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D3 > Hepatobiliary Surgery > Flashcards

Hepatobiliary Surgery Flashcards

1
Q

Gallstones

A

90% remain ASx
slightly more in F
western ^

Aetiology
 Lithogenic bile: Admirand’s Triangle
 Biliary sepsis
 GB hypomotility → stasis
 Pregnancy, OCP
 TPN, fasting

Composition
 Phospholipids: lecithin
 Bile pigments (broken down Hb)
 Cholesterol

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2
Q

Gall stones (cholesterol stones)

A

20%
 Large
 Often solitary

Formation ↑ according to Admirand’s Trangle
 ↓ bile salts
 ↓ lecithin
 ↑ cholesterol

Risk factors
 Female
 OCP, pregnancy
 ↑ age
 High fat diet and obesity
 Racial: e.g. American Indian tribes
 Loss of terminal ileum (↓ bile salts)
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3
Q

Gall Stones (Pigment and mixed)

A

Pigment Stones: 5%
 Small, black, gritty, fragile
 Calcium bilirubinate
 Associated c¯ haemolysis

Mixed Stones: 75%
 Often multiple
 Cholesterol is the major component

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4
Q

Gallstones Complications

A

Gallbladder

  • Biliary colic
  • Acute Cholescystitis w/(o) empyema
  • chronic cholecystisis
  • Mucocoele
  • Carcinoma
  • Mirizzi’s syndrome

CBD - common biliary duct

  • obstructive jaundice
  • pancreatitis
  • cholangitis

Gut - galstone ileus

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5
Q

Biliary Colic

description + presentation

A

Gallbladder Spasm against stone impacted in neck of gallbladder - Hartmann’s Pouch
Less commonly stone in CBD

Presents
Biliary colic
 RUQ pain radiating → back (scapular region)
 Assoc. c¯ sweating, pallor, n/v
 Attacks may be ppted. by fatty food and last <6h

o/e may be tenderness in right hypochondrium
± jaundice if stones passes in to CBD

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6
Q

Biliary Colic DDx

A

cholecystitis/ other gallstone disease
pancreatitis
bowel perforation

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7
Q

Biliary Colic Ix

A

Same work up as cholecystitis as may be difficult to
differentiate clinically.

Urine: bilirubin, urobilinogen, Hb
Bloods: FBC, U+E, amylase, LFTs, G+S, clotting, CRP

Imaging
 AXR: 10% of gallstones are radio-opaque
 Erect CXR: look for perforation
US:
 Stones: acoustic shadow
 Dilated ducts: >6mm
 Inflamed GB: wall oedema

If Dx uncertain after US
 HIDA cholescintigraphy: shows failure of GB filling
(requires functioning liver)
 If dilated ducts seen on US → MRCP

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8
Q

Biliary Colic Rx

A

Conservative
- Rehydrate +NBM
- opioid analgesia (morphing 5-10mg/2h max
high recurrence rate (surgical favoured)

Surgical

  • Urgent lap chole (same admission)
  • elective lap chole 6-12 weeks
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9
Q

Acute cholecystitis

Pathogenesis + sequelae

A

Pathogenesis
 Stone or sludge impaction in Hartmann’s pouch
 → chemical and / or bacterial inflammation
 5% are acalculous: sepsis, burns, DM

Sequelae

  1. Resolution ± recurrence
  2. Gangrene and rarely perforation
  3. Chronic cholecystitis
  4. Empyema
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10
Q

Acute cholecystitis Presentation + examination

A 
Severe RUQ pain
- continuous 
- radiates to right scapula + epigastrium 
Fever 
Vomiting
O/E
Local peritonism in RUQ
Tachycardia c¯ shallow breathing
± jaundice
Murphy’s sign
 2 fingers over the GB and ask pt. to breath in
 → pain and breath catch. Must be –ve on the L
Phlegmon may be palpable
Mass of adherent omentum and bowel
Boas’ sign
 Hyperaesthesia below the right scapula
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11
Q

Murphy’s sign

A

Acute cholecystitis
 2 fingers over the GB and ask pt. to breath in
 → pain and breath catch. Must be –ve on the L

