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Surgery Revision > HepatoBilliary Surgery > Flashcards

HepatoBilliary Surgery Flashcards

1
Q

Definition of acute pancreatitis

A

An acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems

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2
Q

Etiology of acute pancreatitis

A
  • alcohol
  • gallstones
  • idiopathic
  • obstructive
  • metabolic
  • drugs
  • trauma
  • viral infection
  • pregnancy
  • collagen disease
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3
Q

Pathogenesis of acute pancreatities

A
  • inappropriate activation of trypsinogen to trypsin
  • breaks down tissue
  • triggers SIRS
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4
Q

2 pathological types of acute pancreatitis

A
  • acute interstitial oedematous pancreatitis (mild)

- acute necrotising pancreatitis (severe)

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5
Q

Local complications of acute pancreatitis

A
  • acute pancreatic fluid collection
  • pancreatic psuedocyst
  • acute necrotic collection
  • walled-off necrosis
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6
Q

Other organ complications of acute pancreatitis

A
  • gastric outlet obstruction
  • splenic/portal vein thrombosis
  • intestinal necrosis
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7
Q

Diagnosis of acute pancreatitis

A

2 of the following:

  • abdominal pain
  • serum lipase/amylase >3x normal
  • characteristic findings on CT/MRI
  • N+V
  • Cullen’s/ Grey-Turner
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8
Q

Definition of SIRS

A

2 or more of:

  • HR>90
  • temp <36 or >38
  • WCC <4000 or >12000
  • resp >20 or pCO2 <32

Increased risk of organ failure

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9
Q

Definition of organ failure

A

Score of 2 or more for 1 of the organ systems using the modified Marshall scoring system
(renal, resp, CVS)

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10
Q

Grading the severity of acute pancreatitis

A
  • mild acute pancreatitis (MAP)
  • moderate severe acute pancreatitis (MSAP)
  • severe acute pancreatitis (SAP)
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11
Q

Management of gallstone pancreatitits

A
  • initial conservative management
  • elective cholecystectomy 4 weeks later
  • if jaundiced, do ERCP
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12
Q

How to recognise SAP

A
  • haemodynamic instability
  • hypoxic confusion
  • pleural effusion + pulm infiltrates on CXRAY
  • SIRS response
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13
Q

Why do patients with SAP need ICU admission?

A
  • resus for hypovolaemic shock
  • may need ventilation
  • metabolic management
  • enteral nutrition
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14
Q

Scoring systems for SAP

A
  • CRP

- Ranson’s

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15
Q

Definition of chronic pancreatitis

A

A continuing inflammatory disease of the pancrease characterised by irreversible morphologic changes

  • assoc with pain and loss of exo/endocrine function
  • involves parenchyma and ductal system
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16
Q

Etiology of chronic pancreatitis

A
  • alcohol
  • nutritional
  • CF
  • hereditary
  • idiopathic
  • AI
  • obstructive
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17
Q

Pathogenesis of pain in chronic pancreatitis

A
  • inflammatory processes lead to fibrosis and ductal dilatation
  • damaged neural structures
  • oxygen free radicals
  • compartment syndrome
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18
Q

Complications of chronic pancreatitis

A
  • diabetes
  • fat malabsorption
  • pseudocyts
  • pancreatic ascites
  • false aneurysm
  • splenic vein thrombosis - portal HPT
  • biliary/ duodenal stenosis/ obstruction
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19
Q

2 clinical patterns of chronic pancreatitis

A
  • intermittent mild attacks

- progressive, severe and persistent

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20
Q

How to test pancreatic function

A
  • direct

- indirect = faecal elastase

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21
Q

Step-up pain management regime for chronic pancreatitis

A
  • abstinence with low fat diet
  • paracetamol/NSAIDS
  • trial of high dose pancreatic enzymes with acid support
  • narcotics
  • anti-depressants
  • percutaneous coeliac plexus block
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22
Q

Drainage procedures for chronic pancreatitis

A
  • pancreatico-jujenostomy

- Frey procedure

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23
Q

Types of glass stones

A
  • chol
  • BR
  • calciums salts
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24
Q

Causes of black pigment stones

A

Haemolytic conditions

Liver cirrhosis

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25
Q

Cause of brown pigment stones

A

Worm infestation

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26
Q

Constituents of bile

A
  • Chol
  • bile salts
  • phospholipids
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27
Q

Calot’s triangle

A
  • cystic duct inf
  • common hepatic duct med
  • cystic artery sup
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28
Q

