Hepatobiliary Flashcards Preview

Surgery > Hepatobiliary > Flashcards

Flashcards in Hepatobiliary Deck (71)
Loading flashcards...
1
Q

risk factors for gallstones?

A

usually female, forty, fertile, fat

high fat diet

OCP, pregnancy

loss of terminal ileum (decreased bile salts)

2
Q

what causes increased formation of cholesterol gallstones?

A

20% of all gallstones

large

often solitary

formation increases according to Admirand’s triangle

-> low bile salts, low lecithin, high cholesterol

3
Q

what kind of gall stones are associated with haemolysis?

A

calcium bilirubinate

small, black, gritty, fragile

-> increases w blood transfusions/ increased haemolysis

4
Q

complications of gallstones?

A

in gallbladder:

biliary colic

acute cholecystitis +/- empyema

chronic cholecystitis

mucocele

carcinoma

Mirizzi’s syndrome

in common bile duct:

  1. obstructive jaundice
  2. pancreatitis
  3. ascending cholangitis

in gut:

  1. gallstone ileus
5
Q

pathogenesis of biliary colic?

A

gallbladder spasm against a stone impacted in the gallbladder

commonly in Hartmanns pouch

less commonly, stone may be in common bile duct

6
Q

presentation of biliary colic?

A

RUQ pain radiating -> back (scapula)

sweating, pallor, n/v

attacks precipitated by fatty foods

o/e tenderness in right hypochondrium +/- jaundice if stone passes in to Common bile duct

7
Q

Ix of biliary colic?

A

same work up as cholecystitis as difficult to differentiate clinically

Urine: bilirubin, urobilinogen, Hb

Bloods: FBC, U+E, amylase, LFTs, G+S, clotting, CRP

Imaging:

  1. AXR - 10% gallstones are radioopaque
  2. Erect CXR: look for perforation
  3. US: - stones, dilated ducts, inflamed gallbladder

If dilated ducts seen on US -> MRCP

8
Q

mx of biliary colic?

A

conservative:

rehydrate and NBM

opioid analgesia: morphine 5-10mg/ 2 h max

high recurrence rate -> surgical mx favoured

surgical:

  • urgent lap chole
  • elective lap chole @ 6-12 wks
9
Q

pathogenesis of acute cholecystitis?

A

stone or sludge impaction in Hartmanns pouch

-> chemical and/or bacterial inflammation

5% are due to sepsis, burns, DM

10
Q

what may acute cholecystitis lead to?

A
  1. resolution +/- recurrence
  2. gangrene and rarely perforation
  3. chronic cholecystitis
  4. empyema
11
Q

presentation of acute cholecystitis?

A

fever

vomiting

severe RUQ pain

  • continuous, radiates to right scapula and epigastrium
12
Q

examination findings of acute cholecystitis?

A

local peritonism in RUQ

tachycardia w shallow breathing

+/- jaundice

murphy’s sign +ve:

hand below costal margin -> ask pt to breathe in -> +ve when pain or pt catches breath

(has to be -ve on L side)

boas sign +ve

hyperaesthesia below the right scapula

13
Q

mx of acute cholecystitis?

A

conservative:

NBM, fluid resus

analgesia

abx: cefuroxime and metronidazole

80-90% settle over 24-48h

surgical:

elective surgery @ 6-12 wks

if <72h, may perform lap chole in acute phase

14
Q

mx of empyema following acute cholecystitis?

A

percutaneous drainage: cholecystotomy (tube for drainage in gallbladder)

15
Q

features of chronic cholecystitis?

A

flatulent dyspepsia

vague upper abdo discomfort

distension, bloating

nausea

flatulence, burping

symptoms exacerbated by fatty foods

16
Q

ix of chronic cholecystitis?

A

AXR: porcelain gallbladder

US: stones, fibrotic, shrunken gallbladder

MRCP

17
Q

Mx of chronic cholecystitis?

A

medical:

bile salts (not v effective)

Surgical: elective cholecystectomy

ERCP first if US shows dilated ducts and stones

18
Q

what is a gallbladder mucocele?

A

distention of the gallbladder by an inappropriate accumulation of mucus

neck of gallbladder blocked by stone but contents remain sterile

can be v large -> palpable mass

may become infected -> empyema

19
Q

gallbladder carcinoma assoc w?

A

gallstones

gallbladder polyps

20
Q

what is a porcelain gallbladder?

A

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

21
Q

what is Mirizzi’s syndrome?

