Bile duct 16-20

Bile duct 16-20

 Bile Duct Injury

Meticulous dissection at the time of cholecystectomy is important for preventing bile duct injury. These are MCQs on management of bile duct injury and cholangiocarcinoma.


                                                                    Questions on Bile ducts

Questions 1-6              Questions 7-11                   Questions 18-20


Q16 Which of the following Bile duct  injury do not present immediately after surgery
a) Type A
b) Type B
c) Type C
d) Type D
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Q17.Which of the following is not true regarding ERCP in  bile duct injury of biliary tract
a)  ERCP should be the initial investigation in all cases of injuries to the ble duct to define the extent of injury
b)  ERCP is of  value if there is a incomplete stricture
c)  ERCP is helpful if it is a Type A or Type D injury
d)  ERCP is of no use if clinically or radiologically the bile leak has stopped
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Q18 What is not true regarding the role of (IOC) Intra Operative Cholangiography in Bile duct injury
a) IOC should be done in all cases of cholecystectomy as it prevents inadvertent injury
b) Cholangiography only serves to limit the extent of injury
c) It allows for immediate recognition of injury and repair
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 Q19 What is not true about the diagnostic approach of a patient newly diagnosed with hilar cholangiocarcinoma?

 a. CA19.9 and CEA should be done in all patients

b. Imaging will show intra hepatic duct dilatation with normal extra hepatic ducts

c. Contrast enhanced MRCP is the imaging of choice

d. ERCP should be done in most cases to get the brush cytology

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 Q20) A 55 year old male presents with obstructive jaundice. Ultrasound evaluation reveals a hyperechoic 4 cm mass in segment VI of liver with peripheral duct dilatation. CT abdomen shows a hypodense mass with delayed enhancement in portal phase. What is the most likely diagnosis

a) Hepatocellular carcinoma

b) Intrahepatic cholangiocarcinoma

c) Metastatic Adenocarcinoma

d) Carcinoid

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 Answers to bile duct injury

 
 
16. b
According to Strasberg's classification of biliary injuries, Type B injury is the one in which there is no bile leak. It is a occulson of Right sectoral duct.
 
 For Bismuth classification of bile duct injuries see here
 
17) a
 
ERCP is not the initial investigation if there is a suspicion of complete ductal occlusion. This is because ERCP would not demonstrate the proximal extent of injury.In these cases PTC (Percutaneous Transhepatic Chonalgiography) would be more useful.
 
 18. a
Routine intraoperative cholangiography does not decrease the rate of injuries associated with Lap Cholecystectomy. Cholangiography is clearly not preventive if the injury occurs after a normal study or if the study serves only to identify an injury that already is there.
 
Notes
Successful management of biliary strictures depend on
1. Defining the type and extent of injury
2. Treat sepsis,cholangitis, ongoing biliary leaks, abscess
3. Achieving a tension free duct to mucosa anastomose
 
Questions Bile duct injuries
Notes on Laparoscopic CBD management
Normally 6% of all asymptomatic patients with gall stones will have stones in the common bile duct (CBD) (Majeed et al 1999)
 
In patients with CBD stones who are asymptomatic 26% will have stones spontaneously passing.
 
Indications of Choledochoduodenostomy
Multiple stones and debris
 
Primary Duct stones
 
Evidence of obstruction at the lower end
 
Uncertainity if the duct is clear
 
There are two types of laparoscopic surgeries for CBD stones
1. Transcystic
2. Choledocholithotomy
 
Indications for Transcystic extraction
1. Stones less than 8 in number
2. stone size less than 9 mm
3. Distal to cystic duct
 
Contraindication to Transcystic extraction is
Friable cystic duct
Intra hepatic stones
Multiple large stones
 
SUCCESSFUL EXTRACTION IN 67-96%
Infection and pancreatitis in 5-10 % with a mortality rate of 1%
 
In Laparoscopic choledochotmy
success rate is 90%
Complications 5-10%
Mortality 1-2%
Complications include- laceration of the CBD, bile leakage, sewn-in T-tubes, and postoperative CBD strictures
 
 
 Stewart Way Classification of Biliary injury- Bases on cognitive factors
 
Class I - CBD mistaken for cystic duct recognised cholangiogram incision in cystic duct extended to CBD
Class II- Lateral damage to CHD, bleeding with poor visibility
Class III- CBD mistaken for cystic duct, not recognised
Class IV- RHD mistaken for cystic duct, RHA mistaken for cystic artery

19 d)

A suspected case of cholangiocarcinoma should undergo evaluation to rule out benign biliary diseases and staging workup in cases of malignancy.

Contrast MRI and MRCP are the initial investigations of choice.

Hilar cholangiocarcinoma or Klatskin tumor is at the biliary confluence and causes dilatation of both intrahepatic ducts.

ERCP is not preferred for diagnostic purposes because

  1. It is invasive
  2. It fails to drain/stent some times leading to ascending cholangitis
  3. Brush cytology has a very low sensitivity (25-30%)

20 b) Intrahepatic cholangiocarcinoma (IHCC)

IHCC - Mass forming type- have gradual central enhancement and variable delayed enhancement on portal phase

Hepatocellular carcinoma present ....Premium content

 with arterial enhancement and rapid washout in portal phase,

Metastatic adenocarcinoma- Enhancement is typically peripheral, and although there may be central filling in portal phase, delayed phase will show washout.

Carcinoid are vascular tumor and show rapid arterial filling.

Intrahepatic cholangiocarcinomas (IHCC) in an intrhepatic bile duct tumor has an incidence of .85/100000. 

Etiological risk factors for IHCC

  1. Primary sclerosing cholangitis(PSC) - Risk is 1.5% per year. Risk also increases in people with concomitant inflamatory bowel disease (IBD). In PSC,IHCC develops earlier and at an advanced stage
  2. Parasitic infections- Opisthorchis viverrini and Clinorchis sinensis
  3. Hepatolithiasis - Recurrent Pyogenic Cholangitis (RPC) and intrahepatic stones
  4. Congenital biliary cyst- Choledochal cyst
  5. Cirrhosis and viral infections of liver- Although HCC is more common, IHCC can also develop in these settings
  6. Benign biliary cysts
  7. Chemicals- Thorotrast, Asbestos, Vinyl Chloride

CT features- Tripple phase CT scan in Intrahepatic Cholangiocarcinoma shows

  1. Hypodense lesion with irregular inflitrative margins
  2. Variable delayed enhancement in portal phase

MRI - Hypointesne in T1, Hyperintense in T2 with pooling of contrast in T2

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