GI/GEN - Hepatobiliary Conditions Flashcards
Biliary Colic
Risk Factors for Gallstones
Clinical Features
Bedside Investigations
Imaging
Management
1.) Risk Factors for Gallstones
- 5Fs: female, fertile, fat, fair, forty
- increasing age, FH, diabetes (metabolic syndrome), oral contraception
- sudden weight loss: eg after obesity surgery
- loss of bile salts: e.g. ileal resection, terminal ileitis seen in Crohn’s
2.) Clinical Features - sudden, dull, colicky pain in RUQ
- pain can last for hours and can also radiate to the epigastrium, back, and shoulders (interscapular region)
- can be associated with nausea and vomiting
- may occur after fatty meals (↑CCK –> contraction)
- no signs of inflammation
3,) Bedside Investigations - bloods, urinalysis
- WCC and CRP normal due to no inflammation
- raised ALP (obstruction) normal ALT and bilirubin
- amylase/lipase to check for evidence of pancreatitis
- urinalysis (inc hCG) to exclude renal or gynae issues
4.) Imaging - USS, MRCP
- 1°biliary USS: looking for stones, gallbladder wall thickness, bile duct dilation
- MRCP (if USS inconclusive): defects in the biliary tree
5.) Management
- analgesia: paracetamol +/- NSAIDs +/- opiates
- lifestyle: low fat diet, weight loss, increased exercise
- definitive: elective laparoscopic cholecystectomy within 6 wks
Acute Cholecystitis
Clinical Features
Bedside Investigations
Imaging
Management
1.) Clinical Features - constant pain in RUQ/epigastrium w/ inflammatory signs e.g. fever, lethargy
- tender in RUQ
- positive Murphy’s sign: arrest of respiration due to severe pain on inhalation
2.) Investigations - bloods, urinalysis
- ↑WCC and ↑CRP due to inflammation
- ↑ALP (obstruction), normal ALT and bilirubin
- amylase/lipase to check for evidence of pancreatitis
- urinalysis (inc hCG) to exclude renal or gynae issues
3.) Imaging - USS, HIDA MRCP
- 1°biliary USS: stones, gallbladder wall thickness, bile duct dilation
- 2°cholescintigraphy (HIDA scan): gallbladder not visualised due to cystic duct obstruction
- 3°MRCP (USS inconclusive): defects in the biliary tree
- CT scans are poor at visualising the biliary tree and gallbladder
4.) Management
- analgesia, antibiotics, antiemetics
- definitive: 1°ERCP, 2°PTC (percutaneous transhepatic cholangiography)
- lap cholecystectomy w/in 3-7days, a CBD stone causing symptoms is a complication of a lap chole
- percutaneous cholecystectomy if not fit for surgery
Ascending Cholangitis
What is it?
Clinical Features
Investigations/Imaging
Management
1.) What is it? - biliary outflow obstruction + infection
- aetiology: occlusion of the biliary tree (common causes: gallstones, ECRP, cholangiocarcinoma)
2.) Clinical Features - constant pain in RUQ
- Charcot’s triad: pain in RUQ, fever, jaundice
- Reynolds pentad: Charcot’s + hypotension, confusion
- pruritus due to bile accumulation
- pale stools/dark urine (obstructive jaundice)
3.) Investigations/Imaging
- routine bloods: ↑WCC/CRP, ↑ALP +/- GGT, ↑bilirubin
- blood cultures
- biliary USS: bile duct dilation (>6mm), gallstones
- ECRP (gold): diagnostic and therapeutic
4.) Management
- sepsis 6 (patients may present w/ sepsis)
- endoscopic biliary decompression via ERCP or PTC (percutaneous transhepatic cholangiography) after 24-48 hours to relieve any obstruction
Acute Pancreatitis
Diagnostic Triad
Causes/Risk Factors (IGETSMASHED)
Bedside Investigations
Glasgow Score (PANCREAS)
Management
1.) Diagnostic Triad - 2/3 needed (symptoms, investigations, radiological evidence)
- Sx: severe acute onset of burning epigastric pain (blockage of the pancreatic duct), worse when supine and may radiate to the back, can cause severe N+V
- Ix: amylase x3 upper limit of normal
- radiological evidence (ultrasound, CT or MRI)
- other signs: jaundice, abdominal tenderness w/ guarding, ↓bowel sounds,
Cullen’s and Grey Turner signs
2.) Causes/Risk Factors - I GET SMASHED
