Helpfully, the mneumonic to remember the score is PANCREAS: pO2 55yrs, Neutrophils (/WCC) >15×109/L, Calcium 16mmol/L, Enzymes LDH>600U/L or AST>200U/L, Albumin 10mmol/L

HEPATOBILIARY AND PANCREATIC Flashcards by Javeria Anzar

Courvoisier’s law

if gallbladder is palpable in a jaundiced patient, it is unlikely to be due to gallstones

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Charcot’s triad of symptoms

(pain, fever, jaundice)
Occurs in cholangitis

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Which site of pancreatic carcinoma causes obstruction

Head of pancreas

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Thrombophelebitis migrans occur in

Pancreatic Ca

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Side effects of long term TPN usage

hepatic dysfunction and fatty liver

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Which drug can be used for pancreatic necrosis

Imipenem

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Rx of pancreatic necrosis

Radiological drainage or
Surgical necrosectomy.

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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

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Which drug causes acute pancreatitis

Azathioprine, NSAIDs, esteogen containing drugs or Diuretics

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Why hypocalcemia occurs in pancreatitis

Fat necrosis from pancreatic enzymes release fatty acids in circulation which combined with calcium of blood causing hypocalcemia

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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)

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Differential causes of hyperamylasaemia

Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis

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Assessment of severity of acute pancreatitis is done by

Glasgow, Ranson scoring systems and APACHE II

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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

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Which infections causes acute pancreatitis

Mumps, Coxsackie virus,Typhoid

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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*.

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Pancreatic cyst usually presents at

lesser sac obstructing the gastro-epiploic foramen by inflammatory adhesions..

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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.

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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

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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

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MCC of HCC

Viral hepatitis

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Causesof HCC

Viralnhepatitis, chronic alcohol excess, hereditary haemochromatosis, primary biliary cirrhosis (PBC), and aflatoxin exposure (a toxic fungal metabolite), smoking, >70 years

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initial imaging modality of choice for suspected HCC,

USS

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Which scores are used to assess the risk of mortality from cirrhosis

Child-Pugh
MELD

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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 be left 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 >>FNAC to rule out infections >> 'If infection positive then two options 1. radiological drainage or 2. \ surgical necrosectomy.

Steps after pancreatic necrosis

Extensive necrosis with suspected infections >>FNAC to rule out infections >> '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