Hepatobiliary-pancreatic Flashcards
1
Q
- What is biliary colic?
A
- Biliary colic is an acute abdominal pain caused by a transient obstruction of the gallbladder (usually by a gallstone in Hartmann’s pouch or the cystic duct).
- The pain occurs when the gallbladder attempts to contract against the obstruction (contraction is stimulated by cholecystokinin from the duodenum)
- At this stage the gallbladder is not inflamed or infected.
- The pain is not a true colic due it’s typical pain pattern of rising to a plateau and then being continuous in nature
Presentation:
- Severe RUQ or epigastric pain
- Radiation as a band across the upper abdomen and to the inferior angle of the right scapula is common
- Onset of pain is typically post-prandial (e.g. a fatty meal that stimulates CCK release)
- The patients tend to be lying still and are usually not systemically unwell (i.e. absence of fever)
- Associated nausea, vomiting and sweating
Investigations and Management:
- Blood tests (FBC, UEC, CRP, LFTs, Lipase)
- Abdominal USS – stones or sludge
- Analgesia (opioid drugs e.g. morphine or fentanyl)
- Nil by mouth
- NSAIDs and antispasmodics may also be helpful
- IV fluid resuscitation
- Cholecystectomy should be considered
Complications:
- Acute cholecystitis or chronic cholecystitis
- Acute pancreatitis
- Ascending cholangitis
- Mucocoele or empyema formation
- Rarely – perforation or fistula formation
- Carcinoma of the gallbladder
3
Q
- What causes cholangitis?
A
- Cholangitis is infection and inflammation of the CBD usually as a complication of choledocholithiasis.
- Inflammation in the CBD leads to obstruction, so unconjugated bilirubin can no longer drain through it and causes jaundice.
- The stasis of bile allows for infection of the biliary tree by gut bacteria.
- The infection can easily spread up the biliary tree to the liver and into the circulation, which causes the systemic symptoms.
-
Causes:
- Choledocholithiasis
- Surgical injury causing strictures
- ERCP introduced gut bacteria
- Biliary tumours
- Radiation induced biliary injury
4
Q
- What are the clinical features of cholangitis?
A
Charcot’s triad:
- RUQ pain
- Jaundice
- Fever with rigors
Reynold’s Pentad
- RUQ pain
- Jaundice
- Fever with rigors
- Shock (hypotension)
- Altered Mental Status (confusion)
Other Clinical Features:
- Acholic stools
- Pruritus
5
Q
- What is cholecystitis?
A
- Cholecystitis is inflammation of the gallbladder – it develops in 10% of patients with symptomatic gallstones
- Acute cholecystitis (90-95%) – caused by a complete obstruction of the cystic duct
- As water is absorbed by the gallbladder the bile becomes very concentrated and irritates the gallbladder, causing a sterile, chemical cholecystitis.
- However, due to the stasis of bile the gallbladder often becomes infected by gut bacteria
- Acalculous cholecystitis (5-10%) – occurs in patients that are critically unwell
- Bile inspissation (clogging of the lumen from a thickened fluid) due to dehydration
- Bile stasis due to trauma or severe systemic illness
- Acute cholecystitis (90-95%) – caused by a complete obstruction of the cystic duct
Presentation
- RUQ or epigastric abdominal pain
- Radiation to the right flank and back
- Abdominal guarding
- Murphy’s Signs positive – tenderness over the gallbladder during inspiration
- Anorexia
- Fever & tachycardia
Complications:
- Rare- empyema or abscess formation, perforation, fistula formation, Mirizzi syndrome (jaundice due to extrinsic compression of the adjacent CBD)
6
Q
- What techniques are available for treating common bile duct stones? Describe the technique briefly.
