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General Surgery (Year 3) > Hepatobilliary > Flashcards

Hepatobilliary Flashcards

1
Q

RF for Mixed/cholesterol gallstone calculi

2

A 
FmHx
Obesity
DM
Ileal resection
Sudden weight loss
F
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2
Q

RF for Pure pigment gallstones

2

A

Asian

Haemolytic diorder

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3
Q

Function of gallbladder

A

Storage and concentration of bile

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4
Q

Explain the release of bile

A

Fatty food in duo

Stimulates CCK release

CCK stimulates gallbladder contraction

Bile released into the duodenum

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5
Q

Function of bile

2

A

Lipid emulsification

Fat soluble vitamin absorption (A,D,E,K)

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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

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7
Q

Formation of gallstones

A
  1. Lithogenic bile is formed (sand)
  2. There is stasis
  3. The sand clumps together and forms a Nidus (microscopic stone)
  4. Nidus grows by lamination (macroscopic)
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8
Q

Causes of gallstone formation

3

A
  1. Change in bile composition
    - Less bile salts (in terminal ileum disease) results in excess cholesterol
  2. Biliary stasis
  3. Infection
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9
Q

Are gallstones seen on XR?

A
  • 90% radiolucent (unseen)

- 10% radio-opaque

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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
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11
Q

Cause of biliary colic

A

Intermittent blockage of the Cystic duct /CBD by a gallstone

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12
Q

Define Cholecystitis

A

Infalmmation of the gallbladder

Because the cystic duct is completely obstructed

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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
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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
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15
Q

Signs of cholecystitis

4

A
  • Localised RUQ tenderness
  • RUQ Mass
  • Murphy’s sign (Pain worse on insp)
  • Fever
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16
Q

Complications of cholecystitis

3

A

Empyema

Perforation

Gallstone Ileus

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17
Q

Cause of choledocholithiasis

A

Gallstones in CBD

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18
Q

Main symptoms of choledocholithiasis

A

Jaundice

May be asymptomatic

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19
Q

General sx of gallstones

6

A
  • Pale stools (Steathorroea)
  • Dark Urine
  • Jaundice
  • RUQ/Epigastric pain
  • Nausea/vomiting (especially after fatty meals)
  • +/- Fever
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20
Q

Complications of Choledocholithiasis

A

Ascending cholangitis

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21
Q

Diagnostic criteria for Pancreatitis

A

Serum amylase x3 upper limit of normal

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22
Q

Cause of gallstone pancreatitis

A

Gallstones or sludge block pancreatic duct

Pancreatic enzymes can’t get out

Results in inflammation of pancreas

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23
Q

Cause of gallstone Ileus

A

Gallstone erodes into SI via Cholecystduodenal fistula and travels to terminal ileum

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24
Q

Complications of gallstone ileus

A
  • SI obstruction
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25
Q

Signs of Gallstone Ileus on AXR

2

A

SI distended with gas

Radio-opaque lesion in RIF

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26
Q

Ix Gallstones

A
  1. Bloods:
    - FBC: CRP, WCC
    - LFT: T.Billi, ALP+GGT (obstruction), Amylase
    - Cultures
  2. Urinary
    - Urinary Bilirubin
  3. USS
  4. MRCP
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27
Q

Advantages, disadvantages USS

A

Can see gallbladder stones

Can’t see CBD stones

But can see CBD dilatation proximal to stone

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28
Q

Conservative Management of Gallstones

A
  • Ursodeoxycholic acid
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29
Q

Indication for Ursodeoxycholic acid

A

Multiple small cholesterol stones

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30
Q

Surgical management of Gallstones

A

ERCP:

  • Bile duct exploration
  • Sphincterotomy (stone removal) is needed

Cholecystectomy:
- Lap or Open (prevent further episodes)

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31
Q

Open Cholecystectomy Incision

A

Kocher’s Subcostal Incision

RUQ

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32
Q

Complications of Cholecystectomy

4

A
  • CBD injury
  • Bowel Herniation
  • Haemorrhage
  • Infection
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33
Q

Icterus

A

Jaundice

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34
Q

Define jaundice

A

Yellow discolouration of the skin, sclera and mucus membranes due to excess plasma bilirubin

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35
Q

Normal range of plasma bilirubin

A

5-17 mmol/l

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36
Q

What bilirubin level does jaundice start?

