Hepatobiliary – Hepatobiliary – Hepatobiliary MOZZAR

NO LIST OF DIAGNOSIS PATHO/RISK FACTORS/ CAUSES CLINICAL PRESENTATION/ COMPLICATIONS INVESTIGATION MANAGEMENT
1 Portal hypertension - Hepatic venous pressure gradient (HVPG) Cx; Ascites, spontaneous bacterial peritonitis Ultrasound (Liver & Spleen) – dilated splenic and SMV,
≥6mmHg (bet hepatic & portal vein) (SBP), formation of portosystemic shunts, hepatic splenomegaly >12cm, dilated portal vein, porto-systemic
- Chronic increase in portal P d/t mechanical encephalopathy collaterals, ascites, nodular liver
obstruction as consequence of cirrhosis
- Causes; Pre-sinusoidal, Sinusoidal, Post-
sinusoidal
2 Ascites - Progressive liver cirrhosis  obstruct intra- Progressive abdominal distension, painless, SAAG; Conservative; low salt diet, fluid restriction,
hepatic vasculature  Portal HTN  abdominal discomfort, weight gain, SOB, early - ≥1.1g/dL; liver cirrhosis, alcoholic hepatitis, CHF, Budd- monitor
splanchnic vasodilation satiety Chiari syndrome, portal vein thrombosis Pharmacological; Diuresis (spironolactone,
- Low effective intra-abdominal blood V Fever, abdominal tenderness, altered mental - <1.1g/dL; peritoneal carcinomatosis, peritoneal TB, furosemide), Antibiotics (if suspect SBP) (IV
- Renal hypoperfusion  RAAS stimulated  status (AMS)  suspect SBP pancreatitis, pancreatic ascites, nephrotic syndrome ceftriaxone or oral quinolones)
vasoconstriction, high aldosterone  salt and PE; abdominal distension, flank dullness, shifting FBC, U/E/Cr, LFT, CXR, Liver & Spleen US/CT scan Therapeutic paracentesis + IV albumin 20%
water retention dullness, fluid thrill, CLD stigmata, raised JVP, Peritoneal tap infusion
anasarca (in nephrotic syndrome) Surgical – liver transplantation and shunts
Treat underlying cause, Liver transplant for
cirrhosis
3 Liver haemangioma - Benign vascular lesions. Endothelium Usually asymptomatic, incidental finding Do not biopsy (risk of fatal haemorrhage) Asymptomatic, <4cm – observation
hamartomatous outgrowth made of widened Pain from liver capsule stretch, non-specific Ultrasound; well circumscribed, homogenous, hyperechoic Symptomatic/ complicated lesions – surgical
blood vessels abdominal fullness, vague abdominal pain, mass lesion, compressibility of lesion (pathognomonic) removal
- Most common benign liver tumour effects Triphasic CT scan; peripheral enhancement (arterial phase), Large, unresectable – low-dose radiotherapy or
- Vascular malformation enlarged by ectasia Cx; life-threatening haemorrhage, CHF, centripetal filling (portal venous phase), contrast retention + embolization
Kasabach-Merritt syndrome (consumptive appears brightest + uniformly enhanced (delayed phase) Spontaneous rupture – arterial
coagulopathy) Gadolinium-enhanced MRI; hyperintense on T2-weighted angioembolization then definitive resection
images (“light bulb sign”)
4 Focal Nodular - Benign, nodular in appearance. Central stellate Asymptomatic, incidental on imaging Triphasic CT scan; bright homogenous enhancement w Conservative Mx for asymptomatic
Hyperplasia (FNH) scar Symptomatic; RUQ pain hypoattenuating central scar (arterial phase), isoattenuating Surgery/ Liver resection for symptomatic
- Second commonest benign liver tumour (portal venous phase), hyper-attenuation of central scar
