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Y3(S) - General > HPB > Flashcards

HPB Flashcards

1
Q

What is the typical presentation of acute pancreatitis?

A

Epigastric pain radiating to the back

May be jaundiced

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2
Q

Why may an acute pancreatitis be jaundiced?

A

If it’s an obstructive cause of Pancreatitis like gallstones

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3
Q

What would be looking for on examination for acute pancreatitis?

A

Jaundiced
Epigastric tenderness (radiates to back)
Cullens
Grey turners

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4
Q

What is Cullens and Grey Turners sign and what are they caused by?

A

Cullens = C shaped bruising around the umbilicus

Grey turners = bruising on side of abdomen

Caused by retroperitoneal haemorrhage from the pancreatitis

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5
Q

What investigations would you do to assess for acute pancreatitis?

A

FBC (infection)
LFTs (ALP)
U+Es
Serum amylase
Bilirubin levels (conjugated elevated?)

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6
Q

How much does amylase need to be elevated by to be a diagnosis of pancreatitis?

A

X3 the baseline

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7
Q

What imaging is used to assess for acute pancreatitis?

A

USS abdomen if its available

CT Abdo pelvis with IV contrast

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8
Q

What additional imaging/treatment method can be used if gallstones is found to be the cause of the acute pancreatitis?

A

ERCP

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9
Q

Where does an ERCP travel?

A

Mouth -> oesophagus -> stomach -> duodenum -> ampulla of Vater -> common bile duct -> pancreatic duct

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10
Q

What is the management process for acute pancreatitis?

A

Supportive is the only option if its not caused by gallstones

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11
Q

What is the supportive management of acute pancreatitis?

A

Analgesia (WHO Pain ladder)
Aggressive fluid resus
Anti emetics or NG tube if excess vomitting
Fluid balance chart + catheter

Escalate to HDU

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12
Q

What interventional treatment can be given to a patient with acute pancreatitis caused by gallstones?

A

ERCP
Laparoscopic cholecystectomy

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13
Q

What is the WHO pain ladder?

A

Order we give analgesia

Mild = non opioid + adjuvant
Mild to moderate = weak opioid + adjuvant
Moderate to severe = strong opioid

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14
Q

What is an example of analgesics classed as mild on the WHO pain ladder?

A

NSAID like Ibuprofen + paracetamol

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15
Q

What is an example of analgesics classed as mild-moderate on the WHO pain ladder?

A

Codeine, tramadol or oxycodone

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16
Q

What is an example of analgesics classed as moderate - severe on the WHO pain ladder?

A

Morphine
Oromorph

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17
Q

What type of medication would you consider prescribing with an opioid?

A

Laxative

Counters the anti motility effect of opioids

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18
Q

What is the way to remember the causes of acute pancreatitis?

A

I GET SMASHED

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19
Q

What are the causes of acute pancreatitis?

A

I GET SMASHED

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hypercalcaemia and hyperlipidaemia
ERCP
Drugs

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20
Q

What drugs can causes acute pancreatitis?

A

Azathioprine
NSAIDs
Diuretics like thiazides and furosemide

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21
Q

What scoring system evaluates the severity of acute pancreatitis?

A

Glasgow score

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22
Q

What is the criteria for the Glasgow score for acute pancreatitis?

A

PANCREAS

Pa02< 8kPa
Age > 55
Neutrophils > 15 x 10^9
Calcium < 2mmol/l
Renal function (UREA) > 16mmol/L
Enzymes LDH > 600U/L or AST> 200U/L
Albumin < 32g/L
Sugar > 10mmol/L

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23
Q

What Glasgow score and above indicates severe pancreatitis?

A

Over 3

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24
Q

What are some systemic complications of acute pancreatitis?

A

-Acute Respiratory Distress Syndrome (ARDS)

-Hypocalcaemia (fat necrosis leads to free fatty acids react with serum calcium forming chalky deposits)

-Hyperglycaemia (Type 3c diabetes)

-DIC

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25
Q

What are some local complications of acute pancreatitis?

A

-Pancreatic necrosis

-pancreatic pseudocysts which can lead to Type 3c diabetes from autoimmune islets of langerhans destruction

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26
Q

What is given to patients which have developed Type 3c diabetes from autoimmune destruction of islets of langerhans?

