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Y5 - Surgery > Hepatobiliary > Flashcards

Hepatobiliary Flashcards

1
Q

Causes of obstructive jaundice

A

Biliary Obstruction

  • Dark urine, pale stools
  • Elevated UCB and CB
  • Elevated ALP, GGT, cholesterol

Causes:

  • Cholelithiasis
  • Intrinsic and extrinsic tumours (cholangiocarcinoma, head of pancreas tumour)
  • Primary sclerosing cholangitis
  • Acute and chronic pancreatitis
  • Strictures after invasive procedures
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2
Q

Laparoscopic Cholecystectomy

A
  • Removal of the gallbladder using a laparoscope
  • Instruments to remove the gallbladder are inserted into the abdomen via 4 small cuts in the abdomen
  • During the surgery contrast is injected and x-rays are taken of the bile duct -> to look for gallstones and to help outline bile duct anatomy -> reduces chance of bile duct injury
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3
Q

Laparoscopic Cholecystectomy - specific risks

A
  • Damage to gut when instruments are inserted
  • Clips or ties might come off
  • Stones within the abdominal cavity
  • Allergic reaction to contrast
  • Damage to bile ducts
  • Damage to large blood vessels -> bleeding
  • Development of hernia
  • Adhesions
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4
Q

Laparoscopic cholecystectomy - safety netting prior to discharge

A

Return to ED if:

  • Large amounts of bloody discharge from wound
  • Fever, chills
  • Pain not relieved by painkillers
  • Swollen abdomen
  • Swelling, tenderness or redness at or around the cuts
  • Yellowing of your eyes and skin
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5
Q

Cholelithiasis

A

Gallstones within the gallbladder

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6
Q

Cholelithiasis - risk factors

A

5 F’s = Female, forty, fat (obesity), fertile, fair

  • Diet - high in cholesterol/fat
  • Diabetes
  • Family hx
  • OCP
  • Rapid weight loss
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7
Q

Types of Gallstones

A

Cholesterol stones (cholesterol monohydrate) - caused by:

  • Supersaturation of bile - bile salts become completely saturated with cholesterol -> excess cholesterol precipitates into stones
  • Insufficient amount of bile salts/acids
  • Gallbladder stasis

Pigment stones (bilirubin calcium salts)

  • More likely in the presence of UB in the biliary tree as occurs in haemolytic anaemia and infections of the biliary tract
  • In extravascular haemolysis -> ↑bilirubin -> binds Ca2+ -> precipitates to form stones
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8
Q

Symptoms of cholelithiasis (biliary pain)

A

Obstructive:

  • Occurs when the neck of the gallbladder is obstructed by a stone and gallbladder contraction continues -> rise in tension of gallbladder wall detected by SN -> coeliac plexus
  • Dull, poorly localised pain radiating from epigastrium to back, can be felt between the scapulae
  • Nausea, vomiting
  • Pain lasts number of hours, only subsides when the stone is dislodged
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9
Q

Diagnosis - cholelithiasis

A
  • Abdominal ultrasound -> shows bright echo (white) with acoustic shadowing (dark area) radiating beyond the stone
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10
Q

Cholecystitis

A
  • Inflammation of the gallbladder

- Can be acute, chronic or acute on chronic

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11
Q

Cholecystitis - Types

A
  • Acute calculous cholecystitis = acute inflammation of a gallbladder that contains stones (90% of cases)
  • Precipitated by obstruction of the gallbladder neck or cystic duct
  • Most common major complication of gallstones
  • Acalculous cholecystitis (5-10% of cases)
  • Most cases occur in seriously ill patients
  • Predisposing insults - major surgery, severe trauma or burns, sepsis
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12
Q

Cholecystitis - Symptoms

A
  • Biliary pain lasting >6hrs
  • Severe, steady pain in epigastrium or RUQ, radiating to R shoulder
  • Pain aggravated on deep inspiration
  • Fever, nausea, vomiting
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13
Q