(delayed phase)
Sulphur colloid scan – have Kupffer cells, will take up sulphur
colloid
MRI – central scar hyperintense on T2 weighted images
5 Hepatic adenoma - Benign proliferation of hepatocytes Asymptomatic Triphasic CT scan; sharply defined borders, homogenous Conservative Mx for small, asymptomatic lesions
Symptomatic – spontaneous rupture and enhancement (arterial phase), isodensity (portal venous and Surgical resection for symptomatic lesion or
intraperitoneal haemorrhage of lesions >5cm, delayed phase) lesions > 4-5cm
abdominal pain, vague symptoms of fullness, Sulphur colloid scan (cold) – no Kupffer cells thus no uptake If got acute haemorrhage, proceed to hepatic
RUQ discomfort MRI – hypervascular tumour angioembolization followed by surgery
Histology – lack bile duct glands and Kupffer cells, no true
lobules, congested hepatocytes
6 Hepatic cysts - Classification; Non parasitic (simple, Asymptomatic Simple liver cyst – percutaneous aspiration with
polycystic, neoplastic), Echinococcal (hydatid) Symptomatic – RUQ tenderness, hepatomegaly, sclerotherapy or laparoscopic “unroofing” if
cysts bleeding, infection, torsion, mass effect of IVC symptomatic
compression, CBD compression, portal HTN, Polycystic liver disease – laparoscopic
fistulation “unroofing” or liver resection if symptomatic
Neoplastic cyst – resection or enucleation
Hydatid cyst – surgery or unroofing
7 Hepatocellular - Risk factors; CLD, chronic HBV/HCV infection, Local S&S; upper abdominal pain, dull, persistent, Diagnostic approach Curative; surgical resection, liver transplantation
carcinoma alcohol, NAFLD, autoimmune (PBC, SBC), early satiety, vomiting, constitutional symptoms, Triphasic CT scan as GOLD STANDARD – early enhancement Palliative;
metabolic (haemochromatosis, A1AT pyrexia, jaundice + hyper-dense lesion (arterial phase), dull/wash out + hypo- - Local – radiofrequency ablation, microwave
deficiency), others (diet, aflatoxins B1, DM, Tumour rupture; severe abdominal pain, pallor dense (portal venous phase), tumour capsule (delayed ablation, thermal ablation, cryotherapy
smoking) Features of decompensated CLD phase) - Regional – TACE, selective internal
- Chronic inflammation or on-going Features of portal HTN Hallmark – arterial hypervascularity + venous/ late phase radiotherapy
hepatocellular damage with high cellular Metastases; bone pain, dyspnoea washout - Systemic – sorafenib/ Lenvatinib
regeneration leading to increased mutation Paraneoplastic syn; hypoglycemia, hyperCa, etc Lipiodol contrast CT scan, AFP, hepatic markers, MRI, USG Others – symptomatic treatment
Hepatobiliary – Hepatobiliary – Hepatobiliary
8 Secondary liver - Metastatic liver tumours more common than Metastasis to liver parenchyma; incidental
malignancy primary liver tumours d/t liver dual blood finding, fullness in RUQ, RHC pain, constitutional
supply symptoms
PE; hard, irregular, nodular hepatomegaly. Late
jaundice
Metastasis to porta-hepatis lymph nodes;
obstructive jaundice
PE; hepatomegaly may not be present. Early
jaundice
9 Hepatic abscess - Pus-filled area usually in R lobe secondary to Spiking fever with chills, RHC pain, jaundice,
(Pyogenic) other sources of bacterial sepsis hepatomegaly, non-specific symptoms (anorexia,
- Klebsiella, E-coli, proteus vulgaris, Strep anemia, LOW, pain radiates to shoulder, malaise,
