Hydrops

Impacted stone at cystic duct leads to bile reabsorption and increased mucus production - thus white or clear bile

treatment - cholecystectomy

Gallbladder Polyp

Indications for surgery - symptomatic polyp, polyp with gallstones, > 1cm, age > 50

Cholesterolosis or Strawberry Gallbladder

accumulation of cholesterol in macrophages leading to deposition on surface of gallbladder

benign condition - does not need resection

Choledochal cyst

Type I: fusiform cyst (most common)
Type II: diverticulum of common bile duct
Type III: choledochocele (intraduodenal portion of CBD)
Type IVa: intra- and extrahepatic cysts
Type IVb: only extrahepatic cysts
Type V: Caroli’s Disease (only intrahepatic cysts)
Treatment: Hepaticojejunostomy (type I); diverticulectomy (type II); excision / sphincteroplasty (type III); OLT (types IV & V) to reduce malignancy risk

Gallstones

Cholesterol stones - due to cholesterol insolubilization secondary to stasis - cholecystectomy

Pigmented stones

    brown - bacteria (usually E.coli) or parasite infection, composed of calcium bilirubinate, need biliary drainage procedure (sphincteroplasty)

    black - associated with hemolytic disorder, ileal resection, chronic TPN - cholecystectomy

Chronic Cholecystitis

associated with recurrent symptomatic cholelithiasis or biliary colic

Aschoff-Rokitansky sinuses = epithelium or mucosa protrudes into muscular layer

Bile

Consists of bile salts (80%), phospholipids (15%), and cholesterol (5%)

Primary Bile salts - cholic acid and chenodeoxycholic acid

Secondary bile salts - lithocholate and deoxycholate

Sterobilin - conguated bilirubin breakdown product - gives stool brown color

Urobilin - conjugated bilirubin breakdown product - gets reabsorbed in blood and delivery to kidney, secreted in urine, gives yellow color

Emphysematous Cholecystitis

Question: what is classical seen on imaging? treatment?
Answer: Air in gallbladder wall - urgent cholecystectomy

Cholangiocarcinoma

Type I - CHD only

Type II - confluence of right and left hepatic ducts

Type IIIa - right secondary

Type IIIb - left secondary

Type IV - involve both right and left hepatic ducts

Type V - involve CBD

Treatment - Type I-IV = resection of entire extrahepatic biliary tree with hepatic resection if necessary, Type V - Whipple

Sclerosing Cholangitis

Inflammatory strictures leading to recurrent biliary infection and malignancy

Associated with ulcerative colitis - colectomy does not change sclerosing cholangitis

Treatment = liver transplant

Gallbladder Carcinoma

Question: treatment of gallbladder cancer
Answer:

If T1 (not into perimuscular connective tissue) - then no additional surgery

If T2-4 - then radical cholecystectomy (segment IVb and V and hepatoduodenal ligament lymphadenopathy) with post op radiation therapy

Medullary carcinoma

produce calcitonin, amyloid is diagnostic, part of MEN II, FMTC(familial non-MEN medullary thyroid cancer), or sporadic cases.

Question: Treatment for medullary thyroid carcinoma?

Answer: Total with central node dissection

Question: Mutation associated with medullary thyroid carcinoma?

Answer: RET proto-oncogene

Hurthle Cell Carcinoma

Question: What is the management for Hurthle cell carcinoma?

Answer: <2cm then lobectomy adequate, if > 2cm than total

Follicular carcinoma

HEMATOGENOUS SPREAD

distinction between follicular adenoma and follicular carcinoma cannot be made on FNA or frozen section - NEED LOBECTOMY for DX

Question: management of follicular thyroid carcinoma?

Answer: if lobectomy is adenoma then stop, if follicular CA then total if > 1cm  (MRND if in nodes or out of thyroid tissue)

Papillary carcinoma

MOST COMMON, associated with prior neck irradiation and psammoma bodies, spreads to LYMPHATICS

Question: Surgery for papillary carcinoma?

Answer: Lobectomy for < 1cm, Total for > 1cm, multicentric, previous XRT, (MRND if in nodes or out of thyroid tissue) 

Question: What is lateral aberrant thyroid?

Answer: ectopic neck thyroid tissue that is usually metastatic papillary carcinoma

Temporal Arteritis

Question: How do you diagnosis and why start steroids?

Answer: 2cm bilateral temporal artery biopsy - steroids are started to reduce the incidence of potential blindness

Carotid Disease

Carotid DiseaseStroke Risk:
-Asymptomatic with stenosis (ACAS Study) >60%: CEA decreases 5yr stroke rate from 11% to 5%.
-Symptomatic with stenosis >70% (NASCET Study) : CEA reduces 5yr stroke rate from 26% to 9%.
-SAPPHIRE Study for carotid stenting in HIGH RISK patients showed decreased morbidity relative to CEA due to decreased MI rate with equivalent stroke prevention outcomes at two years.
Question: When do you preform a CEA?

Answer: 50-70% = medical therapy, CEA if symptoms refractory to medical care, >70% with symptoms, or > 80% stenosis
Question: When do you not preform a CEA?

Answer: If 100% in neuro-intact patient

Question: Most commonly injuried nerve during CEA?

Answer: Vagus - causes hoarseness

Question: Buldging mass 6 months after CEA is?

Answer: Pseudoaneursym - needs reoperation

Question: What is amaurosis fugax?

Answer: atheroemboli to ophthalmic artery