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Yr3 - General Surgery > HPB > Flashcards

HPB Flashcards

1
Q

Define jaundice

A

Yellow discolouration of sclera and skin

Due to hyperbilirubinaemia

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2
Q

Pathophysiology of jaundice

A

High levels of bilirubin in blood
Normal breakdown product from catabolism of haem
Normally conjugated within liver - water-soluble
Excreted via bile into GI tract

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3
Q

Types of jaundice

A 
Pre-hepatic 
- excessive red cell breakdown
- unconjugated bilirubin
Hepatocellular
- dysfunction of hepatic cells
- mixed bilirubin
Post-hepatic
- obstruction of biliary drainage
- conjugated bilirubin
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4
Q

Causes of pre-hepatic jaundice

A

Haemolytic anaemia
Gilbert’s syndrome
Criggler-Najjar syndrome

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5
Q

Causes of hepatocellular jaundice

A 
Alcoholic liver disease 
Viral hepatitis
Iatrogenic - medication
Hereditary haemochromatosis
Autoimmune hepatitis
PBC or PSC
Hepatocellular carcinoma
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6
Q

Causes of post-hepatic jaundice

A 
Intraluminal 
- gallstones
Mural
- cholangiocarcinoma
- strictures
- drug-induced cholestasis
Extra-mural
- pancreatic cancer
- abdominal masses
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7
Q

Investigations for jaundice

A

LFTs
- AST and ALT raised in hepatocellular injury
- ALP raised in biliary obstruction
- Gamma-GT more specific for biliary obstruction
Coagulation studies
FBC - anaemia, raised MCV and thrombocytopenia seen in liver disease
Bilirubin
Albumin - marker of liver synthesising function
USS abdomen
MRCP
Liver biopsy

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8
Q

Management of jaundice

A

ERCP - gallstone removal
Symptomatic treatment for itching
Identify and manage complications
Monitor for coagulopathy

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9
Q

Define a simple liver cysts

A

Fluid-filled epithelial-lined sacs
Most commonly in the right lobe
Thought to be due to congenitally malformed bile duct cells

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10
Q

Clinical features of simple liver cysts

A

Normally asymptomatic - often detect incidentally

Abdominal pain, nausea and early satiety

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11
Q

Investigations for simple liver cysts

A

LFTs normal - may have raised GGT
USS imaging
- anechoic
- well-defined
- thin-walled
- oval/spherical lesions with no septations
- strong posterior wall acoustic enchancement

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12
Q

Management of simple cysts

A

< 4cm - no intervention
> 4cm - USS follow-up at 3,6 and 12 months
USS guided aspiration
Laparoscopic de-roofing

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13
Q

Define polycystic liver disease

A

Presence of > 20 cysts within the liver parechyma
Caused by
- Autosomal dominant polycystic kidney disease
- Autosomal dominant polycystic liver disease

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14
Q

Clinical features of polycystic liver disease

A

Majority asymptomatic

Abdominal pain as cysts grow in size

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15
Q

Investigations for polycystic liver disease

A

Normal LFTs

USS imaging - demonstrates multiple cysts

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16
Q

Management of polycystic liver disease

A

Asymptomatic left alone
Somatostatin analogues
USS guided aspiration
Laparacopic de-roofing of cysts

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17
Q

Define a cystic neoplasm

A

Cystadenoma - non-invasive mucinous cystic neoplasms

Premalignant lesions

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18
Q

Clinical features of cystic neoplasms

A

Asymptomatic
Abdominal pain
Anorexia

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19
Q

Investigations for cystic neoplasms

A

LFTs are normal

CT imaging with contrast

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20
Q

Management for cystic neoplasm

A

Liver lobe resection

Avoid aspiration or biopsy - potential peritoneal seeding

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21
Q

Define a liver absces

A

Polymicrobial bacterial infection spread from biliary or gastrointestinal tract

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22
Q

Common causes of liver absces

A 
Cholecystitis
Cholangitis
Diverticulitits
Appendicitis
Septicaemia
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23
Q

