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Questions and Answers
What is the purpose of a HIDA scan?
What is the purpose of a HIDA scan?
Severe cholecystitis is classified under Grade I according to the Tokyo consensus guidelines.
Severe cholecystitis is classified under Grade I according to the Tokyo consensus guidelines.
False
What is the first-line definitive management for a patient with Grade I cholecystitis who is fit for surgery?
What is the first-line definitive management for a patient with Grade I cholecystitis who is fit for surgery?
Early laparoscopic cholecystectomy
In acute cholecystitis, a non-visualization of the gallbladder during a HIDA scan indicates __________.
In acute cholecystitis, a non-visualization of the gallbladder during a HIDA scan indicates __________.
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Match the features of the Tokyo consensus guidelines with their corresponding grades:
Match the features of the Tokyo consensus guidelines with their corresponding grades:
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Which of the following is the most common encapsulated bacteria associated with OPSI after splenectomy?
Which of the following is the most common encapsulated bacteria associated with OPSI after splenectomy?
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Basophilic stippling is a permanent hematological change found on a peripheral smear.
Basophilic stippling is a permanent hematological change found on a peripheral smear.
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What is the recommended management for preventing thrombosis in patients with transient increases in all cell lines following splenectomy?
What is the recommended management for preventing thrombosis in patients with transient increases in all cell lines following splenectomy?
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Vaccination against Pneumococcus and Meningococcus is repeated every ______ years after splenectomy.
Vaccination against Pneumococcus and Meningococcus is repeated every ______ years after splenectomy.
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Match the vaccine with its frequency after splenectomy:
Match the vaccine with its frequency after splenectomy:
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What is a significant risk that increases after a splenectomy?
What is a significant risk that increases after a splenectomy?
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True or False: Splenunculi are common findings within the spleen itself and do not have clinical significance.
True or False: Splenunculi are common findings within the spleen itself and do not have clinical significance.
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What type of splenic cyst is typically associated with a history of trauma?
What type of splenic cyst is typically associated with a history of trauma?
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A hydatid cyst in the spleen is associated with exposure to __________.
A hydatid cyst in the spleen is associated with exposure to __________.
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Match the following splenic conditions with their descriptions:
Match the following splenic conditions with their descriptions:
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What is the function of the cystic plate in relation to the gall bladder?
What is the function of the cystic plate in relation to the gall bladder?
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The R4U line connects Rouviere's sulcus to the umbilical fissure.
The R4U line connects Rouviere's sulcus to the umbilical fissure.
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What happens when the CBD is present below the R4U line during surgery?
What happens when the CBD is present below the R4U line during surgery?
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The __________ does not increase the risk of cancer in the gall bladder.
The __________ does not increase the risk of cancer in the gall bladder.
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Match the following anatomical features with their descriptions:
Match the following anatomical features with their descriptions:
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What is the primary imaging technique used for diagnosing splenic abscesses?
What is the primary imaging technique used for diagnosing splenic abscesses?
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Trauma is the most common indication for splenectomy.
Trauma is the most common indication for splenectomy.
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What is the primary management option for Grade II patients when an advanced technique is available?
What is the primary management option for Grade II patients when an advanced technique is available?
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Name one malignant tumor that may require splenectomy.
Name one malignant tumor that may require splenectomy.
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Acalculous cholecystitis occurs with the presence of gallstones.
Acalculous cholecystitis occurs with the presence of gallstones.
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Injury to the tail of the pancreas during splenectomy presents with _______ in the drain.
Injury to the tail of the pancreas during splenectomy presents with _______ in the drain.
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What factors are considered predictive of a poor surgical outcome in patients being evaluated for cholecystectomy?
What factors are considered predictive of a poor surgical outcome in patients being evaluated for cholecystectomy?
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Match the indications for splenectomy with their respective categories:
Match the indications for splenectomy with their respective categories:
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In cases where the patient is unfit for surgery and shows no improvement, __________ cholecystostomy may be performed.
