Hepatobiliary Flashcards
risk factors for gallstones?
usually female, forty, fertile, fat
high fat diet
OCP, pregnancy
loss of terminal ileum (decreased bile salts)
what causes increased formation of cholesterol gallstones?
20% of all gallstones
large
often solitary
formation increases according to Admirand’s triangle
-> low bile salts, low lecithin, high cholesterol
what kind of gall stones are associated with haemolysis?
calcium bilirubinate
small, black, gritty, fragile
-> increases w blood transfusions/ increased haemolysis
complications of gallstones?
in gallbladder:
biliary colic
acute cholecystitis +/- empyema
chronic cholecystitis
mucocele
carcinoma
Mirizzi’s syndrome
in common bile duct:
- obstructive jaundice
- pancreatitis
- ascending cholangitis
in gut:
- gallstone ileus
pathogenesis of biliary colic?
gallbladder spasm against a stone impacted in the gallbladder
commonly in Hartmanns pouch
less commonly, stone may be in common bile duct
presentation of biliary colic?
RUQ pain radiating -> back (scapula)
sweating, pallor, n/v
attacks precipitated by fatty foods
o/e tenderness in right hypochondrium +/- jaundice if stone passes in to Common bile duct
Ix of biliary colic?
same work up as cholecystitis as difficult to differentiate clinically
Urine: bilirubin, urobilinogen, Hb
Bloods: FBC, U+E, amylase, LFTs, G+S, clotting, CRP
Imaging:
- AXR - 10% gallstones are radioopaque
- Erect CXR: look for perforation
- US: - stones, dilated ducts, inflamed gallbladder
If dilated ducts seen on US -> MRCP
mx of biliary colic?
conservative:
rehydrate and NBM
opioid analgesia: morphine 5-10mg/ 2 h max
high recurrence rate -> surgical mx favoured
surgical:
- urgent lap chole
- elective lap chole @ 6-12 wks
pathogenesis of acute cholecystitis?
stone or sludge impaction in Hartmanns pouch
-> chemical and/or bacterial inflammation
5% are due to sepsis, burns, DM
what may acute cholecystitis lead to?
- resolution +/- recurrence
- gangrene and rarely perforation
- chronic cholecystitis
- empyema
presentation of acute cholecystitis?
fever
vomiting
severe RUQ pain
- continuous, radiates to right scapula and epigastrium
examination findings of acute cholecystitis?
local peritonism in RUQ
tachycardia w shallow breathing
+/- jaundice
murphy’s sign +ve:
hand below costal margin -> ask pt to breathe in -> +ve when pain or pt catches breath
(has to be -ve on L side)
boas sign +ve
hyperaesthesia below the right scapula
mx of acute cholecystitis?
conservative:
NBM, fluid resus
analgesia
abx: cefuroxime and metronidazole
80-90% settle over 24-48h
surgical:
elective surgery @ 6-12 wks
if <72h, may perform lap chole in acute phase
mx of empyema following acute cholecystitis?
percutaneous drainage: cholecystotomy (tube for drainage in gallbladder)
features of chronic cholecystitis?
flatulent dyspepsia
vague upper abdo discomfort
distension, bloating
nausea
flatulence, burping
symptoms exacerbated by fatty foods
ix of chronic cholecystitis?
AXR: porcelain gallbladder
US: stones, fibrotic, shrunken gallbladder
MRCP
Mx of chronic cholecystitis?
medical:
bile salts (not v effective)
Surgical: elective cholecystectomy
ERCP first if US shows dilated ducts and stones
what is a gallbladder mucocele?
distention of the gallbladder by an inappropriate accumulation of mucus
neck of gallbladder blocked by stone but contents remain sterile
can be v large -> palpable mass
may become infected -> empyema
gallbladder carcinoma assoc w?
gallstones
gallbladder polyps
what is a porcelain gallbladder?
calcification of the gallbladder believed to be brought on by excessive gallstones
what is Mirizzi’s syndrome?
common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or Hartmann’s pouch of the gallbladder
- > obstructive jaundice
- > may erode through into the ducts
what is gallstone ileus?
when a large stone erodes from gallbladder -> duodenum through fistula caused by chronic inflammation
may impact in terminal ileus -> Small bowel obstruction
diagnosis of Gallstone ileus?
