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HPB Flashcards

1
Q

Most common causes of acute pancreatitis

A

I GET SMASHED
I - idiopathic
G - gallstones
E - ethanol
T - trauma
S - steroids
M - mumps
A - autoimmune
S - scorpion poison
H - hypercalcaemia/hypertriglyceridemia
E - ERCP
D - drugs

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2
Q

Acute pancreatitis pathophysiology

A

Intrapancreatic activation of pancreatic enzymes → increased proteolytic and lipolytic enzyme activity → destruction of pancreatic parenchyma → attraction of inflammatory cells → release of inflammatory cytokines → acute pancreatitis

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3
Q

The three main sequelae of acute pancreatitis are:

A

Distributive shock
Pancreatic necrosis
Hypocalcaemia

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4
Q

Symptoms associated with acute pancreatitis

A

Constant, severe epigastric pain radiating towards the back.
Nausea +/- vomiting.
Fever.

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5
Q

Examination findings associated with acute pancreatitis

A

Signs of shock: tachycardia, hypotension, oliguria/anuria.
Abdominal: tenderness, distension.
Skin: Cullen sign, Grey Turner sign, Fox sign

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6
Q

Cullen sign

A

Periumbilical ecchymosis and discolouration. Associated with acute pancreatitis.

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7
Q

Grey Turner sign

A

Flank ecchymosis with discolouration. Associated with acute pancreatitis.

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8
Q

Fox sign

A

Bruising over the inguinal ligament. Associated with acute pancreatitis.

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9
Q

Diagnosis of acute pancreatitis is made if the patient has at least 2 of the following features:

A
  1. Characteristic abdominal pain
  2. Biochemical evidence of pancreatitis (serum amylase or lipase elevated more than 3 times the ULN)
  3. Radiographic evidence of pancreatitis on imaging
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10
Q

Mild acute pancreatitis is characterised by

A

no local or systemic complications.

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11
Q

Moderate acute pancreatitis is characterised by

A

local or systemic complications or organ failure that resolves within 48hrs.

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12
Q

Severe acute pancreatitis is characterised by

A

organ failure that persists for more than 48hrs.

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13
Q

Initial management of acute pancreatitis (regardless of severity) includes

A

Fluid administration
Analgesia

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14
Q

Gallstones most commonly consist of:

A

Cholesterol

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15
Q

Cholelithiasis definition

A

The presence of gallstones in the gallbladder

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16
Q

6 Fs of gallstones

A

Fat
Female
Fertile
Forty
Fair skinned
Family history

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17
Q

20/20/20 rule of gallstones

A

20% of the population have gallstones
20% of those people will be symptomatic
20% of those will have complications

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18
Q

Increased levels of oestrogen predispose to gallstone development by:

A

Increased secretion of bile rich in cholesterol (lithogenic bile)

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19
Q

Increased progesterone predisposes to gallstones by:

A

Smooth muscle relaxation, decreased gallbladder contraction and subsequent cholestasis

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20
Q

Pregnancy predisposes patients to the development of gallstones due to:

A

Dramatically increased oestrogen levels

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21
Q

Medications that increase oestrogen levels include:

A

OCPs, HRT

22
Q

Medications that alter cholesterol metabolism and increase risk of gallstones include:

A

Fibrates

23
Q

Transabdominal ultrasound findings for cholelithiasis include

A

Gallstones visualised within the gallbladder with posterior acoustic shadowing

24
Q

Biliary colic definition

A

Constant, dull right upper quadrant pain lasting less than 6hrs caused by gallstones intermittently obstructing the neck of the gallbladder (cystic duct)

25
Q

Biliary colic especially occurs:

A

post-prandially

26
Q

Mechanism by which eating induces biliary colic onset:

A

CCK release following a fatty meal —> gallbladder contraction —> attempts to force stone into the cystic duct

27
Q

Points of pain radiation in biliary colic

A

Epigastrium, right shoulder tip or back

28
Q

In choledocolithiasis, LFTs often show:

A

Elevated ALP and bilirubin

29
Q

Lifestyle changes to reduce the occurrence of biliary colic include:

A

Low fat diet and weight loss

30
Q

Choledocolithiasis definition

A

Presence of gallstones in the common bile duct.

31
Q

Pain associated with choledocolithiasis is usually __________ compared with uncomplicated biliary colic

A

more severe/prolonged, and lasting >6hrs

32
Q

Signs of extrahepatic cholestasis

A

Jaundice, pale stools, dark urine, pruritus.

33
Q

Cholestasis usually appears as a __________ picture on LFTs

A

Obstructive

34
Q

Obstructive LFT picture:

A

Increased ALP and GGT with conjugated hyperbilirubinaemia.

35
Q

Ultrasound findings associated with choledocolithiasis

A

Dilated CBD (>6mm). Presence of gallstones in the gallbladder with associated posterior acoustic shadowing.

36
Q

Acute/ascending cholangitis definition

A

Bacterial infection of the biliary tract, typically secondary to biliary obstruction and stasis.

37
Q

Acute cholangitis occurs in __% of patients with cholelithiasis

A

9%

38
Q

Acute cholangitis pathophysiology

A

Biliary obstruction —> bile stasis with increased intraductal pressure —> bacterial translocation into the bile ducts —> bacterial infection ascends the biliary tract —> acute cholangitis

39
Q

The most common cause of ascending cholangitis is:

A

Choledocolithiasis

40
Q

Other causes of acute cholangitis include:

A

Biliary strictures, malignant obstruction (cholangiocarcinoma, pancreatic cancer), contamination of bile with intestinal contents due to manipulation of the biliary tract.

41
Q

Charcot’s triad is associated with:

A

Ascending cholangitis

42
Q

Charcot’s triad

A

Right upper quadrant abdominal pain, fever and jaundice

43
Q

Reynold’s pentad is associated with:

A

Acute cholangitis

44
Q

Reynold’s pentad

A

RUQ abdominal pain, fever, jaundice, hypotension, mental status changes

45
Q

Bloods of a patient with acute cholangitis will likely show the following derangements:

A

Elevated CRP, leukocytosis with left shift, signs of cholestasis on LFTs (elevated GGT, ALP, ALT, hyperbilirubinaemia), possible positive blood cultures in the case of concurrent sepsis

46
Q

Imaging findings for patients with ascending cholangitis include:

A

Dilated CBD, pneumobilia, bile duct sclerosis

47
Q

Common causes of pneumobilia include

A

IBD and infection

48
Q

Elevated ALP and GGT are associated with:

A

An obstructive picture.

49
Q

5 Fs of gallstones

A

Female
Fertile
Fat
Fair
Forty

50
Q

ALP and AST are _________ markers

A

Intrahepatic

51
Q

Glasgow-Imrie Criteria

A

Used for severity grading of acute pancreatitis. 3 or more of the listed features in the first 48hrs indicates severe acute pancreatitis and patient may require transfer to HDU/ICU.
Mnemonic: PANCREAS
Pa02 <8KPa
Age >55
Neutrophils >15
Calcium <2mmolL
Renal function (urea>16mmolL)
Enzymes (LDH>600IU/L, AST>2000IU/L)
Albumin <32g/L
Sugar >10mmolL

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