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
Give 2 local complications of Acute Pancreatitis
Pancreatic Necrosis
Pancreatic Pseudocyst
Give four causes of Chronic Pancreatitis
Chronic alcohol abuse
Autoimmune
Hereditary (CF)
Metabolic (Hyperlipidaemia)
Describe the two different types of pathophysiology of Chronic Pancreatitis
Large Duct - Calcification, More common in Males
Small Duct - No Calcification, More common in Women
Describe four clinical features of Chronic Pancreatitis
Chronic Epigastric Pain (radiating to back, eased by leaning forward)
Nausea and Vomiting
Steatorrhoea
DM
Describe three laboratory abnormalities of Chronic Pancreatitis
Raised Blood Glucose
Raised Serum Calcium
Abnormal LFTs
Describe two imaging techniques of Chronic Pancreatitis
USS - First Line
CT Abdo Pelvis - for pancreatic calcification/pseudocysts
Describe the initial management of Chronic Pancreatitis
Analgesia + Opioid
Creon
Steroids
The definitive management of Chronic Pancreatitis requires more intervention, describe the endoscopic options
ERCP (Endoscopic Retrograde Cholangiopancreatography)
EUS with stent
The definitive management of Chronic Pancreatitis requires more intervention, describe the surgical options
Lateral Pancreaticojejunostomy
Pancreaticoduodenectomy (AKA Whipples)
Total Pancreatectomy
What is removed in a Pancreaticoduodenectomy procedure?
Pancreatic Head, Gall Bladder, Bile Ducts, Pyloric Antrum, 1st and 2nd parts of Duodenum
Describe the histology of Pancreatic Cancer
Usually a Ductal Carcinoma
Can be Exocrine (Pancreatic Cystic Carcinoma) or Endocrine (Derived from Islet Cells of Pancreas)
Pancreatic Cancer normally doesn’t present until it has metastasised hence its poor prognosis, but what are some clinical features
Obstructive Jaundice
Abdo Pain (Secondary to invasion of coeliac plexus)
Acute Pancreatitis
Thrombophlebitis Migrans
What is Courvoisier’s Law?
Presence of a palpably enlarged Gall Bladder and painless jaundice is unlikely to be due to Gall Stones (more likely to be Pancreatic Malignancy)
Describe three laboratory features of Pancreatic Cancer
Anaemia
Obstructive Jaundice (Raised ALP and Bilirubin)
Ca19-9
Describe two imaging options for Pancreatic Cancer
USS - Pancreatic Mass or Dilated Biliary Tree
CT Pancreas
What is the definitive management of Pancreatic Cancer
Either Whipples Procedure or Distal Pancreatectomy (depending on location)
Contraindicated if any distant metastases
Describe the chemotherapy used for Pancreatic Cancer (FOLFIRINOX)
Folinic Acid
5FU
Irinotecan
Oxaliplatin
Describe three palliative managements of Pancreatic Cancer
Biliary Stent (ERCP)
Chemo
Creon
State four types of Pancreatic Endocrine Tumours
Gastrinoma (AKA Zollinger Ellison)
Glucagonoma
Insulinoma
Somatostatinoma
Describe the clinical features of a Pancreatic Cyst
Abdo/Back Pain
Post Obstructive Jaundice
Nausea
How would you manage Pancreatic Cysts?
Manage with surveillance due to malignancy risk
State three components of Bile
Cholesterol
Phospholipids
Bile Pigments
State the three types of Gall Stones
Cholesterol (Link with obesity and poor diet)
Pigment (commonly seen in those with Haemolytic Anaemia)
Mixed
Give 6 risk factors for Gall Stones
Fat
Fair
Female
Forty
Family History
COCP (Oestrogen causes more cholesterol to be secreted into bile)
Describe the presentation of Biliary Colic
Sudden, Dull and Intermittent RUQ pain (contraction against obstruction)
Precipitated by fatty foods
Describe the presentation of Acute Cholecystitis
Constant pain ini RUQ/Epigastrium with associated signs of inflammation
Associated signs of inflammation (fever, lethargy)
What is Murphy’s Sign?
