Pancreas, Liver, Gallbladder

Question 1

Pancreatic cancer aetiology

Answer 1

painless jaundice and palpable gallbladder

75% in head of pancreas arising from exocrine tissue

less common- MEN1 tumours arising from endocrine tissue

poor prognosis as often diagnosed late

Question 2

pancreatic cancer risk factors

Answer 2

increasing age
obesity
smoking
T2DM
chronic pancreatitis

Question 3

pancreatic cancer presentation

Answer 3

painless jaundice
weight loss
non-specific signs
loss of exocrine function > steatorrhoea
loss of endocrine function > diabetes
Trousseu’s sign
palpable gall bladder
hepatomegaly if mets

Question 4

pancreatic cancer ix

Answer 4

biopsy via ERCP or EUS

bloods- CA19-9
USS
HRCT

Question 5

pancreatic cancer mx

Answer 5

<20% suitable for surgery due to mets - ERCP with stenting
Whipple’s resection + adjuvant chemo
pancreaticoduodenectomy only if resectable

Question 6

pancreatic cancer complications

Answer 6

dumping syndrome
peptic ulcer disease

Question 7

cholangiocarcinoma aetiology

Answer 7

cancer arising in the bile ducts either intrahepatic or extrahepatic
most common is extrahepatic
most are adenocarcinomas arising from cholangiocytes in biliary tree

Question 8

cholangiocarcinoma risk factors

Answer 8

increasing age
male
smoking
obesity
chronic inflammation of bile ducts
- primary sclerosing cholangitis
- congenital (Caroli’s disease, choledochal cyst)
- intraductal gallstone formation
- infective (liver flukes, hepatitis virus)
- toxins
- liver cirrhosis

Question 9

cholangiocarcinoma presentation

Answer 9

weight loss
RUQ pain
vague symptoms
if extrahepatic
- painless jaundice
- palpable gallbladder
- pruritus
- pale stool, dark urine

Virchow’s node
Sister Mary Joseph nodule

Question 10

cholangiocarcinoma ix

Answer 10

ERCP with biopsy

bloods - LFTs, clotting studies, CA19-9 and CEA
imaging - USS, MRCP
radiography - ERCP, PTC

Question 11

cholangiocarcinoma mx

Answer 11

pt often present late so limits scope for surgery

removal of bile duct - small and localised tumour
partial hepatectomy - intrahepatic
Whipple’s procedure - for distal bile duct tumours

adjuvant chemo and radiotherapy to prevent recurrence

Question 12

hepatocellular carcinoma aetiology

Answer 12

primary malignancy of hepatocytes
forms 90% of primary liver tumours
most commonly arises from chronic inflammation
- viral hepatitis
- chronic alcohol excess

Question 13

hepatocellular carcinoma risk factors

Answer 13

liver cirrhosis
aflatoxin exposure
smoking
advanced age
positive FHx

Question 14

hepatocellular carcinoma presentation

Answer 14

presents late
FLAWS
may present with decompensation
- acute deterioration in liver function
- hepatic encephalopathy

signs of chronic liver failure
- hepatosplenomegaly
- pruritus
- jaundice

Question 15

hepatocellular carcinoma ix

Answer 15

prognosis poor unless diagnosed early

screening for high risk groups

bloods
- aFP, tumour marker
- FBC, LFTs

imaging
- USS
- MRI
- CT

diagnosis can be made radiologically or histologically

Question 16

hepatocellular carcinoma management

Answer 16

early disease:
- surgical resection (non-cirrhotic)
- liver transplantation (cirrhotic)

unsuitable for surgery:
- percutaneous ethanol injection for peripheral lesions
- sorafenib - multikinase inhibitor