HPB Flashcards
Treatment for bleeding esophageal varices
Fluid and PCT resuscitation
Octreotide(somatostatin)
Prophylactic Abx
What are some clinical signs of Necrotising pancreatitis
Grey turner and cullens signs
What do grey turners sign suggest
Necoritising pancreatitis or retroperitoneal hemorrhage
Signs of Decompensated Liver failure
Albumin: Pedal Edema
Coagulopathy:Ecchymoses
Bilirubin:Jaundice/hyperbilirubinemia
Distension: Ascites
Encephalopathy/asterixis
Portal HTN signs
Signs of chronic liver disease
Palmar erythema
Spider naevi
Dilated abdominal veins
Gynaecomastia
Clubbing
Jaundice
4 Fs of cholelithiasis
Female
Forty
Fertile(pregnant)
Fat
Type of jaundice with most intense itch
Post hepatic obstructive jaundice
boundaries of Calots/hepatocystic triangle
- inferior edge of liver
- Common hepatic duct
- Cystic duct
Contents of Calots triangle to avoid in surgery
- Right hepatic artery
- Cystic artery
- Cystic lymph node of lund
- Lymphatics
- Connective tissue
Score for pancreatitis
Glasgow Imrie score
5 exceptions to Courvoisiers Law
- Mirizzi syndrome
- Bile duct structures
- Parasites eg ascaris, liver flukes
- Stone in both cystic duct and CHD
5?
Medbear page 309
Eponymous name of hilar cholangiocarcinoma
Klatskin tumor
Causes of hepatic bruit
Arteriovenous malformations, alcoholic liver cirrhosis
Dydx caput medusae vs dilated abdominal veins(IVC obstruction)
Below umbilicus
-caput medusae point inferiorly ?
-dilated abdominal veins point superiorly?
Dydx hepatomegaly vs liver mass
Liver mass usually does not cross midline unless bilobar disease
Cardinal Sx of Chronic Pancreatitis
1) Pain
2) Diabetes
3) Steatorrhea
4) malnutrition
What to look for in a Endoscopic Retrograde Pancreatography
For any
1) Filling defects including gallbladder +- masses
2) shouldering(strictures)
3) Rat tailing(flow of contrast from CBD into ampulla)
4) CBD size >7mm(age and s/p dependent)
5) abnormal biliary tree
- LHD and RHD
- distal tapering of contrast
Pathognomonic sign of gallstone ileus on XR
Rigler’s triad
Pneumobilia
SBIO
Gallstone often at RUQ( Ileocecal valve)
Why ERCP perforation unlikely to cause pneumoperitoneum on erect CXR
D2 where ampulla of vater enters, is retroperitoneal
Dy/dx Hepatocellular carcinoma, liver metastases, hepatic haemangioma in triphasic CT
HCC: portal venous washout
Mets: Portal venous enhancement
Haemangioma: delayed phase enhancement
Contraindications to Trans Arterial Chemo Embolisation(TACE) for HCC
- Decompensated Liver Cirrhosis
- Portal Vein Thrombosis
Contraindicated surgical approach in gallbladder cancer
Laparoscopic: tendency for tumor deposits on trocar(keyhole) sites
Condition associated with Primary Sclerosing Cholangitis
IBD specifically Ulcerative COlitis
Risk factors for cholangiocarcinoma
Non modifiable
Age
Female
Primary Sclerosing Cholangitis
Modifiable
Choledocholithiasis/ Hepatolithiasis
Biliary tree abnormalities
Choledochal cyst
Anomalous biliary-pancreatic malformations
Liver Cirrhosis
Viral Hepatitis:: B, C and HIV
Parasitic Infections
Carcinogen exposure, mainly occupational: Thorotrast
Diabetes Mellitus
Bismuth Corlette Classification of Cholangiocarcinomas
I: Below confluence of hepatic ducts
II: Tumor involving confluence
IIIa: Tumor involving confluence and right hepatic duct
IIIb: Tumor involving confluence and left hepatic duct
IV: Tumor involving both hepatic ducts and confluence OR mulicentric
Classification of non hilar cholangiocarcinomas
- Mass forming
- Intra ductal
- Peri ductal/sclerosing
Surgical options for cholangiocarcinoma
Intrahepatic tumor: Hepatic Lobectomy and excision of affected duct
Hilar tumor(Klatskin’s): Bile duct resection + bilateral hepaticojejunostomy and caudate lobectomy
Extrahepatic involving Common bile duct: Biliary tree and hilar lymphatics resection
Distal tumor: Pancreaticoduodenectomy( Whipple’s)
Aim and options for palliative treatment of cholangiocarcinoma
Relieve jaundice and pruritus, avoid cholangitis and liver failure, improve quality of life
Endoscopic biliary drainage
Endoscopic or percutaneous stents with SEMS( Self expanding metal stents)
PTBD
RT
Chemo
Photodynamic therapy
Reason post ERCP perforation is most likely to be retroperitoneal
Occurs at D2, at the site of the sphincterotomy OR in the bile duct, which is retroperitoneal
Invx for epigastric pain post ERCP
Pancreatitis: Amylase
Inferior AMI: ECG and troponins
Perforation: CT Scan( often retroperitoneal)
What is OPSI and how to treat
Overwhelming Post Splenectomy Infection
- blood c/s
- empirical broad spectrum Abx
Why patients have higher risk of VTE post splenectomy
Post splenectomy thrombocytosis