Cholecystitis - Focused examination

A

General Inspection
- Patient lying still

Vitals
- PR: tachycardic - if in pain, RR, BP, Temp: febrile

Focused Examination
- Hands/arms - jaundice, CRT
- Eyes - scleral jaundice
- Mouth - hydration
- Abdomen
* Inspection
* Palpation - guarding, localised tenderness over gallbladder (below R costal margin), RUQ tenderness
* Percussion
* Auscultation
- Special test: Murphy’s sign = positive
Ask patient to exhale, place hand below the right costal margin at the mid-clavicular line, ask the patient to inspire
Positive sign – patient stops breathing and winces with a ‘catch’ in breath (due to the inflamed gallbladder being palpated as it descends on inspiration -> acute cholecystitis

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14
Q

Cholecystitis - complications

A
  • Infection of gallbladder (E. coli, Klebsiella, Enterococcus)
  • Gallbladder perforation -> peritonitis
  • Sepsis
  • Biliary enteric fistula
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15
Q

Cholecystitis - differentials

A
  • Acute pancreatitis
  • Appendicitis
  • Acute hepatitis
  • Liver abscess
  • PUD
  • R-sided pneumonia
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16
Q

Cholecystitis - investigations

A

Bloods

  • FBC - WCC - raised
  • CRP - raised
  • LFTs - ALP - raised (if stone is obstructing the duct)

Imaging

  • Ultrasound - detection of gallstones, thickened gallbladder wall (>4mm)
  • HIDA scan - shows obstructed duct (highly sensitive and specific in acute calculous cholecystitis)
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17
Q

Cholecystitis - Treatment

A
  • Surgical team admission
  • NBM, IV fluids
  • Analgesia
  • IV abx - gentamicin + amoxycillin (TSV hosp - ceft/met)
  • Laparoscopic cholecystectomy
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18
Q

Cholangitis

A
  • Acute inflammation of the wall of bile ducts
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19
Q

Cholangitis - causes

A
  • Almost always caused by bacterial infection, which can result from any lesion obstructing the bile flow (most commonly choledocholithiasis)
  • Other causes = tumours, indwelling stents or catheters, acute pancreatitis, and benign strictures
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20
Q

Cholangitis - Pathophys

A
  • Bacteria most likely enter the sphincter of Oddi -> travel up biliary duct
  • Normally biliary ducts have outflow -> keeps them sterile, but with an obstruction the bacteria can spread
  • Most common pathogens = E. coli, Klebsiella, Enterococci, Clostridium, Bacteroides
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21
Q

Cholangitis - Clinical Features

A

Charcot’s Triad

  • Fever
  • Jaundice
  • RUQ pain

Severe form: Reynold’s pentad:
- Fever, jaundice, RUQ pain, hypotension, confusion

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22
Q

Cholangitis - O/E

A

GI: - Appear unwell, pale, confused, jaundiced
Vitals: PR - tachycardic, BP - hypotensive, temp - febrile

Focused examination

  • Hands/arms - jaundice, CRT
  • Eyes - scleral jaundice
  • Mouth - hydration
  • Abdomen
  • Inspection
  • Palpation - localised tenderness over gallbladder (below R costal margin), RUQ tenderness
  • Percussion
  • Auscultation
  • Special test: Murphy’s sign = negative (only for cholecystitis)
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23
Q

Cholangitis - differentials

A
  • Acute cholecystitis, acute pancreatitis, acute hepatitis
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24
Q

Cholangitis - Investigations

A 
Bloods:
- FBC - WBCs - leukocytosis
- LFTs - raised bilirubin, raised ALP
- CRP - raised
- Blood culture - positive for E. coli, Klebsiella, Enterococci, Clostridium, Bacteroides
Imaging
- Abdominal ultrasound - presence of stones in CBD, biliary dilatation
- ERCP
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25
Q

Cholangitis - Treatment

A
  • IV fluid, NBM, analgesia
  • IV abx - gentamicin + amoxycillin
  • Remove obstruction - ERCP, shockwave lithotripsy
  • Widen ducts - stenting
  • Laparoscopic cholecystectomy
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26
Q

Cholangiocarcinoma

A
  • Cancer that originates from the epithelial lining of bile ducts (most commonly - adenocarcinoma)
  • Rare tumour
  • Classified based on location within biliary tree (intrahepatic, perihilar, extrahepatic)
  • Highly lethal, most patients die within a few months of diagnosis
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27
Q