milleri, Staph epidermidis, bacteroides fragilis diaphoresis)
10 Hepatic abscess - Caused by liquefaction necrosis. Cavity full of Travellers from endemic area
(Amoebic) blood and liquefied liver tissue (“anchovy Persistent fever, RUQ pain, referred to
sauce”) epigastrium or R shoulder, diarrhoea,
- Entamoeba histolytica – haematogenous hepatomegaly, point tenderness over liver,
spread from gut via portal vein jaundice
Cx; rupture of abscess causing peritonitis,
bacterial superinfection, erosion into
surrounding structures
11 Acute pancreatitis - Reversible pancreatic parenchymal damage Acute, constant epigastric pain, radiates to back,
- Causes; I-GET-SMASHED (Idiopathic, unable to get comfortable when lying supine,
Gallstone, Ethanol, Trauma, Steroids, Mumps, pain alleviated by sitting up and leaning forward,
Autoimmune, Scorpion toxin, nausea, vomiting
Hypertriglyceridemia/ HyperCa, ERCP, Drugs,
others) Cx; respi failure secondary to diaphragmatic
- Trypsin activation unregulated  pro- inflammation, renal failure, GI failure, fever,
enzymes activation  auto-digestion  hypotension, SIRS response (eg tachycardia,
inflammatory cascade tachypnoea, fever), obstructive jaundice
- Gallstone – obstruction  increased P 
pancreatic juice extravasate  injury Signs of peritonism; rebound tenderness,
guarding, board-like rigidity
Signs of haemorrhagic pancreatitis; Grey-Turner
sign, Cullen’s sign, Fox’s sign
Histology – Hallmark; stromal invasion
Staging studies
Biochemical assessment via Child-Pugh score
Indocyanine green (ICG) assessment
CT volumetry
ECOG performance scale
Biochemical Ix
Triphasic liver CT scan; hypodense (arterial phase),
increasing contrast uptake (portal venous and delayed
phases)
Biochemical; FBC, ESR, CRP, renal panel, UFEME, blood/ pus
culture, HbA1c
Imaging;
- CXR (elevation of R hemidiaphragm, infiltration at R lung
base, R-sided pleural effusion)
- USG of HBS (septations, hypoechoic rim)
- CT scan as definitive Dx & 1st line Ix (irregular lesion with
central area of necrosis, air fluid levels, rim-enhancing
appearance)
Diagnostic; percutaneous drainage + send pus for cultures,
amoebic serology, PCR stool, melioidosis serology
US/CTAP – rounded lesion abutting liver capsule, without
rim enhancement of pyogenic abscess
Serum antibody testing – confirm causative organism
Diagnostic; Serum amylase, lipase
Assess severity and prognosticate dz; FBC, RP, Ca, Glucose,
LFT, ABG, CRP
Other; ECG, cardiac enzymes, coagulation profile, lactate
Radiological Ix
Erect CXR – air under diaphragm, pleural effusion, elevated
hemidiaphragm
Supine CXR – sentinel loop sign, colon cut-off sign,
pancreatic calcifications
US HBS – diffusely enlarged and hypoechoic pancreas
CTAP, MRI/ MRCP
Ix underlying aetiology
LFT, metabolic screen, autoimmune screen, US HBS, EUS
Scoring for severity – Ranson’s criteria, Glasgow, APACHE II
MOZZAR
Usually palliative except in selected cases
Colorectal liver metastases – liver resection
recommended
Neuroendocrine liver metastases – hepatic
resection if resectable
Resuscitate, close monitoring, watch for Cx
Long-term Abx via PICC – IV ceftriaxone +
metronidazole. Change later if got C&S result
Drainage if >3cm – open, laparoscopic or
percutaneous
Colonoscopy for pt > 50 y/o with DM, K.