A
-
Endoscopic Retrograde Cholangiopancreatography (ERCP) techniques: using a side viewing endoscope to visualise the duodenal papilla, a small cannula is introduced into the biliary system and radiographic contrast is used to view the anatomy with fluoroscopy. Interventions can also be used (e.g. electrocautery, stenting, balloons, baskets and lithotripsy)
- Sphincterotomy/ Papillotomy:
- Cutting the superficial papillary sphincter and the sphincter of Oddi with electrocautery
- Papillary balloon dilatation:
- Inflation of a balloon catheter in the ampulla to enlarge the opening
- Stone collection:
- Balloon retrieval – for single stones or undilated duct – the deflated balloon is inserted past the stone, then inflated and withdrawn (pulling the stone with it as it is pulled out)
- Basket retrieval – when there are multiple stones, dilated duct, or the balloon in unsuccessful - the basket is inserted past the stone, expanded and withdrawn (collecting the stones as it goes past)
- Lithotripsy
- Designed to break stones that could not be extracted with the standard methods
- The stones are first captured with the basket
- Mechanical/ laser/ electrohydraulic lithotripsy devices
- Sphincterotomy/ Papillotomy:
- Intra-operative CBD exploration (uncommon)
- Use of an open or laparoscopic incision to access the CBD and extract the stone
- Extracorporeal Shock Wave Lithotripsy (ESWL) – rarely used
7
Q
- What are the symptoms of biliary colic? How can it be differentiated from acute cholecystitis clinically?
A
Biliary Colic:
- RUQ/ epigastric pain
- Radiation to the right back (inferior scapular)
- Diaphoresis
- Nausea and vomiting
- Lasts <6 hours
- No fever
- No peritoneal signs
Differentiating symptoms that are seen in cholecystitis
- Longer duration of the illness
- Fever
- Peritoneal signs and Murphy’s sign positive
8
Q
- What are the common causes of painless obstructive jaundice in a 65 yoa person?
A
- The most common causes of painless jaundice are stones in the CBD or cancer of the head of the pancreas
- Choledocholithiasis:
- May have a history of biliary colic
- Jaundice is progressive if the stone is impacted or fluctuant is the stone is mobile
- Intermittent jaundice if small stones continually get impacted and then pass through to the duodenum
- Carcinoma of the head of the pancreas:
- CBD is compressed by the tumour as it passes through the pancreas
- Painless jaundice that is persistent and progressive
- May have an non-tender palpable enlarged gallbladder
- May also have weight loss, dark urine, pale stools
Other causes:
- Biliary stricture (PSC, post-inflammatory, iatrogenic)
- Peri-ampullary malignancy (e.g. cholangiocarcinoma, portal lymphadenopathy, gallbladder carcinoma, HCC)
- External biliary tree compression (pancreatic pseudocyst, Mirizzi syndrome)
Classification of Jaundice
Unconjugated:
- Haemolysis
- Impaired conjugation (decreased activity of glucuronyl transferase)
- Gilbert’s syndrome
- Diagnosed by exclusion of haemolysis, the presence of normal LFTs and a rise in bilirubin after fasting
- Crigler-Najjar syndrome (types I and II)
- Gilbert’s syndrome
Conjugated:
- Hepatocellular disease
- Hepatitis
- Viral, autoimmune, alcoholic
- Cirrhosis
- Drugs and toxins
- Venous Obstruction
- Hepatitis
- Cholestatic Disease
- Intrahepatic cholestasis
- Drugs, recurrent jaundice of pregnancy, PBC, benign recurrent intrahepatic cholestasis (BRIC)
- Extrahepatic biliary obstruction
- Stones, carcinoma of the pancreas or bile duct, strictures of the bile duct
- Intrahepatic cholestasis
- Familial (e.g. Dubin-Johnson syndrome)
9
Q
- What are the potential complications of an ERCP?
A
General Procedure Complications:
- Allergy
- Cardiorespiratory issues (aspiration, hypoxaemia, cardiac dysrhythmia)
- PONV
- Pain
Specific ERCP Complications:
- Pancreatitis
- Injection of contrast up the pancreatic duct
- Irritation of mucosa at the ampulla causing oedema and obstruction
- Bleeding
- From sphincterotomy or injury from catheter or instruments
- Check platelet count and PTT pre-op
- Perforation
- Of oesophagus/ stomach/ duodenum/ jejunum from the endoscope
- CBD perforation from instruments/ catheter
- Infection (i.e. cholangitis)
- Due to manipulation and irritation of pancreaticobiliary system
- May occur from introducing contaminated equipment
- Stricture formation
- Due to inflammatory fibrosis
12
Q
- How might a person with pancreatic cancer present to their GP?
