HPB🥳 Flashcards
BILIARY COLIC & CHOLECYSTITIS pathophysiology of gallstone formation?
cholesterol+phospholipids+bile pigments=bile
gallstones form from the supersaturation of bile
BILIARY COLIC & CHOLECYSTITIS 3 main types of gallstone
- cholesterol stones (due to? seen in pts w?)
- pigment stones (due to? seen in pts w?)
- mixed stones - (?)
BILIARY COLIC & CHOLECYSTITIS risk factors?
5 FS
Fat Female Fertile Forty Fhx
also: preganancy, COCP, haemolytic anaemia, malabsorption
BILIARY COLIC & CHOLECYSTITIS what is biliary colic?
gallbladder neck impacted by gallstone. contraction of gallbladder against occluded neck causes pain. typically sudden, dull & colicky in RUQ (can radiate to epigastrium or back). precipitated by fatty food (why?). pt complains of n&v. pain relief settles sx.
BILIARY COLIC & CHOLECYSTITIS what is acute cholecystitis ?
gallstone in gallbladder neck + inflammation of gb. constant pain in RUQ or epigastrium associated w signs of inflammation eg fever or lethargy. positive murphys sign (??)
check for signs of guarding (may suggest gb perf) or sepsis
BILIARY COLIC & CHOLECYSTITIS differentials
gord, pud, acute pancreatitis, ibd
BILIARY COLIC & CHOLECYSTITIS investigations
- bloods: fbc& crp (why?), lfts (what is raised?), amylase (why?), +- preg test & urinalysis
- imaging: trans abdominal USS. shows: presence of gallstones, gallbladder wall thickness, bile duct dilatation (what do these all indicate?). inconclusive? MRCP
BILIARY COLIC & CHOLECYSTITIS management for biliary colic?
analgesia, lifestyle factor advice (eg ? x3). elective laparoscopic cholecystectomy is warranted due to inc risk of recurrence
BILIARY COLIC & CHOLECYSTITIS acute cholecystitis management?
iv abx (eg??), analgesia, antiemetics
laparoscopic cholecystectomy within 1 wk
not fit for surgery & not responding to med? percutaneous cholecystostomy to drain infection but gallstone remains so may recur
BILIARY COLIC & CHOLECYSTITIS comps?
- mirizzi syndrome - ?
- gallbladder empyema - ?
- chronic cholecystitis - ?
- bouverets syndroke & gallstone ileus - ?
CHOLANGITIS what is it?
infection of the biliary tract
CHOLANGITIS cause?
biliary outflow obstruction -> stasis of fluid + elevated intraluminal pressure -> pathological bacterial colonisation of the biliary tree
- whatever causes obstruction eg gallstones, ercp (iatrogenic), cholangiocarcinoma
- infective organisms : e. coli, klebsiella species, enterococcus
CHOLANGITIS clinical features
- charcots traid - jaundice, fever, ruq pain
other sx; itching (why?0, pale stool w dark urine (why?)
CHOLANGITIS OE?
pyrexia, rigours, jaundice, ruq tenderness, confusion, hypotension, tachycardia
CHOLANGITIS differentials
biliary colic, cholecystitis
CHOLANGITIS investigations
- bloods - fbc (?), lfts (what’s raised?)
- blood cultures
- USS shows bile duct dilatation & underlying cause
- gold standard - ERCP - diagnostic & therapeutic
CHOLANGITIS immediate management?
sepsis presenting ? sepsis 6
CHOLANGITIS definitive management ?
- endoscopic biliary decompression via ERCP
- percutaneous transhepatic cholangiography is 2nd line
LIVER ABSCESS what is it?
contained infection caused by spread from a poly microbial bacterial infection from the biliary or GI tract via contiguous spread or seeding from the portal/hepatic veins
LIVER ABSCESS common causes ?
cholecystitis, cholangitis, diverticulitis, appendicitis, septicaemia
LIVER ABSCESS common causative organisms?
e. coli, k pneumoniae, s constellatus
LIVER ABSCESS pt presentation ?
fever, rigours & abdo pain + bloating, nausea, anorexia, wt loss, fatigues, jaundice
LIVER ABSCESS OE?