pneumoniae PLA
Metronidazole
Needle aspiration if patient not responsive to Abx
Intraluminal agents – iodoquinol, diloxanide
furoate
Supportive Tx: Fluid resuscitation, Monitoring,
Pain control with opioid analgesics (tramadol),
Nutrition, Antibiotics, Support for organ failure
Managing Cx
Acute peripancreatic fluid collection
Acute necrotic collection – prophylactic Abx with
imipenem, supportive care
Pancreatic pseudocyst, Fistula, Haemorrhage,
Rupture, Obstruction, Infection
Walled-off pancreatic necrosis (WOPN) – EUS
guided cystgastrostomy, laparoscopic
cystgastrostomy, open surgical necrosectomy
(many more Cx)
Treatment of underlying aetiology
ERCP for gallstones
Laparoscopic cholecystectomy for biliary
pancreatitis
Lifestyle modification
Hepatobiliary – Hepatobiliary – Hepatobiliary
12 Chronic pancreatitis - Inflammation, fibrosis and loss of acinar and
islet cells
- Causes; toxic-metabolic factors, alcohol,
smoking, genetic, autoimmune, recurrent and
sever acute pancreatitis, idiopathic, etc
- Progressive destruction by repeated flare-ups
of acute pancreatitis
MOZZAR
Epigastric pain, radiates to back, worse after Radiological Treat underlying aetiology
eating, nausea, vomiting CT, MRI, US – calcifications, ductal dilatation, enlarged Lifestyle modification
Pancreatic insufficiency symptoms; fat pancreas, fluid collections
malabsorption (steatorrhea, vitamins ADEK and MRCP – calcifications, pancreatic duct obstruction Supportive Tx; malabsorption/ steatorrhea
B12 deficiencies), pancreatic diabetes ERCP – “chain of lakes” of main pancreatic duct (pancreatic enzyme supplements), DM (lifestyle
EUS – based on Rosemont criteria changes, OHA, insulin), pain (narcotics/ TCAs)
Cx; pseudocyst, pancreatic ductal stones, Biochemical; Pancreatic secretin stimulation test,
pancreatic ascites, fistula, head of pancreas mass, postprandial pancreatic polypeptide hormone, pancreatic Cx Tx; pancreatic pleural effusion (tube
CBD obstruction, duodenal obstruction endocrine function, 72hr faecal collection for estimation of thoracostomy), pancreatic ascites (paracentesis),
pancreatic Ca, pancreatic insufficiency daily faecal fat ductal Cx (ERCP), pseudocyst/aneurysm/fistula
(surgical Mx)

Surgery if unremitting pain, unable TRO

neoplasm, Cx Tx, variceal haemorrhage
Whipple procedure; en-bloc removal of distal
segment of stomach, duodenum, proximal 15cm
jejunum, head of pancreas, CBD, gallbladder
13 Pancreatic cancer - Majority are adenocarcinoma originating from Early stage usually clinically silent Biochemical Chemotherapy and Radiotherapy
exocrine part Classical Courvoisier sign (palpable GB with FBC, U/E/Cr, LFT, amylase/lipase, PT/INR, random glucose
- Risk factors; Modifiable (smoking, obesity, painless obstructive jaundice), tea-coloured test, CA 19-9, Lewis blood group antigen (cell surface Surgery – Curative resection for resectable
high fat diet, alcohol, occupational exposure), urine, scleral icterus, pruritis, pale/clay-coloured glycoprotein) disease
Non-modifiable (FHx, age above 60, male, stools, pain Pre-operative biliary drainage
personal history, genetic predisposition, etc) New onset DM in elderly, endoscopy negative Radiological Whipple operation
- Dominant RF; smoking, chronic pancreatitis, epigastric pain, malabsorption, LOA, LOW, Transabdominal US – CBD dilatation, pancreatic duct Pylorus-preserving pancreaticoduodenectomy
familial pancreatic cancer anorexia, nausea, vomiting, UGIB dilatation
Triphasic “pancreatic protocol CT scan” – hypo-attenuating Palliative Mx for obstructive jaundice or UGI tract
