HpB Flashcards
What is biliary colic?
Biliary colic is a sharp, severe pain located in the RUQ that typically rises to a plateau in minutes and then continues unrelentingly for several hours. It is typically brought on by the digestion of food (particularly fat heavy). The pain can resolves spontaneously or through the use of analgesics. It is caused by a transient obstruction of the gallbladder in addition to contraction.
Vomiting and nausea are commonly present. Patients are often afebrile. Attacks >24 hrs indicated acute cholecystitis
What causes cholangitis?
Cholangitis is an infection of the biliary tree. Typically caused secondary to obstruction. Acute cholangitis is a medical emergency. Gallstones cause stasis and infection ascends the system. Obstruction can also be caused from strictures or neoplasm. Cholangitis can be caused by:
choledocolithiasis, cholelithiasis, ERCP, surgically induced strictures, biliary tumours, radiation therapy
Management is with gentamicin + amoxicillin for gram negative coverage.
What are the clinical features of cholangitis?
Clinical features can be described by:
Charcot’s triad -> fever, RUQ pain, jaundice
Reynold’s pentad -> fever, RUQ pain, jaundice, altered mental status, hypotension
Fever and RUQ pain are most common. Patients rarely present with all symptoms.
What is cholecystitis?
Cholecystitis is inflammation of the gallbladder and is a major complication following cholecystitis. It develops in ~10% of patients with symptomatic gallstones. 90% of cases are due to stones, with 10% due to bile thickening/trauma.
Common features include previous episodes of biliary pain, RUQ pain, fever, +ve Murphy’s sign, palpable mass.
Complications that can arise include perforation, Mirizzi syndrome, abscess formation or fistula formation.
Confirm with USS. Surgical intervention is required in most cases. Gentamicin and amoxicillin should be given when complications are present.
What techniques are available for treating common bile duct stones?
Describe the technique briefly.
Medical management for people unfit for surgery -> chenodeoxycholic acid (bile acid)
Surgical management is gold standard:
ERCP -> identify filling defects with intra-operative cholangiogram. Stole collection with balloon, lithotripsy or sphincterotomy
Choledocotomy -> laparasopic incision in CBD then removal
Transhepatic approach -> used when CBD is very distended (e.g. head of pancreas cancer). Needle is passed through the liver
What are the potential complications of an ERCP?
Intra-operative -> anaesthetic reaction, perforation, haemorrhage (vitamin K deficiency), damage to structures
Post-operative -> infection, recurrence, pancreatitis, cholangitis, stricture formation
What are the symptoms of biliary colic?
How can it be differentiated from acute cholecystitis clinically?
Biliary colic is a constant cramping RUQ pain that rises to a plateau that lasts for several hours. Pain can resolve spontaneously or through the use of analgesics.
It can be differentiated from cholecystitis with duration <6 hours, no fever, no Murphy’s sign or peritoneal involvement.
What are the common causes of painless obstructive jaundice in a 65 year-old person?
Jaundice is the clinical presentation of hyperbilirubinaemia. Obstructive jaundice is due to blockage of bile. Causes include: head of pancreas cancer, biliary carcinoma, biliary stricture, ampullary adenoma, liver disease
Unconjugated jaundice -> haemolysis, Crigler-Najaar, Gilbert syndrome
Conjugated -> cholelithiasis, choledocolithiasis, cholangitis, Mirizzi syndrome, hepatitis, cirrhosis
How might a person with pancreatic cancer present to their GP?
Pancreatic cancer often presents as asymptomatic until the final stages. Presents as jaundice (obstruction of bile duct), weight loss, night sweats, poor food absorption, abdominal pain, nausea/vomiting, darkened urine. Ductal adenoma counts for ~85%.
Initial investigations include LFT/lipases, USS/CT,
Risk factors include FHx, high alcohol, smoking, obesity, DM
Why does a tumour of the head of pancreas cause jaundice?
What are the haematological consequences of biliary obstruction?
The CBD travels through the head of the pancreas to merge with the pancreatic duct at the ampulla of Vater where it drains into the duodenum through the sphincter of Oddi. Enlargement of the pancreas can compress the CBD and prevent bile flow through obstruction.
This results in conjugated hyperbilirubinaemia, decreased absorption of fat soluble vitamins (ADEK), prolonged PT time, obstructive hepatic pattern (increased GGT and ALP)
Why or how do gallstones cause pancreatitis?
Gallstones can cause pancreatitis through 2 different mechanisms:
Blockage of CBD causes retrograde flow of bile into the pancreas or blockage at the ampulla of Vater
The mechanism of pancreatitis is when the activity of trypsin overwhelms that of antitrypsin. Trypsinogen is the enzyme released by the pancreas that is converted to active form in the duodenum. When there is a blockage this enzyme is activated within the pancreas, leading to activation of cytokines and inflammatory signalling. This results in SIRS and organ failure if severe.
What are the common causes of pancreatitis?
Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion bites Hyperlipidaemia ERCP Drugs
How do you assess the severity of an episode of pancreatitis when the patient is first being admitted to the hospital?
P -> PaO2 lowered A -> Age >55 N -> neutrophilia (>15) C-> calcium lowered R -> renal function raised urea E -> enzymes raised (LDH, amylase) A -> albumin decreased S -> sugar increased >3 is 20% high chance of severe pancreatitis. >6 is severe pancreatitis.
What is the initial management of pancreatitis?
Pancreatitis should be managed in hospital with continuous monitoring due to risk of developing complications.
Initial management should be with IV fluid resuscitation and analgesia. There is no indication for antibiotics. Alse O2 therapy may be required and reintroduction if feeding is important.
There is no role for surgery during the acute attack, unless the cause is gallstones. If this is the case then ERCP/cholecystectomy should be performed on same admission after recovery.
In severe acute pancreatitis, patients should undergo therapeutic ERCP within 72 hours of onset of pain. Sphincterotomy is always required.
What are the potential late complications of severe, acute pancreatitis, late being two or three weeks after the start of the episode?
Pancreatic necrosis (results in DM, intestinal malabsorption), pancreatic pseudocyst, pancreatic abscess, splenic vein thrombosis, enteric fistula, ileus resulting in obstruction, pseudoaneurysm Things of variable timeframe include: sepsis, MODS, retroperitoneal bleeding, infected pancreatic necrosis.