Lymph node in the middle of Calot’s triangle

A
  • Mascagni/ Lund
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29
Q

Surgical objectives of cholecystectomy

A
  • eliminate gallbladder
  • eliminate gallstones
  • exclude stones in biliary tree
  • ensure bile ducts aren’t damaged
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30
Q

Medical treatment of gallstones

A
  • medical dissolution therapy
  • contact dissolution therapy
  • extracorporeal shockwave lithotripsy
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31
Q

Definition of acute cholecystitis

A

A gallstone becomes impacted in cystic duct/ Hartman’s pouch

- leads to inflammation and infection of gallbladder wall

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32
Q

Symptoms of acute cholecystitis

A
  • severe pain
  • nausea and vomiting
  • pyrexia and Murphy’s sign
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33
Q

Things found on US in cholecystitis

A
  • stone
  • thickwalled gallbladder
  • radiological Murphys
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34
Q

Natural history of cholecystitis

A
  • stone impacts leading to fibrosis
  • asbscess forms (empyema)
  • perforation
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35
Q

Definition of choledocholithiasis

A

Stones in the CBD

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36
Q

Symptoms of cholangitis (Charcot’s triad)

A
  • biliary colic
  • jaundice
  • fever/rigors
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37
Q

Courvasier’s Law

A

Painless obstructive jaundice and a palpable gallbladder cannot be due to gallstones

38
Q

Structure of the pancreas

A
  • acini = enzymes
  • ducts = transport enzymes
  • Islet’s of Langerhans = endocrine cells
39
Q

Most common type of pancreatic neoplasm

A

Pancreatic ductal adenocarcinoma

40
Q

Risk factors for pancreatic ductal adenocarcinoma

A
  • predisposing cancer syndrome
  • smoking
  • chronic pancreatitis
  • DM + obesity
41
Q

Cancer syndromes that predispose to pancreatic cancer

A
  • HNPCC
  • BRCA2
  • PAP
  • Peutz-Jager
42
Q

Clinical presentation of pancreatic cancer

A
  • painless obstructive jaundice
  • upper abdo pain that rad to back
  • weight loss
  • late onset diabetes
  • gastric outlet obstruction
  • ascites
  • abdo mass
  • thrombophlebitis migrans (Trousseu’s syndrome)
  • dyspepsia
43
Q

Examination findings in pancreatic cancer

A
  • temp wasting
  • skin excoriation
  • Virchow’s node
  • Sister mary Joseph nodule
44
Q

Best radiological investigation for pancreatic cancer

A

CT scan

45
Q

Contraindications for pancreatic resection

A
  • mets
  • lymph node involvement
  • major vessel involvement
  • co-morbid disease
46
Q

Resection operations for pancreatic cancer

A
  • Whipples
  • distal pancreatectomy
  • pancreaticoduodenectomy
47
Q

Types of pancreatic neuroendocrine tumours

A
  • insulinomas
  • gastrinomas
  • glucagonoma
48
Q

What is Whipple’s triad?

A
  • symptoms of hypoglycaemia
  • glucose <5
  • relief of hypoglycaemia with glucose
49
Q

Symptoms of insulinoma

A
  • anxiety, confusion, LOC
  • Weight gain
  • often confused with psych
50
Q

Management of an insulinoma

A
  • resection (cherry-red mass)

- enucleation

51
Q

Where are gastrinomas found?

A

The gastrinoma triangle

52
Q

The gastrinoma triangle

A

Sup: confluence of cystic and CBD
Inf: junction of 2nd and 3rd parts of dudenum
Med: junction of neck and body of pancreas

53
Q

Symptoms of a gastrinoma

A
  • fulminant PUD (Zollinger Ellison)
  • epigastric pain
  • diarrhoea that resolves with PPIs
54
Q

Symptoms of a glucogonoma

A
  • cachexia
  • malnutrition
  • protein depletion
  • rash (necrolytic migratpry erythema)
  • glucose intolerance
  • DVT
55
Q

Cystic neoplasms of the pancrease

A
  • serous cystic neoplasms
  • mucinous cystic neoplasms
  • Intraductal papillary mucinous neoplasms
  • solid pseudopapillary tumor
56
Q

Causes of portal hypertension

A
  • prehepatic
  • hepatic
  • post-hepatic
57
Q

Pharmacological management of acute oesophageal variceal bleeding

A
  • vasopressin
  • somatostatin
  • octreotide
58
Q

Endoscopic management of oesophageal varices

A
  • band ligation

- injection sclerotherapy

59
Q

Management of oesophageal variceal bleeding

A
  • pharmacologicla
  • endoscopic
  • balloon tamponade
  • TIPS
  • surgical (shunts/ surgical transection)
60
Q

What does TIPS stand for?

