Hepatobiliary Surgery

Question 1

Gallstones

Answer 1

90% remain ASx
slightly more in F
western ^

Aetiology
 Lithogenic bile: Admirand’s Triangle
 Biliary sepsis
 GB hypomotility → stasis
 Pregnancy, OCP
 TPN, fasting

Composition
 Phospholipids: lecithin
 Bile pigments (broken down Hb)
 Cholesterol

Question 2

Gall stones (cholesterol stones)

Answer 2

20%
 Large
 Often solitary

Formation ↑ according to Admirand’s Trangle
 ↓ bile salts
 ↓ lecithin
 ↑ cholesterol

Risk factors
 Female
 OCP, pregnancy
 ↑ age
 High fat diet and obesity
 Racial: e.g. American Indian tribes
 Loss of terminal ileum (↓ bile salts)

Question 3

Gall Stones (Pigment and mixed)

Answer 3

Pigment Stones: 5%
 Small, black, gritty, fragile
 Calcium bilirubinate
 Associated c¯ haemolysis

Mixed Stones: 75%
 Often multiple
 Cholesterol is the major component

Question 4

Gallstones Complications

Answer 4

Gallbladder

• Biliary colic
• Acute Cholescystitis w/(o) empyema
• chronic cholecystisis
• Mucocoele
• Carcinoma
• Mirizzi’s syndrome

CBD - common biliary duct

• obstructive jaundice
• pancreatitis
• cholangitis

Gut - galstone ileus

Question 5

Biliary Colic

description + presentation

Answer 5

Gallbladder Spasm against stone impacted in neck of gallbladder - Hartmann’s Pouch
Less commonly stone in CBD

Presents
Biliary colic
 RUQ pain radiating → back (scapular region)
 Assoc. c¯ sweating, pallor, n/v
 Attacks may be ppted. by fatty food and last <6h

o/e may be tenderness in right hypochondrium
± jaundice if stones passes in to CBD

Question 6

Biliary Colic DDx

Answer 6

cholecystitis/ other gallstone disease
pancreatitis
bowel perforation

Question 7

Biliary Colic Ix

Answer 7

Same work up as cholecystitis as may be difficult to
differentiate clinically.

Urine: bilirubin, urobilinogen, Hb
Bloods: FBC, U+E, amylase, LFTs, G+S, clotting, CRP

Imaging
 AXR: 10% of gallstones are radio-opaque
 Erect CXR: look for perforation
US:
 Stones: acoustic shadow
 Dilated ducts: >6mm
 Inflamed GB: wall oedema

If Dx uncertain after US
 HIDA cholescintigraphy: shows failure of GB filling
(requires functioning liver)
 If dilated ducts seen on US → MRCP

Question 8

Biliary Colic Rx

Answer 8

Conservative
- Rehydrate +NBM
- opioid analgesia (morphing 5-10mg/2h max
high recurrence rate (surgical favoured)

Surgical

• Urgent lap chole (same admission)
• elective lap chole 6-12 weeks

Question 9

Acute cholecystitis

Pathogenesis + sequelae

Answer 9

Pathogenesis
 Stone or sludge impaction in Hartmann’s pouch
 → chemical and / or bacterial inflammation
 5% are acalculous: sepsis, burns, DM

Sequelae

1. Resolution ± recurrence
2. Gangrene and rarely perforation
3. Chronic cholecystitis
4. Empyema

Question 10

Acute cholecystitis Presentation + examination

Answer 10

Severe RUQ pain
- continuous 
- radiates to right scapula + epigastrium 
Fever 
Vomiting

O/E
Local peritonism in RUQ
Tachycardia c¯ shallow breathing
± jaundice
Murphy’s sign
 2 fingers over the GB and ask pt. to breath in
 → pain and breath catch. Must be –ve on the L
Phlegmon may be palpable
Mass of adherent omentum and bowel
Boas’ sign
 Hyperaesthesia below the right scapula

Question 11

Murphy’s sign

Answer 11

Acute cholecystitis
 2 fingers over the GB and ask pt. to breath in
 → pain and breath catch. Must be –ve on the L

Question 12

Phlegmon

Answer 12

Mass of adherent omentum and bowel

(acute cholecystitis)