RUQ tenderness +/- hepatomegaly.
what will pt present w if abscess ruptures?
LIVER ABSCESS investigations?
- bloods - leucocytosis, ^ alp
- send off peripheral blood & fluid cultures for microscopy
- USS - shows? x4
- ct w contrast
LIVER ABSCESS mgmt?
- fluid resus
- abx
- uss/ct guided aspiration
ACUTE PANCREATITIS what is it?
inflammation of pancreas
ACUTE PANCREATITIS how is it differentiated from chronic?
limited damage to secretory function of gland, no gross structural damage,
repeated eps? can lead to chronic
ACUTE PANCREATITIS causes?
Gall stones Ethanol Trauma Scorpion bite Mumps AI Steroids Hypercalcaemia ERCP Drugs eg NSAIDs
ACUTE PANCREATITIS disease process?
cause -> triggers premature & exaggerated activation of digestive enzymes in pancreas -> pancreatic inflammatory response -> inc vascular perm -> fluid shifts (third spacing) -> enzymes released into systemic circulation-> fat necrosis (leads to?) & BV auto digestion (leads to?)
end stage? necrosis of…
ACUTE PANCREATITIS pt present?
sudden onset severe epigastrium pain
radiates back
n&v
ACUTE PANCREATITIS OE?
epigastrium tenderness w or w/o guarding
cullens sign ?
grey turners sign ?
tetany - why??/
ACUTE PANCREATITIS differentials ?
ones where abdo pain radiates to back:
aaa, renal stones, chronic pancreatitis , aortic dissection, pud
ACUTE PANCREATITIS investigations ?
- serum amylase - 3x upper limit
- lfts - cholestsaic pic??
- lipase
- abdo uss
- axr - sentinel loop sign - what is this & why?
- ct w contrast - 48hrs after initial presentation what will it show?
ACUTE PANCREATITIS mgmt?
- treat underlying cause
- supportive:
iv fluid resus w crystalloids, ng tube if vomiting, catheter to monitor urine output & fluid balance, opioid analgesia
gall stones? what surgery opt?
CHRONIC PANCREATITIS what is it?
chronic fibro inflammatory disease of the pancreas resulting in progressive & irreversible damage to the pancreatic parenchyma
CHRONIC PANCREATITIS causes?
*** chronic alcohol abuse
** idiopathic
metabolic eg?
infection eg?
AI eg?
anatomical eg?
congenital abnormalities eg?
hereditary eg?
CHRONIC PANCREATITIS pt present?
- chronic pain complicated w recurring attacks of acute pancreatitis (acute on chronic_, typically epigastrium & back associated w N&V
- also may present w (due to parenchyma damage ) endocrine insufficiency (resulting in?) & exocrine insufficiency (resulting in?)
CHRONIC PANCREATITIS OE?
soft abdo but tender in epigastrium. significant cachexia
!!!! often pseudocysts present due to prev recurrent attacks. may present with sx of mass effect eg biliary obstruction or gastric outlet obstruction
CHRONIC PANCREATITIS differentials ?
for central abdo pain: pud, reflux, aaa, biliary colic, chronic mesenteric ischaemia
CHRONIC PANCREATITIS investigations ?
- establish disease so amylase/lipase not raised
- bm (2 to?)
- lfts (to ensure?)
- faecal elastase low if exocrine insufficiency & can aid diagnosis (what is this?)
- CT - shows? x2
- USS/MRCP to show anatomy
- uncertain? special tests. secretin stimulation test or endoscopic US
CHRONIC PANCREATITIS mgmt?
- definitively ? treat any reversible underlying cause eg alcohol cessation or statin therapy for hyperlipidaemia
- mainstay: analgesia
- exocrine dysfunction ? enzyme replacement (+fat soluble vitamins too! what ones are these?)
- pancreogenic diabetes ? insulin regimes & HBA1c surveillance.
- steroids reduce sx if AI
- non surgical if targetable underlying cause: ERCP (for what causes?) or ESWL (when?)
- surgical: large stones? freys procedure (what is this?), lateral pancreaticojejunostomy (when?)
