HepatoBilliary Surgery Flashcards
Definition of acute pancreatitis
An acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems
Etiology of acute pancreatitis
- alcohol
- gallstones
- idiopathic
- obstructive
- metabolic
- drugs
- trauma
- viral infection
- pregnancy
- collagen disease
Pathogenesis of acute pancreatities
- inappropriate activation of trypsinogen to trypsin
- breaks down tissue
- triggers SIRS
2 pathological types of acute pancreatitis
- acute interstitial oedematous pancreatitis (mild)
- acute necrotising pancreatitis (severe)
Local complications of acute pancreatitis
- acute pancreatic fluid collection
- pancreatic psuedocyst
- acute necrotic collection
- walled-off necrosis
Other organ complications of acute pancreatitis
- gastric outlet obstruction
- splenic/portal vein thrombosis
- intestinal necrosis
Diagnosis of acute pancreatitis
2 of the following:
- abdominal pain
- serum lipase/amylase >3x normal
- characteristic findings on CT/MRI
- N+V
- Cullen’s/ Grey-Turner
Definition of SIRS
2 or more of:
- HR>90
- temp <36 or >38
- WCC <4000 or >12000
- resp >20 or pCO2 <32
Increased risk of organ failure
Definition of organ failure
Score of 2 or more for 1 of the organ systems using the modified Marshall scoring system
(renal, resp, CVS)
Grading the severity of acute pancreatitis
- mild acute pancreatitis (MAP)
- moderate severe acute pancreatitis (MSAP)
- severe acute pancreatitis (SAP)
Management of gallstone pancreatitits
- initial conservative management
- elective cholecystectomy 4 weeks later
- if jaundiced, do ERCP
How to recognise SAP
- haemodynamic instability
- hypoxic confusion
- pleural effusion + pulm infiltrates on CXRAY
- SIRS response
Why do patients with SAP need ICU admission?
- resus for hypovolaemic shock
- may need ventilation
- metabolic management
- enteral nutrition
Scoring systems for SAP
- CRP
- Ranson’s
Definition of chronic pancreatitis
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
Etiology of chronic pancreatitis
- alcohol
- nutritional
- CF
- hereditary
- idiopathic
- AI
- obstructive
Pathogenesis of pain in chronic pancreatitis
- inflammatory processes lead to fibrosis and ductal dilatation
- damaged neural structures
- oxygen free radicals
- compartment syndrome
Complications of chronic pancreatitis
- diabetes
- fat malabsorption
- pseudocyts
- pancreatic ascites
- false aneurysm
- splenic vein thrombosis - portal HPT
- biliary/ duodenal stenosis/ obstruction
2 clinical patterns of chronic pancreatitis
- intermittent mild attacks
- progressive, severe and persistent
How to test pancreatic function
- direct
- indirect = faecal elastase
Step-up pain management regime for chronic pancreatitis
- abstinence with low fat diet
- paracetamol/NSAIDS
- trial of high dose pancreatic enzymes with acid support
- narcotics
- anti-depressants
- percutaneous coeliac plexus block
Drainage procedures for chronic pancreatitis
- pancreatico-jujenostomy
- Frey procedure
Types of glass stones
- chol
- BR
- calciums salts
Causes of black pigment stones
Haemolytic conditions
Liver cirrhosis
Cause of brown pigment stones
Worm infestation
Constituents of bile
- Chol
- bile salts
- phospholipids
Calot’s triangle
- cystic duct inf
- common hepatic duct med
- cystic artery sup
Lymph node in the middle of Calot’s triangle
- Mascagni/ Lund
Surgical objectives of cholecystectomy
- eliminate gallbladder
- eliminate gallstones
- exclude stones in biliary tree
- ensure bile ducts aren’t damaged
Medical treatment of gallstones
- medical dissolution therapy
- contact dissolution therapy
- extracorporeal shockwave lithotripsy
Definition of acute cholecystitis
A gallstone becomes impacted in cystic duct/ Hartman’s pouch
- leads to inflammation and infection of gallbladder wall
Symptoms of acute cholecystitis
- severe pain
- nausea and vomiting
- pyrexia and Murphy’s sign
Things found on US in cholecystitis
- stone
- thickwalled gallbladder
- radiological Murphys
Natural history of cholecystitis
- stone impacts leading to fibrosis
- asbscess forms (empyema)
- perforation
Definition of choledocholithiasis
Stones in the CBD
Symptoms of cholangitis (Charcot’s triad)
- biliary colic
- jaundice
- fever/rigors
Courvasier’s Law
Painless obstructive jaundice and a palpable gallbladder cannot be due to gallstones
Structure of the pancreas
- acini = enzymes
- ducts = transport enzymes
- Islet’s of Langerhans = endocrine cells
Most common type of pancreatic neoplasm
Pancreatic ductal adenocarcinoma
Risk factors for pancreatic ductal adenocarcinoma
- predisposing cancer syndrome
- smoking
- chronic pancreatitis
- DM + obesity
Cancer syndromes that predispose to pancreatic cancer
- HNPCC
- BRCA2
- PAP
- Peutz-Jager
Clinical presentation of pancreatic cancer
- 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
Examination findings in pancreatic cancer
- temp wasting
- skin excoriation
- Virchow’s node
- Sister mary Joseph nodule
Best radiological investigation for pancreatic cancer
CT scan
Contraindications for pancreatic resection
- mets
- lymph node involvement
- major vessel involvement
- co-morbid disease
Resection operations for pancreatic cancer
- Whipples
- distal pancreatectomy
- pancreaticoduodenectomy
Types of pancreatic neuroendocrine tumours
- insulinomas
- gastrinomas
- glucagonoma
What is Whipple’s triad?
