HPB

Question 1

causes of pancreatitis

Answer 1

I GET SMASHED
Idiopathic

Gallstones
Ethanol
Trauma (blunt)

Steroids
Mumps
Autoimmune
Scorpion sting - the Trinidad titus trinitatis
Hyperlipidaemia, hypercalcaemia, hyperparathyroidism
ERCP
Drugs - azathioprine

Question 2

LFTs

Answer 2

raised ALT = specific hepatocyte damage
raised AST = hepatocyte, skeletal and cardiac damage 
AST:ALT >2 = alcoholic liver disease, <1 possibly viral 
raised ALP = cholestasis or bone 
raised gamma GT = alcoholic liver disease 
reduced prothrombin time = liver damage
reduced albumin (caused increased cholesterol) = liver damage

Question 3

causes of jaundice

Answer 3

pre-hepatic (unconjugated hyperbilirubinaemia) –> haemolytic anaemia, malaria, DIC, Gilbert’s/ Criggle-Najjar syndrome
hepatic (mixed hyperbilirubinaemia) –> hepatitis, cirrhosis, syphilis, alcoholic liver disease, HCC, medications
post-hepatic (conjugated hypernilirubinaemia) –> luminal: gallstones, mural: cholangiocarcinoma, strictures, extra-mural: pancreatic cancer, lymphoma

Question 4

ascending cholangitis

Answer 4

fever, RUQ pain, jaundice (+ hypotension and confusion)
IV Ax and ERCP after 24-48hrs
caused by bacterial infection of biliary tree often ppt by impacted gallstones

Question 5

biliary colic

Answer 5

postprandial (fatty) RUQ abdo pain with N&V, pain radiates to interscapular region (if diaphragm is irritated)
caused by gallstones in bile duct

DDx are acute cholecystitis but there is no fever or raised inflammatory markers

Question 6

acute cholecystitis

Answer 6

RUQ pain with fever and raised inflammatory markers
caused by inflammation/ infection secondary to impacted gallstones
+ve Murphy’s sign

Question 7

acute pancreatitis

Answer 7

very severe epigastric pain that may radiate to the back

O/E tenderness, ileus and low grade fever

Question 8

assessing severity of pancreatitis

Answer 8

PANCREAS need >3 
PaO2 <8kPa
Age >55
Neutrophils >15x10^9/L
Calcium <2mmol/L
Renal function - urea >16mmol/L
Enzymes LDH>600iU/L / AST>2000iU/L
Albumin <32g/L
Sugar >10mmol/L of glucose

Question 9

gallstone types

Answer 9

cholesterol (yellow, softer)
bile pigment (dark brown/black)
mixed

Question 10

pancreatic cancer

Answer 10

95% are adenocarcinomas
weight loss, painless jaundice, malaise

only ~ 20% are resectable by Whipple’s
raised CA19-9
USS, CT CAP, PET scan, MRI and laparoscopy to look for micromets on peritoneum

–> IVI, analgesia, CREON. ursodeoxycholic acid, vitamin K, chlorphenamine, thrombophrophlaxis, chemotherapy and nutritional support

Question 11

what feature of LTFs is present in carcinoma of the head of the pancreas?

Answer 11

the LFTs become deranged

Question 12

Hepatitis Screen

Answer 12

HBsAg +ve if CURRENTLY infected

anti-HBsAg +ve if RESOLVED infection or IMMUNISED

IgA anti-HBsAg +ve if CHRONICALLY or PREVIOUSLY infected as takes a while to become positive

Question 13

Wilson’s disease

Answer 13

an autosomal dominant disorder characterised by excessive copper deposition in the tissues
increased copper absorption and reduced hepatic copper excretion = reduced serum copper and increased urinary copper
onset of symptoms between 10-25 y/o in kids more likely to be liver disease (hepatitis, cirrhosis)
whereas adults present with neurological disease (basal ganglia degeneration, speech and behavioural problems)
treatment is penicillamine to chelate the copper

Question 14

haemochromatosis

Answer 14

autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation
bronze skin pigmentation
Rx: venesection