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12
Q

Phlegmon

A

Mass of adherent omentum and bowel

(acute cholecystitis)

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13
Q

Boas’ Sign

A

Hyperaesthesia below the right scapular

acute cholecystitis

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14
Q

Acute cholecystitis Ix

A

Urine: bilirubin, urobilinogen

Bloods
 FBC: ↑ WCC
 U+E: dehydration from vomiting
 Amylase, LFTs, G+S, clotting, CRP

Imaging
 AXR: gallstone, porcelain gallbladder
 Erect CXR: look for perforation
US
 Stones: acoustic shadow
 Dilated ducts (>6mm)
 Inflamed GB: wall oedema

If Dx uncertain after US
 HIDA cholescintigraphy: shows failure of GB
filling (requires functioning liver)
 MRCP if dilated ducts seen on US

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15
Q

Acute Cholecystitis Mx

A 
Conservative
 NBM
 Fluid resuscitation
 Analgesia: paracetamol, diclofenac, codeine
 Abx: cefuroxime and metronidazole
 80-90% settle over 24-48h
 Deterioration: perforation, empyema

Surgical
 May be elective surgery @ 6-12wks (↓ inflam)
 If <72h, may perform lap chole in acute phase

Empyema
 High fever
 RUQ mass
 Percutaneous drainage: cholecystostomy

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16
Q

Chronic Cholecystitis Sx

A 
Flatulent Dyspesia
Vague upper abdominal discomfort
Distension, bloating
Nausea
Flatulence, burping
Symptoms exacerbated by fatty foods
 CCK release stimulates gallbladder
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17
Q

Chronic Cholecystitis Ix + Mx

A

Ix
 AXR: porcelain gallbladder
 US: stones, fibrotic, shrunken gallbladder
 MRCP

Mx
Medical
 Bile salts (not very effective)

Surgical
 Elective cholecystectomy
 ERCP first if US shows dilated ducts and stones

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18
Q

Mucocele

A

Neck of gallbladder blocked by stone but contents
remains sterile
 Can be very large → palpable mass
 May become infected → empyema

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19
Q

Gallbladder Carcinoma

A

Rare
 Associated c¯ gallstones and gallbladder polyps.
 Calcification of gallbladder → porcelain GB
 Incidental Ca found in 0.5-1% of lap choles.

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20
Q

Mirizzi’s Syndrome

A

Rare
 Large stone in GB presses on the common hepatic duct
→ obstructive jaundice.
 Stone may erode through into the ducts

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21
Q

Gallstone Ileus

A 
Large stone (>2.5cm) erodes from GB → duodenum
through a cholecysto-duodenal fistula 2ndary to chronic inflam.
May impact in distal ileum → obstruction

Rigler’s Triad:
 Pneumobiliia
 Small bowel obstruction
 Gallstone in RLQ

Rx: stone removal via enterotomy

NB. Bouveret’s syn. = duodenal obstruction

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22
Q

Obstructive Jaundice

A

33% stones
33% Ca head of the pancreas

33% Other
 LNs @ porta hepatis: TB, Ca
 Inflammatory: PBC, PSC
 Drugs: OCP, sulfonylureas, flucolox
 Neoplastic: Cholangiocarcinoma
 Mirizzi’s syndrome
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23
Q

Obstructive jaundice clinical features

A

Jaundice (noticeable at 50mM) - seen on tongue frenulum first

Dark urine, pale stools
Itch (Bile salts)

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24
Q

Obstructive Jaundice Ix

A

Urine -Dark
 ↑ bilirubin ↓ urobilinogen

Bloods
 FBC: ↑ WCC in cholangitis
 U+E: hepatorenal syndrome
 LFT: ↑cBR, ↑↑ ALP, ↑AST/ALT
 Clotting: ↓ vit K → ↑ INR
 G+S: may need ERCP
 Immune: AMA, ANCA, ANA

Imaging
AXR - May visualise stone
 Pneumobilia suggests gas forming infection

US
 Dilated ducts >6mm
 Stones (95% accurate)
 Tumour

MRCP or ERCP
Percutaneous Transhepatic Cholangiography

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25
Q

Mx of stones in obstructive jaundice

A 
Conservative
 Monitor LFTs: passage of stone may → resolution
 Vitamins ADEK
 Analgesia
 Cholestyramine

Interventional
 If: no resolution, worsening LFTs or cholangitis
 ERCP c¯ sphincterotomy and stone extraction

Surgical
Open / lap stone removal c¯ T tube placement
 T tube cholangiogram 8d later to confirm stone removal.