A
· Key factors
- Presence of risk factors
- Tobacco use
- Family history
- Hereditary cancer syndromes
- Jaundice
- Non-specific upper abdominal pain or discomfort
- Weight loss and anorexia
- Age 65-75
- Less common
- Steatorrhoea
- Thirst, polyuria, nocturia and weight loss
- Nausea, vomiting, anorexia, and mid-epigastric pain
- Hepatomegaly
- Epigastric abdominal mass
- Positive Courvoisier’s sign
- Petechiae, purpura, bruising
- Trousseau’s sign
Risk Factors:
- Strong
- Smoking
- Family history of pancreatic cancer
- Other hereditary cancer syndromes
- HNPCC
- Familial breast cancer
- Hereditary pancreatitis
- Ataxia-telangiectasia
- Peutz-Jeghers syndrome
- Familial atypical multiple mole melanoma (FAMMM)
- Weak
- Chronic sporadic pancreatitis
- Diabetes mellitus
- Obesity
- Dietary factors
- High alcohol
- Diets high in meats and fat
- Low serum folate levels
13
Q
- How do you assess the severity of an episode of pancreatitis when the patient is first being admitted to the hospital?
A
intensity of pain does not reflect severity of pancreatitis
14
Q
- Why does a tumour of the head of pancreas cause jaundice? What are the haematomological consequence of biliary obstruction?
A
- The common bile duct (CBD) passes through the head of the pancreas to join with the pancreatic duct before entering the duodenum.
- A tumour of the head of the pancreas will cause extrinsic compression of the CBD, leading to obstruction of flow into the duodenum, backflow into the biliary system and leakage of conjugated bilirubin through tight junction between hepatocytes into the blood.
- Alternatively, metastatic lymphadenopathy of the porta hepatis may also result in biliary obstruction.
- Jaundice is caused by elevated levels of bilirubin in the blood – for jaundice to be visible serum bilirubin needs to be > 30
(normal range is 3-17 )
Haematological consequences:
- Elevated conjugated bilirubin
- Obstructive LFT pattern (elevated ALP and GGT, with smaller elevation of AST and ALT)
- Hypercholesterolaemia
- Prolonged Prothrombin Time (PT) due to malabsorption of vitamin K and other fat soluble vitamins (ADEK)
15
Q
- Why or how do gallstones cause pancreatitis?
A
- Small gallstones (< 5mm) have the propensity to pass through the cystic duct and CBD and get lodged at the ampulla of Vater.
- This leads to obstruction of the pancreatic duct and prevents exocrine pancreatic excretion, as well as reflux of bile into the pancreatic duct.
- The onset of pancreatitis is due to inappropriate activation of pancreatic digestive enzymes and autodigestion of the pancreas.
- There are many pancreatic enzymes secreted but trypsinogen is a particularly important zymogen that is normally secreted and not activated until it enters the duodenum and is activated by enterokinase to become trypsin. Trypsin then triggers a cascade of activation of lipases, amylases and nucleases.
- Trypsinogen also has the capacity to spontaneously activate into trypsin but this process is normally inhibited by pancreatic trypsin inhibitor.
- With obstruction the normal inhibitory processes are overcome and trypsin starts to activate the other enzymes and initiate auto-digestion.
- Once the autodigestion process has been initiated the inflammatory process leads to:
- Oedema, haemorrhage and eventually necrosis
- The cytokines produced lead to SIRS and potentially ARDS and DIC
- The third space fluid losses can lead to shock and renal failure.
16
Q
- What is this investigation/procedure? What does it show? Describe 3 complications of this intervention
A
Most likely – Endoscopic retrograde cholangiopancreatography (ERCP)
- ERCP shows a side viewing endoscope in the 2nd part of the duodenum, with a catheter injection contrast into the biliary tree (visualising the pancreatic duct, CB, cystic duct, gall bladder, CHD, RHD, and LHD)
- In the image above there are stones in the gallbladder (filling defects) and ?stones in the cystic duct
Complications
- Anaesthetics
- Allergy
- Cardiorespiratory issues (aspiration, hypoxaemia, cardiac dysrhythmia)
- PONV
- Pain
- Specific to ERCP
- Pancreatitis
- Injection of contrast up to the pancreatic duct
- Irritation of mucosa at the ampulla causing oedema and obstruction
- Bleeding
- From sphincterotomy or injury from catheter to instruments
- Check platelet count and PTT pre-op
- Perforation
- Of oesophagus/ stomach/ duodenum/ jejunum from the endoscope
- CBD perforation from instruments/ catheter
- Infection (i.e. cholangitis)
- Due to manipulation and irritation of pancreatobiliary system
- May occur from introducing contaminated equipment
- Pancreatitis
17
Q
- What are the potential complications of severe, acute pancreatitis, early being in the first 24 to 72 hours of the episode?
