Q1 Which of the following is not associated with Primary sclerosing cholangitis?
a) Retroperitoneal fibrosis
b) Riedel's thyroiditis
c) Ulcerative colitis
d) Cholelithiasis
Q2) What is the pressure of sphincter of oddi?
a) 15 mmHg
b) 40 mmHg
c) 30 mm Hg
d) 50 mm Hg
Q3) What is the preferred biliary anastomosis after liver transplant?
a) Choledocho-choledochal
b) Choledochojejunostomy
c) Choledochoduodenostomy
d) All have same results
Q4) Which variety of Klatskin tumor grows in the cystic duct?
a) Nodular
b) Sclerosing
c) Papillary
d) All
Q5) Which of the following is not a criteria for papillary stenosis?
a) Pain right upper abdomen
b) Increased pressure at sphincter of oddi
c) Dilated (Common Bile duct) CBD on ERCP
d) 30 min delay in contrast
Answers
1. d)
Primary sclerosing cholangitis (PSC) is a disease of extrahepatic and intrahepatic biliary system with difuse involvement of bile ducts. It is a disease of young males with most people in the late 30s.
PSC is strongly associated with inflammatory bowel disease (IBD)In about 60-70% cases of primary sclerosing cholangitis ulcerative colitis is seen.
Cholangiography shows a characterstic beaded apperance.Primary sclerosing cholangitis is more common in certain HLA haplotypes such as B8/DR3 which is also common in patients with other autoimmune diseases such as insulin-dependent diabetes mellitus, Graves’ disease, Sjögren’s syndrome, and myasthenia gravis.
It has strong association with ulcerative colitis and Cholangiocarcinoma. There is no association of PSC with cholelithiasis
The symptoms may include fatigue, pruritus, right upper quadrant pain, weight loss, and manifestations related to portal hypertension (i.e., ascites, gastrointestinal bleed from esophageal varices). Symptoms of bacterial cholangitis are less common, except if the patient has dominant biliary strictures and/or biliary stones. The physical examination of symptomatic patients may reveal jaundice, hepatomegaly, splenomegaly, skin excoriations, ascites, and peripheral edema.
Currently, the most frequent clinical presentation is an asymptomatic patient with persistently increased levels of alkaline phosphatase noted on routine serum biochemical testing.
Refrence: Sabiston textbook of Surgery 17th edition.
Notes::
1.The classic cholangiographic findings of PSC include multifocal stricturing and beading throughout the biliary tree.
2.Strictures are often diffusely distributed with intervening segments of dilated ducts.
3.The cholangiographic findings usually involve both the intrahepatic and extrahepatic bile ducts
4. Strictures can vary from 1 to 2 mm to several centimeters in length.
5. Mural irregularities producing a shaggy appearance; these lesions may vary from a fine brush border to frank nodularity
6. In approximately 20% of PSC patients, only the intrahepatic and proximal extrahepatic bile ducts are involved, and as many as 15% of PSC patients have involvement of the gallbladder and cystic duct
2.a
Normal sphincter of oddi pressure is 5-15 mmHg. Phasic contractions occur three to seven times/minute and can raise the pressure of sphincter of Oddi upto 30-150 mmHg.
3.a
The biliary anastomosis is an end-to-end anastomosis from the donor common bile duct to the recipient common hepatic duct (choledochocholedochostomy). This is the preferred anastomotic technique as it avoids intestinal surgery, preserves the sphincter of Oddi, and reduces the risk of enteric reflux into the biliary tree. If the recipient common hepatic duct is diseased, absent, too short, or too small, then a choledochojejunostomy is fashioned. However, with this technique there is an increased risk of infection from bacterial overgrowth and anastomotic breakdown and bleeding
4.