Delayed cholecystectomy to prevent recurrence

26
Q

Ascending Cholangitis

A

May complicate CBD obstruction

Charcot’s Triad - fever/rigors, RUQ pain, jaundice

Reynolds Pentad - Charcot’s triad + confusion + shock

27
Q

Ascending cholangitis Mx

A

Cef and met
 1st: ERCP
 2nd: Open or lap stone removal c¯ T tube drain

28
Q

Charcot’s triad

A

Fever/rigors, jaundice, RUQ pain

Ascending cholangitis

29
Q

Courvoisier’s Law

A

Painless obstructive jaundice w a palpable gallbladder unlikely to be due to stones

30
Q

Pancreatic Carcinoma RF + pathology

A 
SINED
Smoking
Inflammation - chronic pancreatitis
Nutrition (fatty diet)
EtOH
DM
90% ductal carinoma 
Presents late, mets early 
 Direct extension to local structures
 Lymphatics
 Blood → liver and lungs 
60% head, 25% body, 15% tail
31
Q

Pancreatic Carcinoma Presentation + signs

A

60+ M
 Painless obstructive jaundice: dark urine, pale stools
 Epigastric pain: radiates to back, relieved sitting forward
 Anorexia, wt. loss and malabsorption
 Acute pancreatitis
 Sudden onset DM in the elderly

Signs
 Palpable gallbladder
 Jaundice
 Epigastric mass
 Thrombophlebitis migrans (Trousseau Sign)
 Splenomegaly: PV thrombosis → portal HTN
 Ascites

32
Q

Pancreatic Carcinoma Ix

A

Bloods: cholestatic LFTs, ↑Ca19-9 (90% sens), ↑Ca

Imaging
 US: pancreatic mass, dilated ducts, hepatic
mets, guide biopsy
 EUS: better than CT/MRI for staging
 CXR: mets
 Laparoscopy: mets, staging

ERCP
 Shows anatomy
 Allows stenting
 Biopsy of peri-ampullary lesions

33
Q

Pancreatic Cancer Rx + Prognosis

A 
Surgery
 Fit, no mets, tumour ≤3cm (≤10% of pts)
 Whipple’s pancreaticoduodenectomy
 Distal pancreatectomy
 Post-op chemo delays progression
 5ys = 5-14%

Palliation
 Endoscopic / percutaneous stenting of CBD
 Palliative bypass surgery:
– cholecystojejunostomy + gastrojejunostomy
 Pain relief – may need coeliac plexus block

Prognosis

  • mean survival <6mo
  • 5ys = <2%
34
Q

Acute Pancreatitis Path

A

Pancreatic enzymes released and activated in vicious
circle → multi-stage process.
1. Oedema + fluid shift + vomiting → hypovolaemic
shock while enzymes → autodigestion and fat necrosis
2. Vessel autodigestion → retroperitoneal haemorrhage
3. Inflammation → pancreatic necrosis
4. Super-added infection: 50% of pts. c¯ necrosis

10% mortality

35
Q

Acute pancreatitis causes

A

Idiopathic (20%) ?microstones

Gallstones (45%)
Ethanol (25%)
Trauma

Steroids
Mumps (other infections - Coxackie B)
Autoimmune (PAN)
Scorpion (trinidad)
Hyperlipidaemia, hypercalcaemia, hypothermia
ERCP - 5% risk
Drugs - thiazides, azathioprine
36
Q

Acute Pancreatitis Sx + Signs

A

Sx
Severe epigastric pain → back
 May be relieved by sitting forward
Vomiting

Signs
 ↑HR, ↑RR, Fever
Hypovolaemia → shock
Epigastric tenderness
Jaundice
Ileus → absent bowel sounds
Ecchymoses
 Grey Turners: flank
 Cullens: periumbilical (tracks up Falciform)
37
Q