A

common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or Hartmann’s pouch of the gallbladder

  • > obstructive jaundice
  • > may erode through into the ducts
22
Q

what is gallstone ileus?

A

when a large stone erodes from gallbladder -> duodenum through fistula caused by chronic inflammation

may impact in terminal ileus -> Small bowel obstruction

23
Q

diagnosis of Gallstone ileus?

A

Rigler’s Triad:

pneumobilia

small bowel obstruction

gallstone in RLQ

24
Q

mx of gallstone ileus?

A

IV fluids

NG tube

Stone removal via enterotomy

25
Q

causes of obstructive jaundice?

A

30% stones

30% Ca head of pancreas

30% other

e. g. inflammatory: PBC, PSC
drugs: OCP, sulphonylureas

Neoplastic: cholangioca

LNs @ porta hepatitis: TB, Ca

Mirizzis syndrome

26
Q

features of obstructive jaundice?

A

jaundice

-seen at tongue frenulum first

dark urine, pale stools

itching (Bile salts)

27
Q

ix of obstructive jaundice?

A

urine: high bilirubin, low urobilinogen (dark)

bloods:

FBC- raised WCC in cholangitis

U+E- hepatorenal syndrome

LFTs: raised Br, HIGH Alk phos

Clotting: raised INR

G+S, X-match

immune markers: AMA, ANCA, ANA

imaging: AXR

US: dilated ducts, stones, tumour

MRCP/ ERCP

28
Q

mx of gallstones if no resolution, worsening LFTs or cholangitis?

A

ERCP w sphincterotomy and stone extraction

  • delayed cholecystectomy to prevent recurrence
29
Q

Features of ascending cholangitis?

A

bacterial infection of the biliary tract due to obstruction

Charcot’s triad: fever/ rigors, RUQ pain, jaundice

Reynolds pentad: Charcots triad + hypotension + confusion

30
Q

what is charcot’s triad?

A

fever/ rigors, RUQ pain, jaundice

31
Q

What is reynold’s pentad?

A

Charcots triad + hypotension + confusion

32
Q

mx of ascending cholangitis?

A

cef and met

1st: ERCP
2nd: Open or lap stone removal

33
Q

risk factors of pancreatic ca?

A

smoking

chronic pancreatitis

high fat diet

alcohol

diabetes

34
Q

most common type of pancreatic ca?

A

ductal adenoca

(most commonly in head of pancreas)

35
Q

presentation of pancreatic ca?

A

painless obstructive jaundice

anorexia, weight loss, malabsorption

epigastric pain

acute panc

sudden onset DM in the elderly

36
Q

signs of pancreatic ca?

A

palpable gallbladder

jaundice

epigastric mass

thrombophlebitis migrans (Trousseau sign)

Splenomegaly: PV thrombosis -> portal HTN

ascites

37
Q

what is courvoisier’s law?

A

in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to stones

38
Q

what tumour marker is assoc w pancreatic ca?

A

Ca 19-9 (90% sensitivity)

39
Q

mx of pancreatic ca?

A

surgery:

fit, no mets, small tumour

whipple’s pancreaticoduodenectomy

distal pancreatectomy

+ post op chemo

palliation:

endoscopic/ percutaneous stenting of Common bile duct

palliative bypass surgery: cholecystojejunostomy + gastrojejunostomy

pain relief - may need coeliac plexus block

40
Q

most common cause of acute pancreatitis?

A
  1. gallstones
  2. ethanol
41
Q

pathophysiology of acute pancreatitis?

A

pancreatic enzymes released ->

hypovolaemic shock

autodigestion and fat necrosis

vessel autodigestion -> retroperitoneal haemorrhage

pancreatic necrosis

42
Q

features of acute pancreatitis?

A

severe epigastric pain -> back

  • relieved by sitting forward

vomiting

43
Q

signs of acute pancreatitis?

A

Grey Turners: bruising along flanks

Cullens: periumbilical bruising

44
Q

what is the modified glasgow criteria?

A

assess severity and predict mortality of acute pancreatitis

valid for gallstones/ alcohol

3 or more: severe, treat in ITU

45
Q

what is the factors used to score in the modified glasgow criteria?

A

PANCREAS

PaO2 < 8

Age > 55

Neutrophils > 15 x 109

hypoCalcaemia < 2

Renal function Urea > 16

Enzymes: LDH > 600, AST >200

Albumin < 32

Sugar > 10mM

46
Q

Abnormal bloods in acute pancreatitis?

