Hepatobiliary Flashcards

Question

Classification of Acute Pancreatitis

Answer 1

Mild Acute Pancreatitis (MAP) -no organ failure -no systemic sx Moderately severe Acute Pancreatitis (MSAP) -transient organ failure resolves wishing 48h -local/systemic sx w/o multiple organ failure Severe Acute Pancreatitis (SAP) -persistent single or multiple organ failure lasting >48h

Answer 2

Perforated peptic ulcer Small bowel infarction

Answer 3

Serum amylase and lipase: >3*normal Bloods: Calcium and Lipid profile. Blood gas and full biochemistry. CXR and AXR: pleural effusion on L side,ileus with sentinel loop and colon cutoff sign, pancreatic calcifications U/S: gall stones ERCP: contraindicated in acute settings unless as a therapeutic procedure in pt with gallstone pancreatitis associated with/w jaundice and cholangitis

Answer 4

Alcohol Gallstones Idiopathic Miscellaneous Obstructive: postERCP, pancreatic carcinoma, congenital Choledochal cysts and pancreas division Metabolic: hyperlipidemia, hyperparathyroidism, aminoaciduria, porphyria Drugs: Anti-TB, Anti-biotics, Anti-retrovirals, thiazide diuretics Trauma : blunt or postoperative Viral infections Pregnancy (ass/w gall stones) Collagen disease

Answer 5

General treatment Mild pancreatitis Supportive: hospitalisation with supportive measures such as bedrest, nil per mouth, IV fluids and analgesia Counselling on alcohol if it’s the main cause Nasogastric suction if there is an ileus or severe pain US for gallstones. Hypertriglycerides and rarely hypercalcemia need to be excluded Gallstones Pancreatitis on US: Initial conservative, then elective cholecystectomy 1-4 weeks after the acute attack. Early intervention in progressive jaundice w/ or w/o chalangitis, Do ERCP or Papillectomy (prevents recurrence of pancreatitis) Management of Severe Acute Pancreatitis ICU management Volume replacement for hypovolemic shock Respiratory failure management with ventilation Metabolic: hyperglycaemia, Hypocalcemia, renal failure Ensure patient nutrition via NGT No surgery in early phases of severe pancreatitis unless bowel is ischemic or if there’s abdo compartment syndrome Poor prognosis in : obese, age >60, multiple organ failure Local complications Acute peipancreatic fluid collections and necrosis on US, endoscopic US, CT and MRI Drainage indicated in symptomatic collections or infected necrosis after 2weeks of onset of severe pancreatitis 1. Percutaneously under US or CT 2. Endoscopic using endoscopic US, stents are placed between stomach/duodenum to allow drainage 3. Surgery, at laparotomy a communication is placed between cyst and enteral lumen Bleeding from false aneurysm: selective angiographic embolisation

Answer 6

Haemodynamic instability Hypoxic confusion Pleural effusion and pulmonary infiltrates on CXR SIRS response (2or more criteria)

Answer 7

Synthesis -clotting factors synthesis -Lipoprotein -Cholesterol transport -Globulin - immune function -Albumin -oncotic pressure -Ceruloplasmin -Copper bioavailability Storage Micronutients -Minerals (copper, zinc, magnesium, Iron) -Vitamins (A,D,E,K,B12) Glycogen for Blood sugar balance Secretion Bile needed for digestion and GI anti-microbial Cholesterol- precursor of sex hormones , vit D Detoxification Drugs/alcohol Fatty acids Steroid hormones Ammonia-urea Environmental toxins or allergens Metabolism Detoxification of fat T4-T3 Immune system Contains viruses adn pathogens Maintain hepatic and portal being immune system

Answer 8

ALP is an enzyme associated with/w cholestasis Bilirubin measure of bile conjugation and excretion yGGT is a measure of enzyme induction ALT and AST are increased in hepatocyte injury Albumin measure synthetic capability of liver and is a product of hepatocellular protein synthesis

