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
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
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
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
5
Q
Cholelithiasis
A
Gallstones within the gallbladder
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
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
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
9
Q
Diagnosis - cholelithiasis
A
- Abdominal ultrasound -> shows bright echo (white) with acoustic shadowing (dark area) radiating beyond the stone
10
Q
Cholecystitis
A
- Inflammation of the gallbladder
- Can be acute, chronic or acute on chronic
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
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
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
14
Q
Cholecystitis - complications
A
- Infection of gallbladder (E. coli, Klebsiella, Enterococcus)
- Gallbladder perforation -> peritonitis
- Sepsis
- Biliary enteric fistula
15
Q
Cholecystitis - differentials
A
- Acute pancreatitis
- Appendicitis
- Acute hepatitis
- Liver abscess
- PUD
- R-sided pneumonia
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)
17
Q
Cholecystitis - Treatment
A
- Surgical team admission
- NBM, IV fluids
- Analgesia
- IV abx - gentamicin + amoxycillin (TSV hosp - ceft/met)
- Laparoscopic cholecystectomy
18
Q
Cholangitis
A
- Acute inflammation of the wall of bile ducts
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
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
21
Q
Cholangitis - Clinical Features
A
Charcot’s Triad
- Fever
- Jaundice
- RUQ pain
Severe form: Reynold’s pentad:
- Fever, jaundice, RUQ pain, hypotension, confusion
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)
23
Q
Cholangitis - differentials
A
- Acute cholecystitis, acute pancreatitis, acute hepatitis
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
25
Cholangitis - Treatment
- IV fluid, NBM, analgesia
- IV abx - gentamicin + amoxycillin
- Remove obstruction - ERCP, shockwave lithotripsy
- Widen ducts - stenting
- Laparoscopic cholecystectomy
26
Cholangiocarcinoma
- 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
27
Cholangiocarcinoma
- 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
28
Cholangiocarcinoma - Risk factors
- Age >60
- Sex - male
- Genetics
- Race - Hispanic/Asian
- Primary sclerosing cholangitis
- Choledochal cysts
- Cirrhosis
- Hep B, Hep C
29
Cholangiocarcinoma - clinical features
- Asymptomatic in early stages
- Painless obstructive jaundice (pale stools, dark urine, pruritis)
- Weight loss, malaise, abdominal pain
30
Cholangiocarcinoma - O/E
- Scleral icterus
- Jaundice
- Abdomen
Tender palpable mass in RUQ
Hepatomegaly
Ascites
31
Cholangiocarcinoma - Investigations
Bloods
- LFTs (bilirubin, ALP)
- Tumour biomarkers: CA-19-9, CEA
Imaging
- Endoscopic ultrasonography (dilated intrahepatic ducts)
- MRCP
32
Cholangiocarcinoma - Management
- Surgical resection
- Palliative bypass surgery
- Chemotherapy, radiotherapy
33
Primary Sclerosing Cholangitis
- 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
Primary Sclerosing Cholangitis - risk factor
- IBD
35
Primary Sclerosing Cholangitis - pathophys
- 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
Primary Sclerosing Cholangitis - clinical features
- Intermittent or progressive jaundice
- Pruritus
- Fatigue
May also present with advanced liver disease and decompensated cirrhosis or hepatic failure
37
Primary Sclerosing Cholangitis - O/E
- Scratch marks
- Abdomen
* Hepatomegaly
* Splenomegaly
* Signs of liver disease/cirrhosis
38
Primary Sclerosing Cholangitis - complications
- Liver - intrahepatic ducts are close to portal veins -> fibrosis constricts portal veins -> portal hypertension -> hepatosplenomegaly
- Cirrhosis
- Cholangiocarcinoma
- Pancreatitis
39
Primary Sclerosing Cholangitis - Investigations
```
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
Primary Sclerosing Cholangitis - management
- Ursodeoxycholic acid - controversial
- Metronidazole
- Fibrates
- Endoscopic balloon dilatation
- Liver transplantation - for decompensated cirrhosis, recurrent bacterial cholangitis
- Symptom management - pruritus
41
Gallbladder - neurovascular supply
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
Pancreas - anatomy
- Retroperitoneal structure
- Located in epigastric and left hypochondrium regions
- 5 parts:
Head
Uncinate process
Neck
Body
Tail
43
Pancreas - Function
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
Pancreas - neurovascular supply
- 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
Acute pancreatitis
- Sudden inflammation and haemorrhaging of the pancreas due to destruction by its own digestive enzymes (autodigestion)
- Damage can be reversible
46
Acute pancreatitis - Causes
```
- 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
Acute pancreatitis - pathophys
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
Acute pancreatitis - clinical features
- 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
Acute pancreatitis - O/E
- 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
Acute pancreatitis - complications
- 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
Acute pancreatitis - Investigations
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
Acute pancreatitis - Diagnosis
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
Acute pancreatitis - Management
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
Acute pancreatitis - Ranson Criteria
```
- 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
Chronic pancreatitis
- Irreversible damage to the pancreas due to recurrent or persistent inflammation and progressive fibrosis -> loss of exocrine and endocrine function
56
Chronic pancreatitis - causes
- 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
Chronic pancreatitis - pathophys
- 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
Chronic pancreatitis - clinical features
- 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
Chronic pancreatitis - focused examination
- Abdominal tenderness
| - Malnutrition signs - cachexia
60
Chronic pancreatitis - complications
- 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
Chronic pancreatitis - Investigations
- 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
Chronic pancreatitis - management
- Analgesia
- Low fat, high protein diet
- Digestive enzymes
- Nutritional supplements
- Insulin therapy - if diabetes has developed
- Reduce ETOH intake
63
Pancreatic cancer
- >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
Pancreatic cancer - risk factors
Non-modifiable:
- Age >65, sex (m), family hx
Modifiable
- Smoking, diabetes, chronic pancreatitis, alcoholism, obesity
65
Pancreatic cancer - pathophys
- 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
Pancreatic cancer - clinical features
- 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
Pancreatic cancer - focused examination
- Cachectic
- Jaundiced
- Supraclavicular lymphadenopathy - Virchow’s node
- Abdomen:
* Inspection
* Palpation - palpable epigastric mass
* Distended, palpable gallbladder
68
Pancreatic cancer - investigations
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
Whipple's (Pancreaticoduodenectomy)
- 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
