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Year 3 General Surgery > Biliary Conditions > Flashcards

Biliary Conditions Flashcards

1
Q

what are the risk factors for developing gallstones?

A
  • female
  • pregnancy
  • obesity
  • age >40
    family history
  • diabetes
  • Crohn’s disease
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2
Q

what are the symptoms of gallstones, when they are symptomatic?

A
  • RUQ pain -> biliary colic that radiates to back

- jaundice (+/-)

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3
Q

what makes gallstones symptomatic?

A

if they migrate to the cystic duct or common bile duct and beyond

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4
Q

describe biliary colic

A

pain in the RUQ that tends to increase in intensity and lasts several hours before resolving

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5
Q

what is the management of symptomatic gallstones?

A
  • Analgesia (morphine)
  • fluid rehydration
  • nil baby mouth
  • elective laparoscopic cholecystectomy
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6
Q

what is acute cholecystitis?

A
  • inflammation of the gallbladder
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7
Q

what is the most common cause of acute cholecystitis?

A

impaction in the neck of the gallbladder by sludge or a gallstone

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8
Q

what are the symptoms of acute cholecystitis?

A
  • Constant epigastric or RUQ pain, referred to the shoulder tip
  • vomiting
  • fever
  • rigors
  • jaundice
  • pale stools
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9
Q

what are the signs of acute cholecystitis?

A
  • local peritoneum
  • gallbladder mass
  • Murphy’s sign +
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10
Q

how would you elicit Murphy’s sign?

A

lay 2 fingers on patient’s RUQ
ask patient to breathe in
causes pain and arrest of inspiration if positive - cholecystitis
Repeat in LUQ - Murphy’s sign only positive if negative in LUQ

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11
Q

how would you investigate acute cholecystitis?

A
  • FBC (raised WCC)
  • CRP (Raised)
  • Serum amylase (slightly raised - very high suggests pancreatitis)
  • Ultrasound (thick walled, shrunken gallbladder, may see gallstones)
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12
Q

how would you manage acute cholecystitis?

A
  • Nil by mouth
  • Pain relief (morphine)
  • IV antibiotics (co-amoxiclav)
  • laparoscopic cholecystectomy if no perforation
  • laparaotomy if there is perforation of GB
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13
Q

what is chronic cholecystitis?

A

chronic inflammation of the gallbladder +/- biliary colic

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14
Q

what are the symptoms of chronic cholecystitis ?

A 
vague abdominal discomfort 
distension 
nausea
flatulence 
fat intolerance 
chronic diarrhoea
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15
Q

what are the investigations for chronic cholecystitis?

A

ultrasound - to look for gallstones

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16
Q

what is the management for chronic cholecystitis?

A

cholecystectomy

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17
Q

what is acute cholangitis?

A

infection in the bile duct

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18
Q

what is acute cholangitis usually caused by?

A

bacteria ascending from the junction between bile duct and the duodenum
it tends to occur if the bile duct is already partially obstructed by a gallstone

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19
Q

what are the symptoms of acute cholangitis?

A 
Charcot's triad:
- RUQ pain 
- Fever +/- rigors 
- jaundice 
Reynold's pentad:
- above +
- mental state changes
- low blood pressure
20
Q

where can the infection in acute cholangitis ascend and what does this cause?

A

infection can ascend to the liver, causing liver abscess and cirrhosis

21
Q

what are the investigations carried out when suspecting acute cholangitis?

A
  • FBC (increased WCC)
  • Inflammatory markers (raised ESR and CRP)
  • U&Es
  • LFTs (raised ALP, gamma GT, AST and ALT)
  • ABG (sepsis)
  • Blood cultures
  • Imaging - ultrasound, CT (biliary dilatation, stones, strictures)
22
Q

what is the management for acute cholangitis?

A
  • fluid resuscitation (if patient is septic)
  • monitor fluid and electrolyte balance
  • IV antibiotics (piperacillin with tazobactam)
  • Endoscopic retrograde cholangiopancreatography (clears bile ducts)
23
Q

what is primary biliary cholangitis?

A

chronic autoimmune granulomatous inflammation of the small interlobular bile ducts (part of portal triad) in the liver

24
Q

what is the pathophysiology of primary biliary cholangitis?

A

autoimmune granulomatous inflammation of interlobular bile ducts causes cholestasis which damages bile duct cells and hepatocytes and leads to fibrosis, cirrhosis and portal hypertension

25
Q

what are the symptoms of primary biliary cholangitis?

A
  • asymptomatic in early disease
  • lethargy -> most common
  • pruritus (cholestasis)
26
Q

what are the signs of primary biliary cholangitis?

A
  • hepatomegaly
  • hyperpigmentation (increased amounts of melanin)
  • splenomegaly
  • jaundice
  • cirrhosis (ascites, spider naevi)
27
Q

what are the investigations for primary biliary cholangitis?

A
  • FBC (often normal)
  • ESR (elevated)
  • LFTs (alkaline phosphatase
    and gamma GT elevated, AST and ALT can sometimes be mildly elevated)
  • bilirubin rises as disease progresses
  • prothrombin time (increased)
  • albumin (decreased- impaired liver function)
  • abdominal US (to exclude obstructive lesion within bile ducts)
  • serum immunoglobulin - IgM is raised
  • antimitochondrial antibodies present
28
Q

what are the risk factors for primary biliary cholangitis?