A
- Pancreatic necrosis
- Haemorrhage
- Rhabdomysolis
- Acute peripancreatic fluid collection
- Abdominal compartment syndrome
- Shock
- AKI
- MODS
- ARDs
18
Q
- This is an ERCP on a patient who has had a bile duct injury at Laparoscpoic Cholecystectomy.
1) What does this show?
2) What might this patient present with?
3) What are the features of cholangitis?
A
Most likely: contrast leak, stones, obstruction (stenosis), surgical clip on CBD
Presentation:
- Peritonism
- Abdominal pain
- Fever, chills
- N&V
- Jaundice
Features of cholangitis:
- Charcot’s triad:
- RUQ pain/ tenderness
- Jaundice
- Fevers and rigors
- Reynauds Pentad (Charcot’s triad plus)
- Hypotension (shock)
- Confusion (altered mental status)
- Other features
- Acholic stools
- Pruritis
19
Q
- This patient is having an operation about 1 week after an episode of acute Pancreatitis
1) What does the patches of white on the fat represent? (examiner needs to point to the area on the right of the picture)
2) What is the mechanism of this?
3) what effect does this have on the serum calcium during the acute phase?
A
- Fat necrosis and saponification
- The inflammation of acute pancreatitis leads to release of enzymes (including pancreatic lipase) and damage to cells (including adipocytes).
- This leads to necrosis of the pancreatic and peripancreatic fat.
- The free fatty acids released in this process complex with salts (including calcium) to form soaps (a process called fat saponification) – this is what the chalky white deposits are.
- Acutely this is sequestering calcium from the serum and therefore causes a lowering of serum calcium (hypocalcaemia)
- However this is not the only proposed mechanism of hypocalcaemia in severe acute pancreatitis (transient hypoparathyroidism and hypomagnesaemia are other theories)
20
Q
- This patient presents with painless jaundice, dark urine and itch
1) what organ is the surgeon palpating for in this photo?
2) What is the significance of being able to palpate this organ which is not normally palpable?
3) explain why this is so?
4) what is the name of this sign?
A
Painless jaundice, dark urine and itch –> obstructive jaundice
- The examiner is most likely attempting to palpate the gall bladder
- Courvoisier’s law states that obstructive jaundice in the presence of a palpable gallbladder is not due to stone (and therefor likely to be caused by tumour)
- The theory is that gallstones cause chronic inflammation leading to gallbladder fibrosis or intermittent stone obstruction leads to hypertrophy of the gallbladder wall, either preventing its distension. In malignancy, progressive obstruction occurs over a short period and the non-thickened gall bladder distends easily.
- More recently MCRP radiological studies have validated Courvoisier’s findings
21
Q
- This patient is having a liver biopsy.
1) What can you see?
2) what is the purpose of a liver biopsy?
3) what are the complications?
A
what can you see?
- May be a patient (e.g. jaundiced)
- May be laparascopic view (e.g. fibrotic liver)
- May be imaging (e.g. USS)
What is the purpose of a liver biopsy?
- Histopathological examination of biopsy tissue can provide otherwise unobtainable qualitative information regarding the structural integrity of the liver and type and degree of injury and/or fibrosis. It is usually performed only after thorough non-invasive clinical evaluation
- Indications
- Histopathological diagnosis, staging and prognosis of liver parenchymal disease
- Focal/diffuse abnormalities on imaging
- Abnormal LFTs of unknown aetiology
- Fever of unknown origin
- Monitoring progress
What are the complications?
- Pain
- Bleeding
- Bile peritonitis
- Transient bacteraemia
- Perforation
- Subcutaneous emphysema
- Pneumoperitoneum
- Subphrenic abscess
- Carcinoid crisis
22
Q
- This woman presented with some upper abdominal fullness and early satiety.
1) What is the lesion and what modalities have been used for its investigation?
2) What kind of hepatic cysts do you know? This lesion is much bigger than most hepatic cysts. What complications do you know of large hepatic cysts?
A
Most likely: cystic lesion of the liver on USS, CT or MRI
Types of hepatic cysts:
- Simple cysts
- Simple (solitary cyst)
- Adult polycystic liver disease
- Choledochal cysts (congenital)
- Caroli’s Disease (rare inherited disorder)
- Infectious
- Hydatid cyst (Echinococcosis)
- Hepatic Abscess
- Neoplastic
- Cystadenoma (Premalignant) [aka mucinous cystic neoplasm]
- Cystadenocarcinoma
- Cystic hepatic metastasis
23
Q
- This X-ray shows the right upper Quadrant of a patient who has had cancer of the pancreas.