Signs of advanced malignancy; malignant pleural indistinct mass (late arterial phase), Double Duct sign (CBD obstruction
effusion, Virchow’s node (left supraclavicular and pancreatic duct simultaneous dilatations)
node enlargement), Trousseau sign (migratory MRI pancreas with MRCP, EUS + FNAC, ERCP, staging Cx of Whipple’s operation;
superficial thrombophlebitis), Sister Mary Joseph laparoscopy Early – delayed gastric emptying, pancreatic
nodule (umbilical metastatic lesion), fistula, wound infection, bleeding, etc
hepatomegaly, non-bacterial thrombotic STAGING – AJCC 8th Edition (TNM) Late – malabsorption, steatorrhea, gastric stasis
endocarditis with pylorus-preserving Whipple, diarrhoea, DM
14 Pancreatic - Gastrinoma – Zollinger-Ellison syndrome (ZES) Gastrinoma – refractory peptic ulcer, Gastrinoma – Diagnostic by raised fasting serum gastrin. Duodenal gastrinoma – full-thickness excision of
Neuroendocrine - Insulinoma steatorrhea, esophagitis with stricture, Stomach basal acid output, secretin stimulation test, SSTR duodenal wall
Tumour (PNET) - Other; glucagonoma, VIPomas, heartburn, epigastric pain octreotide scan Pancreatic gastrinoma – simple enucleation if
somatostatinomas <2cm or resection if >2cm
Insulinoma – Whipple’s triad (symptomatic Insulinoma – insulin to glucose ratio >0.4 after fasting,
fasting hypoglycaemia, serum glucose <2.8 elevated C-peptide levels, increased serum pro-insulin, Insulinoma – surgical exploration wit intra-
mmol/L, symptom relief with glucose triphasic CT pancreas (vascular, well seen in arterial phase) operative ultrasound, medical (diazoxide Tx),
administration), neuroglycopenic Sx (visual metastatic (5FU)
change, diplopia, confusion), autonomic Sx
(anxiety, palpitations, trembling, diaphoresis)
15 Cystic Neoplasm of - Serous cystadenoma – benign tumour Serous cystadenoma; if symptomatic – mild Serous cystadenoma – observe with serial CT
Pancreas - Mucinous cystadenoma & upper abdominal pain, epigastric fullness, LOW, MCNs – Imaging (CT, EUS, MR); cystic lesion, thick walls, wall scans if asymptomatic, surgical resection if
cystadenocarcinoma (MCNs) jaundice, gastric outlet obstruction calcifications or nodules. Fluid amylase/Fluid CEA, cytology, symptomatic
- Intraductal papillary mucinous neoplasm IPMN – abdominal pain, recurrent pancreatitis, histology (tall columnar mucinous epithelium surrounded by MCNs – open surgical resection, Whipple’s
(IPMN) LOW, exocrine insufficiency, steatorrhea, cellular ovarian-type stroma) operation, distal pancreatectomy with
diabetes IPMN – CT scan (diffuse dilatation of pancreatic duct, splenectomy
atrophic pancreatic parenchyma), ERCP (mucin extruding IPMN – resection if there’s malignant
from ampulla of Vater) transformation
16 Splenic Cyst & - Splenic cysts; causes include parasitic, non- Splenic cyst – vague LUQ discomfort Splenic cyst – conservative, surgical intervention
Abscess parasitic, secondary if symptomatic
- Splenic abscess – hematogenous spread Splenic abscess – IV Abx, splenectomy
Hepatobiliary – Hepatobiliary – Hepatobiliary
17 Cholelithiasis - Gallstones in gallbladder
- Cholesterol stones (85%)
- Pigment stones (15%); black (sterile), brown
(infected), mixed, biliary sludge
18 Acute calculous - GB inflammation caused by gallstones
cholecystitis - Cystic duct obstruction  increased
intraluminal P  compromise blood flow 
ischemia and necrosis  inflammation 
secondary bacterial infection with enteric
organism can occur
19 Acute acalculous - GB acute inflammation without gallstones
