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Year 3 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
  1. Severe Epigastric Pain radiating to the back
  2. Nausea and Vomiting
  3. Guarding
  4. 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

what laboratory tests would you do for acute pancreatits?

A
  • Serum amylase
  • LFTs
  • Serum lipase - more accurate for pamcreatitis but not routinely done
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34
Q

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

A
  • Bowel Perforation
  • DKA
  • Ectopic Pregnancy
  • mesenteric ischaemia
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35
Q

what imaging can be done in acute pancreatitis?

A

Abdominal USS - if underlying cause is unknown - can look for gallstones

CT abdomen with contrast - if bloods/clinical assessment are inconclusive (will show oedema and swelling if performed in first 48 hours)

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36
Q

How is the severity of Acute Pancreatitis scored?

A

modified Glasgow Criteria - used within 1st 48 hours of admission >3 = severe

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

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37
Q

Managements of Acute Pancreatitis

A

No curative management

Treat underlying cause

High flow oxygen

IV fluids

NG tube - if vomiting profusely

Catheterisation & fluid chart

Opiods

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38
Q

when are antibiotics used in acute pancreatitis and which one?

A

Broad spectrum - Imipenem

Prophylaxis against infection in cases of conformed pancreatic necrosis - shown to decarease mortality

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39
Q

Systemic complications of Acute Pancreatitis

A
  • DIC
  • Acute Respiratory Distress Syndrome (ARDS)
  • Hypocalcaemia
  • Hyperglycaemia
  • Hypovolemic shock and multiorgan failure
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40
Q

describe 2 local complications of Acute Pancreatitis

A

Pancreatic Necrosis - ongoing inflammation leads to ischaemic infacrtion of pancreas, prone to infection - suspect in patients with persistent systemic inflammation for more than 7-10 days after onset

Pancreatic Pseudocyst - collection of fluid containing pancreatic enzymes, blood and necrotic tissue, incidental finding or present with symptoms of mass effect ie biliart obstruction

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41
Q

Causes of Chronic Pancreatitis

A

Chronic alcohol abuse - most common

Idiopathic

Infection

Autoimmune

Hereditary (CF)

Obstruction of pancreatic duct

Metabolic (Hyperlipidaemia/hypercalcaemia)

42
Q

Describe the two different types of pathophysiology of Chronic Pancreatitis

A

Large Duct - dilation and dysfunction of the large pancreatic ducts. diffuse pancreatic calcification, More common in Males

Small Duct - No Calcification and normal imaging, More common in Women

43
Q

risk factors for chrnoic pancreatitis

A

excess alcohol abuse and smoking

44
Q

Describe four clinical features of Chronic Pancreatitis

A
  • Chronic Epigastric Pain (radiating to back, eased by leaning forward)
  • Nausea and Vomiting
  • Steatorrhoea
  • DM
45
Q

DDx for chronic pancreatitis

A
  • acute cholecystitis
  • peptic ulcer disease
  • acute hepatitis
  • sphincter of oddi dysfunction
46
Q

Describe three laboratory abnormalities of Chronic Pancreatitis

A
  • Raised Blood Glucose
  • Raised Serum Calcium
  • Abnormal LFTs
  • serum amylase rarely significantly raised in established disease
47
Q

what is a sensitive test for chronic pancreatitis?

A

faecal elastase - abnormally low in majority of cases

48
Q

Describe two imaging techniques of Chronic Pancreatitis

A

USS - First Line

CT Abdo Pelvis - for pancreatic calcification/pseudocysts

49
Q

what are 2 other investigation/imaging modalities that can be used and how can they be helpful for chronic pancreatitis?

A

MRCP - identify presence of biliary obstruction and asses pancreatic duct

ERCP - more accurate way of eliciting the anatomy of the pancreatic duct and can be combined with intervention

can be combined with administration of scecretin which causes the pamcrease to produce bicarbonate rich fluid - may reveal pancreatic duct stricture

50
Q

Describe the initial management of Chronic Pancreatitis

A

simple analgesia and opioids

pancreatic enzyme supplements - creon

51
Q

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

A

ERCP (Endoscopic Retrograde Cholangiopancreatography) EUS with stent - facilitate drainage of any pseudocysts - temporary and stent needs removing after few weeks

52
Q

what is one of the risks patients have to be warned about with endoscopic procedures for chronic pancreatitis?

A

can induce acute-on-chronic pancreatitis

53
Q

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

A

Lateral Pancreaticojejunostomy - side to side anastomosis of pancreatic duct to the jejumun

Pancreaticoduodenectomy (AKA Whipples) - resection of pancreatic head, gallbladder and bile fuct, pyloric antrum, 1st and 2nd portions of duodenum with the tail of pancreas anastamosed with the duodenum and the body of stomach anastamosed to distal duodenum

Total Pancreatectomy - removal of entire pancreas

54
Q

What is removed in a Pancreaticoduodenectomy procedure?

A

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

55
Q

when are steroids used in chronic pancreatitis?

A

effective at reducing symptoms in chronic pancreatitis with autoimmune aetiology

high dose pred to bring symptoms under control and low dose maintenance regime

56
Q

what are some complications of chronic pancreatitis?

