Hepatobiliary

Question 1

gallstones summary

Answer 1

mainly made of cholesterol, usually mixed compo

risk factors - gall bladder hypomotility (pregnant, COCP, TPN, fasting), female, diet

Question 2

gallstones complications

Answer 2

in gallbladder - biliary colic, cholecystitis

in CBD - obstructive jaundice, pancreatitis, cholangitis

gut - gallstone ileus

Question 3

biliary colic presentation

Answer 3

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

Question 4

biliary colic / cholecystitis investigations

Answer 4

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

Question 5

treating bil colic / cholecyst

Answer 5

NBM and morphine
fluids
remove gall bladder

Question 6

cholecystitis , acute

Answer 6

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)

Question 7

treat cholecystitis acute

Answer 7

NBM
fluids
morphine
cef + met

remove

if empyema, drain using cholecystotomy

Question 8

chronic cholecystits

Answer 8

vague discomfort
distension, bloating
worse with fatty foods
flatulent, burping

DDx - peptic ulcers, IBS, chronic panc, hiatus hern

Question 9

inv and management chronic cholecystitis

Answer 9

porcelain gallbladder AXR
US shrunken gallbladder
MRCP

ERCP if dilated ducts
otherwise remove

Question 10

Rigler triad on AXR

Answer 10

pneumobilia
small bowel obstruction
ectopic calcified gallstone, usually in the right iliac fossa

Question 11

causes of obstructive jaundice x3 groups

Answer 11

head of pancreas cancer
gallstone obstruction
1/3rd other (e.g. autoinflamm, drugs)

Question 12

assessing jaundice clinically

Answer 12

first evident at BR of 50
look under the tongue at frenulum as appears there first
dark urine
pale stools
itch!

Question 13

investigations needed and possible results with jaundice

Answer 13

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

Question 14

divide management of gallstones into conservative, medical and surgical

Answer 14

cons - monitor LFTs, vitamins ADEK give

med - analgesia, cholestyramine

surg - ERCP sphincterotomy and stone extraction, open stone removal, GB out

Question 15

ascending cholangitis

Answer 15

Charcot’s triad
jaundice, fever, RUQ pain

cef+met
ERCP
if failed open removal

Question 16

normal presentation pancreatic carcinoma

Answer 16

RFs present - e.g. diet, smoking, chronic panc

painless obstructive jaundice or
epigastric pain relieved on sitting forwards or
sudden onset elderly diabetes

+ anorexia

Question 17

Courvoisier’s law

Answer 17

In the presence of painless obstructive jaundice, a

palpable gallbladder is unlikely to be due to stones.

Question 18

signs o/e of pancreas cancer

Answer 18

• Palpable gallbladder
• Jaundice
• Epigastric mass
• Thrombophlebitis migrans (Trousseau sign)
• Splenomegaly: PV thrombosis → portal HTN
• Ascites

Question 19

investigations pancreas cancer

Answer 19

cholestatic LFTs, raised Ca19-9, raised calcium

endoscopic ultrasound for staging

CXR+laparoscopy for metastatis screen

ERCP - stenting and biopsy

Question 20

management pancreatic cancer

Answer 20

Whipple’s if small enough

palliation for vast majority - stenting, pancreas bypass, coeliac plexus block

Question 21

acute pancreatitis summarise pathophysiology

Answer 21

Pancreatic enzymes released - autodigestion
Oedema + fluid shift + vomiting → hypovolaemic
shock
Vessel autodigestion → retroperitoneal haemorrhage
Inflammation → pancreatic necrosis
Infection on top of it all common

Question 22

common causes of pancreatitis

Answer 22

gallstones
ethanol

steroids
other drugs
high cholesterol

Question 23

symptoms and signs in acute pancreatitsi

Answer 23

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)

Question 24

differentials for acute pancreatitis

Answer 24

MI
perforated duodenal ulcer
mesenteric ischaemia

Question 25

criteria used for assessing severity of acute pancreas

Answer 25

Glasgow valid for ethanol and stones

Ranson can be used after 48hrs for alcoholic panc

Question 26

bloods and urine results acute pancreatitis

Answer 26

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

Question 27

imaging in acute pancreatitis

Answer 27

§ CXR: ARDS, exclude perfed DU
§ AXR: sentinel loop, pancreatic calcification
§ US: Gallstones and dilated ducts, inflammation
§ Contrast CT: Balthazar Severity Score

Question 28

managing acute pancreatitis

Answer 28

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

Question 29

complications of acute pancreatitis

Answer 29

early - ARDS, shock, renal failure, DIC, metabolic derangement

late - 1 week +
pancreatic necrosis, abscess, pseudocyst
bleeding, thrombosis
fistula

Question 30

what is a pancreatic pseudocyst?

Answer 30

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

Question 31

chronic pancreatitis

Answer 31

alcohol background
chronic epigastric pain
steatorrhoea
weight loss
DM

speckled pancreatic calcifications
reduced faecal elastase

Question 32

treating chronic pancreatitis

Answer 32

low fat, no alc diet
pain relief
ADEK supplements
enzyme supplementation
treat any diabetes

surgery only if blockage or constant pain

Question 33

complications chronic pancreatitis

Answer 33

Pseudocyst
• DM
• Pancreatic Ca
• Pancreatic swelling → biliary obstruction
• Splenic vein thrombosis → splenomegaly

Question 34

pancreatic endocrine neoplasias

Answer 34

insulinoma - high insulin and c peptide, low glucose

gastrinoma - ZE syndrome

glucagonoma - classic blistering rash

VIPoma - watery diarrhoea, low potassium

somatostatinoma - v malignant usually

Question 35

cholangiocarcinoma signs

Answer 35

PSC risk factor but it is rare

progressive painless obstructive jaundice
non-palpable gall-bladder
steatorrhoea
weight loss

ca19-9 like pancreatic

Question 36

hydatid cyst

Answer 36

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