Hepatobiliary Flashcards
Bilirubin Cycle
Old or defective RBC are engulfed in liver & spleen.
Hb –> Globin (AA) & Heme
Heme –> Iron (Ferritin) & biliverdin
Biliverdin –> unconjugated bilirubin (insoluble)
UB binds Albumin for transportation to liver
- conjugated –> soluble –> excreted into biliary canaliculi with bile salts into duodenum.
- Bilirubin –> urobilinogen –> stercobilin (brown faeces) & reabsorbed
What are the main types of gallstones?
Mixed (cholesterol, calcium and bile salts)
Pure cholesterol
Pigment stones (bilirubin calcium)
Brown (calcium)
Biliary colic, acute cholecystitis vs cholangitis?
Biliary colic = RUQ pain
Acute Cholecystitis = RUQ pain + fever & increased WCC
Cholangitis = RUQ pain + Fever & increased WCC + Jaundice
Treatment for biliary colic
- ABCs
- NBM until cholecystitis ruled out
- Analgesia 1) regular paracetamol & NSAIDs 2) PRN oxycodone
- Anti-emetic (ondansetron 8mg sublingual)
- Oral fluids as tolerated
- Educate - caused by gallstones, likely to recur, low fat diet, weight loss & exercise
- Elective laparoscopic cholecystectomy
- Interoperative choleangiogram
- Refer to gen surg clinic, USS
- Safety net - if get fever or pain persists present to ED
Investigations for cholecystitis
Bedside - ECG (MI ruleout), Dipstick (UTI)
Labs: FBC (WCC up . = cholecystitis), UEC (dehydration), LFT (?CBD obstruction), lipase, CRP
Imaging:
- Erect CXR (rule out perforations & RLL pneumonia)
- Biliary USS (gallstones, acoustic shadowing, thickened wall (>4mm), peri-cholecystic fluid, dilated bile duct. NO stones on USS generally means NO cholecystitis.
- MRCP (magnetic resonance cholangiopancreatography) - replaced ERCP for diagnostic purposes - diagnose CBD obstruction. Indications in gallstone disease, high suspicion of CBD block e.g.
> deranged LFTs
> Raised bilirubin or jaundice
> USS shows dilated ducts
> Pancreatitis
Findings: filling defect, dilated ducts
- Intraoperative cholangiogram (IOC) = contrast XRAY during surgery to define anatomy and detect choledocholithiasis
Complications of Cholecystitis
Gallbladder empyema
Perforation
Gallstone ileus
Pancreatitis
Management of Cholecystitis
- Resus (ABCs - IVF, usually dehydrated)
- Non-pharm: Educate, SNAP
- Medical: Empirical Abs; Gentamicin (GNs) + amplicilin (Enterococcus) IV (Same as pyelonephritis)
- Surgical: Urgent laparoscopic cholecystectomy with intraoperative cholangiogram
> NBM
- Supportive > urine output monitor > IV fluids > Analgesics > Anti-emetics > VTW prophylaxis
- Closing > educate on condition and management > Referral to gen surg > Safety net > Follow up (elective)
Management of choledocholithiasis
- Admit or transfer to ERCP capable centre
- Ab: IV gent + ampicillin
- Surg: 1) MRCP, 2) ERCP (even if asymptomatic), 3) Lap cholecystectomy
When is ERCP indicated
Recurrent biliary pain/pancreatitis when gallstones are suspected of being underlying cause but not identified on USS (e.g. LFT derangement or cystic duct dilation)
- Not in uncomplicated gallstone disease
Post operative care
- Analgesia (regular NSAIDS & paracetamol + oxycodone PRN
- Commence normal diet and fluids
- VTE prophylaxis
- No heavy lifting for next 4-6 weeks
- Dressings off in 7-10 days
- Represent if any change in pain, vomiting or concerns
Cholangitis treatment
Resus
- B - 15L O2 non-rebreather
- C - bore access x2, IVFs, inotropes
- Correct electrolytes
Urgent biliary decompression/ERCP
Book for lap chole for later date/elective once stones removed
Antibiotics - Gentamicin (GN) + amoxycilin IV
ERCP vs MRCP
MRCP = only imaging (type of MRI) ERCP= imaging and removal of stones - Effective, quick - Need anaesthetic - NBM 6 hours pre, stpo CHOW drugs
At what level of bilirubin does jaundice become visible and what is the first sign?
> 50
Scleral icterus
What are the causes of Jaundice?
Pre-hepatic:
- Gilbert’s
- Haemolytic anaemia
- Neonatal
Hepatocellular (hepatic): (mixed)
- hepatocellular dysfunction (unconjugated bilirubin leakage)
- hepatocellular swelling –> obstruction –> conjugated bilirubin leak
Obstructive (post-hepatic):
- Choledocholithiasis (pain)
- Carcinoma of pancreas head or cholangiocarcinoma (painless)
- Biliary stricture, abdominal masses, drug induced cholestasis
Workup for jaundice
FBC (anaemia, thrombocytopenia) Smear Reticulocyte count LFTs Bilirubin Coagulation (synthetic function) UECs Liver screen: > hep serology > Paracetamol level > Iron studies > Autoantibodies .
USS biliary tract
MRCP (if obstructive)
Fibroscan (cirrhosis)
Liver biopsy