Grey Turner’s

A

Flank ecchymoses

acute pancreatitis

38
Q

Cullen’s

A

Periumbilical ecchymoses
Tracks up falciform

acute pancreatitis

39
Q

Modified Glasgow Criteria

A

Valid for EtOH and Gallstones
- Assess severity + predict mortality

PANCREAS
 PaO2 <8kPa 
 Age >55yrs
 Neutrophils >15 x109/L
 Ca2+ <2mM
 Renal function U>16mM
 Enzymes LDH>600iu/L
AST>200 iu/L
 Albumin <32g/L
 Sugar >10mM 
1 = mild
2 = mod
3 = severe
40
Q

Acute Pancreatitis Ix

A 
Bloods
FBC: ↑WCC
↑amylase (>1000 / 3x ULN) and ↑lipase
 ↑ in 80%
 Returns to normal by 5-7d
U+E: dehydration and renal failure
LFTs: cholestatic picture, ↑AST, ↑LDH
Ca2+: ↓
Glucose: ↑
CRP: monitor progress, >150

Urine: glucose, ↑cBR, ↓urobilinogen

Imaging
 CXR: ARDS, exclude perfed DU
 AXR: sentinel loop, pancreatic calcification
 US: Gallstones and dilated ducts, inflammation
 Contrast CT: Balthazar Severity Score

41
Q

Conservative Mx of Acute Pancreatitis

A

Manage @ appropriate level: e.g. ITU if severe
 Constant reassessment is key
 Hrly TPR, UO
 Daily FBC, U+E, Ca2+, glucose, amylase ABG

Fluid resus - aggressive - keep UO>30ml/h
Catheter +/- CVP

Pancreatic rest
NBM, NGT if vomiting, poss TPN to prevent catabolism

Analgesia - pethidine via PCA, or morphine 5-10mg/2h max

Abx - not routine if mild, use if suspicion of infection or before ERCP
- Penems (meropenem, imipenem)

42
Q

Conservative Mx Complications of Acute Pancreatitis

A 
Mx Complications
 ARDS: O2 therapy or ventilation
 ↑ glucose: insulin sliding scale
 ↑/↓Ca
 EtOH withdrawal: chlordiazepoxide
43
Q

Interventional Mx of Acute Pancreatitis

A

ERCP (Endoscopic Retrograde Cholangio-Pancreatography)

If pancreatitis w dilated ducts 2ndary to gallstones
ERCP + sphincterectomy > less complications

Surgical Mx

  • infected pancreatic necrosis
  • pseudocyst or abscess
  • unsure Dx

Operations
 Laparotomy + necrosectomy (pancreatic debridement)
 Laparotomy + peritoneal lavage
 Laparostomy: abdomen left open c¯ sterile packs in ITU

44
Q

Early Complications of Acute Pancreatitis

A 
Early: Systemic
Respiratory: ARDS, pleural effusion
Shock: hypovolaemic or septic
Renal failure
DIC

Metabolic
 ↓ Ca2+
 ↑ glucose
 Metabolic acidosis

45
Q

Late Complications of Acute Pancreatitis

A 
Late (>1wk): Local 
Pancreatic necrosis
Pancreatic infection
Pancreatic abscess
May form in pseudocyst or in pancreas
Open or percutaneous drainage
Bleeding: e.g. from splenic artery
May require embolisation

Thrombosis
- Splenic A., GDA or colic branches of SMA
 May → bowel necrosis
-Portal vein → portal HTN

Fistula formation
 Pancreato-cutaneous → skin breakdown

46
Q

Pancreatic Pseudocyst

A

Collection of pancreatic fluid in the lesser sac surrounded by granulation tissue
Occur in 20% (esp. in EtOH pancreatitis)

Presentation
 4-6wks after acute attack
 Persisting abdominal pain
 Epigastric mass → early satiety

Complications
 Infection → abscess
 Obstruction of duodenum or CBD

Ix
 Persistently ↑ amylase ± LFTs
 US / CT

Rx
<6cm: spontaneous resolution
>6cm
 Endoscopic cyst-gastrostomy
 Percutaneous drainage under US/CT
47
Q

