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Surgery > Hepatobiliary > Flashcards

Hepatobiliary Flashcards

1
Q

Courvoisier sign

A
  • 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
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2
Q

How to determine ascites caused by liver cirrhosis or not?

A

> Serum-ascites albumin gradient (SAAG)

  • > = 1.1g/dL: liver cirrhosis (81%)
  • <1.1g/dL: peritoneal TB, pancreatitis etc
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3
Q

Definitive management for variceal bleed

A

> Endoscopy

  • Sclerotherapy
  • Variceal band ligation

> Transjugular Intrahepatic Porto-Systemic Shunt (TIPSS)
- Stent between branches of hepatic and portal venous circulation

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4
Q

Component of Child-Pugh score

A
  • Albumin
  • Bilirubin
  • Coagulopathy (Prothrombin time/ INR)
  • Distention (Ascites)
  • Encephalopathy
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5
Q

Classes of Child-Pugh score

A
  • A: well compensated
  • B: significant functional compromised
  • C: decompensated disease
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6
Q

Investigation for Hepatocellular carcinoma

A

> Diagnosis

  • Triphasic CT scan
  • Ultrasound

> Staging

  • LFT, PT/aPTT (Child’s score)
  • CT TAP
  • Bone scan
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7
Q

Management for Hepatocellular carcinoma

A
  • 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
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8
Q

Causes of Pre-hepatic Jaundice

A 
Hemolytic anemia
> Inherited 
- Thalassemia 
- G6PD
- Spherocytosis
- Sickle cell anemia

> Acquired

  • Malaria
  • SLE
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9
Q

Causes of Hepatic Jaundice

A

> Infective
- Acute viral hepatitis

> Autoimmune
- SLE

> Chronic liver disease

  • Alcohol liver disease
  • Chronic viral hepatitis
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10
Q

Causes of Post-hepatic Jaundice

A

> Intraluminal

  • Gallstones
  • Parasites

> Mural

  • Biliary strictures
  • Cholangitis
  • Distal cholangiocarcinoma

> Extraluminal
- Ca head of pancreas

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11
Q

Liver enzyme correlate to which part

A
  • Transaminases (AST, ALT) = hepatocyte

- ALP, GGT = bile duct epithelium

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12
Q

Charcot’s triad

A
  • RUQ pain
  • Fever with chills
  • Jaundice
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13
Q

Reynold’s pentad

A
  • Charcot’s triad
  • Mental obtundation
  • Hemodynamic instability
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14
Q

What is Mirizzi’s syndrome?

A
  • 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
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15
Q

Jaundice clinically detectable at which level

A

Total bilirubin >40umol/L

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16
Q

Direct vs Indirect hyperbilirubinemia

A
  • Direct: tea colored urine, pale stools, pruritus

- Indirect: normal colored urine and stools

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17
Q

Medical vs Surgical jaundice

A
  • Medical: defect in hepatocellular function

- Surgical: obstruction in biliary tree

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18
Q

Stigmata of chronic liver disease

A
  • 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)
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19
Q

Features of hepatic decompensation

A
  • Encephalopathy
  • Ascites
  • Jaundice
  • GIT bleeding
  • Coagulopathy
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20
Q

Complication of cholecystectomy

A
  • Bleeding -> right hepatic artery
  • Bile leak
  • Infection
  • Gallbladder perforation (Laparoscopic)
  • Bowel injury (Laparoscopic)
  • Post-cholecystectomy syndrome
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21
Q

Complication of acute cholecystitis

A
  • Gangrenous cholecystitis
  • Perforation
  • Mucocele
  • Emphysematous cholecystitis
  • Cholecystoenteric fistula
  • Gallstone ileus
22
Q

Exception for Courvoisier law

A
  • Klatskin tumor
23
Q

4 types of periampullary tumor

A
  • Pancreatic head Ca
  • Cholangiocarcinoma
  • Periampullary duodenum Ca
  • Ampulla of Vater Ca
24
Q

Describe surgery for periampullary Ca

A

> 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

25
Q

Why ERCP preferred over PTBD for biliary decompression

A
  • Better survival rate

- Allows internal biliary drainage and obviated the need for external catheter drainage

26
Q

How to confirm bile leak post cholecystectomy

A
  • Ultrasound/ CT: subhepatic, perihepatic or free intraperitoneal fluid
  • HIDA scan: extravasation of isotopes
  • ERCP: failure to visualize proximal common bile duct or lobar branches
27
Q

Jaundice is clinically detectable at which level?

