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Q1: Classification (2 min)
- Prehepatic / hepatic / post-hepatic (obstructive)
- Intrahepatic cholestasis vs extrahepatic mechanical obstruction
- Extrahepatic causes: stones, stricture, malignancy, parasites, pancreatitis
Q2: Courvoisier (2 min)
- Palpable GB + jaundice unlikely pure stone disease
- Rationale: chronic stone cholecystitis scars GB
- Malignant distal obstruction distends compliant GB
Q3: Investigation ladder (3 min)
- Bloods: conjugated bilirubin, ALP/GGT, PT/INR, cultures if septic
- US first: ducts, stones, level of obstruction
- MRCP non-invasive duct mapping; CT for staging masses
- ERCP therapeutic; EUS for small lesions/FNA
- Vitamin K before invasive procedures if cholestatic coagulopathy
Q4: Cholangitis (3 min)
- Charcot / Reynolds; Tokyo severity grades
- Resuscitate + cultures + IV antibiotics (pip-tazo example)
- Urgent biliary drainage ERCP (or PTBD)
- Mortality high if source control delayed
Q5: Malignant pathways (2 min)
- Pancreatic head / periampullary / cholangiocarcinoma / nodes
- MDT resectability; SEMS palliation
- Avoid unnecessary preoperative drainage in all resectable patients
Q6: Stone disease pathway (2 min)
- CBD stones: ERCP clearance then laparoscopic cholecystectomy
- Intraoperative cholangiogram / laparoscopic CBD exploration alternatives
- Mirizzi, retained stones, post-cholecystectomy bile leak as complications
Q7: Special populations (2 min)
- Pregnancy: US/MRCP preferred; ERCP with shielding if essential
- Elderly: atypical sepsis without frank triad
- Stent choice: plastic temporary vs metal for unresectable malignancy
Q8: Tokyo and antibiotics (2 min)
- Grade III = organ failure — urgent drainage + ICU
- Pip-tazo typical first-line; culture-directed de-escalation
- Elective cholecystectomy after stone cholangitis settles