Hepatobilliary Flashcards
1
Q
RF for Mixed/cholesterol gallstone calculi
2
A
FmHx Obesity DM Ileal resection Sudden weight loss F
2
Q
RF for Pure pigment gallstones
2
A
Asian
Haemolytic diorder
3
Q
Function of gallbladder
A
Storage and concentration of bile
4
Q
Explain the release of bile
A
Fatty food in duo
Stimulates CCK release
CCK stimulates gallbladder contraction
Bile released into the duodenum
5
Q
Function of bile
2
A
Lipid emulsification
Fat soluble vitamin absorption (A,D,E,K)
6
Q
Relationship between Gallstones and coagulation disorders
A
Decreased Vit K absorption as it is a fat soluble vitamin
So.. Decreased prothrombin synthesis
Increased risk of bleeding
Increased PT
7
Q
Formation of gallstones
A
- Lithogenic bile is formed (sand)
- There is stasis
- The sand clumps together and forms a Nidus (microscopic stone)
- Nidus grows by lamination (macroscopic)
8
Q
Causes of gallstone formation
3
A
- Change in bile composition
- Less bile salts (in terminal ileum disease) results in excess cholesterol - Biliary stasis
- Infection
9
Q
Are gallstones seen on XR?
A
- 90% radiolucent (unseen)
- 10% radio-opaque
10
Q
Biliary Colic symptoms
A
S: Epigastric pain O: After fatty meals C: Colicky R: RUQ A: Mucocoele, Nausea, Vomiting T: Episodic, Lasts <24hrs E: Fatty food S: Secere
11
Q
Cause of biliary colic
A
Intermittent blockage of the Cystic duct /CBD by a gallstone
12
Q
Define Cholecystitis
A
Infalmmation of the gallbladder
Because the cystic duct is completely obstructed
13
Q
Cause of cholecystitis
A
- Gallstone blocks cystic duct
- Result = bile stasis in gallbladder
- Result
= Physical/chemical irritation
= Bacterial infection: Ascending cholangitis - Result = Inflammation of gallbladder
14
Q
Sx of cholecystitis
A
S: RUQ (localised) O: May be fatty food ingestion C: R: A: FEVER, SIRS, SEPSIS, vomiting, nausea T: Unrelenting E: S: 10
15
Q
Signs of cholecystitis
4
A
- Localised RUQ tenderness
- RUQ Mass
- Murphy’s sign (Pain worse on insp)
- Fever
16
Q
Complications of cholecystitis
3
A
Empyema
Perforation
Gallstone Ileus
17
Q
Cause of choledocholithiasis
A
Gallstones in CBD
18
Q
Main symptoms of choledocholithiasis
A
Jaundice
May be asymptomatic
19
Q
General sx of gallstones
6
A
- Pale stools (Steathorroea)
- Dark Urine
- Jaundice
- RUQ/Epigastric pain
- Nausea/vomiting (especially after fatty meals)
- +/- Fever
20
Q
Complications of Choledocholithiasis
A
Ascending cholangitis
21
Q
Diagnostic criteria for Pancreatitis
A
Serum amylase x3 upper limit of normal
22
Q
Cause of gallstone pancreatitis
A
Gallstones or sludge block pancreatic duct
Pancreatic enzymes can’t get out
Results in inflammation of pancreas
23
Q
Cause of gallstone Ileus
A
Gallstone erodes into SI via Cholecystduodenal fistula and travels to terminal ileum
24
Q
Complications of gallstone ileus
A
- SI obstruction
25
Signs of Gallstone Ileus on AXR
2
SI distended with gas
Radio-opaque lesion in RIF
26
Ix Gallstones
1. Bloods:
- FBC: CRP, WCC
- LFT: T.Billi, ALP+GGT (obstruction), Amylase
- Cultures
2. Urinary
- Urinary Bilirubin
3. USS
4. MRCP
27
Advantages, disadvantages USS
Can see gallbladder stones
Can’t see CBD stones
But can see CBD dilatation proximal to stone
28
Conservative Management of Gallstones
- Ursodeoxycholic acid
29
Indication for Ursodeoxycholic acid
Multiple small cholesterol stones
30
Surgical management of Gallstones
ERCP:
- Bile duct exploration
- Sphincterotomy (stone removal) is needed
Cholecystectomy:
- Lap or Open (prevent further episodes)
31
Open Cholecystectomy Incision
Kocher’s Subcostal Incision
RUQ
32
Complications of Cholecystectomy
4
- CBD injury
- Bowel Herniation
- Haemorrhage
- Infection
33
Icterus
Jaundice
34
Define jaundice
Yellow discolouration of the skin, sclera and mucus membranes due to excess plasma bilirubin
35
Normal range of plasma bilirubin
5-17 mmol/l
36
What bilirubin level does jaundice start?