cholecystitis - Primary pathology – bile stasis and ischemia
- Risk factors; critically ill pt (prolonged ICU
stay), sepsis with hypotension, extensive
burns, multiple traumas, pt on total parenteral
nutrition (leading to biliary stasis)
20 Choledocholithiasis - Gallstones in CBD
21 Mirizzi’s syndrome - Common hepatic duct obstruction secondary
to extrinsic compression from impacted
gallstone in cystic duct or GB infundibulum
22 Cholangitis - Life-threatening ascending bacterial infection
a/w partial/complete ductal system
obstruction
- Aetiology; choledocholithiasis, benign biliary
strictures, malignancy, foreign bodies,
previous ERCP, Mirizzi’s syndrome
23 Choledochal cyst - Congenital cystic dilatation of extrahepatic
and/or intrahepatic biliary tree
- Risk factor; females, Asians
- Type 1 (fusiform or saccular), 2 (saccular), 3
(bile duct dilatation w duodenal wall), 4 and 5
Epigastric/ RHC pain, within hours after eating,
waxing-and-waning, radiates to inferior angle of
scapula or tip of R shoulder, no relieved by
squatting or bowel movement, 30 mins to several
hours, intense
Associated Sx; N/V, bloating, abdominal
distension, LUQ pain
Cx; acute calculous cholecystitis, empyema of GB,
porcelain GB, GB cancer, Mirizzi’s syndrome,
obstructive jaundice, ascending cholangitis,
fistula
RHC pain, constant, unremitting, severe, history
of fatty food digestion prior to pain, pain radiates
to inferior angle of scapula, fever, nausea,
vomiting, anorexia
PE; RHC tenderness with guarding, Murphy’s sign
positive sign, Boas’s sign (hyperaesthesia below R
scapula), palpable GB
Cx; hydrops, empyema, gangrene, perforation,
cholecystoenteric fistula, gallstone ileus
Insidious onset
RUQ or epigastric pain, nausea, vomiting,
obstructive jaundice with tea coloured urine and
pale stool
PE; jaundice, febrile, hypotension,
RUQ/epigastric tenderness, palpable GB
Cx; acute cholangitis, acute pancreatitis
RUQ pain, fever, jaundice, cholangitis
Charcot’s triad – fever/chills, RUQ pain, jaundice
Reynold’s pentad – Charcot’s triad + hypotension
+ altered mental status
PE; febrile, hypotension, tachycardia,
tachypnoea, RUQ tenderness
Cx; sepsis/ septic shock, electrolyte abnormality,
coagulopathy, stricture, liver abscess
Non-specific abdominal pain, episodic RUQ pain,
fever, jaundice, cholangitis, palpable abdominal
mass, infants present like biliary atresia
MOZZAR
Plain abdominal X-ray Asymptomatic; dietary modifications, avoid fats
US HBS (Ix of choice); strong echogenic rim with posterior and large meals, no surgery required
acoustic shadowing
CT scan – only in symptomatic pt with uncertain cause Symptomatic
MRCP Indication; abdominal pain with US proven stone,
ERCP – therapeutic use only nowadays recurrent attack, typical biliary colic symptoms,
PTC/ PTBD – mostly for therapeutic pain radiates to back, positive response to
analgesics
Definitive Tx; elective laparoscopic
cholecystectomy
[Cx of surgery; injury to bile duct, bile leak, injury
to neighbouring structure, incisional hernia,
bleeding, wound infection]
CXR, KUB – radiopaque gallstone, aerobilia d/t fistula IV fluid resuscitation, septic workup, analgesia,
US HBS – thickened GB wall, sonographic Murphy’s positive, empirical IV Abx (ceftriaxone and metronidazole),
pericholecystic fluid, presence of gallstones, contracted GB NBM for bowel rest, monitoring
CT abdomen pelvis – fat stranding, GB wall thickening,
pericholecystic fluid, gallstones presence, air in GB wall Definitive Tx – laparoscopic cholecystectomy KIV
open