Answer 9

Alcohol is the most common cause During acute exacerbation there is increased interstitial oedema, necrosis, and inflammatory infiltration. Introductal calcification seen in alcohol induced, tropical pancreatitis and is commonly seen in advanced disease. Alcohol induced pancreatitis hypothesis: Necrosis-Inflammation-Fibrosis sequence. This sequence once established may be self perpetuating. Smoking is an important co-factor in pathological processes precipitated by alcohol. Formation of calcified stones: As a result of bicarbonate and water secretion on one hand and protein and calcium on the other. Pain, what causes it: 1. Inflammatory process and calcified ductal protein plugs leading to parenchyma fibrosis and ductal epithelium damage, ductal changes lead to strictures and obstruction with tissue and ductal hypertension. Ductal dilatation often occurs. 2. Interaction between products of inflammation and damaged neural structures 3. Toxin metabolism and the generation of excessive oxygen derived free radicals which exceed normal protective mechanisms 4. Parenchyma fibrosis leads to a form of compartment syndrome with micro vascular eschemia and pain

Answer 10

Pain Nausea and vomiting Palpable cyst mass Ascites obstructive jaundice GI bleeding from false aneurysm DM requiring insilun Hypoglycaemia during to lack of control by glucagon to insulin Steatorrhea from fat malabsorption Pain is the predominant symptom. Pain in the epigastrium and radiates to the back, worse after meals and May be relieved by sitting upright or leaning forward. May be relieved by hot water bottles also. First attack of alcohol is usually preceded by long period (+- 10yrs) of excessive alcohol intake. Attack usually induced by binge drinking and present on on the afternoon on the night before Pain may be persist despite pt being abstinent

Answer 11

Pancreatic destruction with endocrine and/or exocrine insufficiency with development of DM and fat malabsorption. Psedocysts and Ascites (from inflammation, necrosis and ductal hypertension ) False aneurysms, with subsequent haemorrhage in relation to a pseudocys SVT (leading to Portal hypertension) Portal hypertension Biliary stenosis Duodenal stenosis Mortality

Answer 12

Bloods: 1. Serum amylase/lipase 2. Random/Fasting glucose or HBA1C 3. Albumin (L) 4. LFTs (bili, ALP, GGT) Pancreatic Function Tests Faecal Acid steatocrit and Elastase Imaging Endoscopic US CT Scan MRI/MRCP ERCP has limited diagnostic but offers therapeutic benefits

Answer 13

Abstinence from alcohol Low fat diet Non narcotic analgesics Paracetamolor NSAID Trial of high dose pancreatic enzymes together with acid suppression Narcotic analgesia, progressing in potency as necessary Antidepressants

Answer 14

Cholesterol Bilirubin Calcium salts

Answer 15

Cholesterol Bilirubin Calcium salts

Answer 16

Age BMI/obese Child bearing or pregnancy Drugs (oestrogen, somatostatin analogue) Ethnicity Family hx Gender (female Hypercholestrolemia

Answer 17

Cholesterol Water Bile salts Phospholipid

Answer 18

Black stones= bilirubin and large amounts of mucin glycoproteins. Common in chronic haemolytic disorders and cirrhosis. Form in gallbladder. Brown stones = calcium bilirubinate stones occur in presence of infected bile and may be related to worm manifestations. Ass/w stasis and anaerobic infections. Form in bile ducts, within biliary tree.

Answer 19

1. Family history 2. Smoking 3.Cancer predisposing syndromes: hereditary nonpolyposis colon cancer, familial denomatous polyposis (FAP), familial breast cancer BRCA2, Peutz-Jehers syndrome. 4.Chronic Pancreatitis 5.DM 6. Obesity

Answer 20

Painless obstructive jaundice Upper abdo pain radiating to the back Abdominal mass Weight loss Late onset DM Gastric outlet obstruction Dyspepsia Ascites Thrombophlebitis migrants

Answer 21

C A- 19-9 (tumour markers for pancreatic cancer) expression requires presence of Lewis blood group antigen

Answer 22

Clues: Peptic ulcer refractory to medical therapy Peptic ulcers at unusual sites Absence of risk factors to peptic ulcers Secretory diarrhea that resolves on NGT or PPIs Confirmatory Gastric acid hypersecretion Hypergastrinaemia (fasting level high) Pt should have stopped PPIs a week prior to testing

Answer 23

Edges The cystic duct Boarders of 2nd and 3rd part of duodenum Junction of the neck and body of pancreas Triangle where most gsstrinomas are found

Answer 24

Edges The cystic duct Boarders of 2nd and 3rd part of duodenum Junction of the neck and body of pancreas Triangle where most gsstrinomas are found

Answer 25

If not localised, Longitudinal Duodenotomy. Small well encapsulated pancreas tumour= enuclation Large poorly encapsulated: distal pancreatectomy