Common causative organisms of liver abscesses

A

E.coli
K.pneumoniae
S.constellatus

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24
Q

Clinical features of liver abscesses

A 
Fever
Rigors
Abdo pain
RUQ tenderness +/- hepatomegaly
Shock if ruptures
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25
Q

Investigations for liver abcesses

A 
FBC - leucocytosis
Raised ALP
Peripheral blood and fluid cultures
USS - poor-defined lesions
CT imaging with contrast
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26
Q

Management of liver abcesses

A

Appropriate antibiotic therapy

Image-guided aspiration of abcess

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27
Q

Are the majority of liver tumours primary or metastatic?

A

Metastatic 90%

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28
Q

How does hepatocellular carcinoma forms?

A

Chronic inflammatory process of the liver

  • viral hepatitis
  • chronic alcoholism
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29
Q

Risk factors for hepatocellular carcinoma

A 
Viral hepatitis - B and C
High alcohol intake
Smoking
Advanced age
Aflatoxin exposure
Family history of liver disease
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30
Q

Clinical features of hepatocellular cancer

A

Liver cirrhosis
Dull ache in RUQ
Irregular, enlarged, craggy and tender liver on examination

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31
Q

Investigations for hepatocellular cancer

A 
LFTs
Low platelets
Prolonged clotting
USS
Staging CT
Biopsy or percutaneous fine-needle aspiration
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32
Q

Management of hepatocellular cancer

A

Surgical resection
Transplantation
Image guided ablation
Transarterial chemoembolisation - high concentrations of chemotherapy drugs injected directly into hepatic artery and embolising agent to induce ischaemia

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33
Q

Common cancers to metastasise to the liver

A 
Bowel 
Breast
Pancreas
Stomach
Lung
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34
Q

Causes of acute pancreatitis

A 
Gallstones
Alcohol
Trauma
Steroids
Mumps
Autoimmune disease - SLE
Hypercalcaemia
ERCP
Drugs - azathioprine, NSAIDs or Diuretics
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35
Q

Pathogenesis of acute pancreatitis

A

Premature and exaggerated activation of digestive enzymes within the pancreas
Pancreatic inflammatory response
Enzymes released into systemic circulation
Auto-digestion of fats and blood vessels
Necrosis of pancreas

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36
Q

Clinical features of acute pancreasitis

A 
Severe epigastric pain - radiated to back
N+V
Epigastric tenderness
Soft abdomen with normal bowel sounds
Grey-Turner’s and Cullen’s sign
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37
Q

Investigations for acute pancreatitis

A 
Serum amylase - 3x upper limit 
LFTs
Serum lipase
USS abdomen
AXR - sentinal loop sign
Contrast-enhanced CT scan - pancreatic oedema and swelling
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38
Q

Management of acute pancreatitis

A 
High-flow oxygen
IV fluid resuscitation
Nasogastric tube - if vomiting profusely
Catheterisation + fluid chart
Opioid analgesia
Broad spectrum antibiotic
Treat underlying cause
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39
Q

Complications of acute pancreatitis

A 
DIC
ARDS
Hypocalaemia
Hyperglycaemia
Hypovolemic shock and multiorgan failure
Pancreatic necrosis
Pancreatic pseudocyst
40
Q

Define chronic pancreatitis

A

Chronic fibro-inflammatory disease of the pancreas with progressive and irreversible damage to the pancreatic parenchyma

41
Q

Causes of chronic pancreatitis

A 
Chronic alcohol abuse - 60%
Idiopathic - 30%
Metabolic
- hyperlipidaemia
- hypercalcaemia
Infection
- viral - HIV, mumps
- bacterial - echinococcus
Hereditary
- cystic fibrosis
Autoimmune
- autoimmune pancreatitis
- SLE
Obstruction
- stricture formation
- neoplasm
Congenital
- pancreas divisum
- annular pancreas
42
Q

Forms of chronic pancreatitis

A

Large duct disease - dilation and dysfunction of pancreatic ducts
Small duct disease - associated with normal imaging