A

> 30 mmol/l (probs 35)

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37
Q

Causes of pre hepatic jaundice

5

A

Haematoma resorption

Haemolytic anaemia

Hereditary Spherocytosis

Sickle cell anaemia

Thalassaemia

38
Q

Causes of hepatic jaundice

4

A

Cirrhosis

Hepatitis

PBC

Liver ca

39
Q

causes of post hepatic jaundice

2

A

Gallstones

tumour of head of pancreas

40
Q

Infectious diseases that cause jaundice

2

A

Hepatitis

Malaria

41
Q

HPC Jaundice

A

Onset, Duration, progression

Pain (RUQ/Epigastrium)
Pruritus
Dark Urine
Pale stools
Weight loss
Fatigue
42
Q

PmHx Jaundice

A

Previous epidodes

Gallstones , PBC

Pancreatitis/ ca

Liver ca, hepatitis, cirrhosis

Blood transfusion, anaemia, sickle cell, thalassaemia, sperocytosis, haemolysis, recent trauma (haematoma)

Malaria

43
Q

Social Hx jaundice

Drug Hx

A 
Alcohol
IV Drug
Travel (Hep/Malaria)
Contacts with Hep carriers
Sewage worker (hepatotoxic chemicals)

Hepatotoxic drugs

44
Q

Dx this:

Sudden onset painful jaundice

A

Gallstones

45
Q

Dx this:

Slow onset of painless jaundice +/- weight loss, anorexia

A

Pancreatic Ca

46
Q

DDx pale stool + dark urine + Jaundice

2

A

Obstructive Jaundice

Viral Hepatitis

47
Q

Examination findings liver disease

8

A 
Jaundice skin/sclera
Scratch marks
Spider nevai 
Testicular atrophy
Gynaechomastia
Liver flap
Ascites
Hepatomegaly
48
Q

Urinary bilirubin and urinary urobilogen results in

Haemolytic jaundice

A

Normal urinary bilirubin

Raised Urinary urobillogen

49
Q

Urinary bilirubin and urinary urobilogen results in

Liver failure

A

Normal/Raised Urinary Bilirubin

Normal/Raised Urinary urobillogen

50
Q

Urinary bilirubin and urinary urobilogen results in

Obstructive Jaundice

A

Raised Urinary Bilirubin

Low/absent Urinary Urobillogen

51
Q

What is urinary billogen sensitive for?

3

A

Liver damage (hepatitis, toxic injury)

Haemolytic anaemia

Severe infections

52
Q

DDx Raised unconjugated Bilirubin

3

A

Gilbert’s syndrome

Haemolysis

Chronic hepatitis

53
Q

Blood results suggesting haemolysis

4

A

Raised unconjugated bilirubin

Raised reticulocyte count

Raised Urinary Urobillogen

Low Serum Hp

54
Q

DDx Raised conjugated bilirubin

3

A

Obstructive jaundice

Liver disease

Dubin Johnston syndrome

55
Q

Factors that give artificial bilirubin result

2

A

Light exposure decreases bilirubin

Shaking elevates bilirubin levels

56
Q

DDx raised ALP

5

A 
Gallstones 
Pancreatic ca
Pregnancy
Drugs
PBC
57
Q

Raised ALP and GGT

A

Cholestasis (obstruction)

