Disease of the liver and biliary tract...

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Disease of the liver and biliary tract (Lecture) . 1 30 1. 2.1 (liver abscess) 2.2 benign malignant 2. 3.1 Gallstone related diseases 3.2 cholangitis and obstructive jaundice 3.3 Tumor of gallbladder and biliary tract 1.Liver abscess 1.1 Pyogenic liver abscess 1.2 Amebic liver abscess 2.Benign liver tumors 3.Malignant liver tumors 4.Gallstone disease 4.1 Asymptomatic gallstone 4.2 Acute and chronic cholecystitis 4.3 Choledocholithiasis 4.4 Cholangitis 4.5 Intrahepatic duct stone 5.Tumors of gallbladder and biliary tract 6.Approach obstructive jaundice 1. 2. 1.LCD presentation 2. power point MCQ, OSCE

Transcript of Disease of the liver and biliary tract...

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Disease of the liver and biliary tract (Lecture)

������ ��.����� � ���������� ��� 1 ������� 30 ���� �!"#$%&'�()*& +�,- �� �!"�#�"�$�����������"!� ����%��&���"����' 1.!(�)����*+!�,�) �������-.�� & ����������*+!�,�)$��,/!01��#0$2!�/��'3�,2!� 2.1 567�,�) (liver abscess) 2.2 �� #!�!�+!�,�)��#� benign & �malignant 2.!(�)����*+!�����$���#G�$� �������-.�� & ����������*����$���#G�$�$��,/!01��#0$2!�/��'3�,2!� 3.1 Gallstone related diseases 3.2 cholangitis and obstructive jaundice 3.3 Tumor of gallbladder and biliary tract ��./�0

1.Liver abscess 1.1 Pyogenic liver abscess 1.2 Amebic liver abscess 2.Benign liver tumors 3.Malignant liver tumors 4.Gallstone disease 4.1 Asymptomatic gallstone 4.2 Acute and chronic cholecystitis 4.3 Choledocholithiasis 4.4 Cholangitis 4.5 Intrahepatic duct stone 5.Tumors of gallbladder and biliary tract 6.Approach obstructive jaundice

1 &2!3%&'�41 &5*�&6+�&�� 1.)�������*��\� 2.]��'��1^_�� �.7�1 &��� 1.LCD presentation 2.*!�����,!��1�&��� power point 1 &%&'�8,��� MCQ, OSCE

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��1� &�� (�,( 1.Timothy D, Curley S. Liver in Charles Brunicardi.Schwartzhs Principles of surgery 8th ed. New York: McGraw-Hill Company 2005:1139-1186. 2.Oddsdottir M, HunterJ. Gallbladder and the extrabiliary system in Charles Brunicardi.Schwartzhs Principles of surgery 8th ed. New York: McGraw-Hill Company 2005:1187-1220. 3.DhAngelica M, Fong Y.The liver in Townsend Sabiston Textbook of Surgery 17th ed.2004:1513-1574. 4.Ahrendt S, Pitt H. Biliary tract in Townsend Sabiston Textbook of Surgery 17th ed.2004:1597-1642. 5.�����( ������u�!���, "���� �#����-G����_.Approach of liver mass 7�"��(-�, ������, ����� ��"�"���, "���, ��������,�+-�, ������ ���(�"��"$�v ()��w�(����) �� ���",�����u� 23 Current practice in clinical surgery 2546:245-277. 6."��(-�, ������. Acute toxic cholangitis : Pathogenesis, Etiology and Clinical presentation 7� ��� ��,��3�!�, ���_ � ���u�, ���3� ���"�/����u��� , ��)� "�-�� , 0��� ��������()��w�(����) �� ���",�����u� 27 Complicated problem in HBP surgery 2546:179-188. 7.��� ��,��3�!�.intrahepatic duct stones 7���� ��,��3�!�, ���_ � ���u�, ���3� ���"�/����u��� , ��)� "�-�� , 0��� ��������()��w�(����) �� ���",�����u� 27 Complicated problem in HBP surgery 2546:223-242. 8."����,�v ����,���. Carcinoma of gallbladder 7�1�����( ������, ���� ��,�"����w, ��_��� ����,����� ()��w�(����) �� ���",�����u� 34 Difficult Surgery 2549:164-176. 9."����� ��_-� ��.Cystic diseases of the liver 7�1�����( ������, ���� ��,�"����w, ��_��� ����,����� ()��w�(����) �� ���",�����u� 34 Difficult Surgery 2549:191-201. 10."����� ��_-� ��. Gallsone and common bile duct stones 7�"���, ��������,�+-�, ����� ��"�"���, -��"��� �����* , "���� "�����w ()��w�(����) �� ���",������* Modern surgical practice 2547:127-140. 11.����� )�_��"��*���. Liver abscess 7�"���, ��������,�+-�, ����� ��"�"���, -��"��� �����* , "���� "�����w ()��w�(����) �� ���",������* Modern surgical practice 2547:151-166. 12."����,�v ����,���.Hepatocellular carcinoma 7�"���, ��������,�+-�, ����� ��"�"���, -��"��� �����* , "���� "�����w ()��w�(����) �� ���",������* Modern surgical practice 2547:429-436. 13.������� ���(�"��"$�v, (����u� *3���1���, ����� 7-"'���,�-���-�, ,1�����, � �����,� +!1���"��x & �*w�.&��������1y�)�,� ���$3& ����z321{����*����|�,�)& ��/!�#G�$�."G�������� ��1�����"�+���&�/���,� 2549:6-35. 14.Bruix J, Sherman M. Management of Hepatocellular Carcinoma. HEPATOLOGY 2005;42(5):1208-1236. 15. Heilpern K, Quest T.Jaundice in Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.2008:243-246.

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Liver and biliary systems

Liver

,�)�1�� solid organ���7�_/���"�$7��/��������#G�����1����w 1.5 ��� ���� ,�#�!�3/)����w7,2����*��+�� )����w�!)�,�)�� structure ������$-�� peritoneum 2 ��#���������������/� ligament ]%��0$2&�/ coronary ligament & � triangular ligament$2��]2��& �+��]%���%$,�)��)���)�� � & � falciform ligament ]%���%$,�)��)���)�� � z�����2��2!� & �"�$ ! �!�-����# falciform ligament ���&)/�,�)]��]2���1�� lateral & � medial segment

&,/�$�����&)/�,�),���������*�1�� 2 ]���$�7�2 Cantliehs line ( ��-��+!)$2��]2��+!� inferior vena cava '%� gallbladder) 1^--�)��&)/�,�),�� Couinaud ]%���1�� functional anatomy]%��&)/��$�7�2 ���0� +!��#G�$�& �� !$� !$������ �#�� �1�� 8 segment �$�&,/ � segment -��� portal triad (1���!)$2�� hepatic artery, portal vein & � bile duct) +!�&,/ � segment �!�$���31

&�% liver 8 segments " 8 Couinaud

,�)���"2�� !$��� �#�� 2 �"2�� ��* ! portal vein & � hepatic artery �$� Portal vein7�2 blood flow 01,�) 75% "/�� hepatic artery 7�2 blood flow 25% &,/7�2 oxygenation !�/�� � 50% -����#�� !$-�!!�-��,�)��� hepatic vein 3 �"2� (left, middle & � right hepatic vein) & ��+2�"3/ inferior vena cava

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Infectious diseases

��*,�$�� #!+!�,�)����))/!�0$2&�/ pyogenic liver abscess, amebic liver abscess & � hydatid cyst (echinococcal cyst) 7������# +!� /��'%��.��� 2 �� �!�&��]%���)0$2)/!���/�

1.Pyogenic liver abscess ��*��#�)0$2)/!���/� amebic liver abscess ����)7�z321{��!��� 50 16+%#�01 �$�"���,������ #!��*�+2�"3/,�)��0$2� �� ��� 0$2&�/ (1) Biliary tree �1��"���,�����)0$2)/!����"�$ �$�������$ abscess !�-�1��� ��-������$���#G�$�!�$,��0�/�/�-������ �� !