A

> 40umol/L (Normal: <22umol/L)

28
Q

What is Hepatorenal syndrome

A
  • 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
29
Q

Management of Hepatorenal syndrome

A
  • 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)
30
Q

Outcome of Hepatorenal syndrome

A
  • Die within weeks of onset of kidney impairment

- Outcome strongly depend on reversal of hepatic failure

31
Q

Exception to Courvoiser’s law

A

> DHE exception

  • Double impacted stone (CBD + cystic duct) with mucocele of gallbladder
  • Large stone in Hartmann’s pouch/ Mirizzi syndrome
  • Empyema gallbladder
32
Q

Investigation for choledocholithiasis

A

> Blood

  • LFT (increase serum AST/ ALT/ bilirubin)
  • FBC (leukocytosis)
  • Serum amylase (may have underlying pancreatitis)

> Imaging

  • Ultrasound HBS
  • MRCP
  • EUS
33
Q

Management of choledocholithiasis

A
  • ERCP with sphincterotomy and stone removal

- Laparoscopic cholecystectomy + intraoperative cholangiography followed by CBD exploration if stone seen

34
Q

Complication of ERCP

A
  • 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)
35
Q

Management of cholelithiasis

A

> Asymptomatic
- Expectant management and close follow-up

> Symptomatic

  • Cholecystectomy
  • Other treatment have high recurrence, no long term benefit: shockwave lithotripsy + bile salt therapy, chemodissolution
36
Q

Primary or Secondary Liver Ca more commonly presented with jaundice?

A
  • Secondary
  • Metastasis to the LN at the porta hepatis causing LN enlargement
  • Obstruct the biliary tract, thus resulting in obstructive jaundice
37
Q

Vit K deficiency affect which clotting factor

A
  • Factor 2, 7, 9, 10

- Protein C and S

38
Q

PT and aPTT measuring what

A
  • PT: Extrinsic and common pathway

- aPTT: Intrinsic and common pathway

39
Q

Options to correct high INR

A
  • 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)
40
Q

Complication of FFP transfusion

A
  • Febrile and allergic reaction
  • Volume overload
  • Infection
41
Q

Time taken for INR correction different options

A
  • 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
42
Q

Investigation for acute cholecystitis

A

> 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)
43
Q

Management of cholecystitis

A

> Supportive

  • IV hydration
  • Pain control
  • IV Abx
  • NBM

> Definitive
- Open/ Laparoscopic cholecystectomy

44
Q

Indication for emergency cholecystectomy

A
  • Complicated acute cholecystitis

- Disease progression (eg: high fever, hemodynamic instability or intractable pain might suggest gangrene)

45
Q

Early vs Late cholecystectomy

A

> Early

  • Shorten hospital stay
  • Decrease use of ERCP
  • Without increase rate of morbidity and mortality

> Delayed
- Lower rate of wound infection

46
Q

Type of gallstone

A

> 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
47
Q

Parasite blocking bile duct

A
  • Ascaris lumbricoides

- Schistosomiasis

48
Q

Indication of ERCP

A
  • Choledocholithiasis
  • Drainage of malignant biliary obstruction (eg: pancreatic ca)
  • Post-surgical biliary complication (eg: stricture)
  • Endoscopic therapy for patient with sphincter of Oddi dysfunction
49
Q

Clinical sign for acute cholecystitis

A
  • 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
50
Q

Indication for cholecystectomy

A
  • Symptomatic cholelithiasis with/ without complications
  • Acalculous cholecystitis
  • Porcelain gallbladder

Surgery (11 decks)

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