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Finals > General Surgery (HPB) > Flashcards

General Surgery (HPB) Flashcards

1
Q

Briefly describe bilirubin excretion

A

Insoluble bilirubin is bound to albumin
Conjugation in the liver makes it water soluble
Excreted via bile to GI tract
Intestinal bacteria convert it to urobilinogen
Urobilinogen is either converted to stercobilinogen or reabsorbed and excreted via the kidneys

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2
Q

A conjugated hyperbilirubinaemia presents how?

A

pale stool and dark urine

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3
Q

State some causes of pre hepatic jaundice

A

pre: haemolysis, ischaemic hepatitis, Gilberts
intra: hepatitis, cirrhosis, abscess

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4
Q

State some causes of intra-hepatic jaundice

A

hepatic cell dysfunction:

  • viral hepatitis
  • alcohol
  • paracetamol
  • PBC and PSC
  • hepatocellular carcinoma

Cirrhosis
- intrahepatic parts of the biliary tree and compressed giving a conjugated hyperbilirubinemia

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5
Q

State some causes of post-hepatic jaundice

A

Lumen: gallstones
Wall: Strictures, PBC, cholestasis (steroids and co-amox), cholangiocarcinoma
Outside: pancreatic cancer, lymphoma

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6
Q

Compare the AST and ALT in alcoholic vs viral hepatitis

A

Alcohol = AST:ALT >2 (i.e. AST proportionately +++)

Viral = AST:ALT 1 (i.e. both raised)

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7
Q

What blood test results would you see in pre, intra and post hepatic jaundice?

A

pre: unconjugated, anaemia, normal ALT, AST, ALP
intra: mixed, raised ALT and AST, normal ALP, dysfunctional clotting (prolonged PT)
post: conjugated, normal/high ALT and AST, raised ALP and gamma-GT

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8
Q

Aside from treating the cause, how else is jaundice managed?

A

Manage hypoglycaemia
FFP for clotting abnormalities
Antihistamines for the itch
Laxatives - reduce ammonia producing gut bacteria so lower risk of hepatic encephalopathy

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9
Q

How do you lower the risk of a jaundice patient getting hepatic encephalopathy?

A

Laxatives

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10
Q

What are the risk factors for developing gallstones?

A 
Fat
Female
Forty
Family history
COCP
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11
Q

What are the two types of gallstones? What are the risk factors/ associations for each?

A

cholesterol (high cholesterol diet)

pigmented (associated with haemolytic anaemic and cirrhosis)

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12
Q

What is biliary colic?

A

gallstone blocks the biliary system. Often at the neck of the GB

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13
Q

How and when does biliary colic present?

A

Presents after eating
RUQ pain - dull, radiates to back
N&V
Sweating

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14
Q

What imaging would you do to diagnose gallstones?

A

MRCP

USS

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15
Q

What would you see on an USS to suggest gallstones?

A

thickened gallbladder wall

dilated ducts

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16
Q

What are the complications of gall stones?

A

acute cholecystitis
cholangitis
fistulas
pancreatitis

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17
Q

Gallbladder fistulas can classically present in 1 of 2 ways, name and describe these

A

Gallstone ileus: stone in terminal ileum causing SBO

Bouverte’s: stone in proximal duodenum causing gastric outlet obstruction

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18
Q

What is Mirizzi syndrome? How does it present?

A

If a stone is in Hartman’s pouch of the gallbladder it can compress the common hepatic duct causing obstructive jaundice

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19
Q

What is acute cholecystitis?

A

Inflammation of the cystic duct due to a gallstone

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20
Q

How does acute cholecystitis present?

A

Fever
RUQ pain and guarding
+ Murphy’s sign (halt inspiration with palpating under right costal margin)

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21
Q

How is acute cholecystitis managed?

A

IV abx

cholecystectomy within 72 hours

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22
Q

What is acute ascending cholangitis?

A

Infection of the biliary tract

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23
Q

What are the causes of acute ascending cholangitis?

What organism normally causes acute ascending cholangitis?

A

Stone, ERCP, cholangiocarcinoma

E.coli or klebsiella

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24
Q

How does acute ascending cholangitis present?

A

RUQ + fever + jaundice

+/- confusion
+/- hypotension

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25
Q

What is primary sclerosing cholangitis?

A

inflammation and fibrosis of the biliary tract

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26
Q

What is primary sclerosing cholangitis associated with?

A

UC

Less so to Crohns and HIV

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27
Q

How does primary sclerosing cholangitis present?

A

Pruritis
Jaundice
Fatigue
RUQ pain

28
Q

What blood test results would be expected in primary sclerosing cholangitis?

A

Raised ALP

P-ANCA +ve

29
Q

What imaging modality if first line for investigating primary sclerosing cholangitis? What would it show?

A

ERCP shows multiple biliary strictures

30
Q

Having primary sclerosing cholangitis increases your risk of what?