Cholangiocarcinoma

A
  • Cancer that originates from the epithelial lining of bile ducts (most commonly - adenocarcinoma)
  • Rare tumour
  • Classified based on location within biliary tree (intrahepatic, perihilar, extrahepatic)
  • Highly lethal, most patients die within a few months of diagnosis
  • Exact cause = unknown
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28
Q

Cholangiocarcinoma - Risk factors

A
  • Age >60
  • Sex - male
  • Genetics
  • Race - Hispanic/Asian
  • Primary sclerosing cholangitis
  • Choledochal cysts
  • Cirrhosis
  • Hep B, Hep C
29
Q

Cholangiocarcinoma - clinical features

A
  • Asymptomatic in early stages
  • Painless obstructive jaundice (pale stools, dark urine, pruritis)
  • Weight loss, malaise, abdominal pain
30
Q

Cholangiocarcinoma - O/E

A
  • Scleral icterus
  • Jaundice
  • Abdomen
    Tender palpable mass in RUQ
    Hepatomegaly
    Ascites
31
Q

Cholangiocarcinoma - Investigations

A

Bloods

  • LFTs (bilirubin, ALP)
  • Tumour biomarkers: CA-19-9, CEA

Imaging

  • Endoscopic ultrasonography (dilated intrahepatic ducts)
  • MRCP
32
Q

Cholangiocarcinoma - Management

A
  • Surgical resection
  • Palliative bypass surgery
  • Chemotherapy, radiotherapy
33
Q

Primary Sclerosing Cholangitis

A
  • Chronic, progressive cholestatic liver disease
  • Characterised by segmental fibrosing and inflammation of intrahepatic and extrahepatic bile ducts -> impaired bile formation or flow, progressive liver dysfunction
  • 70% of patients have concurrent IBD
  • Exact cause = unknown, ?autoimmune
34
Q

Primary Sclerosing Cholangitis - risk factor

A
  • IBD
35
Q

Primary Sclerosing Cholangitis - pathophys

A
  • Theory - T cells attack intra and extrahepatic bile duct epithelial cells
  • Cells become inflamed -> die -> fibrosis -> hardening -> narrowing of ducts in some parts, other parts of ducts dilate -> beaded appearance of bile duct
36
Q

Primary Sclerosing Cholangitis - clinical features

A
  • Intermittent or progressive jaundice
  • Pruritus
  • Fatigue

May also present with advanced liver disease and decompensated cirrhosis or hepatic failure

37
Q

Primary Sclerosing Cholangitis - O/E

A
  • Scratch marks
  • Abdomen
    * Hepatomegaly
    * Splenomegaly
  • Signs of liver disease/cirrhosis
38
Q

Primary Sclerosing Cholangitis - complications

A
  • Liver - intrahepatic ducts are close to portal veins -> fibrosis constricts portal veins -> portal hypertension -> hepatosplenomegaly
  • Cirrhosis
  • Cholangiocarcinoma
  • Pancreatitis
39
Q

Primary Sclerosing Cholangitis - Investigations

A 
Bloods
- LFTs
      ALP, GGT - elevated
      AST/ALT
      Bilirubin - elevated 
- Autoimmune - pANCA (found in 88% of patients), ANA, ASMA)
- Serum IgG4 
- Urine - increased bilirubin, reduced urobilinogen (CB can’t reach the gut to be converted)
  • Imaging - cholangiography (ERCP)
40
Q

Primary Sclerosing Cholangitis - management

A
  • Ursodeoxycholic acid - controversial
  • Metronidazole
  • Fibrates
  • Endoscopic balloon dilatation
  • Liver transplantation - for decompensated cirrhosis, recurrent bacterial cholangitis
  • Symptom management - pruritus
41
Q

Gallbladder - neurovascular supply

A

Neurovascular supply

  • Arterial = cystic artery (from common hepatic artery -> from coeliac trunk)
  • Venous = cystic vein -> portal vein
  • Coeliac plexus = carries SNS and sensory fibres
  • Vagus nerve = PNS -> contraction of gallbladder and secretion of bile into cystic duct
  • Main stimulator of bile = cholecystokinin - secreted by the duodenum and travels in the blood
42
Q

