Hepatobiliary Surgery Flashcards
1
Q
Epidemiology of gallstones?
A
8% of population >40 yrs.
Incidence increased over last 20yrs.
Incidence increased over last 20yrs: western diet
Slightly increased incidence in females
90% of gallstones remain asymptomatic
2
Q
Formation of gallstones?
A
General composition
- Phospholipid: Lecithin
- Bile pigments (broken down Hb)
- Cholesterol
3
Q
Aetiology of gallstones?
A
- Lithogenic bile: Admirand’s Triangle?
- Biliary sepsis
- gallbladder hypomobility –> - Stasis
- Pregnancy, OCP
- TPN, fasting
- Sudden weight loss (Obesity surgery)
- Loss of bile salts - Terminal ileitis
- Diabetes - metabolic syndrome
4
Q
What are cholesterol stones?
A
Large Often Solitary Formation increased according to Admirand's triangle: - decreased bile salts - Decreased lecithin - Increased cholesterol
5
Q
Risk factors for cholesterol stones?
A
- Female
- OCP, Pregnancy
- Increase Age
- High fat diet and obesity
- Racial: E.g American indian tribes
- Loss of terminal ileum (decreased bile salts)
6
Q
What are pigment stones?
A
- Small, black, gritty, fragile
- Calcium bilirubinate
- Associated with haemolysis
7
Q
Mixed stones: 75%
A
Often multiple
Cholesterol is the major component
8
Q
Complication of gallstones in the gallbladder?
A
- Biliary Colic
- Acute cholecystitis + empyema (RUQ + Fever)
- Chronic cholecystitis
- Mucocele
- Carcinoma
- Mirizzi’s syndrome (deranged LFT)
9
Q
Complications of gallstones in the CBD?
A
Obstructive jaundice
Pancreatitis
Cholangitis
10
Q
Complications of gallstones in the gut?
A
Gallstone ileus
11
Q
What is the pathogenesis of biliary colic?
A
- Gallbladder spasm against a stone impacted in the neck of the gallbladder
- Less commonly the stone may be in the CBD.
12
Q
Presentation of biliary colic?
A
Biliary colic
- RUQ pain radiating –> back (scapular region)
- Associated with sweating, pallor, n/v.
- Attacks may be ppted by fatty food and last 6hr.
- Tenderness in the right hypochondrium
- ± jaundice if stones passes into the CBD.
RUQ pain- colic
RUQ pain plus fever- cholecystitis
RUQ pain plus fever plus jaundice (charcot triad)- cholangitis
epigastric pain- more likely pancreatitis
13
Q
What are the differentials for biliary colic?
A
- Cholecystitis/other gallstone disease
- Pancreatitis
- Bowel perforation
14
Q
Investigations in biliary colic?
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: looking for perforation
US:
- Stones: acoustic shadow
- Dilated ducts >6mm
- Inflamed GB: wall oedema
- If dilated ducts seen on US –> MRCP
If diagnosis uncertain after US
- HIDA cholescintigraphy:
shows failure of GB filling
15
Q
Management of Biliary Colic?
A
Conservative
- Rehydrate + NBM
- Opioid analgesia: morphine 5-10mg/2hr max
- High recurrence rate therefore surgical management favoured
Surgical management
- As for conservative + either:
Urgent lap chole (same admission)
- Elective lap chole @ 6-12 weeks.
16
Q
What is acute cholecystitis?
A
Path
- Stone or sludge impaction in Hartmann’s pouch
- -> Chemical and/or bacterial inflammation
- 5% are acalculous: sepsis, burns, DM.
17
Q
Sequelae of disease of acute cholecystitis?
A
- Resolution ± recurrence
- Gangrene and rarely perforation
- Chronic cholecystitis
- Empyema
18
Q
Presentation of acute cholecystitis?
A
Severe RUQ pain
- Continous
- Radiates to right scapula and epigastrium
Fever
Vomiting
19
Q
Examination of acute cholecystitis?
A
- Local peritonism im RUQ
- Tachycardia with 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.
- Phlegmom may be palpable
Mass of adherent omentum nad bowel - Boas’ sign
Hyperaesthesia below the right scapula.
20
Q
What are the investigations of acute cholecystitis?
A
- Urine: bilirubin, urobilinogen
- Blood:
FBC: Increased WCC,
U+E: dehydration from vomiting
Amylase, LFTs, G+S, clotting, CRP
Imaging - AXR: gallstones, porcelain gallbladder - Erect CXR: look for perforation - US Stones: acoustic shadow Dilated ducts (>6mm) Inflamed GB: wall oedema
If diagnosis uncertain after US
- HIDA cholescintigraphy: shows failure of GB filling
MRCP if dilated ducts seen on US.
