Hepatobiliary

Question 1

Describe the serum markers of liver damage and the causes of their release

Answer 1

• Transaminases such as alkaline transaminase (ALT) and aspartate transaminase (AST) - contained within the hepatocyte, increases in levels when hepatocytes die.
  
  • In alcoholic liver damage AST is raised more than ALT (AST:ALT >1).
  • In viral hepatitis, ALT (VirAL) is raised higher than AST (AST:ALT <1).
• Alkaline phosphatase (ALP) - found in sinusoidal and canaliculi membranes.
  
  • ALP is raised in obstructive jaundice and bile duct damage. Less elevated in viral and alcoholic liver disease.
  • Also raised in bone and metastatic disease.
• Gamma glutamyl transferase (GGT) - also found within hepatocytes and small bile duct epithelium.
  
  • GGT is raised in chronic alcohol use, liver metastases (not viral) and bile duct disease.

Question 2

What are the serum markers of liver function?

Answer 2

• Albumin
  
  • Low production in chronic liver disease and malnutrition
  • Increase loss from Gut and kidney (nephrotic syndrome)
  • Low albumin also in sepsis due to movement into third space.
• Pro-thrombin time
  
  • Acute marker of liver function
• Bilirubin:

Question 3

What is a serum tumour marker that rises in hepatocellular carcinoma?

Answer 3

alpha-fetoprotien may rise in hepatocellular carcinoma.

Question 4

Describe the common approach to evaluating the type of jaundice

Answer 4

Question 5

What is a cholecystectomy and what are its indications?

Answer 5

A cholecystectomy is the surgical removal of the gallbladder. Can be done openly or laparoscopically (gold standard). It is one of the most commonly performed abdominal surgical procedures.

Indications:

Cholelithiasis (gall stones), causing biliary colic or pancreatitis

Cholecystitis

Gall bladder cancer

Question 6

What are the specific complications of a cholecystectomy?

Answer 6

• Gallbladder perforation which results in the spillage of bile and/or stones. Stones left in the abdomen can later become a site of infection.
• Vascular injury - bleeding from cystic or hepatic artery can be much more difficult to deal with laparoscopically
• Bowel injury
• Bile duct injuries can lead to the leaking of bile and cause a painful and potentially dangerous infection.

Question 7

What is an ERCP and its indications?

Answer 7

Question 8

What are the complications of an ERCP?

Answer 8

The major risk of an ERCP is the development of pancreatitis, which can occur in 5% of all patients.

Smaller risks includes of intestinal perforation (especially if a sphincterotomy is performed). There is also risk of an allergic reaction to the contrast dye which contains iodine.

Question 9

What is biliary colic?

Answer 9

Question 10

What clinical features can help distinguish biliary colic caused by temporary gallstone obstruction from other causes of biliary colic?

Answer 10

Biliary colic is its own disease entity, as well as a presentation (I think). Distinguish biliary colic from acute cholecystitis, acute pancreatitis, obstructive jaundice, ascending cholangitis by:

• Nature and characteristics of pain.
  
  • Biliary colic is more colicky, whereas cholecystitis can be more constant and radiate to the shoulder.
• Presence/absence of jaundice; obstructive jaundice is caused by obstruction to the common bile duct. Therefore caused by cholangitis, common bile duct stone and acute pancreatitis.
• Presence/absence of fever (and leukocytosis). A fever points to an infective process such as cholecystitis (though this is more inflammatory) or cholangitis.

Question 11

Describe the investigations for biliary colic

Answer 11

These are the same investigations as cholecystitis as it may be difficult to differentiate clinically.

Bloods:

• FBC is important as leukocytosis points to cholecytitis rather than biliary colic
• U&Es
• LFTs
  
  • Elevated ALP suggests obstruction of the cystic or common bile duct.
• Serum lipase and amylase (to investigate pancreatitis)
• Group and save in case surgery needs to be performed.
• Acute phase reactants (CRP)

Imaging:

• AXR - only 10% of stones are radio-opaque
• Erect CXR to look for perforation
• Ultrasound may show:
  
  • Dilated ducts
  • Stones seen as acoustic shadow
  • Inflammed gallbladder seen as wall oedema

If dilated ducts are still not seen on ultrasound, an MRCP (Magnetic resonance cholangiopancreatography) can be performed. However an ERCP (Endoscopic retrograde cholangiopancreatography) is the preferred way to visualise gallstones as therapy can be provided at the same time.