Apply pressure to RUQ and ask patient to breathe in
Halt in inspiration due to pain
Indicates gall bladder inflammation (AKA Cholecystitis)
Describe three features of USS of Gallstones
Presence of Gallstones
Gallbladder Wall Thickness
Bile Duct DIlation
What is the difference between MRCP and ERCP?
MRCP - Identifies any biliary obstruction
ERCP - Identifies any biliary obstruction and allows for intervention
How would you manage simple Biliary Colic?
Analgesia
Lifestyle Factors
Elective Laproscopic Cholecystectomy
How would you manage Acute Cholecystitis?
IV Antibiotics (Co-Amox)
Anaglesia and Anti-Emetics
Laproscopic Cholecystectomy/Percutaneous Cholecystectomy
What is Mirizzi Syndrome
Stone can cause compression of adjacent bile duct, causing obstructive jaundice
What is Bouverets and Gallstone Ileus?
Bouveret’s - Stone impacts in proximal duodenum causing gastric outflow obstruction
Gallstone Ileus - Stone impacts at terminal ileum causing outflow obstruction
What is Cholangitis?
Infection of biliary tract associated with biliary stasis from obstruction
Give 3 causes and 3 causative organisms for Cholangitis
Gallstones, ERCP, Cholangiocarcinoma
E.Coli, Klebsiella, Enterococcus
Describe the clinical features of Cholangitis (Reynolds Pentad)
Charcots Triad (RUQ pain, Fever, Jaundice)
Shock
Altered Mental State
Describe the clinical features of Reynolds Pentad
RUQ Pain
Fever
Jaundice
Confusion
Hypotension
Describe two investigations for Cholangitis and what they would show
Abnormal LFTs (Raised ALP, raised GGT)
USS - Bile ducts dilated to greater than 6mm
How would you manage Cholangitis
Abx (Co-Amoxiclav)
ERCP/Percutaneous Transhepatic Cholangiography
If repeated Gall Stones - Cholecystectomy
What is a Cholangiocarcinoma?
Cancer of the biliary system predominantly occurring in the extrahepatic bile ducts (most commonly at bifurcation of left and right hepatic)
Give four risk factors for Cholangiocarcinoma
PSC
UC
Fluke Infection
Alcohol
Give three clinical features of Cholangiocarcinomas
Often asymptomatic until late stage
Post Hepatic Jaundice, Pruritus, Pale Stools/Dark Urine
How would you investigate Cholangiocarcinomas?
Bloods - Obstructive Jaundice, potentially raised markers
MRCP
ERCP - If biopsy requires
CT- Staging
The only cure for Cholangiocarcinomas is complete resection, describe the possible procedures
Intrahepatic ducts - Partial Hepatic Resection and Biliary Tree Reconstruction
Extrahepatic ducts - Whipples
What is a Splenic Infarct?
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
Give 3 causes of Splenic Infarcts
Haematological Disorders - Sickle Cell/Polycythaemia Vera
Embolic Disorders - AF
Vasculitis
Give 3 clinical features of Splenic Infarcts
May be asymptomatic
LUQ pain radiating to right shoulder (Kehr’s sign)
Nausea
Give two differentials for Splenic Infarcts
Pyelonephritis
Left Basal Pneumonia
What is the gold standard investigation for a Splenic Infarct
CT with contrast
Segmental wedge if branch of splenic artery is occluded
Whole spleen will be hypoattenuated if splenic artery itself is occluded
How would you manage a Splenic Infarct?
Analgesia
IV Hydration
Manage underlying disease
?Long term anticoagulation
Try to avoid Splenectomy
Name two complications of Splenic Infarcts
Splenic Abscess (if cause was non sterile embolus)
Autosplenectomy (repeated infarctions lead to fibrosis and atrophy of the spleen)
Give three causes of Splenic Rupture
Blunt Trauma
Iatrogenic
Infection (EBV)
Give 3 clinical features of Splenic Ruptures
Abdominal Pain
Hypovolaemic Shock (some)
LUQ tenderness
How would you manage a suspected Splenic Rupture
If haemodynamically unstable - urgent laparotomy
If not unstable CT Abdo and prophylactic vaccinations
How would you investigate gall stones?
USS
Then MRCP
Then ERCP +/- lap chole
Name four complications of gall stones
Fistula (Bouverets and Gallstone Ileus)
Mucocele
Empyema
Gangrene
