HPB

Question 1

What is acute cholecystitis?

Answer 1

Inflammation of the gallbladder

Question 2

What’s the pathophysiology of acute cholecystitis?

Answer 2

Secondary to gallstones in 90% of pts

Remaining 10%:
-typically seen in hospitalised and severely ill patients
-multifactorial pathophysiology: gallbladder stasis, hypoperfusion, infection
-in immunosuppressed patients it may develop secondary to Cryptosporidium or cytomegalovirus
-associated with high morbidity and mortality rates

Question 3

What are some features of acute cholecystitis?

Answer 3

RUQ pain - may radiate to shoulder

Fever and systemic symptoms

Murphy’s sign on exam - inspiratory arrest upon palpation of RUQ

LFTs typically normal

Question 4

What are the first line investigations for acute cholecystitis?

Answer 4

Ultrasound of the abdomen

MRCP

If diagnosis still unclear - Cholescintigraphy

Question 5

What are the treatment options for acute cholecystitis?

Answer 5

IV Abx

ERCP can remove stones
Cholecystectomy - within 1 wk of diagnosis

NBM
IV fluids
NG tube if vomiting

Question 6

How can you illicit Murphy’s sign on examination?

Answer 6

Place a hand in RUQ and apply pressure

Ask the patient to take a deep breath in

The gallbladder will move downwards during inspiration and come in contact with your hand

Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration

Question 7

What are signs of acute cholecystitis on abdominal ultrasound?

Answer 7

Thickened gallbladder wall
Stones or sludge in gallbladder
Fluid around the gallbladder

Question 8

What is ascending/acute cholangitis?

Answer 8

Bacterial infection and inflammation of the biliary tree (bile ducts)

Question 9

What are the two main causes of acute cholangitis?

Answer 9

Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct)

Infection introduced during an ERCP procedure

Question 10

What is Charcot’s triad?

Answer 10

Acute cholangitis presents with a triad of symptoms:

RUQ pain
Fever
Jaundice (raised bilirubin)

Question 11

How is acute cholangitis managed?

Answer 11

Nil by mouth
IV fluids
Blood cultures
IV antibiotics (as per local guidelines)
Involvement of seniors and potentially HDU or ICU

ERCP to remove stones

PTC - drain obstruction

Question 12

What imaging can be done to diagnose common bile duct (CBD) stones and cholangitis?

Answer 12

Abdominal ultrasound scan
CT scan
Magnetic resonance cholangio-pancreatography (MRCP)
Endoscopic ultrasound

Question 13

What are the most common causative organisms of acute cholangitis?

Answer 13

Escherichia coli

Klebsiella species

Enterococcus species

Question 14

What is Reynolds’ Pentad?

Answer 14

Clinical presentation of ascending cholangitis

Charcots triad (jaundice, RUQ pain, fever) + hypotension + altered mental state

Question 15

What are the risk factors for gallstones?

Answer 15

4 Fs

Fat
Fertility (pregnancy)
Female
Forty

Question 16

What’s the typical presentation of symptomatic gallstones?

Answer 16

Biliary Colic:

Severe, colicky epigastric or right upper quadrant pain
Often triggered by meals (particularly high fat meals)
Lasting between 30 minutes and 8 hours
May be associated with nausea and vomiting

Question 17

What are some complications of gallstones?

Answer 17

Acute cholecystitis
Acute cholangitis
Obstructive jaundice (if the stone blocks the ducts)
Pancreatitis

Question 18

How is biliary colic caused?

Answer 18

is caused by stones temporarily obstructing drainage of the gallbladder. It may get lodged at the neck of the gallbladder or in the cystic duct, then when it falls back into the gallbladder the symptoms resolve

Question 19

Why do fatty meals exacerbate biliary colic?

Answer 19

Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum.

CCK triggers contraction of the gallbladder, which leads to biliary colic.

Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction

Question 20

How are gallstones formed?

Answer 20

that form within the gallbladder. The stones form from concentrated bile from the bile ducts. Most stones are made of cholesterol.

Question 21

How do LFTs appear in pt with gallstones?

Answer 21

Bilirubin - raised if gallstone is obstructive

ALP - raised in biliary obstruction

ALT and AST - may be raised but not as high as ALP

Question 22

What is the first line imaging for investigating gallstones?

Answer 22

USS abdomen

Question 23

What is MRCP?

Answer 23

Magnetic Resonance Cholangio-Pancreatography

MRI scan, detailed image of the biliary system

With gallstone disease, MRCP is typically used to investigate further if the ultrasound scan does not show stones in the duct

Question 24

What management is available for gallstones?