Pancreas - anatomy

A
  • Retroperitoneal structure
  • Located in epigastric and left hypochondrium regions
  • 5 parts:
    Head
    Uncinate process
    Neck
    Body
    Tail
43
Q

Pancreas - Function

A

Exocrine

  • Serous gland, composed of acini connected by intercalated ducts -> collecting ducts -> pancreatic duct -> unites with common bile duct -> forming ampulla of vater -> opens into the duodenum
  • Release of secretions into the duodenum are controlled by sphincter of Odi

Endocrine - Islets of Langerhans - pancreatic alpha (glucagon) and beta cells (insulin)

44
Q

Pancreas - neurovascular supply

A
  • Pancreas is supplied by pancreatic branches of splenic artery
  • Venous drainage of the head of the pancreas is into superior mesenteric branches of hepatic portal vein, rest of pancreas -> pancreatic veins -> splenic vein
45
Q

Acute pancreatitis

A
  • Sudden inflammation and haemorrhaging of the pancreas due to destruction by its own digestive enzymes (autodigestion)
  • Damage can be reversible
46
Q

Acute pancreatitis - Causes

A 
- 2 most common causes: gallstones, alcohol
Neumonic:
I - Idiopathic
G - Gallstones
E - ETOH
T - Trauma
S - Steroids
M - Mumps
A - Autoimmune
S - Scorpion
H - Hypertriglyceridaemia, hypercalcaemia
E - ERCP trauma
D - Drugs - sulphur, protease inhibitors
47
Q

Acute pancreatitis - pathophys

A

Alcohol

  • Alcohol increases zymogen secretion, decreases fluid and bicarb in pancreatic ducts -> pancreatic juice becomes thickened -> blocks duct -> buildup of pancreatic juices -> premature conversion of trypsinogen to trypsin -> autodigestion -> acute pancreatitis
  • Gallstones can lodge in sphincter of Oddi -> block release of pancreatic juice

Proteases + inflammation -> pancreatic tissue destruction -> pancreatic swelling -> liquefactive haemorrhagic necrosis

48
Q

Acute pancreatitis - clinical features

A
  • Sudden onset epigastric abdominal pain, moderate to severe, lasts for hours to days
  • Pain radiates to the back, relieved by sitting forward or lying down on one side with knees flexed
  • Nausea, vomiting
  • May have past hx of previous attacks or past hx of alcoholism
49
Q

Acute pancreatitis - O/E

A
  • Patient is weak, pale, sweating, anxious
  • Are they leaning forward or lying on one side?

Vitals

  • PR: tachycardic
  • RR: tachypnoeic
  • BP: hypotensive
  • Temp: Febrile

Focused Examination
- Hands - look for signs of alcoholism - tremor, Dupuytren’s contracture
- Arms - look for biliary causes - jaundice, scratch marks
- Eyes - scleral jaundice
- Mouth - signs of anaemia - if PUD was differential
- Abdomen:
Inspection
Cullen’s sign - peri-umbilical bruising
Grey-Turner’s sign - bruising along flank
Palpation - tenderness in epigastric region, no guarding, rigidity or rebound tenderness, abdominal aorta - not enlarged or pulsatile
Percussion
Auscultation
Special Signs
- Murphy’s sign negative - rule out gallstones

  • Bruising is caused by necrosis-induced haemorrhage which has spread to the soft tissue

Resp - look for signs of pleural effusion
Neuro - signs of hypocalcaemia
- Muscle spasm
- Chvostek’s sign - tap below the zygomatic bone -> twitching of ipsilateral facial muscles
- Trousseau’s sign (more sensitive and specific) - inflate a BP cuff above systolic BP for several minutes -> flexion of the wrist and MCP joints