Question 12

Describe the management of biliary colic

Answer 12

Conservative management includes rehydration and keeping the patient NBM. Opioid analgesia is effective at reducing pain. However due to high recurrence rate surgical management is preferred. Cholecystectomy is commonly performed laparoscopically.

Question 13

What is the epidemiology and risk factors for cholelithiasis?

Answer 13

Gall stones are very common in the west - 20% of adults have them while 85% of patients remain asymptomatic. It is more common in women (2:1). It is not possible to predict which subgroup of patients will become symptomatic and, therefore, cholecystectomy cannot be recommended routinely in asymptomatic patients

Risk factors include:

• Age
• Gender (females > males)
• Hereditary - disorders of bile metabolism
• Drugs - such as oral contraceptives
• Rapid weight loss
• Haemolytic disease (pigment gallstones)

Question 14

What are the features of the two main types of gallstones?

Answer 14

There are basically two types of gallstones:

• Cholesterol (75%)- contain more than 50% of cholesterol. They are usually single and radiolucent (so will not be seen in an X-ray)
• Pigment (25%)- contain calcium salts of unconjugated bilirubin (calcium bilirubinate). There may be multiple and are mostly radio-opaque.

Question 15

What are the complications of gallstones?

Answer 15

Question 16

What is cholecystitis?

Answer 16

Question 17

What are the clinical features of cholecystitis?

Answer 17

Most patients have a history of biliary colic, (epigastric to RUQ pain, nausea and vomiting) but with the pain becoming more severe and localised to the right upper quadrant. Importantly the presence of a fever indicates infection or inflammation. Furthermore, unlike biliary colic, patients will prefer to lie still and take shallow breaths (now a form of local peritonitis, not colic).

On examination, the patient presents with tenderness and muscle guarding or rigidity.

A positive Murphy’s sign can also be elicited. This is when fingers are placed on the right costal margin by the midline, and asking patients to inspire. A positive Murphy’s sign is the cessation of inspiration when the gallbladder descends and hits the fingers. Murphy’s sign is highly sensitive, but not very specific. You must also perform this test on the left costal margin to exclude nonspecific reactions due to other pathology.

Question 18

Describe the investigations for cholecystitis

Answer 18

These are the same investigations as biliary colic as it may be difficult to differentiate clinically.

Bloods:

• FBC is important as leukocytosis points to cholecystitis rather than biliary colic
• U&Es
• LFTs - marginally raised bilirubin, ALT and AST may also be seen.
• Serum lipase and amylase (to investigate pancreatitis)
• Group and save in case surgery needs to be performed.
• Acute phase reactants (CRP) are raised

Imaging:

• AXR - only 10% of stones are radio-opaque
• Erect CXR to look for perforation
• An abdominal ultrasound is the single most useful investigation when taken with a history of fever and a positive Murphy’s sign. The US can show a biliary stone, but also gallbladder wall thickening and oedema.

If dilated ducts or gallstones are still not seen on ultrasound, an MRCP (Magnetic resonance cholangiopancreatography) can be performed. However, an ERCP (Endoscopic retrograde cholangiopancreatography) is the preferred way to visualise gallstones as therapy can be provided at the same time.

Only very occasionally a HIDA (radioisotope) scan is used to help confirm or exclude cholecystitis.

Question 19

Describe the management of cholecystitis

Answer 19

It is first critical to stabilise the patient with I.V fluids (keeping them nil by mouth). I.V antibiotics is also administered to prevent sepsis although cholecystitis (in comparison to cholangitis) is primarily an inflammatory and only secondarily an infective process. Opiates can be given to help with pain.