58
Q

Raised GGT and Raised MCV

A

Alcohol abuse

59
Q

Raised GGT

Raised MCV

Raised ALT

A

Liver cell damage

60
Q

Very high GGT

2

A

Biliary obstruction

Hepatic ca

61
Q

AST > ALT

4

A

Cirrhosis

Intrahepatic neoplasia

Haemolytic Jaundice

Alcoholic hepatitis

62
Q

ALT>AST

2

A

Acute Hepatitis

Extrahepatic obstruction

63
Q

Blood Ix PBC

3

A

AMA
ANA
ANCA

64
Q

DDx increased IgG in setting of hepatobiliary disease

A

Autoimmune hepatits

65
Q

DDx increased IgM in setting of hepatobiliary disease

2

A

PBC

Chronic infection

66
Q

Initial management of acutely jaundiced patient

4

A

IVF
Check for sepsis
PT (give Vit K if necessary)
Stop hepatotoxic drugs

67
Q

Causes of pancreatitis

A

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
Q

Sx Pancreatitis

A

Pain

S= Epigastrium
O=
C= 
R= Towards back
A= Nausea, Vomiting
T= 
E= Relieved by leaning forward
S= Severe
69
Q

Signs of pancreatitis

4

A

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
Q

How to Dx Pancreatitis

A

Hx , Examination

Serum amylase or lipase (x3 normal)

CT scan

  • If severe
  • If amylase/lipase not at peak but still suspect pancreatitis
71
Q

DDx Pancreatitis

7

A 
Peptic Ulcer
Cholecystitis/Choledocholithiasis
Viral Hepatitis
Appendicitis
Mesenteric ischaemia
Peritonitis
MI
72
Q

How is severity of pancreatitis graded?

4

A

Glasgow (Imrie) Score
Ranson (New York) System

CRP

APACHE2

73
Q

Explain Glasgow score

A 
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
Q

Management of Acute Pancreatitis

A

Initial:

  • Analgesia
  • IVF
  • Anti-emetic
  • NBM
  • NG tube

Mild= Rx cause

Severe:

  • Refer to ICU/HDU
  • Rx complications
75
Q

When is glasgow / ranson scores most sensitive?

A

48hrs later

76
Q

How is CRP used to grade pancreatitis severity?

A

Severe=

  • > 210 in first 4d
  • > 120 by end of first week
77
Q

Management of gallstone pancreatitis

A

USS
MRCP

Lap chole +/- ERCP within 2-4 w

78
Q

Explain severe acute pancreatitis

A

SIRS

leading to

Multi-organ failure

79
Q

Order in which organ systems fail

A
  1. Pulmonary
  2. cardiac
  3. Urinary
  4. Liver
80
Q

Explain Balthazar score

A

Used to determine how much pancreatic necrosis is present

on contrast enhanced CT

White area = no necrosis
Black area = necrosis

81
Q

Complications of acute pancreatitis

7

A 
Pseudocyst
Necrosis
Abscess
Exocrine insufficiency (Steatorrhoea)
Endocrine insufficiency (DM)
Chronic
MODS
82
Q

What is a pancreatic pseudocyst?

A

Collection of fluid in lesser sac (behind stomach)

Inflammatory exudate + necrosis etc

83
Q

Signs of pancreatic pseudocyst

3

A

Abdo pain
Delayed gastric emptying
Palpable mass

84
Q

Management pancreatic pseudocyst

A

Drain it into stomach

Cystgastrostomy

85
Q

Management of pancreatic necrosis

2

A

Minimally invasive resection of pancreas (MIRP)
- Via endoscope

+/-

Necrosectomy
- Open surgical debridement

86
Q

What bloods would be suggestive of Alcohol as cause of pancreatitis?

A

Raised GGT and MCV

87
Q

Complications of chronic pancreatitis

5

A

Fibrosis, stricturing and dilation of pancreatic duct

Pseudocyst formation

Pancreatic ca

88
Q

cause of chronic pancreatitis

A

Alcohol

89
Q

Radiological signs of chronic pancreatitis

A

Calcification

90
Q

Management of exocrine insufficiency caused by pancreatitis

A

Creon (oral enzyme supplementation)

General Surgery (Year 3) (1 decks)

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