1) What does it show? This patient initially presented with obstructive jaundice and had an endoscopic procedure to relieve that.
2) what was the procedure and which stent relates to that? A second procedure was needed at 3 months later because of repeated vomiting.
3) What was that and outline the stent?
A
- AXR may show stent from bile duct to duodenum in situ (temporary – plastic, or permanent – metal)
- This procedure is ERCP with stent placement – most likely a plastic stent because they are inexpensive, effective and can easily be removed or exchanged.
- The negatives include the development of occlusions from sludge and/or bacterial biofilm, which requires repeat ERCP
- Metal stents we introduced to alleviate this issue; however they have significantly higher cost and may not be removable.
- Biliary stenting is used as a bridge to surgery in patients with resectable disease and for palliation in patients with biliary obstruction in the setting of unresectable disease
- The complications of biliary stent placement include
- Stent stenosis
- Stent migration
- Cholecystitis/ cholangitis/ pancreatitis
- Perforation
- Bleeding
- The patient most likely developed malignant duodenal obstruction (gastric outlet obstruction)
- Therefore the procedure would have been the placement of a duodenal stent to relieve the obstruction and most likely placement on a metal biliary stent at the same time
- Alternatively a surgical bypass can be performed with a gastrojejunostomy
24
Q
- This 40 year old female underwent laparoscopic cholecystectomy. During the operation this X-ray was taken.
1) what is this Xray
2) What does it show?
A
Most likely: Intra-operative cholangiogram
Things that should be examined on intra-operative cholangiogram
- The cystic duct is the injection site
- The left and right hepatic ducts are visualised
- The common bile duct tapers down
- Contrast empties into the duodenum
- The bile ducts are of normal size with no intraluminal filling defects.
25
Q
- This is the laparoscopic photograph of a patient with chronic liver disease.
1) What does it show?
2) what are the common causes of this condition?
3) What are the common significant complications of cirrhosis?
A
Most likely: liver cirrhosis
Appearance: distortion of the liver architecture, nodular appearance of the surface appears to be fibrosed
- Common causes
- EtOH abuse
- Chronic viral hepatitis B/C
- NAFLD
- Haemochromatosis
- Less common
- Autoimmune hepatitis
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Medications (isoniazid, methotrexate etc)
- Wilson’s disease
- Hepatic Venous Outflow obstruction
- Right sided heart failure
Common complications
- Portal hypertension
- Ascites
- Variceal haemorrhage
- Spontaneous bacterial peritonitis
- Hepatic encephalopathy
- Hepatocellular carcinoma
- Low protein
- Coagulopathy
- Pruritus
- Portal vein thrombosis
- Oestrogen excess – spider naevi, hypogonadism, gynaecomastia, infertility
27
Q
- This series of photographs shows a duodenal papilla before during and after an ERCP and endoscopic sphincterotomy.
1) what are the usual indications for this procedure?
2) what are the common complications of this procedure
3) what preventative therapy do you know of that can reduce the risk of some of these complications?
A
I_ndications:_
- Extraction of the common bile duct stones
- Treatment of papillary stenosis
- Facilitation of endotherapy such as stenting, structure dilatation, tissue sampling
Common complications
- Pancreatitis
- Haemorrhage
- Infection
- Perforation
- Papillary stenosis/ structuring
Preventative measures
- Pancreatitis
- NSAIDs (rectal)
- Limit cannulation attempts
- Minimise contrast injections into the pancreatic duct
- Prophylactic pancreatic stent placement
- Haemorrhage
- Obtain FBC and Coagulation studies prior to procedure
- Correct coagulopathy
- Cease antiplatelets and anticoagulants prior to procedure
- Ensure haemostasis intraoperatively
- Obtain FBC and Coagulation studies prior to procedure
- Infection
- Prophylactic abx in high risk procedures
- Treat cholangitis
42
Q
- What is biliary colic?
A
- Biliary colic is an acute abdominal pain caused by a transient obstruction of the gallbladder (usually by a gallstone in Hartmann’s pouch or the cystic duct).
- The pain occurs when the gallbladder attempts to contract against the obstruction (contraction is stimulated by cholecystokinin from the duodenum)
- At this stage the gallbladder is not inflamed or infected.