A

Pseudocyst

Steatorrhoea and malabsorption - poor exocrine function - treat with creon

Diabetes - loss of endocrine function - treat with insulin

Effusions - ascites and pleural effusion - usually need surgery

Pancreatic maligancy - risk if had for 20 years

57
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)

58
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)
  • Weight loss
  • Acute Pancreatitis
  • Thrombophlebitis Migrans
59
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 Billary/Pancreatic Malignancy)

60
Q

Describe three laboratory features of Pancreatic Cancer

A

Anaemia

Obstructive Jaundice (Raised ALP, Bilirubin and gamma GT)

Ca19-9 - tumour marker (used in assessing response to treatment rather than diagnosis)

61
Q

Describe 3 imaging options for Pancreatic Cancer

A

USS - Pancreatic Mass or Dilated Biliary Tree

pancreatic protocol CT scan - can stage progression too (will then need chest abdo pelvis CT

EUS - used to guide fine needle aspiration biopsy to histologically evaluate the lesion

62
Q

What is the definitive management of Pancreatic Cancer

A

Either Whipples Procedure (head) or Distal Pancreatectomy (body or tail)

Contraindicated if any distant metastases

63
Q

Describe the chemotherapy used for Pancreatic Cancer (FOLFIRINOX)

A
  • adjuvant chemotherapy recommended after surgery
  • Folinic Acid
  • 5-fluorouracil
  • Irinotecan
  • Oxaliplatin
64
Q

Describe three palliative managements of Pancreatic Cancer

A

Biliary Stent (ERCP)

Chemo

Creon

65
Q

State four types of Pancreatic Endocrine Tumours

A

Gastrinoma (AKA Zollinger Ellison)

Glucagonoma

Insulinoma

Somatostatinoma

66
Q

Describe the clinical features of a Pancreatic Cyst

A
  • Abdo/Back Pain
  • Post Obstructive Jaundice
  • Nausea

if infected - systemic features

67
Q

How would you manage Pancreatic Cysts?

A

Manage with surveillance due to malignancy risk

68
Q

State three components of Bile

A
  • Cholesterol
  • Phospholipids
  • Bile Pigments
69
Q

State the three types of Gall Stones

A
  1. Cholesterol (Link with obesity and poor diet)
  2. Pigment (commonly seen in those with Haemolytic Anaemia)
  3. Mixed
70
Q

Give 6 risk factors for Gall Stones

A

Fat

Fair

Female

Forty

Family History

Fertile

COCP (Oestrogen causes more cholesterol to be secreted into bile)

Pregnancy

Haemolytic anaemia

71
Q

Describe the presentation of Biliary Colic

A

Sudden, Dull and Intermittent (colicky) RUQ pain (contraction against obstruction) may raidate to epigastrium and/or back

Precipitated by fatty foods

72
Q

Describe the presentation of Acute Cholecystitis

A

Constant pain ini RUQ/Epigastrium with associated signs of inflammation

Associated signs of inflammation (fever, lethargy)

73
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)

74
Q

Describe three features of USS of Gallstones

A

Presence of Gallstones

Gallbladder Wall Thickness

Bile Duct DIlation

75
Q

What is the difference between MRCP and ERCP?

A

MRCP - Identifies any biliary obstruction

ERCP - Identifies any biliary obstruction and allows for intervention

76
Q

How would you manage simple Biliary Colic?

A

Analgesia

Lifestyle Factors

Elective Laproscopic Cholecystectomy

77
Q

How would you manage Acute Cholecystitis?

A

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

78
Q

What is Mirizzi Syndrome

A

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

79
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

80
Q

What is Cholangitis?

A

Infection of biliary tract associated with biliary stasis from obstruction

81
Q

Give 3 causes and 3 causative organisms for Cholangitis

A

Gallstones, ERCP, Cholangiocarcinoma E.Coli, Klebsiella, Enterococcus

82
Q

Describe the clinical features of Cholangitis

A

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

83
Q

Describe the clinical features of Reynolds Pentad

A

RUQ Pain Fever Jaundice Confusion Hypotension

84
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

85
Q

How would you manage Cholangitis

A

Abx (Co-Amoxiclav) ERCP/Percutaneous Transhepatic Cholangiography If repeated Gall Stones - Cholecystectomy

86
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)

87
Q

Give four risk factors for Cholangiocarcinoma

A

PSC UC Fluke Infection Alcohol

88
Q

Give three clinical features of Cholangiocarcinomas

A

Often asymptomatic until late stage Post Hepatic Jaundice, Pruritus, Pale Stools/Dark Urine

89
Q

How would you investigate Cholangiocarcinomas?

A

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

90
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

91
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

92
Q

Give 3 causes of Splenic Infarcts

A

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

93
Q

Give 3 clinical features of Splenic Infarcts

A

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

94
Q

Give two differentials for Splenic Infarcts

A

Pyelonephritis Left Basal Pneumonia

95
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

96
Q

How would you manage a Splenic Infarct?

A

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

97
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)

98
Q

Give three causes of Splenic Rupture

A

Blunt Trauma Iatrogenic Infection (EBV)

99
Q

Give 3 clinical features of Splenic Ruptures

A

Abdominal Pain Hypovolaemic Shock (some) LUQ tenderness

100
Q

How would you manage a suspected Splenic Rupture

A

If haemodynamically unstable - urgent laparotomy If not unstable CT Abdo and prophylactic vaccinations

Year 3 Surgery (10 decks)

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