# Clinical Cases: Hepatobiliary Surgery

## Case 1: Acute Cholecystitis

### Patient Demographics
- **Age:** 45 years
- **Sex:** Female
- **Occupation:** School administrator

### Chief Complaint
"I have severe pain under my right ribs that started after dinner last night."

### History of Present Illness
The patient presents with an 18-hour history of constant, severe right upper quadrant pain. The pain began after eating a fatty meal and has been progressively worsening. She reports nausea with two episodes of non-bilious vomiting. She has had prior episodes of milder, similar pain that resolved spontaneously (biliary colic), but this episode is more severe and persistent. She reports subjective fever and chills.

### Past Medical History
- Obesity (BMI 32)
- History of biliary colic (diagnosed on ultrasound 2 years ago, declined surgery)
- Hyperlipidemia

### Medications
- Atorvastatin 20 mg daily

### Risk Factors
Classic "4 F's": Female, Forty, Fat, Fertile

### Physical Examination
- **Vitals:** BP 142/88 mmHg, HR 98 bpm, Temp 38.4°C, RR 18/min
- **General:** Overweight female in moderate distress
- **Abdomen:**
  - RUQ tenderness with guarding
  - Positive Murphy's sign (inspiratory arrest during RUQ palpation)
  - No rebound tenderness
  - No palpable mass
  - Bowel sounds present

### Laboratory Results
- WBC: 14,600/μL (left shift)
- Total bilirubin: 1.4 mg/dL (mildly elevated)
- ALT: 68 U/L (mildly elevated)
- AST: 54 U/L
- Alkaline phosphatase: 142 U/L (mildly elevated)
- Lipase: 45 U/L (normal)

### Imaging

**Right Upper Quadrant Ultrasound:**
- Gallstones present (multiple)
- Gallbladder wall thickening (5 mm)
- Pericholecystic fluid
- Sonographic Murphy's sign positive
- Common bile duct: 4 mm (normal)
- No intrahepatic ductal dilation

### Diagnosis
Acute calculous cholecystitis

### Initial Management
1. NPO
2. IV fluid resuscitation
3. IV antibiotics (ceftriaxone + metronidazole)
4. Pain control (IV ketorolac, opioids)
5. Surgical consultation for cholecystectomy

### Timing of Surgery
- Tokyo Guidelines Grade II (moderate) cholecystitis
- Patient is surgical candidate
- Plan: Early laparoscopic cholecystectomy (within 72 hours preferred)

### Operative Procedure
Laparoscopic cholecystectomy:
- Omental adhesions to gallbladder
- Gallbladder distended, inflamed, wall edematous
- Achieved critical view of safety (CVS)
- Cystic duct and cystic artery clearly identified and clipped
- Gallbladder removed in retrieval bag
- Subhepatic drain NOT placed (routine drainage not recommended)

### Intraoperative Cholangiogram
- Not performed (preoperative labs and imaging did not suggest CBD stones)
- Alternative: Could have performed if concern for choledocholithiasis

### Pathology
- Acute cholecystitis with cholelithiasis
- Multiple cholesterol stones
- No evidence of malignancy

### Postoperative Course
- Diet advanced evening of surgery
- Pain well controlled with oral analgesics
- Discharged POD 1

### Follow-up
- Wound check at 1 week: Healing well
- Full activity resumed at 2 weeks

### Teaching Points
1. Positive Murphy's sign is specific for acute cholecystitis
2. Ultrasound is first-line imaging
3. Early cholecystectomy (<72 hours) is preferred when feasible
4. Critical view of safety (CVS) prevents bile duct injury
5. Mild liver enzyme elevation can occur with cholecystitis (reactive hepatitis)
6. CBD stones should be considered if bilirubin elevated or CBD dilated

### Clinical Image
![Acute Cholecystitis Ultrasound](case_01_image.jpg)

**Image Description:** Right upper quadrant ultrasound demonstrating gallstones with posterior acoustic shadowing, gallbladder wall thickening (>4 mm), and pericholecystic fluid consistent with acute cholecystitis.