Question 13

Boas’ Sign

Answer 13

Hyperaesthesia below the right scapular

acute cholecystitis

Question 14

Acute cholecystitis Ix

Answer 14

Urine: bilirubin, urobilinogen

Bloods
 FBC: ↑ WCC
 U+E: dehydration from vomiting
 Amylase, LFTs, G+S, clotting, CRP

Imaging
 AXR: gallstone, porcelain gallbladder
 Erect CXR: look for perforation
US
 Stones: acoustic shadow
 Dilated ducts (>6mm)
 Inflamed GB: wall oedema

If Dx uncertain after US
 HIDA cholescintigraphy: shows failure of GB
filling (requires functioning liver)
 MRCP if dilated ducts seen on US

Question 15

Acute Cholecystitis Mx

Answer 15

Conservative
 NBM
 Fluid resuscitation
 Analgesia: paracetamol, diclofenac, codeine
 Abx: cefuroxime and metronidazole
 80-90% settle over 24-48h
 Deterioration: perforation, empyema

Surgical
 May be elective surgery @ 6-12wks (↓ inflam)
 If <72h, may perform lap chole in acute phase

Empyema
 High fever
 RUQ mass
 Percutaneous drainage: cholecystostomy

Question 16

Chronic Cholecystitis Sx

Answer 16

Flatulent Dyspesia
Vague upper abdominal discomfort
Distension, bloating
Nausea
Flatulence, burping
Symptoms exacerbated by fatty foods
 CCK release stimulates gallbladder

Question 17

Chronic Cholecystitis Ix + Mx

Answer 17

Ix
 AXR: porcelain gallbladder
 US: stones, fibrotic, shrunken gallbladder
 MRCP

Mx
Medical
 Bile salts (not very effective)

Surgical
 Elective cholecystectomy
 ERCP first if US shows dilated ducts and stones

Question 18

Mucocele

Answer 18

Neck of gallbladder blocked by stone but contents
remains sterile
 Can be very large → palpable mass
 May become infected → empyema

Question 19

Gallbladder Carcinoma

Answer 19

Rare
 Associated c¯ gallstones and gallbladder polyps.
 Calcification of gallbladder → porcelain GB
 Incidental Ca found in 0.5-1% of lap choles.

Question 20

Mirizzi’s Syndrome

Answer 20

Rare
 Large stone in GB presses on the common hepatic duct
→ obstructive jaundice.
 Stone may erode through into the ducts

Question 21

Gallstone Ileus

Answer 21

Large stone (>2.5cm) erodes from GB → duodenum
through a cholecysto-duodenal fistula 2ndary to chronic inflam.
May impact in distal ileum → obstruction

Rigler’s Triad:
 Pneumobiliia
 Small bowel obstruction
 Gallstone in RLQ

Rx: stone removal via enterotomy

NB. Bouveret’s syn. = duodenal obstruction

Question 22

Obstructive Jaundice

Answer 22

33% stones
33% Ca head of the pancreas

33% Other
 LNs @ porta hepatis: TB, Ca
 Inflammatory: PBC, PSC
 Drugs: OCP, sulfonylureas, flucolox
 Neoplastic: Cholangiocarcinoma
 Mirizzi’s syndrome

Question 23

Obstructive jaundice clinical features

Answer 23

Jaundice (noticeable at 50mM) - seen on tongue frenulum first

Dark urine, pale stools
Itch (Bile salts)

Question 24

Obstructive Jaundice Ix

Answer 24

Urine -Dark
 ↑ bilirubin ↓ urobilinogen

Bloods
 FBC: ↑ WCC in cholangitis
 U+E: hepatorenal syndrome
 LFT: ↑cBR, ↑↑ ALP, ↑AST/ALT
 Clotting: ↓ vit K → ↑ INR
 G+S: may need ERCP
 Immune: AMA, ANCA, ANA