>30 mmol/l (probs 35)
37
Causes of pre hepatic jaundice
5
Haematoma resorption
Haemolytic anaemia
Hereditary Spherocytosis
Sickle cell anaemia
Thalassaemia
38
Causes of hepatic jaundice
4
Cirrhosis
Hepatitis
PBC
Liver ca
39
causes of post hepatic jaundice
2
Gallstones
tumour of head of pancreas
40
Infectious diseases that cause jaundice
2
Hepatitis
Malaria
41
HPC Jaundice
Onset, Duration, progression
```
Pain (RUQ/Epigastrium)
Pruritus
Dark Urine
Pale stools
Weight loss
Fatigue
```
42
PmHx Jaundice
Previous epidodes
Gallstones , PBC
Pancreatitis/ ca
Liver ca, hepatitis, cirrhosis
Blood transfusion, anaemia, sickle cell, thalassaemia, sperocytosis, haemolysis, recent trauma (haematoma)
Malaria
43
Social Hx jaundice
Drug Hx
```
Alcohol
IV Drug
Travel (Hep/Malaria)
Contacts with Hep carriers
Sewage worker (hepatotoxic chemicals)
```
Hepatotoxic drugs
44
Dx this:
Sudden onset painful jaundice
Gallstones
45
Dx this:
Slow onset of painless jaundice +/- weight loss, anorexia
Pancreatic Ca
46
DDx pale stool + dark urine + Jaundice
2
Obstructive Jaundice
Viral Hepatitis
47
Examination findings liver disease
8
```
Jaundice skin/sclera
Scratch marks
Spider nevai
Testicular atrophy
Gynaechomastia
Liver flap
Ascites
Hepatomegaly
```
48
Urinary bilirubin and urinary urobilogen results in
Haemolytic jaundice
Normal urinary bilirubin
Raised Urinary urobillogen
49
Urinary bilirubin and urinary urobilogen results in
Liver failure
Normal/Raised Urinary Bilirubin
Normal/Raised Urinary urobillogen
50
Urinary bilirubin and urinary urobilogen results in
Obstructive Jaundice
Raised Urinary Bilirubin
Low/absent Urinary Urobillogen
51
What is urinary billogen sensitive for?
3
Liver damage (hepatitis, toxic injury)
Haemolytic anaemia
Severe infections
52
DDx Raised unconjugated Bilirubin
3
Gilbert’s syndrome
Haemolysis
Chronic hepatitis
53
Blood results suggesting haemolysis
4
Raised unconjugated bilirubin
Raised reticulocyte count
Raised Urinary Urobillogen
Low Serum Hp
54
DDx Raised conjugated bilirubin
3
Obstructive jaundice
Liver disease
Dubin Johnston syndrome
55
Factors that give artificial bilirubin result
2
Light exposure decreases bilirubin
Shaking elevates bilirubin levels
56
DDx raised ALP
5
```
Gallstones
Pancreatic ca
Pregnancy
Drugs
PBC
```
57
Raised ALP and GGT
Cholestasis (obstruction)
58
Raised GGT and Raised MCV
Alcohol abuse
59
Raised GGT
Raised MCV
Raised ALT
Liver cell damage
60
Very high GGT
2
Biliary obstruction
Hepatic ca
61
AST > ALT
4
Cirrhosis
Intrahepatic neoplasia
Haemolytic Jaundice
Alcoholic hepatitis
62
ALT>AST
2
Acute Hepatitis
Extrahepatic obstruction
63
Blood Ix PBC
3
AMA
ANA
ANCA
64
DDx increased IgG in setting of hepatobiliary disease
Autoimmune hepatits
65
DDx increased IgM in setting of hepatobiliary disease
2
PBC
| Chronic infection
66
Initial management of acutely jaundiced patient
4
IVF
Check for sepsis
PT (give Vit K if necessary)
Stop hepatotoxic drugs
67
Causes of pancreatitis
GET SMASHED
1. Gallstones
