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Dan Surgery > General Surgery (Hepatobiliary) > Flashcards

General Surgery (Hepatobiliary) Flashcards

1
Q

What are Simple Liver Cysts?

A

Fluid filled epithelial sacs (most commonly in right lobe of liver)
Thought to be congenitally malformed bile ducts

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2
Q

Describe 3 symptoms of Simple Liver Cysts

A

Abdominal Pain
Nausea
Vomiting

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3
Q

What investigations should be carried out if you suspected Liver Cysts?

A

USS (well defined, thin walled)

LFTs may be normal

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4
Q

How would you manage Simple Liver Cysts?

A

Most require no intervention
For Cysts>4cm use follow up scans

If symptomatic then US Guided Aspiration/Laroscopic Deroofing

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5
Q

Define Polycystic Liver Disease

A

Presence of more than 20 cysts in the parenchyma of the liver (each one more than 1cm wide)

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6
Q

Describe the two causes of Polycystic Liver DIsease

A

ADPKD (60% patients have liver cysts)

ADPLD (Chromosome 6 or 19 mutations, generally not related to renal disease)

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7
Q

Describe 3 clinical features of Polycystic Liver Disease

A

Majority are asymptomatic
Abdominal Pain as cysts grow
Hepatomegaly

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8
Q

The management of Polycystic Liver Disease is generally the same as Simple Liver Cysts. However what extra pharmacological intervention can be tried?

A

Somatostatin Analogues such as Octreotide may help decrease Cyst Volume

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9
Q

Describe how USS can help differentiate between the different types of Liver Cysts

A

Malignancy - Septations, Nodularity
Abscess - Debris within lesion
Hyatid - Calcification

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10
Q

What are Hyatid Cysts?

A

Infection by tapeworm

Eggs are passed faeco-orally and pass into the hepatic portal system where they form cysts

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11
Q

How would you manage Hyatid Cysts?

A

Aspiration not recommended (rupture can causes anaphylaxis)

Cystic Deroofing and Anti-Parasitics

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12
Q

Describe the pathophysiology of Liver Abscesses

A

Typically from bacterial infection spreading from Biliary/GI Tract either via Contiguous Spread or seeding from Portal/Hepatic Veins

Typical Organisms include E.Coli and Klebsiella Pneumoniae

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13
Q

Describe 5 clinical features of Liver Abscesses

A 
Fevers
Rigors
Abdominal Pain
Bloating
Ruptured - Shock
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14
Q

Describe 3 possible investigations for Liver Abscesses and what they would show

A

FBC - Leucocytosis
LFTs - Raised ALP, Deranged ALT and Bilirubin
USS - Poorly defined lesions with potential gas bubbles

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15
Q

Describe three managements of Liver Abscesses

A

Antibiotics
Ultrasound/CT Guided Drainage
Surgery only if ruptured

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16
Q

What is an Amoebic Abscess?

A

Most common extra-intestinal manifestation of Entomoeba Histiolytica (from spread via portal system)

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17
Q

Describe two pharmacological agents used to treat Amoebic Abscesses

A

Metronidazole

Paromycin (Eradicates amoebiasis in colon)

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18
Q

Give 3 causes of Hepatocellular Carcinoma

A

Viral Hepatitis
Chronic Alcoholism
Hereditary Haemachromatoses

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19
Q

Describe the results of Lab Investigations for suspected Liver Cancer

A

Deranged LFTs
Decreased Synthetic Function
Raised AFP

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20
Q

What is diagnostic of Liver Cancer?

A

USS showing mass of >2cm along with raised AFP

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21
Q

What is the staging tool of Liver Cancer called?

