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HepatoBilliary Surgery Flashcards

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1
Q

Definition of acute pancreatitis

A

An acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems

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2
Q

Etiology of acute pancreatitis

A
  • alcohol
  • gallstones
  • idiopathic
  • obstructive
  • metabolic
  • drugs
  • trauma
  • viral infection
  • pregnancy
  • collagen disease
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3
Q

Pathogenesis of acute pancreatities

A
  • inappropriate activation of trypsinogen to trypsin
  • breaks down tissue
  • triggers SIRS
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4
Q

2 pathological types of acute pancreatitis

A
  • acute interstitial oedematous pancreatitis (mild)

- acute necrotising pancreatitis (severe)

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5
Q

Local complications of acute pancreatitis

A
  • acute pancreatic fluid collection
  • pancreatic psuedocyst
  • acute necrotic collection
  • walled-off necrosis
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6
Q

Other organ complications of acute pancreatitis

A
  • gastric outlet obstruction
  • splenic/portal vein thrombosis
  • intestinal necrosis
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7
Q

Diagnosis of acute pancreatitis

A

2 of the following:

  • abdominal pain
  • serum lipase/amylase >3x normal
  • characteristic findings on CT/MRI
  • N+V
  • Cullen’s/ Grey-Turner
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8
Q

Definition of SIRS

A

2 or more of:

  • HR>90
  • temp <36 or >38
  • WCC <4000 or >12000
  • resp >20 or pCO2 <32

Increased risk of organ failure

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9
Q

Definition of organ failure

A

Score of 2 or more for 1 of the organ systems using the modified Marshall scoring system
(renal, resp, CVS)

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10
Q

Grading the severity of acute pancreatitis

A
  • mild acute pancreatitis (MAP)
  • moderate severe acute pancreatitis (MSAP)
  • severe acute pancreatitis (SAP)
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11
Q

Management of gallstone pancreatitits

A
  • initial conservative management
  • elective cholecystectomy 4 weeks later
  • if jaundiced, do ERCP
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12
Q

How to recognise SAP

A
  • haemodynamic instability
  • hypoxic confusion
  • pleural effusion + pulm infiltrates on CXRAY
  • SIRS response
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13
Q

Why do patients with SAP need ICU admission?

A
  • resus for hypovolaemic shock
  • may need ventilation
  • metabolic management
  • enteral nutrition
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14
Q

Scoring systems for SAP

A
  • CRP

- Ranson’s

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15
Q

Definition of chronic pancreatitis

A

A continuing inflammatory disease of the pancrease characterised by irreversible morphologic changes

  • assoc with pain and loss of exo/endocrine function
  • involves parenchyma and ductal system
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16
Q

Etiology of chronic pancreatitis

A
  • alcohol
  • nutritional
  • CF
  • hereditary
  • idiopathic
  • AI
  • obstructive
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17
Q

Pathogenesis of pain in chronic pancreatitis

A
  • inflammatory processes lead to fibrosis and ductal dilatation
  • damaged neural structures
  • oxygen free radicals
  • compartment syndrome
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18
Q

Complications of chronic pancreatitis

A
  • diabetes
  • fat malabsorption
  • pseudocyts
  • pancreatic ascites
  • false aneurysm
  • splenic vein thrombosis - portal HPT
  • biliary/ duodenal stenosis/ obstruction
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19
Q

2 clinical patterns of chronic pancreatitis

A
  • intermittent mild attacks

- progressive, severe and persistent

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20
Q

How to test pancreatic function

A
  • direct

- indirect = faecal elastase

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21
Q

Step-up pain management regime for chronic pancreatitis

A
  • abstinence with low fat diet
  • paracetamol/NSAIDS
  • trial of high dose pancreatic enzymes with acid support
  • narcotics
  • anti-depressants
  • percutaneous coeliac plexus block
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22
Q

