Hepatobiliary Flashcards
What are the most common causes of splenic rupture?
trauma
iatrogenic
EBV
in an haemodynamically unastable patient with left shouldtertip pain what is the presumed diagnosis and definitive treatment?
splenic rupture and laparotomy
How many grades of splenic injury are there and what is the first and last classified as ?
1 -5
1= calsular tear <1cm parenchymal depth <10% surface area
5= shattered spleen
what are options for management of splenic rupture?
grade 1-3 can be considered for conservative management if HD stable. grade 4 and definitely 5 need urgent laparotomy and splenectomy. splenic arterial embolisation.
if considering conservative management of a splenic rutpure what is your managment?
resusitation with permissive hypertension. observations in ICU. serial abdominal examinations and low threshold to rescan.
What vaccinations and antibiotic prophylaxis are required post splenectomy?
Strep Pneumoniae, Haemophilus Influenzae B (HIB) and Meningococcus and Penicillin V
what are complications post conservative management / embolisation and full splenectomy ?
conservative: abscess, necrosis, ongoing bleeding, transient thrombocytosis (may need aspirin if > 1000).
splenectomy: overwhelming post splenectomy infection,
what is jaundice secondary to ?
hyperbilirubinaemia
what are some causes of pre-hepatic jaundice and comment on the congugation of bilirubin.
haemolytic conditions, EBV and will cause un-congugated bilirubin. thus cannot be seen in the urine.
what are some hepatic causes of jaundice? comment on the congugation of bilirubin
hepatitis, PBC, HCC, haemochromatosis, inflammation leads to partial obstruction, mixed picture of congugated and uncongugated. can be seen in the urine coca cola urine.
what are some post hepatic causes of jaundice? comment on the congugation, the appearances of the stool and urine.
obstruction to the bile duct, stones, malignant mass, extra mural mass, will be congugated and seen in the urine, pale stools secondary to less stercobillin.
what are some blood tests to order when investigating for jaundice?
bilirubin and congugates, glucose and albumin, AST and ALT as markers of hepatitis, Alkaline phosphotase will be elevated in obstruction, Gamma GT.
what imaging would you perfrom to investigate for jaundice ?
USS upper abdomen. MRCP. if chronic liver biopsy.
if someone is itchy from jaundice what can you give them?
cholestyramine
what can you give to stabilise hepatic coagulopathy ?
Vitamin K
what can you give a patient with hepatic encephalopathy to help?
lactulose
what antibiotic can be given to reduce the amount of ammonia forming bacteria in the bowels ?
rifampacin
what type of gall stones are there? (3)
cholesterol, pigment and mixed
what are risk factors for gall stone formation?
female, pregnancy, obesity, cholesterol, OCP, haemolytic anaemia, ilial resection or Chrons disease.
what is the management of biliary colic?
lifestyle advice analgesia
what is a clinical difference between biliary colic and acute cholecystitis?
colicky pain will come and go but actue cystitis pain will be constant
what are the clinical features of acute cholecysitis?
constant RUP pain, inflammatory features, positive murphys sign, may be guarding if perf therefore giving peritoniits.
What are some conditions which may mimic acute cholecystitis?
acute appendicits, GORD, gastritis, duodenal ulcer, IBD.
what is the management of acute cholecystitis?
analgesia
antibiotics ADF and metronidazole
antiemetics
lap chole within 72 hours
if unfit: perc cholecystotomy
what should you consider if 1 week after lap chole the patient is still complaining of RUQ pain?
retained common bile duct stone
what blood tests and initial invesstigations would you use to investigate for acute cholecytitis?
fbc, uec, crp, lft, lipase, bhcg and urine analysis.
what are some key findings of interest in a USS gallbladder?
distension, wall thickness, stones, emphysema, sludge.
what is the gold standard investigation for acute cholecystitis?
MRCP
what are some complications of gall stones in the biliary tracct? (4)
Mirizzi syndrome, chronic cholecystitis, empyema, fistula.
what is mirizzi syndrome? how do you investigate and treat it?
when a stone in the cystic duct or hartmanns pouch compressess the common hepatic duct . MRCP. Lap chole.
what is the investigation and treatment for gallbladder empyema?