43
Q

Risk factors for chronic pancreatitis

A

Excess alcohol consumption

Smoking

44
Q

Clinical features of chronic pancreatitis

A 
Chronic pain
- epigastruim radiating to the back
- eased by leaning forward
- a/w N+V
Endocrine dysfunction
- DM
Exocrine dysfunction
- steatorrhoea
- malabsorption
45
Q

Signs of physical examination of chronic pancreatitis

A

Epigastric tenderness

Fullness/mass in epigastrium - pseudocyst or inflammatory mass

46
Q

Investigations for chronic pancreatitis

A

BM - raised glucose
Serum calcium - hypercalaemia
LFTs - abnormal
Faecal elastase level - low

47
Q

Imaging for chronic pancreatitis

A

Abdo USS
CT abdo-pelvis
MRCP - biliary obstruction
ERCP

48
Q

Management for chronic pancreatitis

A 
Initial
- simple analgesia plus opioid
- pancreatic enzyme supplements
Definitive
- avoidance of precipitating factor
- management of chronic pain
- nutritional support
49
Q

Surgical management of chronic pancreatitis

A 
Endoscopic
- ERCP
- EUS - drainage of pseudocysts
- Pancreatis sphincterotmy
Surgical
- lateral pancreaticojejunostomy
- pancreaticoduodenectomy  (Whipple's)
- total pancreatectomy
Steriods
- reduce symptoms when autoimmune aetiology
50
Q

Complications of chronic pancreatisis

A 
Pseudocyst
Steatorrhoea and malabsorption
Diabetes
Effusions
Pancreatic malignancy
51
Q

Pathophysiology of pancreatic cancer

A

Ductal carcinoma
Spreads by direct invasion of local structures - spleen, transverse colon, adrenal glands
Lymphatic metastasis - regional lymph nodes, liver, lungs and peritoneum

52
Q

Risk factors for pancreatic cancer

A 
Smoking
Chronic pancreatitis
Recent onset of diabetes mellitus
Family history
Late onset diabetes
53
Q

Clinical presentation of pancreatic carcinoma

A 
Depends on site of tumour
Head of pancreas
- obstructive jaundice
- adbo pain
- weight loss
Cachectic, malnourished and jaundiced on examination
Palpable abdominal mass
54
Q

Courvoisier’s Law

A

Presence of jaundice and an enlarged/palpable gallbladder - malignancy of the biliary tree or pancreas should be strongly suspected

55
Q

Investigations for pancreatic cancer

A 
Anaemia, thrombocytopenia, raised bilirubin, ALP and gamma-GT
CA19-9
Abdo USS
Pancreatic CT
EUS - fine needle aspiration biopsy
56
Q

Management of pancreatic cancer

A 
Radical resection
- Whipple's for head
- distal pancreatectomy
Chemotherapy
- 5-flourouracil
Palliative
- chemotherapy
- ERCP stent
- enzyme replacement
57
Q

Define pancreatic cyst

A

Collections of fluid that form within the pancreas

58
Q

Classification of pancreatic cysts

A

Serous - low malignancy risk

Mucinous - high malignancy risk

59
Q

Presentation of pancreatic cysts

A

Asymptomatic
Abdominal pain or back pain - mass effect and compression
Post-obstructive jaundice
Vomiting

60
Q

Define pancreatic pseudocyst

A

Collection of fluid within the pancreatic tissue

Formed by inflammatory reaction producing necrotic space which fills with pancreatic fluid

61
Q

Imaging of pancreatic cyst

A

Pancreatic protocol CT scan

Magnetic resonance cholangiopancreatography

62
Q

Imaging features of low risk pancreatic cysts

A

Diameter < 3cm
Cystic morphology with central calcification
Asymptomatic

63
Q

Imaging features of high risk pancreatic cysts

A

Cyst diameter > 3cm
Main pancreatic duct dilation greater than 10mm
Enhancing solid component
Non-enhancing mural nodule