A
  • female gender
  • positive family history
  • age between 45-60
29
Q

describe the management for primary biliary cholangitis

A
  • ursodexycholic acid
  • prednisolone (immunomodulatory)
  • colestyramine (sequesters bile acids in the intestine, preventing their absorption)
  • liver transplantation is the only cure but disease can recur in transplanted liver
30
Q

what is primary sclerosis cholangitis?

A

progressive cholestasis with bile duct inflammation and strictures - both intrahepatic and extrahepatic bile ducts can be affected

31
Q

what is the difference between primary biliary cholangitis and primary sclerosis cholangitis?

A

primary biliary - inflammation of interlobular bile ducts (more common in women)
primary sclerosing cholangitis - inflammation of both intrahepatic and extra hepatic bile ducts and stricture formation (more common in men)

32
Q

what are the symptoms of primary sclerosing cholangitis?

A
  • may be asymptomatic
  • jaundice nd pruritos
  • RUQ pain
  • Fatigue
  • Weight loss
  • Fever
  • Sweats
33
Q

what are the signs of primary sclerosis cholangitis?

A
  • hepatomegaly
  • jaundice
  • signs of cirrhosis and portal hypertension (caput medusa, oesophageal varices, ascites)
34
Q

what are the investigations for primary sclerosing cholangitis?

A
  • LFTs (ALP, Gamma GT usually raised, AST slightly raised, bilirubin raised, albumin decreased and PT time increased)
  • FBC (normal or shows liver dysfunction such as thrombocytopenia)
  • antimitochondrial antibody (negative in sclerosis, positive in biliary)
  • Ultrasound (abnormal bile ducts, liver cirrhosis)
  • MRCP (strictures and dilatations)
35
Q

what is the management of primary sclerosis cholangitis?

A
  • observation and lifestyle changes for asymptomatic patients
  • bone mineral density scan at diagnosis and at 2-3 year intervals
  • colestyramine for pruritus
  • ergocalciferol and calcium carbonate (vitamin D and calcium supplements) if hepatic osteopenia
  • ERCP with balloon +/- stent to treat strictures
  • liver transplantation
36
Q

what is cholangiocarcinoma?

A

cancers arising from bile duct epithelium

can bee intrahepatic or extrahepatic

37
Q

what is the presentation of cholangiocarcinomas?

A
  • painless jaundice - most common

- weight loss and abdominal pain are fairly uncommon

38
Q

what are the risk factors for chlonagiocarcinoma?

A
  • age>50
  • cholangitis
  • gallstones
  • ulcerative colitis
  • primary sclerosing cholangitis
  • liver cirrhosis
  • alcoholic liver disease
  • HIV
  • Hepatitis B and C
39
Q

what investigations are done when suspecting cholangiocarcinoma?

A
  • LFTs (serum bilirubin raised, alk phos raised, gamma GT raised, AST slightly raised, PT time increased)
  • Cancer markers (CA-19-9 and CEA elevated)
  • abdominal ultrasound (shows mass and dilated ducts)
  • abdominal CT or MRI
40
Q

what is the management for cholangiocarcinoma?

A 
Resectable tumours:
• Intrahepatic tumour:
	◦ Partial liver resection 
	◦ Chemotherapy / radiotherapy 
• Extrahepatic tumour:
	◦ Surgical excision 
	◦ Chemotherapy / radiotherapy

Unresectable tumours:
• Liver transplant if they are a candidate
• Chemotherapy / radiotherapy

41
Q

what problems does liver failure lead to?

A
  • increased susceptibility to infections
  • increased susceptibility to toxins and drugs
  • increased blood ammonia -> hepatic encephalopathy
42
Q

what is acute liver failure?

A

rapid failure of the liver’s synthetic and metabolic function in the absence of a known pre-existing liver disease

43
Q

how is acute liver failure classified?

A

based on the time interval between the initial onset of jaundice and the development of encephalopathy:

  • hyper acute (0-7 days)
  • acute (8-28 days)
  • subacute (29 days - 12 weeks)
44
Q

what is the most common cause for acute liver failure?

A
  • paracetamol overdose (UK)

- acute viral hepatitis (worldwide)

45
Q

what is the presentation of acute liver failure?

A
  • jaundice
  • evidence of risk factors such as overdose, hepatitis and hepatotoxic drugs
  • signs of hepatic encephalopathy (lethargy, confusion, asterixis)
  • abdominal pain
  • nausea and vomiting
  • hepatomegaly
46
Q

how would you investigate acute liver failure?

A
  • LFTs (high bilirubin, very high AST and ALT in paracetamol overdose)
  • prothrombin time increased
  • U&Es (metabolic derangements and elevated urea)
  • FBC (leukocytosis, anaemia, thrombocytopenia)
  • blood type and screen (in case transfusion needed)
  • ABG (acidosis and raised lactate are prognostic factors)
  • paracetamol level
  • viral hepatitis serology
  • autoimmune hepatitis markers (autoantibodies) to help diagnosis
  • pregnancy test (can have liver disorders in pregnancy)
  • abdominal ultrasound with doppler (for hepatic vessel thrombosis and hepatomegaly)
47
Q

what is the management for acute liver failure?

A
  • intensive care
  • liver transplantation assessment + contact transplant centre
  • neurological status monitoring for advanced encephalopathy
  • monitor blood glucose, electrolytes and blood cultures
  • acetylcysteine for paracetamol overdose
  • acyclovir for herpes simplex virus
  • methylprednisolone for autoimmune hepatitis
  • fluid resuscitation

Year 3 General Surgery (9 decks)

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