����|�!�$,������$���#G�$�& 2��/!7�2���$ ascending cholangitis �� !���$,��� �� biliary tract surgery �1��,2� (2) Portal vein ���$-��������!�����7��/!��2!�!���"),�$�� #! & ��� #!�+2�"3/,�)��� portal vein ��/� ����diverticulitis,

appendicitis �1��,2� (3) Hepatic artery ��)�� #!��*-�� systemic infection 0$2&�/ endocarditis, pneumonia, osteomyelitis �1��,2� (4) Direct extension -�����!���")+!�!�����+2���*��� ��/� acute cholecystitis, subphrenic abscess �� ! perforation +!� G�0"2

01���,�) (5) Trauma

(6) Cryptogenic cause * !0�/���)"���,� ��#���#���������/�!�-���$-�� undiagnosed abdominal pathology, resolved infective process �� !,�)�� pathology !�3/�/!� ]%��0�/0$2��)�������-.�� & 2�,�$�� #!+%#� ��/� infected liver cyst

"G����)�� #!��*����) 40-60% �1�� single organism & �"/��7�_/ 70% �1�� gram negative bacilli 0$2&�/ E.coli , K.pneumonia, Enterococcus faecalis, Enterococcus faecium &,/�|"����'�)�� #!���$! ��0$2+%#���)"���,�+!� liver abscess ��/�'2����$,��� �� intraabdominal infection "����'�)���#! B.fragilis �� !'2����$,��� �� trauma, bacterial endocarditis -��)����� S.aureus �� ! Streptococci spp. ,G�&��/�+!� abscess "/��7�_/�1�����,�)� �)+�� & �*�%����%��-��)�/��1�� single abscess

Clinical manifestation

!������0$2,�#�&,/0+2 1�$�2!�)����w7,2����*��+�� (right upper quadrant abdomen), ,���� !�,��� !� )�����!�-��$2��!����!���� peritonitis -��������56&,��+2�017��/!��2!� ���,��-�/������) fever, RUQ tenderness ]%���1�� most common findings, jaundice �)0$2 25% "G����) laboratory investigation �) leucocytosis 70-90%, LFT �) mildly elevated ALP 80%, elevated bilirubin 20-50% & �mildly transminitis 60%

� ��-�����"�"�� pyogenic liver abscess -��z ���,��-,/��� +�#�,/!01�1������ �����$��G� imaging study ]%�� initial test * ! ultrasonography 7���w����"�"���/� intraabdominal pathology !�-�1��"���,�+!� abscess *��"/� CT scan abdomen "/������G� MRI 0�/��1��������� !��/� CT scan

Treatment �������&)/��1�� 2 "/��� ��* ! ���������� abscess & �����������"���,�+!� abscess ��/� associated

intraabdominal pathology

(1) ������� abscess 1���!)01$2�����7�2 appropriate antibiotics & ������)����!�]%���/!�7�2���/��� #!,2!��G� hemoculture �/!� & �*��"/� abscess fluid gram stain & � culture

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- ���7�2 broad spectrum antibiotics &���G�7�2 third generation cephalosporins �/����) metronidazole �� !!�-7�2 ampicillin+gentamicin+metronidazole �$�����017�2��.�$���1����w 10-14 ��� -����#�7�2�����,/!!��1����w 1 �$ !� -"G����)���drain abscess ��� ����(�0$2&�/ percutaneous needle aspiration (PNA), percutaneous drainage (PCD) & � surgical drainage �$� PCD �1����(���������"����"�$ &,/!�-�G���-��w��G� PNA 7���w� unilocular abscess ���+��$� |���/� 5 cm �$�����01����G� PCD 1��")z "G���|-�����/� PNA +2!)/���#+!����z/�,�$0$2&�/

1.z/�,�$�� �!���� primary pathologic process ��/� z/�,�$���� acute appendicitis ����1��"���,� 2.failed percutaneous drainage

(2) �������"���,�+!� abscess ��/����"���,����$-�� acute appendicitis ,2!��G� appendectomy, "���,�-�� acute cholangitis !�-,2!��G� endoscopic retrograde cholangiopancreatography (ERCP) �1��,2�

2.Amebic liver abscess

��*��#�))/!�7�1������+,�2!� & �1������G� ����u�����"�+!�����0�/$� �))/!�7�z321{����� !����2!���/� 50 16 �$��������))/!���/�����_��'%� 10 ��/� ��+2!�3 �/������� alcohol �G�7�2,�$�� #!��#�/��+%#�-������G����+!� Kupffer cell & � immunity ����"��01

�� #!�/!��** ! Entamoeba histolytica ]%��,�$�� #!z/����� fecal-oral route ���$-��������������� cyst form �+2�01-����#� cyst -�� ���1�� trophozoite 7� G�0"2 � |� & ��+2�"3/ G�0"27�_/ -����#� invade mucosa +!� G�0"27�_/�+2�"3/ portal system �+2�"3/,�)& ����$�1��56,/!01

&�% Life cycle D�( Entamoeba histolytica

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Amebic liver abscess �))/!�7�,�)� �)+����/��$�����) pyogenic liver abscess &,/�)�1�� unilocular abscess )/!���/� �$�7�,��7-� ��+!� abscess 1���!)$2�� acellular proteinaceous debris ]%��������/� anchovy pus 2!��!)$2�� amebic trophozoite )����w+!)+!� abscess

Clinical manifestation

!��������01* 2�������) pyogenic liver abscess ����2�delay onset & �sepsis �2!���/� &�2�/� 1 7� 3 +!�z321{����!�����2!��"�� &,/�����/� 70% +!�z321{��,��- stool exam 0�/�)�� #!!��)� CBC �) leucocytosis 0$2 &,/0�/*/!��� eosinophilia ���"/�,��- circulating amebic antibody 0$2z ���&�/�!���/� ��/� ELISA, IHA �$� sensitivity & � specificity 1����w 95%

"G����) imaging study �|* ! ultrasonography &,/-��G� CT scan �|,/!�� �!7�2���/��� #!& 2�!����0�/$�+%#�, �������-.�� amebic liver abscess ���0�/&�/�!� �� !"�"���/��� complication ��/�56&,��� �

