Hepatobiliary surgery Flashcards
Four risk factors for gallstones
Obesity
Female
Pregnancy
Forty
Typical presentation of gallstones
- Biliary colic :
- Severe, colicky epigastric or right upper quadrant pain
- Often triggered by meals (particularly high fat meals)
- Lasting between 30 minutes and 8 hours
- May be associated with nausea and vomiting
First line investigation for gallstones
USS
Definition of acute cholecystitis
Inflammation of the gallbladder due to gallstones
Features of acute cholecystitis
-> RUQ pain, might radiate to the shoulder
-> Fever
-> Murphys sign
What would be seen on abdo USS in cholecystitis
Thickened gallbladder wall
Stones or sludge in gallbladder
Fluid around the gallbladder
Definition of cholangitis
Infection and inflammation of the bile ducts
most common organisms causing cholangitis
- Escherichia coli
- Klebsiella species
- Enterococcus species
Presentation of acute cholangitis
CHARCOT’S TRIAD
- Fever
- RUQ pain
- Jaundice
Management of cholangitis
- Nil by mouth
- IV fluids
- Blood cultures
- IV antibiotics (as per local guidelines)
- ERCP (after 24-48 hrs to relieve any obstruction)
what is a cholangiocarcinoma and where is the most common site ?
- Cancer originating in the bile ducts
- Most common site : perihilar region
Main RF for cholangiocarcinoma
- PSC
key presenting feature of cholangiocarcinoma
Obstructive jaundice : dark urine, pale stools and generalised itching
what are 2 key differentials for painless jaundice
- Pancreatic cancer (more common)
- Cholangiocarcinoma
what is courvoisier’s law ?
A palpable gallbladder + jaundice = unlikely to be gallstones. Cause is usually cholangiocarcinoma or pancreatic cancer
Tumour marker for cholangiocarcinoma
CA 19-9
Common presentation of pancreatic cancer
- Painless obstructive jaundice
- New onset or rapid worsening of gycaemic control type 2 DM
when can someone be referred for a direct access CT abdomen for suspected pancreatic cancer ? (7)
Over 60 with weight loss + an additional symptoms :
- Diarrhoea
- Back pain
- Abdominal pain
- Nausea
- Vomiting
- Constipation
- New-onset diabetes
3 key causes of pancreatitis
Gallstones
Alcohol
Post-ERCP
Name 11 causes of pancreatitis
I GET SMASHED
I – Idiopathic
G – Gallstones
E – Ethanol
T – Trauma
S – Steroids
M – Mumps
A – Autoimmune
S – Scorpion sting
H – Hyperlipidaemia
E – ERCP
D – Drugs (furosemide, thiazide diuretics and azathioprine)
Presentation of acute pancreatitis
-> Severe epigastric pain
-> Radiating through to the back
-> Associated vomiting
-> Abdominal tenderness
-> Systemically unwell (e.g., low-grade fever and tachycardia)
What will most often be raised in acute pancreatitis ?
-> Amylase : more than 3x upper limit of normal
-> Lipase : more sensitive and specific that amylase
what is used to assess severity of pancreatitis ?
Glasgow score
0 or 1 – mild pancreatitis
2 – moderate pancreatitis
3 or more – severe pancreatitis
What criteria is used in the glasgow score for pancreatitis ?
P – Pa02 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)
Complications of acute pancreatitis (5)
- Peripancreatic fluid collections
- Pseudocysts
- Pancreatic necrosis
- Pancreatic abscess
- Haemorrhage
most common cause of chronic pancreatitis
Alcohol
Features of chronic pancreatitis
- Pain, worse 15/30 mins after meal
- Steatorrhoea (pancreatic insufficiency)
- DM (20 yrs after Sx begin)
CI to liver transplant
- Significant co-morbidities (e.g., severe kidney, lung or heart disease)
- Current illicit drug use
- Continuing alcohol misuse (generally 6 months of abstinence is required)
- Untreated HIV
- Current or previous cancer (except certain liver cancers)
Incision involved in a liver transplant
- Rooftop incision
- Mercedes benz incision
what is FAP ?