Rigler’s Triad:
pneumobilia
small bowel obstruction
gallstone in RLQ
mx of gallstone ileus?
IV fluids
NG tube
Stone removal via enterotomy
causes of obstructive jaundice?
30% stones
30% Ca head of pancreas
30% other
e. g. inflammatory: PBC, PSC
drugs: OCP, sulphonylureas
Neoplastic: cholangioca
LNs @ porta hepatitis: TB, Ca
Mirizzis syndrome
features of obstructive jaundice?
jaundice
-seen at tongue frenulum first
dark urine, pale stools
itching (Bile salts)
ix of obstructive jaundice?
urine: high bilirubin, low urobilinogen (dark)
bloods:
FBC- raised WCC in cholangitis
U+E- hepatorenal syndrome
LFTs: raised Br, HIGH Alk phos
Clotting: raised INR
G+S, X-match
immune markers: AMA, ANCA, ANA
imaging: AXR
US: dilated ducts, stones, tumour
MRCP/ ERCP
mx of gallstones if no resolution, worsening LFTs or cholangitis?
ERCP w sphincterotomy and stone extraction
- delayed cholecystectomy to prevent recurrence
Features of ascending cholangitis?
bacterial infection of the biliary tract due to obstruction
Charcot’s triad: fever/ rigors, RUQ pain, jaundice
Reynolds pentad: Charcots triad + hypotension + confusion
what is charcot’s triad?
fever/ rigors, RUQ pain, jaundice
What is reynold’s pentad?
Charcots triad + hypotension + confusion
mx of ascending cholangitis?
cef and met
1st: ERCP
2nd: Open or lap stone removal
risk factors of pancreatic ca?
smoking
chronic pancreatitis
high fat diet
alcohol
diabetes
most common type of pancreatic ca?
ductal adenoca
(most commonly in head of pancreas)
presentation of pancreatic ca?
painless obstructive jaundice
anorexia, weight loss, malabsorption
epigastric pain
acute panc
sudden onset DM in the elderly
signs of pancreatic ca?
palpable gallbladder
jaundice
epigastric mass
thrombophlebitis migrans (Trousseau sign)
Splenomegaly: PV thrombosis -> portal HTN
ascites
what is courvoisier’s law?
in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to stones
what tumour marker is assoc w pancreatic ca?
Ca 19-9 (90% sensitivity)
mx of pancreatic ca?
surgery:
fit, no mets, small tumour
whipple’s pancreaticoduodenectomy
distal pancreatectomy
+ post op chemo
palliation:
endoscopic/ percutaneous stenting of Common bile duct
palliative bypass surgery: cholecystojejunostomy + gastrojejunostomy
pain relief - may need coeliac plexus block
most common cause of acute pancreatitis?
- gallstones
- ethanol
pathophysiology of acute pancreatitis?
pancreatic enzymes released ->
hypovolaemic shock
autodigestion and fat necrosis
vessel autodigestion -> retroperitoneal haemorrhage
pancreatic necrosis
features of acute pancreatitis?
severe epigastric pain -> back
- relieved by sitting forward
vomiting
signs of acute pancreatitis?
Grey Turners: bruising along flanks
Cullens: periumbilical bruising
what is the modified glasgow criteria?
assess severity and predict mortality of acute pancreatitis
valid for gallstones/ alcohol
3 or more: severe, treat in ITU
what is the factors used to score in the modified glasgow criteria?
PANCREAS
PaO2 < 8
Age > 55
Neutrophils > 15 x 109
hypoCalcaemia < 2
Renal function Urea > 16
Enzymes: LDH > 600, AST >200
Albumin < 32
Sugar > 10mM
Abnormal bloods in acute pancreatitis?
