HEPATOBILIARY AND PANCREATIC Flashcards
Courvoisier’s law
if gallbladder is palpable in a jaundiced patient, it is unlikely to be due to gallstones
Charcot’s triad of symptoms
(pain, fever, jaundice)
Occurs in cholangitis
Which site of pancreatic carcinoma causes obstruction
Head of pancreas
Thrombophelebitis migrans occur in
Pancreatic Ca
Side effects of long term TPN usage
hepatic dysfunction and fatty liver
Which drug can be used for pancreatic necrosis
Imipenem
Rx of pancreatic necrosis
Radiological drainage or
Surgical necrosectomy.
Causes of Acute Pancreatitis
GET SMASHED’:
Gallstones
Ethanol (Alcohol)
Trauma
Steroids
Mumps
Autoimmune disease, such as Systemic Lupus Erythematosus (SLE) or Sjogren’s syndrome
Scorpion venom (a rare and unlikely cause in most countries)
Hypercalcaemia
Endoscopic retrograde cholangio-pancreatography (ERCP)
Drugs, such as Azathioprine, NSAIDs, or Diuretics
Which drug causes acute pancreatitis
Azathioprine, NSAIDs, esteogen containing drugs or Diuretics
Why hypocalcemia occurs in pancreatitis
Fat necrosis from pancreatic enzymes release fatty acids in circulation which combined with calcium of blood causing hypocalcemia
What is caused by the enzymes released from pancreas due to inflammation in systemic circulation
These enzymes cause fat necrosis and necrosis of blood vessels (the latter is the cause of retroperitoneal hemorrhage)
Differential causes of hyperamylasaemia
Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis
Assessment of severity of acute pancreatitis is done by
Glasgow, Ranson scoring systems and APACHE II
How how to assess gallstones as the cause of acute pancreatitis
An alanine transaminase (ALT) level >150U/L has a positive predictive value of 85% for gallstones as the underlying cause
Which infections causes acute pancreatitis
Mumps, Coxsackie virus,Typhoid
What is Balthazar score and when it should be done
A CT Scoring system to risk stratification of Pancreatitis
A/c to UK guidelines it should be done 6-10 days after admission in patients with features of persistent inflammatory response or organ failure*.
Pancreatic cyst usually presents at
lesser sac obstructing the gastro-epiploic foramen by inflammatory adhesions..
Pancreatic necrosis vs pseudocyst timeline
Necrosis occurs with evidence of persistent systemic inflammation for more than 7-10 days after the onset of pancreatitis.
Peudocyst: typically formed weeks after the initial acute pancreatitis episode.
Which criteria is used in first 48 hours of acute pancreatitis for risk stratification
The modified Glasgow criteria is used to assess the severity of acute pancreatitis within the first 48 hours of admission
Glasgow Score
Helpfully, the mneumonic to remember the score is PANCREAS:
pO2 <8kPa,
Age >55yrs,
Neutrophils (/WCC) >15×109/L,
Calcium <2mmol/L,
Renal function (Urea) >16mmol/L,
Enzymes LDH>600U/L or AST>200U/L,
Albumin <32g/L,
Sugar (blood glucose) >10mmol/L
MCC of HCC
Viral hepatitis
Causesof HCC
Viralnhepatitis, chronic alcohol excess, hereditary haemochromatosis, primary biliary cirrhosis (PBC), and aflatoxin exposure (a toxic fungal metabolite), smoking, >70 years
initial imaging modality of choice for suspected HCC,
USS
Which scores are used to assess the risk of mortality from cirrhosis
Child-Pugh
MELD
Ca metastasiza from which organs to liver
bowel, breast, pancreas, gastric, and lung
Milan Criteria for TRANSPLANTATION
Milan Criteria: (1) one lesion is smaller than 5cm or three lesions are smaller than 3cm (2) no extrahepatic manifestations (3) no vascular infiltration
Non-Surgical Management for HCC
Image-Guided Ablation and Alcohol ablation in BCLC stage 0 or A
Transarterial Chemoembolisation (TACE) in BCLC stage B
MELD asses
creatinine, bilirubin, INR, sodium, and the use of dialysis (at least twice per week).
MELD us Child Pugh Score
Both asses riskof mortality from Cirrhosis but MELD score can also be used to predict the likelihood of a patient tolerating a potential liver transplant
Screening ofpatients with cirrhosis for HCC
serum AFP and liver USS every 6-12 months
If adenoma of liver found with ahealthy liver then what to do
Remove it as itis a risk factor for Hcc development
CT finding of HCC
suspicious lesion which is highlighted during the arterial phase with washout during the venous phase, this reflects the hypervascularity of the lesions.
TACE is done atwhat stage and with what
Stage B
With doxorubicin
Rx ofstage C of BCLC
Sorafenib’, oral multi tyrosine kinase inhibitor
Treatment of gallstone Ileus
remove the gallstone from an enterotomy proximal to the site of stone impaction and under almost all circumstances the gallbladder should beleft in situ
Acalculous cholecystitis develops in
Patients with inter current illness
NICE guidance gfor cholecystectomy after axute cholecystitis
Ideally 48 hours
C must be After 1 week
IV antibiotic in acute cholecystitis
Co amoxiclav +/- Metronidazole
Bouveret’s Syndrome
stone impacts in the proximal duodenum, causing a gastric outlet obstruction
Biliary colic occurs when
the gallbladder neck becomes impacted by a gallstone.