Treatment

�������� ��* !���7�2���/��� #! �$�&���G�7�2�1�� metronidazole 750 mg ������ � 3 �� ��1���� � 10 ��� �$�����01!����-�$�+%#����7� 3 ��� & � 95% +!�z321{��-�,!)"�!�,/!�������$2���� -����#�&���G�7�2������/��� #!7� G�0"2$2�� 0$2&�/ iodoquinol, paromomycin �� ! diloxanide furoate

"G����)����-����)����!� (percutaneous needle aspiration) 0�/�G�7�z321{�������� &,/�G��.���7���w���� abscess7�_/��/� 5 cm ]%�����!��"&,�"3�, abscess ��� Lt lobe liver �� �!�-�����!��"&,��+2� pericardium, ��w�"�"�� secondary bacterial infection, !����0�/$�+%#�� ��������/��� #! 3-5 ���, amebic cytology inconclusive 0�/&�/7-�/��1�� pyogenic liver abscess �� !�1 /� & �z321{��,�#�*���]%����+2!�2��,/!�������� metronidazole

"G����)7��������0�/��*���-G��1��,2!�,�$,�� ultrasonography �� ! CT abdomen �� �!�-�� abscess 7�2�� ������/�-����01 ��#����!����� �)�1��1�,�& 2�

Bening liver tumor

��*��#����)7�,�)1�,����0�/�1��,�)&+|� z321{��"/��7�_/0�/��!����& �!����&"$� & �,��-�)�2!��$�)���!�_������"������ �� !����/��z/�,�$�/!��2!� "/��7�_/�)7�����_�� �� #!�!�����))/!�0$2&�/ cavernous hemangioma, focal nodular hyperplasia, hepatic adenoma, hepatic cyst "/������)�2!� 0$2&�/ angiomyolipoma, biliary cystadenoma, bile duct hamartoma �1��,2�

1. Cavernous hemagioma

�1�� benign liver tumor ����))/!����"�$ �)0$2 1.4% +!�1������ ����)�$�)���!�_-������G� ultrasonography & �� �����������-.��$2�� dynamic CT scan �� ! MRI �$�0�/-G��1��,2!��G� tissue biopsy�� �!�-�� ��w�������"�*/!�+2��-G�����,/!��* & ����!��"�"����,/!����"��� !$-������G� biopsy ��*��#0�/��*����"����,/!����1������|�

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Treatment 7���w�����2!�+��$� |���/� 5 cm & �0�/��!���� 0�/,2!��G�������� & ����,�$,��$2�� ultrasonography 1��-G�16

�|0�/��*���-G��1�� '2�0�/��!���� &,/�2!�+��$7�_/��/� 10 cm !�-,�$,���$�����G� ultrasonography "G����)+2!)/���#7����z/�,�$0$2&�/ 1.!����1�$�2!�-���2!� �$�,2!� rule out "���,�����1��010$2!�/��! ��& 2� 2.�2!��,��|� 3.0�/&�/7-7��������-.�� ���0�/"����' rule out ����|�0$2 4.������&���]2!�-���2!� ��/� �2!�&,�, Kasabach-Merritt syndrome (���� dissiminated intravascular coagulation -���2!�) "G����)���z/�,�$��,�#�&,/ enucleation, liver resection �� ! liver transplantation ���� !���(�z/�,�$+%#���),G�&��/� & �+��$+!��2!�

"G����)����G� angiogram embolization ��)�)��7� multiple hemangiomas, extensive hilar involvement �� !�� �! $����"��� !$����/��z/�,�$

2. Focal nodular hyperplasia (FNH)

�1�� benign tumor like lesion �))/!��1��!��$�) 2 �� �!�/����$-�� hyperplasia/regeneration process �����/��1�� neoplastic process 0�/��*����"����,/!����1������|� & ����0�/������&���]2!�

Treatment ��w����0�/��!�����|0�/,2!��G��������7$� +2!)/���#7����z/�,�$* ! 1.0�/&�/7-7��������-.�� ���0�/"����' rule out ����|�0$2 2.��!����1�$-���2!� �$� rule out "���,�! ��01& 2� ��*��#&���G�7�2�G� surgical resection with clear margin�����/� enucleation

3.Hepatic adenoma ��*��#��*���"�����(��)���7�2��*���G����$ �$�!�,���"���������,�������� ��������� ��*��#��*����"����,/!���

�1������|� & ��)�/����$ tumor rupture 0$2'%� 25% ]%��"/�z 7�2���$���,�� !$7��/!��2!�-� shock0$2 Treatment

��w�����2!�� |���/� 4 cm & �z321{�������*���G����$ &���G�7�2���$��*���G����$�/!� &,/��-��w��G�z/�,�$7���w�����2!�7�_/��/� 4 cm, �2!�0�/� |� �� �����$��*���G����$, z321{�����0�/"����'���$��*���G����$ & �z321{�����,2!����-�,�#�*��� (���,�#�*����G�7�2�2!����!��"&,�0$2���+%#�) �$�����01&���G�7�2z/�,�$ anatomic �� ! segmental resection

4.Simple hepatic cyst

�1�� benign liver lesion ����))/!����"�$ �������&���G��.���7���������!������/�!����-��&�/��2!�)����w �#�16� !�����|� * ��0"2!��-��� �$���(��������0$2&�/

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(1) Percutaneous aspiration instillation and reaspiration (PAIR) * !���$3$�#G�!!�-�� cyst -����#�.�$"�� sclerosing agent ��/� alcohol �� ! tetracycline �� �!�G� �� secretory epithelium �$��/!�.�$,2!�$3�/� content ���$3$!!�0�/7�/� !$ �� ! bile �� �!� ��� ��������G�!��,���,/!�/!�#G�$� & �� !$� !$

��� aspiration !�/���$��� 0�/&���G� ����� recurrence rate "3�'%� 100% (2)Cyst unroof �� !fenestration �1�����,�$z���)��"/��+!� cyst �� �!7�2�#G�7� cyst 0� "3/�/!��2!�& 2�'3�$3$]%�7����� �� (3)Cystectomy �$�����010�/�G���(���# ����2�"�"������|� ��/� z���+!� cyst �/�+��+���� !�� septation

5.Biliary cystadenoma �1�� cystic biliary epithelium z������ ���7��� septation, nodularity ��*��#��*����"����,/!����1������|�'%� 25% (biliary

cystadenocarcinoma) $����#�,2!��G� surgical resection ������

Malignant liver tumor ����|�����))/!�7�,�)�� 3 ��*� ��0$2&�/ hepatocellular carcinoma, cholangiocarcinoma & �metastatic liver tumor

1.Hepatocellular carcinoma (HCC) �1������|�����))/!��1��!��$�)��� 5 +!�����|������ � "���,�+!�������$����|�0$2&�/ cirrhosis, ���,�$�� #! hepatitis B

& � C, "���/!����|���/� aflatoxin �� !alcohol, ��*������(����� ��/� hemochromatosis �� ! Wilsonhs disease �1��,2� Clinical manifestation