Chronic Pancreatitis Causes

A 
AGITS
Alcohol (70%)
Genetic - CF, HH
Immune -  Lymphoplasmacytic sclerosing pancreatitis (↑IgG4)
Triglycerides ↑
Structural
 Obstruction by tumour
 Pancreas divisum
48
Q

Chronic Pancreatitis Presentation

A 
Epigastric Pain
 Bores through to back
 Relieved by sitting back or hot water bottle →
erythema ab igne
 Exacerbated by fatty food or EtOH

Steatorrhoea and wt. loss
DM: polyuria, polydipsia
Epigastric mass: pseudocyst

49
Q

Chronic Pancreatitis Ix

A 
↑ glucose
↓ faecal elastase: ↓ exocrine function
US: pseudocyst
AXR: speckled pancreatic calcifications
CT: pancreatic calcifications
50
Q

Chronic Pancreatitis Rx

A

Diet
 No EtOH
 ↓ fat, ↑ carb

Drugs
 Analgesia: may need coeliac plexus block
 Enzyme supplements: pancreatin (Creon)
 ADEK vitamins
 DM Rx

Surgery Indications
 Unremitting pain
 Wt. loss
 Duct blockage

Procedures
 Distal pancreatectomy, Whipple’s
 Pancreaticojejunostomy: drainage
 Endoscopic stenting

51
Q

Chronic Pancreatitis Complications

A 
Pseudocyst
DM
Pancreatic Ca
Pancreatic swelling → biliary obstruction
Splenic vein thrombosis → splenomegaly
52
Q

Pancreatic Insulinoma

A

> fasting/exercise-induced hypoglycaemia
Confusion,stupor, LOC

↑ insulin + ↑ c-peptide + ↓glucose

53
Q

Pancreatic Gastrinoma

A

Zollinger-Ellison
Hypergastrinaemia → hyperchlorhydria → PUD and
chronic diarrhoea (inactivation of pancreatic enzymes)

54
Q

Pancreatic Glucagonoma

A

↑ se glucagon → mild DM

Characteristic blistering rash
 Necrolytic migratory erythema

55
Q

Pancreatic VIPoma

A

Verner-Morrison
XS VIP

Watery Diarrhoea
Hypokalaemia
Achlorhydria
Acidosis

56
Q

Somatostatinoma

A

Somatostatin - inhibits glucagon + insulin release
- inhibits pancreatic enzyme secretion

Features

  • DM
  • Steatorrhoea
  • Gall stones

usually v malignant > poor progn

57
Q

Pancreatic Malformations

A

Ectopic Pancreas

  • Meckel’s diverticulum
  • Small Bowel
58
Q

Pancreas Divisum

A

Failure of fusion of dorsal and ventral buds
→ bulk of pancreas drains through smaller accessory duct.
Usually asymptomatic
May → chronic pancreatitis

59
Q

Annular Pancreas

A

Fusion of dorsal and ventral buds around duodenum

 May present c¯ infantile duodenal obstruction.

60
Q

Cholangiocarcinoma Path + RF

A

Rare bile duct tumouir
Adenocarcinoma
Typically at confluence of R+L heaptic ducts (Klatskin tumours)

RF
Primary Sclerosing Cholangitis
Ulcerative colitis
Choledocholithiasis
Hep B/C
Choledochal cysts
Lynch 2
Flukes
61
Q

Cholangiocarcinoma Presentation Ix Rx

A

Progressive painless obstructive jaundice
 Gallbladder not palpable
Steatorrhoea
Wt. loss

Ix
 Cholestatic LFTs
 CA 19-9

Rx
 Poor prognosis: no curative Rx
 Palliative stenting by ERCP

62
Q

Hydatid Cyst

A

Zoonotic infection by Echinococcus granulosus
 Occurs in sheep-rearing communities
 Parasite penetrates the portal system and infects the
liver → calcified cyst

Presentation
Mostly asymptomatic
2ndary infection

Pressure effects
 Non-specific pain
 Abdominal fullness
 Obstructive jaundice

Rupture
 Biliary colic
 Jaundice
 Urticaria
 Anaphylaxis

Ix - eosinophilia, CT

Rx - Medical - albendazole
Surgical - cystectomy (for large cysts)

D3 (14 decks)

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