Once the patient is stabilised, a cholecystectomy is the treatment of choice for virtually all patients to prevent recurrence. This can be done laparoscopically.

Question 20

What are the complications of cholecystitis?

Answer 20

• Gallbladder perforation
• Empyema
• Gallbladder carcinoma
• Gallstone ileus

Question 21

What do you know about gallbladder perforation?

Answer 21

Cholecystitis may progress to gangrene followed by perforation.

• Patients present with sepsis and peritonitis.
• Treat by resuscitation followed by urgent open cholecystectomy.

Question 22

What do you know about gallbladder empyema?

Answer 22

Clinical features similar to cholecystitis, except patients are more unwell with high fever and tender, palpable GB. Some sources say a swinging fever.

• Treat as for cholecystitis plus consider US-guided aspiration of pus, followed by emergency cholecystectomy.

Differential diagnosis is a mucocoele: this is when patients have a tender palpable GB (due to mucus causing distention), but no signs of sepsis.

Question 23

What do you know about gallstone ileus?

Answer 23

This is a misnomer; it is small bowel obstruction and not ileus (cessation of peristalsis). A rare complication of cholecystitis in which a large gallstone (usually >2.5cm) erodes directly through the gallbladder wall into the duodenum. This process takes a very long time, after which the gallstone travels down the intestinal tract getting stuck in the narrowest part after the gastro-oesophageal junction. Usually occurs in the elderly.

Gas in the biliary tree in the presence of features of small bowel obstruction on a plain abdominal X-ray is diagnostic.

Treat by urgent laparotomy. The gallstone is retrieved via a longitudinal enterotomy (closed transversely to prevent stricture formation) in the distal ileum. Presence of gangrene +/− perforation may require small bowel resection +/− primary anastomosis. Cholecystectomy is contra-indicated in patients with a cholecystoduodenal fistula.

Question 24

What are the hallmark features of obstructive jaundice?

Answer 24

Jaundice

Dark urine and pale stools

Pruritus (bile salts)

Question 25

What are the causes of obstructive jaundice?

Answer 25

Causes of obstructive jaundice include:

• Gallstones (30%) which can lead to ascending cholangitis
• Cancer head of the pancreas (30%)
• Other (30%)
  
  • Lymph nodes at porta hepatis (secondary to TB or cancer)
  • Inflammatory (PBC, PSC)
  • Drugs
  • Other neoplastic causes
  • Mirizzi’s syndrome

Question 26

How would you investigate obstructive jaundice?

Answer 26

Urine:

• Urine is dark
• Analysis shows raised bilirubin and reduced urobilinogen (due to reduced conjugated bilirubin getting to bacteria that convert it into urobilins)

Bloods:

• FBC may show leukocytosis indicating cholangitis
• U&Es may show hepatorenal syndrome
• LFTs to investigate cause/type of jaundice.
  
  • Increase in conjugated bilirubin (remember this is in the blood rather than getting to the intestines).
  • Great increase in ALP (>4 x normal)
  • Transaminases (ALT/ASTs) may be increased as well but <400 U/L
• Group and save as may need ERCP
• Immune screen - AMA, ANCA and ANA

Imaging:

• AXR to visualise stone.
• Ultrasound may show dilated ducts and visualise the stones or tumour.
• MRCP or ERCP

Question 27

What is the definition and aetiology of cholangitis?

Answer 27

Acute cholangitis is inflammation of the biliary tree usually due to stasis and infection in the tract. Cholangitis is also called ascending cholangitis as bacteria from the duodenum are allowed to climb up the blocked biliary tree, and can take residence in the stone (or whatever is causing the stasis, such as malignancy).

Causes of obstruction include:

• Gall stones (cholelithiasis)
• Biliary strictures (as in primary sclerosing cholangitis, pancreatic cancer and cholangiocarcinoma)
• Following an ERCP

Question 28

What are the clinical features of cholangitis?

Answer 28

Charcot’s triad:

• Fever (>90%)
• Jaundice (65%)
• Right upper quadrant pain (>80%)

Reynold’s pentad:

• Charcot’s triad +
• Septic shock
• Confusion

Secondary complications include acute renal failure, disseminated intravascular coagulation and liver abscess formation.