Imaging
AXR - May visualise stone
 Pneumobilia suggests gas forming infection

US
 Dilated ducts >6mm
 Stones (95% accurate)
 Tumour

MRCP or ERCP
Percutaneous Transhepatic Cholangiography

Question 25

Mx of stones in obstructive jaundice

Answer 25

``` Conservative  Monitor LFTs: passage of stone may → resolution  Vitamins ADEK  Analgesia  Cholestyramine ``` Interventional  If: no resolution, worsening LFTs or cholangitis  ERCP c¯ sphincterotomy and stone extraction Surgical Open / lap stone removal c¯ T tube placement  T tube cholangiogram 8d later to confirm stone removal. Delayed cholecystectomy to prevent recurrence

Question 26

Ascending Cholangitis

Answer 26

May complicate CBD obstruction Charcot's Triad - fever/rigors, RUQ pain, jaundice Reynolds Pentad - Charcot's triad + confusion + shock

Question 27

Ascending cholangitis Mx

Answer 27

Cef and met  1st: ERCP  2nd: Open or lap stone removal c¯ T tube drain

Question 28

Charcot's triad

Answer 28

Fever/rigors, jaundice, RUQ pain Ascending cholangitis

Question 29

Courvoisier's Law

Answer 29

Painless obstructive jaundice w a palpable gallbladder unlikely to be due to stones

Question 30

Pancreatic Carcinoma RF + pathology

Answer 30

``` SINED Smoking Inflammation - chronic pancreatitis Nutrition (fatty diet) EtOH DM ``` ``` 90% ductal carinoma Presents late, mets early  Direct extension to local structures  Lymphatics  Blood → liver and lungs 60% head, 25% body, 15% tail ```

Question 31

Pancreatic Carcinoma Presentation + signs

Answer 31

60+ M  Painless obstructive jaundice: dark urine, pale stools  Epigastric pain: radiates to back, relieved sitting forward  Anorexia, wt. loss and malabsorption  Acute pancreatitis  Sudden onset DM in the elderly Signs  Palpable gallbladder  Jaundice  Epigastric mass  Thrombophlebitis migrans (Trousseau Sign)  Splenomegaly: PV thrombosis → portal HTN  Ascites

Question 32

Pancreatic Carcinoma Ix

Answer 32

Bloods: cholestatic LFTs, ↑Ca19-9 (90% sens), ↑Ca ``` Imaging  US: pancreatic mass, dilated ducts, hepatic mets, guide biopsy  EUS: better than CT/MRI for staging  CXR: mets  Laparoscopy: mets, staging ``` ERCP  Shows anatomy  Allows stenting  Biopsy of peri-ampullary lesions

Question 33

Pancreatic Cancer Rx + Prognosis

Answer 33

``` Surgery  Fit, no mets, tumour ≤3cm (≤10% of pts)  Whipple’s pancreaticoduodenectomy  Distal pancreatectomy  Post-op chemo delays progression  5ys = 5-14% ``` Palliation  Endoscopic / percutaneous stenting of CBD  Palliative bypass surgery: – cholecystojejunostomy + gastrojejunostomy  Pain relief – may need coeliac plexus block Prognosis - mean survival <6mo - 5ys = <2%

Question 34

Acute Pancreatitis Path

Answer 34

Pancreatic enzymes released and activated in vicious circle → multi-stage process. 1. Oedema + fluid shift + vomiting → hypovolaemic shock while enzymes → autodigestion and fat necrosis 2. Vessel autodigestion → retroperitoneal haemorrhage 3. Inflammation → pancreatic necrosis 4. Super-added infection: 50% of pts. c¯ necrosis 10% mortality

Question 35

Acute pancreatitis causes

Answer 35

Idiopathic (20%) ?microstones Gallstones (45%) Ethanol (25%) Trauma ``` Steroids Mumps (other infections - Coxackie B) Autoimmune (PAN) Scorpion (trinidad) Hyperlipidaemia, hypercalcaemia, hypothermia ERCP - 5% risk Drugs - thiazides, azathioprine ```

Question 36

Acute Pancreatitis Sx + Signs

Answer 36

Sx Severe epigastric pain → back  May be relieved by sitting forward Vomiting ``` Signs ↑HR, ↑RR, Fever Hypovolaemia → shock Epigastric tenderness Jaundice Ileus → absent bowel sounds Ecchymoses  Grey Turners: flank  Cullens: periumbilical (tracks up Falciform) ```

Question 37

Grey Turner's

Answer 37

Flank ecchymoses acute pancreatitis

Question 38

Cullen's

Answer 38

Periumbilical ecchymoses Tracks up falciform acute pancreatitis

Question 39

Modified Glasgow Criteria

Answer 39

Valid for EtOH and Gallstones - Assess severity + predict mortality ``` PANCREAS  PaO2 <8kPa  Age >55yrs  Neutrophils >15 x109/L  Ca2+ <2mM  Renal function U>16mM  Enzymes LDH>600iu/L AST>200 iu/L  Albumin <32g/L  Sugar >10mM ``` ``` 1 = mild 2 = mod 3 = severe ```

Question 40

Acute Pancreatitis Ix

Answer 40

