Surgery Marrow Pg 271-280 (GIT)
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Questions and Answers

Which Strasberg classification corresponds to a leak from an aberrant right hepatic duct?

  • D
  • B
  • C (correct)
  • Type IV

    • Bile duct injury types include classifications for cystic duct leaks and occlusions.

    True

    What is the management strategy for gallstones diagnosed in the first trimester of pregnancy?

    Conservative management for mild cases

    A stricture at the hilum of the liver, while preserving confluence, is classified as __________.

    <p>Type II</p> Signup and view all the answers

    What hormonal change during pregnancy can lead to gallstones?

    <p>Increased cholesterol secretion</p> Signup and view all the answers

    Match the type of biliary stricture with its classification:

    <p>Cystic duct leak = A Hilar stricture = Type II Stricture to aberrant RHD = Type III Common hepatic duct stricture = Type I</p> Signup and view all the answers

    NSAIDs are recommended for managing gallstones in the first trimester of pregnancy.

    <p>False</p> Signup and view all the answers

    What imaging technique is used for the diagnosis of gallstones during pregnancy?

    <p>Ultrasound</p> Signup and view all the answers

    What is the proper management for residual stones detected after a laparoscopic cholecystectomy?

    <p>Retain T-tube for 2-3 weeks and utilize Burhenne technique</p> Signup and view all the answers

    Symptoms of CBD stones detected after laparoscopic cholecystectomy can include pain, fever, and jaundice.

    <p>True</p> Signup and view all the answers

    What imaging technique is used for the initial assessment of CBD stones?

    <p>MRCP</p> Signup and view all the answers

    If CBD stones are retained within _____ years of laparoscopic cholecystectomy, further evaluations including ERCP+Sphincterotomy are necessary.

    <p>2</p> Signup and view all the answers

    Match the conditions with their appropriate management actions:

    <p>Residual Stones Present = Retain T-tube for 2-3 weeks, use Burhenne technique No Residual Stones Absent = Remove T-tube Within 2 years of Lap Cholecystectomy = Further evaluations including ERCP+Sphincterotomy More than 2 years after Lap Cholecystectomy = Further evaluations including ERCP+Sphincterotomy</p> Signup and view all the answers

    What is the management approach for a T1a staging of cancer?

    <p>Simple cholecystectomy</p> Signup and view all the answers

    In T3 staging, the cancer invades only the serosa.

    <p>False</p> Signup and view all the answers

    What is the indication for FNAC/biopsy in gastrointestinal surgeries?

    <p>metastasis, indeterminate diagnosis</p> Signup and view all the answers

    For severe biliary complications, a _____ cholecystectomy is the management for T1b staging.

    <p>radical</p> Signup and view all the answers

    Match the cancer stage with its characteristic:

    <p>T2 = Invasion of perimuscular tissue T3 = Invasion of serosa and liver T4 = Invasion of hepatic artery and main portal vein T1a = Limited to lamina propria</p> Signup and view all the answers

    Which of the following is the most common site of obstruction in gallstone ileus?

    <p>Last 2 feet of the ileum</p> Signup and view all the answers

    Gallstone ileus is a result of a blockage caused by a stone impacted in the neck of the gallbladder.

    <p>False</p> Signup and view all the answers

    What is Rigler's Triad associated with?

    <p>Small bowel obstruction</p> Signup and view all the answers

    The initial investigation for gallstone ileus is an X-ray of the abdomen in both _____ and _____ positions.

    <p>erect, supine</p> Signup and view all the answers

    Match the following clinical features or terms with their corresponding descriptions:

    <p>Obstipated = Severe constipation Empyema = Pus in the gallbladder Bouveret syndrome = Gastric outlet obstruction Pneumobilia = Air in the biliary tree</p> Signup and view all the answers

    What condition is characterized by the adhesion of the gallbladder to the common bile duct leading to fistula formation?

    <p>Mirizzi Syndrome</p> Signup and view all the answers

    Choledocholithiasis is primarily caused by primary stones formed in the common bile duct.

    <p>False</p> Signup and view all the answers

    What is the recommended management for a patient with perforation due to gallbladder disease?

