General Surgery (Hepatobiliary) Flashcards
What are Simple Liver Cysts?
Fluid filled epithelial sacs (most commonly in right lobe of liver)
Thought to be congenitally malformed bile ducts
Describe 3 symptoms of Simple Liver Cysts
Abdominal Pain
Nausea
Vomiting
What investigations should be carried out if you suspected Liver Cysts?
USS (well defined, thin walled)
LFTs may be normal
How would you manage Simple Liver Cysts?
Most require no intervention
For Cysts>4cm use follow up scans
If symptomatic then US Guided Aspiration/Laroscopic Deroofing
Define Polycystic Liver Disease
Presence of more than 20 cysts in the parenchyma of the liver (each one more than 1cm wide)
Describe the two causes of Polycystic Liver DIsease
ADPKD (60% patients have liver cysts)
ADPLD (Chromosome 6 or 19 mutations, generally not related to renal disease)
Describe 3 clinical features of Polycystic Liver Disease
Majority are asymptomatic
Abdominal Pain as cysts grow
Hepatomegaly
The management of Polycystic Liver Disease is generally the same as Simple Liver Cysts. However what extra pharmacological intervention can be tried?
Somatostatin Analogues such as Octreotide may help decrease Cyst Volume
Describe how USS can help differentiate between the different types of Liver Cysts
Malignancy - Septations, Nodularity
Abscess - Debris within lesion
Hyatid - Calcification
What are Hyatid Cysts?
Infection by tapeworm
Eggs are passed faeco-orally and pass into the hepatic portal system where they form cysts
How would you manage Hyatid Cysts?
Aspiration not recommended (rupture can causes anaphylaxis)
Cystic Deroofing and Anti-Parasitics
Describe the pathophysiology of Liver Abscesses
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
Describe 5 clinical features of Liver Abscesses
Fevers
Rigors
Abdominal Pain
Bloating
Ruptured - Shock
Describe 3 possible investigations for Liver Abscesses and what they would show
FBC - Leucocytosis
LFTs - Raised ALP, Deranged ALT and Bilirubin
USS - Poorly defined lesions with potential gas bubbles
Describe three managements of Liver Abscesses
Antibiotics
Ultrasound/CT Guided Drainage
Surgery only if ruptured
What is an Amoebic Abscess?
Most common extra-intestinal manifestation of Entomoeba Histiolytica (from spread via portal system)
Describe two pharmacological agents used to treat Amoebic Abscesses
Metronidazole
Paromycin (Eradicates amoebiasis in colon)
Give 3 causes of Hepatocellular Carcinoma
Viral Hepatitis
Chronic Alcoholism
Hereditary Haemachromatoses
Describe the results of Lab Investigations for suspected Liver Cancer
Deranged LFTs
Decreased Synthetic Function
Raised AFP
What is diagnostic of Liver Cancer?
USS showing mass of >2cm along with raised AFP
What is the staging tool of Liver Cancer called?
Barcelona Clinic Liver Cancer
Give two prognostic scores of Cirrhosis
Childs-Pugh Score (serum bilirubin, INR, albumin, ascites, encephalopathy)
MELD (creatinine, bilirubin, INR, sodium)
Describe the two surgical managements of Liver Cancer
Resection (patients without cirrhosis and a good baseline cirrhosis)
Transplantation (have to fulfill the Milan Criteria - no extrahepatic manifestations/no vascular infiltrations)
Describe three non surgical managements of Liver Cancer
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)
Why are needle biopsies not recommended in Liver Cancer
Risk of seeding
State 5 malignancies commonly metastasising to the Liver
Bowel
Breast
Pancreas
Stomach
Lung
How can Acute Pancreatitis be distinguished from Chronic
Limited damage to secretory function of gland
No gross structural damage
Using the mnemonic ‘GET SMASHED’ to describe the causes of Acute Pancreatitis
Gallstones, Ethanol, Trauma
Steroids, Mumps, Autoimmune, Scorption venom, Hypercalcaemia, ERCP, Drugs (NSAIDS, Azathioprine)
In 4 steps describe the pathophysiology of Acute Pancreatitis
-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
Give 4 clinical features of Acute Pancreatitis
Severe Epigastric Pain radiating to the back
Nausea and Vomiting
Guarding
Cullen & Grey Turners
Give 3 differentials for Acute Pancreatitis
AAA
Aortic Dissection
Duodenal Ulcer
Describe the serum marker of Pancreatitis
Serum Amylase raised three times the upper limit of normal
Give 3 causes (other than Pancreatitis) of raised Serum Amylase
Bowel Perforation
DKA
Ectopic Pregnancy
How is the severity of Acute Pancreatitis scored?
Glasgow Criteria
PANCREAS (pO2, Age, Neutrophils, Calcium, Renal function, Enzymes, Albumin, Sugar)
Give four managements of Acute Pancreatitis
OI OI
O2
Imipenem (Broad Spec Abx)
Opioid Pain Relief
IV fluids
Give 3 systemic complications of Acute Pancreatitis
DIC
Hypocalcaemia
Hyperglycaemia