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
what laboratory tests would you do for acute pancreatits?
- Serum amylase
- LFTs
- Serum lipase - more accurate for pamcreatitis but not routinely done
Give 3 causes (other than Pancreatitis) of raised Serum Amylase
- Bowel Perforation
- DKA
- Ectopic Pregnancy
- mesenteric ischaemia
what imaging can be done in acute pancreatitis?
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)
How is the severity of Acute Pancreatitis scored?
modified Glasgow Criteria - used within 1st 48 hours of admission >3 = severe
PANCREAS (pO2, Age, Neutrophils, Calcium, Renal function, Enzymes, Albumin, Sugar)
Managements of Acute Pancreatitis
No curative management
Treat underlying cause
High flow oxygen
IV fluids
NG tube - if vomiting profusely
Catheterisation & fluid chart
Opiods
when are antibiotics used in acute pancreatitis and which one?
Broad spectrum - Imipenem
Prophylaxis against infection in cases of conformed pancreatic necrosis - shown to decarease mortality
Systemic complications of Acute Pancreatitis
- DIC
- Acute Respiratory Distress Syndrome (ARDS)
- Hypocalcaemia
- Hyperglycaemia
- Hypovolemic shock and multiorgan failure
describe 2 local complications of Acute Pancreatitis
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
Causes of Chronic Pancreatitis
Chronic alcohol abuse - most common
Idiopathic
Infection
Autoimmune
Hereditary (CF)
Obstruction of pancreatic duct
Metabolic (Hyperlipidaemia/hypercalcaemia)
Describe the two different types of pathophysiology of Chronic Pancreatitis
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
risk factors for chrnoic pancreatitis
excess alcohol abuse and smoking
Describe four clinical features of Chronic Pancreatitis
- Chronic Epigastric Pain (radiating to back, eased by leaning forward)
- Nausea and Vomiting
- Steatorrhoea
- DM
DDx for chronic pancreatitis
- acute cholecystitis
- peptic ulcer disease
- acute hepatitis
- sphincter of oddi dysfunction
Describe three laboratory abnormalities of Chronic Pancreatitis
- Raised Blood Glucose
- Raised Serum Calcium
- Abnormal LFTs
- serum amylase rarely significantly raised in established disease
what is a sensitive test for chronic pancreatitis?
faecal elastase - abnormally low in majority of cases
Describe two imaging techniques of Chronic Pancreatitis
USS - First Line
CT Abdo Pelvis - for pancreatic calcification/pseudocysts
what are 2 other investigation/imaging modalities that can be used and how can they be helpful for chronic pancreatitis?
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
Describe the initial management of Chronic Pancreatitis
simple analgesia and opioids
pancreatic enzyme supplements - creon
The definitive management of Chronic Pancreatitis requires more intervention, describe the endoscopic options
ERCP (Endoscopic Retrograde Cholangiopancreatography) EUS with stent - facilitate drainage of any pseudocysts - temporary and stent needs removing after few weeks
what is one of the risks patients have to be warned about with endoscopic procedures for chronic pancreatitis?
can induce acute-on-chronic pancreatitis
The definitive management of Chronic Pancreatitis requires more intervention, describe the surgical options
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
What is removed in a Pancreaticoduodenectomy procedure?
Pancreatic Head, Gall Bladder, Bile Ducts, Pyloric Antrum, 1st and 2nd parts of Duodenum
when are steroids used in chronic pancreatitis?
effective at reducing symptoms in chronic pancreatitis with autoimmune aetiology
high dose pred to bring symptoms under control and low dose maintenance regime
what are some complications of chronic pancreatitis?
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
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)
- Weight loss
- 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 Billary/Pancreatic Malignancy)
Describe three laboratory features of Pancreatic Cancer
Anaemia
Obstructive Jaundice (Raised ALP, Bilirubin and gamma GT)
Ca19-9 - tumour marker (used in assessing response to treatment rather than diagnosis)
Describe 3 imaging options for Pancreatic Cancer
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
What is the definitive management of Pancreatic Cancer
Either Whipples Procedure (head) or Distal Pancreatectomy (body or tail)
Contraindicated if any distant metastases
Describe the chemotherapy used for Pancreatic Cancer (FOLFIRINOX)
- adjuvant chemotherapy recommended after surgery
- Folinic Acid
- 5-fluorouracil
- 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
if infected - systemic features
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
Fertile
COCP (Oestrogen causes more cholesterol to be secreted into bile)
Pregnancy
Haemolytic anaemia
Describe the presentation of Biliary Colic
Sudden, Dull and Intermittent (colicky) RUQ pain (contraction against obstruction) may raidate to epigastrium and/or back
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 & 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
Charcots Triad (RUQ pain, Fever, Jaundice) Pruritus Pale Stools/Dark Urine
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