    <p>Resection &amp; Anastomosis</p> Signup and view all the answers

    Obstructive jaundice is a clinical feature associated with __________ syndrome.

    <p>Mirizzi</p> Signup and view all the answers

    Match the terms to their definitions:

    <p>MRCP = Non-invasive diagnostic test for bile duct conditions Cholecystectomy = Surgical removal of the gallbladder Choledocholithiasis = Presence of gallstones in the common bile duct Fistula = An abnormal connection between two epithelial surfaces</p> Signup and view all the answers

    What is the main position of the patient during a laparoscopic cholecystectomy?

    <p>Reverse Trendelenburg with right up</p> Signup and view all the answers

    The most common complication of laparoscopic cholecystectomy is pain at the left shoulder tip.

    <p>False</p> Signup and view all the answers

    What is visualized before proceeding with surgery?

    <p>Calot's triangle</p> Signup and view all the answers

    In the presence of frozen calots, a possible bailout strategy is to convert to an ________ procedure.

    <p>open</p> Signup and view all the answers

    Match the following components of the B Safe method with their descriptions:

    <p>Bile duct = Main structure to be protected during surgery Hepatic artery = Critical vascular structure near the liver Status of Rouviere = Assessment for anatomical variations Umbilical fissure = Important landmark in liver anatomy</p> Signup and view all the answers

    Which of the following is NOT a component of Reynolds pentad?

    <p>Intermittent fever</p> Signup and view all the answers

    Obstructive jaundice can be caused by obstruction of the common bile duct (CBD).

    <p>True</p> Signup and view all the answers

    What is the most common complication associated with ERCP?

    <p>Pancreatitis</p> Signup and view all the answers

    Charcot's triad includes fever, ________, and jaundice.

    <p>pain</p> Signup and view all the answers

    Match each risk factor for CBD stones with the corresponding evaluation or management approach:

    <p>Low risk = Lap chole Medium risk = MRCP before Sx High risk = Lap chole History of cholangitis/pancreatitis = Further evaluation needed</p> Signup and view all the answers

    What is the treatment for a complete transection of the bile duct without loss of segment?

    <p>Anastomosis with a T-tube</p> Signup and view all the answers

    Residual stones are defined as stones that remain within 2 years after surgery.

    <p>False</p> Signup and view all the answers

    What procedure is often performed for biliary leaks?

    <p>ERCP with stenting</p> Signup and view all the answers

    A _____ classification of bile duct injury indicates that the injury was recognized during surgery.

    <p>surgical</p> Signup and view all the answers

    Match the type of bile duct injury with their corresponding treatment options:

    <p>Partial Tear = Repair with absorbable suture Complete Transection Without Loss of Segment = Anastomosis with T-tube Complete Transection With Loss of Segment = Anastomosis with T-tube and choledochojejunostomy Biliary Leak = ERCP with stenting</p> Signup and view all the answers

    What is the clinical management for a minor bile leak in a stable patient?

    <p>Observation and monitoring</p> Signup and view all the answers

    Anastomosis with T-tube is a treatment option for both partial tears and complete transections.

    <p>True</p> Signup and view all the answers

    Diagnostics often confirm the bile duct injury with _____ imaging.

    <p>MRCP</p> Signup and view all the answers

    Which of the following clinical features is commonly associated with Emphysematous Cholecystitis?

    <p>Pain, Fever, Sepsis</p> Signup and view all the answers

    Chronic Cholecystitis can lead to cancer without any prior episodes.

    <p>False</p> Signup and view all the answers

    What is the management strategy for Mucocele of the Gallbladder?

    <p>Early laparoscopic cholecystectomy or tube cholecystostomy.</p> Signup and view all the answers

    The causative organism for Emphysematous Cholecystitis is __________.

    <p>Clostridium</p> Signup and view all the answers

    Match the investigative method to its finding:

    <p>Ultrasound = Pain, Fever, Sepsis CT = Wall echo shadow (WES) sign Histopathology = Chronic inflammatory cells</p> Signup and view all the answers

    Which of the following is NOT a risk factor for gallbladder cancer?

