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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
Why are needle biopsies not recommended in Liver Cancer
Risk of seeding
26
State 5 malignancies commonly metastasising to the Liver
``` Bowel Breast Pancreas Stomach Lung ```
27
How can Acute Pancreatitis be distinguished from Chronic
Limited damage to secretory function of gland | No gross structural damage
28
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)
29
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
30
Give 4 clinical features of Acute Pancreatitis
Severe Epigastric Pain radiating to the back Nausea and Vomiting Guarding Cullen & Grey Turners
31
Give 3 differentials for Acute Pancreatitis
AAA Aortic Dissection Duodenal Ulcer
32
Describe the serum marker of Pancreatitis
Serum Amylase raised three times the upper limit of normal
33
Give 3 causes (other than Pancreatitis) of raised Serum Amylase
Bowel Perforation DKA Ectopic Pregnancy
34
How is the severity of Acute Pancreatitis scored?
Glasgow Criteria PANCREAS (pO2, Age, Neutrophils, Calcium, Renal function, Enzymes, Albumin, Sugar)
35
Give four managements of Acute Pancreatitis
High Flow O2 IV Fluids Opioid Analgesis Broad Spectrum Abx - Imipenem
36
Give 3 systemic complications of Acute Pancreatitis
DIC Hypocalcaemia Hyperglycaemia
37
Give 2 local complications of Acute Pancreatitis
Pancreatic Necrosis | Pancreatic Pseudocyst
38
Give four causes of Chronic Pancreatitis
Chronic alcohol abuse Autoimmune Hereditary (CF) Metabolic (Hyperlipidaemia)
39
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
40
Describe four clinical features of Chronic Pancreatitis
Chronic Epigastric Pain (radiating to back, eased by leaning forward) Nausea and Vomiting Steatorrhoea DM
41
Describe three laboratory abnormalities of Chronic Pancreatitis
Raised Blood Glucose Raised Serum Calcium Abnormal LFTs
42
Describe two imaging techniques of Chronic Pancreatitis
USS - First Line | CT Abdo Pelvis - for pancreatic calcification/pseudocysts
43
Describe the initial management of Chronic Pancreatitis
Analgesia + Opioid Creon Steroids
44
The definitive management of Chronic Pancreatitis requires more intervention, describe the endoscopic options
ERCP (Endoscopic Retrograde Cholangiopancreatography) | EUS with stent
45
The definitive management of Chronic Pancreatitis requires more intervention, describe the surgical options
Lateral Pancreaticojejunostomy Pancreaticoduodenectomy (AKA Whipples) Total Pancreatectomy
46
What is removed in a Pancreaticoduodenectomy procedure?
Pancreatic Head, Gall Bladder, Bile Ducts, Pyloric Antrum, 1st and 2nd parts of Duodenum
47
Describe the histology of Pancreatic Cancer
Usually a Ductal Carcinoma Can be Exocrine (Pancreatic Cystic Carcinoma) or Endocrine (Derived from Islet Cells of Pancreas)
48
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
49
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)
50
Describe three laboratory features of Pancreatic Cancer
Anaemia Obstructive Jaundice (Raised ALP and Bilirubin) Ca19-9
51
Describe two imaging options for Pancreatic Cancer
USS - Pancreatic Mass or Dilated Biliary Tree | CT Pancreas
52
What is the definitive management of Pancreatic Cancer
Either Whipples Procedure or Distal Pancreatectomy (depending on location) Contraindicated if any distant metastases
53
Describe the chemotherapy used for Pancreatic Cancer (FOLFIRINOX)
Folinic Acid 5FU Irinotecan Oxaliplatin
54
Describe three palliative managements of Pancreatic Cancer
Biliary Stent (ERCP) Chemo Creon
55
State four types of Pancreatic Endocrine Tumours
Gastrinoma (AKA Zollinger Ellison) Glucagonoma Insulinoma Somatostatinoma
56
Describe the clinical features of a Pancreatic Cyst
Abdo/Back Pain Post Obstructive Jaundice Nausea
57
How would you manage Pancreatic Cysts?