A

Creon = pancreatic enzymes

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27
Q

What are the risk factors for gallstone formation?

A

5 Fs:

Forty +
Female
Fertile (pre menopausal)
Fat
Family history

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28
Q

Why can a patient with acute pancreatitis have dark urine and pale foul smelling stools?

A

Post hepatic jaundice caused by gallstone obstruction the outflow of the conjugated bilirubin into the duodenum

Gets absorbed into blood stream extreted in urine

Pancreatic enzymes dont reach intestines to digest the fats, pancreas autodigests its self

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29
Q

What is the pathophysiology of biliary colic?

A

Extreme RUQ pain when the gall bladder contracts impact a gallstone against the neck of the gallbladder

No inflammation occurs

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30
Q

What hormone stimulates contraction of the gall bladder?

What cells produce it?

Where are the located?

A

CCK

I cells

Located in the duodenum

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31
Q

What are the roles of CCK?

A

Gallbladder contraction
Pancreatic enzyme release

32
Q

What is the role of secretin?

What produces it?

Where are these cells found?

A

Regulates acidic stomach pH
Inhibits parietal cells production of gastric acid
Stimulates bicarbonate secretion from pancreas

S cells

33
Q

What is the typical presentation for biliary colic?

A

Severe RUQ pain precipitated by eating fatty spicy foods
Pain is sudden, dull, colicky

34
Q

What is the pathophysiology of acute cholecystitis?

A

Gallstone has been impacted in the cystic duct
This leads to inflammation and bile stasis
This leads to infection of the gall bladder

35
Q

What is the typical presentation of acute cholecystitis and how can you differentiate between this and biliary colic?

A

RUQ pain that is constant
Signs of infection/inflammation Fever and malaise

Pain is in waves with biliary colic and there is no signs of inflammation
Murphys sign +ve for acute cholecystitis

36
Q

How would you investigate biliary colic or acute cholecystitis?

A

Abdominal exam (Murphy’s sign?)
LFTs
U+Es
Urine dip
Pregnancy test

Imaging

37
Q

What imaging would you do for suspected biliary colic or acute cholecystitis?

A

Trans abdominal ultrasound
Or
MRCP

38
Q

What is the management for biliary colic?

A

Analgesia
Fluids

Low fat diet
Weight loss
Exercise

Elective laparoscopic cholecystectomy

39
Q

What is the management for acute cholecystitis?

A

Analgesia
Antibiotics
Antiemetics

Laparoscopic cholecystectomy with 1 week

40
Q

What are some complications of biliary colic / acute cholecystitis?

A

Mirrizzi syndrome
Gallbladder empyema
Chronic cholecystitis

41
Q

What antibiotics normally given for acute cholecystitis?

A

Co-amoxiclav or metronidazole

42
Q

What is ascending cholangitis?

A

Infection of the biliary tree likely due to an obstruction like a gallstone

43
Q

What is the triad of symptoms for ascending cholangitis?

A

Charcots triad

44
Q

What are the 3 signs seen in Charcots triad for ascending cholangitis?

A

Jaundice
RUQ pain
Fever (Inflammation/infection signs)

45
Q

What is the less common collection of signs for ascending cholangitis called?

A

Reynolds Pentad

46
Q

What is Reynolds pentad of signs for ascending cholangitis?

A

Charcots triad + hypotension + confusion

-RUQ pain
-Jaundice
-Fever
-Hypotension
-Confusion

47
Q

What is the management for ascending cholangitis?

A

Analgesia
Antiemetics
IV fluids
BROAD spec abx since can become septic (meropenem)

48
Q

What investigations are done for suspect ascending cholangitis?

A

FBCs
LFTs
Bilirubin
U+Es
Serum amylase
Urine dip
Pregnancy testing

49
Q

What imaging is used for ascending cholangitis?

A

US biliary tree
ERCP (can remove stone if cause)

50
Q

What is the definitive treatment of ascending cholangitis?