Drainage procedures for chronic pancreatitis

A
  • pancreatico-jujenostomy

- Frey procedure

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23
Q

Types of glass stones

A
  • chol
  • BR
  • calciums salts
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24
Q

Causes of black pigment stones

A

Haemolytic conditions

Liver cirrhosis

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25
Cause of brown pigment stones
Worm infestation
26
Constituents of bile
- Chol - bile salts - phospholipids
27
Calot's triangle
- cystic duct inf - common hepatic duct med - cystic artery sup
28
Lymph node in the middle of Calot's triangle
- Mascagni/ Lund
29
Surgical objectives of cholecystectomy
- eliminate gallbladder - eliminate gallstones - exclude stones in biliary tree - ensure bile ducts aren't damaged
30
Medical treatment of gallstones
- medical dissolution therapy - contact dissolution therapy - extracorporeal shockwave lithotripsy
31
Definition of acute cholecystitis
A gallstone becomes impacted in cystic duct/ Hartman's pouch | - leads to inflammation and infection of gallbladder wall
32
Symptoms of acute cholecystitis
- severe pain - nausea and vomiting - pyrexia and Murphy's sign
33
Things found on US in cholecystitis
- stone - thickwalled gallbladder - radiological Murphys
34
Natural history of cholecystitis
- stone impacts leading to fibrosis - asbscess forms (empyema) - perforation
35
Definition of choledocholithiasis
Stones in the CBD
36
Symptoms of cholangitis (Charcot's triad)
- biliary colic - jaundice - fever/rigors
37
Courvasier's Law
Painless obstructive jaundice and a palpable gallbladder cannot be due to gallstones
38
Structure of the pancreas
- acini = enzymes - ducts = transport enzymes - Islet's of Langerhans = endocrine cells
39
Most common type of pancreatic neoplasm
Pancreatic ductal adenocarcinoma
40
Risk factors for pancreatic ductal adenocarcinoma
- predisposing cancer syndrome - smoking - chronic pancreatitis - DM + obesity
41
Cancer syndromes that predispose to pancreatic cancer
- HNPCC - BRCA2 - PAP - Peutz-Jager
42
Clinical presentation of pancreatic cancer
- painless obstructive jaundice - upper abdo pain that rad to back - weight loss - late onset diabetes - gastric outlet obstruction - ascites - abdo mass - thrombophlebitis migrans (Trousseu's syndrome) - dyspepsia
43
Examination findings in pancreatic cancer
- temp wasting - skin excoriation - Virchow's node - Sister mary Joseph nodule
44
Best radiological investigation for pancreatic cancer
CT scan
45
Contraindications for pancreatic resection
- mets - lymph node involvement - major vessel involvement - co-morbid disease
46
Resection operations for pancreatic cancer
- Whipples - distal pancreatectomy - pancreaticoduodenectomy
47
Types of pancreatic neuroendocrine tumours
- insulinomas - gastrinomas - glucagonoma
48
What is Whipple's triad?
- symptoms of hypoglycaemia - glucose <5 - relief of hypoglycaemia with glucose
49
Symptoms of insulinoma
- anxiety, confusion, LOC - Weight gain - often confused with psych
50
Management of an insulinoma
- resection (cherry-red mass) | - enucleation
51
Where are gastrinomas found?
The gastrinoma triangle
52
The gastrinoma triangle
Sup: confluence of cystic and CBD Inf: junction of 2nd and 3rd parts of dudenum Med: junction of neck and body of pancreas
53
Symptoms of a gastrinoma
- fulminant PUD (Zollinger Ellison) - epigastric pain - diarrhoea that resolves with PPIs
54
Symptoms of a glucogonoma
- cachexia - malnutrition - protein depletion - rash (necrolytic migratpry erythema) - glucose intolerance - DVT
55
Cystic neoplasms of the pancrease
- serous cystic neoplasms - mucinous cystic neoplasms - Intraductal papillary mucinous neoplasms - solid pseudopapillary tumor