Manage with surveillance due to malignancy risk
58
State three components of Bile
Cholesterol Phospholipids Bile Pigments
59
State the three types of Gall Stones
Cholesterol (Link with obesity and poor diet) Pigment (commonly seen in those with Haemolytic Anaemia) Mixed
60
Give 6 risk factors for Gall Stones
``` Fat Fair Female Forty Family History COCP (Oestrogen causes more cholesterol to be secreted into bile) ```
61
Describe the presentation of Biliary Colic
Sudden, Dull and Intermittent RUQ pain (contraction against obstruction) Precipitated by fatty foods
62
Describe the presentation of Acute Cholecystitis
Constant pain ini RUQ/Epigastrium with associated signs of inflammation Associated signs of inflammation (fever, lethargy)
63
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)
64
Describe three features of USS of Gallstones
Presence of Gallstones Gallbladder Wall Thickness Bile Duct DIlation
65
What is the difference between MRCP and ERCP?
MRCP - Identifies any biliary obstruction | ERCP - Identifies any biliary obstruction and allows for intervention
66
How would you manage simple Biliary Colic?
Analgesia Lifestyle Factors Elective Laproscopic Cholecystectomy
67
How would you manage Acute Cholecystitis?
IV Antibiotics (Co-Amox) Anaglesia & Anti-Emetics Laproscopic Cholecystectomy/Percutaneous Cholecystectomy
68
What is Mirizzi Syndrome
Stone can cause compression of adjacent bile duct, causing obstructive jaundice
69
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
70
What is Cholangitis?
Infection of biliary tract associated with biliary stasis from obstruction
71
Give 3 causes and 3 causative organisms for Cholangitis
Gallstones, ERCP, Cholangiocarcinoma E.Coli, Klebsiella, Enterococcus
72
Describe the clinical features of Cholangitis
Charcots Triad (RUQ pain, Fever, Jaundice) Pruritus Pale Stools/Dark Urine
73
Describe the clinical features of Reynolds Pentad
``` RUQ Pain Fever Jaundice Confusion Hypotension ```
74
Describe two investigations for Cholangitis and what they would show
``` Abnormal LFTs (Raised ALP, raised GGT) USS - Bile ducts dilated to greater than 6mm ```
75
How would you manage Cholangitis
Abx (Co-Amoxiclav) ERCP/Percutaneous Transhepatic Cholangiography If repeated Gall Stones - Cholecystectomy
76
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)
77
Give four risk factors for Cholangiocarcinoma
PSC UC Fluke Infection Alcohol
78
Give three clinical features of Cholangiocarcinomas
Often asymptomatic until late stage | Post Hepatic Jaundice, Pruritus, Pale Stools/Dark Urine
79
How would you investigate Cholangiocarcinomas?
Bloods - Obstructive Jaundice, potentially raised markers MRCP ERCP - If biopsy requires CT- Staging
80
The only cure for Cholangiocarcinomas is complete resection, describe the possible procedures
Intrahepatic ducts - Partial Hepatic Resection and Biliary Tree Reconstruction Extrahepatic ducts - Whipples
81
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
82
Give 3 causes of Splenic Infarcts
Haematological Disorders - Sickle Cell/Polycythaemia Vera Embolic Disorders - AF Vasculitis
83
Give 3 clinical features of Splenic Infarcts
May be asymptomatic LUQ pain radiating to right shoulder (Kehr's sign) Nausea
84
Give two differentials for Splenic Infarcts
Pyelonephritis | Left Basal Pneumonia
85
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
86
How would you manage a Splenic Infarct?
``` Analgesia IV Hydration Manage underlying disease ?Long term anticoagulation Try to avoid Splenectomy ```
87
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)
88
Give three causes of Splenic Rupture
Blunt Trauma Iatrogenic Infection (EBV)
89
Give 3 clinical features of Splenic Ruptures
``` Abdominal Pain Hypovolaemic Shock (some) LUQ tenderness ```
90
How would you manage a suspected Splenic Rupture
If haemodynamically unstable - urgent laparotomy If not unstable CT Abdo and prophylactic vaccinations

taz year 3 surgery (10 decks)

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