21
Q
Management of acute cholecystits?
A
Conservative
- NBM
- Fluid resus
- Analgesia: paracetamol, diclofenac, codeine
- Abx: cefuroxime and metronidazole
- 80%-90% settle over 24-48hrs
- Deterioration: perforation, empyema
Surgical
- May be elective surgery @ 6-12 weeks (decreased inflammation)
- If <72hrs, may perform lap chole in acute phase.
- Empyema
High fever
RUQ mass
Percutaneous drainage: cholecystostomy.
22
Q
What is chronic cholecystitis?
A
Flatulent dyspepsia - Vague upper abdominal discomfort - Distension, bloating - Nausea - Flatulence, burping - Symptoms exacerbated by fatty foods CCK release stimulated gallbladder (cholecystokinin)
23
Q
Differential for chronic cholecystitis?
A
PUD
IBS
Hiatus Hernia
Chronic pancreatitis
24
Q
Investigations for chronic cholecystitis?
A
AXR: porcelain gallbladder
US: stones, fibrotic, shrunken gallbladder
MRCP
25
Management of chronic cholecystitis?
Medical
- Bile salts (not very effective)
Surgical
- Elective cholecystectomy
- ERCP first if US shows dilated ducts and stones.
26
What is a mucocele?
- Neck of gallbladder blocked by stone but contents remain sterile
- Can be very large --> palpable mass
- May become infected --> empyema
27
Gallbladder carcinoma?
- Rare
- Associated with gallstones and gallbladder polyps
- Calcification of gallbladder --> Porcelain GB
- Incidental Ca found in 0.5-1% of lap choles.
28
Mirizzi's syndrome?
- Rare
- Large stone in GB presses on the common hepatic duct --> obstructive jaundice
- Stones may erode through into the ducts.
29
Gallstone Ileus?
Large stone erodes from GB --> duodenum through a cholecysto-duodenal fistula 2nd to chronic inflammation
May impact in distal ileum --> obstruction
Rigler's Triad
- Pneumobilia (air in bile duct)
- Small bowel obstruction
- Gallstone in the RLQ
Stone removal via enterotomy
30
Acute pancreatitis pathophysiology?
Pancreatic enzyme released and activated in vicious circle
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 with necrosis
31
Epidemiology of acute pancreatitis?
1% of surgical admissions
4th and 5th decade
10% mortality
32
Aetiology of acute pancreatitis? Common
Gallstones (45%)
Ethanol (25%)
Idiopathic (20%): microstones?
```
Trauma
Steroids
Mumps (Coxsackie B)
Autoimmune, Ascaris Infection
Scorpion venom
Hypertriglyceridaemia, Hypercholymicronaemia, Hypercalcaemia, hypothermia
ERCP
Drugs
```
33
More rare causes of acute pancreatitis?
```
Trauma
Steroids
Mumps/Coxsackie B
Autoimmune e.g PAN
Scorpion venom
ERCP
Drugs: thiazides, azathioprine, sodium valproate, furosemide, bendoflumethiazide)
```
34
Symptoms of acute pancreatitis?
Severe epigastric pain --> back pain
- May be relieved by sitting forward
- Vomiting
35
Signs of acute pancreatitis?
```
Increased HR
Increased RR
Fever
Hypovolaemia --> shock
Epigastric tenderness
Jaundice
Ileus --> absent bowel sounds
Ecchymoses
- Grey Turners: Flank
- Cullens: periumbilical (tracks up Falciform)
```
36
Differential for Acute Pancreatitis?
Perforated DU
Mesenteric infarction
MI
37
Modified Glasgow Criteria?
- Valid for EtOH and Gallstones
- Assess severity and predict mortality
- Ranson's criteria are only applicable to EtOH and can only be fully applied after 48hrs.
38
What is PANCREAS used to measure?
```
PaO2 <8 (hypoxia)
Age >55
Neutrophils >15 x 10
Ca2+ <2mM (hypocalcaemia)
Renal function U >16 mM
Enzymes LDH >600, AST >200
Albumin <32
Sugar >10mM (hyperglycaemia)
```
39
Investigations for acute pancreatitis?
```
Bloods
- FBC: Increased WCC
- Increased amylase (>1000/3x ULN) and increased lipase
Increased in 80%
Returns to normal by 5-7d.
```
- U+E: dehydration and renal failure
- LFTs: cholestatic picture, increased AST, increased LDH.