MRCP and lap chole but there is a higher rate of conversion to open.
what is the complications of chronic cholecystitis ? and how do you treat it.
cholangiocarcinoma and fistula. offer elective lap chole.
what are the complications of choledocoduodenal fistula?
gastric outlet obstruction and ilial obstruction (aka gall stone ileus)
what ate some risk factors for cholangiocarcinoma formation?
chronic cholecystitis, family hx, toxin exposure, PSC, liver flukes and hepatitis, chirrosis.
what are the cardinal clinical examination findings of cholangiocarcinoma
painless mass with jaundice
what blood tests would you do to investigate for cholangiocarcinoma?
Ca 19-1 CEA LFTs
what are some treatment options for cholangiocarcinoma?
curative intent: chemo rads and local resection.
palliative intent : chemo rads, stenting of the biliary tree, hepaticojujonostomy
what is the pathophysiology of cholangitis?
bacterial cononisation of the bilairy tree
what are 3 common causes of cholangitis?
ERCP, gall stones, cholangiocarcinoma.
what is the triad of features cardinal to cholangitis?
fever, RUQ pain and jaundice. “charcots triad”
in severe cases of cholangitis what are the 5 cardinal features?
reynolds pentad, fever RUQ pain jaundice, confusion and hypotension.
what is the treatment for cholangitis
sepsis resusitation, blood cultures and antibitoics, ADF and metronidazole, ERCP +/- sphincterotomy, and if too unwell then can consider percutaneous trans hepatic cholangiography.
what are some complications of ERCP
bleeding, especially if sphincterotomy is performed. pancreatitis, cholangitis, perforation which would require surgical intervention to salvage.
what is the most common etiology of HCC?
chronic inflammation and cirrhosis of the liver
What are some other less common causes of HCC?
PBC, haemochromatosis, viral hepatitis, ETOH excess, alfatoxin exposure.
what blood test would you use to investigate for HCC
FBC, UEC, LFT, albumin, AFP, coags
What imaging techniques would you use to investigate a mass in the liver?
contrast enhanced USS, CT and MRI
what definitive investigation could be used for investigating a hepatic mass?
per cutaneous biopsy
What surgical management options are available for HCC?
partial hepatectomy, liver transplant, ablative therapy, trans arterial chemoembolisation
What are risk factors for liver abscess?
portal venous drainage from infection in the GIT, appendicitis, diverticulitis, colitis.
what pathogens are usually responsible for liver abscess?
E.Coli, klebsiella, constellatous. and fungal in the immunocompromised.
what investigations would you perform for a suspected liver abscess?
aspiration fluids MCS, blood cultures, bloods for infection, LFTs. amoebic serology.
What is the initial management of liver abscess
trial of antibiotic therapy
if antibiotics to not help to improve patients condition in liver abscess what would be the next step in treatment?
percutaneous aspiration
if patient is from an amoebic endemic area what additional tests would you add?
Entamoeba histolytica serology
what antibiotic is used to treat amoebic liver abscess?
metronidazole or tinidizole.
what can occur as a response to infection with tapeworm?
hydatid cysts
if a hydatic cyst burst in the abdomen or lung what must be watched out for?
anaphylaxis due to the high amount of antigenic activity .
What might you find in the blood test of a patient with a hydatid cyst?
esinophilia and econoccal serology
how do you treat a hydatid cyst?
surgical excision. drainage is also an option but only after the scolecidal agent has been injected.
What are the acute causes of pancreatitis?
GETSMASHED
G- gallstones
E- ethanol (alcohol)
T- trauma
S- steroids
M- mumps
A- Autoimmuni - SLE - Sjorens
S- scorpion venom
H- hypercalcaemia
E- ERCP
D- Drugs (azothiaprine, NSAIDS, steroids)
What is the aetiology of retroperitoneal bleeding in acute pancreatitis?
inflammation leads to damage of the pancreatic tissue and blood vessels within the peritoneal space , digestive enzymes erode the blood vessel walls cuasing rupture and bleed.
what are the two clinical signs of retroperitoneal bleeding?
Cullen and Grey Turner signs. cullen is infra umbilical and grey-turner is on the flanks.
what is the pathophysiology of coagulopathy in acute pancreatitis
complex interplay by inflammation, endothelial damage and platelet activation. pro-inflammatory mediators from the pancreas lead to systemic activation of the coagulation cascade. causing thombosis and coagulopathy concurrently.
how much higher than the normal range is lipase expected to be in acute pancreatitis?
