Hepatobiliary Flashcards
When to do cholecystectomy
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
Indications for percutaneous cholecystostomy
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
Complications of cholecystitis
mucocele >empyema > gangrene, perforation
sepsis
cholecystoenteric fistula > gallstone ileus
GB Cancer
Acute Pancreatitis- causes
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
SIRS criteria
Systemic inflammatory response syndrome 2/4 of the following - temp <36, >38 - WBC <4, >12, >10% immature type - RR >20, PaO2<32 - HR >90
ARDS criteria
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)
ARDS causes
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
GLASGOW criteria for pancreatitis
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
What is sentinel loop
ileus secondary to inflammation nearby
on supine AXR
Pancreatitis - cx
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
Hypocalcemia symptoms
weakness/ tetany positive trousseau/ Chvostek sign laryngeal stridor dysphagia tingling - perioral and extremties
Courvoisier law and its exceptions
painless jaundice in presence of palpable gallbladder is unlikely due to gallstones
2 types of exceptions
- palpable GB but NOT Cancer
- mirizzi syndrome
- double impacted duct - non palpable GB but Cancer
- klatskin tumour (obstructing common hepatic duct)
- post cholecystecomy
- post stent procedure
RF for HCC
Etiology of liver cirrhosis
- Alcoholic
- 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
MELD and significance
Model for end stage liver diasease
prioritise pt for liver transplant, help to know which patients are unlikely to benefit from TIPSS (>24)
Signs of liver decompensation
Ascites, coagulopathy, jaundice, hepatic encephalopathy
Hepatic Encephalopathy Grading
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
Triggers of hepatic encephalopathy
- Bleeding GIT
- Infections: SBP, sepsis
- Drugs: benzodiazepam, opioid, diuretics
- Electrolyte imbalances: e.g. large vol paracentesis
- Others: constipation, high protein meal, TIPSS, catabolic states
Considerations for hepatic resection for HCC
- Are you fit for sx
- Dz stage - CI in metastatic and tumour in both lobes, cirrhotic b/g liver - field change
- Dz location - resectable? adequate margins?
- Baseline liver function
- CHILD Score: A-4, B-2, C-transplant
- Indocyanine green dye: >15% in 15 min - max 3 segments tolerated
- CT volumetry - Residual liver function (min 20%)
Considerations for liver transplant
- MELD Score
- Milan Criteria
- single node <5cm or max 3 tumour (all <3cm)
- no vascular invasion
- no nodal and distal mets - 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 - Availability of donor: bridging therapy (RFA, TACE) while awaiting
Treatment modalities for HCC
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
TACE CI and CX
CI: Child C, portal thrombosis (worsen perfusion)
CX:
- ischemic hepatitis (AST/ALT rise): worsen liver fx
- fever: release of cytokines 2’ tumour lysis
CT differences of Pri vs metastatic liver CA
HCC: arterial hyperattenuation with venous and delayed washout
Mets: arterial hypo density with increased uptake on venous and delayed phase
Pancreatitis acute mgx
ABC, fluids, O2, analgesia (TCA, morphine)
keep NBM, avoid NSAIDs
no need for abx
Pancreatitis natural progression
- interstitial oedematous > acute peripancreatic fluid collection (within 4w) > pseudocyst (post 4w)
- necrotising (high mortality) > acute necrotising collection > wall of necrosis
Pseudocyst mgx
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)
Necrotising pancreatitis mgx
high mortality rates
give antibiotics
if sterile - leave to granulate before necrosectomy
———- need to read up ———–
Chronic pancreatitis mgx
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
diagnosis of acute pancreatitis
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
diagnosis of chronic pancreatitis
- 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
Screening of anastomotic leak post Whipple?
test for amylase in drain
if >3x of serum amylase - tx as for Anas leak
Chronic pancreatitis causes
Alcohol (most common)
smoking, genetic - cystic fibrosis, autoimmune pancreatitis, congenital (pancreas divisum), metabolic (hyperCa, HyperTG, HyperParathyroidism), drugs (S-A-N-D)
Trauma, Idiopathic
Chronic pancreatitis complications
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
Pancreatic CA RF
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
Pancreatic CA Presentation
- 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
Ix for Pancreatic CA
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
Whipple sx - aka? 3 anastomosis? Pretreatment?
- aka pancreaticoduodenectomy (share arterial supply - gastroduodenal artery)
- gastrojejunostomy, hepaticojejunostomy, pancreaticojejunostomy
- give octreotide 1w prior to reduce pancreatic secretions
Whipple sx - cx?
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
Types of ERCP perforation
- 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
5 criteria for normal cholangiopancreatogram
(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
RF of gb cancer
Chronic cholecystitis (porcelain gallbladder)
Gallbladder polyps
Primary sclerosing cholangitis
Chronic infection (Salmonella, Helicobacter)
Congenital biliary cysts
Cx of ERCP (endoscopic retrograde cholangiopancreatogram)
1) Perforation
2) Pancreatitis
3) Cholangitis
4) Haemorrhage due to sphincterotomy
5) Distal bile duct injury
6) Biliary stricture
PBC vs PSC
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)
tx of hepatic encephalopathy
- 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)
Initial therapy for hepatorenal syndrome
- octreotide
- midodrine
- vasopressin analogue
Resectability criteria for pancreatic ca
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
