Hepatic, pancreatic and biliary surgery Flashcards
Benign HPB disease:
-gallstones are a common cause of HPB disease
Gall stones-what are they?
Most commonly stones are a mix between the 2.
Patients present with RUQ or epigastric pain.
Pain is often colicky or crampy
Key phrases-associated with heavy meal or fatty food, lean towards biliary colic
If pain is constant-peptic ulcer disease, pancreatitis, Gord etc.
How to differentiate between biliary colic and cholecystitis?
Cholecystitis-infection
When palpate RUQ-murphy’s sign positive, ask patient to take deep breath and when they inhale they will feel pain, think about gall bladder related pain more likely cholecystitis
Investigations
FBC-to look for signs of inflammation eg WBC
LFT-alkaline phosphatase deranged in biliary colic
alkaline phosphatase and alt in cholecystitis
For either, don’t expect rise in bilirubin
Always Abdominal Us is first line for pathologies we discuss today. Can allow us to look at 3 main things-is there gallstones in gall bladder (may not see all gall stones on CT as not all are radio opaque), can see thickness of gall bladder. Thick wall points towards cholecystitis as it suggests inflammation.
MRCP-MRI scan of biliary tree. It is almost 100% sensitive for looking for stones and strictures in biliary tree. Don’t do straight away as expensive and harder to come by.
Just say US to look at biliary tree for first investigation.
Treatment:
Analgesia
ABx for cholecystitis
Surgery- likely to get same thing again, unless they are old or comorbid.
Cholecystostomy-drain gall bladder through skin and relieve obstruction in older person
When surgery?
Complications of gall stones:
- Radiological drain- pus comes out in empyema
- Not true ileus. Duodenum can fistulate with small intestine and stones can enter and travel allow small bowel and at narrowed point-ileocaecal valve, can cause obstruction and surgery is required to relieve stone and obstruction.
What can this cause?
=Obstructive jaundice secondary to biliary outflow obstruction
Bile enters blood stream so get jaundice and only way it can clear is kidneys so get dark urine.
When pale stools and dark urine, straight away think biliary obstruction.
Investigations
What is normal size of common bile duct?
Global deranged LFTs
Biliary tree dilatation-in or may have passed
Derangement in bilirubin and dilated bilirubin then need MRCP
Normal size:
If the patient is under 60years then -4-5mm
If patient is over 60, take there age, so if they are 60, take 6 and then minus 1mm, so 6-1=5mm
If they are 70, then 7-1=6mm
If they are 80, then up to 7mm
Treatment
ERCP
Both ERCP and OGD go in top end but ercp camera goes all the way down but camera is sideways facing as needs to see ampulla which is angled in duodenum.
Do an incision in sphincter to allow stone to pass or procedure to be done. Wouldn’t do this is cholecystitis because this isn’t necessarily due to obstruction of biliary tree.
Cholangitis
Obstructive jaundice and infection of biliary tree
Get bacterial translocation as liver gives access to portal circulation
Mortality can be up to 10%
Treatment
Wait for sepsis to settle before surgery and if inflammation around bile ducts wait 6-8 weeks before surgery.
Acute Pancreatitis:
Often causes by smaller stones as hey have to be very small to pass through this far
Not infection but inflammation
10/10 pain, nausea and vomiting, central epigastric pain radiating to the back.
Ruptured triple As present very similarly so consider this. Could be perforated duodenal ulcer or Gord as well.
Acute Pancreatitis-causes top 3 are most common
Not how much a patient drinks but if they drink or not as some patient’s pancreas are very sensitive to alcohol
Pancreatitis leads to vicious sequence of events
Diagnostic tests:
=serum amylase (must be 3x upper limit), serum lipase is a good marker but expensive and doesn’t stay high in the blood after event unlike amylase
USS-to look for gallstones because then we know cause of it and can prevent it.
Ct scan to look for perforated duodenum ulcer
Score related to acute pancreatitis:
The presence of three or more of these criteria within the first 48 hours is indicative of severe pancreatitis. If the score ≥ 3, severe pancreatitis likely- suggest refer to HDU/ICU and if the score < 3, severe pancreatitis is unlikely.
Management:
Purely supportive
Abx-not required
They should eat-consider feeding with NG tube if they can’t feed after a while
Significant complications:
Pancreatic pseudocyst-6-8weeks after collection. Inner lining of cyst contains epithelial cell but in pseudocyst doesn’t have this lining and is fluid surrounded by fibrosis. It has to be drained through stomach.