A

High Amylase and Lipase

Low Calcium

High Glucose

CRP: monitor progress, >150 after 48h = severe

47
Q

Conservative Mx of acute pancreatitis?

A

Manage in ITU if severe

monitor UO, obs

Fluid resus

NBM, NGT if vomiting, TPN may be required

Analgesia: pethidine via PCA or morphine

Antibiotics: used if suspicion of infection or before ERCP (e.g. meropenem)

tx complications:

ARDS- O2 therapy/ ventilation

glucose: insulin sliding scale

Alchol withdrawal: chlordiazepoxide

48
Q

Interventional mx of acute pancreatitis?

A

ERCP + sphincterotomy

49
Q

surgical mx of acute pancreatitis?

indications?

A

indications:

infected pancreatic necrosis

pseudocyst or abscess

unsure dx

laparotomy

50
Q

presentation of pancreatic pseudocyst?

A

collection of pancreatic fluid in lesser sac surrounded by granulation tissue

presents 4-6 wks after acute attack

persisting abdo pain

epigastric mass -> early satiety

51
Q

ix of pancreatic pseudocyst?

A

persistently raised amylase +/- LFTs

US/ CT

52
Q

mx of pancreatic pseudocyst?

A

<6cm: spontaneous resolution
>6 cm: endoscopic cyst-gastrostomy, percutaneous drainage under US/ CT

53
Q

main cause of chronic pancreatitis?

A

alcohol

54
Q

other causes of chronic pancreatitis apart from alcohol?

A

genetic: CF, hereditary haemachromatosis
immune: lymphoplasmacytic sclerosing pancreatitis (high IgG4)

raised triglycerides

obstruction by tumour

55
Q

features of chronic pancreatitis?

A

epigastric pain radiating to back

relieving by hot water bottle -> erythema ab igne

exacerbated by fatty food or alcohol

steatorrhoea and weight loss

56
Q

Ix of chronic pancreatitis?

A

raised glucose

decreased faecal elastase: decreased exocrine function

US: pseudocyst

AXR: speckled pancreatic calcifications

CT: pancreatic calcifications

57
Q

mx of chronic pancreatitis?

A

diet: no alcohol, decrease fat
medical: analgesia- coeliac plexus block

enzyme supplements

ADEK vitamins

DM tx

Surgery: if unremitting pain, weight loss, duct blockage

Distal pancreatectomy, Whipples

Pancreaticojejunostomy: drainage

Endoscopic stenting

58
Q

complications of chronic pancreatitis?

A

pseudocyst

diabetes

pancreatic ca

pancreatic swelling -> biliary obstruction

splenic vein thrombosis -> splenomegaly

59
Q

features of insulinoma?

A

fasting/ exercise-induced hypoglycaemia

high insulin + high c peptide + low glucose

60
Q

features of VIPoma?

A

watery diarrhoea

hypoK

achlorhydria

acidosis

61
Q

somatostatin function?

A

inhibits glucagon and insulin release

inhibits pancreatic enzyme secretion

62
Q

features of a somatostatinoma?

A

DM

steatorrhoea

gall stones

63
Q

what is pancreatic divisum?

A

congenital anomaly

a single pancreatic duct is not formed, but rather remains as two distinct dorsal and ventral ducts.

usually asymptomatic

may -> chronic pancreatitis

64
Q

what is annular pancreas?

A

second part of the duodenum is surrounded by a ring of pancreatic tissue continuous with the head of the pancreas.

may -> infantile duodenal obstruction

65
Q

risk factors for cholangiocarcinoma?

A

PSC

Ulcerative colitis

hep B/C

66
Q

presentation of cholangiocarcinoma?

A

progressive painless obstructive jaundice

  • gallbladder not palpable

steatorrhoea

weight loss

67
Q

mx of cholangiocarcinoma?

A

poor prognosis: no curative tx

palliative stenting by ERCP

68
Q

pathophysiology of hydatid cyst?

A

zoonotic infection by echinococcus granulosus

  • sheep rearing communities

parasite penetrates the portal system and infects the liver -> calcified cyst

69
Q

presentation of hydatid cyst?

A

mostly asymptomatic

pressure effects: abdo fullness, obstructive jaundice, non specific pain

rupture: -> biliary colic, jaundice, urticaria, anaphylaxis

70
Q

ix of hydatid cyst?

A

bloods- eosinophilia

CT

71
Q

mx of hydatid cyst?

A

medical: albendazole

surgical cystectomy

  • indicated for large cysts