3 times normal
what is the mechanism of hypocalcaemia in acute pancreatitis?
autodigestion of the pancreas leads to digestive enqymes in the sysemic curculation. they combine with systemic fats to cause breakdwon into fatty acids. the fatty acids then bind to calcium cause hypocalcaemia.
what is the name of the scoring system to qualify the severity of the pancreatitis?
modified Glasgow criteria, there is also APACHEII
What imaging modality would you use for actue pancreatitis?
CT abdomen and CXR chest to look for effusion.
What are the principles of management of acute pancreatitis?
treat the cause .
supporting management:
IV hydration
blood glucose support
analgeisa
antiemetics
NG tube
(only give antibiotics if concerned for necrosis)
what ate some systemic complications of pancreatitis?
ARDS
coagulopathy DIC
hypocalcaemia
hyperglucaemia
What are some local complications of acute pancreatiits?
pancreatic pseudocyst formation
pseudopneurysm formation
necrotic phlegmon (needs to be electively surgically resected)
What are the two most common caused for chronic pancreatitis?
alcohol and idiopathic
What would be the clinical features of chronic pancreatitis?
epigastric pain and reflux
What are the main two hallmark features of chronic pancreatitis?
endocrine dysfunction adn exocrine dysfunction. will cause hyperglucqemia due to the destruction of the islets of Langerhans and destruction of the acinar cells causing poor digestion of foods malabsorpation,. weight loss, diarrhoea, steatorrhoea.
What blood tests can be requested for chronic pancreatitis?
lipase will often not be elevated. FLTs, glucose and calcium also test fecal elastase
What features on Ct may demonstrate chronic pancreatitis?
calcifications, pseudocyst formation
how do you treat chronic pancreatitis?
conservatively, ensure good mutritional support, may need creon. fat soluable vitamins may need to be suplemnted. bloods sugars may need to be modulated with insulin. analgesia neuropathic agents, avoiding opioids. treat the cause they may need their duct explored if there is a stone or duct diverted if impossible.
What are risk factors for pancreatic cancer?
male, age, smoking ,obseity, chronic pancreatitis, diabetes.
what is the clinical manifestation of pancreatic cancer?
weight loss, jaundice, vague abdominal pain due to invasion of the coeliac plexus. late onset diabetes should always prompt investigation for pancreatic cancer.
what blood tests are required for investigation of pancreatic cancer?
CA19-9 non diagnositic but can be used as a marker in response to treatment. FBC, LFT, glucose.FBC for thrombocytopaenia.
if there is jaundice and enlargement of the gallbladder what is the likely aetiology
malignancy of the biliary tree needs to be ruled out as the condition is unlikely to be gallstones.
What is the only treatment with curative intent for pancreatic cancer
radical resection
what is involved in a whipples procedure
removal of the distal 2/3 stomach, gallbladder and common bile duct, the 1st and 2nd parts of the duodenum, and the head of the pancreas.
what is the common blood supply of all the organs removed in a whipples?
gastro duodenal.
what are some absolute indicators for surgery for a pancreatic cyts?
positive cytology for malignancy or high grade dysplasia. obstruction causing jaundice, solid nodule within cyst. main pancreatic duct > 10mm
what is the arterial blood supply to the spleen?
the splenic artery from the coeliac axis. but there is also the short gastric from the gastro epiploic arteries which collaterally supply
what are some common causes (2) for splenic infarct?
mainly hematological causes CML is the most common cause. sickly cell disease, myelofibrosis, lymphoma, polycythemia and hypercoagulable states.
and embolic causes: cardioembolic from AF or mural thrombus, infected graft, or infected valvular vegetations,
rarely vasculitis or trauma
how may someone present who has a splenic infarct ?
left shoulder tip pain and LUQ pain.
what blood tests would you get to investigate for splenic abscess
D-Dimer will be elevated. FBC, coagulation screen.
what is the mainstay of management of a splenic infarction?
supportive, treat the cause.
post large splenic infarct what vaccination requirements woudl you suggest?
S.Pneumonia , n, Meningitis, H. Influenzae
Penicillin V long term low dose to protect against encapsulated bacteria.
what are some complications of splenic infarction?
rupture, cyst, asbcess formation (particularly if septic emboli)
