HPB the Spleen and Gallbladder

Question 1

Functions of the spleen

Answer 1

Breakdown erythrocytes

Immunological defence

Question 2

Infections –> splenomegaly (6)

Answer 2

Infective endocarditis 
Bacterial sepsis 
EBV
TB
Malaria 
Schistosomaisis

Question 3

Non-infective causes of splenomegaly (3)

Answer 3

Inflammation
Portal HTN
Haemolytic disease

Question 4

Haemolytic diseases –> splenomegaly (4)

Answer 4

Haemolytic anaemia
Leukaemia
Lymphoma
Myeloproliferative disorders

Question 5

where is massive splenomegaly palpable?

Answer 5

RIF

Question 6

Which conditions can cause massive splenomegaly? (6)

Answer 6

Myelofibrosis 
Lymphoma 
CML 
Malaria 
Leishmaniasis 
Gaucher's

Question 7

Causes splenic rupture (7)

Answer 7

Blunt trauma
Penetrating ribs 
Malaria
Mononucleosis 
Haematological disease 
Iatrogenic 
Pre-existing illness

Question 8

PS splenic rupture

Answer 8

Immediate massive bleed

Or peritonism + eventual shock

Question 9

When can splenic rupture present late?

Answer 9

If massive expanding haematoma beneath capsule

Question 10

Adverse consequences splenectomy

Answer 10

Incr risk fulminant/sepsis
Neutrophilia
Decr prod Ig
Reactive thrombocytosis

Question 11

Preventing post-splenectomy sepsis

Answer 11

Elective surgery - 2 weeks before vaccinate
Low dose heparin 4 w post op
Annual flu vaccine
Lifelong pen V

Question 12

Contents of bile (5)

Answer 12

Cholesterol 
Phospholipids
Bile salts 
H2O 
Conjugated  bilirubin

Question 13

Role of bile

Answer 13

Break up + emulsify fats in the gut

Question 14

When does bile flow into the Gall bladder /

Answer 14

When sphincter of oddi is CLOSED

Question 15

What causes the gall bladder to contract and bile to be released?

Answer 15

Presence of FFA or AA in the duodenum

Which leads to the release of CCK (cholecystokinin)

Question 16

Do most gall stones produce symptoms?

Answer 16

No

Question 17

What is cholelithiasis

Answer 17

Formation of gallstones in gall bladder

Question 18

What are the 2 types of gall stones?

Answer 18

Cholesterol gallstones

Bile pigment stones

Question 19

How are cholesterol gallstones formed?

Answer 19

Cholesterol crystallises in bile

B/c XS cholesterol secretion in to bile or loss bile salt content

Question 20

RF cholesterol gallstones (11)

Answer 20

Age 
Obesity 
High fat diet 
Rapid W loss 
Female 
Multiparity 
Pregnancy 
OCP
DM
Ileal disease/resection 
Liver cirrhosis

Question 21

What compound do bile pigment stones contain?

Answer 21

Calcium bilirubinate

Question 22

What are black pigment gallstones associated with?

Answer 22

Haemolytic conditions

Question 23

What are brown pigment gallstones due to?

Answer 23

Biliary stasis/infection

Question 24

Complications of gallstones in the gallbladder (5)

Answer 24

Biliary colic 
Acute cholecytstitis 
Empyema 
Perforation 
Carcinoma

Question 25

Complications of gallstones in the bile ducts (3)

Answer 25

Biliary obstruction Acute cholangitis Acute pancreatitis

Question 26

Complications of gallstones in intestines

Answer 26

Gallstone ileus

Question 27

What is biliary colic due to?

Answer 27

Impaction of gallstone in gall bladder

Question 28

What is choledocolithiasis

Answer 28

Stone impaction in common bile duct

Question 29

What can choledcocolithiasis predispose to?

Answer 29

Ascending cholangitis Or Acute pancreatitis

Question 30

What is Mirizzi's syndrome

Answer 30

Gallstone impacted in cystic duct/Hartmann's pouch --> compression common hepatic duct

Question 31

What is a Gallstone ileus?

