HPB Flashcards by Callum Donoher

What is the typical presentation of acute pancreatitis?

Epigastric pain radiating to the back

May be jaundiced

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Why may an acute pancreatitis be jaundiced?

If it’s an obstructive cause of Pancreatitis like gallstones

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What would be looking for on examination for acute pancreatitis?

Jaundiced
Epigastric tenderness (radiates to back)
Cullens
Grey turners

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

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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What investigations would you do to assess for acute pancreatitis?

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

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

X3 the baseline

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What imaging is used to assess for acute pancreatitis?

USS abdomen if its available

CT Abdo pelvis with IV contrast

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

ERCP

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Where does an ERCP travel?

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

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What is the management process for acute pancreatitis?

Supportive is the only option if its not caused by gallstones

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What is the supportive management of acute pancreatitis?

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

ERCP
Laparoscopic cholecystectomy

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What is the WHO pain ladder?

Order we give analgesia

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

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

NSAID like Ibuprofen + paracetamol

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

Codeine, tramadol or oxycodone

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

Morphine
Oromorph

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

Laxative

Counters the anti motility effect of opioids

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

I GET SMASHED

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What are the causes of acute pancreatitis?

I GET SMASHED

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

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What drugs can causes acute pancreatitis?

Azathioprine (immunosuppressants)
Mesalazine
Steroids
NSAIDs
Diuretics like thiazides and furosemide
Tetracyclines
Metronidazole

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What scoring system evaluates the severity of acute pancreatitis?

Glasgow score

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

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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What Glasgow score and above indicates severe pancreatitis?

Over 3

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What are some systemic complications of acute pancreatitis?

-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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What are some local complications of acute pancreatitis?

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

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

Creon = pancreatic enzymes

What are the risk factors for gallstone formation?

5 Fs: Forty + Female Fertile (pre menopausal) Fat Family history

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

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

What is the pathophysiology of biliary colic?

Extreme RUQ pain when the gall bladder contracts impact a gallstone against the neck of the gallbladder No inflammation occurs

What hormone stimulates contraction of the gall bladder? What cells produce it? Where are the located?

CCK I cells Located in the duodenum

What are the roles of CCK?

Gallbladder contraction Pancreatic enzyme release

What is the role of secretin? What produces it? Where are these cells found?

Regulates acidic stomach pH Inhibits parietal cells production of gastric acid Stimulates bicarbonate secretion from pancreas S cells located in the duodenum

What is the typical presentation for biliary colic?

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

What is the pathophysiology of acute cholecystitis?

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

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

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

How would you investigate biliary colic or acute cholecystitis?

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

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

Trans abdominal ultrasound Or MRCP

What is the management for biliary colic?

Analgesia Fluids Low fat diet Weight loss Exercise Elective laparoscopic cholecystectomy

What is the management for acute cholecystitis?

Analgesia Antibiotics Antiemetics Laparoscopic cholecystectomy with 1 week

What are some complications of biliary colic / acute cholecystitis?

Mirrizzi syndrome Gallbladder empyema Chronic cholecystitis

What antibiotics normally given for acute cholecystitis?

Co-amoxiclav or metronidazole

What is ascending cholangitis?

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

What is the triad of symptoms for ascending cholangitis?

Charcots triad

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

Jaundice RUQ pain Fever (Inflammation/infection signs)

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

Reynolds Pentad

What is Reynolds pentad of signs for ascending cholangitis?

Charcots triad + hypotension + confusion -RUQ pain -Jaundice -Fever -Hypotension -Confusion

What is the management for ascending cholangitis?

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

What investigations are done for suspect ascending cholangitis?

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

What imaging is used for ascending cholangitis?

US biliary tree ERCP (can remove stone if cause)

What is the definitive treatment of ascending cholangitis?

endoscopic biliary tree decompression Can be done by ERCP with or without sphincterotomy and stenting If gallstone the cause, Laparoscopic cholecystectomy

What condition is ALWAYS a painless jaundice until proven otherwise?

Pancreatic cancer

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

Head of pancreas

What type of cancer is most common for pancreatic cancer?

Ductal adenocarcinoma

How can pancreatic cancer present?

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

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

Ascending cholangitis Cholangiocarcinoma Hepatocellular carcinoma

What are some risk factors for pancreatic cancer?

Age Male Smoking Obesity T2DM

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

Jaundice? RUQ smooth mass

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

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

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

Ca19.9

What cancer is the cancer marker AFP typically elevated with?

Hepatocellular carcinoma (Also some non seminomatous germ cell tumours)

Why are you testing coagulation for suspected pancreatic cancer?

Obstructive jaundice, prevents bile salts from reaching the duodenum This prevents fat soluble vitamins (A, D, E, K) from being absorbed at the TERMINAL ILEUM Vitamin K is the main vitamin needed for clotting factors

How would a pancreatic cancer potentially affect INR?

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

What is the management for addressing an elevated INR?

IV vitamin K Cease medications like warfarin

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

Prothrombin complex concentrate

What imaging is done for suspected pancreatic cancer?

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

What needs to be taken into consideration before giving contrast?

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

What is the typical management for pancreatic cancer?

Neoadjuvant + adjuvant chemotherapy + Whipples procedure for head of pancreas tumour Chemotherapy for metastatic disease with ERCP and stenting to manage jaundice

What is removed in a Whipples procedure for pancreatic cancer?

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

Why are the majority of liver malignancies metastasis?

Portal vein drains into the liver

What 3 major blood vessels form the portal vein?

Splenic vein Superior mesenteric vein Inferior mesenteric vein

What are the risk factors for developing hepatocellular carcinoma?

Chronic inflammation of the liver Hepatitis B or Hepatitis C infection Liver cirrhosis (Alcoholism) Aflatoxin Smoking Family history Old

How does hepatocellular carcinoma typically present?

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

What investigations should be done if suspect hepatocellular carcinoma?

Routine bloods FBC LFTs Clotting AFP

What imaging is used to screen for hepatocellular carcinoma?

US of liver/abdomen

What is the imaging of choice for hepatocellular carcinoma?

US liver Can have MRI or CT Can also biopsy the specimen

What is the management for hepatocellular carcinoma?

Discussion in MDT

What are the most common primary locations for liver metastasis?

Bowel Lung Pancreas Breast