- Ca down
- Glucose up
- CRP: monitor progress > 150 after 48hrs = severe
- ABG: decreased O2 suggests ARDS
Urine: glucose, increased conjugated bilirubin, decreased urobilinogen
Imaging
- CXR: ARDS, perf DU
- AXR: sentinel loop, pancreatic calcification
- US: Gallstones, dilated ducts, inflammation
- Contrast CT: Balthazar Severity Score
40
Conservative management of acute pancreatitis?
Manage @ ITU if severe
- Constant reassessment is key
- Hrly TPR, UO
- Daily FBC, U+E, Ca2+, Glucose, amylase ABG. Serum lipase is more sensitive and specific
Fluid resus
- Aggressive fluid resus: keep UO >30ml/h
- Catheter ± CVP
Pancreatic Rest
- NBM
- NGT if vomiting
- TPN may be required if severe to prevent catabolism
Analgesia
- Pethidine via PCa
- Or morphine 5-10 mg/2hr max
Antibiotics
- Not routinely given if mild
- Use if suspicion of infection or before ERCP
- Penems often used meropenem, imipenem
41
Management of complications of acute pancreatitis?
ARDS: o2 therapy or ventilation
Increased glucose: insulin sliding scale
- Increased/decreased Ca
- EToH withdrawal: chlordiazepoxide
42
Intervention management is pancreatitis with dilated ducts 2nd to gallstones
ECRP + sphincterotomy -->
If due to just gallstones - undergo early cholecystectomy
43
Surgical management of acute pancreatitis?
```
Surgical management
- Indications
Infected pancreatic necrosis
- Pseudocyst or abscess
- Unsure diagnosis
```
Operations
- Laparotomy + necrosectomy (pancreatic debridement)
- Laparotomy + peritoneal lavage
- Laparostomy: abdomen let open with sterile packs in ITU
44
What are the early systemic complications of Acute Pancreatitis?
```
Respiratory: ARDS, pleural effusion
Shock: hypovolaemic or septic
Renal failure
DIC
Metabolic
- Decreased Ca
- increased glucose
- metabolic acidosis
```
45
What are the late >1 weeks complication of acute pancreatitis?
```
Pancreatic necrosis
Pancreatic infection
Pancreatic abscess
- May form in pseudocyst or in pancreas
- Open or percutaneous drainage
```
Bleeding: 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
What is a pancreatic pseudocyst (late complication)
- Collection of pancreatic fluid in the lesser sac surrounded by granulation tissue
- Occurs in 20% (esp in EToH pancreatitis)
- Presentation
4-6 weeks after acute attack
Persisting abdominal pain
Epigastric mass --> early satiety
Complications
- Infection --> abscess
- Obstruction of duodenum or CBG
Invx - persistently increased amylase ± LFTs
- US/CT
management
- <6cm - Spontaneous resolution
- >6cm = endoscopic cyst-gastrostomy
- Percutaneous drainage under US/CT.
47
What is chronic pancreatitis caused by?
AGITS
- Alcohol
- Genetic
CF
HH
- Immune
Lymphoplasmacytic sclerosing pancreatitis (Increased IgG4)
- triglycerides increased
- Structural
Obstruction by tumour
Pancreas divisum
48
Presentation of chronic pancreatitis?
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 weight loss
- DM: polyuria, polydipsia
- Epigastric mass; Pseudocyst
49
Investigations for chronic pancreatitis?
Increased Glucose
Decreased faecal elastase: decreased exocrine function
US: pseudocyst
AXR: speckled pancreatitis calcifications
CT: pancreatic calcifications. With IV contrast. Look for pancreatic calcification
50
Management of chronic pancreatitis?
Diet
- No alcohol
- Low fat, increased carbs
Drugs
- Analgesia
- Enzyme supplements: pancreatin (creon)
- ADEK vitamins
- DM management
Surgery
- Indications (unremitting pain, weight loss, duct blockage)
- Can do a Whipple's, pancreaticojejunostomy; drainage
- Endoscopic stenting
51
Complications of chronic pancreatitis?
```
Pseudocyst
DM
Pancreatic Ca
Pancreatic swelling --> biliary obstruction
Splenic vein thrombosis
```
52
Pancreatic Endocrine neoplasia types?
```
Insulinoma
Gastrinoma -.> Zollinger-Ellison
Glucagonoma
VIPoma
Somatostatinoma
```
53
What is an insulinoma?
- Fasting/exercise-induced hypoglycaemia
- Confusion, stupor, LOC
- Increased insulin + increased c-peptide + decreased glucose
54
Gastrinoma (ZE syndrome)
Hypergastrinaemia --> hyperchlorhydia --> PUD + chronic diarrhoea
55
Glucagonoma
Increased glucagon --> Mild DM
Characteristic blistering rash
- Necrolytic migratory erythema
56
VIPoma?