50
Q

Acute pancreatitis - complications

A
  • Pancreatic pseudocyst - forms when fibrous tissue surrounds liquefactive necrotic tissue -> fibrous cavity can fill up with pancreatic juice
  • Pseudocyst can become infected with E. coli -> pancreatic abscess
  • Haemorrhage -> hypovolaemic shock
  • Systemic activation of clotting factors -> DIC
  • Acute respiratory distress syndrome
51
Q

Acute pancreatitis - Investigations

A

Blood tests:

  • FBC - ↑WBCs, ↓ HCT
  • Serum lipase - elevated
  • UEC - ↓Ca2+ (due to consumption of Ca2+ within fat necrosis), ↑ urea
  • LFTs - ↑ALT
  • LDH ↑
  • Serum glucose - elevated
  • Lipids
  • IgG4 (if autoimmune pancreatitis is suspected)
CT
Diffuse parenchymal enlargement
Changes in density - oedema
Indistinct margins - inflammation
Retroperitoneal fat stranding
Abscess, necrosis, haemorrhage
  • Chest X-ray - can have pleural effusion or atelectasis in severe case, also want to rule out pneumoperitoneum (PUD)
  • Ultrasound - useful for detecting cysts or gallstones
52
Q

Acute pancreatitis - Diagnosis

A

Atlantic Criteria
- Diagnosis requires at least 2 of the 3 following criteria:
Abdominal pain consistent with acute pancreatitis
Biochemical evidence of pancreatitis (amylase/lipase >3x upper normal limit)
Confirmatory findings from abdominal imaging - usually CT

53
Q

Acute pancreatitis - Management

A

Surgical admission

  • Analgesia (morphine or fentanyl)
  • IV fluids, low fat solid diet
  • Repeat Ranson’s criteria 48hrs post admission

Management related to cause:

  • ETOH induced - lifestyle counselling - reduce ETOH
  • Gallstones - cholecystectomy
  • High triglycerides - needs insulin infusion

For mild - NBM is no longer recommended, starting on low fat solid diet shortens hospital admission

Severe Pancreatitis

  • Organ failure that persists >48hrs
  • ICU admission
  • Abx only required for extrapancreatic infection + infected pancreatic necrosis

Surgical approaches:
- Necrosectomy - removal of necrotic pancreatic tissue
Open or endoscopic
Performed 5-6 weeks after acute episode of pancreatitis

54
Q

Acute pancreatitis - Ranson Criteria

A 
- Used for prediction of severe acute pancreatitis NOT diagnosis
Age >55yrs
Glucose > 11.1mmol/L
Serum AST > 250units/L
Serum LDH > 350units/L
WBC > 16x10^9/L

Number of criteria and ~mortality:

  • 0-2 = 0%
  • 3-4 = 15%
  • 5-6 = 50%
  • > 6 = 100%
55
Q

Chronic pancreatitis

A
  • Irreversible damage to the pancreas due to recurrent or persistent inflammation and progressive fibrosis -> loss of exocrine and endocrine function
56
Q

Chronic pancreatitis - causes

A
  • Most common = long term alcohol abuse
    TIGAR-O:
    T - toxic/metabolic - chronic alcoholism, smoking, hypercalcaemia, hyperlipidaemia,
    I - idiopathic
    G - genetic - cystic fibrosis
    A - autoimmune
    R - recurrent and severe acute pancreatitis
    O - obstructive - obstruction of pancreatic duct or CBD
57
Q

Chronic pancreatitis - pathophys

A
  • Repeated bouts of acute pancreatitis -> chronic pancreatitis
  • Characterised by:
  • Parenchymal fibrosis -> narrowing of ducts -> stenosis
  • Ductal dilation
  • Reduced number and size of acinar cells
  • Calcium deposits
58
Q

Chronic pancreatitis - clinical features

A
  • Pain
  • Constant
  • Epigastric region, radiates to the back
  • Dull, worse after eating
  • Worse with alcohol intake
  • Nausea/vomiting
  • Jaundice - if they have common bile duct stenosis
  • Weight loss
  • Steatorrhoea
59
Q

