definition - When a gallstone obstructs the common bile ducts and causes intrahepatic cholestasis. Choledocholithiasis and LFT abnormalities - Elevated AST and ALT - Elevated ALP (produced cells lining the biliary ducts) Investigations - Ultrasound abdomen (poor sensitivity) - MRCP Case 5 Question The same patient from the previous question underwent MRCP and it revealed dilatation of intrahepatic ducts and the common bile ducts calibre is measured at 9mm. What is the next most appropriate management option? A. Treat acute cholecystitis alone A/ Patent B. Treat acute cholecystitis + B/ Plan ERCP immediately E/ RUQ pain C. Treat acute cholecystitis + Sats 96% OA Plan ERCP next day RR 22 Murphy’s sign positive D. Treat acute cholecystitis + C/ D/ No rebound Plan ERCP after 48 hours HR 100 Regular GCS 15 tenderness CRT 2 seconds PEARL E. Discharge HS I + II + 0 Temp 38.0 Case 5 Question The same patient from the previous question underwent MRCP and it revealed dilatation of intrahepatic ducts and the common bile ducts calibre is measured at 9mm. What is the next most appropriate management option? A. Treat acute cholecystitis alone A/ Patent B. Treat acute cholecystitis + B/ Plan ERCP immediately E/ RUQ pain C. Treat acute cholecystitis + Sats 96% OA Plan ERCP next day RR 22 Murphy’s sign positive D. Treat acute cholecystitis + C/ D/ No rebound Plan ERCP after 48 hours HR 100 Regular GCS 15 tenderness CRT 2 seconds PEARL E. Discharge HS I + II + 0 Temp 38.0 Case 5 ERCP ERCP = Endoscopic retrograde cholangiopancreatography Benefits Risks Diagnostic + therapeutic purposes Bleeding Avoids surgeryl rate for stone removal Post-ERCP pancreatitis Procedure failure Bowel perforation In case of failure… - Percutaneous drainage - Surgery Case 6 Question 70 year old man presents unwell to A&E. He is complaining of RUQ pain. He also looks jaundiced. His blood results shows: Hb 120; WCC 25; CRP 358; ALT 430; ALP 600; bilirubin 105 His MRCP shows dilated proximal CBD but normal calibre for the rest of the duct. He underwent ERCP but there was no stones found in the CBD. What is the most likely diagnosis? A/ Patent A. Acalculus cholecystitis B/ B. Calculus cholecystitis Sats 92% RA E/ C. Ascending cholangitis RR 28 RUQ pain D. Bourveret syndrome Jaundiced C/ D/ E. Mirizzi syndrome HRBP 110/70lar GCS 15 CRT 3 seconds PEARL HS I + II + 0 Temp 39.0 Case 6 Question 70 year old man presents unwell to A&E. He is complaining of RUQ pain. He also looks jaundiced. His blood results shows: Hb 120; WCC 25; CRP 358; ALT 430; ALP 600; bilirubin 105 His MRCP shows dilated proximal CBD but normal calibre for the rest of the duct. He underwent ERCP but there was no stones found in the CBD. What is the most likely diagnosis? A/ Patent A. Acalculus cholecystitis B/ B. Calculus cholecystitis Sats 92% RA E/ C. Ascending cholangitis RR 28 RUQ pain D. Bourveret syndrome Jaundiced C/ D/ E. Mirizzi syndrome HRBP 110/70lar GCS 15 CRT 3 seconds PEARL HS I + II + 0 Temp 39.0 Case 6 Mirizzi’s syndrome Definition Type I Bilimall ostrultiostrhatioevelops due to CBD compression by a gallstone impacted at the cystic duct or gallbladder neck stone cystic duct or neck of the gallbladder. externally compressing the common bile duct. Adhesions Hernias Type II Cholecystocholedochal fistula formed by stone migration to CBD. Clinical presentation Obstructive jaundice; abdominal pain; N+V, fever if infected Management Surgery ERCP Case 7 Question A 40 year old female presents with RUQ pain She has a history of colicky RUQ pain after meals. However, this pain is constant. An USS shows that there is a gallbladder empyema and the gallbladder is very enlarged and impending rupture. Where is the gallbladder most likely to rupture from? A/ Patent A. Body B/ B. Neck E/ Sats 94% OA C. Fundus RR 24 Scleral icterus D. Hartmann’s pouch C/ D/ E. Head HRBP 110/73lar GCS 15 CRT 3 seconds PEARL HS I + II + 0 Temp 38.6 Case 7 Question A 40 year old female presents with RUQ pain She has a history of colicky RUQ pain after meals. However, this pain is constant. An USS shows that there is a gallbladder empyema and the gallbladder is very enlarged and impending rupture. Where is the gallbladder most likely to rupture from? A/ Patent A. Body B/ B. Neck E/ Sats 94% OA C. Fundus RR 24 Scleral icterus D. Hartmann’s pouch C/ D/ E. Head HRBP 110/73lar GCS 15 CRT 3 seconds PEARL HS I + II + 0 Temp 38.6 Case 7 Arterial supply to gallbladder Gallbladder - Neck - Body - Fundus hepatic Blood supply arteryhepatic artery - Cystic artery supplies the gallbladder, it is a terminal / end artery Cystic artery Common arteryc Case 8 Question 63 year old woman with known gallstones has been experiencing biliary colic. Her GP arranged an ultrasound abdomen for her. On US, it revealed that there are