Question 29

Describe the diagnosis of cholangitis

Answer 29

Acute cholangitis should be suspected if the patient has a fever and is jaundiced. Diagnosis is confirmed by abdominal ultrasound or x-ray showing biliary dilation or evidence of aetiology (e.g stone or stent).

• FBC shows increased WCC and neutrophils
• U&Es may show renal failure associated with septic shock
• LFTs are elevated (increased bilirubin) but also mildly increased ALS/ALT. There will also be increased ALP (obstructive jaundice)
• Blood cultures may be positive in 50% of cases

An ERCP or MCRP can also provide diagnosis.

Question 30

Describe the management of cholangitis

Answer 30

Ascending cholangitis is very dangerous, so you should treat and monitor for sepsis in HDU. This will involve fluid resuscitation and commencement of antibiotics for colonic bacteria (cefuroxime and metronidazole), but importantly drain the obstruction with an ERCP.

Mortality for moderate cholangitis is around 11%, while for severe/complicated cholangitis is up to 30%.

Question 31

What is the difference between mild, moderate and severe pancreatitis?

Answer 31

Mild acute pancreatitis is inflammation without organ failure and local/systemic complications.

Moderately - severe acute pancreatitis has transient organ failure and/or systemic complications without persistent organ failure.

Severe acute pancreatitis is characterised by persistent organ failure that may involve one or multiple organs.

Question 32

What are the causes of acute pancreatitis?

Answer 32

Can be remembered by the mnemonic: I GET SMASHED (not sure if completely acute):

• Idiopathic (10%)
• Gallstones (60%)
• Ethanol (20%)
• Trauma
• Steroids
• Mumps and Malignancy
• Autoimmune
• Scorpion/Spider bites
• Hyperlipidaemia/hypercalcaemia/hyperparathyroidism
• ERCP
• Drugs (azathioprine, thiazides, valproate)

Question 33

What are the clinical features of acute pancreatitis?

Answer 33

Question 34

What are the potential complications of acute pancreatitis?

Answer 34

• Local complications include: pancreatic necrosis, pseudocyst formation, abscess, ascites, pseudoaneurysm, or venous thrombosis.
• Systemic complications are severe and often fatal (70%): multiorgan failure, sepsis, renal failure, ARDS (Acute Respiratory Distress Syndrome), DIC, hypocalcaemia and diabetes.
• Long-term complications include chronic pancreatitis (with diabetes and malabsorption)

Question 35

Describe the diagnosis of acute pancreatitis

Answer 35

The first clue is acute onset severe pain in the epigastric region, radiating to the back, with tenderness on palpation (history and examination). To secure a diagnosis, two of the three criteria are needed:

• Pain as described above
• ↑ in serum lipase and amylase (usually x3 normal)
• Characteristic findings of acute pancreatitis on imaging; US used if gallstones suspected, AXR, and CT also used.

Other blood tests can show ↑WBC, ↑CRP, ↑Glucose, ↓Ca2+, deranged LFTs (may be a cholestatic picture). U&Es are also important to monitor dehydration and kidney function.

Question 36

Describe the management of acute pancreatitis

Answer 36

The principles of management include:

• Liaise with surgeons
• With supportive measures, the majority will subside in 3-10 days. This includes:
  
  • Fluid and electrolyte resuscitation - patients are usually severely volume depleted and elderly patients will benefit from a CVP line.
  • Keep patients nil by mouth initially.
  • Analgesia - NSAIDs +/- opioids; pethidine causes the least spasm of the Sphincter of Odi.
  • Blood sugar monitoring and treat with insulin if high.
  • Meta-analysis shows decreased mortality with enteral feeding.
• Careful observation for the development of complications. Early detection of signs of necrosis or sepsis. Necrosis can be removed by debridement in a specialised unit.
• Identify and treat the cause. ERCP and sphincterotomy for gallstone pancreatitis within 72h