hepatobiliary surgery

Question 1

at what level of bilirubin is jaundice usually seen?

Answer 1

> 35 mmol/L

Question 2

normal serum bilirubin?

Answer 2

3-17 mmol/L

Question 3

causes of prehepatic jaundice?

Answer 3

• autoimmune hemolytic anemia
• drug toxicity
• transfusion reaction
• congenital - hereditary spherocytosis, sickle cell

Question 4

causes of hepatic jaundice?

Answer 4

• gilberts (unconj)
• crigler-najjar (unconj)
• viral hepatitis
• alcoholic liver disease
• toxic drug jaundice
• metastatic disease
• dubin johnsin
• rotor

Question 5

causes of post hepatic jaundice - intraluminal causes ?

Answer 5

choledocholithiasis

Question 6

causes of post hepatic jaundice - mural causes ?

Answer 6

• primary sclerosing cholangitis

- biliary stricture

Question 7

causes of post hepatic jaundice - extrinsic causes ?

Answer 7

• carcinoma of head of pancreas, ampulla of vater or bile duct
• chronic pancreatitis
• enlarged lymph nodes in porta hepatis
• mirizzi syndrome

Question 8

what is mirizzi syndrome?

Answer 8

-external biliary compression from a stone impacting the neck of the gallbladder

Question 9

what is charcots triad?

Answer 9

Triad seen in ascending cholangitis?

• RUQ pain
• fever and rigors
• jaundice

Question 10

murphys sign suggests…

Answer 10

gallbladder inflammation

Question 11

Courviousiers law

Answer 11

A painless, palpable gallbladder in a patient with jaundice is unlikely due to gallstone disease and may suggest malignant obstruction

Question 12

what are the three components of bile?

Answer 12

• cholesterol
• bile salts
• phospholipids

Question 13

complications of acute cholecystitis?

Answer 13

• empyema or abscess of gallbladder
• perforation with peritinitis
• gallstone ileus
• jaundice due to compression of adjacent bile duct (Mirizzi)

Question 14

what is chronic cholecystitis?

Answer 14

-attacks of RUQ and tenderness

Question 15

management of chronic cholecystitis?

Answer 15

-analgesia and routine cholecystectomy

Question 16

patho of a mucocele?

Answer 16

-when stones block the neck of the gallbladder and bile is reabsorbed but mucous is continued to be secrete leading to a large tense globular mass in the RUQ

Question 17

treatment of ascending cholangitis?

Answer 17

-IV fluids, antibiotics and relieving the obstruction

Question 18

next ix after ultrasound for ascending cholangitis?

Answer 18

ERCP

Question 19

next investigation after ERCP for ascending cholangitis?

Answer 19

if stone is identified on ERCP -> MRCP or percutaneous cholangiography

Question 20

SEPSIS 6

Answer 20

TAKE 3:

• lactate
• blood cultures
• urine output

GIVE 3:

• oxygen
• fluids
• antibiotics

Question 21

Management of ascending cholangitis:

Answer 21

• analgesia
• IV fluids
• antibiotics
• oral intake restricted
• THEN plan for either elective cholecystectomy, or perform during admission

Question 22

I GET SMASHED - aetiologies for pancreatitis?

Answer 22

I-idiopathic
G-gallstones
E-ethanol/alcohol
T-trauma
S-steroids
M-mumps & other infections
A-autoimmune
S-spider/scorpion
H-hypertriglyceridemia
E-ERCP
Drugs and toxins

Question 23

severe pancreatitis can result in…

Answer 23

SIRS

Question 24

left flank bruising in pancreatitis =

Answer 24

grey-turners sign

Question 25

periumbilical bruising in pancreatitis =

Answer 25

cullens sign

Question 26

what is the name of the scale that determines MORTALITy of pancreatitis

Answer 26

ransons

Question 27

what is the name of the scale that determines the SEVERITY of pancreatitis

Answer 27

glasgow

Question 28

BEDSIDE investigations for pancreaittis

Answer 28

-ECG, urine dipstick

Question 29

Blood tests for someone with pancreatitis

Answer 29

-FBC, LFTS, ALK phos, coag, cross match, ca, blood glucose, amylase, electrolytes,CRP ABGs

Question 30

why are lipase and urinary amylase sometimes useful for diagnosisng pancreatitis?

Answer 30

they remain elevated longer than serum amylase

Question 31

Imaging for suspected pancreatitis

Answer 31

``` CXRAY - rule out free air under diagphram Ultrasound for gallstones Abdominal XRAY - CT Endoscopic ultrasound MRCP ```

Question 32

Local complications of pancreatitis

Answer 32

- abscess - pseudocyst - necrosis/gangrene - splenic vein thrombosis/hemorhage - peripancreatic fluid collection

Question 33

what is a pseudocyst?

Answer 33

collection of fluid that does not have epithelial lining

Question 34

Systemic complications of pancreatitis

Answer 34

- sepsis - arythmia - hypovolemia - renal failure - ARDS, pleural effusions, pneumonia - DIC - hyperglycemia - hypocalcemia - death - intestinal hemorhage/ileus

Question 35

Ix for CHRONIC pancreatitis

Answer 35

- abdominal xray - abdominal ultrasound - pancreatic duct dilation - CT - MRCP - ERCP - endoscopic ultrasound combined with aspiration cytology/biopsies - fecal elastase to check endocrine function

Question 36

non-surgical management of chronic pancreatitis

Answer 36

- stop offending agents (alcohol) - decrease fat in diet - creon - insulin (if necessary) - pain control

Question 37

surgical options for chronic pancreatitis (if medical therapy fails)?

Answer 37

- pancreatoduodenectomy (whipples procedure) - partial or distal pancreatectomy - pancreaticojejunostomy

Question 38

most common type of pancreatic cancer

Answer 38

ductal adenocarcinoma

Question 39

tumour marker for pancreatic cancer?

Answer 39

CA-19-9

Question 40

most common endocrine tumour of the pancreas?

Answer 40

insulinoma

Question 41

90% of insulinomas are (benign/malignant)

Answer 41

benign