A

Barcelona Clinic Liver Cancer

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22
Q

Give two prognostic scores of Cirrhosis

A

Childs-Pugh Score (serum bilirubin, INR, albumin, ascites, encephalopathy)
MELD (creatinine, bilirubin, INR, sodium)

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23
Q

Describe the two surgical managements of Liver Cancer

A

Resection (patients without cirrhosis and a good baseline cirrhosis)

Transplantation (have to fulfill the Milan Criteria - no extrahepatic manifestations/no vascular infiltrations)

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24
Q

Describe three non surgical managements of Liver Cancer

A 
Image Guided Ablation (US waves initiate necrosis)
Alcohol Ablation (injection of alcohol destroys small tumours)
Transarterial Chemoembolisation (chemo injected into hepatic artery along with embolising agent to reduce ischaemia)
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25
Q

Why are needle biopsies not recommended in Liver Cancer

A

Risk of seeding

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26
Q

State 5 malignancies commonly metastasising to the Liver

A 
Bowel
Breast
Pancreas
Stomach
Lung
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27
Q

How can Acute Pancreatitis be distinguished from Chronic

A

Limited damage to secretory function of gland

No gross structural damage

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28
Q

Using the mnemonic ‘GET SMASHED’ to describe the causes of Acute Pancreatitis

A

Gallstones, Ethanol, Trauma

Steroids, Mumps, Autoimmune, Scorption venom, Hypercalcaemia, ERCP, Drugs (NSAIDS, Azathioprine)

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29
Q

In 4 steps describe the pathophysiology of Acute Pancreatitis

A
  • Premature and exaggerated activation of digestive enzymes
  • Inflammatory response (Increasing vascular permeability and fluid loss)
  • Pancreatic enzymes cause fat autodigestion
  • Free fatty acids react with calcium to form chalky deposits and hypocalcaemia
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30
Q

Give 4 clinical features of Acute Pancreatitis

A

Severe Epigastric Pain radiating to the back
Nausea and Vomiting
Guarding
Cullen & Grey Turners

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31
Q

Give 3 differentials for Acute Pancreatitis

A

AAA
Aortic Dissection
Duodenal Ulcer

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32
Q

Describe the serum marker of Pancreatitis

A

Serum Amylase raised three times the upper limit of normal

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33
Q

Give 3 causes (other than Pancreatitis) of raised Serum Amylase

A

Bowel Perforation
DKA
Ectopic Pregnancy

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34
Q

How is the severity of Acute Pancreatitis scored?

A

Glasgow Criteria

PANCREAS (pO2, Age, Neutrophils, Calcium, Renal function, Enzymes, Albumin, Sugar)

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35
Q

Give four managements of Acute Pancreatitis

A

OI OI

O2
Imipenem (Broad Spec Abx)
Opioid Pain Relief
IV fluids

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36
Q

Give 3 systemic complications of Acute Pancreatitis

A

DIC
Hypocalcaemia
Hyperglycaemia

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37
Q

Give 2 local complications of Acute Pancreatitis

A

Pancreatic Necrosis

Pancreatic Pseudocyst

38
Q

Give four causes of Chronic Pancreatitis

A

Chronic alcohol abuse
Autoimmune
Hereditary (CF)
Metabolic (Hyperlipidaemia)

39
Q

Describe the two different types of pathophysiology of Chronic Pancreatitis

A

Large Duct - Calcification, More common in Males

Small Duct - No Calcification, More common in Women

40
Q

Describe four clinical features of Chronic Pancreatitis

A

Chronic Epigastric Pain (radiating to back, eased by leaning forward)
Nausea and Vomiting
Steatorrhoea
DM

41
Q

Describe three laboratory abnormalities of Chronic Pancreatitis

A

Raised Blood Glucose
Raised Serum Calcium
Abnormal LFTs

42
Q

Describe two imaging techniques of Chronic Pancreatitis

A

USS - First Line

CT Abdo Pelvis - for pancreatic calcification/pseudocysts

43
Q

Describe the initial management of Chronic Pancreatitis

A

Analgesia + Opioid
Creon
Steroids

44
Q

The definitive management of Chronic Pancreatitis requires more intervention, describe the endoscopic options

A

ERCP (Endoscopic Retrograde Cholangiopancreatography)

EUS with stent

45
Q

The definitive management of Chronic Pancreatitis requires more intervention, describe the surgical options

A

Lateral Pancreaticojejunostomy
Pancreaticoduodenectomy (AKA Whipples)
Total Pancreatectomy

46
Q

What is removed in a Pancreaticoduodenectomy procedure?

