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