����)7�z321{�����!��� 50-60 16+%#�01 z321{�����)&���0$2 3 ��w� 0$2&�/ 1.�2!�7,2����*��+�� 1�$�2!� ��0+2 2.z321{�����,�)&+|����/!� & 2�!�������$ �-�������� compensated cirrhosis �1 �����1�� decompensated cirrhosis -�� tumor invade portal vein �� ! IVC 3.0�/��!����7$� &,/�)-�� imaging study

Diagnosis �������-.��7�2,�� American Association for the Surgery of Liver Disease 2005 (AASLD) +!� �$��%$+��$+!��2!�7�

cirrhotic liver -������G� ultrasonography �1��� ��$����# (1) �2!���+��$7�_/��/� 2 cm

7�2"/� dynamic imaging technique 1 ���$�$�����01���� dynamic CT scan '2� CT scan &"$� typical vascular pattern (* !��|� hypervascular mass 7� arterial phase �� �!�-�� HCC 0$2��)� !$��-�� hepatic artery) �|"����'����-.��0$2� � �$�0�/,2!��G� biopsy �� !!�-"/� AFP '2������/� 200 ng/ml �|����-.��0$2� � &,/'2� atypical vascular pattern 7�2 confirm $2������G� biopsy (2) �2!���+��$����/�� 1-2 cm

7�2"/� dynamic imaging study 2 ���$ ��/� dynamic CT scan �/����) dynamic MRI �� ! dynamic ultrasonography -z �1�� typical vascular pattern ��#� 2 imaging study �|����-.�� HCC 0$2� � -z typical vascular pattern 1 imaging �� ! atypical vascular pattern 7�2�G� biopsy

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(3)�2!���+��$� |���/� 1 cm 7�2 repeat ultrasonography ��� 3-4 �$ !�-�*�) 18-24 �$ !� ����/����#'2��2!�7�_/+%#� 7�2�G�,�� guideline ,��+��$

+!��2!�����,+%#�

Algolithm O�3(1 & work up for diagnosis HCC

Staging systems �� staging systems "G����) HCC !�3/� ��&)) ��/�

1.Okuda classification �$���-��w�*/� albumin, bilirubin, ascites & �+��$+!� tumor 2.TNM classification +!� AJCC (American Joint Committee on Cancer) &,/�|0�/�1��������� �����$3�.������,����* HCC

!�/���$��� �$�0�/0$21����������G����+!�,�)

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3.Barcelona clinic liver cancer (BCLC) staging system ]%��1���!)$2�����1������ liver function status (,�� Child-Puge classification), tumor stage (,�� Okuda classification) & � physical status (,�� WHO performance status) +!�z321{���/�������#� 3 parameter

" & (O�3( Child-Pugh classification

Clinical or laboratory feature 1 point 2 points 3 points

Encephalopathy (grade) 0 (absent) 1 � 2 3 � 4

Ascites Absent Slight Poorly

Bilirubin (mg/dl) < 2.0 2.0 � 3.0 > 3.0

Albumin (g/dl) > 3.5 2.8 � 3.5 < 2.8

INR < 1.7 1.7 � 2.2 > 2.3 * 5-6 points = Class A, 7-9 points= Class B, 10-15 points= Class C

" & (O�3( Okuda classification

" & (O�3( World Health Organization Performance Status grades

World Health Organization Performance Status grades

Stage 0 Fully active, normal life, no symptoms

Stage 1 Minor symptoms, able to do light activity

Stage 2 Capable of self-care but unable to carry out work activities Up for more than 50% waking hours

Stage 3 Limited self care capacity Confined to bed or chair > 50% waking hours

Stage 4 Completely disabled Confined to bed or chair

Stage Tumor Size Ascites Albumin Bilirubin

> 50 %

( + )

< 50%

( - )

( + ) ( - ) < 3 g/dl

( + )

> 3 g/dl

( - )

> 3 mg/dl

( + )

< 3 mg/dl

( - )

I ( - ) ( - ) ( - ) ( - )

II 1 or 2 ( + )

III 3 or 4 ( + )

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]%�� staging system ��))��#-�"�����(��)&������������$2��]%��-�� /��7����+2!'�$01

Treatment ��-��w�,�� BCLC staging system $��,����

-��,������|��/�&)/���������1�� 4 &����� * ! (1) Radical curative treatment 0$2&�/����G� hepatic resection, liver transplantation & � PEI/RF (percutaneous ethanol injection/radiofrequenct ablation) ]%�� curative treatment 7�20$27���w� stage 0 & � A ��/���#� ]%���)1����w 20-40% +!�z321{����#���$ (2) Chemoembolization (Transarterial chemoembolization, TACE) * !���.�$���*��)G�)�$��/� doxorubicin z"���) iodized oil z/��"��"���+2�017� hepatic artery ���� #���� #!�!��$�,�� �!�-����#����G����!�$�"2�� !$���� �#���2!�����|��� �!�����*����+2�+2�+!��� & ��G�7�2��*2��7��2!�����|�0$2���+%#� ��(���#' !�1�� palliative treatment ��/���#� & ��1�� palliative treatment ��������G�������"�$ ��+2!�3 �/������� �!�3/�!$+!�z321{�� (survival) ������+%#� ��(���#�2���G�7���w������ complete portal vein thrombosis, Childhs class C, severe renal insufficiency, biliary obstruction & �extrahepatic metastasis (3) New agent drugs 7�27���w������*�1�����& 2� �1�� !�7�2��7��/��)z321{���� �!�����-�� �� �!�-��0�/����(����� ! �����0$2z

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(4) Symptomatic treatment �1�����$3& z321{��7�����"�$�2���� �!0�/7�2�����-��,����* "G����)��������$�7�2���"����� & �.�$���*��)G�)�$�+2�������&"� !$ ���0�/��+2!�3 7��������z321{�� *��7�27������-����/���#�

2. Intrahepatic Cholangiocarcinoma (ICC)

�1������|�����)0$2)/!�7�1�����0����/���� �)���)����w��*,����!!��.������ ! �!� ����1����*��� !+!�1�����0�� )����w�3����*��#1�������!)���!����"���$�)� ]%������ #!1�"�, Opisthorchis viverrini �1��"���,�"G�*�_+!���*, "���,�! ��� 0$2&�/ hepatolithiasis, choledochal cyst, primary sclerosing cholangitis, ulcerative colitis ���'%����0$2��)"�� nitrosamine ��/�������1 ��2� 1 ��-/� 1 �-/!� �1��,2�

Clinical manifestation "/��7�_/z321{����$2��!����1�$-��&�/��2!� !/!��� �� �� !* G�0$2�2!�7��/!��2!� �$�!������ !��)0$2 0-

20% +!�z321{�� ]%��!������ !�-��)7������2���+!���*�����/� ]%��,/��-��7� extrahepatic cholangiocarcinoma ]%����$2���� !��1��!�����$/���/�

Diagnosis ��w�"�"�� intrahepatic cholangiocarcinoma 7�2�-�� LFT !�-�) direct hyperbilirubinemia & �ALP "3�+%#� -����#�"/�

ultrasonography �� �!�)�2!� 7�2"/� CT scan �� ! MRI �� �!�������-.��& ����&z��������,/!01 �����#�"/�,��- tumor marker ]%��-���*/� CA 19-9 & � CEA "3�+%#� Algolithm O�3(1 & approach ICC