    <p>Cholesterol polyps</p> Signup and view all the answers

    Jaundice is one of the earliest clinical features of gallbladder cancer.

    <p>False</p> Signup and view all the answers

    What is the most aggressive type of gallbladder cancer?

    <p>Infiltrating adenocarcinoma</p> Signup and view all the answers

    Gallbladder cancer is commonly associated with a condition characterized by the presence of stones known as __________.

    <p>gallstones</p> Signup and view all the answers

    Match the following types of adenocarcinoma to their characteristics:

    <p>Infiltrating = Most aggressive Nodular = Less aggressive compared to infiltrating Papillary = Characterized by finger-like projections</p> Signup and view all the answers

    Study Notes

    Bismuth and Strasberg Classification of Bile Duct Injury

    • Bismuth and Strasberg classifications describe bile duct injuries.
    • Strasberg Classification A: Cystic duct leak or minor leak.
    • Strasberg Classification B: Occlusion of an aberrant (right) hepatic duct.
    • Strasberg Classification C: Leak from an abnormal right hepatic duct.
    • Strasberg Classification D: Lateral injury to the common bile duct.
    • Bismuth Type I: Stricture of the common hepatic duct.
    • Bismuth Type II: Stricture at the hilum of the liver, with confluence preservation.
    • Bismuth Type III: Stricture leading to an aberrant right hepatic duct.
    • Bismuth Type IV: Stricture to an aberrant right hepatic duct, with confluence involvement.
    • Bismuth Type V: Stricture to an aberrant right hepatic duct.

    Gallstones in Pregnancy

    • Hormonal changes during pregnancy can increase cholesterol secretion and decrease bile acid secretion, potentially slowing gallbladder emptying.
    • Progesterone can decrease bile acid secretion.
    • Gallstones diagnosis during pregnancy is possible using Ultrasound (USG).
    • First-trimester management for mild cases is conservative.
    • Second-trimester management involves Laparoscopic cholecystectomy.
    • Third-trimester management is non-operative.

    CBD Stones Detection and Management

    • CBD stones can be detected during or after laparoscopic cholecystectomy.
    • If CBD stones are detected during laparoscopic cholecystectomy, the procedure includes laparoscopic exploration of CBD and stone removal, followed by T-tube insertion (7-10 days).
    • A T-tube cholangiogram is conducted to check for residual stones after T-tube insertion.
    • If residual stones are present, the T-tube is retained for 2-3 weeks, and a channel is formed via a choledoscope to remove stones using the Burhenne technique.
    • If no residual stones are present, the T-tube is removed.
    • If CBD stones are detected after laparoscopic cholecystectomy, symptoms may include pain, fever, and jaundice.
    • Initial assessment involves imaging using an Imaging of the Common Bile Duct (IOC): MRCP.
    • If residual or retained CBD stones are present within 2 years of lap cholecystectomy, further evaluations including ERCP+Sphincterotomy are necessary.
    • If recurrent/primary CBD stones are present more than 2 years after Lap Cholecystectomy, evaluations including ERCP+Sphincterotomy are necessary.

    Gallstone Ileus

    • Gallstone ileus is a misnomer and refers to dynamic bowel obstruction.
    • It's caused by the impaction of a gallstone in the neck of the gallbladder, leading to bile absorption and mucus production by the GB wall.
    • Symptoms include a distended gallbladder and pain.
    • Diagnosis is made using USG.
    • Treatment involves laparoscopic cholecystectomy.
    • Complications include infected mucocele, leading to empyema of the GB, and gallstone ileus.
    • Common site of obstruction is the last 2 feet/60cm of ileum.
    • The stone rarely can lead to gastric outlet obstruction, causing Bouveret syndrome.

    Gastrointestinal and Abdominal Surgery

    • CECT is the IOC for GIST, GB cancer, and renal cell cancer.

