Liver, pancreatic and biliary surgery

Question 1

Why is parenteral nutrition a risk factor for gallstones?

Answer 1

It leads to alteration of bile constituents

Question 2

Intermittent severe epigastric pain and RUQ pain usually associated with nausea and vomiting. Resolves after a few hours, tenderness over gallbladder during acute episodes.

Answer 2

Gall bladder stones

Question 3

Severe continuous RUQ pain - often radiates to right flank and back, associated with anorexia and pyrexia. Tenderness over gallbladder during inspiration (Murphy’s sign)

Answer 3

Acute cholecystitis

Question 4

When is Murphy’s sign seen?

Answer 4

In acute cholecystitis

Question 5

Complications of acute cholecystitis

Answer 5

Empyema

Question 6

How do you know if it’s empyema?

Answer 6

Swinging fever and severe localised pain

Question 7

What is porcelain gallbladder?

Answer 7

Calcification of the gallbladder believed to be brought on by excessive gallstones

Question 8

Who is suitable for cholecystectomy?

Answer 8

• patients with symptoms caused by gallstones
• asymptomatic patients with gallbladder stones at risk of complications (e.g. really fat people, diabetes, porcelain gallbladder, hx of pancreatitis, long term immunosuppression)

Asymptomatic obese people with gallstones will eventually have symptoms so just take it out

Question 9

Risks of cholecystectomy

Answer 9

• conversion to open operation (5-10%)
• bile duct injury (<1%)
• bleeding (2%)
• bile leak (1%)

Question 10

When might you use percutaneous drainage of the gallbladder?

Answer 10

When you have a gallbladder empyema and surgery is not suitable

• done under US or CT guidance
• after resolution of the infection, the calculi may be removed percutaneously

Question 11

Why is MRCP good?

Answer 11

• avoids radiation exposure

- highly accurate

Question 12

Name 4 risks of ERCP

Answer 12

• haemorrhage
• acute pancreatitis
• ascending infection
• perforation (usually retroduodenal, may cause peritonitis)

Question 13

Gilbert’s syndrome

Answer 13

Deficiencies/abnormalities of unconjugated bilirubin uptake system

Question 14

Crigler-Najjar syndrome

Answer 14

Deficiencies/abnormalities of bilirubin conjugating enzymes

Question 15

What type of hyperbilirubinaemia do gilber’s syndrome abd crigler najjar syndrome cause?

Answer 15

UNconjugated hyperbilirubinaemia

Question 16

What could cause conjugated hyperbilirubinaemia?

Answer 16

Infection (viral - hep A, B, C, CMV), bacterial (e.g. liver abscess, leptospirosis); parasitic (e.g. amoebic)

Drugs (e.g. paracetamol OD, antipsychotics, antibiotics)

Non-infective hepatitis (e.g. chronic active hepatitis, alcohol-related)

Question 17

Causes of pancreatitis:

IGETSMASHED

Answer 17

I - idiopathic
G - gallstones
E - ethanol (most common)
T - trauma
S - steroids
M - mumps/malignancy
A - autoimmune
S - scorpion sting
H - hypercalcemia / hypertriglycerides (usually TG >1000)
E - ERCP
D - drugs (e.g oestrogens, azathioprine, thiazide, valproic acid, sulfasalazine, tetracycline)

Question 18

PANCREAS mneumonic for severity

Answer 18

P - PO2 (<8KPa)
A - age (>55years)
N - neutrophils (>15 x10^9 L)
C - calcium <2mmol/L
R - renal function (urea >16mmol/L)
E - enzymes (LDH >600iU/L / AST >2000iU/L)
A - albumin (<32g/l)
S - sugars (glucose >10mmol/L)

Three or more criteria within 48hours of admission = severe pancreatitis

Question 19

Grey-turner sign

Answer 19

Bruising of the left flank in acute pancreatitis

Question 20

Cullen’s sign

Answer 20

Bruising around the tummy button (periumbilicus) in acute pancreatitis

Question 21

Asides from pancreatitis, when might amylase be elevated?

Answer 21

• intestinal ischaemia
• leaking aneurysm
• perforated ulcer
• cholecystitis

Question 22

How to diagnose acute pancreatitis?

Answer 22

Generally serum amylase >1000U is diagnostic BUT can be normal even in severe cases. Amylase can also be elevated in other acute abdominal events.