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Finals > Hepatobiliary surgery > Flashcards

Hepatobiliary surgery Flashcards

1
Q

Four risk factors for gallstones

A

Obesity
Female
Pregnancy
Forty

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2
Q

Typical presentation of gallstones

A
  1. 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
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3
Q

First line investigation for gallstones

A

USS

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4
Q

Definition of acute cholecystitis

A

Inflammation of the gallbladder due to gallstones

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5
Q

Features of acute cholecystitis

A

-> RUQ pain, might radiate to the shoulder
-> Fever
-> Murphys sign

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6
Q

What would be seen on abdo USS in cholecystitis

A

Thickened gallbladder wall
Stones or sludge in gallbladder
Fluid around the gallbladder

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7
Q

Definition of cholangitis

A

Infection and inflammation of the bile ducts

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8
Q

most common organisms causing cholangitis

A
  1. Escherichia coli
  2. Klebsiella species
  3. Enterococcus species
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9
Q

Presentation of acute cholangitis

A

CHARCOT’S TRIAD

  1. Fever
  2. RUQ pain
  3. Jaundice
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10
Q

Management of cholangitis

A
  • Nil by mouth
  • IV fluids
  • Blood cultures
  • IV antibiotics (as per local guidelines)
  • ERCP (after 24-48 hrs to relieve any obstruction)
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11
Q

what is a cholangiocarcinoma and where is the most common site ?

A
  • Cancer originating in the bile ducts
  • Most common site : perihilar region
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12
Q

Main RF for cholangiocarcinoma

A
  • PSC
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13
Q

key presenting feature of cholangiocarcinoma

A

Obstructive jaundice : dark urine, pale stools and generalised itching

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14
Q

what are 2 key differentials for painless jaundice

A
  1. Pancreatic cancer (more common)
  2. Cholangiocarcinoma
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15
Q

what is courvoisier’s law ?

A

A palpable gallbladder + jaundice = unlikely to be gallstones. Cause is usually cholangiocarcinoma or pancreatic cancer

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16
Q

Tumour marker for cholangiocarcinoma

A

CA 19-9

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17
Q

Common presentation of pancreatic cancer

A
  1. Painless obstructive jaundice
  2. New onset or rapid worsening of gycaemic control type 2 DM
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18
Q

when can someone be referred for a direct access CT abdomen for suspected pancreatic cancer ? (7)

A

Over 60 with weight loss + an additional symptoms :

  • Diarrhoea
  • Back pain
  • Abdominal pain
  • Nausea
  • Vomiting
  • Constipation
  • New-onset diabetes
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19
Q

3 key causes of pancreatitis

A

Gallstones
Alcohol
Post-ERCP

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20
Q

Name 11 causes of pancreatitis

A

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)

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21
Q

Presentation of acute pancreatitis

A

-> Severe epigastric pain
-> Radiating through to the back
-> Associated vomiting
-> Abdominal tenderness
-> Systemically unwell (e.g., low-grade fever and tachycardia)

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22
Q

What will most often be raised in acute pancreatitis ?

A

-> Amylase : more than 3x upper limit of normal
-> Lipase : more sensitive and specific that amylase

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23
Q

what is used to assess severity of pancreatitis ?

A

Glasgow score

0 or 1 – mild pancreatitis
2 – moderate pancreatitis
3 or more – severe pancreatitis

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24
Q

What criteria is used in the glasgow score for pancreatitis ?

A

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)

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25
Q

Complications of acute pancreatitis (5)

A
  • Peripancreatic fluid collections
  • Pseudocysts
  • Pancreatic necrosis
  • Pancreatic abscess
  • Haemorrhage
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26
Q

most common cause of chronic pancreatitis

A

Alcohol

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27
Q

Features of chronic pancreatitis

A
  1. Pain, worse 15/30 mins after meal
  2. Steatorrhoea (pancreatic insufficiency)
  3. DM (20 yrs after Sx begin)
28
Q

CI to liver transplant

A
  1. Significant co-morbidities (e.g., severe kidney, lung or heart disease)
  2. Current illicit drug use
  3. Continuing alcohol misuse (generally 6 months of abstinence is required)
  4. Untreated HIV
  5. Current or previous cancer (except certain liver cancers)
29
Q

Incision involved in a liver transplant

A
  • Rooftop incision
  • Mercedes benz incision
30
Q

what is FAP ?

