Hepatobiliary

Question 1

Jaundice- Imaging

Answer 1

USS abdomen initially
MRCP if obstructive or USS inconclusive. I.e. use ERCP to remove obstruction.
Liver biopsy if diagnosis not yet made.

Question 2

Gallstones-
Types
Risk Factors
Investigation (high ALT but normal bilirubin and AST)

Answer 2

Bile is made from cholesterol, bile pigments and phospholipids.
Stones;
Cholesterol stones- cholesterol only
Pigment stones- Pigment only
Mixed
Female, Forty, Fat, FHx, Fertile
Transabdominal USS will show gallstones/sludge, wall thickening and bile duct dilatation.

Question 3

Biliary colic

Answer 3

RUQ pain, can radiate to the back/epigastrium, colicky pain, worse after eating fatty meal.

Treatment- Analgesia, lifestyle changes, elective cholecystectomy (6weeks).

Question 4

Acute cholecystitis

Answer 4

Constant RUQ pain, fever, Murphy sign positive, N+V.

Treatment- Abx, analgesia, antiemetics, cholecystectomy (1week)

Question 5

Cholangitis

Answer 5

RUQ pain, fever and jaundice. Present usually septic.
Caused by blockage to biliary tree therefore bacteria colonisation. Due to gallstones, ERCP, pancreatitis etc.
Take routine bloods, FBCs, LFTs, blood cultures.
Investigate with ERCP since also therapeutic.
Manage with removal of obstruction i.e ERCP, broad spectrum Abx, may require cholecystectomy in the long run.

Question 6

Types of liver cysts (4)

Answer 6

Simple
Polycystic Liver disease
Hydatid
Neoplastic

All usually asymptomatic, requiring only monitoring. LFTs normal in most cases.
USS for all + CT with contrast for suspected neoplasm.

Question 7

Polycystic Liver disease

Answer 7

Gene for either ADPLD or ADPKD
Will get renal impairment also if kidneys involved.
>20 cysts.
US guided aspiration or cyst deroofing if surgical.

Question 8

Cystic neoplasm

Answer 8

Rare, but usually a premalignant cystadenoma, some may progress to cystadenocarcinoma.
Liver lobe resection if surgical.

Question 9

Hydatid cyst

Answer 9

Infection via tape worm, microbe will travel via the portal system and form cyst in the liver.
If ruptured can cause anaphylaxis.
May have raised eosinophils.
Cyst deroofing if surgery.

Question 10

Indications for surgery in liver cysts

Answer 10

Symptoms not resolved conservatively.
Can’t rule out malignancy on imaging.
Prevention of malignancy.

NB avoid aspiration/biopsy in neoplastic or hydatid cysts to avoid seeding of malignancy and anaphylaxis respectively.

Question 11

Liver Abscess

Answer 11

Bacterial infection from the biliary or GI system. Commonly E.coli, K.pneumoniae.
Present with fever, rigors and ab pain. Also fatigue, jaundice, RUQ pain +/- hepatomegaly. If ruptured abscess then hypovolaemic shock signs.
Increased WBC, deranged LFTs, request culture.
Manage with US/CT guided aspiration and Abx.
Surgery if not responding to Abx or if ruptured.

Question 12

Amoebic Liver Abscess

Answer 12

Caused by E.histolytica. ?recent travel. Vague ab pain, nausea, weight loss etc.
Increased WBC, deranged LFTs, request cultures.
Manage with Abx alone.

Question 13

HCC-
Causes
RF
Differentials

Answer 13

Due to chronic inflammation, liver feels large, craggy, irregular, commonly no RUQ pain. Main cause; viral hepatitis (B/C). Also hereditary hemochromatosis, chronic alcohol.
RF: Smoking, >70yrs, alcohol, viral hepatitis, FHx.
Differentials: Heart failure (hepatomegaly), infectious hepatitis, benign, liver cirrhosis.