Watery diarrhoea
Hypokalaemai
- Achlorhydria
- Acidosis
57
Somatostatinoma
Somatostatin
- Inhibits glucagon + insulin release
- Inhibits pancreatic enzyme secretion
Features
- DM
- Steatorrhoea
- Gall stones
58
Cholangiocarcinoma patholgy?
Pathology
- Rare bile duct tumour
- Adenocarcinoma
- Typically occur @ confluence of right and left hepatic ducts: called Klatskin tumours.
59
Cholangiocarcinoma risk factors?
```
PSC
Ulcerative colitis
Choledocholithiasis (bile stones in duct)
Hep B/C
Choledochal cysts
Lynch 2
Flukes
```
60
Presentation of cholangiocarcinoma
Progressive painless obstructive jaundice
- Gallbladder not palpable
Steatorrhoea
Weight loss
61
Investigations of Cholangiocarcinoma ?
Cholestatic LFTs
| Ca 19-9
62
Management of cholangiocarcinoma ?
Poor prognosis: no curative management
| Palliative stenting by ERCP
63
Causes of Obstructive Jaundice?
```
- Causes
30% Stones
30% Ca head of the pancreas
30% -
LNs @portal hepatitis: TB, Ca
Inflammatory: PBC, PSC
Drugs: OCP, sulphonylureas, fluclox
Neoplastic: cholangiocarcinoma
Mirizzi's syndrome
```
64
Clinical features of obstructive jaundice?
- Noticeable @ ~50mM
Seen @tongue frenulum first
- Dark urine, pale stools.
- Itch (bile salts)
65
Investigations for obstructive jaundice?
Urine
- Dark
- Increased bilirubin
- Decreased urobilinogen
66
Bloods for obstructive jaundice?
- FBC: Increased WCC in cholangitis
- U+E: hepatorenal syndrome
- LFTs: increased cBR, increased ALP a lot, some increase in AST/ALT.
- Clotting: decreased vit K --> Increased INR
- G+S: may need ERCP
Immune: AMA, ANCA, ANA
67
Imaging for obstructive jaundice?
AXR
- May visualise stone
- Pneumobilia suggest gast forming infection
US
- Dilated ducts >6mm
- Stones (95% accurate)
- Tumours
MRCP or ERCP
Percutaneous Transhepatic Cholangiography
68
Management of the stones? Conservative
Monitor LFTs: passage of stones may --> resolution
Vitamin ADEK
Analgesia
Cholestyramine
69
Interventional management of stones?
Interventional
- If: no resolution, worsening LFTs or cholangitis
ERCP with sphincterotomy and stone extraction
Surgical
- Open/lap stone removal with T tube placement -
- T tube cholangiogram 8d later to confirm stone removal
- Delayed cholecystectomy to prevent recurrence
70
Ascending cholangitis?
May complicate CBD obstruction
- Charcot's triad: fever/rigors, RUQ pain, jaundice
- Reynold's pentad: Charcot's triad + shock + confusion
Management
- Cef and Met
1st: ERCP
2nd: open or lap stone removal with T tube drain
71
Risk factors for a pancreatic carcinoma?
```
Smoking
Inflammation: chronic pancreatitis
Nutrition: increased fat diet
EtOH
DM
```
72
Pathology of pancreatic carcinoma?
```
90% ductal adenocarcinoma
Present late, metastasis early
- Direct extension to local structure
- Lymphatics
- Bloods -- Liver and lungs
```
60% located in the head, 25% in body, 15% in tail
73
Presentation of pancreatic carcinoma?
- Typically male >60 yrs
- Painless obstructive jaundice: dark urine, pale stools.
- Epigastric pain: radiates to back, relieved sitting
- Anorexia, weight loss and malabsorption
- Acute pancreatitis
- Sudden onset DM in the elderly
74
Signs of pancreatic carcinoma?
- Palpable gallbladder
- Jaundice
- Epigastric mass
- Thrombophlebitis migrans (Trousseau Sign)
Splenomegaly: PV thrombosis --> Portal HTN
- Ascites
75
What is courvoisier's law?
IN the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to stones.
76
Investigations of pancreatic carcinoma?
Blood: Cholestatic LTFs, increased Ca19-9 (90%) ,increased 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
77
Management of pancreatic cancer?
Surgery
- Fit, not mets, tumour <3cm (<10% of patients)
- Whipple's pancreaticoduodenectomy
- DIstal pancreatectomy
- Post-op chemo delays progression
- 5yrs = 5-14%/
78
Palliation of pancreatic cancer?
Endoscopic/percutaneous stenting of CBD
Palliative bypass surgery
- Cholecystojejunostomy + gastrojejunostomy
- Pain relief - coeliac plexus block