Answer 26

Cachexia Malnutrition Protein depletion Vesicopustular rash on groins (necrotic migratory erythema) Glucose intolerance DVTs

Answer 27

Watery diarrhea Hypokalemia Hypochlorhydia/ achlorhydia (Tumours often in body or tail than head

Answer 28

Haematological 1. Removal of aged and deformed RBC from circulation by phagocytosis 2. Removal of platelets and leukocytes from circulation if abnormal or coated with antibodies 3. Extramedullary haematopoiesis in certain pathologies eg myeloproliferative conditions 4. Platelet reservoir Immunological 1. Removal of bacteria from circulation (after phagocytosis antigens are presented to lymphocytes leading to specific and amplified immune response 2. Opsonin production 3. Antibody production 4. Lymphocyte proliferation

Answer 29

Trauma/disease involving spleen or it’s blood supply Splenic cysts Splenic abscesses Splenic artery aneurysms Benign or malignant tumours related to spleen Staging of non-Hodgkin Left sided Portal HPT Haematological conditions which are potentially curable or ameliorated by splenectomy e.g Haemolytic anaemia (haemolysis) Symptomatic anaemia requiring persistent transfusion Symptoms of splenomegaly Hypersplenism and symptomatic cholelithiasis Myeloproliferative disorders As part of another surgical condition ed distal pancreatectomy Purpura Hereditary: Hereditary spherocytosis, hereditary elliptocytosis, Thalassaemia major.

Answer 30

Benign and Tumours (benign&Malignant) Benign 1. Splenic cysts: -Congenital: have an epithelial lining, can be simple cysts, dermoid or epidermoid cysts -Hydatid from echinococcus granulosis, can enlarge and rupture or 2nd infection -pseudocysts have no epithelial lining form after resolution of haematoma 2. Splenic abscess from haematogenous seeding, penetrating trauma or extension from adjacent structure, ID drug use, immune compromised. 3. Splenic artery aneurysm seen in older people with atherosclerosis, young female as congenital, complication of pancreatitis or pancreatic pseudocyst Tumours Benign: Haemangiomas and Lymphangiomas Malignant 1. Nonhodgkins 2. Nonlymphoid malignancies eg angiosarcoma, plasmacytoma 3. Metastatic

Answer 31

Atherosclerosis in older people Congenital lesions in young females Acute or chronic pancreatitis of pancreatic pseudo aneurysm

Answer 32

Rupture Hypersplenism

Answer 33

Inflammatory/Infective: RA, SLE, Sarcoidosis Malaria, TB, Syphilis Portal HPT Chronic haemolytic anaemias: spherocytosis, thalassaemia Malignancy: lymphoma, leukaemia, mets carcinoma, myeloproliferative Storage diseases: gauchers, amyloidosis

Answer 34

Inflammatory/Infective: RA, SLE, Sarcoidosis Malaria, TB, Syphilis Portal HPT Chronic haemolytic anaemias: spherocytosis, thalassaemia Malignancy: lymphoma, leukaemia, mets carcinoma, myeloproliferative Storage diseases: gauchers, amyloidosis

Answer 35

Early Haemorrhage Gastric perforation Injury to tail of pancrease Subphrenic abscess Atelectasis on lower L lung PVT Late Thrombotic events (from rise in platelet) Overwhelming post splenectomy infection (OPSI)

Answer 36

Streptococcus pneumonia Haemophilus influenza Nisseria meningitidis Vaccinate them atleast 14days post op or before d/c in emergency splenectomy Vaccinated against in 5years

Answer 37

1. Patient education: aware of increased risk of infection, should present as soon as possible in acute febrile illness. 2. Immunisation every 5years (Strep pneumonia, haemophilus influenza, NisseriaMeningitidis) 3. Antibiotic prophylaxis

Answer 38

1. Patient education: aware of increased risk of infection, should present as soon as possible in acute febrile illness. 2. Immunisation every 5years (Strep pneumonia, haemophilus influenza, NisseriaMeningitidis) 3. Antibiotic prophylaxis

Answer 39

Benign -Haematoma -Hepatic Adenoma -FNH Malignant -HCC -Cholangiocarcinoma Colorectal Neuroendocrine

Answer 40

Biliary Via Portal vein Haematogenous via hepatic artery Direct from adjacent organ Trauma

Answer 41

Metronidazole Operate if risk of rupture

Answer 42

Men Bleeding Risk of malignant transformation (screenshot )