- Idiopathic, GALLSTONES, ETHANOL, Trauma
- Steroids, Mumps, Autoimmune, Scorpion venom,
- Hyperlipidaemia, Hypercalcaemia, Hypothermia
- ERCP: occurs within 6hrs of the procedure
- Drugs: NSAIDs, steroids, azathioprine, mesalazine, diuretics, sodium valproate, pentamidine, didanosine
3.) Bedside Investigations
- bloods + amylase, albumin, BG
- coagulation screen and blood type
- ABG if SATS are low, VBG for lactate
- abdo-US is important to help determine aetiology (e.g. gallstones)
4.) Glasgow Score - determines severity, (PANCREAS)
- PaO2 (<8kPa), Age (<55), Neutrophils (>15)
- Calcium (<2mM), Renal Function (urea >16)
- Enzyme (↑LDH/AST), Albumin (<32), Sugar (> 10mM)
- >2 score suggestive of organ failure
- >3 or more in the first 48hrs suggests severe attack and requires admission to HDU
- Ranson score is an alternative: it estimates the mortality of patients based on initial and 48-hour lab values
5.) Management
- aggressive IV fluids (Hartmann’s) because lots of third space losses due to endothelium release
- IV morphine pump (PCA, patient-controlled analgesia)
- catheter to monitor fluid output
- encourage enteral feeding (esp PO): moves bacteria through GI tract to ↓ the risk of pancreatic tissue infection
- NO ANTIBIOTICS
6.) Complications
- fluid collections (ascites), pseudocysts, abscesses
- pancreatic necrosis, haemorrhage
- acute respiratory distress syndrome
- DIC, hyper/hypoglycaemia
Liver Abscess
CAPSULE GI 96
Pancreatic Cancer
Pathophysiology
Clinical Features
Investigations/Imaging
Endocrine Tumours of the Pancreas
1.) Pathophysiology
- most common type is ductal carcinoma (90%)
- metastases common at diagnosis: spleen, transverse colon, adrenal glands, liver, lungs, peritoneum
- risk factors: smoking, chronic pancreatitis, FH, DM (late onset)
2.) Clinical Features - tumours of head of the pancreas
- painless obstructive jaundice (compresses CBD)
- weight loss (also due to exocrine dysfunction)
- abdo pain (non-specific), abdominal mass
- Courvoisier’s Law: jaundice + non tender palpable gallbladder excludes gallstones (suggests malignancy of pancreas of biliary tree)
- others: acute pancreatitis, thrombophlebitis,
3.) Investigations
- bloods: FBC, LFTs (obstructive jaundice), CA19-9
- abdominal USS: mass or dilated biliary tree
- staging CT: once cancer has been diagnosed
- endoscopic US (EUS): to guide aspiration biopsy if diagnosis is unclear, ERCP also for biopsy
4.) Endocrine Tumours of the Pancreas - may be functional (secretory) or non-functional
- gastrinoma (G-cells) –> Zollinger-Ellison syndrome
- glucagon-oma (a-cells) –> hyperglycaemia, DM
- insulin-oma (ß-cells) –> hypoglycaemia symptoms
- somatostatin-oma (D-cells) –> inhibits GH, TSH, PRL, gastrin –> DM, gallstones, weight loss, achlorhydria
Pancreatic Cysts
What are They?
Clinical Features
Pancreatic Pseudocyst
Investigations
Management
1.) What are They? - collections of fluid that form within the pancreas
- true cysts are non-inflammatory, pseudocysts are not
- can be classed by risk of malignancy, serous cysts are lower risk whilst mucinous cysts are high risk
2.) Clinical Features - often asymptomatic (70%)
- abdo/back pain, post-obstructive jaundice, vomiting
- infected cysts present w/ systemic features
- malignant cysts present w/ features of malignancy
3.) Pancreatic Pseudocysts - collection of fluid within pancreatic tissue usually following pancreatitis
- inflammatory reaction produces necrotic space which fills with pancreatic fluid
- often asymptomatic and picked up on imaging
4.) Investigation
- bloods: FBC, U+Es, LFTs, CA19-9
- CT-abdo or MRCP, EUS w/ FNA
- low risk: <3cm, asymptomatic, central calcification
- high risk: >3cm, pancreatic duct >10mm, solid component, mural nodule
5.) Management - majority benign so surveillance
- high risk: resection, MRI scan every 2 years
- low risk: surveillance every 5 years