A 
Cholangiocarcinoma
Hepatocellular carcinoma (to a lesser extent)
31
Q

What is primary biliary cirrhosis?

A

Autoimmune inflammation of the biliary system leading to progressive cholestasis and cirrhosis

32
Q

How does primary biliary cirrhosis present?

A

Pruritis
Fatigue
Jaundice
RUQ pain

+Sicca syndrome: dry eyes, mouth and vagina and arthritis

33
Q

What blood test results would you expect in primary biliary cirrhosis?

A

Raised ALP
Raised IgM
AMA M2 antibodies

34
Q

Primary biliary cirrhosis is associated with Sicca syndrome, what symptoms would suggest this?

A

Dry eyes, mouth and vagina

arthritis

35
Q

How is primary biliary cirrhosis managed?

A

ursodeoxycholic acid
+ cholestyramine for itch
+ fat soluble vitamins

36
Q

Having primary biliary cirrhosis increases your risk of what?

A

Hepatocellular carcinoma

37
Q

What is hereditary hemochromatosis?

A

Autosomal recessive condition
There is overabsorption of iron from the gastrointestinal tract
The iron can’t be excreted so is stored in the liver causing cirrhosis

38
Q

How does hereditary haemochromatosis present?

A

Bronze skin
Cirrhosis
Diabetes

39
Q

How is hereditary haemochromatosis managed?

A

Phlebotomy

40
Q

What is the histology of cholangiocarcinoma? What is the most common type and where would you find it?

A

adenocarcinomas

Klatskin tumour: found at junction of left and right main hepatic ducts

41
Q

What are the risk factors for developing a cholangiocarcinoma?

A

PSC and UC
alcohol
diabetes
gallbladder wall calcification resulting from chronic cholecystitis

42
Q

How does cholangiocarcinoma present? What are your examination findings?

A

Painless jaundice and weight loss
+/- Sister Mary Joseph nodule
+/- biliary colic
+/- RUQ mass (Courvoisiers sign)

43
Q

What tumour markers may be raised in cholangiocarcinoma

A

CEA and CA19-9

44
Q

If a liver cyst is symptomatic how might it present?

A

early satiety and nausea

RUQ pain

45
Q

What blood test results and USS signs would you see in a patient with a liver cyst?

A

Raised LFTs, CEA and CA19-9

USS:

  • well defined
  • no septations
  • anechoic
  • thin walled
46
Q

A polycystic liver is defined as what?

A

> 20 cysts

>1cm each

47
Q

How would a polycystic liver present?

A

RUQ pain
hepatomegaly
early satiety and nausea

48
Q

How is a polycystic liver managed?

A

Somatostatin analogue to reduce the cyst size
Cyst deroofing
Aspiration

49
Q

On USS what would make you suspicious of a cystadenoma?

A
  • multiple septations
  • irregular border
  • wall enhancement
  • nodularity
50
Q

If USS shows suspicious signs of a cystadenoma, what investigation must be done and what must not be done?

A

CT contrast

Do not aspirate as risk of seeding and peritoneal spread

51
Q

What causes a hydatid liver cyst?

A

Tapeworm infection

52
Q

How does a hydatid cyst present?

A

As a simple cyst + malaise

53
Q

What USS findings would suggest a hydatid cyst?

A

calcifications

multiple septations

54
Q

What must you avoid doing to a hydatid cyst and why?

A

aspiration because there is a risk of anaphylaxis

55
Q

What in the history and examination would suggest an amoebic liver abscess?

A

Travel history

Fever, malaise, weight loss, bloating

56
Q

How are amoebic abscesses managed?

A

Metronidazole

57
Q

What antibodies would you find in a hydatid cyst and an amoebic abscess?

A

hydatid: Echinococcal antibodies
amoebic: E.histolytica antibodies

58
Q

What is a haemangioma?

A

hypervascular benign tumour of the liver

59
Q

How would a haemangioma present on USS?

A

hyperechoic

60
Q

If a liver tumour is primary what is its histology?

A

hepatocellular carcinoma

61
Q

What are the risk factors for developing a primary liver tumour?

A

PBC
alcohol
hepatitis
hereditary hemochromatosis

62
Q

How does the liver feel in hepatocellular carcinoma?

A

Tender
Enlarged
Craggy
Irregular

63
Q

What tumour marker is raised in hepatocellular carcinoma?

A

AFP

64
Q

What is seen on CT of a hepatocellular carcinoma?

A

Hypervascularisation of a mass

65
Q

What cancers most commonly metastasise to the liver?

A

Breast, Bowel, Lung, Stomach, Pancreas

66
Q

How does metastatic liver disease present?

A

RUQ pain
Jaundice
Ascites

67
Q

What investigation must you not do if you suspect liver metastasis and why?

A

Biopsy as can lead to peritoneal seeding

Finals (16 decks)

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