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4th year passmedicine by topic > Biliary/Pancreatic Disease > Flashcards

Biliary/Pancreatic Disease Flashcards

1
Q

Primary sclerosing cholangitis is

A

a biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts.

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2
Q

Primary sclerosing cholangitis associations?

A

ulcerative colitis
Crohn’s (much less common association than UC)
HIV

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3
Q

?% of patients with UC have PSC, ?% of patients with PSC have UC

A

4% of patients with UC have PSC, 80% of patients with PSC have UC

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4
Q

PSC bloods

A

raised bilirubin + ALP

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5
Q

PSC sx

A

cholestasis
jaundice, pruritus
right upper quadrant pain
fatigue

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6
Q

PSC ix

A

endoscopic retrograde cholangiopancreatography (ERCP)

or magnetic resonance cholangiopancreatography (MRCP)

are the standard diagnostic investigations, showing multiple biliary strictures giving a ‘beaded’ appearance

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7
Q

PSC which ANCA might be positive

A

p-ANCA may be positive

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8
Q

PSC always use liver biopsy

A

false

limited role for liver biopsy,

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9
Q

PSC what would liver biopsy show

A

fibrous, obliterative cholangitis often described as ‘onion skin’

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10
Q

PSC complications

A

cholangiocarcinoma (in 10%)

increased risk of colorectal cancer

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11
Q

Primary biliary cholangitis is a chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1)

A

true

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12
Q

Primary biliary cholangitis aetiology is not fully understood although it is thought to be an autoimmune condition

A

true

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13
Q

Primary biliary cholangitis classic presentation

A

itching in a middle-aged woman

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14
Q

Primary biliary cholangitis pathophysiology?

A

Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis which may eventually progress to cirrhosis

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15
Q

Primary biliary cholangitis associations

A

Sjogren’s syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease

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16
Q

PBC sx

A

early: may be asymptomatic or fatigue, pruritus
cholestatic jaundice
hyperpigmentation, especially over pressure points
around 10% of patients have right upper quadrant pain
xanthelasmas, xanthomata
also: clubbing, hepatosplenomegaly
late: may progress to liver failure

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17
Q

PBC LFTs

A

raised ALP on routine LFTs

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18
Q

PBC diagnosis?

A

anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific
smooth muscle antibodies in 30% of patients
raised serum IgM

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19
Q

PBC mx

A

first-line: ursodeoxycholic acid
slows disease progression and improves symptoms
pruritus: cholestyramine
fat-soluble vitamin supplementation

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20
Q

PBC liver is transplanted is indicated when?

A

if bilirubin > 100 (PBC is a major indication)

recurrence in graft can occur but is not usually a problem

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21
Q

PBC complications

A

cirrhosis → portal hypertension → ascites, variceal haemorrhage

osteomalacia and osteoporosis

significantly increased risk of hepatocellular carcinoma (20-fold increased risk)

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22
Q

Viral hepatitis common symptoms include:

A

nausea and vomiting, anorexia
myalgia
lethargy
right upper quadrant (RUQ) pain

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23
Q

Viral hepatitis Questions may point to risk factors such as

A

foreign travel or intravenous drug use.

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24
Q

Congestive hepatomegaly sx

A

The liver only usually causes pain if stretched

One common way this can occur is as a consequence of congestive heart failure.

25
Q

Biliary colic sx

A

RUQ pain, intermittent, usually begins abruptly and subsides gradually. Attacks often occur after eating. Nausea is common.

26
Q

Acute cholecystitis sx

A

Pain similar to biliary colic but more severe and persistent. The pain may radiate to the back or right shoulder.

The patient may be pyrexial and Murphy’s sign positive (arrest of inspiration on palpation of the RUQ)

27
Q

Ascending cholangitis sx

A

An infection of the bile ducts commonly secondary to gallstones. Classically presents with a triad of:
fever (rigors are common)
RUQ pain
jaundice

28
Q

Gallstone ileus sx

A

Abdominal pain, distension and vomiting are seen.

29
Q

Cholangiocarcinoma sx

A

Persistent biliary colic symptoms, associated with anorexia, jaundice and weight loss. A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen

30
Q

Acute pancreatitis sx

A

Usually due to alcohol or gallstones
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare

31
Q

Pancreatic cancer sx

A

Painless jaundice is the classical presentation of pancreatic cancer. However pain is actually a relatively common presenting symptom of pancreatic cancer. Anorexia and weight loss are common

32
Q

Amoebic liver abscess sx

A

Typical symptoms are malaise, anorexia and weight loss. The associated RUQ pain tends to be mild and jaundice is uncommon.

