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Hepatobiliary Flashcards

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1
Q

risk factors for gallstones?

A

usually female, forty, fertile, fat

high fat diet

OCP, pregnancy

loss of terminal ileum (decreased bile salts)

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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

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3
Q

what kind of gall stones are associated with haemolysis?

A

calcium bilirubinate

small, black, gritty, fragile

-> increases w blood transfusions/ increased haemolysis

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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
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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

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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

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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

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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
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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

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10
Q

what may acute cholecystitis lead to?

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

presentation of acute cholecystitis?

A

fever

vomiting

severe RUQ pain

  • continuous, radiates to right scapula and epigastrium
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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

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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

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14
Q

mx of empyema following acute cholecystitis?

A

percutaneous drainage: cholecystotomy (tube for drainage in gallbladder)

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15
Q

features of chronic cholecystitis?

A

flatulent dyspepsia

vague upper abdo discomfort

distension, bloating

nausea

flatulence, burping

symptoms exacerbated by fatty foods

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16
Q

ix of chronic cholecystitis?

A

AXR: porcelain gallbladder

US: stones, fibrotic, shrunken gallbladder

MRCP

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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

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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

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19
Q

gallbladder carcinoma assoc w?

A

gallstones

gallbladder polyps

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20
Q

what is a porcelain gallbladder?

A

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

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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
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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

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23
Q

diagnosis of Gallstone ileus?

A

Rigler’s Triad:

pneumobilia

small bowel obstruction

gallstone in RLQ

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24
Q

mx of gallstone ileus?

A

IV fluids

NG tube

Stone removal via enterotomy

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25
causes of obstructive jaundice?
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
features of obstructive jaundice?
jaundice -seen at tongue frenulum first dark urine, pale stools itching (Bile salts)
27
ix of obstructive jaundice?
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
mx of gallstones if no resolution, worsening LFTs or cholangitis?
ERCP w sphincterotomy and stone extraction - delayed cholecystectomy to prevent recurrence
29
Features of ascending cholangitis?
bacterial infection of the biliary tract due to obstruction Charcot's triad: fever/ rigors, RUQ pain, jaundice Reynolds pentad: Charcots triad + hypotension + confusion
30
what is charcot's triad?
fever/ rigors, RUQ pain, jaundice
31
What is reynold's pentad?
Charcots triad + hypotension + confusion
32
mx of ascending cholangitis?
cef and met 1st: ERCP 2nd: Open or lap stone removal
33
risk factors of pancreatic ca?
smoking chronic pancreatitis high fat diet alcohol diabetes
34
most common type of pancreatic ca?
ductal adenoca | (most commonly in head of pancreas)
35
presentation of pancreatic ca?
painless obstructive jaundice anorexia, weight loss, malabsorption epigastric pain acute panc sudden onset DM in the elderly
36
signs of pancreatic ca?
palpable gallbladder jaundice epigastric mass thrombophlebitis migrans (Trousseau sign) Splenomegaly: PV thrombosis -\> portal HTN ascites
37
what is courvoisier's law?
in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to stones
38
what tumour marker is assoc w pancreatic ca?
Ca 19-9 (90% sensitivity)
39
mx of pancreatic ca?
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
most common cause of acute pancreatitis?
1. gallstones 2. ethanol
41
pathophysiology of acute pancreatitis?
pancreatic enzymes released -\> hypovolaemic shock autodigestion and fat necrosis vessel autodigestion -\> retroperitoneal haemorrhage pancreatic necrosis
42
features of acute pancreatitis?
severe epigastric pain -\> back - relieved by sitting forward vomiting
43
signs of acute pancreatitis?
Grey Turners: bruising along flanks Cullens: periumbilical bruising
44
what is the modified glasgow criteria?
assess severity and predict mortality of acute pancreatitis valid for gallstones/ alcohol 3 or more: severe, treat in ITU
45
what is the factors used to score in the modified glasgow criteria?
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
Abnormal bloods in acute pancreatitis?
High Amylase and Lipase Low Calcium High Glucose CRP: monitor progress, \>150 after 48h = severe
47
Conservative Mx of acute pancreatitis?
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
Interventional mx of acute pancreatitis?
ERCP + sphincterotomy
49
surgical mx of acute pancreatitis? indications?
indications: infected pancreatic necrosis pseudocyst or abscess unsure dx laparotomy
50
presentation of pancreatic pseudocyst?
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
ix of pancreatic pseudocyst?
persistently raised amylase +/- LFTs US/ CT
52
mx of pancreatic pseudocyst?
\<6cm: spontaneous resolution \>6 cm: endoscopic cyst-gastrostomy, percutaneous drainage under US/ CT
53
main cause of chronic pancreatitis?
alcohol
54
other causes of chronic pancreatitis apart from alcohol?
genetic: CF, hereditary haemachromatosis immune: lymphoplasmacytic sclerosing pancreatitis (high IgG4) raised triglycerides obstruction by tumour
55
features of chronic pancreatitis?
epigastric pain radiating to back relieving by hot water bottle -\> erythema ab igne exacerbated by fatty food or alcohol steatorrhoea and weight loss
56
Ix of chronic pancreatitis?
raised glucose decreased faecal elastase: decreased exocrine function US: pseudocyst AXR: speckled pancreatic calcifications CT: pancreatic calcifications
57
mx of chronic pancreatitis?
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
complications of chronic pancreatitis?
pseudocyst diabetes pancreatic ca pancreatic swelling -\> biliary obstruction splenic vein thrombosis -\> splenomegaly
59
features of insulinoma?
fasting/ exercise-induced hypoglycaemia high insulin + high c peptide + low glucose
60
features of VIPoma?
watery diarrhoea hypoK achlorhydria acidosis
61
somatostatin function?
inhibits glucagon and insulin release inhibits pancreatic enzyme secretion
62
features of a somatostatinoma?
DM steatorrhoea gall stones
63
what is pancreatic divisum?
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
what is annular pancreas?
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
risk factors for cholangiocarcinoma?
PSC Ulcerative colitis hep B/C
66
presentation of cholangiocarcinoma?
progressive painless obstructive jaundice - gallbladder not palpable steatorrhoea weight loss
67
mx of cholangiocarcinoma?
poor prognosis: no curative tx palliative stenting by ERCP
68
pathophysiology of hydatid cyst?
zoonotic infection by echinococcus granulosus - sheep rearing communities parasite penetrates the portal system and infects the liver -\> calcified cyst
69
presentation of hydatid cyst?
mostly asymptomatic pressure effects: abdo fullness, obstructive jaundice, non specific pain rupture: -\> biliary colic, jaundice, urticaria, anaphylaxis
70
ix of hydatid cyst?
bloods- eosinophilia CT
71
mx of hydatid cyst?
medical: albendazole surgical cystectomy - indicated for large cysts

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