Hepatobiliary Flashcards
Courvoisier sign
- painless jaundice and an enlarged gallbladder (or right upper quadrant mass),
- the cause is unlikely to be gallstones and therefore presumes the cause to be an obstructing pancreatic or biliary neoplasm until proven otherwise
How to determine ascites caused by liver cirrhosis or not?
> Serum-ascites albumin gradient (SAAG)
- > = 1.1g/dL: liver cirrhosis (81%)
- <1.1g/dL: peritoneal TB, pancreatitis etc
Definitive management for variceal bleed
> Endoscopy
- Sclerotherapy
- Variceal band ligation
> Transjugular Intrahepatic Porto-Systemic Shunt (TIPSS)
- Stent between branches of hepatic and portal venous circulation
Component of Child-Pugh score
- Albumin
- Bilirubin
- Coagulopathy (Prothrombin time/ INR)
- Distention (Ascites)
- Encephalopathy
Classes of Child-Pugh score
- A: well compensated
- B: significant functional compromised
- C: decompensated disease
Investigation for Hepatocellular carcinoma
> Diagnosis
- Triphasic CT scan
- Ultrasound
> Staging
- LFT, PT/aPTT (Child’s score)
- CT TAP
- Bone scan
Management for Hepatocellular carcinoma
- Partial hepatectomy (need adequate liver functional reserve; no worse than class A only)
- Radiofrequency ablation (if do not meet resectability criteria, restrict to class A and B; also as “bridging” therapy while waiting liver transplant)
- Liver transplantation
Causes of Pre-hepatic Jaundice
Hemolytic anemia > Inherited - Thalassemia - G6PD - Spherocytosis - Sickle cell anemia
> Acquired
- Malaria
- SLE
Causes of Hepatic Jaundice
> Infective
- Acute viral hepatitis
> Autoimmune
- SLE
> Chronic liver disease
- Alcohol liver disease
- Chronic viral hepatitis
Causes of Post-hepatic Jaundice
> Intraluminal
- Gallstones
- Parasites
> Mural
- Biliary strictures
- Cholangitis
- Distal cholangiocarcinoma
> Extraluminal
- Ca head of pancreas
Liver enzyme correlate to which part
- Transaminases (AST, ALT) = hepatocyte
- ALP, GGT = bile duct epithelium
Charcot’s triad
- RUQ pain
- Fever with chills
- Jaundice
Reynold’s pentad
- Charcot’s triad
- Mental obtundation
- Hemodynamic instability
What is Mirizzi’s syndrome?
- Partial or spastic obstruction of the common hepatic duct secondary to an impacted gallstone in the Hartman’s pouch
- Compression effect is not just mechanical but also by surrounding inflammation
Jaundice clinically detectable at which level
Total bilirubin >40umol/L
Direct vs Indirect hyperbilirubinemia
- Direct: tea colored urine, pale stools, pruritus
- Indirect: normal colored urine and stools
Medical vs Surgical jaundice
- Medical: defect in hepatocellular function
- Surgical: obstruction in biliary tree
Stigmata of chronic liver disease
- Caput medusa
- Splenomegaly
- Palmar erythema
- Dupuytren’s contracture
- Leukonychia (Sign of hypoalbuminemia)
- Gynecomastia (Reduce hepatic clearance of androgen leads to peripheral conversion to estrogen)
- Spider naevi (Due to excess estrogen)
Features of hepatic decompensation
- Encephalopathy
- Ascites
- Jaundice
- GIT bleeding
- Coagulopathy
Complication of cholecystectomy
- Bleeding -> right hepatic artery
- Bile leak
- Infection
- Gallbladder perforation (Laparoscopic)
- Bowel injury (Laparoscopic)
- Post-cholecystectomy syndrome
Complication of acute cholecystitis
- Gangrenous cholecystitis
- Perforation
- Mucocele
- Emphysematous cholecystitis
- Cholecystoenteric fistula
- Gallstone ileus
Exception for Courvoisier law
- Klatskin tumor
4 types of periampullary tumor
- Pancreatic head Ca
- Cholangiocarcinoma
- Periampullary duodenum Ca
- Ampulla of Vater Ca
Describe surgery for periampullary Ca
> Pancreaticoduodenectomy (Whipple operation) +- Pylorus preservation
- En block removal of head of pancreas, duodenum, regional lymph nodes and the gallbladder with the distal part of the common bile duct
Why ERCP preferred over PTBD for biliary decompression
- Better survival rate
- Allows internal biliary drainage and obviated the need for external catheter drainage
How to confirm bile leak post cholecystectomy
- Ultrasound/ CT: subhepatic, perihepatic or free intraperitoneal fluid
- HIDA scan: extravasation of isotopes
- ERCP: failure to visualize proximal common bile duct or lobar branches
Jaundice is clinically detectable at which level?