In cases where the patient is unfit for surgery and shows no improvement, __________ cholecystostomy may be performed.
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Match the grade of cholecystitis with the associated management strategy:
Match the grade of cholecystitis with the associated management strategy:
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What are the boundaries of Calot's triangle?
What are the boundaries of Calot's triangle?
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The Critical View of Safety involves clipping the cystic lymph node.
The Critical View of Safety involves clipping the cystic lymph node.
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What is the clinical significance of Moynihan's Hump during surgery?
What is the clinical significance of Moynihan's Hump during surgery?
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The __________ is the sentinel node of the gall bladder located within Calot's triangle.
The __________ is the sentinel node of the gall bladder located within Calot's triangle.
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Match the following terms with their descriptions:
Match the following terms with their descriptions:
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What is the most common etiology that can lead to splenic artery aneurysm?
What is the most common etiology that can lead to splenic artery aneurysm?
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Splenic infarcts are always symptomatic.
Splenic infarcts are always symptomatic.
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What imaging technique is considered the investigation of choice for diagnosing splenic artery aneurysms?
What imaging technique is considered the investigation of choice for diagnosing splenic artery aneurysms?
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In cases of splenic artery aneurysm rupture, the pain may be referred to the __________ shoulder tip.
In cases of splenic artery aneurysm rupture, the pain may be referred to the __________ shoulder tip.
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Match the following conditions with their management approaches:
Match the following conditions with their management approaches:
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What is the most common type of gall stone?
What is the most common type of gall stone?
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Seagull sign refers to a triradiate stone.
Seagull sign refers to a triradiate stone.
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What are black pigment stones primarily associated with?
What are black pigment stones primarily associated with?
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Brown pigment stones contain ________ and are often seen in infected bile.
Brown pigment stones contain ________ and are often seen in infected bile.
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Match the type of gall stone with its description:
Match the type of gall stone with its description:
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Which condition is indicated for surgery due to an increased risk of cancer?
Which condition is indicated for surgery due to an increased risk of cancer?
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Acute cholecystitis is characterized by pain in the left side of the abdomen.
Acute cholecystitis is characterized by pain in the left side of the abdomen.
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What is the classical USG finding in acute cholecystitis that indicates increased wall thickness?
What is the classical USG finding in acute cholecystitis that indicates increased wall thickness?
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The symptom of __________ is characterized by pressing on the right hypochondrium, which causes the patient to catch their breath.
The symptom of __________ is characterized by pressing on the right hypochondrium, which causes the patient to catch their breath.
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Match the following symptoms of acute cholecystitis with their descriptions:
Match the following symptoms of acute cholecystitis with their descriptions:
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Study Notes
Gall Bladder & Bile Ducts: Part 1
- HIDA Scan: Used to diagnose acute cholecystitis. The scan works by injecting a radioactive substance that travels through the biliary tree. If there is inflammation, the gall bladder will not be visible.
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Tokyo consensus guidelines for severity grading of acute cholecystitis: The severity of acute cholecystitis is classified into three grades based on clinical features.
- Grade III: Severe cholecystitis with organ dysfunction
- Grade II: Moderate cholecystitis with signs such as increased white cell count, palpable tender mass, and duration of more than 72 hours.
- Grade I: Mild cholecystitis.
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Management of Acute Cholecystitis:
- Grade I: Surgery is recommended. Early laparoscopic cholecystectomy is the preferred treatment.
- Grade II: If surgery is contraindicated, antibiotics and supportive care are recommended.
- Grade III: Antibiotics and supportive care are recommended for managing the infection.
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Hematological Changes post Splenectomy:
- Transient increase in all 3 cell lines: There is a temporary increase in the white blood cell count, platelet count, and red blood cell count.
- Predisposition to thrombosis: The increase in platelet count increases the risk of blood clots. Prophylactic aspirin is often recommended.
