Imperial Medicine Year 3 > Hepatobiliary Surgery > Flashcards

Hepatobiliary Surgery Flashcards

(78 cards)

Study These Flashcards
1
Q

Epidemiology of gallstones?

A

8% of population >40 yrs.
Incidence increased over last 20yrs.

Incidence increased over last 20yrs: western diet

Slightly increased incidence in females

90% of gallstones remain asymptomatic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Formation of gallstones?

A

General composition

  • Phospholipid: Lecithin
  • Bile pigments (broken down Hb)
  • Cholesterol
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Aetiology of gallstones?

A
  • Lithogenic bile: Admirand’s Triangle?
  • Biliary sepsis
  • gallbladder hypomobility –> - Stasis
  • Pregnancy, OCP
  • TPN, fasting
  • Sudden weight loss (Obesity surgery)
  • Loss of bile salts - Terminal ileitis
  • Diabetes - metabolic syndrome
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are cholesterol stones?

A 
Large
Often Solitary 
Formation increased according to Admirand's triangle: 
- decreased bile salts 
- Decreased lecithin 
- Increased cholesterol
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Risk factors for cholesterol stones?

A
  • Female
  • OCP, Pregnancy
  • Increase Age
  • High fat diet and obesity
  • Racial: E.g American indian tribes
  • Loss of terminal ileum (decreased bile salts)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are pigment stones?

A
  • Small, black, gritty, fragile
  • Calcium bilirubinate
  • Associated with haemolysis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Mixed stones: 75%

A

Often multiple

Cholesterol is the major component

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Complication of gallstones in the gallbladder?

A
  • Biliary Colic
  • Acute cholecystitis + empyema (RUQ + Fever)
  • Chronic cholecystitis
  • Mucocele
  • Carcinoma
  • Mirizzi’s syndrome (deranged LFT)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Complications of gallstones in the CBD?

A

Obstructive jaundice
Pancreatitis
Cholangitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Complications of gallstones in the gut?

A

Gallstone ileus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the pathogenesis of biliary colic?

A
  • Gallbladder spasm against a stone impacted in the neck of the gallbladder
  • Less commonly the stone may be in the CBD.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Presentation of biliary colic?

A

Biliary colic

  • RUQ pain radiating –> back (scapular region)
  • Associated with sweating, pallor, n/v.
  • Attacks may be ppted by fatty food and last 6hr.
  • Tenderness in the right hypochondrium
  • ± jaundice if stones passes into the CBD.

RUQ pain- colic
RUQ pain plus fever- cholecystitis
RUQ pain plus fever plus jaundice (charcot triad)- cholangitis
epigastric pain- more likely pancreatitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the differentials for biliary colic?

A
  • Cholecystitis/other gallstone disease
  • Pancreatitis
  • Bowel perforation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Investigations in biliary colic?

A

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: looking for perforation

US:

  • Stones: acoustic shadow
  • Dilated ducts >6mm
  • Inflamed GB: wall oedema
  • If dilated ducts seen on US –> MRCP

If diagnosis uncertain after US
- HIDA cholescintigraphy:
shows failure of GB filling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Management of Biliary Colic?

A

Conservative

  • Rehydrate + NBM
  • Opioid analgesia: morphine 5-10mg/2hr max
  • High recurrence rate therefore surgical management favoured

Surgical management
- As for conservative + either:
Urgent lap chole (same admission)
- Elective lap chole @ 6-12 weeks.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is acute cholecystitis?

A

Path

  • Stone or sludge impaction in Hartmann’s pouch
  • -> Chemical and/or bacterial inflammation
  • 5% are acalculous: sepsis, burns, DM.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Sequelae of disease of acute cholecystitis?

A
  • Resolution ± recurrence
  • Gangrene and rarely perforation
  • Chronic cholecystitis
  • Empyema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Presentation of acute cholecystitis?

A

Severe RUQ pain

  • Continous
  • Radiates to right scapula and epigastrium

Fever
Vomiting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Examination of acute cholecystitis?

A
  • Local peritonism im RUQ
  • Tachycardia with 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.
  • Phlegmom may be palpable
    Mass of adherent omentum nad bowel
  • Boas’ sign
    Hyperaesthesia below the right scapula.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the investigations of acute cholecystitis?

A
  • Urine: bilirubin, urobilinogen
  • Blood:
    FBC: Increased WCC,
    U+E: dehydration from vomiting
    Amylase, LFTs, G+S, clotting, CRP
Imaging 
- AXR: gallstones, porcelain gallbladder 
- Erect CXR: look for perforation 
- US
Stones: acoustic shadow
Dilated ducts (>6mm) 
Inflamed GB: wall oedema

If diagnosis uncertain after US
- HIDA cholescintigraphy: shows failure of GB filling

MRCP if dilated ducts seen on US.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Management of acute cholecystits?