A

Pancreatic Head, Gall Bladder, Bile Ducts, Pyloric Antrum, 1st and 2nd parts of Duodenum

47
Q

Describe the histology of Pancreatic Cancer

A

Usually a Ductal Carcinoma

Can be Exocrine (Pancreatic Cystic Carcinoma) or Endocrine (Derived from Islet Cells of Pancreas)

48
Q

Pancreatic Cancer normally doesn’t present until it has metastasised hence its poor prognosis, but what are some clinical features

A

Obstructive Jaundice
Abdo Pain (Secondary to invasion of coeliac plexus)
Acute Pancreatitis
Thrombophlebitis Migrans

49
Q

What is Courvoisier’s Law?

A

Presence of a palpably enlarged Gall Bladder and painless jaundice is unlikely to be due to Gall Stones (more likely to be Pancreatic Malignancy)

50
Q

Describe three laboratory features of Pancreatic Cancer

A

Anaemia
Obstructive Jaundice (Raised ALP and Bilirubin)
Ca19-9

51
Q

Describe two imaging options for Pancreatic Cancer

A

USS - Pancreatic Mass or Dilated Biliary Tree

CT Pancreas

52
Q

What is the definitive management of Pancreatic Cancer

A

Either Whipples Procedure or Distal Pancreatectomy (depending on location)

Contraindicated if any distant metastases

53
Q

Describe the chemotherapy used for Pancreatic Cancer (FOLFIRINOX)

A

Folinic Acid
5FU
Irinotecan
Oxaliplatin

54
Q

Describe three palliative managements of Pancreatic Cancer

A

Biliary Stent (ERCP)
Chemo
Creon

55
Q

State four types of Pancreatic Endocrine Tumours

A

Gastrinoma (AKA Zollinger Ellison)
Glucagonoma
Insulinoma
Somatostatinoma

56
Q

Describe the clinical features of a Pancreatic Cyst

A

Abdo/Back Pain
Post Obstructive Jaundice
Nausea

57
Q

How would you manage Pancreatic Cysts?

A

Manage with surveillance due to malignancy risk

58
Q

State three components of Bile

A

Cholesterol
Phospholipids
Bile Pigments

59
Q

State the three types of Gall Stones

A

Cholesterol (Link with obesity and poor diet)
Pigment (commonly seen in those with Haemolytic Anaemia)
Mixed

60
Q

Give 6 risk factors for Gall Stones

A 
Fat
Fair
Female
Forty
Family History
COCP (Oestrogen causes more cholesterol to be secreted into bile)
61
Q

Describe the presentation of Biliary Colic

A

Sudden, Dull and Intermittent RUQ pain (contraction against obstruction)
Precipitated by fatty foods

62
Q

Describe the presentation of Acute Cholecystitis

A

Constant pain ini RUQ/Epigastrium with associated signs of inflammation
Associated signs of inflammation (fever, lethargy)

63
Q

What is Murphy’s Sign?

A

Apply pressure to RUQ and ask patient to breathe in
Halt in inspiration due to pain

Indicates gall bladder inflammation (AKA Cholecystitis)

64
Q

Describe three features of USS of Gallstones

A

Presence of Gallstones
Gallbladder Wall Thickness
Bile Duct DIlation

65
Q

What is the difference between MRCP and ERCP?

A

MRCP - Identifies any biliary obstruction

ERCP - Identifies any biliary obstruction and allows for intervention

66
Q

How would you manage simple Biliary Colic?

A

Analgesia
Lifestyle Factors
Elective Laproscopic Cholecystectomy

67
Q

How would you manage Acute Cholecystitis?