Treatment ����������0$2z $����"�$* !���z/�,�$$�) & �1^--�)�����0�/�)�/���������"����$�7�2���*��)G�)�$-�0$2z $�

�$�����01z �������0�/*/!�$���� �� �!�-��z321{�������������)� +w�!�3/7������2��+!���*

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Gallbladder O�' biliary tract Anatomy

'���#G�$� (gallbladder) �1��'���31 pear shaped ���!�3/7,2,�)�$�"����'&)/�'���#G�$�0$2�1�� 4 "/��0$2&�/ fundus, body, infundibulum & �neck ��� histology �)�/�'���#G�$�,/��-��!�����! ��7��/!��2!��$�'���#G�$�0�/����#� muscularis mucosa & � submucosa "G����)�"2�� !$������ �#��'���#G�$�* ! cystic artery ]%���1��&+��+!� right hepatic artery '���#G�$���)���#G�$�01"3/ common bile duct ��� cystic duct Extrahepatic bile duct 0$2&�/ right & � left hepatic duct �����,������1�� common hepatic duct -����#��� �!�����) cystic duct -������� �!�1�� common bile duct & �-�01"�#�"�$��� ampulla of vater )����w second part +!� duodenum Common bile duct -����,��!�3/7� hepatoduodenal ligament ]%���� hepatic artery proper, portal vein !�3/+2���*��� �$� common bile duct ���!�3/$2��+��,/! hepatic artery & ���2�,/! portal vein

Gallstone disease

�1��1^_������)0$2)/!��$�����_���))/!���/�������1����w 3 ��/� �!�-����#1-̂-���"����! ��0$2&�/ *���!2��, ���,�#�*���, Crohn's disease, terminal ileal resection, gastric surgery,��* hemolytic anemia !����+!� gallstone disease &)/�!!��1�� 3 � �/�0$2&�/ (1) Asymptomatic gallstone (2) Symptomatic gallstone

(3) Complication related gallstone 0$2&�/ acute cholecystitis, choledocholithiasis with or without cholangitis, gallstone pancreatitis, cholecystocholedochal fistula, cholecystoduodenal fistula, cholecystoenteric fistula �1��,2�

-������%���)�/�z321{�� asymptomatic gallstone � ���1�� symptomatic gallstone 1����w 3% ,/!16 & � z321{�� symptomatic gallstone -�� ���1�� complicated gallstone disease 1����w 3-5% ,/!16 ����7�'���#G�$�&)/�!!��1�� 2 ���$7�_/� * ! cholesterol stone & � pigmented stone ]%��&)/��1�� black & � brown pigmented stone !���� (1) Cholesterol stone �))/!�7����,����,� � 0�������$����* ! �$�1�,��#G�$���"/��1���!)"G�*�_ 3 "/��0$2&�/ cholesterol, phospholipid & � bile salt ,��1�,� bile salt �1��"/����� � ���#G� & ��� �!!�3/7��#G�"����'���,���1��� �/�0$2 "/�� phospholipid (]%�����!�3/7��31+!� lecithin) & �cholesterol -�0�/ � ���#G�&,/-����,����) bile salt �1�� micelle ]%��"����' � ���#G�0$2 "/��1���!) 3 "/����#,2!����!����� ]%��'2�"/��1���!)�1 ����&1 �01 cholesterol -�,�,��!����$�1������0$2 (2) Pigmented stone

- Black stone �))/!�7�z321{�� hemolytic anemia �� �!�-���G�7�2���$ unconjugated bilirubin ]%��0�/ � ���#G� & �,�,��!������) calcium � ���1������ - Brown stone �))/!�7����� bile stasis & 2����$ secondary bacterial infection �$��� #!��*��/� E.coli "����'� ��� Beta glucuronidase �G�7�2 conjugated bilirubin � ���1�� unconjugated bilirubin ]%��0�/ � ���#G�& 2����,����) calcium & ����#!��* ���,��� ���1������,/!01

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1.Asymptomatic gallstone �1���������,��-�)����7�'���#G�$��$�)���!�_ ��/�-�����,��-�/�����1��-G�16�$����z321{��0�/��!����7$�

�$�����010�/,2!��G�������� &,/7�z321{��)�����!�-��-��w��G� phophylactic cholecystectomy �� �!�-�����!��"�1������|�"3�+%#� �� !���!��"������$���!���")7�!��*,0$2 +2!)/���#7����z/�,�$ asymptomatic gallstone ��$����# 1. Gallstone ��+��$7�_/��/� 3 cm 2. Calcified ( porcelain ) gallbladder

3. Gallbladder polyp ���+��$7�_/��/� 1 cm 4. 7���w�����G� splenectomy 7�z321{�� hemolytic anemia �|�G� cholecystectomy 01��2!���� 5. bariatric surgery (�� ������� �! $*���!2��) 6. long term TPN

7. transplant patient ���,2!�7�2 immunosuppressive drug 8. no access to medical care

& �!�-��-��w��G� prophylactic cholecystectomy 7�z321{��!����2!� (�� �!�-�������� �z/��01!�-�/!7�2���$ complication -������), incidental gallstone +w�z/�,�$�/!��2!� �1��,2�

"G����)�)�����0�/' !�/��1��+2!)/���#7�����G� prophylactic cholecystectomy &,/,2!�������/����z321{���)��������$�1�� acute cholecystitis !����-����&����/�*����0�/�1���)�����

2.Acute cholecystitis "���,�"/��7�_/���$-�� gallstone 90-95% +!�z321{�� "���,�! ��� !�-���$-���� #!�!� �� ! acalculous cholecystitis

�$�����-�!�$,��)����w gallbladder neck & � cystic duct �G�7�2'���#G�$��1{� )��& �!���") �$������&���� �!�/����$ inflammatory process -��"�� lysolecithin, bile salt -����#�-%����$ secondary bacterial infection 7�)����w�!����!�-���&�����-�'���#G�$�+�$� !$ ��/� �1��56��!� �� !&,��� �0$2

Clinical manifestation

z321{����$2��!����1�$�2!�)����w �#�16� �� !7,2����*��+�� �$�-�,/����) symptomatic gallstone ��� ��w�1�$+!� acute cholecystitis -��1��&))1�$, !$ 0�/�1�� ��w� biliary colic !�-��!����1�$�2��01���� ��$2��+��)� �� ! interscapular area & ���!����0+2�/��$2�� z321{�������!�����) �!!���� * ��0"2!��-��� ,��-�/�����-��) focal tenderness & � guarding )����w��2��2!�7,2����*��+�� & �,��-�) Murphy's sign

( inspiratory arrest with deep palpation in the right subcostal area) ����-��� !$,��-�) mild-moderate leucocytosis (WBC 12,000-

15,000 cells/mm3) '2� WBC �����/� 20,000 cells/mm3 ,2!������ complicated cholecystitis �$�����01 LFT "3�+%#�0$2 &,/0�/��� �$��� !����0�/���� 4 mg/dl

Diagnosis Ultrasonography �1�� imaging of choice �$��� sensitivity & �specificity 1����w 95% "G����) CT scan �|"����'