**Attribution:** Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Gallstones

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## Case 2: Bile Duct Injury After Cholecystectomy

### Patient Demographics
- **Age:** 52 years
- **Sex:** Female
- **Occupation:** Real estate agent

### Chief Complaint
"I've been leaking fluid from my drain site and turning yellow since my surgery 5 days ago."

### History of Present Illness
The patient underwent laparoscopic cholecystectomy for acute cholecystitis at an outside hospital 5 days ago. The operative note reported a "difficult" case with significant inflammation. A drain was placed. Postoperatively, the drain initially had serosanguinous output, but over the past 2 days, the output has become bilious with increasing volume (now 400 mL/day). She has developed progressive jaundice, pruritus, and pale stools. She is transferred to your tertiary care center for evaluation.

### Past Medical History
- Acute cholecystitis (treated with cholecystectomy 5 days ago)
- Hypertension
- No other surgeries

### Physical Examination
- **Vitals:** BP 128/76 mmHg, HR 88 bpm, Temp 37.2°C
- **General:** Jaundiced female, mild distress
- **Abdomen:**
  - Soft, mildly tender RUQ
  - Surgical drain in place with bilious output
  - Laparoscopic port sites healing
  - No peritonitis
- **Skin:** Icteric sclera, jaundiced skin

### Laboratory Results
- WBC: 11,400/μL
- Total bilirubin: 8.4 mg/dL (elevated)
- Direct bilirubin: 6.8 mg/dL
- ALT: 186 U/L
- AST: 142 U/L
- Alkaline phosphatase: 348 U/L
- GGT: 420 U/L

### Drain Fluid Analysis
- Bilirubin in drain fluid: 24 mg/dL (consistent with bile)

### Imaging

**CT Abdomen with IV contrast:**
- Fluid collection in gallbladder fossa
- Dilated intrahepatic bile ducts
- Surgical clips in porta hepatis
- Concern for bile duct injury

**MRCP (Magnetic Resonance Cholangiopancreatography):**
- Complete transection of common hepatic duct
- Dilated intrahepatic ducts above clip level
- Distal CBD not visualized (separate from proximal system)
- Consistent with Strasberg Type E2 injury

### Diagnosis
Major bile duct injury (Strasberg Type E2 - transection of common hepatic duct)

### Multidisciplinary Discussion
- Hepatobiliary surgery consultation
- Interventional radiology consultation
- Management options:
  1. Immediate surgical repair (not recommended in acute inflammation)
  2. Delayed reconstruction after inflammation resolves

### Initial Management
1. Maintain external drainage (controls bile leak)
2. Percutaneous transhepatic cholangiography (PTC) with biliary drainage
3. Nutrition support
4. Allow inflammation to subside (6-8 weeks)
5. Plan for definitive reconstruction

### PTC and Drainage
- Bilateral percutaneous transhepatic biliary drains placed
- External drainage of bilateral hepatic ducts
- Allows decompression and controls biliary output

### Definitive Surgery (8 weeks later)
Roux-en-Y hepaticojejunostomy:
- Exploratory laparotomy
- Dense adhesions in RUQ
- Proximal bile duct identified (dilated common hepatic duct)
- Scarred distal bile duct excised
- Roux limb (60 cm) created
- End-to-side hepaticojejunostomy (single layer, absorbable sutures)
- Transhepatic stents left in place

### Postoperative Course
- ICU admission for 24 hours
- Diet advanced POD 4
- Transhepatic drains capped, then internalized
- Discharged POD 7

### Follow-up
- Drains removed at 6 weeks (after cholangiogram confirming patent anastomosis)
- Liver enzymes normalized
- No stricture at 1 year follow-up

### Teaching Points
1. Bile duct injury most common with cholecystectomy (0.3-0.5%)
2. Risk factors: Acute inflammation, anomalous anatomy, inadequate exposure
3. Critical view of safety (CVS) helps prevent injury
4. Early recognition allows appropriate referral
5. Delayed reconstruction (6-8 weeks) has better outcomes than immediate repair
6. Hepaticojejunostomy is standard repair for major bile duct injury
7. Long-term stricture risk requires surveillance

### Clinical Image
![Bile Duct Injury MRCP](case_02_image.jpg)

**Image Description:** MRCP image demonstrating complete transection of the common hepatic duct with dilated intrahepatic bile ducts above the level of injury. The discontinuity of the biliary system confirms a major bile duct injury requiring reconstruction.

