HPB Flashcards
What is the aetiology of a splenic infarct?
A
- Haemotological Disease: Lymphoma, Myelofibrosis, Sickle cell, CML, Polycythemia Vera, Hypercoagulable states
- Thromboembolism: endocarditis, AF, post MI mural thrombus,
- Rare causes: trauma, vasculitis, liver surgery, panreatectomy
What are the clinical features of a splenic infarct?
Often asymptomatic
LUQ pain/tenderness that radiates to the left shoulder (Kehr’s sign)
Fever
N+V
Pleuritic chest pain
What differential diagnoses can be considered when a patient presents with symptoms of a splenic infarct?
Peptic ulcer disease
Pyelonephritis
Ureteric colic
Left sided basal pneumonia
What is the immediate and long term management for a patient with a splenic infarct?
Immediate:
Analgesia
IV fluids
Manage underlying condition
Consider long term anticoagulation
Avoid splenectomy due to OPSI
Long-term:
- Vaccination against encapsulated bacteria NHS
Prophylatic low dose abx (Penicillin V)
What are the complications of a splenic infarct?
A
- Splenic rupture: do splenectomy
- Splenic abscess: when cause of infarct was non-sterile embolus e.g infective endocarditis. May be seen on CT scan but confirmed with explorative surgery
- Pseudocyst formation
- Autosplenectomy: causes asplenism. Repeated splenic infarcts leads to progressive fibrosis and atrophy of the spleen. Common in sickle cell as when crises there is splenic artery occlusion. Leaves patient susceptible to infection
What are the clinical features of splenic rupture?
Abdominal pain
Hypovolemic shock
LUQ tenderness/Peritonism
Kehr’s sign due to diaphragm irritation
What investigations do you do for a suspected splenic rupture?
Haemodynamically unstable with peritonism: immediate laparotomy
Haemodynamically stable: urgent CT chest-abdomen-pelvis with IV contrast
What are the main complications of conservative treatment and embolisation treatment for splenic rupture?
Ongoing bleeding
Splenic necrosis
Splenic abscess or cyst formation
Thrombocytosis (give aspirin if platelet count rises)
- OPSI so give prophylatic Penicillin V and vaccinations to prevent sepsis
What would you see on ultrasound with gallstone pathology?
Gallstones or sludge
Thickened gallbladder wall if inflamed
Bile duct dilatation (stone in the distal bile ducts)
What is the difference between MRCP and ERCP?
MRCP - Identifies any biliary obstruction
ERCP - Identifies any biliary obstruction and allows for intervention
What are some complications of gallstones?
Mirizzi Syndrome
Gallbladder empyema
Chronic cholecystitis
Bouveret’s Syndrome
Gallstone ileus
What is Mirizzi Syndrome and how is it managed?
Stone located in Hartmann’s pouch or the cystic duct, that compresses the common hepatic duct
Causes obstructive jaundice
Confirmed with MRCP and manage by laparoscopic cholecystectomy
What is chronic cholecystitis, what are the complications of this and how is it managed?
History of recurrent or untreated cholecystitis
Ongoing RUQ or epigastric pain w/wo N+V
- Complications: gallblader carcinoma, biliary enteric fistula
- Diagnose with CT or often histologically post-cholecystectomy.
Treat with elective cholecystectomy
What is Bouveret’s Syndrome and Gallstone Ileus?
A
Inflammation of gallbladder can form cholecystoduodenal fistula allowing gallstones into small bowel, resulting in bowel obstruction
- Bouveret’s Syndrome – stone impacts proximal duodenum, causing a gastric outlet obstruction
- Gallstone Ileus – stone impacts terminal ileum (narrowest part of small bowel), causing a small bowel obstruction
What is a cholangiocarcinoma and what is the common histology and location of these?
Cancer in the biliary system but usually extrahepatic
- Common location: bifurcation of right and left hepatic ducts (Klatskin tumour).
Slow growing that invades locally and metastases to lymph nodes then peritoneal cavity, liver, lung
- Histology: 95% adenocarcinoma, SCC, lymphoma, sarcomas, small cell cancers
What is Courvoisier’s Law?
In the presence of painless jaundice and an enlarged gallbladder/RUQ mass, there is likely an obstructing pancreatic or gallbladder malignancy not gallstones
Sign only present if tumour obstructing distal to cystic duct
What are some differentials for cholangiocarcinoma?
A
Think of other causes of post-hepatic jaundice:
obstructive choledocholithiasis
bile duct strictures
external compression from extra-biliary tumour
benign biliary tumours
pancreatic tumours
primary biliary cirrhosis
primary sclerosing cholangitis.
Most patients with cholangiocarcinoma will require palliative treatment. What are some of the options for this?
Stenting: with ERCP to relieve obstructing symptoms but may need to be replaced every few months as prone to occlusion
Surgical bypass: if obstruction not relieved by stenting
Palliative radiotherapy and chemotherapy to slow tumour growth e.g cisplatin
How are simple liver cysts managed?
<4cm asymptomatic: no intervention
> 4cm asymptomatic: follow up US scans at 3,6,12 months to check for growth. If size of cyst remains unchanged for 2-3 years no intervention unless becomes asymptomatic
- Symptomatic: ultrasound-guided aspiration or laparoscopic de-roofing (lower rates of recurrence)
What are the clinical features of cystic neoplasms in the liver and what is the histology of these?
Features: asymptomatic as grow very slowly, abdominal pain, anorexia, bloating, fullness, nausea
Histology: cystadenomas (non-invasive mucinous cystic neoplasms). Premalignant biliary epithelium that can become cystadenocarcinomas
What investigative procedure should you avoid if you suspect a cystic neoplasm of the liver?
Aspiration or biopsy should be avoided as can cause peritoneal seeding