����-.����*0$2$� &,/ sensitivity ,�G���/� ultrasonography

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Treatment �������1���!)$2������$�#G�& �!����, fluid resuscitation, 7�2 antibiotic * !)* �� gram negative aerobe & �

anaerobe ��/� third generation cephalosporins with good anaerobic coverage �� ! second generation cephalosporins �/����) metronidazole z321{��������*��0$2��)���z/�,�$'���#G�$�!!� ����2�7���������+2!�2��7����z/�,�$ ��/�"����/����� & ���*1��-G�,�����0�/��������z/�,�$ (medically unfit patient) 1^--�)������G� laparoscopic cholecystectomy �1�� operation of choice �/���� �7����z/�,�$�� 2 &))* ! early cholecystectomy * !z/�,�$���7� 3 ���� �����$��* & �delay cholecystectomy * !z/�*�$�/�� 6-10 "�1$��� ��-��'���#G�$�!���")

�$�1^--�)����&����2��G� early cholecystectomy 7�z321{�������������)� ���7� 3 ���+!�������$��* & �"'�����)� ��*�����2!� &,/'2�z321{����������)� � �� 3 ���+!�������$��**��z/�,�$�1�� delayed cholecystectomy �� �!�-�����z/�,�$�G�0$2���+%#� �!�-����#)����w����7�2��& 2�!����&�/ � �� !�1�� complicated cholecystitis �|-G��1��,2!�z/�,�$.���.��

"G����) medically unfit patient ��-��w��G� cholecystostomy ��)���#G�$�&�� ���"���+!�z321{��$�+%#� !�-*/!�z/�,�$�!�'���#G�$�!!�7����� ���|0$2

3.Chronic cholecystitis �1��"���,�+!����1�$�2!�����))/!� �$�1����w 2 7� 3 +!�z321{�� gallstone disease -��1�� chronic cholecystitis

z321{��-���!����1�$�2!��1������� (recurrent attack of pain) -�� recurrent cystic duct obstruction Clinical manifestation

z321{����!����1�$�2!��2!�)����w �#�16� & �7,2����*��+��&)) biliary colic (�1�� misnomer �$�-����& 2�1�$&)) constant pain �1���� �1����w 1-5 ��. & 2�-%���� �) ���1�$� �����!����0+��� & �1�$�/���� �����/���!�� �) �� �!�-���/��!�����"����'!�$)����w cystic duct 0$2�/��+%#� !�-1�$�2��01����/��"�)�� �� !"�)��$2��+�� ���,��-�/������/�������!����-��) right upper quadrant tenderness &,/7��/�����0�/��!�������,��-�/����� & �z LFT -�1�,�

Diagnosis �$�7�2 ultrasonography �)����7�'���#G�$��/����)!����$��� /��"����'7�2�������-.��0$2� � &,/'2�0�/�)�����)&*/

�� bile sludge �������� recurrent pain attack �/����) ultrasonography �) bile sludge ,�#�&,/ 2 *��#�+%#�01�|"����'7�2�������-.��& �"����'�G� cholecystectomy 0$2� �

Treatment �������� ��* !���z/�,�$ �$��G��1�� elective laparoscopic cholecystectomy (LC)

4.Choledocholithiasis (common bile duct stone, CBD stone) �� !����7��/!�#G�$� �)0$21����w 6-12% +!�z321{����*����7�'���#G�$� �$�"����'&)/� CBD stone !!��1�� primary

& � secondary CBD stone (1) Primary CBD stone * ! �����/!�#G�$�������$����/!�#G�$��!� �))/!�7�����!���� ����)�1�� brown pigmented stone ]%��"�����(

��) bile stasis & � bacterial infection ,��� 0�������$�������� /��+2��,2� (2) Secondary CBD stone ���$-������7�'���#G�$� � /� ���"3/ common bile duct �)7����,����,�0$2)/!���/�

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Clinical manifestation z321{����$2��!����1�$�2!�&)) biliary colic, * ��0"2 !��-��� ,���� !�,��� !� )��*��#���0+2 ���$ cholangitis 0$2

�� !���$�1�� gallstone pancreatitis !����!�-�1��&)) intermittent �� �!�-������"����'�* �!����01��0$2 &,/)��*��#�'2����� impact ��� ampulla of vater �|�G�7�2���$ progressive jaundice 0$2��/����

Diagnosis 7�z321{�����"�"�� CBD stone �����-�����,��- LFT -��) direct hyperbilirubinemia, elevated ALP �����/� 2 ��/�

-����#��G� ultrasonography "����'�) intrahepatic bile duct dilatation, CBD dilatation (> 6 mm) & ��)����0$2 &,/�� sensitivity 20-80% & � specificity 95% -���|��/�*/�sensitivity range */!�+2����2��-��*/�,�G����01"3� $����#�7����������"�"�� CBD stone !�3/�|,2!��G���� investigation ,/!01 ]%�����,��-��� ����(�0$2&�/ magnetic resonance cholangiopancreatography (MRCP), endoscopic

retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS) & � intraoperative cholangiogram (IOC) ]%�� 4 ��(���#�� sensitivity 7� 2�*������1����w 80-95% & � specificity 90-100% ���� !��/�-�"/� investigation $2����(�7$+%#���)�/�z321{�����!��"�� CBD stone ����2!������7$ ��w�������!��"�) CBD stone ����|-�� !� ERCP �� �!�-��"����'�G� therapeutic intervention * !����!�����!!� �� !7"/ stent ,/!0$2� � &,/'2��!��"�)����0�/�������|-�� !���(���� noninvasive ��/��/!� �� �!�-������G� ERCP �/!7�2���$����&���]2!�0$2��/���� &,/��#���#+%#�!�3/��)*�����2!�+!��*� �!�� ! & �&���z32��������_7�&,/ �"'�)��

Treatment �������+%#���)� ��1^--�� ��/�*�����2!�+!�"'�����)� *�����������_+!�&��� �/���� ��������-.��0$2

�/!�z/�,�$ �� !����/��z/�,�$�1��,2� $����#��������!�-0$2&�/ ERCP with CBD stone removal & 2��G� LC ���� �� �� !� �)����G� LC+IOC & 2��G� post op ERCP �� ! LC/OC + common bile duct explorationation (CBDE) �1��,2�

Algolithm 1 &�,�,2 !̂+O�'&!1_ ���%`�+a67�(�!+ CBD stone

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5.Cholangitis �1�������/!�#G�$�!���")�$����$-�� ascending bacterial infection, ��*��#,2!�1���!)$2�� 2 !�*1���!)"G�*�_7�

������$��** ! �������� bacteria 7��#G�$� & ���������*���$��7��/!�#G�$�"3�+%#� 1�,� bacteria "����'z/���+2�!!�����$���#G�$�0$2�1��*��#�*��� &,/�/�������� 0�1�!����0$2&�/ sphincter of oddi 1�!����0�/7�2!����-�� duodenum �+2���7��/!�#G�$�, �!�,/!����/�� hepatocyte 1�!������ #!��*�+2�"3/,�), Kupffer cell �/��7�����G�-�$�� #!��*, �#G�$��� antibacterial properties ��/� IgA, bile salt & ����������0� +!��#G�$�-��)� � /�� &,/'2����$���!�$,��7��/!�#G�$�0�/�/��1��-������ �� !�� #!�!��G�7�2�#G�$�0� �2� � bacteria -� colonization & �&)/�,�������-G�����/!7�2���$���,�$�� #!0$2

