Hepatobiliary Flashcards
What is the pathophysiology of Acute Cholecystitis?
90% of Acute Cholecystitis cases are caused by Gallstones which becomes lodged at the Neck of the Gallbladder or the Cystic Duct- this results in the inflammation of the gallbladder as Cholestasis occurs
This leads to bacterial growth- which usually involves Gram Negative Rods or Anaerobes. This is called Calculous Cholecystitis.
What are the 2 types of Gallstones and what makes up the majority of them?
Cholesterol Stones (yellow) make up the majority of gallstones and the rest are Pigmented Stones (black or brown) composed of Calcium Salts
What is the pathophysiology of Acalculous Acute Cholecystitis?
This is seen in 5-10% of cases and seen in Hospitalised or severely unwell patients
Gallbladder stasis occurs due to (3) Hypovolaemia, Trauma or a Systemic Illness
In Immunocompromised Patients, Cryptosporidium or Cytomegalovirus infections are the common pathogens that underlie Acalculous Acute Cholecystitis
What are the 5 risk factors for Gallstones?
5Fs and Crohn’s
- Fat
- Female
- Forty
- Fair
- Fertile
- Crohn’s
What are the 3 risk factors for Acute Cholecystitis?
Risk factors for Gallstones (5Fs and Crohn’s)
Diabetes
Risk factors for Acalculous Acute Cholecystitis (Trauma, Systemic Illness, Dehydration)
What are the 7 signs of Acute Cholecystitis?
RUQ Abdominal Tenderness (a Positive Murphy’s Sign- where palpating the RUQ while the patient breathes in causes pain)
A Referred Right Shoulder Tip Pain
An Absence of Jaundice
Fever
Abdominal mass due to a Distended Gallbladder (although this may not be present)
a history of Biliary Colic
An RUQ pain which is severe and long-lasting (>30 minutes)
If Jaundice is present With Typical Symptoms of Acute Cholecystitis, what 3 Conditions should be Considered as a Diagnosis?
Mirizzi Syndrome
Common Bile Duct Stone
Ascending Cholangitis
What 7 investigations should be ordered is Acute Cholecystitis is suspected?
First Line- Transabdominal Ultrasound (4)
- Positive Murphy’s Sign (pain on RUQ palpation and inspiration)
- Thickened Gallbladder Wall (3mm or more)
- Distended Gallbladder with the presence of Gallstones
- Pericholecystic Fluid
CT Scan- if Ultrasound is inconclusive
MRCP- if the Ultrasound shows a Dilated CBD with No Gallstones
FBC- Leukocytosis with Neutrophilia
LFTs NOT deranged- if they are deranged then (3)
- Mirizzi Syndrome
- CBD Stone
- Cholangitis
U&Es may be deranged with AKI, secondary to Infection
ABG- assesses for the degree of Lactic Acidosis
High CRP
What is the management for Acute Cholecystitis? (3,1)
First Line (3)-
- IV Fluids and Analgesia
- IV Antibiotics (Broad Spectrum Antibiotics with Gram Negative and Anaerobic Cover)- (2)
1) Cefuroxime
2) Metronidazole - Early Laparoscopic Cholecystectomy (2)
1) Perform within 1 week of diagnosis
2) Associated with Lower Complications, Shorter Hospital Stay, Improved Quality of Life and Better Patient Satisfaction
Second Line- Urgent Cholecystostomy if Early Cholecystectomy is inappropriate due to (3)
- Sepsis
- Gangrene
- Perforation
What is the pathophysiology of Acute Pancreatitis?
The Pancreatic Secretion System is obstructed and there is also a Premature Activation of Pancreatic Proenzymes (Zymogens)- like the activation of Trypsinogen to Trypsin
The release of these pancreatic enzymes into the circulation causes (2)
- Autodigestion of blood vessels (Retroperitoneal Haemorrhage)
- Autodigestion of fat (Fat Necrosis)
What are the Local (2) and Systemic (2) Complications of Acute Pancreatitis?
Local Complications- Chronic Pancreatitis and Pancreatic Pseudocysts
Systemic Complications- Acute Respiratory Distress Syndrome or Pleural Effusions
What are the causes of Acute Pancreatitis?