- AD condition
- Results in adenomas developing along large intestine
- These polyps can then become cancerous
What is lynch syndrome
- AD condition
- Increases risk of colorectal cancer
Red flags suggesting possibility of bowel cancer (6)
-> Change in bowel habit (usually to more loose and frequent stools)
-> Unexplained weight loss
-> Rectal bleeding
-> Unexplained abdominal pain
-> Iron deficiency anaemia (microcytic anaemia with low ferritin)
-> Abdominal or rectal mass on examination
Criteria for two week wait referral for colon cancer
- Over 40 years with abdominal pain and unexplained weight loss
- Over 50 years with unexplained rectal bleeding
- Over 60 years with a change in bowel habit or iron deficiency anaemia
what is used to assess for bowel cancer in those who do not fit the two week wait criteria ?
Faecal immunochemical tests (FIT)
what is the bowel cancer screening programme
People aged 60-74 are sent home FIT tests every 2 years
Gold standard investigation for bowel cancer
Colonoscopy
what is a tumour marker for bowel cancer
Carcinoembryonic antigen (CEA)
what classification system is used for bowel cancer
TNM
Risk factor for acute mesenteric ischaemia and typical cause
- AF
- Thrombus in the superior mesenteric artery
Investigation of choice for acute mesenteric ischaemia
Contrast CT
what will be seen on ABG in acute mesenteric ischaemia
Metabolic acidosis
Raised lactate
3 complications of hernias
-> Incarceration - irreducible
-> Obstruction - blockage of passage of stool = bowel obstruction
-> Strangulation = ischaemia
General management of abdominal wall hernias
Conservative management
Tension-free repair
Tension repair
what is an indirect inguinal hernia
Bowel herniates through inguinal canal
What passes through the inguinal canal in men and women
- Men : spermatic cord
- Women : round ligament
what can be done to differentiate an indirect and direct inguinal hernia
- When an indirect hernia is reduced and pressure is applied to the deep inguinal ring, the hernia with remain reduced
what is an indirect hernia ?
-> Hernia protrudes directly through the abdominal wall at Hesselbach’s triangle
-> Hesselback’s triangle boundaries :
- R : Rectus abdominis muscle
- I : Inferior epigastric vessels
- P : Poupart’s ligmanet
What is a hiatus hernia
Herniation of the stomach up through the diaphram
what are the 4 types of HH
- Type 1: Sliding -> stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax.
- Type 2: Rolling
- Type 3: Combination of sliding and rolling
- Type 4: Large opening with additional abdominal organs entering the thorax
RF for HH
Increasing age
Obesity
Pregnancy
Presentation of a HH
Heartburn
Acid reflux
Reflux of food
Burping
Bloating
Halitosis (bad breath)
what is a femoral hernia ?
-> Herniation of abdo contents through the femoral canal : high risk of incarceration, obstruction and stragulation
-> Boundaries of femoral canal : FLIP
F : Femoral vein laterally
L : Lacunar ligament medially
I : Inguinal ligament anteriorly
P : pectineal ligament posteriorly
Explain fasting rules prior to surgery
6 hours of no food or feeds before operation
2 hours no clear fluids (fully “nil by mouth”)
How can warfarin be rapidly reversed
Vitamin K
When are DOACs stopped before surgery ?
24-72 hours
When is the combined contraceptive pill or HRT stopped before surgery
4 weeks prior to reduce the risk of VTE
How are steroids altered before surgery for patients on long steroid therapy
-> Additional IV hydrocortisone at induction and for the immediate postoperative period (e.g., first 24 hours)
-> Doubling of their normal dose once they are eating and drinking for 24 – 72 hours depending on the operation
what signs can rarely be seen in acute pancreatitis
- Cullen’s sign = periumbilical discoloration
- Grey-turner’s sign = flank discolouration
Boerhaave’s
Spontaneous rupture of oesophagus following repeated vomiting
How is Boerhaave’s diagnosed
CT contrast swallow
What can be seen on chest wall in boerhaave’s
Subcutaneous emphysema
Indicator of pancreatitis severity
Low calcium
Main risk factor for cholangiocarcinoma
PSC
annual blood done on patients with chronic pancreatitis
HbA1c
Complication of pancreatitis (tachypnoeic, SOb and centrally cyanosis)
ARDS
