Hepatobilliary + Pancreas Flashcards
What is cholangiocarcinoma
Cancer of the bile ducts
What are the sings
Obstructive Jaundice - dark urine, pale stools, pruitis Pallapble gallbladder - non tender Painless Abdominal fullness or pain systemic symptoms - fever, malaise etc
what is courvosier’s law?
Courvoisier’s law states that in the presence of a palpably enlarged gallbladder which is non-tender and accompanied with mild painless jaundice, the cause is unlikely to be gallstones –> usually pancreatic carcinoma or colangiocarcinoma
Where can colangiocarcinoma occur and what one is more common
intrahepatic or extrahepatic ducts-
Extrahpeatic = 90%
what is cholangiocarcinoma associated w/
Chronic inflammation and cholestasis
Primary sclerosising cholagnitis
Choledochral cysts
What is the Rx for cholangiocacinoma
If intrahepatic - partial liver resection +/- protal vein embolisaion If distal (extrahepatic) - rescetion --> whipple's procedure (proximal pancreaticduodenectomy w/ choledocho or hepaticojejustomy) Repsonse to chemo is poor but can be used as adjunct Intracavity Brachytherapy (put radioactive source in patient) can help
What does a whipple’s procedure remove
What is joined together?
Distal stomach (except in pylrous preserving surgery)
Dudodenum
Head of Pancreas
Distal common bile duct
Gallbladder
rest of pancreas and jejunum, rest of bile duct and jejonum, rest of stomach and jejunum
what is dumping syndrome, what are the signs
Rapid gastric transit post abdo surgery
N+V, abdo pain and cramping, diarrhoea, post-prandial bloating, weakness, sweating, dizziness, flushing of face
What increases the risk of gallbladder hypomobility
Pregnancy
OCP
TPN
Fasting
What is the most common type of gallstone, and what are the other type
75% are mixed –> mainly cholesterol
20% are cholesteral –> large, usually solitary, more likely in females, OCP, pregnancy, high fat diet
5% are pigment stones –> associated w/ haemolysis
What is admirand’s triangle w/ relation to gallstones
Decreased bile salts, decresased lecitin and increased cholesterol caused increased chancxe of forming a cholesterol stone
What are complications of gallstones in the gallbladder
Biliary colic
Acute cholecystitis
Chronic cholsystitis
gallblader carcinoma –> calcification causes “procelain GB”
Muocele –> neck of gallbladder blocked, can become large, may become infected
Mirizzi’s syndrome –> large stone in Gb pressed on common hepatic duct causing obstructive jaundice –> can erode through
what are the complications of gallstones in the CBD
what about the gut?
Obstructive jaundice Pancreatitis Cholangitis (cholangitis = bile duct inflammation, cholecysitits = GB inflammation)
In the gut = gallstone illeus –> large stone erodes form GB to dudoenum through fistula (formed secondary to chronic inflammation) causing obstruction in distal ileum –> look for pneumobilia, small bowel obstruction and gallstone in RLQ [riggler’s triad]
if it gets stuck in duodenum instead of ileum = Bouveret’s syndrome
what is biliary colic and what are the signs
gallbladder spasming against a stone impacted in the neck of the gallbladder (hartman’s pouch)
Causes episodes of severe acute onset RUQ pain which is constant
Pain can radiate to scapula (back)
Attacks are precipiatated by fatty foods and last <6hr
Also get tenderness in right hypochondrium
may be associated w/ nausea and vomiting
what is the Ix for biliary colic
Urine - biloirubin, urobilogen, Hb
AXR - 10% gallstones are radiopaque
USS - look for stones, dilated ducts (>6mm) and inflammaed GB
If inflammed ducts - MRCP
If uncertain - HIDA cholescinitgraphy if liver works (GB doesn’t fill)
What is the Rx for biliary colic
Conservative - rehydrate, NBM, morphine
Surgery - urgent or elective (6-12w later) lap cholecystectomy
What is acute cholcystitis
Infeciton of the gallbladder
usuaully due to stone or sludge impaction in Hartman’s pouch causing chemical and/or bacterial inflammation
5% are acalous - no stone –> sepsis, burns, DM
What are the features of acute cholecystits
Severe RUQ pain –> continuous, radiating to right scapula and epigastrum
tachycardia and SOb
fever
vomiting
+/- jaundice
Murphy’s sign
Boas sign –> hyperaesthesia below right scapula
Might palpate phlegmon –> oedema of adherent omentum and bowel can be felt as a mass
Might get empyema –> high fever, RUQ mass, requires drainage (cholecystostomy)
What is Murphy’s sign, what condition does it relate to
place 2 fingers over GB and ask patient to breathe in –> feel pain and will catch breath
Must be negative on left
Seen in acute cholecystitis
What are the Ix for acute cholecystitis
USS - show stones, dilated ducts and inflammed GB