``` Bloods FBC: ↑WCC ↑amylase (>1000 / 3x ULN) and ↑lipase  ↑ in 80%  Returns to normal by 5-7d U+E: dehydration and renal failure LFTs: cholestatic picture, ↑AST, ↑LDH Ca2+: ↓ Glucose: ↑ CRP: monitor progress, >150 ``` Urine: glucose, ↑cBR, ↓urobilinogen Imaging  CXR: ARDS, exclude perfed DU  AXR: sentinel loop, pancreatic calcification  US: Gallstones and dilated ducts, inflammation  Contrast CT: Balthazar Severity Score

Question 41

Conservative Mx of Acute Pancreatitis

Answer 41

Manage @ appropriate level: e.g. ITU if severe  Constant reassessment is key  Hrly TPR, UO  Daily FBC, U+E, Ca2+, glucose, amylase ABG Fluid resus - aggressive - keep UO>30ml/h Catheter +/- CVP Pancreatic rest NBM, NGT if vomiting, poss TPN to prevent catabolism Analgesia - pethidine via PCA, or morphine 5-10mg/2h max Abx - not routine if mild, use if suspicion of infection or before ERCP - Penems (meropenem, imipenem)

Question 42

Conservative Mx Complications of Acute Pancreatitis

Answer 42

``` Mx Complications  ARDS: O2 therapy or ventilation  ↑ glucose: insulin sliding scale  ↑/↓Ca  EtOH withdrawal: chlordiazepoxide ```

Question 43

Interventional Mx of Acute Pancreatitis

Answer 43

ERCP (Endoscopic Retrograde Cholangio-Pancreatography) If pancreatitis w dilated ducts 2ndary to gallstones ERCP + sphincterectomy > less complications Surgical Mx - infected pancreatic necrosis - pseudocyst or abscess - unsure Dx Operations  Laparotomy + necrosectomy (pancreatic debridement)  Laparotomy + peritoneal lavage  Laparostomy: abdomen left open c¯ sterile packs in ITU

Question 44

Early Complications of Acute Pancreatitis

Answer 44

``` Early: Systemic Respiratory: ARDS, pleural effusion Shock: hypovolaemic or septic Renal failure DIC ``` Metabolic  ↓ Ca2+  ↑ glucose  Metabolic acidosis

Question 45

Late Complications of Acute Pancreatitis

Answer 45

``` Late (>1wk): Local Pancreatic necrosis Pancreatic infection Pancreatic abscess May form in pseudocyst or in pancreas Open or percutaneous drainage Bleeding: e.g. from splenic artery May require embolisation ``` Thrombosis - Splenic A., GDA or colic branches of SMA  May → bowel necrosis -Portal vein → portal HTN Fistula formation  Pancreato-cutaneous → skin breakdown

Question 46

Pancreatic Pseudocyst

Answer 46

Collection of pancreatic fluid in the lesser sac surrounded by granulation tissue Occur in 20% (esp. in EtOH pancreatitis) Presentation  4-6wks after acute attack  Persisting abdominal pain  Epigastric mass → early satiety Complications  Infection → abscess  Obstruction of duodenum or CBD Ix  Persistently ↑ amylase ± LFTs  US / CT ``` Rx <6cm: spontaneous resolution >6cm  Endoscopic cyst-gastrostomy  Percutaneous drainage under US/CT ```

Question 47

Chronic Pancreatitis Causes

Answer 47