    Gall Bladder Cancer

    • 90% of GB cancer is associated with GB stones.
    • Other risk factors include Salmonella typhi carrier, porcelain gallbladder, abnormal pancreatico biliary duct junction (APBDJ), and heavy metal contamination of water.
    • GB polyps > 10 mm/1 cm in size, multiple polyps, or adenomatous type increase the risk.
    • Cholesterol polyps do not increase the risk.
    • GB polyps < 10mm are monitored with regular USG.
    • Adenocarcinoma is the most common type, including infiltrating, nodular, and papillary types.
    • Clinical presentation may include a GB mass, pain, and jaundice.
    • Spread occurs through direct invasion, lymphatic spread, and hematogenous spread.

    Gall Bladder & Bile Ducts: Part 1

    • Mirizzi syndrome occurs when inflammation causes the GB to adhere to the CBD, leading to fistula formation.
    • Clinical features of Mirizzi syndrome include pain and jaundice.
    • Investigations for Mirizzi syndrome include MRCP and Intraoperative Cholangiopancreatography (IOC).
    • Management involves Lap cholecystectomy.
    • Choledocholithiasis is the presence of stones in the common bile duct. 90% are secondary to GB stones, and 10% are primary.
    • Brown pigment stones are commonly formed within the CBD.

    Laparoscopic Cholecystectomy

    • The surgeon positions on the left side, the assistant on the left side, and the patient in reverse Trendelenburg with the right side up.
    • The "B Safe" method focuses on visualizing the bile duct, status of Rouviere, hepatic artery, umbilical fissure, and enteric/duodenum before proceeding with surgery.
    • Calot's triangle, containing the cystic artery and cystic duct, must be visualized.
    • Traditional laparoscopic cholecystectomy uses multiple ports, including a right hypochondrial port for the left hand, and a fourth port for retraction and GB manipulation.
    • SILS laparoscopic cholecystectomy is performed through a single incision.
    • Bailout strategies, such as aborting the procedure, converting to an open procedure, performing a tube cholecystostomy, or carrying out a subtotal cholecystectomy, are used in cases of frozen Calots.
    • Complications include right shoulder tip pain (most common), bleeding, and injury to the bile duct.

    Bile Duct Injury

    • Types of bile duct injuries include injury to the bowel, residual/recurrent stones, and stricture to the common hepatic or common bile duct.
    • Injuries can be classified by whether awareness occurs during surgery or post-operatively.
    • Partial tear may be treated with repair using an absorbable suture.
    • Complete transection without loss of segment may be treated with anastomosis using a T-tube.
    • Complete transection with loss of segment may require anastomosis with a T-tube and closure of the distal end with choledochojejunostomy.
    • Post-operative management for minor bile leaks involves observation with close monitoring of symptoms.
    • Workup for persistent or worsening symptoms includes CBC, TLC, abdominal ultrasound, and collection below the liver, with confirmation via MRCP.
    • One common intervention for biliary leaks is an ERCP with stenting procedure.
    • The management strategy depends on the complexity of the injury and patient response.

    Chronic Cholecystitis

    • Chronic cholecystitis is characterized by multiple episodes of cholecystitis.
    • Symptoms include right upper quadrant pain, nausea, and vomiting.
    • Diagnosis is made using ultrasound, which may reveal the Wall echo shadow (WES) sign, gallstones, and post-acoustic shadow.
    • Histopathology reveals clefts, chronic inflammatory cells, and Rokitansky Aschoff sinuses.
    • Potential outcomes include rupture, xanthogranulomatous cholecystitis, or cancer.
    • Management involves laparoscopic cholecystectomy.

    Emphysematous Cholecystitis

    • This condition is caused by Clostridium bacteria.
    • Predisposing factors include immunocompromised status.
    • Clinical features include pain, fever, and sepsis.
    • Diagnosis involves ultrasound and computed tomography, which visualize gas within the gallbladder and wall.
    • Management includes nil per oral, intravenous fluids, and broad-spectrum antibiotics.

    Mucocele of Gallbladder

    • Mucocele is aseptic dilatation of the gallbladder caused by a stone impacted at the Hartmann pouch neck.
    • Management involves early laparoscopic cholecystectomy or tube cholecystostomy.

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    Description

    Test your knowledge on the Bismuth and Strasberg classifications of bile duct injuries. This quiz covers details about various types of bile duct injuries, including stricture and leaks. Additionally, explore the impact of pregnancy on gallstone formation.

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