A

endoscopic biliary tree decompression

Can be done by ERCP with or without sphincterotomy and stenting

If gallstone the cause, Laparoscopic cholecystectomy

51
Q

What condition is ALWAYS a painless jaundice until proven otherwise?

A

Pancreatic cancer

52
Q

What region of the pancreas is most commonly affected by pancreatic cancer?

A

Head of pancreas

53
Q

What type of cancer is most common for pancreatic cancer?

A

Ductal adenocarcinoma

54
Q

How can pancreatic cancer present?

A

Jaundiced
Worsening back pain (non specific abdominal pain)
Decreased
Appetite
Weight loss
Dehydration
Late onset diabetes

55
Q

What are some differentials that may present similarly to pancreatic cancer?

A

Ascending cholangitis
Cholangiocarcinoma
Hepatocellular carcinoma

56
Q

What are some risk factors for pancreatic cancer?

A

Age
Male
Smoking
Obesity
T2DM

57
Q

What are you likely too find on examination with a patient with pancreatic cancer?

A

Jaundice?
RUQ smooth mass

58
Q

What investigations would you do if suspecting a potential pancreatic cancer? (Mass in RUQ)

A

FBC
LFT
U+Es
CRP
Serum amylase
Urine dip
Coagulation
G+S
CA19.9
AFP

59
Q

What is the cancer marker that is typically elevated with pancreatic cancer?

A

Ca19.9

60
Q

What cancer is the cancer marker AFP typically elevated with?

A

Hepatocellular carcinoma

(Also some non seminomatous germ cell tumours)

61
Q

Why are you testing coagulation for suspected pancreatic cancer?

A

Obstructive jaundice, prevents bile salts from reaching the duodenum

This prevents fat soluble vitamins (A, D, E, K) from being absorbed

Vitamin K is the main vitamin needed for clotting factors

62
Q

How would a pancreatic cancer potentially affect INR?

A

Would elevate it (takes longer time to clot since body can absorb less vitamin K)

63
Q

What is the management for addressing an elevated INR?

A

IV vitamin K
Cease medications like warfarin

64
Q

What can be given to a patient that needs to go to emergency theatre but has an elevated INR?

A

Prothrombin complex concentrate

65
Q

What imaging is done for suspected pancreatic cancer?

A

CT Abdo pelvis contrast
CT Chest Abdo Pelvis contrast (staging)
PET CT for staging

66
Q

What needs to be taken into consideration before giving contrast?

A

Patients renal function (give fluids before an after if. Poor renal function)
Allergies
Weight

67
Q

What is the typical management for pancreatic cancer?

A

Neoadjuvant + adjuvant chemotherapy + Whipples procedure for head of pancreas tumour

Chemotherapy for metastatic disease with ERCP and stenting to manage jaundice

68
Q

What is removed in a Whipples procedure for pancreatic cancer?

A

Head of pancreas
D1
D2
Antrum of stomach
Lymph nodes
CBD
Gall bladder

69
Q

Why are the majority of liver malignancies metastasis?

A

Portal vein drains into the liver

70
Q

What 3 major blood vessels form the portal vein?

A

Splenic vein
Superior mesenteric vein
Inferior mesenteric vein

71
Q

What are the risk factors for developing hepatocellular carcinoma?

A

Chronic inflammation of the liver

Hepatitis B or Hepatitis C infection
Liver cirrhosis (Alcoholism)
Aflatoxin
Smoking
Family history
Old

72
Q

How does hepatocellular carcinoma typically present?

A

Non specific symtpoms
Fatigue
Weight loss
Jaundice
Confusion
Ascites
Irregular enlarged liver

73
Q

What investigations should be done if suspect hepatocellular carcinoma?

A

Routine bloods
FBC
LFTs
Clotting
AFP

74
Q

What imaging is used to screen for hepatocellular carcinoma?

A

US of liver/abdomen

75
Q

What is the imaging of choice for hepatocellular carcinoma?

A

US liver

Can have MRI or CT

Can also biopsy the specimen

76
Q

What is the management for hepatocellular carcinoma?

A

Discussion in MDT

77
Q

What are the most common primary locations for liver metastasis?

A

Bowel
Lung
Pancreas
Breast

Y3(S) - General (5 decks)

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