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MBBS Surgery > Hepatobiliary > Flashcards

Hepatobiliary Flashcards

1
Q

When to do cholecystectomy

A

early cholecystectomy within first 72h as opposed to interval cholecystectomy because there is no increased risk of bile duct injury, and we do not risk the patient having a recurrence while waiting for interval cholecystectomy

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2
Q

Indications for percutaneous cholecystostomy

A

moribund patients who are not fit for surgery or when early surgery is
difficult due to extensive inflammation

elective cholecystectomy 4-6 weeks later

intrahepatic/ gb dilatation

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3
Q

Complications of cholecystitis

A

mucocele >empyema > gangrene, perforation
sepsis
cholecystoenteric fistula > gallstone ileus
GB Cancer

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4
Q

Acute Pancreatitis- causes

A 
Idiopathic
Gallstone
Ethanol
Trauma
Steroids
Mumps/ malignancy
Autoimmune
Scorpion poison
HyperCa, Hyperlipid (tx with fibrates)
ERCP
Drugs: TCM, steroid, NSAIDs, loop diuretics (thiazides), azathioprine, sodium valproate
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5
Q

SIRS criteria

A 
Systemic inflammatory response syndrome
2/4 of the following
- temp <36, >38
- WBC <4, >12, >10% immature type
- RR >20, PaO2<32
- HR >90
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6
Q

ARDS criteria

A

Berlin definition

  • Onset within 1 week of clinical insult
  • Edema: not fully explained by heart failure, fluid
  • Radiological findings not fully explained by HF, Fluid
  • Severity by Pao2/FiO2 ratio
    1. mild (200-300)
    2. mod (100-200)
    3. severe (<100)
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7
Q

ARDS causes

A 
Direct lung injury:
- pneumonia
- aspiration
- pulmonary contusion
- near drowning
- inhalation injury
- fat emboli
Indirect lung injury:
- sepsis
- severe trauma with shock
- post cardiac sx
- pancreatitis
- drug overdose
- massive transfusion
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8
Q

GLASGOW criteria for pancreatitis

A 
for alcoholic and gall stone pancreatitis
PaO2<60
Age>55
Neutrophil>15
Calcium<2
Renal (urea)>16
Enzymes (LDH>600, AST/ALT>200)
Alb <32
Sugar >10

> 3 = severe

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9
Q

What is sentinel loop

A

ileus secondary to inflammation nearby

on supine AXR

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10
Q

Pancreatitis - cx

A

Local cx

  • psuedocyst: mass effect (GOO, obstructive jaundice, persistent inc amylase)
  • pancreatic necrosis (sterile >infected) if infected: aspirate, cx, abx may need sx: necrosectomy
  • pancreatic pseudoaneurysm
  • Fx cx: exocrine or endocrine deficiency
  • peritonitis: paralytic ileus
  • hemorrhagic pancreatitis: grey turner, Cullen, Fox sign (inguinal ecchymosis)
  • abdominal compartment syndrome

Systemic cx

  • ARDS, SIRS, DCIS, AKI
  • HypoCa
  • Pancreatic ascites

LT cx:
pseudocyst, abscess, ascites, portval vein thrombosis, pseudoaneurysm, chronic pancreatitis

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11
Q

Hypocalcemia symptoms

A 
weakness/ tetany
positive trousseau/ Chvostek sign
laryngeal stridor
dysphagia
tingling - perioral and extremties
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12
Q

Courvoisier law and its exceptions

A

painless jaundice in presence of palpable gallbladder is unlikely due to gallstones

2 types of exceptions

  1. palpable GB but NOT Cancer
    - mirizzi syndrome
    - double impacted duct
  2. non palpable GB but Cancer
    - klatskin tumour (obstructing common hepatic duct)
    - post cholecystecomy
    - post stent procedure
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13
Q

RF for HCC

A

Etiology of liver cirrhosis

  1. Alcoholic
  2. Non alcoholic
    - infectious: Hep B, Hep C
    - Metabolic: wilson, hemachromatosis, alpha1 antitrypsin
    - NASH
    - Autoimmune: Primary biliary cirrhosis, Sec biliary cirrhosis (PSC)

smoking, alcohol, red meat, aflatoxin, diabetics

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14
Q

MELD and significance

A

Model for end stage liver diasease

prioritise pt for liver transplant, help to know which patients are unlikely to benefit from TIPSS (>24)

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15
Q

Signs of liver decompensation

A

Ascites, coagulopathy, jaundice, hepatic encephalopathy

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16
Q

Hepatic Encephalopathy Grading

A

West Haven Classification
I: decreased attn span, sleep wake reversal, insomnia, decreased arithmetic ability, mild asterixis
II: disinhibited behaviour, obvious asterixis
III: stupor, bizarre behaviour
IV: coma

