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Year 3 Hepatobiliary surgery > Obstructive jaundice + pancreatic cancer > Flashcards

Obstructive jaundice + pancreatic cancer Flashcards

1
Q

Causes of obstructive jaundice

A

Gall stones
Ca head of the pancreas

Lymphadenopathy @ porta hepatis: TB, Ca
Inflammatory: PBC, PSC

Neoplastic:

  • Cholangiocarcinoma
  • Mirizzi’s syndrome
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2
Q

Presentation of obstructive jaundice

A
  • Jaundice
  • Dark urine, pale, floating stools
  • Pruritis (bile salts)
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3
Q

Investigations for obstructive jaundice

A

• Bloods

  • FBC: ↑ WCC in cholangitis
  • U+E: hepatorenal syndrome
  • LFT: ↑bilirubin, ↑↑ ALP, ↑AST/ALT
  • Clotting: ↓ vit K → ↑ INR
  • G+S: may need ERCP
  • Immune: AMA, ANCA, ANA
  • CA 19 - 9

• Urine

  • Dark
  • ↑ bilirubin
  • ↓ urobilinogen
• Imaging
AXR 
- may visualise stone
- Pneumobilia - gas forming
infection

USS

  • Dilated ducts >6mm
  • Stones (95% accurate)
  • Tumour

MRCP or ERCP
Percutaneous Transhepatic Cholangiography

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4
Q

Risk factors for pancreatic cancer (SINED)

A
  • Smoking
  • Inflammation: chronic pancreatitis
  • Nutrition: ↑fat diet
  • EtOH
  • DM
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5
Q

Pathology of pancreatic CA

A
  • 90% ductal adenocarcinomas

* Present late, metastasise early

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6
Q

Presentation of pancreatic CA

A

• Male >60yrs
• Painless obstructive jaundice: dark urine, pale stools
• Epigastric pain: radiates to back, relieved sitting
forward
• Anorexia, wt. loss and malabsorption
• Acute pancreatitis
• Sudden onset DM in the elderly

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7
Q

Signs of pancreatic CA

A
  • Palpable gallbladder
  • Jaundice
  • Epigastric mass
  • Thrombophlebitis migrans (Trousseau sign)
  • Splenomegaly and ascites
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8
Q

Courvoisier’s Law

A

In the presence of painless obstructive jaundice, a

palpable gallbladder is unlikely to be due to stones.

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9
Q

Investigations for pancreatic CA

A

Bloods:

  • LFTs
  • ↑Ca19-9 (90% sens)
  • ↑Ca
  • Amylase

Imaging
- USS: pancreatic mass, dilated ducts, hepatic mets, guided biopsy

  • chest-abdomen-pelvis CT scan - staging
  • CXR: mets
  • Laparoscopy: mets, staging
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10
Q

ERCP use

A

Shows anatomy
Allows stenting
Biopsy of peri-ampullary lesions

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11
Q

Tx of pancreatic CA

A

• Surgery
- Whipple’s procedure- pancreaticoduodenectomy

  • Distal pancreatectomy
  • Post-op chemo delays progression
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12
Q

When to do surgery

A

Fit
No mets
Tumour ≤3cm

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13
Q

Palliation for pancreatic CA

A

Endoscopic / percutaneous stenting of CBD

Palliative bypass surgery:
cholecystojejunostomy +
gastrojejunostomy

Pain relief – may need coeliac plexus block

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14
Q

Cholangiocarcinoma pathology

A

• Rare bile duct tumour - adenocarcinoma

• Typically @ confluence of right and left hepatic
ducts: called “Klatskin” tumours

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15
Q

Risk factors for cholangiocarcinomas

A
  • PSC
  • Ulcerative colitis
  • Choledocholithiasis
  • Hep B/C
  • Choledochal cysts
  • Alcohol
  • DM
  • Toxins - rubber
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16
Q

Presentation of cholangiocarcinoma

A 
• Progressive painless obstructive jaundice
- Gallbladder not palpable
• Steatorrhoea
• Wt. loss
•  Pruritis due to bilirubin
17
Q

Cholangiocarcinoma investigations and mx

A
  • Bloods: FBC, LFTs, CA 19-9
  • USS
  • MRCP
  • CT staging

Tx
• Poor prognosis: not curative as many cant undergo complete surgical resection
• Palliative stenting by ERCP

18
Q

RUQ pain and blood tests showing a post-hepatic jaundice, the patient otherwise well and stable. What is the most appropriate initial investigation?

A

USS abdomen

19
Q

Common site for cholangiocarcinoma

A

bifurcation of the right and left hepatic ducts - Klatskin tumour

20
Q

Behaviour of cholangiocarcinoma

A

Adenocarcinomas

Slow growing and invade locally

Metastasise to lymph nodes

Spread to peritoneal cavity, lung, and liver

21
Q

Complications of cholangiocarcinoma

A

Biliary tract sepsis

Secondary biliary cirrhosis

22
Q

Behaviour of pancreatic cancer

A

Direct invasion of local structures:

  • spleen
  • transverse colon
  • and adrenal glands

Lymphatic metastasis:

  • regional lymph nodes
  • liver - commonly
  • lungs
  • peritoneum
23
Q

Absolute contraindications for surgery

A

Peritoneal, liver and distant metastases

24
Q

Whipple’s procedure

A

Removal of the head of the pancreas, the antrum of the stomach, the 1st and 2nd parts of the duodenum, the common bile duct, and the gallbladder.

25
Q

Which imaging is the gold-standard for visualising an insulinoma

A

Upper endoscopic ultrasound

Year 3 Hepatobiliary surgery (7 decks)

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