I GET SMASHED
Iatrogenic
Gallstones
Ethanol Abuse (alcohol)
Trauma (Blunt Abdominal Trauma)
Scorpions and Spider bites
Mumps Virus (Also Measles, Coxsackie B4 and Measles)
Autoimmune (SLE and Sjogren’s)
Steroids
Hypercalcaemia and Hyperlipidaemia
ERCP
Drugs (7)
- Valproate
- Gliptins
- Azathioprine
- Mesalazine
- Oestrogen
- Tetracyclines
- Thiazide Diuretics
What are the 4 risk factors for Acute Pancreatitis?
Age
Type 2 Diabetes
Obesity
High Glycaemic Foods in non-gallstone related Pancreatitis
What are the 11 signs of Acute Pancreatitis?
Suspect in Acute Upper or Generalised Abdominal Pain- Particularly if they have a History of Gallstones or Alcohol Misuse
Pain is continuous and boring
Severe Upper Abdominal pain which radiates to the back (May be LUQ or RUQ)
Nausea, Vomiting and Anorexia
Abdominal Tenderness and Guarding
Steatorrhoea
Abdominal Distension (mainly due to leakage of fluid into peritoneum)
Tachycardic and Hypotensive- so patient may be in Shock
Cullen’s Sign- Periumbilical Bleeding- secondary to Intraperitoneal Haemorrhage
Grey Turner’s Sign- Flank Bleeding- secondary to Intraperitoneal Haemorrhage
Fox’s Sign- Bleeding over Inguinal Ligament- secondary to Retroperitoneal Haemorrhage
What 7 investigations should be ordered if Acute Pancreatitis is suspected?
Diagnose if 2 out of 3 of the following signs are present-
- Clinical features are consistent with Acute Pancreatitis
- Elevation of Serum Amylase or Serum Lipase (at least 3x the Upper limit)
- Radiological Features- inflammation on CT
High Serum Amylase or Serum Lipase (3x the upper limit)
ALT>150= Gallstone-related Pancreatitis
Serum Calcium- to identify Hypocalcaemia
Chest Xray to identify Acute Respiratory Distress Syndrome or Pleural Effusion
Abdominal Xray to exclude Gallstones
Modified Glasgow Scoring (if 3 of these in first 2 days= High Dependency Case)
- pO2<8kPa
- Age > 55 years old
- Neutrophils- WCC> 15x10^9/L
- Calcium<2mmol/L
- Renal function- Urea>16mmol/L
- Enzymes- AST>200U/L or LDH>600U/L
- Albumin<32g/L
- Sugar- Blood Glucose>10mm/L
What is the first line (5) and specific (3) management for Acute Pancreatitis?
Antibiotics are not routinely recommended
First Line-
- IV Fluid Resuscitation
- Catheterisation- to monitor urine output to ensure they are hydrated
- Oxygen Supplementation- if SpO2<94%, supplementary Oxygen is Required
- Opiate Analgesia
- Early Nutritional Support- Oral/ Enteral/ Parenteral Feeding
Specific Management-
- ERCP if Gallstone-related Pancreatitis and Cholangitis
- Cholecystectomy- performed at the same time as admission for Gallstone-related Pancreatitis
- Alcohol Cessation and Withdrawal Management
What 5 antibodies are associated with Autoimmune Hepatitis?
Associated with Type 1 Autoimmune Hepatitis-
ASMA (Anti-Smooth Muscle Antibodies)
ANA (Antinuclear Antibodies)
Anti-SLA/LP (Anti-soluble Liver Antigen/ Liver-pancrease Antibody)
Associated with Type 2 Autoimmune Hepatitis-
Anti-LKM1 (Anti-liver Kidney Microsome Antibody)
Anti-LC1 (Anti-liver Cytosol 1)
What antigens are associated with Type 1 (2) and Type 2 (2) Autoimmune Hepatitis?
Type 1 Autoimmune Hepatitis-
DR3 and DR4
Type 2 Autoimmune Hepatitis-
DQB1 and DRB1
What 2 other autoimmune conditions is Autoimmune Hepatitis associated with?
Hashimoto’s Thyroiditis
Primary Biliary Cholangitis
What are the 13 signs of Autoimmune Hepatitis?