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17
Q

Triggers of hepatic encephalopathy

A
  1. Bleeding GIT
  2. Infections: SBP, sepsis
  3. Drugs: benzodiazepam, opioid, diuretics
  4. Electrolyte imbalances: e.g. large vol paracentesis
  5. Others: constipation, high protein meal, TIPSS, catabolic states
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18
Q

Considerations for hepatic resection for HCC

A
  1. Are you fit for sx
  2. Dz stage - CI in metastatic and tumour in both lobes, cirrhotic b/g liver - field change
  3. Dz location - resectable? adequate margins?
  4. Baseline liver function
    - CHILD Score: A-4, B-2, C-transplant
    - Indocyanine green dye: >15% in 15 min - max 3 segments tolerated
    - CT volumetry
  5. Residual liver function (min 20%)
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19
Q

Considerations for liver transplant

A
  1. MELD Score
  2. Milan Criteria
    - single node <5cm or max 3 tumour (all <3cm)
    - no vascular invasion
    - no nodal and distal mets
  3. b/g dz- HEP B: chance of reinfection of new liver (RF: HbE antigen, high HBV DNA load)
    - anti virals 2 weeks pre transplant
    - lifelong anti-HbV immunoglobulin
  4. Availability of donor: bridging therapy (RFA, TACE) while awaiting
20
Q

Treatment modalities for HCC

A

Curative: hepatectomy, transplant, RFA
Palliative:
- local: Radiofreq ablation, microwave ablat, heat ablation, cryotherapy
- regional: TACE (transarterial chemoembolisation), radioiodine Y90
- systemic: Sorafenib (anti angiogenicn and proliferative)
Others: symptomatic

21
Q

TACE CI and CX

A

CI: Child C, portal thrombosis (worsen perfusion)

CX:

  • ischemic hepatitis (AST/ALT rise): worsen liver fx
  • fever: release of cytokines 2’ tumour lysis
22
Q

CT differences of Pri vs metastatic liver CA

A

HCC: arterial hyperattenuation with venous and delayed washout

Mets: arterial hypo density with increased uptake on venous and delayed phase

23
Q

Pancreatitis acute mgx

A

ABC, fluids, O2, analgesia (TCA, morphine)
keep NBM, avoid NSAIDs

no need for abx

24
Q

Pancreatitis natural progression

A
  1. interstitial oedematous > acute peripancreatic fluid collection (within 4w) > pseudocyst (post 4w)
  2. necrotising (high mortality) > acute necrotising collection > wall of necrosis
25
Q

Pseudocyst mgx

A

Size >6cm: intervention
Size <6cm: intervene if symptomatic or if persistent

methods:
- percutaneous (but high recurrence and failure rates, CI if presence of solid or blood content in cyst or if unable to care for catheter post procedure)
- endoscopic (either transpapillary or transmural - via stomach)
- surgical (anastomosis to nearby organ for drainage - e.g. cystojejunostomy)

26
Q

Necrotising pancreatitis mgx

A

high mortality rates
give antibiotics
if sterile - leave to granulate before necrosectomy

———- need to read up ———–

27
Q

Chronic pancreatitis mgx

A 
CREON TDS (pancreatic enzyme replacement therapy): contain amylases, protease, and lipases
mgx DM - insulin (Not OHGAs)
long term analgesia (TCA, narcotics)

surgery if 1. fail med therapy or 2. cancer

28
Q

diagnosis of acute pancreatitis

A

Atlanta criteria:
2/3 of
1. classic hx and pe
2. ix: 3x upper limit of amylase (100) or lipase (140)
3. radiological findings - AXR: sentinel loop, fat stranding

29
Q

diagnosis of chronic pancreatitis

A
  • rule out pancreatic CA
  • endocrine fx: DM?
  • exocrine fx: pancreatic secretin stimulation test, 72h fecal fat collection
  • endoscopic: ERCP (chain of lakes), EUS (rosemont criteria)
  • radio: AXR - calcifications, CT/MRI, MRCP
30
Q

Screening of anastomotic leak post Whipple?