�)�/�"���,�����))/!����"�$+!� cholangitis * ! gallstone �!�-����#���/� benign/malignant stricture, parasite �� #! bacteria ����))/!�0$2&�/ Escherichia coli, Klebsiella pneumoniae, Streptococcus faecalis & � Bacteroides fragilis

Clinical manifestation !��������G�z321{����������)� * !0+2����"��� 1�$�2!�)����w �#�16��� !�/!��2!�$2��+��)� & �,���� !�,�

�� !� ��#� 3 !������#������/� Charcoths triad ]%���)0$2 2 7� 3 +!�z321{�� cholangitis ��z321{�� cholangitis 1����w 5% �����!�������&����� ������/� acute toxic cholangitis -���!���� septic shock �/����) mental status change ���01��) Charcoths triad ������1�� Reynoldhs pentad (fever, jaundice, right upper quadrant pain, septic shock, and mental status changes) ' !�1��������/�$/��,2!���)��)������$���#G�$�&)).���.��

Diagnosis z � !$�) leucocytosis, hyperbilirubinemia, and elevation of alkaline phosphatase and transaminases -����#�7�2"/�

ultrasonography �� �!1�������/������!�$,������$���#G�$� 1������ IHD (intrahepatic bile duct) dilatation & � definite diagnosis * ! ERC (Endoscopic retrograde cholangiography) '2��G� ERC 0�/0$2!�-,2!��G� PTC (Percutaneous transhepatic cholangiography) 7���w����"�"���/�"���,�!�-�1��-���� #!�!�7�2"/� CT scan �� ! MRI $2��

Treatment ������������&��* !�$�#G��$!���� ���7�2 fluid resuscitation & �7�2���/��� #! �/����)�����)���#G�$��$���� ERCP

�� ! PTBD (percutaneous transbiliary drainage)+%#���)�/��1�� proximal & � distal obstruction 7���w�����1�� acute toxic cholangitis ,2!�0$2��)�����)���#G�$�.���.��!�-�G���� PTBD �� ! ERCP +%#���),G�&��/����

!�$,�� ���z/�,�$�� �!��)���#G�$��G��.�����w����!�3/7�"'�����)� ���0�/�� PTBD/ERCP & �0�/"����'"/�,/!z321{��0$2 �� ! failed PTBD+ERCP ������-G��1��,2!���)���#G�$�.���.��7����� acute toxic cholangitis �� �!�-��������*���$��7��/!�#G�$�"3�����G�7�2���/��� #!0�/"����'�+2�017��/!�#G�$�0$2

6.Intrahepatic duct stone (IHD stone) �1����������))/!�7�&')���1�!�����$��.���1�����&')�!����,����!!�0� ��/� 0,2���� �/!��� _��1�{�

"/��7�1�����0���)0$20�/)/!���� ��*��#���0�/0$2��)���$3& ����!�/��'3�,2!�!�-"/�z 7�2���$���,�$�� #! �1��,�)&+|� ����|�����$���#G�$�7�,�),/!010$2

�����+!� intrahepatic duct stone �� ! hepatolithiasis * !�������!�3/7��/!�#G�$�+�#�,�) ��� ! hepatic confluence "/��7�_/�)7� left intrahepatic duct )/!���/�

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Clinical manifestation �)�/� 60% +!�z321{����!���� !�� 40% 0�/��!����-������ �$�!������#���,�#�&,/1�$ �#�16 �� !7,2����*��+�� ��

!�����/!�#G�$�!���") 567�,�) ,�)&+|� ,�)5{!������ �� !����|�����$���#G�$� � �/����0�/��!�����)�/����,�$,��,/!7�������� (�����/� 10 16 ) �)�/�-���!��������� 11%

Diagnosis �����-�� ultrasonography ��/����]%��"����'��|� IHD stone, IHD dilatation -����#�������&z��������-G��1��,2!��32

��� ��!��$,/���0$2&�/ ,G�&��/�+!�����, �!�,�), ���+����,+!��/!�#G�$�, ����G����+!�,�), ,�)5{!������, ,�)&+|�& � portal hypertension & �����|�����$���#G�$� �$� MRCP �1�� imaging of choice '2�0�/��7�2��-��w� CT scan �/����) ERCP �� ! PTC

,2!�,��- tumor marker ��/� CA 19-9, CEA ��������!��"�1������|�0$2 & �'2�-G��1��,2!��G����,�$,�),2!�1������ liver reserve function $2��

Treatment '2�0�/��!����0�/,2!��G�������� 7�2,�$,��!�����1������ -��G��������,/!�� �!z321{����!���� �� !,�)5{! �� !

������|�����$���#G�$� �1��,2� ��(���������� 3 ��(�� ��0$2&�/ (1) surgery : bilioenteric bypass, liver resection, liver transplantation (2) endoscopic treatment (3) percutaneous removal

�$��������+%#���),G�&��/����� & ��!�,�) ������|��� !0�/ "���,�) "�����*1��-G�,��+!�z321{�� ��/�'2�,�)0�/$� �2���G� liver resection �� !'2���*1��-G�,��z321{����� !�-�G� open surgery 0�/0$2

Malignant tumor of gallbladder and biliary tract

1.Gallbladder carcinoma ����|�'���#G�$��))/!��1��!��$�)5 +!�����|�7���))����$��!���� �� !1����w 2-4% +!�����|���))����$��

!���� �)7�����_��)/!���/������� 2-3 ��/� & �����)7�z321{��!��������/� 70 16 "G����)1-̂-���"����+!�����|�'���#G�$�0$2&�/ ����7�'���#G�$����+��$7�_/��/� 3 cm (�"����,/!����|� 10 ��/�+!�*�1�,�), calcified gallbladder (porcelain gallbladder), choledochal cyst, chronic inflammation ��/� typhoid, gallbladder polyp ���+��$7�_/��/� 1 cm, ���� anomalous pancreaticobiliary duct junction (APBDJ), ���0$2��)"���/!����|� ��/� nitrosamine, azotoluene �)�/�1����w 90% �1�� adenocarcinoma

Clinical manifestation !����&��0$2�����) cholecystitis �� ! cholelithiasis ��/���!����1�$�2!�)����w �#�16��� !7,2����*��+��, * ��0"2

!��-��� &,/!�-�)!����,���� !�,��� !�0$21����w 25-50%, ���"/�,��-� !$����2!�1y�)�,����0�/"����'����-.����*0$2 &,/*���z�$1�,�+!� LFT ����1�� ��w� biliary obstruction �G�7�2-G��1��,2!��G����" )*2�,/! �)�/������/�*�%����%��+!�z321{��0�/���)�/��1������|��/!��G����z/�,�$