A

Conservative

  • NBM
  • Fluid resus
  • Analgesia: paracetamol, diclofenac, codeine
  • Abx: cefuroxime and metronidazole
  • 80%-90% settle over 24-48hrs
  • Deterioration: perforation, empyema

Surgical

  • May be elective surgery @ 6-12 weeks (decreased inflammation)
  • If <72hrs, may perform lap chole in acute phase.
  • Empyema
    High fever
    RUQ mass
    Percutaneous drainage: cholecystostomy.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is chronic cholecystitis?

A 
Flatulent dyspepsia
- Vague upper abdominal discomfort
- Distension, bloating 
- Nausea 
- Flatulence, burping 
- Symptoms exacerbated by fatty foods 
CCK release stimulated gallbladder (cholecystokinin)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Differential for chronic cholecystitis?

A

PUD
IBS
Hiatus Hernia
Chronic pancreatitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Investigations for chronic cholecystitis?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Management of chronic cholecystitis?
Medical - Bile salts (not very effective) Surgical - Elective cholecystectomy - ERCP first if US shows dilated ducts and stones.
26
What is a mucocele?
- Neck of gallbladder blocked by stone but contents remain sterile - Can be very large --> palpable mass - May become infected --> empyema
27
Gallbladder carcinoma?
- Rare - Associated with gallstones and gallbladder polyps - Calcification of gallbladder --> Porcelain GB - Incidental Ca found in 0.5-1% of lap choles.
28
Mirizzi's syndrome?
- Rare - Large stone in GB presses on the common hepatic duct --> obstructive jaundice - Stones may erode through into the ducts.
29
Gallstone Ileus?
Large stone erodes from GB --> duodenum through a cholecysto-duodenal fistula 2nd to chronic inflammation May impact in distal ileum --> obstruction Rigler's Triad - Pneumobilia (air in bile duct) - Small bowel obstruction - Gallstone in the RLQ Stone removal via enterotomy
30
Acute pancreatitis pathophysiology?
Pancreatic enzyme released and activated in vicious circle 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 with necrosis
31
Epidemiology of acute pancreatitis?
1% of surgical admissions 4th and 5th decade 10% mortality
32
Aetiology of acute pancreatitis? Common
Gallstones (45%) Ethanol (25%) Idiopathic (20%): microstones? ``` Trauma Steroids Mumps (Coxsackie B) Autoimmune, Ascaris Infection Scorpion venom Hypertriglyceridaemia, Hypercholymicronaemia, Hypercalcaemia, hypothermia ERCP Drugs ```
33
More rare causes of acute pancreatitis?
``` Trauma Steroids Mumps/Coxsackie B Autoimmune e.g PAN Scorpion venom ERCP Drugs: thiazides, azathioprine, sodium valproate, furosemide, bendoflumethiazide) ```
34
Symptoms of acute pancreatitis?
Severe epigastric pain --> back pain - May be relieved by sitting forward - Vomiting
35
Signs of acute pancreatitis?
``` Increased HR Increased RR Fever Hypovolaemia --> shock Epigastric tenderness Jaundice Ileus --> absent bowel sounds Ecchymoses - Grey Turners: Flank - Cullens: periumbilical (tracks up Falciform) ```
36
Differential for Acute Pancreatitis?
Perforated DU Mesenteric infarction MI
37
Modified Glasgow Criteria?
- Valid for EtOH and Gallstones - Assess severity and predict mortality - Ranson's criteria are only applicable to EtOH and can only be fully applied after 48hrs.
38
What is PANCREAS used to measure?
``` PaO2 <8 (hypoxia) Age >55 Neutrophils >15 x 10 Ca2+ <2mM (hypocalcaemia) Renal function U >16 mM Enzymes LDH >600, AST >200 Albumin <32 Sugar >10mM (hyperglycaemia) ```
39
Investigations for acute pancreatitis?
``` Bloods - FBC: Increased WCC - Increased amylase (>1000/3x ULN) and increased lipase Increased in 80% Returns to normal by 5-7d. ``` - U+E: dehydration and renal failure - LFTs: cholestatic picture, increased AST, increased LDH. - Ca down - Glucose up - CRP: monitor progress > 150 after 48hrs = severe - ABG: decreased O2 suggests ARDS Urine: glucose, increased conjugated bilirubin, decreased urobilinogen Imaging - CXR: ARDS, perf DU - AXR: sentinel loop, pancreatic calcification - US: Gallstones, dilated ducts, inflammation - Contrast CT: Balthazar Severity Score