General Symptoms (5)
- Fatigue
- Arthralgia
- Weight Loss
- Nausea
- Amenorrhoea
Evidence of Chronic Liver Disease (4)
- Jaundice
- Spider Telangiectasia
- Gynaecomastia
- Splenomegaly
Evidence of Acute Liver Failure (These are less common)
- Jaundice
- Ascites
- Variceal Bleed
- Encephalopathy
What 3 investigations should be ordered if Autoimmune Hepatitis is suspected?
Elevated ALT, Elevated AST, Normal or Mildly Elevated ALP, Bilirubin may also be Raised
Immunoglobulins- IgG is raised in 85% of patients
Check for Piecemeal Necrosis (4)
- Inflammation of Hepatocytes at the Junction of the Portal Tract and Hepatic Parenchyma
- Viral Screen- to exclude Hepatitis
- Autoimmune Screen- ANA, Anti-SMA, AntiSLA/LP, Anti-LKM1, Anti-LC1
- Hereditary Screen- Exclude metabolic causes (2)- Hereditary Haemochromatosis and Wilson’s Disease
What is the management of Autoimmune Hepatitis? (3,1)
First line-
- Immunosuppression (Give Prednisolone and Azathioprine together)
- Upon remission, patients can stop therapy and be on Long-term Azathioprine
- Hepatitis A and B Vaccinations given for all patients
Second line-
- Transplantation
What are 3 complications of Autoimmune Hepatitis?
Cirrhosis
Osteoporosis due to steroids
Cushing’s Syndrome due to steroids
What are the 4 risk factors for Biliary Colic?
Gallstones Risk factors (F,F,F,F,F, and Crohn’s)
Diabetes
Medication (4)
- Oestrogen
- Oral Contraceptive Pill
- Hormone Replacement Therapy
- Fibrates also increase the risk
Haemolytic Conditions
- Haemolysis (because of Sickle Cell Anaemia)- causes Excess Bilirubin which results in Pigment Gallstones
What are the 5 signs of Biliary Colic? What are 3 other conditions associated with Gallstones?
RUQ or Epigastric Abdominal Pain (5)
- Pain is constant and Not Colicky
- Typically lasts longer than 30 minutes
- Pain is worse after eating Fatty Food
- Pain radiates to the Right Shoulder or Interscapular Region
- Murphy’s Sign Negative
Cholecystitis (3)
- RUQ tenderness
- Positive Murphy’s Sign
- Fever
Ascending Cholangitis (Charcot’s Triad (3))
- Jaundice
- Fever
- RUQ pain
Common Bile Duct Stone
- Features of Obstructive Jaundice (4)
- Jaundice
- Dark Urine
- Pale Stools
- Pruritus
What 5 investigations should be ordered if Biliary Colic is suspected?
Abdominal Ultrasound
LFTs- Raised ALP and Bilirubin
Raised CRP and Raised Neutrophilia would suggest Cholecystitis
Amylase level- if suspecting Pancreatitis secondary to a gallstone disease
MRCP- if No Common Bile Duct Stones are seen on Abdominal Ultrasound and the Common Bile Duct is Dilated OR Abnormal LFTs
What are the 4 management options for Biliary Colic?
If Mild-to-Moderate Pain-
- Oral NSAID (Diclofenac) or Paracetamol (while waiting for Cholecystectomy)
Severe Pain-
- IM Diclofenac or IM Opioid (Morphine, Pethidine or Buprenorphine) if Diclofenac is ineffective
Elective Laparoscopic Cholecystectomy- refer all people diagnosed with symptomatic gallstone disease
Lifestyle changes-
- Avoid Fatty Food
- Increase Fibre Intake
What are the 7 facts about Bilirubin Physiology?
Unconjugated Bilirubin is a breakdown product of Haem (from Senescent Red Blood Cells)
Unconjugated Bilirubin is NOT water-soluble- so needs to be Conjugated to be released
UGT (UDP-Glucuronosyl Transferase) converts Unconjugated Bilirubin into Conjugated Bilirubin, making it water-soluble. Conjugation is the addition of Glucuronic Acid to Bilirubin
Conjugated Bilirubin is secreted into the Bile Canalculi and stored in the gallbladder as a component of bile
When it is released into the intestinal tract, Conjugated Bilirubin is broken down into Urobilinogen and Stercobilin by bacteria
Stercobilin is excreted in Faeces- which gives it a Brown Colour
Urobilinogen is reabsorbed and it is either directed back into making bile (through the Enteropathic Circulation) or excreted in Urine (giving it a Yellow Colour)
What is the pathophysiology of Cholangitis?