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Permanent Hematological Changes on Peripheral Smear:
- Basophilic stippling: A characteristic feature of lead poisoning
- Howell Jolly bodies: Small, round inclusions seen in red blood cells, often seen in patients with splenectomy.
- Reticulocytes: Immature red blood cells, indicating increased red blood cell production.
- Hypersegmented WBC's: Neutrophils with more than 5 lobes, indicative of megaloblastic anemia or vitamin B12 deficiency.
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Left lower lobe atelectasis/pneumonia (m/c): A common post-splenectomy complication due to decreased lung expansion.
- Prevention: Chest physiotherapy using incentive spirometry and pain control to promote deep breaths.
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OPSI: Opportunistic overwhelming post splenectomy infections: A serious complication that occurs due to the loss of the spleen's immune function.
- Etiology: Encapsulated bacteria such as pneumococcus, meningococcus, and H. influenzae.
- Occurrence: More common in children than adults and typically occurs within the first two years following splenectomy.
- Vaccination: Vaccination against pneumococcus, meningococcus, and H. influenzae is highly recommended.
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Spleen Functions:
- Immunological: Produces antibodies and plays a critical role in immune function.
- Acts as graveyard for blood cells: Filters out old and damaged blood cells.
- Hematopoiesis (Physiological): Occurs during the 3rd-5th week of intrauterine life.
- Reservoir function: Stores white blood cells, red blood cells, and platelets.
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Applied Aspects of Splenic Tissue:
- Splenunculi: Accessory splenic tissue that can occur in the hilum of the spleen. Important in hematological conditions like ITP. Removal of the spleen may lead to recurrence if splenunculi are not removed.
- Splenosis: Splenic tissue deposits in the omentum and bowel often following trauma.
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Benign Conditions of the Spleen:
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Splenic Cyst: A fluid-filled sac within the spleen.
- Pseudocyst: A false cyst not lined by epithelium often caused by trauma. Usually resolves spontaneously.
- True Cyst: Lined by epithelium. Hydatid cysts are true splenic cysts caused by infection with Echinococcus.
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Splenic Cyst: A fluid-filled sac within the spleen.
- Couinaud Segments: Functional Division: A way to divide the liver into eight segments based on the distribution of hepatic veins and portal veins.
- Cystic Plate: A sheet of tissue that covers the gall bladder fossa and is continuous with liver capsule of segments 4 & 5. Important to identify for safety during laparoscopic cholecystectomy.
- Rouviere's Sulcus: Present on the undersurface of the right lobe of the liver.
- R4U Line: A line drawn from the roof of the Rouviere sulcus to the umbilical fissure (u) - important for minimizing CBD injury during laparoscopic cholecystectomy.
- General Anatomy of the Gall Bladder: Important to remember that the Gallbladder lacks a submucosa and contains subserosal lymphatics.
- Spread of Gallbladder Cancer into the Liver: Can occur through subserosal lymphatics, direct infiltration, and hematogenous spread.
- Phrygian Cap: A physiological variant in which the fundus of the gallbladder is folded and appears like a cap. Not a cause for concern and does not increase the risk of cancer.
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Gastrointestinal and Abdominal Surgery:
- Decision Tree for Cholecystectomy: A guide to manage cholecystectomy based on patient grade and the presence of gallstones.
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Acalculous Cholecystitis: Cholecystitis without gallstones.
- Risk Factors: Commonly seen in ICU patients, post-CABG patient, or those with prolonged total parenteral nutrition
- Management of Acalculous Cholecystitis: Supportive care, IV fluids, IV antibiotics, and analgesics.
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Splenic Abscess: Infection within the spleen, associated with immunocompromised patients and post-splenic infarcts.
- Clinical Features: Fever and pleuritic pain.
- Imaging: CECT (Computed Tomography Enhanced) is the imaging of choice.
- Management: Pigtail catheter drainage.
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Splenectomy: Surgical removal of the spleen.