FBC (elevated TWC), CRP, amylase, LFT, RP, coagulation Early cholecystectomy within 1 week of
profile symptoms onset
Delayed/Interval – 6 weeks after Sx settled
Dx – 2013/2018 Tokyo Guidelines
US HBS – presence of sludge, GB wall thickening, Broad spectrum Abx
pericholecystic fluid Emergent cholecystectomy
If unstable, consider percutaneous
cholecystostomy with interval cholecystectomy
FBC (leucocytosis), RP (dehydration), LFT, serum amylase Surgery: Laparoscopic cholecystectomy (LC) ±
US HBS – gallstones in GB, dilated CBD intraoperative cholangiography (IOC) ±
MRCP, EUS, ERCP laparoscopic CBD exploration (LCBDE) ± open
CBD exploration/ post-op ERCP
Endoscopic: ERCP with sphincterotomy and stone
removal with interval ± IOC
FBC (leucocytosis), LFT (elevated bilirubin and ALP/GGT) Grade 1 – attempt LC
Imaging: US HBS/ CT/MRCP – dilatation of biliary system Grades 2-4 – open cholecystectomy with CBDE
above level of GB neck, stone impacted in GB neck
US HBS (Ix of choice) – CBD dilatation, CBD stone, gallstone Main goals – treat biliary infection and
Blood culture, FBC (leucocytosis), RP (dehydration), LFT, obstruction (achieve decompression of biliary
ABG/lactate tract)
CT/MRCP/EUS Resuscitation, monitor urine (keep >0.5
ml/kg/hr)
For severity assessment – 2013/2018 Tokyo Guidelines IV Abx – ceftriaxone, metronidazole
Emergent biliary decompression by ERCP
Definitive Tx – LC ± IOC or ERCP sphincterotomy
with removal of biliary stones followed by
cholecystectomy
MRCP/ERCP to image biliary tree and assess feasibility of Type 1/2/4 – excision of cyst with
surgical resection cholecystectomy and RYHJ
Type 3 – sphincterotomy
Type 5 (Caroli dz) – partial/ non-anatomical liver
resection/ liver transplant
Hepatobiliary – Hepatobiliary – Hepatobiliary
24 Gallbladder - Likely related to chronic inflammation
carcinoma - Risk factors; cholelithiasis, calcified porcelain
GB, GB polyps, chronic cholecystitis, Mirizzi’s
syndrome, choledochal cyst, exposure to
carcinogens
25 Cholangiocarcinoma - Malignant tumour arises from ductular
epithelium of biliary tree
- Adenocarcinoma (95%)
- Risk factors; chronic cholestasis (PSC, parasitic
infection, hepatolithiasis, liver cirrhosis, viral
hepatitis), congenital biliary tract disorders
(choledochal cysts, congenital hepatic
fibrosis), occupation toxin, DM
Asymptomatic
Early – mimic gallstone inflammation – biliary
colic, cholecystitis (RHC pain)
Late – biliary & stomach obstruction – jaundice,
vomiting, LOA, LOW, palpable mass
Intrahepatic – non specific Sx of malaise, LOW,
abdominal pain
Extrahepatic – painless progressive obstructive
jaundice, dark urine, pale stools, pruritus,
LOW/abdominal pain/fever, malaise, fatigue,
night sweats
PE; jaundice, hepatomegaly, RUQ mass, fever,
RUQ tenderness
MOZZAR
US – thickened, irregular GB wall or mass replacing GB, 1 stage: cholecystectomy with intraoperative
tumor invasion of liver, doppler signal in GB mass, enlarged frozen section
lymph nodes, dilated biliary tree 2 stage: simple cholecystectomy then waits for
CTAP – for staging, assessment of local invasion histology to guide further Mx
MRCP – complete assessment of organ involvement
FBC, RP, coagulation profile, CA 19-9, CEA Curative Tx; complete surgical resection with
US HBS as 1st line – biliary duct dilatation, intrahepatic duct histologically negative margins
dilatation Palliative approach
Triphasic CT scan – detect extent of tumour, adjacent lymph
nodes and metastatic disease
Cholangiography
EUS with FNAC for cytologic Dx and assess nodal
involvement