> 40umol/L (Normal: <22umol/L)
What is Hepatorenal syndrome
- Portal HPT trigger increase production or activity of Nitric Oxide
- Causing vasodilation (particularly splanchnic circulation) and reduction in total vascular resistance
- The decline in kidney perfusion reduce the GFR, sodium excretion, and fall in mean arterial pressure, despite intense renal vasoconstriction
Management of Hepatorenal syndrome
- Ideally, improvement of liver function (eg: antiviral therapy, liver transplant)
- If improvement of liver function not feasible -> medical therapy to raise arterial pressure (eg: norepinephrine, terlipressin, octreotide)
Outcome of Hepatorenal syndrome
- Die within weeks of onset of kidney impairment
- Outcome strongly depend on reversal of hepatic failure
Exception to Courvoiser’s law
> DHE exception
- Double impacted stone (CBD + cystic duct) with mucocele of gallbladder
- Large stone in Hartmann’s pouch/ Mirizzi syndrome
- Empyema gallbladder
Investigation for choledocholithiasis
> Blood
- LFT (increase serum AST/ ALT/ bilirubin)
- FBC (leukocytosis)
- Serum amylase (may have underlying pancreatitis)
> Imaging
- Ultrasound HBS
- MRCP
- EUS
Management of choledocholithiasis
- ERCP with sphincterotomy and stone removal
- Laparoscopic cholecystectomy + intraoperative cholangiography followed by CBD exploration if stone seen
Complication of ERCP
- Pancreatitis (mechanical injury to pancreatic duct, hydrostatic injury from contrast injection or guidewire manipulation)
- Bleeding (during sphincterotomy)
- Infection (incomplete drainage of infected biliary system)
- Perforation (of esophagus, stomach and small intestine)
Management of cholelithiasis
> Asymptomatic
- Expectant management and close follow-up
> Symptomatic
- Cholecystectomy
- Other treatment have high recurrence, no long term benefit: shockwave lithotripsy + bile salt therapy, chemodissolution
Primary or Secondary Liver Ca more commonly presented with jaundice?
- Secondary
- Metastasis to the LN at the porta hepatis causing LN enlargement
- Obstruct the biliary tract, thus resulting in obstructive jaundice
Vit K deficiency affect which clotting factor
- Factor 2, 7, 9, 10
- Protein C and S
PT and aPTT measuring what
- PT: Extrinsic and common pathway
- aPTT: Intrinsic and common pathway
Options to correct high INR
- Warfarin dose omission
- Oral/ IV Vitamin K
- Fresh frozen plasma (low cost, in case coagulopathy no need to correct rapidly)
- Prothrombin complex concentrate (contain VitK dependent clotting factor; for life-, sight-, and limb- threatening bleeding due to high cost)
Complication of FFP transfusion
- Febrile and allergic reaction
- Volume overload
- Infection
Time taken for INR correction different options
- PCC: within minutes
- FFP: take hours due to volume required
- Vit K: take 12-24 hours, however needed to counteract the long half life of warfarin
Investigation for acute cholecystitis
> Blood
- FBC (leukocytosis)
- LFT (bilirubin level, elevated liver/ pancreatic enzyme)
- BUSE (dehydration)
- Serum calcium
> Imaging
- Ultrasound HBS
- HIDA scan
- MRCP
- CXR, KUB (exclude lower lobe pneumonia, urolithiasis)
- CT abdomen (exclude complication eg: empyema, perforation)
Management of cholecystitis
> Supportive
- IV hydration
- Pain control
- IV Abx
- NBM
> Definitive
- Open/ Laparoscopic cholecystectomy
Indication for emergency cholecystectomy
- Complicated acute cholecystitis
- Disease progression (eg: high fever, hemodynamic instability or intractable pain might suggest gangrene)
Early vs Late cholecystectomy
> Early
- Shorten hospital stay
- Decrease use of ERCP
- Without increase rate of morbidity and mortality
> Delayed
- Lower rate of wound infection
Type of gallstone
> Cholesterol (85%)
- Yellow, finely granular, hard
- Fat, female, forty, fertile
- C/b increase cholesterol secretion in bile/ decrease emptying
> Pigmented stone (15%)
- Calcium salt, hard, speculated, brittle
- C/b increase secretion of bilirubin into bile (eg: chronic hemolysis), infection, biliary stasis
Parasite blocking bile duct
- Ascaris lumbricoides
- Schistosomiasis
Indication of ERCP
- Choledocholithiasis
- Drainage of malignant biliary obstruction (eg: pancreatic ca)
- Post-surgical biliary complication (eg: stricture)
- Endoscopic therapy for patient with sphincter of Oddi dysfunction
Clinical sign for acute cholecystitis
- RHC tenderness with guarding
- Tatchycardia, low grade fever, dehydration
- Murphy’s sign positive
- Boas’s sign (hyperesthesia below the right scapula)
- Palpable gallbladder
- Mild jaundice
Indication for cholecystectomy
- Symptomatic cholelithiasis with/ without complications
- Acalculous cholecystitis
- Porcelain gallbladder
