Hepatobiliary Flashcards
gallstones summary
mainly made of cholesterol, usually mixed compo
risk factors - gall bladder hypomotility (pregnant, COCP, TPN, fasting), female, diet
gallstones complications
in gallbladder - biliary colic, cholecystitis
in CBD - obstructive jaundice, pancreatitis, cholangitis
gut - gallstone ileus
biliary colic presentation
it is the GB spasming against a stone caught on way out
RUQ pain radiating to back in waves
sweating, pallor
fatty food precipitates
tender in RUQ o/e
biliary colic / cholecystitis investigations
Urine: bilirubin, urobilinogen, Hb • Bloods: FBC, U+E, amylase, LFTs, G+S, clotting, CRP • Imaging § AXR: 10% of gallstones are radio-opaque § Erect CXR: look for perforation § US: - Stones: acoustic shadow - Dilated ducts: >6mm - Inflamed GB: wall oedema • If Dx uncertain after US § HIDA cholescintigraphy: shows failure of GB filling (requires functioning liver) • If dilated ducts seen on US → MRCP
treating bil colic / cholecyst
NBM and morphine
fluids
remove gall bladder
cholecystitis , acute
biliary colic + infection
so also fever, vomiting
RUQ pain
shallow breathing
Murphy’s positive (and negative on left too)
Boas positive (hyperasthesia below right scapula)
treat cholecystitis acute
NBM
fluids
morphine
cef + met
remove
if empyema, drain using cholecystotomy
chronic cholecystits
vague discomfort
distension, bloating
worse with fatty foods
flatulent, burping
DDx - peptic ulcers, IBS, chronic panc, hiatus hern
inv and management chronic cholecystitis
porcelain gallbladder AXR
US shrunken gallbladder
MRCP
ERCP if dilated ducts
otherwise remove
Rigler triad on AXR
pneumobilia
small bowel obstruction
ectopic calcified gallstone, usually in the right iliac fossa
causes of obstructive jaundice x3 groups
head of pancreas cancer
gallstone obstruction
1/3rd other (e.g. autoinflamm, drugs)
assessing jaundice clinically
first evident at BR of 50 look under the tongue at frenulum as appears there first dark urine pale stools itch!
investigations needed and possible results with jaundice
urine - dark
FBC - WCC up in cholangitis, U+E - for hepatorenal syndrome LFT - high BR, v high ALP, others deranged clotting - INR raised G+S in case of ERCP immune panel - AMA etc
AXR - stones USS - ducts/ stones or tumours MRCP - imaging ERCP - procedure perc transhepatic cholangiography - prior to drainage / if others failed
divide management of gallstones into conservative, medical and surgical
cons - monitor LFTs, vitamins ADEK give
med - analgesia, cholestyramine
surg - ERCP sphincterotomy and stone extraction, open stone removal, GB out
ascending cholangitis
Charcot’s triad
jaundice, fever, RUQ pain
cef+met
ERCP
if failed open removal
normal presentation pancreatic carcinoma
RFs present - e.g. diet, smoking, chronic panc
painless obstructive jaundice or
epigastric pain relieved on sitting forwards or
sudden onset elderly diabetes
+ anorexia
Courvoisier’s law
In the presence of painless obstructive jaundice, a
palpable gallbladder is unlikely to be due to stones.
signs o/e of pancreas cancer
- Palpable gallbladder
- Jaundice
- Epigastric mass
- Thrombophlebitis migrans (Trousseau sign)
- Splenomegaly: PV thrombosis → portal HTN
- Ascites
investigations pancreas cancer
cholestatic LFTs, raised Ca19-9, raised calcium
endoscopic ultrasound for staging
CXR+laparoscopy for metastatis screen
ERCP - stenting and biopsy
management pancreatic cancer
Whipple’s if small enough
palliation for vast majority - stenting, pancreas bypass, coeliac plexus block
acute pancreatitis summarise pathophysiology
Pancreatic enzymes released - autodigestion
Oedema + fluid shift + vomiting → hypovolaemic
shock
Vessel autodigestion → retroperitoneal haemorrhage
Inflammation → pancreatic necrosis
Infection on top of it all common
common causes of pancreatitis
gallstones
ethanol
steroids
other drugs
high cholesterol
symptoms and signs in acute pancreatitsi
Severe epigastric pain rad to back, relieved by sitting forward
Vomiting
obs deranged Hypovolaemia → shock Epigastric tenderness Jaundice Ileus → absent bowel sounds Ecchymoses § Grey Turners: flank § Cullens: periumbilical (tracks up Falciform)
differentials for acute pancreatitis
MI
perforated duodenal ulcer
mesenteric ischaemia
criteria used for assessing severity of acute pancreas
Glasgow valid for ethanol and stones
Ranson can be used after 48hrs for alcoholic panc
bloods and urine results acute pancreatitis
Bloods § FBC: ↑WCC § ↑amylase (>1000 / 3x ULN) and ↑lipase - ↑ in 80% - Returns to normal by 5-7d § U+E: dehydration and renal failure § LFTs: cholestatic picture, ↑AST, ↑LDH § Ca2+: ↓ § Glucose: ↑ § CRP: monitor progress, >150 after 48hrs = sev § ABG: ↓O2 suggests ARDS
• Urine: glucose, ↑cBR, ↓urobilinogen
imaging in acute pancreatitis
§ CXR: ARDS, exclude perfed DU
§ AXR: sentinel loop, pancreatic calcification
§ US: Gallstones and dilated ducts, inflammation
§ Contrast CT: Balthazar Severity Score
managing acute pancreatitis
ongoing regular reassessment is crucial
daily bloods incl amylase
aggressive fluid resus to maintain UO at 30ml+/hr
catheter
NG or TPN
treat any alc withdrawal
surgery only if abscess or pseudocyst or unsure of Dx
complications of acute pancreatitis
early - ARDS, shock, renal failure, DIC, metabolic derangement
late - 1 week +
pancreatic necrosis, abscess, pseudocyst
bleeding, thrombosis
fistula
what is a pancreatic pseudocyst?
more commonly with alcohol induced panc
4-6 weeks post attack
persistent abdo pain
abdo mass and early satiety
can get infected or cause obstruction
amylase will still be raised
if large enough, needs drainage
chronic pancreatitis
alcohol background chronic epigastric pain steatorrhoea weight loss DM
speckled pancreatic calcifications
reduced faecal elastase
treating chronic pancreatitis
low fat, no alc diet pain relief ADEK supplements enzyme supplementation treat any diabetes
surgery only if blockage or constant pain
complications chronic pancreatitis
Pseudocyst • DM • Pancreatic Ca • Pancreatic swelling → biliary obstruction • Splenic vein thrombosis → splenomegaly
pancreatic endocrine neoplasias
insulinoma - high insulin and c peptide, low glucose
gastrinoma - ZE syndrome
glucagonoma - classic blistering rash
VIPoma - watery diarrhoea, low potassium
somatostatinoma - v malignant usually
cholangiocarcinoma signs
PSC risk factor but it is rare
progressive painless obstructive jaundice
non-palpable gall-bladder
steatorrhoea
weight loss
ca19-9 like pancreatic
hydatid cyst
zoonotic infection from sheep by Echinococcus granulosus
calcified cyst in liver
pressure effects - ‘fullness’, obst jaundice,
can rupture and cause biliary colic
see eosinophilia
treat: albendazole and cystectomy if large