**Attribution:** Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Liver_cancer

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## Case 3: Hepatocellular Carcinoma

### Patient Demographics
- **Age:** 62 years
- **Sex:** Male
- **Occupation:** Retired factory worker

### Chief Complaint
"I had a scan for something else and they found a spot on my liver."

### History of Present Illness
The patient was undergoing workup for vague abdominal discomfort when an abdominal ultrasound revealed a liver mass. He denies weight loss, jaundice, or abdominal swelling. He has a history of chronic hepatitis C infection that was treated and cured 3 years ago with direct-acting antivirals. He has been told he has "some liver scarring" but has not had regular surveillance.

### Past Medical History
- Chronic hepatitis C (SVR achieved 3 years ago with sofosbuvir/ledipasvir)
- Cirrhosis (diagnosed on prior biopsy, compensated)
- History of IV drug use (remote, now clean 20 years)
- No prior liver decompensation (no ascites, variceal bleeding, or encephalopathy)

### Medications
- None currently

### Physical Examination
- **Vitals:** Normal
- **General:** Appears well, no cachexia
- **Abdomen:**
  - Soft, non-tender
  - No palpable hepatomegaly or splenomegaly
  - No ascites
- **Skin:** No spider angiomata, palmar erythema, or jaundice
- **Extremities:** No edema

### Laboratory Results
- Platelets: 112,000/μL (low - consistent with cirrhosis)
- Albumin: 3.8 g/dL
- Total bilirubin: 1.1 mg/dL
- INR: 1.1
- Creatinine: 0.9 mg/dL
- AFP: 86 ng/mL (elevated, normal <10)
- Hepatitis C: SVR confirmed (undetectable viral load)

### Liver Function Assessment
- Child-Pugh Score: A5 (well-compensated cirrhosis)
- MELD score: 8

### Imaging

**Multiphasic CT Liver:**
- 3.5 cm mass in segment VI of liver
- Arterial phase hyperenhancement
- Washout on portal venous and delayed phases
- Diagnostic for HCC (LI-RADS 5)
- No portal vein invasion
- No satellite lesions
- No extrahepatic disease

**MRI Liver with Primovist:**
- Confirms 3.5 cm HCC in segment VI
- No additional lesions
- Hepatobiliary phase hypointensity (characteristic of HCC)

### Diagnosis
Hepatocellular carcinoma (HCC), single lesion, 3.5 cm, in compensated cirrhosis

### Staging
- BCLC Stage A (early stage - single tumor <5 cm, preserved liver function)
- Milan criteria: Within (single tumor ≤5 cm)

### Treatment Options Discussed
1. **Surgical resection:** Good option for single lesion with preserved liver function
2. **Liver transplantation:** Treats both HCC and underlying cirrhosis
3. **Ablation:** Alternative for tumors <3 cm or if not surgical candidate

### Transplant Evaluation
- Within Milan criteria
- Listed for liver transplant with MELD exception points
- Expected wait time: 6-12 months in this region

### Bridge Therapy (While Awaiting Transplant)
- Transarterial chemoembolization (TACE) performed
- Good response with tumor necrosis on follow-up imaging

### Liver Transplant (10 months after listing)
- Deceased donor liver transplant performed
- Explant pathology:
  - 2.8 cm HCC with extensive necrosis (TACE effect)
  - Well-differentiated
  - No vascular invasion
  - No satellite lesions
  - Background cirrhosis with no dysplastic nodules

### Post-Transplant Course
- Immunosuppression: Tacrolimus-based regimen
- Discharged POD 8
- Close surveillance for HCC recurrence and rejection

### Follow-up
- AFP normalized
- CT surveillance: No recurrence at 1 year
- Excellent graft function

### Teaching Points
1. HCC surveillance essential in cirrhotics (US + AFP every 6 months)
2. SVR from HCV does not eliminate HCC risk in cirrhotics
3. Diagnosis often by imaging criteria (LI-RADS 5) without biopsy
4. BCLC staging guides treatment selection
5. Milan criteria determine transplant eligibility
6. Bridge therapy (TACE, ablation) while awaiting transplant
7. Transplant treats both cancer and underlying liver disease

### Clinical Image
![HCC CT Scan](case_03_image.jpg)

**Image Description:** Multiphasic CT scan demonstrating a hepatocellular carcinoma with characteristic arterial phase hyperenhancement. The tumor shows avid contrast uptake during the arterial phase with subsequent washout, diagnostic of HCC in the setting of cirrhosis.

**Attribution:** Image from Wikimedia Commons, Category:CT images of liver cancer. Source: https://commons.wikimedia.org/wiki/Category:CT_images_of_liver_cancer