- The pain is not a true colic due it’s typical pain pattern of rising to a plateau and then being continuous in nature
Presentation:
- Severe RUQ or epigastric pain
- Radiation as a band across the upper abdomen and to the inferior angle of the right scapula is common
- Onset of pain is typically post-prandial (e.g. a fatty meal that stimulates CCK release)
- The patients tend to be lying still and are usually not systemically unwell (i.e. absence of fever)
- Associated nausea, vomiting and sweating
Investigations and Management:
- Blood tests (FBC, UEC, CRP, LFTs, Lipase)
- Abdominal USS – stones or sludge
- Analgesia (opioid drugs e.g. morphine or fentanyl)
- Nil by mouth
- NSAIDs and antispasmodics may also be helpful
- IV fluid resuscitation
- Cholecystectomy should be considered
Complications:
- Acute cholecystitis or chronic cholecystitis
- Acute pancreatitis
- Ascending cholangitis
- Mucocoele or empyema formation
- Rarely – perforation or fistula formation
- Carcinoma of the gallbladder
48
Q
- What are the symptoms of biliary colic? How can it be differentiated from acute cholecystitis clinically?
A
Biliary Colic:
- RUQ/ epigastric pain
- Radiation to the right back (inferior scapular)
- Diaphoresis
- Nausea and vomiting
- Lasts <6 hours
- No fever
- No peritoneal signs
Differentiating symptoms that are seen in cholecystitis
- Longer duration of the illness
- Fever
- Peritoneal signs and Murphy’s sign positive
49
Q
- What are the common causes of painless obstructive jaundice in a 65 yoa person?
A
- The most common causes of painless jaundice are stones in the CBD or cancer of the head of the pancreas
- Choledocholithiasis:
- May have a history of biliary colic
- Jaundice is progressive if the stone is impacted or fluctuant is the stone is mobile
- Intermittent jaundice if small stones continually get impacted and then pass through to the duodenum
- Carcinoma of the head of the pancreas:
- CBD is compressed by the tumour as it passes through the pancreas
- Painless jaundice that is persistent and progressive
- May have an non-tender palpable enlarged gallbladder
- May also have weight loss, dark urine, pale stools
Other causes:
- Biliary stricture (PSC, post-inflammatory, iatrogenic)
- Peri-ampullary malignancy (e.g. cholangiocarcinoma, portal lymphadenopathy, gallbladder carcinoma, HCC)
- External biliary tree compression (pancreatic pseudocyst, Mirizzi syndrome)
Classification of Jaundice
Unconjugated:
- Haemolysis
- Impaired conjugation (decreased activity of glucuronyl transferase)
- Gilbert’s syndrome
- Diagnosed by exclusion of haemolysis, the presence of normal LFTs and a rise in bilirubin after fasting
- Crigler-Najjar syndrome (types I and II)
- Gilbert’s syndrome
Conjugated:
- Hepatocellular disease
- Hepatitis
- Viral, autoimmune, alcoholic
- Cirrhosis
- Drugs and toxins
- Venous Obstruction
- Hepatitis
- Cholestatic Disease
- Intrahepatic cholestasis
- Drugs, recurrent jaundice of pregnancy, PBC, benign recurrent intrahepatic cholestasis (BRIC)
- Extrahepatic biliary obstruction
- Stones, carcinoma of the pancreas or bile duct, strictures of the bile duct
- Intrahepatic cholestasis
- Familial (e.g. Dubin-Johnson syndrome)
54
Q
- How do you assess the severity of an episode of pancreatitis when the patient is first being admitted to the hospital?
A
intensity of pain does not reflect severity of pancreatitis
57
Q
- What is this investigation/procedure? What does it show? Describe 3 complications of this intervention
A
Most likely – Endoscopic retrograde cholangiopancreatography (ERCP)
- ERCP shows a side viewing endoscope in the 2nd part of the duodenum, with a catheter injection contrast into the biliary tree (visualising the pancreatic duct, CB, cystic duct, gall bladder, CHD, RHD, and LHD)
- In the image above there are stones in the gallbladder (filling defects) and ?stones in the cystic duct
Complications
- Anaesthetics
- Allergy
- Cardiorespiratory issues (aspiration, hypoxaemia, cardiac dysrhythmia)
- PONV
- Pain
- Specific to ERCP
- Pancreatitis
- Injection of contrast up to the pancreatic duct
- Irritation of mucosa at the ampulla causing oedema and obstruction
- Bleeding
- From sphincterotomy or injury from catheter to instruments
- Check platelet count and PTT pre-op
- Perforation
- Of oesophagus/ stomach/ duodenum/ jejunum from the endoscope
- CBD perforation from instruments/ catheter
- Infection (i.e. cholangitis)
- Due to manipulation and irritation of pancreatobiliary system
- May occur from introducing contaminated equipment
- Pancreatitis
58
Q
- What are the potential complications of severe, acute pancreatitis, early being in the first 24 to 72 hours of the episode?
