HPB

Question 1

What is jaundice

Answer 1

Yellow discolouration of skin and sclera

Due to hyperbilirubinaemia

Question 2

What is pre-hepatic jaundice

Answer 2

Excessive RBC breakdown

Overwhelm liver’s ability to conjugate bilirubin

Question 3

What is hepatocellular jaundice

Answer 3

Dysfunction of hepatic cells

Get a mixed picture (conjugated and unconjugated bilirubin)

Question 4

What is post-hepatic jaundice

Answer 4

Obstruction of biliary drainage

Bilirubin conjugated by liver

Question 5

What investigations are needed for jaundice

Answer 5

Bilirubin, albumin, AST, ALT, ALP, gamma GT

Coagulation studies

FBC, U&Es

Liver screen

Question 6

What investigations are needed for jaundice

Answer 6

Ultrasound abdomen (first line)

MRCP (visualise biliary tree)

Liver biopsy

Question 7

What are the types of gallstones

Answer 7

Cholesterol

Pigment (bile)

Mixed (cholesterol and bile)

Question 8

What are the risk factors for gallstones

Answer 8

Fat

Female

Fertile

Forty

Family history

Pregnancy

Oral contraception

Haemolytic anaemia

Malabsorption

Question 9

What is biliary colic

Answer 9

Gallbladder neck impacted by gallstone

Pain due to contraction against blockage

No inflammation

Question 10

How might biliary colic present

Answer 10

Sudden onset, dull, colicky RUQ pain

Can radiate to epigastric region or back

Brought on by eating fatty food

Nausea and vomiting

Question 11

How might acute cholecystitis present

Answer 11

Constant RUQ pain

Radiation to epigastrium

Fever

Lethargy

Tender RUQ

Murphy’s sign: pressure to RUQ, inspire, positive if halt inspiration due to pain

Check for guarding

Question 12

What are the differentials for biliary colic and acute cholecystitis

Answer 12

GORD

Peptic ulcer

Acute pancreatitis

Inflammatory bowel disease

Question 13

What investigations are needed for biliary colic and acute cholecystitis

Answer 13

FBC, CRP, LFTs, amylase, urinalysis

Ultrasound (see gallstones or sludge, thick gallbladder wall, bile duct dilation)

MRCP (gold standard)

Question 14

What is the management for biliary colic

Answer 14

Analgesia

Lifestyle advice

Laparoscopic cholecystectomy (high risk of recurrence, within 6 weeks)

Question 15

What is the management for acute cholecystitis

Answer 15

IV antibiotics

Analgesia

Antiemetics

Laparoscopic cholecystectomy (within 1 week)

Question 16

What are the complications of biliary colic and acute cholecystitis

Answer 16

Mirizzi syndrome: stone in Hartmann’s pouch, compression of common bile duct

Gallbladder emphysema: gallbladder fills with pus

Chronic cholecystitis: persistent inflammation of gallbladder wall

Bouveret’s syndrome: can get fistula between gallbladder and small bowel

Question 17

What is cholangitis

Answer 17

Infection of biliary tree

High morbidity and mortality

Causes biliary outflow obstruction and biliary infection

Question 18

What are the causes of cholangitis

Answer 18

Gallstones

Iatrogenic

Cholangiocarcinoma

Pancreatitis

Primary sclerosing cholangitis

Ischaemic cholangiopathy

Parasitic infection

Common organisms: E coli, klebsiella, enterococcus

Question 19

How might cholangitis present

Answer 19

RUQ pain

Fever

Jaundice

Pruritus

Pyrexia

Rigors

Charcot’s triad

Reynold’s pentad

Question 20

What is Charcot’s triad for cholangitis

Answer 20

Jaundice

Fever

RUQ pain

Question 21

What is Reynold’s pentad for cholangitis

Answer 21

Jaundice

Fever

RUQ pain

Hypotension

Confusion

Question 22

What investigations are needed for cholangitis

Answer 22

Routine bloods

Blood cultures

Ultrasound biliary tree

ERCP (gold standard)

Question 23

What is the management for cholangitis

Answer 23

Immediate: sepsis 6, IV fluids, routine bloods, blood cultures, broad spectrum IV antibiotics

Definitive: endoscopic biliary decompression, cholecystectomy

Question 24

What is cholangiocarcinoma

Answer 24

Cancer of biliary tree

95% adenocarcinomas

Question 25

What is Courvoisier's law

Answer 25

If have jaundice and enlarged palpable gallbladder, strongly suspect malignancy of biliary tree or pancreas

Question 26

What is acute pancreatitis

Answer 26

Inflammation of pancreas Scoring via Glasgow criteria

Question 27

What are the causes of pancreatitis

Answer 27

GET SMASHED Gallstones Ethanol Trauma Steroids Mumps Autoimmune disease Scorpion venom Hypercalcaemia ERCP Drugs (azathioprine, NSAIDs, diuretics)

Question 28

How might acute pancreatitis present

Answer 28

Severe epigastric pain Radiates to back Nausea and vomiting Guarding Haemodynamic instability Cullen's sign Grey Turner's sign Tetany Jaundice

Question 29

What are the differentials for acute pancreatitis

Answer 29

Abdominal aortic aneurysm Renal calculi Chronic pancreatitis Aortic dissection Peptic ulcer disease

Question 30

What investigations are needed for acute pancreatitis

Answer 30

Routine bloods Serum amylase (diagnostic if 3x normal) Serum lipase Abdominal ultrasound CT (pancreatic oedema/swelling/necrosis)

Question 31

How is acute pancreatitis managed

Answer 31

Treat underlying cause Supportive: fluids, oxygen, NG insertion, analgesia All patients with acute pancreatitis should be treated in HDU/ITU If confirmed pancreatic necrosis, consider prophylactic broad-spectrum antibiotics

Question 32

What are the complications of acute pancreatitis

Answer 32

DIC Acute respiratory distress syndrome Hypocalcaemia Hyperglycaemia Pancreatic necrosis Pancreatic pseudocysts

Question 33

What are the most common causes of chronic pancreatitis

Answer 33

Chronic alcohol abuse Idiopathic

Question 34

How might chronic pancreatitis present

Answer 34

Chronic pain in epigastrium and back Nausea and vomiting Endocrine/exocrine insufficiency

Question 35

What investigations are needed for chronic pancreatitis

Answer 35

Faecal elastase (low) CT (pancreatic atrophy/calcification/pseudocysts)

Question 36

How is chronic pancreatitis managed

Answer 36

Analgesia Enzyme replacement Vitamin supplements ERCP Steroids (for autoimmune cases)

Question 37

Which tumour marker is specific to pancreatic cancer

Answer 37

CA19-9

Question 38

What is a splenic infarct

Answer 38

Occlusion of splenic artery Get tissue necrosis Infarct often not complete (collateral blood supply)

Question 39

What are the causes of splenic infarct

Answer 39

Haematological disease Endocrine disorders Vasculitis Trauma Surgery

Question 40

How might splenic infarct present

Answer 40

LUQ pain Radiation to left shoulder Fever Nausea Vomiting Pleuritic chest pain

Question 41

What investigations are needed for splenic infarct

Answer 41

CT (gold standard) Routine bloods

Question 42

What is the management for splenic infarct

Answer 42

Analgesia Fluids Avoid splenectomy is possible Low dose antibiotic cover

Question 43

How might splenic rupture present

Answer 43

History of trauma Abdominal pain Hypovolaemic shock LUQ tenderness Left shoulder pain

Question 44

Which vaccinations should be given to asplenic patients

Answer 44

Strep pneumoniae Haemophilus influenzae B Meningococcal