40
Conservative management of acute pancreatitis?
Manage @ ITU if severe - Constant reassessment is key - Hrly TPR, UO - Daily FBC, U+E, Ca2+, Glucose, amylase ABG. Serum lipase is more sensitive and specific Fluid resus - Aggressive fluid resus: keep UO >30ml/h - Catheter ± CVP Pancreatic Rest - NBM - NGT if vomiting - TPN may be required if severe to prevent catabolism Analgesia - Pethidine via PCa - Or morphine 5-10 mg/2hr max Antibiotics - Not routinely given if mild - Use if suspicion of infection or before ERCP - Penems often used meropenem, imipenem
41
Management of complications of acute pancreatitis?
ARDS: o2 therapy or ventilation Increased glucose: insulin sliding scale - Increased/decreased Ca - EToH withdrawal: chlordiazepoxide
42
Intervention management is pancreatitis with dilated ducts 2nd to gallstones
ECRP + sphincterotomy --> If due to just gallstones - undergo early cholecystectomy
43
Surgical management of acute pancreatitis?
``` Surgical management - Indications Infected pancreatic necrosis - Pseudocyst or abscess - Unsure diagnosis ``` Operations - Laparotomy + necrosectomy (pancreatic debridement) - Laparotomy + peritoneal lavage - Laparostomy: abdomen let open with sterile packs in ITU
44
What are the early systemic complications of Acute Pancreatitis?
``` Respiratory: ARDS, pleural effusion Shock: hypovolaemic or septic Renal failure DIC Metabolic - Decreased Ca - increased glucose - metabolic acidosis ```
45
What are the late >1 weeks complication of acute pancreatitis?
``` Pancreatic necrosis Pancreatic infection Pancreatic abscess - May form in pseudocyst or in pancreas - Open or percutaneous drainage ``` Bleeding: 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
46
What is a pancreatic pseudocyst (late complication)
- Collection of pancreatic fluid in the lesser sac surrounded by granulation tissue - Occurs in 20% (esp in EToH pancreatitis) - Presentation 4-6 weeks after acute attack Persisting abdominal pain Epigastric mass --> early satiety Complications - Infection --> abscess - Obstruction of duodenum or CBG Invx - persistently increased amylase ± LFTs - US/CT management - <6cm - Spontaneous resolution - >6cm = endoscopic cyst-gastrostomy - Percutaneous drainage under US/CT.
47
What is chronic pancreatitis caused by?
AGITS - Alcohol - Genetic CF HH - Immune Lymphoplasmacytic sclerosing pancreatitis (Increased IgG4) - triglycerides increased - Structural Obstruction by tumour Pancreas divisum
48
Presentation of chronic pancreatitis?
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 weight loss - DM: polyuria, polydipsia - Epigastric mass; Pseudocyst
49
Investigations for chronic pancreatitis?
Increased Glucose Decreased faecal elastase: decreased exocrine function US: pseudocyst AXR: speckled pancreatitis calcifications CT: pancreatic calcifications. With IV contrast. Look for pancreatic calcification
50
Management of chronic pancreatitis?
Diet - No alcohol - Low fat, increased carbs Drugs - Analgesia - Enzyme supplements: pancreatin (creon) - ADEK vitamins - DM management Surgery - Indications (unremitting pain, weight loss, duct blockage) - Can do a Whipple's, pancreaticojejunostomy; drainage - Endoscopic stenting
51
Complications of chronic pancreatitis?
``` Pseudocyst DM Pancreatic Ca Pancreatic swelling --> biliary obstruction Splenic vein thrombosis ```
52
Pancreatic Endocrine neoplasia types?
``` Insulinoma Gastrinoma -.> Zollinger-Ellison Glucagonoma VIPoma Somatostatinoma ```
53
What is an insulinoma?
- Fasting/exercise-induced hypoglycaemia - Confusion, stupor, LOC - Increased insulin + increased c-peptide + decreased glucose
54
Gastrinoma (ZE syndrome)
Hypergastrinaemia --> hyperchlorhydia --> PUD + chronic diarrhoea
55
Glucagonoma
Increased glucagon --> Mild DM Characteristic blistering rash - Necrolytic migratory erythema
56
VIPoma?
Watery diarrhoea Hypokalaemai - Achlorhydria - Acidosis
57
Somatostatinoma