A

IV Antibiotics (Co-Amox)
Anaglesia & Anti-Emetics
Laproscopic Cholecystectomy/Percutaneous Cholecystectomy

68
Q

What is Mirizzi Syndrome

A

Stone can cause compression of adjacent bile duct, causing obstructive jaundice

69
Q

What is Bouverets and Gallstone Ileus?

A

Bouveret’s - Stone impacts in proximal duodenum causing gastric outflow obstruction
Gallstone Ileus - Stone impacts at terminal ileum causing outflow obstruction

70
Q

What is Cholangitis?

A

Infection of biliary tract associated with biliary stasis from obstruction

71
Q

Give 3 causes and 3 causative organisms for Cholangitis

A

Gallstones, ERCP, Cholangiocarcinoma

E.Coli, Klebsiella, Enterococcus

72
Q

Describe the clinical features of Cholangitis

A

Charcots Triad (RUQ pain, Fever, Jaundice)
Pruritus
Pale Stools/Dark Urine

73
Q

Describe the clinical features of Reynolds Pentad

A 
RUQ Pain
Fever
Jaundice
Confusion
Hypotension
74
Q

Describe two investigations for Cholangitis and what they would show

A 
Abnormal LFTs (Raised ALP, raised GGT)
USS - Bile ducts dilated to greater than 6mm
75
Q

How would you manage Cholangitis

A

Abx (Co-Amoxiclav)
ERCP/Percutaneous Transhepatic Cholangiography

If repeated Gall Stones - Cholecystectomy

76
Q

What is a Cholangiocarcinoma?

A

Cancer of the biliary system predominantly occurring in the extrahepatic bile ducts (most commonly at bifurcation of left and right hepatic)

77
Q

Give four risk factors for Cholangiocarcinoma

A

PSC
UC
Fluke Infection
Alcohol

78
Q

Give three clinical features of Cholangiocarcinomas

A

Often asymptomatic until late stage

Post Hepatic Jaundice, Pruritus, Pale Stools/Dark Urine

79
Q

How would you investigate Cholangiocarcinomas?

A

Bloods - Obstructive Jaundice, potentially raised markers
MRCP
ERCP - If biopsy requires
CT- Staging

80
Q

The only cure for Cholangiocarcinomas is complete resection, describe the possible procedures

A

Intrahepatic ducts - Partial Hepatic Resection and Biliary Tree Reconstruction
Extrahepatic ducts - Whipples

81
Q

What is a Splenic Infarct?

A

Occlusion of Splenic Artery or one of its branches resulting in tissue necrosis.
Often not complete necrosis due to collateral supply from splenic artery and short gastric

82
Q

Give 3 causes of Splenic Infarcts

A

Haematological Disorders - Sickle Cell/Polycythaemia Vera
Embolic Disorders - AF
Vasculitis

83
Q

Give 3 clinical features of Splenic Infarcts

A

May be asymptomatic
LUQ pain radiating to right shoulder (Kehr’s sign)
Nausea

84
Q

Give two differentials for Splenic Infarcts

A

Pyelonephritis

Left Basal Pneumonia

85
Q

What is the gold standard investigation for a Splenic Infarct

A

CT with contrast

Segmental wedge if branch of splenic artery is occluded
Whole spleen will be hypoattenuated if splenic artery itself is occluded

86
Q

How would you manage a Splenic Infarct?

A 
Analgesia
IV Hydration
Manage underlying disease
?Long term anticoagulation
Try to avoid Splenectomy
87
Q

Name two complications of Splenic Infarcts

A

Splenic Abscess (if cause was non sterile embolus)

Autosplenectomy (repeated infarctions lead to fibrosis and atrophy of the spleen)

88
Q

Give three causes of Splenic Rupture

A

Blunt Trauma
Iatrogenic
Infection (EBV)

89
Q

Give 3 clinical features of Splenic Ruptures

A 
Abdominal Pain
Hypovolaemic Shock (some)
LUQ tenderness
90
Q

How would you manage a suspected Splenic Rupture

A

If haemodynamically unstable - urgent laparotomy

If not unstable CT Abdo and prophylactic vaccinations

Dan Surgery (9 decks)

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