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12. CP - Diseases of the Hepatobiliary system and Pancreas > (59b) Liver tumours, biliary tract, and pancreas > Flashcards

(59b) Liver tumours, biliary tract, and pancreas Flashcards

1
Q

Name a major risk factor for hepatocellular carcinoma

A

Cirrhosis

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2
Q

Who gets hepatocellular carcinoma?

A

Males more than females

Increasing incidence in west (obesity and alcohol)

Geographical variation, depending on prevalence of viral hepatitis

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3
Q

What are late stage clinical features of HCC?

A
  • worsening liver function

- weight loss

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4
Q

How are patients with cirrhosis surveilled?

A
  • 6 month USS

- blood test (raised alpha feto-protein in serum in 75% but less than 50% in non-cirrhotic patients and small HCC)

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5
Q

How does HCC appear macroscopically?

A
  • expansile soft nodules, often green (bile)
  • involvement of portal vein (60%), hepatic vein (20%), bile duct (5%)
  • often multifocal in cirrhosis
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6
Q

How does HCC appear microscopically?

A
  • cancer cells look like hepatocytes
  • may produce bile = diagnostic
  • confirm with immunohistochemistry
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7
Q

A targeted liver biopsy should be done if diagnosis is unclear. What is the differential diagnosis?

A
  • benign liver vs. well differentiated HCC

- metastatic carcinoma vs. poorly differentiated HCC

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8
Q

What is the general prognosis of HCC?

A

Very poor (less than one year) unless diagnosed early - so surveillance is important!

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9
Q

How is HCC treated?

A
  • surgery (if non-cirrhotic or small, peripheral)

- transplant (if 1 tumour 5cm or less, if 3 or less tumours 3cm or less)

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10
Q

How is non-resectable HCC treated? (multiple, large, metastasised)

A
  • ablation - radio frequency
  • embolisation
  • chemotherapy - sorafenib
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11
Q

What are the TNM stages for HCC?

A
  • pT1
  • pT2
  • pT3a
  • pT3b
  • pT4
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12
Q

What is a pT1 HCC?

A

Solitary tumour without vascular invasion

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13
Q

What is a pT2 HCC?

A

Solitary tumour with vascular invasion or multiple tumours, none more than 5cm in greatest dimension

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14
Q

What is a pT3a HCC?

A

Multiple tumours, any more than 5cm

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15
Q

What is a pT3b HCC?

A

Single or multiple tumours of any size involving a major branch of the portal vein or hepatic vein

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16
Q

What is a pT4 HCC?

A

Tumour(s) with direct invasion of adjacent organs other than the gall bladder or with perforation of visceral peritoneum

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17
Q

How common are metastatic tumours of the liver?

A

Much commoner than primary liver cancer

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18
Q

What type of liver metastasis has few large nodules? (suitable for surgical excision)

A

Large bowel

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19
Q

What types of metastatic tumours of the liver are multinodular or infiltrative?

A
  • lung
  • pancreas
  • breast
  • stomach
  • melanoma
20
Q

Name the other primary liver cancer, other than hepatocellular carcinoma

A

Cholangiocarcinoma

21
Q

What is a cholangiocarcinoma?

A

An adenocarcinoma arising in the bile ducts

22
Q

What are the 2 types of cholangiocarcinoma?

A
  • intrahepatic

- perihilar

23
Q

What are the features of intrahepatic cholangiocarcinoma?

A
  • from small intrahepatic ducts
  • peripheral, mass forming, presents late
  • risk factor = none, or cirrhosis
24
Q

What are the features of perihilar cholangiocarcinoma?

A
  • from large ducts
  • causes obstructive jaundice early
  • risk factor = bile duct disease, primary sclerosing cholangitis
  • liver flukes
25
Q

Summarise liver cancer

A
  • primary = HCC (in patients with cirrhosis, surveillance), cholangiocarcinoma
  • metastatic = much more common, most adenocarcinoma (lung, colon, stomach, breast, pancreas, melanoma)
26
Q

How much bile is excreted?

A

0.5-1l per day is excreted by the liver and concentrated in the gall bladder

27
Q

What does bile contain?

A

Viscid green liquid that contains bile salts, phospholipids, cholesterol, bilirubin and calcium salts + mucin from peribiliary glands

28
Q

What are the risk factors for gallstones and why?

A
  • female
  • obesity
  • diabetes

Causes an imbalance of bile constituents causing it to precipitate

29
Q

What are the 2 main types of gallstone?

A
  • cholesterol stones
  • pigment stones

(or mixed = most common)

30
Q

Describe cholesterol stones

A
  • yellow and opalescent

- contain undissolved cholesterol

31
Q

Describe pigment stones

A
  • small and black

- in haemolytic anaemia (bile contains too much bilirubin)

32
Q

10% of gallstones contain what?

A

Calcium (visible on plain X-ray)

33
Q

What are the complications of gallstones?

A
  • cholecystitis
  • mucocele
  • predisposition to carcinoma of gallbladder
  • obstruction of biliary system
  • cholangitis and liver abscesses
  • gallstone illeus
  • pancreatitis
34
Q

What is cholecystitis?

A

Inflammation of the gallbladder

35
Q

What is mucocele? (complication of gallstones)

A

Distention of the gallbladder by an inappropriate accumulation of mucus. Decreased bile flow = predisposing factor

36
Q

Gallstones cause obstruction of biliary system which results in what?

A

Biliary colic and jaundice

37
Q

What is biliary colic?

A

Pain related to the gallbladder that occurs when a gallstone transiently obstructs the cystic duct and the gallbladder contracts

38
Q

Why do cholangitis and liver abscesses occur as a complication of gallstones?

A

Due to infection of static bile

39
Q

Why does gallstone ileus occur as a complication of gallstones?

A

Due to intestinal obstruction by a gallstone that has entered the gut through a fistulous connection with the gallbladder

40
Q

What are the indications for cholecystectomy?

A
  • pain
  • gallstones
  • pancreatitis
  • gall bladder polyp (rarely)
41
Q

Describe the features of acute cholecystitis

A
  • duct blocked by stone
  • initially sterile, later infected
  • large, swollen, congested, ulcerated
  • complications = empyema, rupture
42
Q

Describe the features of chronic cholecystitis

A
  • usually gallstones
  • small, fibrotic, stones
  • fibrosis
  • Rokitansky Aschoff sinuses
43
Q

What are Rokitansky-Aschoff sinuses?

A

Pseudodiverticula or pockets in the wall of the gallbladder.

Outpouchings of gallbladder mucosa into the gallbladder muscle layer and subserosal tissue as a result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the gallbladder wall.

Associated with cholecystitis.

44
Q

What happens to all gall bladders after cholecystectomy?

A

They are examined to detect gall bladder cancer

45
Q

What are the associated premalignant lesions before gall bladder cancer?

A
  • polyp

- dysplasia

12. CP - Diseases of the Hepatobiliary system and Pancreas (5 decks)

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