2. Alcohol
3. Idiopathic
```
G= Gallstones
E= Ethanol
T= Trauma
```
```
S= Steroids
M= Mumps
A= Autoimmune disease
S= Scorpion venom
H= Hypercalcaemia, Hyperlipidaemia, Hereditary, Hypothermia
E= ERCP
D= Drugs (thiazide)
```
Other:
- Coxsackie virus
- Anorexia, Bulimia, Malnutrition
68
Sx Pancreatitis
Pain
```
S= Epigastrium
O=
C=
R= Towards back
A= Nausea, Vomiting
T=
E= Relieved by leaning forward
S= Severe
```
69
Signs of pancreatitis
4
Epigastric tenderness and rebound tenderness
Shallow breathing (increase pain on deep inspiration)
Grey-Turner’s Sign: Flank bruising
Cullen’s Sign: Peri-umbilical bruising
70
How to Dx Pancreatitis
Hx , Examination
Serum amylase or lipase (x3 normal)
CT scan
- If severe
- If amylase/lipase not at peak but still suspect pancreatitis
71
DDx Pancreatitis
7
```
Peptic Ulcer
Cholecystitis/Choledocholithiasis
Viral Hepatitis
Appendicitis
Mesenteric ischaemia
Peritonitis
MI
```
72
How is severity of pancreatitis graded?
4
Glasgow (Imrie) Score
Ranson (New York) System
CRP
APACHE2
73
Explain Glasgow score
```
P = PaO2 <8kPa
A = Age > 55
N = Neutrophilia WCC>15
C = Ca2+ <2
R = Renal Function >Urea
E = Enzymes AST >100 and LDH >600
A = Albumin >32
S = Sugar >10
```
3 or more = severe pancreatitis
74
Management of Acute Pancreatitis
Initial:
- Analgesia
- IVF
- Anti-emetic
- NBM
- NG tube
Mild= Rx cause
Severe:
- Refer to ICU/HDU
- Rx complications
75
When is glasgow / ranson scores most sensitive?
48hrs later
76
How is CRP used to grade pancreatitis severity?
Severe=
- >210 in first 4d
- >120 by end of first week
77
Management of gallstone pancreatitis
USS
MRCP
Lap chole +/- ERCP within 2-4 w
78
Explain severe acute pancreatitis
SIRS
leading to
Multi-organ failure
79
Order in which organ systems fail
1. Pulmonary
2. cardiac
3. Urinary
4. Liver
80
Explain Balthazar score
Used to determine how much pancreatic necrosis is present
on contrast enhanced CT
White area = no necrosis
Black area = necrosis
81
Complications of acute pancreatitis
7
```
Pseudocyst
Necrosis
Abscess
Exocrine insufficiency (Steatorrhoea)
Endocrine insufficiency (DM)
Chronic
MODS
```
82
What is a pancreatic pseudocyst?
Collection of fluid in lesser sac (behind stomach)
Inflammatory exudate + necrosis etc
83
Signs of pancreatic pseudocyst
3
Abdo pain
Delayed gastric emptying
Palpable mass
84
Management pancreatic pseudocyst
Drain it into stomach
Cystgastrostomy
85
Management of pancreatic necrosis
2
Minimally invasive resection of pancreas (MIRP)
- Via endoscope
+/-
Necrosectomy
- Open surgical debridement
86
What bloods would be suggestive of Alcohol as cause of pancreatitis?
Raised GGT and MCV
87
Complications of chronic pancreatitis
5
Fibrosis, stricturing and dilation of pancreatic duct
Pseudocyst formation
Pancreatic ca
88
cause of chronic pancreatitis
Alcohol
89
Radiological signs of chronic pancreatitis
Calcification
90
Management of exocrine insufficiency caused by pancreatitis
Creon (oral enzyme supplementation)