Chronic pancreatitis - focused examination

A
  • Abdominal tenderness

- Malnutrition signs - cachexia

60
Q

Chronic pancreatitis - complications

A
  • Diabetes
  • Pancreatic pseudocyst
  • Pancreatic cancer
  • Common bile duct stenosis -> obstructive jaundice
  • Splenic artery aneurysm - splenic/portal veins may become compressed by a pancreatic pseudocyst or may be occluded by fibrosis from adjacent inflammation
  • Leaky pseudocyst -> unilateral or bilateral pleural effusion
  • Deficiency of Vit. A, D, E, K
61
Q

Chronic pancreatitis - Investigations

A
  • Diagnosis is difficult - should be suspected in all patients with unexplained abdominal pain, especially those with a long-standing hx of alcoholism

Bloods:

  • Serum lipase - won’t be elevated, may not be enough healthy pancreatic tissue to produce lipase
  • Serum glucose
  • Serum trypsinogen
  • LFTs
  • Faecal pancreatic elastase
  • Secretin-CCK stimulation test = gold standard, rarely used
  • Imaging:
  • X-ray - pancreatic calculi
  • CT abdomen - exclude other disorders, identify complications - pseudocyst, enlarged common bile duct, neoplastic masses
  • ERCP - ductal changes, not used as commonly now, due to high cost and risk of complications
  • MRCP - ductal changes
62
Q

Chronic pancreatitis - management

A
  • Analgesia
  • Low fat, high protein diet
  • Digestive enzymes
  • Nutritional supplements
  • Insulin therapy - if diabetes has developed
  • Reduce ETOH intake
63
Q

Pancreatic cancer

A
  • > 90% = infiltrating ductal adenocarcinoma
  • Others: neuroendocrine tumours
  • 5th most common cause of death in Aus
  • 5 year survival rate = 7.7%
  • Region:
  • 60% arise in the head of the gland
  • 20% - diffuse
  • 15% in the body
  • 5% in the tail
64
Q

Pancreatic cancer - risk factors

A

Non-modifiable:
- Age >65, sex (m), family hx

Modifiable
- Smoking, diabetes, chronic pancreatitis, alcoholism, obesity

65
Q

Pancreatic cancer - pathophys

A
  • Normal ductal epithelium -> low-grade pancreatic intraepithelial neoplasia -> high grade pancreatic intraepithelial neoplasia -> invasive carcinoma
  • Head of the pancreas carcinoma -> obstruct distal CBD -> distension of biliary tree, jaundice
  • If the tumour extends through the retroperitoneal space and entrap adjacent nerves -> pain
66
Q

Pancreatic cancer - clinical features

A
  • Early signs:
  • Pain in upper abdomen
  • Anorexia, nausea, vomiting
  • Weight loss
  • Changed bowel motions
  • Obstructive jaundice (jaundice, pale stools, dark urine)
  • Other:
  • Back pain
  • Onset of diabetes
  • Migratory thrombophlebitis (Trousseau syndrome) - unexplained thrombotic events that precede the diagnosis of a malignancy - occurs in about 10% of patients
67
Q

Pancreatic cancer - focused examination

A
  • Cachectic
  • Jaundiced
  • Supraclavicular lymphadenopathy - Virchow’s node
  • Abdomen:
  • Inspection
  • Palpation - palpable epigastric mass
  • Distended, palpable gallbladder
68
Q

Pancreatic cancer - investigations

A

Blood:

  • LFTs - ALP, bilirubin
  • Lipase

Imaging:

  • CT
  • Endoscopic ultrasound-guided fine needle aspiration - biopsy

CA 19-9 - used for monitoring therapeutic progress, not early detection

69
Q

Whipple’s (Pancreaticoduodenectomy)

A
  • Indication: 10-20% of patients whose lesion is <5cm, solitary and without regional invasion
  • The surgeon removes the head of the pancreas, the gallbladder, the duodenum, a portion of the stomach and surrounding lymph nodes
  • Modified version = pylorus-preserving Whipple
  • Risks: breakdown of the anastomosis -> leakage of pancreatic, bile or gastric juices into the abdominal cavity, bleeding, damage to the bowel, delayed gastric emptying

Tumours in the body or tail can be removed with a distal pancreatectomy, which often includes a splenectomy

Y5 - Surgery (12 decks)

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