A
- Pancreatic necrosis
- Haemorrhage
- Rhabdomysolis
- Acute peripancreatic fluid collection
- Abdominal compartment syndrome
- Shock
- AKI
- MODS
- ARDs
59
Q
- This is an ERCP on a patient who has had a bile duct injury at Laparoscpoic Cholecystectomy.
1) What does this show?
2) What might this patient present with?
3) What are the features of cholangitis?
A
Most likely: contrast leak, stones, obstruction (stenosis), surgical clip on CBD
Presentation:
- Peritonism
- Abdominal pain
- Fever, chills
- N&V
- Jaundice
Features of cholangitis:
- Charcot’s triad:
- RUQ pain/ tenderness
- Jaundice
- Fevers and rigors
- Reynauds Pentad (Charcot’s triad plus)
- Hypotension (shock)
- Confusion (altered mental status)
- Other features
- Acholic stools
- Pruritis
60
Q
- This patient is having an operation about 1 week after an episode of acute Pancreatitis
1) What does the patches of white on the fat represent? (examiner needs to point to the area on the right of the picture)
2) What is the mechanism of this?
3) what effect does this have on the serum calcium during the acute phase?
A
- Fat necrosis and saponification
- The inflammation of acute pancreatitis leads to release of enzymes (including pancreatic lipase) and damage to cells (including adipocytes).
- This leads to necrosis of the pancreatic and peripancreatic fat.
- The free fatty acids released in this process complex with salts (including calcium) to form soaps (a process called fat saponification) – this is what the chalky white deposits are.
- Acutely this is sequestering calcium from the serum and therefore causes a lowering of serum calcium (hypocalcaemia)
- However this is not the only proposed mechanism of hypocalcaemia in severe acute pancreatitis (transient hypoparathyroidism and hypomagnesaemia are other theories)
61
Q
- This patient presents with painless jaundice, dark urine and itch
1) what organ is the surgeon palpating for in this photo?
2) What is the significance of being able to palpate this organ which is not normally palpable?
3) explain why this is so?
4) what is the name of this sign?
A
Painless jaundice, dark urine and itch –> obstructive jaundice
- The examiner is most likely attempting to palpate the gall bladder
- Courvoisier’s law states that obstructive jaundice in the presence of a palpable gallbladder is not due to stone (and therefor likely to be caused by tumour)
- The theory is that gallstones cause chronic inflammation leading to gallbladder fibrosis or intermittent stone obstruction leads to hypertrophy of the gallbladder wall, either preventing its distension. In malignancy, progressive obstruction occurs over a short period and the non-thickened gall bladder distends easily.
- More recently MCRP radiological studies have validated Courvoisier’s findings
62
Q
- This patient is having a liver biopsy.
1) What can you see?
2) what is the purpose of a liver biopsy?
3) what are the complications?
A
what can you see?
- May be a patient (e.g. jaundiced)
- May be laparascopic view (e.g. fibrotic liver)
- May be imaging (e.g. USS)
What is the purpose of a liver biopsy?
- Histopathological examination of biopsy tissue can provide otherwise unobtainable qualitative information regarding the structural integrity of the liver and type and degree of injury and/or fibrosis. It is usually performed only after thorough non-invasive clinical evaluation
- Indications
- Histopathological diagnosis, staging and prognosis of liver parenchymal disease
- Focal/diffuse abnormalities on imaging
- Abnormal LFTs of unknown aetiology
- Fever of unknown origin
- Monitoring progress
What are the complications?
- Pain
- Bleeding
- Bile peritonitis
- Transient bacteraemia
- Perforation
- Subcutaneous emphysema
- Pneumoperitoneum
- Subphrenic abscess
- Carcinoid crisis
63
Q
- This woman presented with some upper abdominal fullness and early satiety.
1) What is the lesion and what modalities have been used for its investigation?
2) What kind of hepatic cysts do you know? This lesion is much bigger than most hepatic cysts. What complications do you know of large hepatic cysts?
A
Most likely: cystic lesion of the liver on USS, CT or MRI
Types of hepatic cysts:
- Simple cysts
- Simple (solitary cyst)
- Adult polycystic liver disease
- Choledochal cysts (congenital)
- Caroli’s Disease (rare inherited disorder)
- Infectious
- Hydatid cyst (Echinococcosis)
- Hepatic Abscess
- Neoplastic
- Cystadenoma (Premalignant) [aka mucinous cystic neoplasm]
- Cystadenocarcinoma
- Cystic hepatic metastasis
64
Q
- This X-ray shows the right upper Quadrant of a patient who has had cancer of the pancreas.
1) What does it show? This patient initially presented with obstructive jaundice and had an endoscopic procedure to relieve that.
2) what was the procedure and which stent relates to that? A second procedure was needed at 3 months later because of repeated vomiting.
3) What was that and outline the stent?
A
- AXR may show stent from bile duct to duodenum in situ (temporary – plastic, or permanent – metal)
- This procedure is ERCP with stent placement – most likely a plastic stent because they are inexpensive, effective and can easily be removed or exchanged.
- The negatives include the development of occlusions from sludge and/or bacterial biofilm, which requires repeat ERCP
- Metal stents we introduced to alleviate this issue; however they have significantly higher cost and may not be removable.
- Biliary stenting is used as a bridge to surgery in patients with resectable disease and for palliation in patients with biliary obstruction in the setting of unresectable disease
- The complications of biliary stent placement include
- Stent stenosis
- Stent migration
- Cholecystitis/ cholangitis/ pancreatitis
- Perforation
- Bleeding
- The patient most likely developed malignant duodenal obstruction (gastric outlet obstruction)
- Therefore the procedure would have been the placement of a duodenal stent to relieve the obstruction and most likely placement on a metal biliary stent at the same time
- Alternatively a surgical bypass can be performed with a gastrojejunostomy
65
Q
- This 40 year old female underwent laparoscopic cholecystectomy. During the operation this X-ray was taken.
1) what is this Xray
2) What does it show?
A
Most likely: Intra-operative cholangiogram
Things that should be examined on intra-operative cholangiogram
- The cystic duct is the injection site
- The left and right hepatic ducts are visualised
- The common bile duct tapers down
- Contrast empties into the duodenum
- The bile ducts are of normal size with no intraluminal filling defects.
66
Q
- This is the laparoscopic photograph of a patient with chronic liver disease.
1) What does it show?
2) what are the common causes of this condition?
3) What are the common significant complications of cirrhosis?
A
Most likely: liver cirrhosis
Appearance: distortion of the liver architecture, nodular appearance of the surface appears to be fibrosed
- Common causes
- EtOH abuse
- Chronic viral hepatitis B/C
- NAFLD
- Haemochromatosis
- Less common
- Autoimmune hepatitis
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Medications (isoniazid, methotrexate etc)
- Wilson’s disease
- Hepatic Venous Outflow obstruction
- Right sided heart failure
Common complications
- Portal hypertension
- Ascites
- Variceal haemorrhage
- Spontaneous bacterial peritonitis
- Hepatic encephalopathy
- Hepatocellular carcinoma
- Low protein
- Coagulopathy
- Pruritus
- Portal vein thrombosis
- Oestrogen excess – spider naevi, hypogonadism, gynaecomastia, infertility
68
Q
- This series of photographs shows a duodenal papilla before during and after an ERCP and endoscopic sphincterotomy.
1) what are the usual indications for this procedure?
2) what are the common complications of this procedure
3) what preventative therapy do you know of that can reduce the risk of some of these complications?
A
I_ndications:_
- Extraction of the common bile duct stones
- Treatment of papillary stenosis
- Facilitation of endotherapy such as stenting, structure dilatation, tissue sampling
Common complications
- Pancreatitis
- Haemorrhage
- Infection
- Perforation
- Papillary stenosis/ structuring
Preventative measures
- Pancreatitis
- NSAIDs (rectal)
- Limit cannulation attempts
- Minimise contrast injections into the pancreatic duct
- Prophylactic pancreatic stent placement
- Haemorrhage
- Obtain FBC and Coagulation studies prior to procedure
- Correct coagulopathy
- Cease antiplatelets and anticoagulants prior to procedure
- Ensure haemostasis intraoperatively
- Obtain FBC and Coagulation studies prior to procedure
- Infection
- Prophylactic abx in high risk procedures
- Treat cholangitis