56
Causes of portal hypertension
- prehepatic - hepatic - post-hepatic
57
Pharmacological management of acute oesophageal variceal bleeding
- vasopressin - somatostatin - octreotide
58
Endoscopic management of oesophageal varices
- band ligation | - injection sclerotherapy
59
Management of oesophageal variceal bleeding
- pharmacologicla - endoscopic - balloon tamponade - TIPS - surgical (shunts/ surgical transection)
60
What does TIPS stand for?
Transjugular intrahepatic portosystemic shunt
61
How to score prognosis for chronic liver disease
Child-Pugh score
62
Components of Child Pugh score
- MR - albumin - prothrombin time - Ascites - encephalopathy
63
Long-term management to prevent variceal bleeding
- endoscopic - pharmacotherapy - surgery - liver transplant
64
Causes of ascites
- portal HPT - hypoalbuminaemia - neoplasms - misc.
65
Treatment of ascites
- reduce salt intake - diuretics - abstain from alcohol - paracentesis
66
Features of hepatic encephalopathy
- monotonous speech - flat affect - tremor - muscular incoord - asterixis - fetor hepaticus - coma - upgoing plantars - deranged reflexes - decerebrate posturing
67
Events that precipitate encephalopathy in cirrhotic patients
- electrolyte imbalance - GI bleeding - drugs - infection - constipation
68
Treatment of hepatic encephalopathy
- treat precipitating factors - non-absorbable disaccharides (lactulose) - antibiotics - protein restriction
69
What is hepatorenal syndrom
Acute oliguric renal failure in cirrhotic liver disease resulting from intense intrarenal vasoconstruction in otherwise normal kidneys
70
What is SBP?
Infection of ascites in the absence of a local infectious source - usually in cirrhotic ascites - gram neg enteric bacteria
71
MELD (model for End-stange liver disease
- BR - INR - creat
72
Objectives of assessing a liver mass
- establish a diagnosis - determine whether surgery is indicated - judge whether resection is possible
73
Symptoms of a pyogenic liver abscess
- abdo pain - swinging pyrexia - nocturnal sweating - vomiting - anorexia - malaise
74
Antibiotics for pyogenic liver abscess
- penicillin, aminoglycoside and metronidazole for 4 weeks
75
Methods of drainage for pyogenic liver abscess
- percutaneous - catheter - surgical
76
Organism in amoebic liver abscess
Entamoeba histolytica | - single abscess filled with anchovy pasts
77
AB for amoebic liver abscess
Metronidazole 500mg 3x daily for 5 days
78
Organism responsible for hydatid disease
Echinococcus granulosis
79
Presentation of hydatid liver abscess
- liver enlargement - RUQ pain - complication
80
Complications of hydatid liver disease
- cyst rupture (urticaria, anaphylaxis) - erodes into bile duct (pain, jaundice) - perforation through diaphragm
81
Treatment of hydatid liver disease
All symptomatic need surgery | - Albendazole for 2 weeks
82
Side effects of albendazole
- bone marrow depression | - liver and renal toxicity
83
Classification of liver tumours
- cystic vs solid | - benign vs malignant
84
Signs of cystic tumours on US
- thick walled - septae - nodules - echogenic
85
Types of cystic liver tumours
- cystadenoma | - cystadenocarcinoma
86
Benign tumours of the liver
- haemangioma - liver cell adenoma - focal nodular hyperplasia
87
Risk factors for HCC
- hep B+C | - aflatoxin
88
Symptoms of HCC
- decrease in liver function - acute complication of cirrhosis - upper abdominal pain and fever
89
Tumour marker or HCC
AFP
90
What is fibrolamellar carcinoma
A subtype of HCC occurring in non-cirrhotic livers wtih Hep B/C
91
Mets common in the liver
- GIT tumours - bronchus - breast - ovary - lymphoma

Surgery Revision (8 decks)

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