Answer 31

When a large gallstone erodes through the gall bladder lumen --. fustula into adjacent duodenum

Question 32

AXR findings gallstone ileus

Answer 32

Small bowel obstruction GAll stone Aerobilia

Question 33

What is Aerobilia

Answer 33

Air in the biliary tree

Question 34

Def biliary colic

Answer 34

Pain assoc w/ temp obstruction of cystic duct or CBD by a stone migrating from the GB

Question 35

SOCRATES biliary colic

Answer 35

``` S - epigastric/RUQ pain O - peaks 2hrs after eating C - sharp, crescendo, constant R - R shoulder/subscapular A - N+V T - hr E - fatty foods, lying down, insp R - opiates S - severe ```

Question 36

what is acute cholecystitis?

Answer 36

Obstruction of gall bladder from emptying

Question 37

Why is there a 2' inflamm response in acute cholecystitis?

Answer 37

B/c H2O = still reabsorbed from bile | Bile becomes highly concentrated

Question 38

Sx acute cholecystitis (once inflamm component develops)

Answer 38

Localised RUQ pain Assoc w/ guarding + rigidity, vom + systemic upset Murphy's sign

Question 39

What is Murphy's sign

Answer 39

Continuous P over GB when pt is inhaling will cause pt to catch their breath at point of max inhalation

Question 40

What is chornic cholecystitis?

Answer 40

Repeated eps of inflamm due to gallstones --> fibrosis + thickening GB wall

Question 41

Sx chronic cholecysitis | ;

Answer 41

Recurrent bouts of abdo pain | Discomfort + flatulence after fatty meals

Question 42

What is common bile duct obstruction usually due to?

Answer 42

CHoledocholithiasis

Question 43

Couviosiers' law

Answer 43

In the presence of jaundice the GB is palpable but non-tender - then jaundice = unlikely due to a stone

Question 44

what is ascending cholangitis?

Answer 44

Infection of the CBD --> sepsis

Question 45

What does ascending cholangitis usually occur 2' to?

Answer 45

Choledocholeithiasis

Question 46

Charcot's triad in ascending cholangitis

Answer 46

Obstructive jaundice High fever RUQ pain

Question 47

What may happen to the liver in ascending cholangitis

Answer 47

May become dotted with small mutliple abscesses

Question 48

Blood Ix in diagnosing gallstones

Answer 48

``` WBC/inflamm markers LFTs Amylase Prothrombin time (pre-intervention) GLucose ```

Question 49

Imaging Ix gallstones

Answer 49

ABDO USS = 1st line | MRCP

Question 50

What 3 things are you looking for - abdo USS gallstones

Answer 50

Stones in GB Thickened GB wall Incr diameter CBD (>7mm)

Question 51

Mx asymp gallstones

Answer 51

Watch + wait | Cholecystectomy if co-morbiditis or v young

Question 52

Mx biliary colic

Answer 52

Admit + supportive | Laparoscopic cholecystectmy

Question 53

what is a hot cholecystectomy

Answer 53

Done within 72hrs of admission

Question 54

What is a cold cholecystectomy

Answer 54

done 6w after admission

Question 55

Risks of biliary surgery (5)

Answer 55

``` Perf Gallstone ileus Aerobilia Obstruction CBD injury ```

Question 56

Med Mx of biliary colic

Answer 56

chenodeoxycholic acid

Question 57

Who can have med Mx of biliary colic

Answer 57

If have small, non-calcified stones

Question 58

Mx acute biliary sepsis

Answer 58

``` A-E analgesia IV f+ electrolytes Catheterise IV tazocin +/- gentamicin ```

Question 59

Mx acute cholecystitis

Answer 59

As per biliary colic | + IV cefuroxime

Question 60

Mx chronic cholecystitis

Answer 60

Laparoscopic cholecystectomy + chonagiogram

Question 61

Mx obstructive jaundice due to stones

Answer 61

ERCP + sphincterectomy Vit K beforehand electic lap chole

Question 62

Who gets carcinoma of the gallbladder?

Answer 62

Elderly | w/ longstanding gallstones

Question 63

how does carcinoma of the GB spread?

Answer 63

Direct invasion of liver | Lymphatics

Question 64

Sx carcinoma of the GB (6)

Answer 64

RUQ pain N+V W loss Obstructive jaundice + palp mass

Question 65

Tx carcinoma GB

Answer 65

Radical cholecystectomy +/- liver resection

Question 66

Prognosis carcinoma GB

Answer 66

Poor - usually presents too late for therapy