A
  • AD condition
  • Results in adenomas developing along large intestine
  • These polyps can then become cancerous
31
Q

What is lynch syndrome

A
  • AD condition
  • Increases risk of colorectal cancer
32
Q

Red flags suggesting possibility of bowel cancer (6)

A

-> 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

33
Q

Criteria for two week wait referral for colon cancer

A
  • 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
34
Q

what is used to assess for bowel cancer in those who do not fit the two week wait criteria ?

A

Faecal immunochemical tests (FIT)

35
Q

what is the bowel cancer screening programme

A

People aged 60-74 are sent home FIT tests every 2 years

36
Q

Gold standard investigation for bowel cancer

A

Colonoscopy

37
Q

what is a tumour marker for bowel cancer

A

Carcinoembryonic antigen (CEA)

38
Q

what classification system is used for bowel cancer

A

TNM

39
Q

Risk factor for acute mesenteric ischaemia and typical cause

A
  • AF
  • Thrombus in the superior mesenteric artery
40
Q

Investigation of choice for acute mesenteric ischaemia

A

Contrast CT

41
Q

what will be seen on ABG in acute mesenteric ischaemia

A

Metabolic acidosis
Raised lactate

42
Q

3 complications of hernias

A

-> Incarceration - irreducible
-> Obstruction - blockage of passage of stool = bowel obstruction
-> Strangulation = ischaemia

43
Q

General management of abdominal wall hernias

A

Conservative management
Tension-free repair
Tension repair

44
Q

what is an indirect inguinal hernia

A

Bowel herniates through inguinal canal

45
Q

What passes through the inguinal canal in men and women

A
  • Men : spermatic cord
  • Women : round ligament
46
Q

what can be done to differentiate an indirect and direct inguinal hernia

A
  • When an indirect hernia is reduced and pressure is applied to the deep inguinal ring, the hernia with remain reduced
47
Q

what is an indirect hernia ?

A

-> 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

48
Q

What is a hiatus hernia

A

Herniation of the stomach up through the diaphram

49
Q

what are the 4 types of HH

A
  • 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
50
Q

RF for HH

A

Increasing age
Obesity
Pregnancy

51
Q

Presentation of a HH

A

Heartburn
Acid reflux
Reflux of food
Burping
Bloating
Halitosis (bad breath)

52
Q

what is a femoral hernia ?

A

-> 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

53
Q

Explain fasting rules prior to surgery

A

6 hours of no food or feeds before operation
2 hours no clear fluids (fully “nil by mouth”)

54
Q

How can warfarin be rapidly reversed

A

Vitamin K

55
Q

When are DOACs stopped before surgery ?

A

24-72 hours

56
Q

When is the combined contraceptive pill or HRT stopped before surgery

A

4 weeks prior to reduce the risk of VTE

57
Q

How are steroids altered before surgery for patients on long steroid therapy

A

-> 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

58
Q

what signs can rarely be seen in acute pancreatitis

A
  1. Cullen’s sign = periumbilical discoloration
  2. Grey-turner’s sign = flank discolouration
59
Q

Boerhaave’s

A

Spontaneous rupture of oesophagus following repeated vomiting

60
Q

How is Boerhaave’s diagnosed

A

CT contrast swallow

61
Q

What can be seen on chest wall in boerhaave’s

A

Subcutaneous emphysema

62
Q

Indicator of pancreatitis severity

A

Low calcium

63
Q

Main risk factor for cholangiocarcinoma

A

PSC

64
Q

annual blood done on patients with chronic pancreatitis

A

HbA1c

65
Q

Complication of pancreatitis (tachypnoeic, SOb and centrally cyanosis)

A

ARDS

66
Q
A

Finals (92 decks)

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