multiple stones within the gallbladder and in addition, there is multiple growths present on the gallbladder. Her blood results shows: WCC 8; CRP 7; ALT 15; Bili 10; ALP 80 What are the growths mostly likely to be? A/ Patent A. Cholesterol polyps B/ B. Adenomyomas Sats 96% OA C. Inflammatory polyps RR 20 E/ D. Adenocarcinoma HR 72 Regular D/ E. Squamous cell carcinoma BP 115/70 GCS 15 CRT 2 seconds PEARL HS I + II + 0 Temp 36.4 Case 8 Question 63 year old woman with known gallstones has been experiencing biliary colic. Her GP arranged an ultrasound abdomen for her. On US, it revealed that there are multiple stones within the gallbladder and in addition, there is multiple growths present on the gallbladder. Her blood results shows: WCC 8; CRP 7; ALT 15; Bili 10; ALP 80 What are the growths mostly likely to be? A/ Patent B/ A. Cholesterol polyps Sats 96% OA B. Adenomyomas RR 20 E/ C. Inflammatory polyps C/ D/ D. Adenocarcinoma HBP 115/70lar GCS 15 CRT 2 seconds PEARL E. Squamous cell carcinoma HS I + II + 0 Temp 36.4 Case 8 Gallbladder polyps Definition Gallbladder polyps Growths in gallbladder mucosa that protrude into the lumen. Clinical presentation Non-neoplastic polyps Neoplastic polyps Often asymptomatic - Cholesterol polyps - Most common type Incidentally found on USS - Adenomyomas - hyperplastic lesions formed from hyperproliferation of Benign Malignant surface epithelium. - Inflammatory polyps - Adenomas (pre-malignant)- Squamous cell carcinoma - chronic inflammation - Mucinous cystadenoma leading to granulation and - Adenoacanthomas fibrous tissue formation Case 9 Question 70 year old man presents to the GP with 6 months history of mild RUQ tenderness after meals. Occasionally, he also experiences nausea and vomiting, bloating and gastric reflux. The GP arranges outpatient x-ray and USS. X-ray shows increased radio-opacity around the gallbladder USS shows a fibrotic gallbladder with multiple stones. What is the most appropriate management plan? A/ Patent A. Conservative management with low B/ fat diet Sats 97% OA E/ B. Urgent cholecystectomy RR 18 C. Elective cholecystectomy D. Serial abdominal ultrasound for the HR 72 Regular D/ BP 140/80 GCS 15 next few years CRT 2 seconds PEARL E. Do nothing HS I + II + 0 Temp 36 Case 9 Question 70 year old man presents to the GP with 6 months history of mild RUQ tenderness after meals. Occasionally, he also experiences nausea and vomiting, bloating and gastric reflux. The GP arranges outpatient x-ray and USS. X-ray shows increased radio-opacity around the gallbladder USS shows a fibrotic gallbladder with multiple stones. What is the most appropriate management plan? A/ Patent A. Conservative management with low B/ fat diet Sats 97% OA E/ B. Urgent cholecystectomy RR 18 C. Elective cholecystectomy D. Serial abdominal ultrasound for the HR 72 Regular D/ BP 140/80 GCS 15 next few years CRT 2 seconds PEARL E. Do nothing HS I + II + 0 Temp 36 Case 9 Porcelain gallbladder It is a rare condition when the inner wall of the gallbladder becomes calcified. It is a result of chronic inflammation e.g. chronic cholecystitis Often asymptomatic Usually treated with prophylactic cholecystectomy Case 10 Question The GP put the previous patient on the waiting list for elective cholecystectomy. However, patient did not want to go through with the procedure as the symptoms has gone away since seeing the GP. Fast forward 5 years, the same patient presents again. This time with general malaise, weight loss of 10Kg in the last 3 months. What is the most likely diagnosis in this case? A/ Patent A. Acute cholecystitis B/ E/ Jaundice B. Ascending cholangitis Sats 97% OA RR 18 Courvoisier’s sign on C. Cholangiocarcinoma D. Porcelain gallbladder abdo exam HR 72 Regular D/ E. Chronic cholecystitis BP 140/80 GCS 15 CRT 2 seconds PEARL HS I + II + 0 Temp 36 Case 10 Question The GP put the previous patient on the waiting list for elective cholecystectomy. However, patient did not want to go through with the procedure as the symptoms has gone away since seeing the GP. Fast forward 5 years, the same patient presents again. This time with general malaise, weight loss of 10Kg in the last 3 months. What is the most likely diagnosis in this case? A/ Patent A. Acute cholecystitis B/ E/ Jaundice B. Ascending cholangitis Sats 97% OA RR 18 Courvoisier’s sign on C. Cholangiocarcinoma D. Porcelain gallbladder abdo exam HR 72 Regular D/ E. Chronic cholecystitis BP 140/80 GCS 15 CRT 2 seconds PEARL HS I + II + 0 Temp 36 Case 8 Cholangiocarcinoma Gallbladder cancer is a multi-stage process where the gallbladder epithelium undergo metaplasia and dysplasia. Clinical presentations Abdominal discomfort, FLAWS Pruritis, jaundice O FC O F Feedback + 3 N O CF 3 NH O Cl CH 3 CH3 OH CH3 CH 3 OH HC CH 3 3 HC O 3