- Indications: Trauma, oncological conditions, hematological disorders.
- Complications: Hemorrhage, Portal hypertension.
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Steps for Splenectomy (Dissection):
- Dissection of the aspect of spleen.
- Dissection of the lateral aspect and retroperitoneal attachments.
- Transection of the splenic hilum.
- Dissection of short gastric vessels.
- Removal of the spleen.
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Splenic Artery Aneurysm: Enlargement of the splenic artery.
- Etiology: Visceral artery aneurysm, pancreatitis, trauma, atherosclerosis, pregnancy.
- Clinical Features: Often asymptomatic but can cause pain if rupture occurs.
- Management: Embolization, grafting, or splenectomy.
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Splenic Infarct: A blockage of blood flow to the spleen.
- Etiology: Hypersplenism due to conditions like portal hypertension or myelodysplastic syndromes.
- Clinical Features: Often asymptomatic but can cause pain, left upper quadrant pain, pleuritic pain, or referred left shoulder pain.
- Management: Conservative or surgical excision.
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Gall Bladder Functions:
- Reservoir of bile: Stores bile produced by the liver.
- Secretion of mucin: Mucin production in the gall bladder protects the lining from the harsh digestive juices.
- Concentration of bile: Gallbladder concentrates and stores bile, increasing its digestive capabilities.
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Gall Stones:
- Types: Cholesterol, pigment, and mixed stones.
- Cholesterol Stones: Pure cholesterol stones are more common.
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Pigment Stones: Consist of bilirubin, calcium palmitate, and calcium bilirubinate.
- Brown pigment stones: Associated with infections like ascariasis, clonorchis, and cholangitis.
- Black pigment stones: Common in hemolytic disorders such as G6PD deficiency, sickle cell anemia, and spherocytosis.
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Risk Factors for Gall Stones:
- Lithogenic bile (excess cholesterol).
- Obesity.
- Post-ileal resection.
- Stasis in the gallbladder.
- Pregnancy.
- Oral contraceptives (OCP).
- Post-vagotomy.
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Investigation
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X-ray:
- Most gallstones are radiolucent and do not show up on an X-ray.
- About 10% of stones are radiopaque (visible on X-ray)
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SIGNS:
- Seagull sign: A biradiate stone.
- Mercedes Benz sign: A triradiate stone.
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X-ray:
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Presentation & Management
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Asymptomatic stones:
- Observation: If asymptomatic, no treatment is normally required.
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Indications for Surgery:
- Porcelain gall bladder: Calcification of the gall bladder wall (increased risk of gallbladder cancer).
- Salmonella typhi carrier: Removal of the gallbladder can help to eliminate infection.
- Diabetes: First attack of gallstones can cause severe pain.
- > 2 cm stone: Large stones have an increased risk of causing complications.
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Acute Cholecystitis:
- Symptoms: Pain in the right upper abdomen, nausea, vomiting, and anorexia.
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Signs:
- Murphy's sign: Pain on palpation of the right upper abdomen.
- Boa's sign: Hyperesthesia over the 12th rib.
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Tokyo consensus guidelines diagnostic criteria:
- Localized signs of inflammation: Murphy's sign.
- Systemic Signs of inflammation: Fever.
- Imaging findings: Characterisitic ultrasonographic findings of acute cholecystitis.
- Diagnosis: Suspected diagnosis: 1 of A + 1 of B or Definite diagnosis: 1 of B + 1 of A + C.
- Investigation: Ultrasound is the primary imaging for diagnosis.
- Ultrasound: Shows thickened gall bladder wall (>3 mm), pericholecystic fluid, and probe tenderness.
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Asymptomatic stones:
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Description
This quiz covers essential concepts related to the gall bladder and bile ducts, focusing on the diagnosis of acute cholecystitis using HIDA scans and the Tokyo consensus guidelines for severity grading. It also addresses management strategies based on the severity of cholecystitis. Test your understanding of these critical aspects of biliary health.