Somatostatin - Inhibits glucagon + insulin release - Inhibits pancreatic enzyme secretion Features - DM - Steatorrhoea - Gall stones
58
Cholangiocarcinoma patholgy?
Pathology - Rare bile duct tumour - Adenocarcinoma - Typically occur @ confluence of right and left hepatic ducts: called Klatskin tumours.
59
Cholangiocarcinoma risk factors?
``` PSC Ulcerative colitis Choledocholithiasis (bile stones in duct) Hep B/C Choledochal cysts Lynch 2 Flukes ```
60
Presentation of cholangiocarcinoma
Progressive painless obstructive jaundice - Gallbladder not palpable Steatorrhoea Weight loss
61
Investigations of Cholangiocarcinoma ?
Cholestatic LFTs | Ca 19-9
62
Management of cholangiocarcinoma ?
Poor prognosis: no curative management | Palliative stenting by ERCP
63
Causes of Obstructive Jaundice?
``` - Causes 30% Stones 30% Ca head of the pancreas 30% - LNs @portal hepatitis: TB, Ca Inflammatory: PBC, PSC Drugs: OCP, sulphonylureas, fluclox Neoplastic: cholangiocarcinoma Mirizzi's syndrome ```
64
Clinical features of obstructive jaundice?
- Noticeable @ ~50mM Seen @tongue frenulum first - Dark urine, pale stools. - Itch (bile salts)
65
Investigations for obstructive jaundice?
Urine - Dark - Increased bilirubin - Decreased urobilinogen
66
Bloods for obstructive jaundice?
- FBC: Increased WCC in cholangitis - U+E: hepatorenal syndrome - LFTs: increased cBR, increased ALP a lot, some increase in AST/ALT. - Clotting: decreased vit K --> Increased INR - G+S: may need ERCP Immune: AMA, ANCA, ANA
67
Imaging for obstructive jaundice?
AXR - May visualise stone - Pneumobilia suggest gast forming infection US - Dilated ducts >6mm - Stones (95% accurate) - Tumours MRCP or ERCP Percutaneous Transhepatic Cholangiography
68
Management of the stones? Conservative
Monitor LFTs: passage of stones may --> resolution Vitamin ADEK Analgesia Cholestyramine
69
Interventional management of stones?
Interventional - If: no resolution, worsening LFTs or cholangitis ERCP with sphincterotomy and stone extraction Surgical - Open/lap stone removal with T tube placement - - T tube cholangiogram 8d later to confirm stone removal - Delayed cholecystectomy to prevent recurrence
70
Ascending cholangitis?
May complicate CBD obstruction - Charcot's triad: fever/rigors, RUQ pain, jaundice - Reynold's pentad: Charcot's triad + shock + confusion Management - Cef and Met 1st: ERCP 2nd: open or lap stone removal with T tube drain
71
Risk factors for a pancreatic carcinoma?
``` Smoking Inflammation: chronic pancreatitis Nutrition: increased fat diet EtOH DM ```
72
Pathology of pancreatic carcinoma?
``` 90% ductal adenocarcinoma Present late, metastasis early - Direct extension to local structure - Lymphatics - Bloods -- Liver and lungs ``` 60% located in the head, 25% in body, 15% in tail
73
Presentation of pancreatic carcinoma?
- Typically male >60 yrs - Painless obstructive jaundice: dark urine, pale stools. - Epigastric pain: radiates to back, relieved sitting - Anorexia, weight loss and malabsorption - Acute pancreatitis - Sudden onset DM in the elderly
74
Signs of pancreatic carcinoma?
- Palpable gallbladder - Jaundice - Epigastric mass - Thrombophlebitis migrans (Trousseau Sign) Splenomegaly: PV thrombosis --> Portal HTN - Ascites
75
What is courvoisier's law?
IN the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to stones.
76
Investigations of pancreatic carcinoma?
Blood: Cholestatic LTFs, increased Ca19-9 (90%) ,increased 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
77
Management of pancreatic cancer?
Surgery - Fit, not mets, tumour <3cm (<10% of patients) - Whipple's pancreaticoduodenectomy - DIstal pancreatectomy - Post-op chemo delays progression - 5yrs = 5-14%/
78
Palliation of pancreatic cancer?
Endoscopic/percutaneous stenting of CBD Palliative bypass surgery - Cholecystojejunostomy + gastrojejunostomy - Pain relief - coeliac plexus block
Imperial Medicine Year 3
flashcards
Decks in class (35)
# Cards
Brainscape helps you reach your goals faster, through stronger study habits.
© 2026 Bold Learning Solutions. Terms and Conditions