Answer 24

Cholecystectomy - removal of gallbladder

indicated where patients are symptomatic of gallstones, or the gallstones are leading to complications

Question 25

What are some complications of cholecystectomy?

Answer 25

Bleeding, infection, pain and scars Damage to the bile duct including leakage and strictures Stones left in the bile duct Damage to the bowel, blood vessels or other organs Anaesthetic risks Venous thromboembolism (deep vein thrombosis or pulmonary embolism) Post-cholecystectomy syndrome

Question 26

What is post-cholecystectomy syndrome?

Answer 26

group of non-specific symptoms that can occur after a cholecystectomy Diarrhoea Indigestion Epigastric or right upper quadrant pain and discomfort Nausea Intolerance of fatty foods Flatulence

Question 27

What is pancreatitis?

Answer 27

Inflammation of pancreas Acute - rapid onset inflammation and symptoms Chronic - long-term inflammation and symptoms, progressive and permanent deterioration in function

Question 28

What are some causes of pancreatitis?

Answer 28

I - idiopathic G - gallstones E - ethanol (alcohol) T - trauma S - steroids M - mumps A - autoimmune S - scorpion sting H - hyperlipidemia E - ERCP D - Drugs (furosemide thiazide diuretics, azathioprine, GLP1 agonists)

Question 29

How does alcohol cause pancreatitis?

Answer 29

is directly toxic to pancreatic cells, resulting in inflammation

Question 30

How do gallstones cause pancreatitis?

Answer 30

caused by gallstones getting trapped at the end of the biliary system (ampulla of Vater), blocking the flow of bile and pancreatic juice into the duodenum. The reflux of bile into the pancreatic duct, and the prevention of pancreatic juice containing enzymes from being secreted, results in inflammation in the pancreas

Question 31

What is the typical presentation of acute pancreatitis?

Answer 31

Severe epigastric pain Radiating through to the back Associated vomiting Abdominal tenderness Systemically unwell (e.g., low-grade fever and tachycardia)

Question 32

What investigations are required for investigating potential pancreatitis?

Answer 32

FBC (for white cell count) U&E (for urea) LFT (for transaminases and albumin) Calcium ABG (for PaO2 and blood glucose) Amylase ( more than x3 upper limit of normal in acute) Lipase raised CRP USS abdo for gallstones CT abdominal

Question 33

What score is used to assess severity of pancreatitis?

Answer 33

Glasgow score 0 or 1 – mild pancreatitis 2 – moderate pancreatitis 3 or more – severe pancreatitis P – Pa02 < 8 KPa A – Age > 55 N – Neutrophils (WBC > 15) C – Calcium < 2 R – uRea >16 E – Enzymes (LDH > 600 or AST/ALT >200) A – Albumin < 32 S – Sugar (Glucose >10)

Question 34

How is acute pancreatitis managed?

Answer 34

Initial resuscitation (ABCDE approach) IV fluids Analgesia Nutritional support (by mouth wherever possible, with parenteral nutrition if oral intake is not possible) Careful monitoring Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy) Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area) Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)

Question 35

What are some complications of pancreatitis?

Answer 35

Necrosis of the pancreas Infection in a necrotic area Abscess formation Acute peripancreatic fluid collections Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis Chronic pancreatitis

Question 36

What is cholangiocarcinoma?

Answer 36

Bile duct cancer The majority are adenocarcinomas most common site is in the perihilar region

Question 38

What are the key risk factors for cholangiocarcinoma?

Answer 38

Primary sclerosing cholangitis Liver flukes

Question 39

What’s the typical presentation of cholangiocarcinoma?

Answer 39

Obstructive Jaundice: -Pale stools -Dark urine -Generalised itching Unexplained weight loss Right upper quadrant pain Palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder) Hepatomegaly

Question 40

What tumour may be raised in cholangiocarcinoma and pancreatic cancer?

Answer 40

CA 19-9

Question 41

How can the causes of jaundice be divided?

Answer 41

Pre hepatic Intrahepatic Post hepatic

Question 42

What ar the pre-hepatic causes of jaundice?

Answer 42

Haemolysis Unconjugated bilirubin

Question 43

What are some hepatic causes of jaundice?

Answer 43

Viral hepatitis Drugs Alc hepatitis Cirrhosis Pregnancy Recurrent idiopathic cholestasis

Question 44

What are some post-hepatic causes of jaundice?

Answer 44

Obstructive Gallstones Cholangitis Pancreatic carcinoma Biliary stricture Sclerosing cholangitis