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Diagnosis �����-�����"/� ultrasonography ]%��"����' gallbladder mass �� ! focal wall thickening -����#�-G��1��,2!�"/� imaging study ! ��������,�� �� �!�-��,2!�1������ biliary, vascular, nodal, hepatic , adjacent organ involvement & � distant metastasis �/!�z/�,�$ ]%��1^--�)�� MRCP �1�� single imaging study ���1���������!�/��$��� /��0$2 &,/��w����0�/�� MRCP !�-7�2 CT scan, ERCP �� ! PTC �$&��0$2 "G����) tumor marker 7�2�-�� CA 19-9

����G� biopsy �/!�z/�,�$0�/��*���-G��1���� �!�-��!�-�G�7�2�] ����|����-��017��/!��2!� �!�-�� preoperative work up �)�/��1�� unresectable disease !�-��-��w��G� biopsy �� �!� �����������-.���/!���-��w�7�2���*��)G�)�$

Treatment �������� ��* !���z/�,�$ �$��������+%#���)����+!���*�$�'2��1������� T1 lesion (tumor invades mucosa,

muscularis propria) 7�2�G�z/�,�$����� simple cholecystectomy (,�$�.���'���#G�$�!!�!�/���$���) &,/'2��1�� T2 lesion (tumor invades the perimuscular connective tissue without extension beyond the serosa or into the liver) 7�2�G� extended cholecystectomy * !,�$'���#G�$��/����),/!��#G��� !�+2���*���& �,�$,�))����w segment IVB & � V, "G����)����1�� T stage ���"3���/���#�* !�� � serosa �� ! invades ,�)�� !!�����+2���*��� ,2!��G� extended right hepatectomy (,�$,�) segment IV,V,VI,VII & � VIII) ��w�����1�� metastatic disease �� !���-��01���,/!��#G��� !����0� !!�01��-��w��G� palliative treatment ��/��G������)������$���#G�$�!�$,���$� PTBD �� ! ERCP "G����)���7�2��������"����$����.��&"��� !7�2���*��)G�)�$z 0�/*/!�$����

2.Extrahepatic cholangiocarcinoma �1������|�����))/!�7���*!�"��& ���*��� !+!�1�����0�� �$�1^--���"������� !����� /��0�27� intrahepatic

cholangiocarcinoma "����'&)/� tumor �1�� 3 "/��,��,G�&��/�0$2&�/ hilar, middle & � distal location �$�,G�&��/� hilar lesion �1��,G�&��/�����))/!����"�$* !�)1����w 2 7� 3 +!� extrahepatic cholangiocarcinoma ��#���$ & ����������|����,G�&��/���#�/� Klatskin tumor

Clinical manifestation O�' Diagnosis !��������G�z321{����������)� )/!����"�$* ! painless jaundice ]%���1��&)) cholestatic jaundice

investigation &�������-�� ultrasonography -���|� tumor & � bile duct proximal ,/! tumor dilatation -����#�7�2 investigation ,/!�$� MRCP �|�1�� single useful imaging �� �!�-��"����'1������ biliary anatomy, lymph nodes, vascular involvement & � tumor growth/invasion 0$2 &,/�|!�-7�2 CT �/����)ERCP �� ! PTC �$&��0$2��/����

"G����) tissue diagnosis�G�0$2��� & ��� sensitivity ,�G� -%�&���G�7�2�G�surgical exploration �$�!���������+2!�3 -��!�������"�"�� & � imaging study �|�! & ���/������-��w��G� biopsy �� �!�1�� preoperative staging �)�/��1�� unresecatble disease �� �!��-��w�7�2�������&))! ��,/! ��/����7�2���*��)G�)�$

Treatment �������+%#���),G�&��/�+!��� #!�!� $����# (1) Hilar cholangiocarcinoma "����'&)/����$�$�7�2 Bismuth-Corlette classification �1�� 4 type Type I : lesion of main hepatic duct, not involve main confluence Type II : lesion involving the confluence but clear of the right and left hepatic duct

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Type IIIa : lesion involving the right hepatic duct Type IIIb : lesion involving the left hepatic duct Type IV : lesion involving the right and left hepatic duct

�$� type I �G�z/�,�$ hilar resection+lymphadenectomy+/- caudate lobe resection "/�� type II �G� hilar resection+lymphadenectomy+caudate lobe resection , type IIIa �G� right hepatectomy, type IIIb �G� left hepatectomy "/�� type IV ' !�/��1�� unresectable disease 7�2�G� palliative treatment �� �!7�2�#G�$���)��0$2 (2) Middle lesion 7�2�G� major common bile duct resection (3) Distal lesion 7�2�G� Whipple operation (pancreaticoduodenectomy)

Approach to jaundice z321{�������!����,���� !�,��� !� �� !$�]/�� ��"���,�,/��������� ]%��-G��1��,2!�����-.��"���,�7�2'3�,2!�

��.���#��G�7�2�������z�$��(� /��2� "/�z �"��&�/z321{��0$2 "G����)��� approach z321{��$�]/�� ��� ����(���/� -G�&���/��1�� prehepatic, hepatic �� !posthepatic jaundice, -G�&���1��

unconjugated �� ! conjugated jyperbilirubinemia , -G�&���/��1�� hemolytic, hepatocellular �� ! cholestatic jaundice &,/�$�����01����� �����-�&��z321{���� !��1�� medical �� ! surgical jaundice ]%������ surgical jaundice (�� ! obstructive jaundice �� ! cholestatic jaundice)���$-�����!�$,��+!��/!����$���#G�$��G�7�2�#G�$�0�/"����'0� "3/ duodenum 0$2 �� !0� �$2��*��� G�)�� �G�7�2 conjugated bilirubin reflux �+2�"3/���&"� !$ "/�z 7�2���$!����,���� !�,��� !� & ������� 0�/�� bile �"3/ G�0"2�G�7�2!�--���0�/"����'�1 �����1�� stercobilin "/�z 7�2!�--�����"�]�$ �!�-����#1^""���-��+2��1��"� bile -�� conjugated bilirubin ]%�� � ���#G� z/��01���0, & �+�)!!����1^""��� "/��!����*�� ���$-�� bile salt ]%���1�� pruritogenic agent ���,�2�7�2*�� �� !)����\��) endogenous opioid 7����&"� !$+!�z321{����� & ����7�2 opioid antagonist �G�7�2!����$�+%#� �$�"��1 symptom/sign ����G�7�2"�"�� surgical jaundice 0$2&�/ (1) 1����,�$�]/�� �/����)!�--���]�$ 1^""����+2� & �*�� (2) !����1�$�2!� (3) ���,��-�)�2!�7��/!��2!� ��/����* G�0$2'���#G�$��1{��!� -���� #!�!�!�$,��)����w�/!�#G�$����!�3/,�G���/� cystic duct ]%��������/� Courvoisierhs law

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(4) LFT �) conjugated hyperbilirubinemia, elevated ALP �� �!"�"�� surgical jaundice 7�2"/� ultrasonography $3�/��� ��w����!�$,���/!� -����#���-��w�"/� ERCP �� ! PTC ,��*��������"�,/!01

Algolithm O�3(1 & approach jaundice