It is an infection of the biliary tree commonly caused by gallstones
The obstruction causes Cholestasis and promotes the growth of bacteria (commonly E. Coli) which causes an ascending infection
What are the 3 other causes of Cholangitis (aside from Gallstones)?
Biliary Strictures
Sclerosing Cholangitis
Cholangiocarcinoma
What are the 6 signs of Cholangitis?
Charcot’s Triad (3)-
- RUQ Pain
- Jaundice
- Fever
Scleral Icterus (because of Jaundice)
Dark Urine and Pale Stools (Cholestasis)
Pruritus (Itchy Skin)
Hypotension
Confusion
What 5 investigations should be ordered if Cholangitis is suspected?
Transabdominal Ultrasound (First Line) - CT scan if Ultrasound is negative
Leukocytosis with Neutrophilia
Obstructive Jaundice (Raised ALP>AST and Raised Bilirubin)
U&Es- pre-renal Kidney AKI in Sepsis
Lactate and Acidosis in Suspected Sepsis
What is the 3 step management approach to Cholangitis?
IV Antibiotics with Gram Negative and Anaerobic Cover (Cefotaxime and Metronidazole)
IV Fluids as the patients are often septic and require rehydration
ERCP (First line after IV antibiotics and fluids)
What is the pathophysiology of Chronic Pancreatitis?
It is the irreversible Inflammation and/or Fibrosis of the Pancreas due to the inappropriate activation of Trypsinogen to Trypsin, which reacts with the Pancreatic Tissue
What are the 5 causes of Chronic Pancreatitis?
Alcohol- causes 80% of the cases
Acute Pancreatitis
Ductal Obstruction (Gallstones)
Autoimmune Pancreatitis
Cystic Fibrosis
What are the 3 risk factors for Chronic Pancreatitis?
Autoimmune Pancreatitis
Smoking
Cystic Fibrosis AND Haemachromatosis
What are the 4 signs of Chronic Pancreatitis?
Epigastric Pain (3)
- Dull and radiates to the back
- Improved by Leaning Forward
- Occurs after Eating
Steatorrhoea and Diarrhoea- Foul smelling stools which are hard to flush
Signs of Liver Disease due to Alcohol Excess (2)
- Jaundice
- Ascites
Signs of Diabetes in Late Disease (2)
- Polyuria
- Polydipsia
What 6 investigations should be ordered if Chronic Pancreatitis is suspected?
Transabdominal Ultrasound (first line)- Pancreas appears (3)
- Atrophied
- Calcified
- Fibrotic
CT if the Ultrasound is suggestive
LFTs- Abnormal if there is a coexisting Liver Disease
- AST>ALT suggests Alcoholic Liver Disease
HbA1c- Islet cell destruction reduces the Endocrine Function (Pancreatic B cells can’t produce Insulin)
Faecal Elastase= Reduced in Severe Disease
IgG4- Associated with Autoimmune Chronic Pancreatitis
What is the 5 step management for Chronic Pancreatitis (4, 3)?
Stop Alcohol and Smoking
Diet- Low Fat, High Calorie with Vitamin ADEK Supplementation
Analgesia- Paracetamol or NSAIDs
Pancreatic Enzyme Replacement- CREON
Second Line (3)
- Endoscopic Stenting
- Coeliac Plexus Nerve Blocks
- Drainage of Pseudocysts
When should Necrotising Pancreatitis be suspected?
If the patient presents with Pancreatitis that doesn’t respond to treatment- with (3) Epigastric Pain, Nausea and Fever
What investigation should be ordered of Necrotising Pancreatitis is suspected and what is the relevant management?
CT- it would show Non-enhancing Low Attenuating Pancreatic Tissue
Management- Necrosectomy
What is the pathophysiology of Pancreatic Cancer?
An Adenocarcinoma which affects the Head of the Pancreas
Develops from a Pre-Invasive Pancreatic Intraepithelial Neoplasia
Most cases carry a faulty K-RAS Gene
What are the 5 risk factors for Pancreatic Cancer?
Age
Smoking
Diabetes
BRCA1 and BRCA2 Mutations (as well as K-RAS)
Multiple Endocrine Neoplasia
What are the 5 signs of Pancreatic Cancer?
