Liver: Surgical

Question 1

Primary benign liver masses (4)

Answer 1

Cysts
Haemangioma

Focal nodular hyperplasia (has bile duct elements)

Hepatocellular adenoma

Question 2

Primary malignant liver masses (3)

Answer 2

HCC (malignnat epithelial)

Cholangiocarcinoma

Angiosarcoma (vascular tumour, quite rare)

Question 3

Hyatid cysts are caused by which organism?

Answer 3

Enchinococcus

Benign cyst

Question 4

Common origin sites for secondary malignant liver tumour?

Answer 4

Much more common than primary cancer

From colon, lung, breast, stomach, pancreas, melanoma etc..

Question 5

Difference between primary and secondary liver tumours?

Answer 5

Primary usually solitary, secondary usually multiple

Exceptions: eg solitary metastasis from colon

Question 6

Aetiological factors of HCC?

Answer 6

Hepatitis B and C
Aflatoxins
Cirrhosis of any cause

Question 7

Clinical features of HCC?

Answer 7

Rapid increase in liver size in cirrhotic patient

Worsening of ascites, fever, pain

Question 8

Prognosis of HCC?

Answer 8

Usually incurable

Median survival is 7 months

Small lesions may be resectable

Embolisation of tumour may be used palliatively

Question 9

Morphology of HCC

Answer 9

Can be unifocal, multifocal or diffusely infiltrative

Question 10

Which liver tumour is most commonly associated with the use of OCP?

Answer 10

Hepatocellular adenoma

Question 11

Risk factors for cholelithiasis and cholecystits

Answer 11

Female
Fair
Fat
Forties
Fertile

Also diabetes

Question 12

What colour are cholesterol gallstones?

Answer 12

Pale

Question 13

What colour are bile gallstones?

Answer 13

Dark green

Most stones are a mix of cholesterol and bile

Question 14

Complications of gallstones

Answer 14

Can impact in Hartmann’s pouch or neck of gallbladder:

Cholecystitis
Mucocele
Biliary colic
Obstructive jaundice
Ascending cholangitis
Pancreatitis

VERY RARE: GB carcinoma

Question 15

Prognosis of gallbladder carcinoma?

Answer 15

Rare complication of gallstones

Usually elderly females

Advanced stage at presentation, poor prognosis

Question 16

True/false: gallbladder papillomas are the most common benign tumours of the gallbladder

Answer 16

True

Question 17

True/false: Cholangiocarcinoma is the commonest malignancy seen in the gallbladder

Answer 17

False, adenocarcinoma

Question 18

Causes of extrahepatic biliary tract obstruction

Answer 18

Lumen: stones

Within wall: Stricture, tumour

Outsdie wall: Pancreas tumour, ampulla carcinoma, lymphoma, surgical ligation of bile duct

Question 19

Clinical features of biliary obstruction

Answer 19

Obstructive jaundice (raised bili, pale stools, dark urine)

Raised ALP

Complications: cholangitis, abscesses

Question 20

Radiology investigations for biliary tract obstruction

Answer 20

USS first line for gallstones

Percutaneous transhepatic cholangiogram (PTCA) to inject DYE

ERCP ?stone, benign or malignant stricture

Cytology of bile duct brushing ?malignancy

CT/MRI

Question 21

What is a cholangiocarcinoma?

Answer 21

Adenocarcinoma of bile ducts (intra or extrahepatic)

Presents at early stage with obstructive jaundice

Question 22

Risk factors for cholangiocarcinoma

Answer 22

Sclerosing cholangitis/UC

Liver fluke

Congenital biliary tree anomaly

Question 23

How is cholangiocarcinoma diagnosed?

Answer 23

Diagnosis of exclusion (need to exclude primary tumours from pancreas or stomach which can closely mimic intrahepatic cholangiocarcinoma)

Question 24

Where does an Ampullary carcinoma occur?

Answer 24

Ampulla of Vater, origin may be in duodenum, pancreas, bile duct, or ampulla itself

Important to distinguish from periampullary duodenal carcinoma or metastatic spread

Question 25

Pathology of acute pancreatitis

Answer 25

- Due to acinar cell injury and inflammation - Causes release of exocrine enzymes and autodigestion of pancreas - Associated inflammatory response by cytokines, which leads to pancreas necrosis, surround FAT NECROSIS, and haemorrhage

Question 26

Pathology of chronic pancreatitis

Answer 26

Repeated inflammation leads to loss of pancreas parenchyma and fibrosis Also get inspissation of secretions in pancreas ducts, forming DUCTAL PLUGS This results in calcification which can be picked up on imaging

Question 27

Causes of pancreatitis (metabolic, mechanical, vascular, infectious)

Answer 27

Metabolic: alcohol, cholesterol, hypercalcaemia, drugs (THIAZIDES AND CICLOSPORIN) Mechanical: Gallstones, trauma, post ERCP Vascular: shock, embolism, vasculitis Infectious: Mumps, mycoplasma, cocksackie virus

Question 28

Presentation of acute pancreatitis

Answer 28

Epigastric pain radiating to back Acute abdomen Shock ARDS, organ failure Raised serum amylase HYPOCALCAEMIA Rarely jaundice Hyperglycaemia

Question 29

Clinical effects of chronic pancreatitis

Answer 29

Common cause: alcohol Relapsing episodes of pain Malabsorption due to enzyme loss Exocrine more affected than endocrine DM is late sign Pseudocyst formation

Question 30

How does chronic pancreatitis appear on imaging?

Answer 30

Calcification on CT/xray Distorted ducts on ERCP

Question 31

Risk factors fro pancreatic carcinoma

Answer 31

Smoking Chronic pancreatitis Genetic factors

Question 32

Where is the most common site for carcinoma in the pancreas?

Answer 32

Head (60-70%)

Question 33

Symptoms of pancreatic carcinoma

Answer 33

Painless jaundice (due to tumour on the head. Body and tail tumours present later) Cachexia Metastases Thrombophlebitis

Question 34

Serum markers for pancreatic cancer

Answer 34

CA19.9 most useful CEA and CA125 may be elevated but are less specific

Question 35

Diagnosis of pancreatic carcinoma

Answer 35

Definitive: needle/core biopsy under CT guidance

Question 36

Prognosis of pancreatic cancer

Answer 36

<5% 5 year survival rate

Question 37

What surgical procedure can be used to resect a pancreas head tumour?

Answer 37

Whipple's pancreaticoduodenectomy

Question 38

What are the 3 syndromes associated with pancreatic endocrine neoplasms (PENs)?

Answer 38

Insulinomas Gastrinoma MEN type 1

Question 39

What is an insulinoma?

Answer 39

Syndrome of pancreatic endocrine neoplasm Usually sporadic, single and benign Secrete insulin, resulting in hypoglycaemia Worsened by exercise or fasting Can present with confusion

Question 40

What are gastrinomas?

Answer 40

Syndrome linked to pancreatic endocrine neoplasm Ofent multiple, can be malignant Arise from G cells which secrete gastrin Causes Zollinger Ellison syndrome (peptic ulceration)

Question 41

WHich MEN type is associated with pancreatic endocrine neoplasms (PEN)?

Answer 41

MEN type 1 Autosomal recessive inherited condition. Tumours in pancreas, pituitary gland, and parathyroid glands (remember PPP!!!!)