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Anatomical site of origin of cholangiocarcinoma?
- Intrahepatic (10%),
- Hilar (65%)Q (Klatskin tumorQ) and
- Distal (25%).
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Macroscopic growth pattern of cholangiocarcinoma?
- Sclerosing – MC type, most difficult to treat
- Nodular
- Papillary – more common in distal CBD
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Clinical features of cholangiocarcinoma?
- Painless jaundice (70–90%) - MC symptomQ
- Pruritus (66%),
- Abdominal pain,
- Weight loss (30–50%),
- Fever (20%).
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Tumor markers for cholangiocarcinoma?
- CA19-9Q - poor prognostic factorQ
- CEA
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Investigation of choice for cholangiocarcinoma?
MRI/MRCP
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Treatment of cholangiocarcinoma?
- Perihilar cholangiocarcinoma - CBD resection + Lymphadenectomy + Hepatic resectionQ
- Intrahepatic cholangiocarcinoma - Hepatic resectionQ
- Distal cholangiocarcinoma - Pancreaticoduodenectomy (Whipple's procedure)Q
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Chemotherapy for cholangiocarcinoma?
Gemcitabine + CisplatinQ
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Bismuth-Corelette Classification of Hilar Cholangiocarcinoma?
- I - Tumor confined to hepatic duct, not involving the main biliary confluenceQ
- II - Tumor involving the main biliary confluence but not extending to the right or left ductsQ
- IIIa - Tumor extending upto the right secondary biliary confluenceQ
- IIIb - Tumor extending upto the left secondary biliary confluenceQ
- IV - Tumor extending bilaterally to the secondary biliary confluenceQ
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Criteria of Un-resectability in Hilar Cholangiocarcinoma?
- • Hepatic duct involvement up to secondary radicals bilaterallyQ
- • Encasement or occlusion of the main portal vein proximal to its bifurcationQ
- • Atrophy of one lobe with encasement of contralateral portal vein branchQ
- • Atrophy of one lobe with contralateral involvement of secondary biliary radicalsQ
- • Histologically proven metastasis to N2 lymph nodesQ
- • Liver, lung or peritoneal metastasis
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Modes of Stenting in cholangiocarcinoma?
- • Hilar obstructions - Percutaneous transhepatic routeQ
- • Distal CBD obstruction - through endoscopy (ERCPQ)
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Indications for Biliary Decompression in Inoperable Cholangiocarcinoma
- • Intractable pruritus
- • CholangitisQ
- • The need of access for intra-luminal radiotherapyQ
- • To allow recovery of hepatic function in patients receiving chemotherapeutic agentsQ
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Newer Treatment Modalities in Cholangiocarcinoma?
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RebeccamycinQ analogue, which is a novel antitumor antibiotic with both topoisomerase I and II activity
Photodynamic therapyQ
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Hemobilia – arterial or venous bleeding?
Arterial bleeding, venous bleeding is rare
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What is Quinck’s triad?
Seen in Hemobilia - GI hemorrhage + biliary colic + jaundiceQ.
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Investigations for Hemobilia?
- Endoscopy: First investigationQ to be done (visualize bleeding from the ampulla of Vater)
- Angiography: Investigation of choiceQ (reveal the source of bleeding in 90%)
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Treatment for hemobilia?
- • First line therapy for major hemobilia: Transarterial embolization (TAE)Q
- • Surgery: When conservative therapy and TAE have failed
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What is Bilhemia?
Bile flows into the bloodstream either through the hepatic veins or portal vein branchesQ
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Length and diameter of CHD?
- Length - 1–4 cm
- Diameter - 4 mmQ
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Length and diameter of CBD?
- Length - 7–11 cm
- Diameter - 5–10 mm diameterQ
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Which layer is absent in bile duct?
- Muscle layer - only thin, longitudinally oriented layers of smooth muscle are present.
- CBD does not have a primary propulsive function, the elastic fibers and the longitudinally oriented smooth muscle provides a tonic pressure which help to overcome the tonic resistance of the sphincter of OddiQ
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Normal diameter of CBD?
- By ultrasound is <6 mm
- By ERCP <10 mm
- By intraoperative extraluminal measurements <12 mmQ.
- Ultrasound measurement records the nondistended lumen, whereas at ERCP, contrast material produces distension, intraoperative measurements include wall thicknessQ
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The venous drainage of the gallbladder?
Into the veins that drain the bile duct and does not flow directly to the portal veinQ.
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Principle of MRCP?
Uses T2-weighted images, in which stationary or slowly moving fluid, including bile, is high in signal intensity; all the surrounding tissues, including retroperitoneal fat and the solid visceral organs, are lower in signal.
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Blood supply of bile duct?
- Arteries run in 3 and 9 o’ clockQ positions.
- 60% of the blood supply to the supraduodenal bile duct - oiginates inferiorly from the pancreaticoduodenal and retroduodenal arteriesQ.
- 38% of the blood supply originate superiorly from the right hepatic artery and cystic duct arteryQ.
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