Positive Courvoisier’s Sign-
- Painless Jaundice and Palpable Gallbladder
- Unlikely to be Gallstones
(3) Epigastric or Atypical Back Pain, Anorexia and Weight Loss
New Onset Diabetes
Dark Urine and Pale Stools due to Obstructive Jaundice
Steatorrhoea- loss of Exocrine Function
What 4 investigations should be considered if Pancreatic Cancer is suspected?
Abdominal Ultrasound- First line
- Shows a Double Duct sign due to both the Pancreatic Duct and the Common Bile Duct being dilated
Proceed to CT if the Abdominal Ultrasound is suspicious
LFTs- shows an Obstructive Picture- (3)
- Raised ALP
- Raised GGT
- Raised Bilirubin
Perform a Coagulation Profile to assess the synthetic function of the Liver to determine whether there is sign of Liver Metastasis
What is the management for a Localised (2) or Locally Advanced or Metastatic (2) Pancreatic Cancer?
Localised-
- Whipple’s Resection- Removal of Antrum of the Stomach, Proximal Duodenum, Head of the Pancreas, Common Bile Duct and Gallbladder
- Adjuvant Chemotherapy after the Surgery
Metastatic-
- Palliative Management (2)
- ERCP with Stenting for Symptomatic Relief
- Chemotherapy and Chemoradiotherapy
Describe the presentation and management of Peripancreatic Fluid Collection in Acute Pancreatitis?
May be Asymptomatic but can have Abdominal Pain and Distension if it is a large collection
It is an Early Presentation
Management- Most resolve spontaneously
Describe the presentation and management of Pancreatic Pseudocyst in Acute Pancreatitis?
May be Asymptomatic but can have (5)
- Abdominal Pain
- Palpable Mass
- Nausea
- Indigestion
- Small Weight Loss
It is a Late Presentation
Management- Conservative Management or Drainage
Describe the presentation and management of Pancreatic Abscess in Acute Pancreatitis?
It usually occurs due to infection of Pseudocysts by E. Coli
It consists of (5)
- Abdominal Pain
- Fever
- Anorexia
- Nausea
- Vomiting
Management-
- Antibiotics and Drainage
What is the pathophysiology of Primary Biliary Cholangitis? (3)
It is an Autoimmune Condition that involves the Granulomatous Destruction of the Intrahepatic Bile Ducts which leads to Cholestasis
This leads to (3)- Progressive Fibrosis, Cirrhosis and Liver Failure
What kind of Antibodies are present in all patients with Primary Biliary Cholangitis?
Anti-Microbial Antibodies
What are the 5 possible Autoimmune Conditions that a patient with Primary Biliary Cholangitis may have?
Sjogren’s Syndrome
Raynaud’s Phenomenon
Autoimmune Thyroid Disease
Rheumatoid Arthritis
Systemic Sclerosis
What are the 4 risk factors for Primary Biliary Cholangitis?
Female
Middle-Aged
Smoking
Autoimmune Condition
What are the 9 signs of Primary Biliary Cholangitis?
Pruritus
Fatigue and Weight loss
Skin Hyperpigmentation due to Increased Melanin
Clubbing
Mild Hepatosplenomegaly
Dry Eyes and Mouth- a sign of Sjogren’s
Scleral Icterus- a Late Sign
Xanthelasma and Xanthomata- a Late Sign
Obstructive Jaundice- a Late Sign
- Icteric
- Pale Stools and Dark Urine
What are the 6 investigations to be ordered if Primary Biliary Cholangitis is suspected?
First Line- Transabdominal Ultrasound
Antimicrobial Antibodies
Antinuclear Antibodies- present in Half of all Patients
Smooth Muscle Antibodies- in a Third of all Patients
LFTs- Show an Obstructive Picture (2)
- Raised ALP, GGT and Bilirubin
- AST and ALT may be mildly deranged
Elevated IgM
What is the 4 step management plan for Primary Biliary Cholangitis?
Ursodeoxycholic Acid- First Line in all patients
- Combine it with Obeticholic Acid if it doesn’t work on its own
Vitamin ADEK Supplements
Cholestyramine for symptomatic relief of Pruritus
Second Line- Liver Transplantation (2)
- if MELD Score is 15 or higher
- or if Bilirubin is >85 micromol/L