High Amylase and Lipase
Low Calcium
High Glucose
CRP: monitor progress, >150 after 48h = severe
Conservative Mx of acute pancreatitis?
Manage in ITU if severe
monitor UO, obs
Fluid resus
NBM, NGT if vomiting, TPN may be required
Analgesia: pethidine via PCA or morphine
Antibiotics: used if suspicion of infection or before ERCP (e.g. meropenem)
tx complications:
ARDS- O2 therapy/ ventilation
glucose: insulin sliding scale
Alchol withdrawal: chlordiazepoxide
Interventional mx of acute pancreatitis?
ERCP + sphincterotomy
surgical mx of acute pancreatitis?
indications?
indications:
infected pancreatic necrosis
pseudocyst or abscess
unsure dx
laparotomy
presentation of pancreatic pseudocyst?
collection of pancreatic fluid in lesser sac surrounded by granulation tissue
presents 4-6 wks after acute attack
persisting abdo pain
epigastric mass -> early satiety
ix of pancreatic pseudocyst?
persistently raised amylase +/- LFTs
US/ CT
mx of pancreatic pseudocyst?
<6cm: spontaneous resolution
>6 cm: endoscopic cyst-gastrostomy, percutaneous drainage under US/ CT
main cause of chronic pancreatitis?
alcohol
other causes of chronic pancreatitis apart from alcohol?
genetic: CF, hereditary haemachromatosis
immune: lymphoplasmacytic sclerosing pancreatitis (high IgG4)
raised triglycerides
obstruction by tumour
features of chronic pancreatitis?
epigastric pain radiating to back
relieving by hot water bottle -> erythema ab igne
exacerbated by fatty food or alcohol
steatorrhoea and weight loss
Ix of chronic pancreatitis?
raised glucose
decreased faecal elastase: decreased exocrine function
US: pseudocyst
AXR: speckled pancreatic calcifications
CT: pancreatic calcifications
mx of chronic pancreatitis?
diet: no alcohol, decrease fat
medical: analgesia- coeliac plexus block
enzyme supplements
ADEK vitamins
DM tx
Surgery: if unremitting pain, weight loss, duct blockage
Distal pancreatectomy, Whipples
Pancreaticojejunostomy: drainage
Endoscopic stenting
complications of chronic pancreatitis?
pseudocyst
diabetes
pancreatic ca
pancreatic swelling -> biliary obstruction
splenic vein thrombosis -> splenomegaly
features of insulinoma?
fasting/ exercise-induced hypoglycaemia
high insulin + high c peptide + low glucose
features of VIPoma?
watery diarrhoea
hypoK
achlorhydria
acidosis
somatostatin function?
inhibits glucagon and insulin release
inhibits pancreatic enzyme secretion
features of a somatostatinoma?
DM
steatorrhoea
gall stones
what is pancreatic divisum?
congenital anomaly
a single pancreatic duct is not formed, but rather remains as two distinct dorsal and ventral ducts.
usually asymptomatic
may -> chronic pancreatitis
what is annular pancreas?
second part of the duodenum is surrounded by a ring of pancreatic tissue continuous with the head of the pancreas.
may -> infantile duodenal obstruction
risk factors for cholangiocarcinoma?
PSC
Ulcerative colitis
hep B/C
presentation of cholangiocarcinoma?
progressive painless obstructive jaundice
- gallbladder not palpable
steatorrhoea
weight loss
mx of cholangiocarcinoma?
poor prognosis: no curative tx
palliative stenting by ERCP
pathophysiology of hydatid cyst?
zoonotic infection by echinococcus granulosus
- sheep rearing communities
parasite penetrates the portal system and infects the liver -> calcified cyst
presentation of hydatid cyst?
mostly asymptomatic
pressure effects: abdo fullness, obstructive jaundice, non specific pain
rupture: -> biliary colic, jaundice, urticaria, anaphylaxis
ix of hydatid cyst?
bloods- eosinophilia
CT
mx of hydatid cyst?
medical: albendazole
surgical cystectomy
- indicated for large cysts
