HPB

Question 1

Most common causes of acute pancreatitis

Answer 1

I GET SMASHED
I - idiopathic
G - gallstones
E - ethanol
T - trauma
S - steroids
M - mumps
A - autoimmune
S - scorpion poison
H - hypercalcaemia/hypertriglyceridemia
E - ERCP
D - drugs

Question 2

Acute pancreatitis pathophysiology

Answer 2

Intrapancreatic activation of pancreatic enzymes → increased proteolytic and lipolytic enzyme activity → destruction of pancreatic parenchyma → attraction of inflammatory cells → release of inflammatory cytokines → acute pancreatitis

Question 3

The three main sequelae of acute pancreatitis are:

Answer 3

Distributive shock
Pancreatic necrosis
Hypocalcaemia

Question 4

Symptoms associated with acute pancreatitis

Answer 4

Constant, severe epigastric pain radiating towards the back.
Nausea +/- vomiting.
Fever.

Question 5

Examination findings associated with acute pancreatitis

Answer 5

Signs of shock: tachycardia, hypotension, oliguria/anuria.
Abdominal: tenderness, distension.
Skin: Cullen sign, Grey Turner sign, Fox sign

Question 6

Cullen sign

Answer 6

Periumbilical ecchymosis and discolouration. Associated with acute pancreatitis.

Question 7

Grey Turner sign

Answer 7

Flank ecchymosis with discolouration. Associated with acute pancreatitis.

Question 8

Fox sign

Answer 8

Bruising over the inguinal ligament. Associated with acute pancreatitis.

Question 9

Diagnosis of acute pancreatitis is made if the patient has at least 2 of the following features:

Answer 9

1. Characteristic abdominal pain
2. Biochemical evidence of pancreatitis (serum amylase or lipase elevated more than 3 times the ULN)
3. Radiographic evidence of pancreatitis on imaging

Question 10

Mild acute pancreatitis is characterised by

Answer 10

no local or systemic complications.

Question 11

Moderate acute pancreatitis is characterised by

Answer 11

local or systemic complications or organ failure that resolves within 48hrs.

Question 12

Severe acute pancreatitis is characterised by

Answer 12

organ failure that persists for more than 48hrs.

Question 13

Initial management of acute pancreatitis (regardless of severity) includes

Answer 13

Fluid administration
Analgesia

Question 14

Gallstones most commonly consist of:

Answer 14

Cholesterol

Question 15

Cholelithiasis definition

Answer 15

The presence of gallstones in the gallbladder

Question 16

6 Fs of gallstones

Answer 16

Fat
Female
Fertile
Forty
Fair skinned
Family history

Question 17

20/20/20 rule of gallstones

Answer 17

20% of the population have gallstones
20% of those people will be symptomatic
20% of those will have complications

Question 18

Increased levels of oestrogen predispose to gallstone development by:

Answer 18

Increased secretion of bile rich in cholesterol (lithogenic bile)

Question 19

Increased progesterone predisposes to gallstones by:

Answer 19

Smooth muscle relaxation, decreased gallbladder contraction and subsequent cholestasis

Question 20

Pregnancy predisposes patients to the development of gallstones due to:

Answer 20

Dramatically increased oestrogen levels

Question 21

Medications that increase oestrogen levels include:

Answer 21

OCPs, HRT

Question 22

Medications that alter cholesterol metabolism and increase risk of gallstones include:

Answer 22

Fibrates

Question 23

Transabdominal ultrasound findings for cholelithiasis include

Answer 23

Gallstones visualised within the gallbladder with posterior acoustic shadowing

Question 24

Biliary colic definition

Answer 24

Constant, dull right upper quadrant pain lasting less than 6hrs caused by gallstones intermittently obstructing the neck of the gallbladder (cystic duct)

Question 25

Biliary colic especially occurs:

Answer 25

post-prandially

Question 26

Mechanism by which eating induces biliary colic onset:

Answer 26

CCK release following a fatty meal —> gallbladder contraction —> attempts to force stone into the cystic duct

Question 27

Points of pain radiation in biliary colic

Answer 27

Epigastrium, right shoulder tip or back

Question 28

In choledocolithiasis, LFTs often show:

Answer 28

Elevated ALP and bilirubin

Question 29

Lifestyle changes to reduce the occurrence of biliary colic include:

Answer 29

Low fat diet and weight loss

Question 30

Choledocolithiasis definition

Answer 30

Presence of gallstones in the common bile duct.

Question 31

Pain associated with choledocolithiasis is usually __________ compared with uncomplicated biliary colic

Answer 31

more severe/prolonged, and lasting >6hrs

Question 32

Signs of extrahepatic cholestasis

Answer 32

Jaundice, pale stools, dark urine, pruritus.

Question 33

Cholestasis usually appears as a __________ picture on LFTs

Answer 33

Obstructive

Question 34

Obstructive LFT picture:

Answer 34

Increased ALP and GGT with conjugated hyperbilirubinaemia.

Question 35

Ultrasound findings associated with choledocolithiasis

Answer 35

Dilated CBD (>6mm). Presence of gallstones in the gallbladder with associated posterior acoustic shadowing.

Question 36

Acute/ascending cholangitis definition

Answer 36

Bacterial infection of the biliary tract, typically secondary to biliary obstruction and stasis.

Question 37

Acute cholangitis occurs in __% of patients with cholelithiasis

Answer 37

9%

Question 38

Acute cholangitis pathophysiology

Answer 38

Biliary obstruction —> bile stasis with increased intraductal pressure —> bacterial translocation into the bile ducts —> bacterial infection ascends the biliary tract —> acute cholangitis

Question 39

The most common cause of ascending cholangitis is:

Answer 39

Choledocolithiasis

Question 40

Other causes of acute cholangitis include:

Answer 40

Biliary strictures, malignant obstruction (cholangiocarcinoma, pancreatic cancer), contamination of bile with intestinal contents due to manipulation of the biliary tract.

Question 41

Charcot’s triad is associated with:

Answer 41

Ascending cholangitis

Question 42

Charcot’s triad

Answer 42

Right upper quadrant abdominal pain, fever and jaundice

Question 43

Reynold’s pentad is associated with:

Answer 43

Acute cholangitis

Question 44

Reynold’s pentad

Answer 44

RUQ abdominal pain, fever, jaundice, hypotension, mental status changes

Question 45

Bloods of a patient with acute cholangitis will likely show the following derangements:

Answer 45

Elevated CRP, leukocytosis with left shift, signs of cholestasis on LFTs (elevated GGT, ALP, ALT, hyperbilirubinaemia), possible positive blood cultures in the case of concurrent sepsis

Question 46

Imaging findings for patients with ascending cholangitis include:

Answer 46

Dilated CBD, pneumobilia, bile duct sclerosis

Question 47

Common causes of pneumobilia include

Answer 47

IBD and infection

Question 48

Elevated ALP and GGT are associated with:

Answer 48

An obstructive picture.

Question 49

5 Fs of gallstones

Answer 49

Female Fertile Fat Fair Forty

Question 50

ALP and AST are _________ markers

Answer 50

Intrahepatic

Question 51

Glasgow-Imrie Criteria

Answer 51

Used for severity grading of acute pancreatitis. 3 or more of the listed features in the first 48hrs indicates severe acute pancreatitis and patient may require transfer to HDU/ICU. Mnemonic: PANCREAS Pa02 <8KPa Age >55 Neutrophils >15 Calcium <2mmolL Renal function (urea>16mmolL) Enzymes (LDH>600IU/L, AST>2000IU/L) Albumin <32g/L Sugar >10mmolL