No inflammation
Which size gallstones will pass on their own
5mm
Which size CBD shouldn’t be explored
The exploration of a small duct is challenging and ducts of less than 8mm should not be explored
By which ways a bile duct can be seen during laparoscopic cholecystectomy
Intra operative cholangiography or
Laparoscopic USS
to either confirm anatomy or to exclude CBD stones.
In which route does bile duct can be surgically explored easily
Transcystic route
MCC of cholangitis
gallstones, ERCP (iatrogenic), and cholangiocarcinoma
Organisms causing cholangitis
Escherichia Coli (27%), Klebsiella species (16%), and Enterococcus
Two common eponymous syndromes associated with cholangitis are:
Charcots Triad: Jaundice, Fever, and RUQ Pain
Reynold’s Pentad: Jaundice, Fever, and RUQ Pain, Hypotension, and Confusion
The gold standard investigation for cholangitis is
ERCP
If cholangitis with features of biliary tract obstruction and no response to antibiotic
Immediate ERCP
definitive management of cholangitis
is via endoscopic biliary decompression,
Commonest cholecystitis in diabetics type 2
Acalculous
Rising AFP and liver USS showing a nodule greater than 1cm in diameter means suspected HCC so
Perform MRI now before resection
Pale color stools which site jaundice
Post hepatic
Calot is extremely difficult to delineate in which
. Mirrizi
If jaundice them 1st test to perform,
USS
If pancreas vs HEPATOBILIARY pathology onUSS then
CT with pancreatic protocol for pancreas
MRI/MRCP for liver/cholangiocarcinoma
If the bile duct has been inadvertently excised then
a hepatico-jejunostomy will need to be created (difficult!)
Cirrhosis
AFP >400
Lesion >2cm
Diagnosis
HCC
If gallbladder empyema only vs associated issue
of Calot triangle like MiWrizi
Ifonly GB empyema thenTreatment is via laparoscopic cholecystectomy*
If associated issue of Calot triangle then percutaneous cholecystostomy
What proportion of patients presenting for cholecystectomy for treatment of biliary colic due to gallstones will have stones in the common bile duct?
Up to 10% of all patients may have stones in the CBD
From criteria of severity of infratitis what score shows severe pancreatitis
> 3 positive criteria indicates severe pancreatitis.
Infective hepatitis in travellers is by
Hep A
Traveler from India
Painless jaundice
No Orgernomegaly
HepA infection
Hepatocellular Adenomas in males are likely to be
smaller but have a greater risk of malignant transformation
critena of Hepatocellular adenoma resection
> 5cm
In males
haemorrhage or symptoms
Hepatocellular adenoma
In women
Linked to use ofOCP
Asymptomatic >5cm are usually excised
USS and CT of Hepatocellular carcinoma
On ultrasound the appearances are of mixed echoity and heterogeneous texture. On CT most lesions are hypodense
You wish to exclude a perforated viscus, and determine whether pancreatitis is present
CT scan with IV contrast
When cholecystostomy is preferred over sub total cholecystectomy in difficult calot
When only fundus is visible
If severe abdominal pain post ercp then what could be the cause
Either pancreatitis or perferated small bowl and they can be differentiated through CT scan
Normal size of bile duct
4mm
If pancreatic necrosis infection is suspected then what to do
First line is FNAC
If unsuitable or any other issue or in fection is proved then perform Pancreatic Necrosectomy
Enteral feed relation with pancreatitis
Enteral feeding helps minimise gut bacterial translocation and should be given to most patients with pancreatitis.
If pancreatitis 2° gallstones then
undergo early cholecystectomy.
Steps after pancreatic necrosis
Extensive necrosis with suspected infections»_space;FNAC to rule out infections»_space; ‘If infection positive then two options
1. radiological drainage or
2. \ surgical necrosectomy.
Steps after pancreatic necrosis
Extensive necrosis with suspected infections»_space;FNAC to rule out infections»_space; ‘If infection positive then two options
1. radiological drainage or
2. \ surgical necrosectomy.
If resectable head of Pancreas carcinoma then best method of biliary decompression
ERCP and placement of stent
If resectable head of Pancreas carcinoma then best method of biliary decompression
ERCP and placement of stent
If resectable{ no mets} head of Pancreas carcinoma then best method of biliary decompression
ERCP and placement of stent
If resectable head of Pancreas carcinoma then best method of biliary decompression
ERCP and placement of stent
If resectable head of Pancreas carcinoma then best method of biliary decompression
ERCP and placement of stent
Rokitansky-Aschoff sinuses, or Luschka’s crypts seen in
Chronic cholecystitia
Typically painless jaundice with palpable gallbladder
Shows distal biliary obstruction due to head ofpancreas carcinoma
If suspected bile duct injury due to Cholecystectomy then
Perform ERCP first then stent can also be placed
If suspected bile duct injury due to Cholecystectomy then
Perform ERCP first then stent can also be placed
If suspected bile duct injury due to Cholecystectomy then
Perform ERCP first then stent can also be placed
If suspected bile duct injury due to Cholecystectomy then
Perform ERCP first then stent can also be placed
Ultrasound of the liver in biliary atresia
in biliary atresia infant may have tiny or invisible gallbladder
Early vs late sign of Metastatic biliary disease
Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier
