hepatobiliary surgery Flashcards
at what level of bilirubin is jaundice usually seen?
> 35 mmol/L
normal serum bilirubin?
3-17 mmol/L
causes of prehepatic jaundice?
- autoimmune hemolytic anemia
- drug toxicity
- transfusion reaction
- congenital - hereditary spherocytosis, sickle cell
causes of hepatic jaundice?
- gilberts (unconj)
- crigler-najjar (unconj)
- viral hepatitis
- alcoholic liver disease
- toxic drug jaundice
- metastatic disease
- dubin johnsin
- rotor
causes of post hepatic jaundice - intraluminal causes ?
choledocholithiasis
causes of post hepatic jaundice - mural causes ?
- primary sclerosing cholangitis
- biliary stricture
causes of post hepatic jaundice - extrinsic causes ?
- carcinoma of head of pancreas, ampulla of vater or bile duct
- chronic pancreatitis
- enlarged lymph nodes in porta hepatis
- mirizzi syndrome
what is mirizzi syndrome?
-external biliary compression from a stone impacting the neck of the gallbladder
what is charcots triad?
Triad seen in ascending cholangitis?
- RUQ pain
- fever and rigors
- jaundice
murphys sign suggests…
gallbladder inflammation
Courviousiers law
A painless, palpable gallbladder in a patient with jaundice is unlikely due to gallstone disease and may suggest malignant obstruction
what are the three components of bile?
- cholesterol
- bile salts
- phospholipids
complications of acute cholecystitis?
- empyema or abscess of gallbladder
- perforation with peritinitis
- gallstone ileus
- jaundice due to compression of adjacent bile duct (Mirizzi)
what is chronic cholecystitis?
-attacks of RUQ and tenderness
management of chronic cholecystitis?
-analgesia and routine cholecystectomy
patho of a mucocele?
-when stones block the neck of the gallbladder and bile is reabsorbed but mucous is continued to be secrete leading to a large tense globular mass in the RUQ
treatment of ascending cholangitis?
-IV fluids, antibiotics and relieving the obstruction
next ix after ultrasound for ascending cholangitis?
ERCP
next investigation after ERCP for ascending cholangitis?
if stone is identified on ERCP -> MRCP or percutaneous cholangiography
SEPSIS 6
TAKE 3:
- lactate
- blood cultures
- urine output
GIVE 3:
- oxygen
- fluids
- antibiotics
Management of ascending cholangitis:
- analgesia
- IV fluids
- antibiotics
- oral intake restricted
- THEN plan for either elective cholecystectomy, or perform during admission
I GET SMASHED - aetiologies for pancreatitis?
I-idiopathic G-gallstones E-ethanol/alcohol T-trauma S-steroids M-mumps & other infections A-autoimmune S-spider/scorpion H-hypertriglyceridemia E-ERCP Drugs and toxins
severe pancreatitis can result in…
SIRS
left flank bruising in pancreatitis =
grey-turners sign
periumbilical bruising in pancreatitis =
cullens sign
what is the name of the scale that determines MORTALITy of pancreatitis
ransons
what is the name of the scale that determines the SEVERITY of pancreatitis
glasgow
BEDSIDE investigations for pancreaittis
-ECG, urine dipstick
Blood tests for someone with pancreatitis
-FBC, LFTS, ALK phos, coag, cross match, ca, blood glucose, amylase, electrolytes,CRP
ABGs
why are lipase and urinary amylase sometimes useful for diagnosisng pancreatitis?
they remain elevated longer than serum amylase
Imaging for suspected pancreatitis
CXRAY - rule out free air under diagphram Ultrasound for gallstones Abdominal XRAY - CT Endoscopic ultrasound MRCP
Local complications of pancreatitis
- abscess
- pseudocyst
- necrosis/gangrene
- splenic vein thrombosis/hemorhage
- peripancreatic fluid collection
what is a pseudocyst?
collection of fluid that does not have epithelial lining
Systemic complications of pancreatitis
- sepsis
- arythmia
- hypovolemia
- renal failure
- ARDS, pleural effusions, pneumonia
- DIC
- hyperglycemia
- hypocalcemia
- death
- intestinal hemorhage/ileus
Ix for CHRONIC pancreatitis
- abdominal xray
- abdominal ultrasound - pancreatic duct dilation
- CT
- MRCP
- ERCP
- endoscopic ultrasound combined with aspiration cytology/biopsies
- fecal elastase to check endocrine function
non-surgical management of chronic pancreatitis
- stop offending agents (alcohol)
- decrease fat in diet
- creon
- insulin (if necessary)
- pain control
surgical options for chronic pancreatitis (if medical therapy fails)?
- pancreatoduodenectomy (whipples procedure)
- partial or distal pancreatectomy
- pancreaticojejunostomy
most common type of pancreatic cancer
ductal adenocarcinoma
tumour marker for pancreatic cancer?
CA-19-9
most common endocrine tumour of the pancreas?
insulinoma
90% of insulinomas are (benign/malignant)
benign