Question 14

HCC-

Investigations

Answer 14

Alpha fetoprotein- high in most cases, if raised with USS evidence then diagnostic.
Deranged LFTs, low platelet, prolonged clotting.
Can confirm with MRI or CT. Avoid biopsy in case of seeding.

Question 15

HCC- Management

Prognosis- Median 6 months survival.

Answer 15

Surgical Resection- If good baseline health and no cirrhosis.
Transplant- If one lesion <5cm or three < 3cm, no extra hepatic manifestations, no vascular involvement.
Image guided ablation.
Transarterial chemoembolism- Inject chemo drug into a hepatic artery to induce ischaemia.

Question 16

Secondary liver malignancy

Answer 16

Metastasis from bowel, breast, lungs, stomach and pancreas.
Present with hepatomegaly, jaundice, ascites etc.
Deranged LFTs (high ALP), image with USS.
Only treat surgically/ via TACE if metastasis confined to the liver and primary disease under control. Otherwise consider palliative care.
Avoid biopsy to avoid seeding.

Question 17

Chronic pancreatitis-
Causes
Presentation
Differential Diagnosis

Answer 17

Main causes are chronic alcohol or idiopathic.
Chronic epigastrium and back pain with N+V, also poor exocrine function (weight loss, malabsorption), poor endocrine function (hyperG, DM).
Differentials- Biliary colic, AAA, peptic ulcer disease, reflux.

Question 18

Chronic pancreatitis- Investigations

Answer 18

Bloods LFTs deranged. No significant amylase/lipase increase. Look at BG. Low faecal elastase.
CT but also MRCP. (ERCP as therapeutic- remove obstruction, add stent etc).

Question 19

Chronic pancreatitis- Management

Answer 19

Treat underlying cause (alcohol reduction, statins)
Analgesia
ERCP
If autoimmune mediated then steroids effective
Insulin
Enzyme replacement therapy (creon)
Vitamin supplementation

Question 20

Pancreatic cancer-
Presentation
RF
Differentials

Answer 20

Majority being ductal cell carcinomas, the remainder endo/exocrine carcinomas.
Present with painless obstructive jaundice, malnourished, weight loss, non specific abdnominal pain. At presentation will already have local invasion/metastasis.
RF- Smoking and chronic pancreatitis.
Differentials- Obstructive jaundice causes; gallstones, cholangiocarcinoma. Epigastric pain causes; peptic ulcer, ACS, gallstones etc.

Question 21

Pancreatic cancer-

Investigations

Answer 21

Deranged LFTs, CA19-9 tumour marker, anaemia RBC.
Image with ab-USS of pancreas and CT.
Follow with CT chest-abdo-pelvis for staging. May also consider CT-PET for mets.

Question 22

Pancreatic cancer-

Management

Answer 22

Surgery usually unlikely but if head of pancreas- pancreaticodudenectomy. If tail/body then pancrectomy. Give adjuvant chemo. Complications include pancreatic insufficiency, pancreatic fistula or delayed gastric emptying.
Conservative; enzyme replacement, stent in biliary tree to reduce obstructive jaundice, palliative chemo.

Question 23

Pancreatic cysts

Answer 23

Found incidentally.
High risk or low risk depending on the size, if invasive and content (Serous is lower risk than mucinous).
Usually asymptomatic but can get epigastric/back pain, obstructive jaundice, vomiting.
Investigate with CT, also MRCP.
If low risk then surveillance every 5 years, if high risk then resection followed by 2 years MRI.

Question 24

Courvoisier’s Law

Answer 24

Palpable gallbladder + jaundice- Likely either pancreatic or biliary tree malignancy.

Question 25

Cholangiocarcinoma

Answer 25

Rare malignancy, 95% of which are adenocarcinomas.

Present often in late-stage disease, with symptoms including post-hepatic jaundice, and pruritus, pale stools, and dark urine.

The gold-standard investigation is via MRCP.

Definitive cure for cholangiocarcinoma is complete surgical resection, yet most patients will only be suitable for palliative management.