A

Transjugular intrahepatic portosystemic shunt

61
Q

How to score prognosis for chronic liver disease

A

Child-Pugh score

62
Q

Components of Child Pugh score

A
  • MR
  • albumin
  • prothrombin time
  • Ascites
  • encephalopathy
63
Q

Long-term management to prevent variceal bleeding

A
  • endoscopic
  • pharmacotherapy
  • surgery
  • liver transplant
64
Q

Causes of ascites

A
  • portal HPT
  • hypoalbuminaemia
  • neoplasms
  • misc.
65
Q

Treatment of ascites

A
  • reduce salt intake
  • diuretics
  • abstain from alcohol
  • paracentesis
66
Q

Features of hepatic encephalopathy

A
  • monotonous speech
  • flat affect
  • tremor
  • muscular incoord
  • asterixis
  • fetor hepaticus
  • coma
  • upgoing plantars
  • deranged reflexes
  • decerebrate posturing
67
Q

Events that precipitate encephalopathy in cirrhotic patients

A
  • electrolyte imbalance
  • GI bleeding
  • drugs
  • infection
  • constipation
68
Q

Treatment of hepatic encephalopathy

A
  • treat precipitating factors
  • non-absorbable disaccharides (lactulose)
  • antibiotics
  • protein restriction
69
Q

What is hepatorenal syndrom

A

Acute oliguric renal failure in cirrhotic liver disease resulting from intense intrarenal vasoconstruction in otherwise normal kidneys

70
Q

What is SBP?

A

Infection of ascites in the absence of a local infectious source

  • usually in cirrhotic ascites
  • gram neg enteric bacteria
71
Q

MELD (model for End-stange liver disease

A
  • BR
  • INR
  • creat
72
Q

Objectives of assessing a liver mass

A
  • establish a diagnosis
  • determine whether surgery is indicated
  • judge whether resection is possible
73
Q

Symptoms of a pyogenic liver abscess

A
  • abdo pain
  • swinging pyrexia
  • nocturnal sweating
  • vomiting
  • anorexia
  • malaise
74
Q

Antibiotics for pyogenic liver abscess

A
  • penicillin, aminoglycoside and metronidazole for 4 weeks
75
Q

Methods of drainage for pyogenic liver abscess

A
  • percutaneous
  • catheter
  • surgical
76
Q

Organism in amoebic liver abscess

A

Entamoeba histolytica

- single abscess filled with anchovy pasts

77
Q

AB for amoebic liver abscess

A

Metronidazole 500mg 3x daily for 5 days

78
Q

Organism responsible for hydatid disease

A

Echinococcus granulosis

79
Q

Presentation of hydatid liver abscess

A
  • liver enlargement
  • RUQ pain
  • complication
80
Q

Complications of hydatid liver disease

A
  • cyst rupture (urticaria, anaphylaxis)
  • erodes into bile duct (pain, jaundice)
  • perforation through diaphragm
81
Q

Treatment of hydatid liver disease

A

All symptomatic need surgery

- Albendazole for 2 weeks

82
Q

Side effects of albendazole

A
  • bone marrow depression

- liver and renal toxicity

83
Q

Classification of liver tumours

A
  • cystic vs solid

- benign vs malignant

84
Q

Signs of cystic tumours on US

A
  • thick walled
  • septae
  • nodules
  • echogenic
85
Q

Types of cystic liver tumours

A
  • cystadenoma

- cystadenocarcinoma

86
Q

Benign tumours of the liver

A
  • haemangioma
  • liver cell adenoma
  • focal nodular hyperplasia
87
Q

Risk factors for HCC

A
  • hep B+C

- aflatoxin

88
Q

Symptoms of HCC

A
  • decrease in liver function
  • acute complication of cirrhosis
  • upper abdominal pain and fever
89
Q

Tumour marker or HCC

A

AFP

90
Q

What is fibrolamellar carcinoma

A

A subtype of HCC occurring in non-cirrhotic livers wtih Hep B/C

91
Q

Mets common in the liver

A
  • GIT tumours
  • bronchus
  • breast
  • ovary
  • lymphoma

Surgery Revision (8 decks)

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