if see dilated ducts, need MRCP
FBC - raised WCC
U+E - show dehydration from vomiting
Amylase - rule out pancreatitis
HIDA chelscintigraphy if diagnosis unsure
What is the Rx for acute cholecystitis
Conservative - NBM, fluid resus, analgesia
Abx - usually cefuroxime and metronidazole but check local guidelines
80-90% settle over 24-48hrs
May require elective lap chole once inflammation has settled - 6-12 weeks later –> if <72h from onset, can perform in acute phase
If empyema, need percutaneous drainage - cholecstostomy
What are the symptoms, Ix and Rx for chronic cholecystitis
Vague upper GI discomfort, flatulence, dyspepsia, distension/bloating, nausea
Symptoms exacerbated by fatty foods (CCK stimulates GB)
AXR shows procelain GB (can see it on AXR)
US might show stones, fibrosis or a shrunken GB
Might need MRCP
Mx = elective cholecystectomy or ERCP if US shows dilated ducts + stones
what are the causes of obstructive jaundice
stones Ca head of pancreas LN @ porta hepatis (where ducts come out) - TB, Ca Inflammatory - PBC, PSC Drugs - OCP, sulphonyureas, fluclox Neoplastic - cholangiocarcinoma
what are the clinical features of obstructive jaundice
Jaundice - seen @ tongue frenulum first
Dark urine
Pale stools
Itchy
What is the Ix for obstructive jaundice
Urine test - dark, increased bilirubin, decreased urobilogen
LFTs - raised ALP, slightly less raised AST, increased, increased conugated bilirubin
Vit K is decreased - raised INR
Hepatorenal syndrome - raising Creatinine (no proteinuria)
Increased WCC if cholangitis
USS - dialted ducts, stone, tumours
MRCP or ERCP - Magnetic resonance/ Endoscopic retrograde cholangiopancreatography
Can do percutaneous transhepatic cholangiography
What is the Rx for stones in obstructive jaundice
Conservative - montior LFTs, vitamins ADEK, analgesia, Colestyramine (stop bile acid reabsoprtion)
Can do ERCP w/ sphincterotomy and stone extraction if worsening LFTs, no resolution or cholangitis
Surgical = open/lap stone removal with T tube placement (need to cholangiogram 8d later to ensure stone has come out)
Might need delayed cholecstectomy to prevent recurrence
What is ascending cholangitis
Inflammation of the bile ducts caused by CBD obstrction
What are the signs of ascending cholangitis
Charcot’s triad - fever/rigors, RUQ pain and jaundice
Reynold’s pentad = above + shock + confusion
What is Charcot’s triad, what condition is it linked w/
Charcot’s triad - fever/rigors, RUQ pain and jaundice
Ascending cholangitis
What is Reynold’s pentad, what condition is it linked w/
Reynold’s pentad = Fever/rigors + RUQ pain + jaundice + shock + confusion
Ascending cholangitis
what are the risk factors for pancreatic carcinoma (SINED)
Smoking Inflammation- chronic pancreatitis Nutrition - high fat diet ETOH DM
what are the most common type and location of pancreatic ca
90% ductal adenocarcinomas
60% in head
what are the symptoms and signs of pancreatic Ca
Male >60
Painless obstructive jaundice - dark urine pale stool
might have epigastric pain –> radiates to back, relived sitting forwards
Anorexia, wt loss, malabsorption
Actue pancreatitis,
Sudden onset DM
Palpable GB
Epigastric mass
Thrombophlebitis migrant (Trousseau sign) –> phlebitis caused by thrombus in different areas
Splenomegaly, ascitites (PV thrombus)
what tumour marker is used for pancreatic cancer
Ca19-9
What Ix is required for pancreatic ca
USS/ EUS (Endoscopic USS, which is better for staging than CT/MRI) Might need CXR, laparoscopy for mets ERCP Raised Calcium LFTs
What is the Rx for pancreatic cancer
If fit, no mets and tumour less than 3cm, can have Whipple’s procedure or distal pancreatectomy + chemo
if not fit for surgery –> stenting of CBD, palliative bypass surgery (cholecysrtojujostomy + gastrojujostomy).
Need pain relief = might need coeliac plexus block
mean survival <6m
what is I GET SMASHED an acronym for
Acute pancreatitis
What are the causes of acute pancreatitis (I GET SMASHED)
Idiopathic Gallstones Ethanol Trauma Steroids Mumps/Malignancy Autoimmune (e.g PAN) Scorpion bite Hyperlipiademia ERCP Drugs (thiazides, azathioprine, valproate)
What are the signs and symptoms of acute pancreatitis
Severe epigastric pain, radiating to back, relieved by sitting forwards
Vomiting
Increased HR and RR
Shock
Fever
Epigastric tenderness
Jaundice
Ileus (failure of peristalsis) = absent bowel sounds
Ecchymoses - Grey Turner (flank), Cullens (periumbilical)
What is the modified Glasgow criteria used for in acute pancreatitis, and what does it contain?
Valid for ETOh and gallstones Used to assess severity and predict mortality PaO2 <8 Age >55 Neutrophils >15 Ca <2 Renal function (urea >16) Enzymes LDH >600, AST >200 ALbumin <32 Sugar >10
