HPB Flashcards
What is jaundice
Yellow discolouration of skin and sclera
Due to hyperbilirubinaemia
What is pre-hepatic jaundice
Excessive RBC breakdown
Overwhelm liver’s ability to conjugate bilirubin
What is hepatocellular jaundice
Dysfunction of hepatic cells
Get a mixed picture (conjugated and unconjugated bilirubin)
What is post-hepatic jaundice
Obstruction of biliary drainage
Bilirubin conjugated by liver
What investigations are needed for jaundice
Bilirubin, albumin, AST, ALT, ALP, gamma GT
Coagulation studies
FBC, U&Es
Liver screen
What investigations are needed for jaundice
Ultrasound abdomen (first line)
MRCP (visualise biliary tree)
Liver biopsy
What are the types of gallstones
Cholesterol
Pigment (bile)
Mixed (cholesterol and bile)
What are the risk factors for gallstones
Fat
Female
Fertile
Forty
Family history
Pregnancy
Oral contraception
Haemolytic anaemia
Malabsorption
What is biliary colic
Gallbladder neck impacted by gallstone
Pain due to contraction against blockage
No inflammation
How might biliary colic present
Sudden onset, dull, colicky RUQ pain
Can radiate to epigastric region or back
Brought on by eating fatty food
Nausea and vomiting
How might acute cholecystitis present
Constant RUQ pain
Radiation to epigastrium
Fever
Lethargy
Tender RUQ
Murphy’s sign: pressure to RUQ, inspire, positive if halt inspiration due to pain
Check for guarding
What are the differentials for biliary colic and acute cholecystitis
GORD
Peptic ulcer
Acute pancreatitis
Inflammatory bowel disease
What investigations are needed for biliary colic and acute cholecystitis
FBC, CRP, LFTs, amylase, urinalysis
Ultrasound (see gallstones or sludge, thick gallbladder wall, bile duct dilation)
MRCP (gold standard)
What is the management for biliary colic
Analgesia
Lifestyle advice
Laparoscopic cholecystectomy (high risk of recurrence, within 6 weeks)
What is the management for acute cholecystitis
IV antibiotics
Analgesia
Antiemetics
Laparoscopic cholecystectomy (within 1 week)
What are the complications of biliary colic and acute cholecystitis
Mirizzi syndrome: stone in Hartmann’s pouch, compression of common bile duct
Gallbladder emphysema: gallbladder fills with pus
Chronic cholecystitis: persistent inflammation of gallbladder wall
Bouveret’s syndrome: can get fistula between gallbladder and small bowel
What is cholangitis
Infection of biliary tree
High morbidity and mortality
Causes biliary outflow obstruction and biliary infection
What are the causes of cholangitis
Gallstones
Iatrogenic
Cholangiocarcinoma
Pancreatitis
Primary sclerosing cholangitis
Ischaemic cholangiopathy
Parasitic infection
Common organisms: E coli, klebsiella, enterococcus
How might cholangitis present
RUQ pain
Fever
Jaundice
Pruritus
Pyrexia
Rigors
Charcot’s triad
Reynold’s pentad
What is Charcot’s triad for cholangitis
Jaundice
Fever
RUQ pain
What is Reynold’s pentad for cholangitis
Jaundice
Fever
RUQ pain
Hypotension
Confusion
What investigations are needed for cholangitis
Routine bloods
Blood cultures
Ultrasound biliary tree
ERCP (gold standard)
What is the management for cholangitis
Immediate: sepsis 6, IV fluids, routine bloods, blood cultures, broad spectrum IV antibiotics
Definitive: endoscopic biliary decompression, cholecystectomy
What is cholangiocarcinoma
Cancer of biliary tree
95% adenocarcinomas
What is Courvoisier’s law
If have jaundice and enlarged palpable gallbladder, strongly suspect malignancy of biliary tree or pancreas
What is acute pancreatitis
Inflammation of pancreas
Scoring via Glasgow criteria
What are the causes of pancreatitis
GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune disease
Scorpion venom
Hypercalcaemia
ERCP
Drugs (azathioprine, NSAIDs, diuretics)
How might acute pancreatitis present
Severe epigastric pain
Radiates to back
Nausea and vomiting
Guarding
Haemodynamic instability
Cullen’s sign
Grey Turner’s sign
Tetany
Jaundice
What are the differentials for acute pancreatitis
Abdominal aortic aneurysm
Renal calculi
Chronic pancreatitis
Aortic dissection
Peptic ulcer disease
What investigations are needed for acute pancreatitis
Routine bloods
Serum amylase (diagnostic if 3x normal)
Serum lipase
Abdominal ultrasound
CT (pancreatic oedema/swelling/necrosis)
How is acute pancreatitis managed
Treat underlying cause
Supportive: fluids, oxygen, NG insertion, analgesia
All patients with acute pancreatitis should be treated in HDU/ITU
If confirmed pancreatic necrosis, consider prophylactic broad-spectrum antibiotics
What are the complications of acute pancreatitis
DIC
Acute respiratory distress syndrome
Hypocalcaemia
Hyperglycaemia
Pancreatic necrosis
Pancreatic pseudocysts
What are the most common causes of chronic pancreatitis
Chronic alcohol abuse
Idiopathic
How might chronic pancreatitis present
Chronic pain in epigastrium and back
Nausea and vomiting
Endocrine/exocrine insufficiency
What investigations are needed for chronic pancreatitis
Faecal elastase (low)
CT (pancreatic atrophy/calcification/pseudocysts)
How is chronic pancreatitis managed
Analgesia
Enzyme replacement
Vitamin supplements
ERCP
Steroids (for autoimmune cases)
Which tumour marker is specific to pancreatic cancer
CA19-9
What is a splenic infarct
Occlusion of splenic artery
Get tissue necrosis
Infarct often not complete (collateral blood supply)
What are the causes of splenic infarct
Haematological disease
Endocrine disorders
Vasculitis
Trauma
Surgery
How might splenic infarct present
LUQ pain
Radiation to left shoulder
Fever
Nausea
Vomiting
Pleuritic chest pain
What investigations are needed for splenic infarct
CT (gold standard)
Routine bloods
What is the management for splenic infarct
Analgesia
Fluids
Avoid splenectomy is possible
Low dose antibiotic cover
How might splenic rupture present
History of trauma
Abdominal pain
Hypovolaemic shock
LUQ tenderness
Left shoulder pain
Which vaccinations should be given to asplenic patients
Strep pneumoniae
Haemophilus influenzae B
Meningococcal