``` AGITS Alcohol (70%) Genetic - CF, HH Immune - Lymphoplasmacytic sclerosing pancreatitis (↑IgG4) Triglycerides ↑ Structural  Obstruction by tumour  Pancreas divisum ```

Question 48

Chronic Pancreatitis Presentation

Answer 48

``` Epigastric Pain  Bores through to back  Relieved by sitting back or hot water bottle → erythema ab igne  Exacerbated by fatty food or EtOH ``` Steatorrhoea and wt. loss DM: polyuria, polydipsia Epigastric mass: pseudocyst

Question 49

Chronic Pancreatitis Ix

Answer 49

``` ↑ glucose ↓ faecal elastase: ↓ exocrine function US: pseudocyst AXR: speckled pancreatic calcifications CT: pancreatic calcifications ```

Question 50

Chronic Pancreatitis Rx

Answer 50

Diet  No EtOH  ↓ fat, ↑ carb ``` Drugs  Analgesia: may need coeliac plexus block  Enzyme supplements: pancreatin (Creon)  ADEK vitamins  DM Rx ``` Surgery Indications  Unremitting pain  Wt. loss  Duct blockage Procedures  Distal pancreatectomy, Whipple’s  Pancreaticojejunostomy: drainage  Endoscopic stenting

Question 51

Chronic Pancreatitis Complications

Answer 51

``` Pseudocyst DM Pancreatic Ca Pancreatic swelling → biliary obstruction Splenic vein thrombosis → splenomegaly ```

Question 52

Pancreatic Insulinoma

Answer 52

> fasting/exercise-induced hypoglycaemia Confusion,stupor, LOC ↑ insulin + ↑ c-peptide + ↓glucose

Question 53

Pancreatic Gastrinoma

Answer 53

Zollinger-Ellison Hypergastrinaemia → hyperchlorhydria → PUD and chronic diarrhoea (inactivation of pancreatic enzymes)

Question 54

Pancreatic Glucagonoma

Answer 54

↑ se glucagon → mild DM Characteristic blistering rash  Necrolytic migratory erythema

Question 55

Pancreatic VIPoma

Answer 55

Verner-Morrison XS VIP Watery Diarrhoea Hypokalaemia Achlorhydria Acidosis

Question 56

Somatostatinoma

Answer 56

Somatostatin - inhibits glucagon + insulin release - inhibits pancreatic enzyme secretion Features - DM - Steatorrhoea - Gall stones usually v malignant > poor progn

Question 57

Pancreatic Malformations

Answer 57

Ectopic Pancreas - Meckel's diverticulum - Small Bowel

Question 58

Pancreas Divisum

Answer 58

Failure of fusion of dorsal and ventral buds → bulk of pancreas drains through smaller accessory duct. Usually asymptomatic May → chronic pancreatitis

Question 59

Annular Pancreas

Answer 59

Fusion of dorsal and ventral buds around duodenum |  May present c¯ infantile duodenal obstruction.

Question 60

Cholangiocarcinoma Path + RF

Answer 60

Rare bile duct tumouir Adenocarcinoma Typically at confluence of R+L heaptic ducts (Klatskin tumours) ``` RF Primary Sclerosing Cholangitis Ulcerative colitis Choledocholithiasis Hep B/C Choledochal cysts Lynch 2 Flukes ```

Question 61

Cholangiocarcinoma Presentation Ix Rx

Answer 61

Progressive painless obstructive jaundice  Gallbladder not palpable Steatorrhoea Wt. loss Ix  Cholestatic LFTs  CA 19-9 Rx  Poor prognosis: no curative Rx  Palliative stenting by ERCP

Question 62

Hydatid Cyst

Answer 62

Zoonotic infection by Echinococcus granulosus  Occurs in sheep-rearing communities  Parasite penetrates the portal system and infects the liver → calcified cyst Presentation Mostly asymptomatic 2ndary infection Pressure effects  Non-specific pain  Abdominal fullness  Obstructive jaundice ``` Rupture  Biliary colic  Jaundice  Urticaria  Anaphylaxis ``` Ix - eosinophilia, CT Rx - Medical - albendazole Surgical - cystectomy (for large cysts)