A

test for amylase in drain

if >3x of serum amylase - tx as for Anas leak

31
Q

Chronic pancreatitis causes

A

Alcohol (most common)
smoking, genetic - cystic fibrosis, autoimmune pancreatitis, congenital (pancreas divisum), metabolic (hyperCa, HyperTG, HyperParathyroidism), drugs (S-A-N-D)
Trauma, Idiopathic

32
Q

Chronic pancreatitis complications

A 
Endocrine insufficiency: DM
Exocrine insufficiency: malnutrition, LOW, diarrhea, vit loss
Mass effect: GOO, IO (duodenal obs)
Inflammation/ stricture formation: 
- bile duct obs - jaundice/ hepatomeg
- splenic vein thrombosis - splenomeg
- fistula formation - pancreatic ascites
Pancreatic CA
33
Q

Pancreatic CA RF

A

Non modifiable: age, men, family hx of chronic pancreatitis, pancreatic cancer related syndromes (PJ, HNPCC)

Modifiable: smoking, alcohol, obesity, diet - high fat, high meat, low fibre, DM, Occupation - nickel, industrial carcinogens

34
Q

Pancreatic CA Presentation

A
  • constitutional sypmtoms: LOA, LOA
  • local symptoms: ab pain going to back, relieved on bending forward
  • pancreas function: exocrine, endocrine (DM)
  • local complications:
    — > GOO. IO, painless jaundice, splenomegaly
    — > fistula formation (ascites)
    — > bleed GIT
  • metastatic symptoms: bone pain, headaches, breathlessness, jaundice
  • paraneoplatic conditions: migratory thrombophlebitis (trousseau sign), panniculitis, DVT
35
Q

Ix for Pancreatic CA

A

diagnosis: triphasic pancreas protocol CT scan (thin slices <3mm) (alt: ERCP, MRCP)
biopsy via EUS + FNAC (alt: ERCP)

Stage: CTTAP, AXR, bone scan, EUS, staging laparoscopy
Prognosticate: CA19-9
Assess complications: FBC, LFT, UECR (any GOO), glucose
Prep for opp: ECG, PT/PTT, GXM

36
Q

Whipple sx - aka? 3 anastomosis? Pretreatment?

A
  • aka pancreaticoduodenectomy (share arterial supply - gastroduodenal artery)
  • gastrojejunostomy, hepaticojejunostomy, pancreaticojejunostomy
  • give octreotide 1w prior to reduce pancreatic secretions
37
Q

Whipple sx - cx?

A

Early/ immediate
- most common: delayed gastric emptying, pancreatic fistula, wound infection
- infection, bleeding, damage to nearby structures: kidney, bowel, liver
- anastomosis leak, pancreatitis, pseudocyst formation
Late
- exocrine and endocrine insufficiency
- recurrence of cancer

38
Q

Types of ERCP perforation

A
  • Type I: Free bowel wall perforation
  • Type II: Retroperitoneal duodenal perforation secondary to periampullary injury
  • Type III: Perforation of the pancreatic or bile duct
  • Type IV: Retroperitoneal air alone
39
Q

5 criteria for normal cholangiopancreatogram

A

(a) Normal intrahepatic ducts
(b) No filling defects
(c) Smooth common bile duct
(d) No stricture/narrowing of the common bile duct
(e) Good and free flow of contrast into duodenum

40
Q

RF of gb cancer

A

Chronic cholecystitis (porcelain gallbladder)
Gallbladder polyps
Primary sclerosing cholangitis
Chronic infection (Salmonella, Helicobacter)
Congenital biliary cysts

41
Q

Cx of ERCP (endoscopic retrograde cholangiopancreatogram)

A

1) Perforation
2) Pancreatitis
3) Cholangitis
4) Haemorrhage due to sphincterotomy
5) Distal bile duct injury
6) Biliary stricture

42
Q

PBC vs PSC

A

PBC – characterized by inflammation and granulomatous destruction of intrahepatic bile ducts, more common in middle aged women presenting with pruritus, serology(+) anti-mitochondria antibodies
(diagnosis: liver biopsy)

PSC – characterized by segmental inflammation and fibrosing destruction of intrahepatic and extrahepatic bile ducts (concentric fibrosis around bile ducts with segmental stenosis – onion skin appearance), more common in young males with inflammatory bowel disease
(diagnosis: MRCP)

43
Q

tx of hepatic encephalopathy

A
  • lactulose (2-3 stools a day, to prevent NH3 uptake)
  • low protein diet
  • branched chain AA
  • no abx unless specific infection
  • neomycin (get rid of ammonia producing bacteria in gut)
44
Q

Initial therapy for hepatorenal syndrome

A
  • octreotide
  • midodrine
  • vasopressin analogue
45
Q

Resectability criteria for pancreatic ca

A

Frank unresectable:

  • SMV/ PV: encasement
  • Celiac art, common hepatic artery: encasement
  • Abutment of SMA>180
  • IVC or aorta invasion or encasement

Borderline, Marginal resectable:

  • SMV/ PV: severe impingement
  • CA, Common HA: abutment
  • SMA <180
  • colon invasion

MBBS Surgery (18 decks)

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