33
Q

Bile-acid malabsorption is a cause of

A

chronic diarrhoea

34
Q

Bile-acid malabsorption may be primary, due to

A

excessive production of bile acid, or secondary to an underlying gastrointestinal disorder causing reduced bile acid absorption.

35
Q

Bile-acid malabsorption leads to

A

steatorrhoea and vitamin A, D, E, K malabsorption.

36
Q

Bile-acid malabsorption secondary causes?

A

patients with ileal disease, such as with Crohn’s. Other secondary causes include:
cholecystectomy
coeliac disease
small intestinal bacterial overgrowth

37
Q

Bile-acid malabsorption ix

A

the test of choice is SeHCAT
nuclear medicine test using a gamma-emitting selenium molecule in selenium homocholic acid taurine or tauroselcholic acid (SeHCAT)
scans are done 7 days apart to assess the retention/loss of radiolabelled 75SeHCAT

38
Q

Bile-acid malabsorption mx

A

bile acid sequestrants e.g. cholestyramine

39
Q

Raised levels of unconjugated bilirubin may occur as a result of

A

haemolysis, which is to say a pre-hepatic source, for example, autoimmune-mediated haemolytic anaemia. Red blood cell breakdown exposes heme-containing proteins and, as discussed above, these are then processed to form unconjugated bilirubin.

40
Q

Raised levels of conjugated bilirubin can result from

A

defective excretion of bilirubin, for example, Dubin-Johnson Syndrome, or cholestasis.

41
Q

Jaundice starts to appear when bilirubin reaches an excess of

A

35umol/l

42
Q

Gallstones ix

A

abdominal ultrasound and liver function tests

43
Q

Biliary colic mx

A

If imaging shows gallstones and history compatible then laparoscopic cholecystectomy

44
Q

Acute cholecystitis mx

A

Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2)

45
Q

Gallbladder abscess mx

A

Imaging with USS +/- CT Scanning
Ideally, surgery although subtotal cholecystectomy may be needed if Calot’s triangle is hostile
In unfit patients, percutaneous drainage may be considered

46
Q

Cholangitis mx

A

Fluid resuscitation
Broad-spectrum intravenous antibiotics
Correct any coagulopathy
Early ERCP

47
Q

Gallstone ileus mx

A

Laparotomy and removal of the gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with.

48
Q

Acalculous cholecystitis mx

A

If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy

49
Q

Risks of ERCP(1)

A

Bleeding 0.9% (rises to 1.5% if sphincterotomy performed)
Duodenal perforation 0.4%
Cholangitis 1.1%
Pancreatitis 1.5%

50
Q

Pancreatic cancer is often diagnosed late as

A

it tends to present in a non-specific way

51
Q

Over 80% of pancreatic tumours are ?

A

adenocarcinomas

52
Q

Over 80% of pancreatic tumours typically occur where

A

at the head of the pancreas.

53
Q

Pancreatic cancer assoc

A

increasing age
smoking
diabetes
chronic pancreatitis (alcohol does not appear an independent risk factor though)
hereditary non-polyposis colorectal carcinoma
multiple endocrine neoplasia

54
Q

Pancreatic cancer genetics

A

BRCA2 gene

KRAS gene mutation

55
Q

Pancreatic cancer sx

A

classically painless jaundice
pale stools, dark urine, and pruritus

patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
loss of exocrine function (e.g. steatorrhoea)
loss of endocrine function (e.g. diabetes mellitus)
atypical back pain is often seen

56
Q

cholestatic liver function tests seen in pancreatic cancer

A

true

57
Q

Trousseau sign

A 
pancreatic cancer 
migratory thrombophlebitis (Trousseau sign) is more common than with other cancers
58
Q

Pancreatic cancer ix

A

ultrasound has a sensitivity of around 60-90%
high-resolution CT scanning is the investigation of choice if the diagnosis is suspected
imaging may demonstrate the ‘double duct’ sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts

59
Q

Pancreatic cancer mx

A

less than 20% are suitable for surgery at diagnosis
a Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple’s include dumping syndrome and peptic ulcer disease
adjuvant chemotherapy is usually given following surgery
ERCP with stenting is often used for palliation

4th year passmedicine by topic (96 decks)

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