Gen surg: gallbladder - cholangitis, cholecystitis, biliary colic, cancer Flashcards
What are the RF for gallbladder carcinoma??
Hx of gallstones or chronic cholecystitis
Porcelain gallbladder
Smoking
Obesity
Primary sclerosing cholangitis
UC/crohns colitis
Oestrogens
Occupational exposure
How does gallbladder carcinoma present?
Usually presents late with vague symptoms of abdo pain
A patient comes in with jaundice, upon investigation, the cause is post- hepatic. What are your ddx?
acute cholangitis, cholecystitis, bile duct strictures, obstructive choledocholithiasis, external compression from extra- billiard tumour, pancreatic tumour, primary biliary cirrhosis and primary sclerosing cholangitis
What conditions increase risk of anal carcinoma?
HPV, Chrons, HIV
What are the symptoms of gallstone disease?
Can be asymptomatic
RUQ pain
Biliary colic
Nausea
Vomitting
Pale urine
Dark stools
Fever
Jaundice
What are the risk factors of gallstone disease?
Fair, fat, forty, family history, fertile
Poor diet
Oral contraceptives
Pregnancy
Malabsorption
Ethnicity- Native American and hispanic
What is biliary colic?
Stone is temporarily obstructing the neck of the gall bladder, impeding drainage
What is the most likely picture of LFTs when a patients presents with biliary colic?
Raised ALP, raised bilirubin
What is the first line investigation for patients who have suspected gallstone disease?
Ultrasound (trans abdominal)- helpful in identifying any gallstones in the gallbladder, gallstones in the ducts, bile duct dilatation, acute cholecystitis (thicken GB wall, or sludge in the gallbladder with fluid around the gallbladder)
What is the indication of MRCP in suspected gallstone disease?
Investigate further if ultrasound doesn’t show the presence of stones, but there is dilatation of the bile duct or raised bilirubin which suggests obstruction
What is acute cholecystitis?
Gallstone blocking the cystic duct or neck of the gallbladder causing the gallbladder to become inflamed.
What are the signs and symptoms of acute cholecystitis?
Pain in the RUQ
Fever
Nausea
Vomiting
Tachycardia and tachypnoea
Murphy’s sign positive
What is Murphy’s sign?
Hand on the RUQ and apply pressure, ask patient to take a deep breath in, the gallbladder will move downwards and come in contact with your hand and cause pain for the patient.
What is the first line investigation for acute cholecystitis?
Abdo ultrasound showing thickened gallbladder wall, stones or sludge in gallbladder, fluid around the gallbladder
What is the management of acute cholecystitis?
Conservative includes, Nil by mouth, Co-amoxiclav +/- metronidazole, antiemetics
Laproscopic cholecsytectomy is performed usually during the acute admission (within 72 hours) and sometimes delayed by 6-8 weeks to allow for the inflammation to subside
What is acute cholangitis?
Biliary outflow obstruction and infection
Due to gallstone which fully stops bile flow, causing stasis and then infection
ERCP, infection introduced
What is Charcot’s triad?
Presentation of acute cholangitis
RUQ pain
Fever
Jaundice
What are the most common organisms causing acute cholangitis?
Escherichia coli
Klebsiella species
Enterococcus species
How would a patient with acute cholangitis behave on examination?
Confused
RUQ tenderness
Jaundice
Hypotension
Tachycardic
Why is acute cholangitis a surgical emergency?
Due to the risk of sepsis and septicaemia
What would investigations find in acute cholangitis?
FBC- leukocytosis
LFTs-elevated ALP +/- GGT & bilirubin
blood cultures - not always positive
ultrasound buliary tract - duct dilation
How is acute cholangitis managed?
risk of sepsis- fluid resuscitation, routine bloods,
blood cultures, broad spectrum Abx
(co-amoxiclav + metronidazole)
definitive managment:
endoscopic biliary decompression using ERCP
cholecystectomy maybe required if
gallstones the underlying cause
What is a cholangiocarcinoma?
Cancer of the biliary system
What is a Klaskin tumour?
A tumour at the bifurcation of the L and R hepatic duct. It is a slow growing tumour which invades local lymph nodes
What are the risk factors for cholangiocarcinoma?
Primary scerlosing cholangitis
UC
Infective causes (liver flukes, HIV, hep)
Airplane and rubber fumes
Congential
Alcohol excess
DM
What are the clinical features of cholangiocarcinoma?
usually asymptomatic until later stages
post hepatic jaundice
pruritus
pale stools and dark urine
Less commonly- RUQ pain, early satiety, weight loss, anorexia and malaise
How does cholangiocarcinoma present on examination?
Jaundice and cachexia and courvoisiers rule applies
What is courvoisiers law?
Palpable gallbladder with painless jaundice–> pancreatic or biliary pathology should be suspected
What do you expect to be present on LFTs in a cholangiocarcinoma?
Obstructive jaundice, elevated bilirubin, ALP, y gamma transferase
What is the gold standard imaging for cholangiocarcinoma?
MRCP
ERCP can be used to obtain samples
What is the most common aim of treatment with cholangiocarcinoma?
Palliative
What is the definitive cure of cholangiocarcinoma?
Surgery
How do you treat a Klaskin tumour?
Partial hepatectomy and reconstruction of biliary tree
What are the palliative treatment options for cholangiocarcinoma?
Stenting- to relieve the obstruction
Bypass surgery- to bypass the obstruction, stenting doesn’t work
Palliative radiotherapy- to prolong survival some chemo agents may be used with radiotherapy
What are some conditions that can predispose you to hepatocellular carcinoma?
Viral hep B and c
Hereditary haemochromatosis
Primary biliary cirrhosis
What are some risk factors for hepatocellular carcinoma?
Male
Over 70
Fhx liver disease
High alcohol intake
aflatoxin poisoining
smoking
viral hep b and c
How do patients with hepatocellular carcinoma present?
Similar to liver cirrhosis
Vague and non-specific symptoms: leathery, weight loss, fatigue, fever
Dull ache in RUQ is uncommon but if present can be suspicious of malignancy
What are the examination findings of a patient with hepatocellular carcinoma?
Large, craggy, tender and irregular liver–>v suggestive of malignancy
What are the blood abnormalities in a patient with hepatocellular carcinoma?
LFTs deranged
Low platelets and clotting due to liver failure
Alpha fetoprotein should be measure as is raised in 70% of cases, and is good indication of treatment progress
What investigative imaging do you use in hepatocellular carcinoma?
US. Mass >2cm, with raised alpha fetoprotein (AFP) is virtually diagnostic of hepatocellular carcinoma
Rising AFP with nodular liver–> MRI
What is the name of the staging criteria for hepatocellular carcinoma?
Barcelona Clinic (no need to know the different stages_)
When can transplantation be considered in hepatocellular carcinoma?
Milan Criteria is used and needs to be fulfilled:
One lesion less than 5cm or 3 lesions are smaller than 3 cm
No extra hepatic manifestations
No vascular infiltration
When would surgery be indicated in a patient with hepatocellular carcinoma?
Good baseline function and no cirrhosis
What are the non-surgical treatment options fo hepatocellular carcinoma?
Image guided ablation- low grade tumours
Alcohol ablation
Transarteril chemoembolisation
Which organs metastasise to the liver most frequently?
bowel, breast, stomach, pancreas and lung
What is a rare but serious complication of gallstone disease?
Gallstone ileus
What is gallstone ileus?
Gallstone passing into the intestinal system via a biliary-enteric fistula causing distal obstruction
Differentials for RUQ pain?
Biliary colic
Acute cholangitis
Acute cholecystitis