- symptoms of hypoglycaemia
- glucose <5
- relief of hypoglycaemia with glucose
Symptoms of insulinoma
- anxiety, confusion, LOC
- Weight gain
- often confused with psych
Management of an insulinoma
- resection (cherry-red mass)
- enucleation
Where are gastrinomas found?
The gastrinoma triangle
The gastrinoma triangle
Sup: confluence of cystic and CBD
Inf: junction of 2nd and 3rd parts of dudenum
Med: junction of neck and body of pancreas
Symptoms of a gastrinoma
- fulminant PUD (Zollinger Ellison)
- epigastric pain
- diarrhoea that resolves with PPIs
Symptoms of a glucogonoma
- cachexia
- malnutrition
- protein depletion
- rash (necrolytic migratpry erythema)
- glucose intolerance
- DVT
Cystic neoplasms of the pancrease
- serous cystic neoplasms
- mucinous cystic neoplasms
- Intraductal papillary mucinous neoplasms
- solid pseudopapillary tumor
Causes of portal hypertension
- prehepatic
- hepatic
- post-hepatic
Pharmacological management of acute oesophageal variceal bleeding
- vasopressin
- somatostatin
- octreotide
Endoscopic management of oesophageal varices
- band ligation
- injection sclerotherapy
Management of oesophageal variceal bleeding
- pharmacologicla
- endoscopic
- balloon tamponade
- TIPS
- surgical (shunts/ surgical transection)
What does TIPS stand for?
Transjugular intrahepatic portosystemic shunt
How to score prognosis for chronic liver disease
Child-Pugh score
Components of Child Pugh score
- MR
- albumin
- prothrombin time
- Ascites
- encephalopathy
Long-term management to prevent variceal bleeding
- endoscopic
- pharmacotherapy
- surgery
- liver transplant
Causes of ascites
- portal HPT
- hypoalbuminaemia
- neoplasms
- misc.
Treatment of ascites
- reduce salt intake
- diuretics
- abstain from alcohol
- paracentesis
Features of hepatic encephalopathy
- monotonous speech
- flat affect
- tremor
- muscular incoord
- asterixis
- fetor hepaticus
- coma
- upgoing plantars
- deranged reflexes
- decerebrate posturing
Events that precipitate encephalopathy in cirrhotic patients
- electrolyte imbalance
- GI bleeding
- drugs
- infection
- constipation
Treatment of hepatic encephalopathy
- treat precipitating factors
- non-absorbable disaccharides (lactulose)
- antibiotics
- protein restriction
What is hepatorenal syndrom
Acute oliguric renal failure in cirrhotic liver disease resulting from intense intrarenal vasoconstruction in otherwise normal kidneys
What is SBP?
Infection of ascites in the absence of a local infectious source
- usually in cirrhotic ascites
- gram neg enteric bacteria
MELD (model for End-stange liver disease
- BR
- INR
- creat
Objectives of assessing a liver mass
- establish a diagnosis
- determine whether surgery is indicated
- judge whether resection is possible
Symptoms of a pyogenic liver abscess
- abdo pain
- swinging pyrexia
- nocturnal sweating
- vomiting
- anorexia
- malaise
Antibiotics for pyogenic liver abscess
- penicillin, aminoglycoside and metronidazole for 4 weeks
Methods of drainage for pyogenic liver abscess
- percutaneous
- catheter
- surgical
Organism in amoebic liver abscess
Entamoeba histolytica
- single abscess filled with anchovy pasts
AB for amoebic liver abscess
Metronidazole 500mg 3x daily for 5 days
Organism responsible for hydatid disease
Echinococcus granulosis
Presentation of hydatid liver abscess
- liver enlargement
- RUQ pain
- complication
Complications of hydatid liver disease
- cyst rupture (urticaria, anaphylaxis)
- erodes into bile duct (pain, jaundice)
- perforation through diaphragm
Treatment of hydatid liver disease
All symptomatic need surgery
- Albendazole for 2 weeks
Side effects of albendazole
- bone marrow depression
- liver and renal toxicity
Classification of liver tumours
- cystic vs solid
- benign vs malignant
Signs of cystic tumours on US
- thick walled
- septae
- nodules
- echogenic
Types of cystic liver tumours
- cystadenoma
- cystadenocarcinoma
Benign tumours of the liver
- haemangioma
- liver cell adenoma
- focal nodular hyperplasia
Risk factors for HCC
- hep B+C
- aflatoxin
Symptoms of HCC
- decrease in liver function
- acute complication of cirrhosis
- upper abdominal pain and fever
Tumour marker or HCC
AFP
What is fibrolamellar carcinoma
A subtype of HCC occurring in non-cirrhotic livers wtih Hep B/C
Mets common in the liver
- GIT tumours
- bronchus
- breast
- ovary
- lymphoma