64
Q

Pancreatic cyst management

A

Surveillance

Resection

65
Q

Types of gallstones

A 
Cholesterol stones
- pure cholesterol - excess production
- poor diet and obesity
Pigment stones
- bile pigments - excess production
- haemolytic anaemia
Mixed
66
Q

Risk factors for gallstones

A 
Fat
Female
Fertile
Forty
Family history
Pregnancy
Oral contraceptives
67
Q

Clinical features of gallstones

A

Asymptomatic
Biliary colic
Acute cholecystitis

68
Q

Features of biliary colic

A

Gallbladder neck becomes impacted by gallstone

- no inflammatory response

69
Q

Presentation of biliary colic

A

Sudden, dull and colicky pain
RUQ - radiated to epigastrium or back
Precipitated by consumption of fatty foods
N+V

70
Q

Presentation of acute choecystitis

A

Constant pain - persistent despite pain relief
Signs of infection - fever, raised WCC
Derangement of liver function tests

71
Q

Murphy’s sign

A

Apply pressure to RUQ and ask patient to inspire

Positive when halt in inspiration due to pain -> inflamed gallbladder

72
Q

Investigations for gallstones

A 
FBC and CRP - inflammation
U&amp;Es - dehydration
LFTs
Amylase - pancreatitis
Trans-abdominal USS
- presence of gallstones
- gallbladder wall thickness
- bile duct dilation
73
Q

Management of biliary colic

A 
Analgesia - NSAIDs and PRN + anti-emetic
Advised about lifestyle factors
Elective cholecystectomy 
- high chance of recurrence
- development of complications
74
Q

Management of acute cholecystitis

A 
IV antibiotics - co-amoxiclav +/- metronidazole
Fluid resuscitation
NG tube + NBM if vomiting
Cholecystectomy
- laparoscopic 
- percutaneous
75
Q

Complications of gallstones

A

Gallbladder empyema
- abscess within gallbladder
Chronic choleystitis
- chronic inflammation
Gallstone ileus
- fistula between gallbladder wall and duodenum
- stone impacts and obstructs at terminal ileum

76
Q

Define cholangitis

A

Infection of the biliary tract

77
Q

Causes of cholangitis

A

Occlusion of biliary tree

  • gallstones
  • ERCP
  • cholangiocarcinoma
78
Q

Common infective organisms of cholangitis

A

Escherichia coli
Klebsiella species
Enterococcus

79
Q

Clinical features of cholangitis

A 
Charcots Triad
- RUQ pain
- fever
- jaundice
Reynold's Pentad
- jaundice
- fever
- RUQ pain
- hypotension
- confusion
80
Q

Investigations for cholangitis

A 
FBC - leucocytosis
LFTs - raised ALP +/- GGT and raised bilirubin
Blood cultures
USS of biliary tract
- bile duct dilation
ERCP
81
Q

Management of cholangitis

A

Sepsis 6
Endoscopic biliary decompression
- ERCP

82
Q

Define cholangiocarcinoma

A

Cancer of biliary system

- common site is bifurcation of right and left hepatic ducts

83
Q

Risk factors for cholangiocarcinoma

A 
Primary sclerosing cholangitis
Ulcerative colitis
Infective - HIV, hepatitis
Toxins - rubber and aircraft industry
Congential 
Alcohol excess
Diabetes mellitus
84
Q

Clinical features of cholangiocarcinoma

A

Asymptomatic till late stage
Post-hepatic jaundice and pruritus
Pale stools and dark urine

85
Q

Investigations for cholangiocarcinoma

A 
Blood for obstructive jaundice
Tumour markers CEA and CA19-9
USS
MRCP
CT - staging
86
Q

Management of cholangiocarcinoma

A 
Surgery - complete surgical resection
- partial hepatectomy and biliary tree reconstruction
- pancreaticoduodenectomy (Whipple's)
Radiotherpay
Palliative
- stenting - ERCP
- surgery - bypass
- medical - radio and chemotherapy
87
Q

Complications of cholangiocarcinoma

A

Biliary tract sepsis

Secondary biliary cirrhosis

88
Q

Causes of splenic infarct

A

Occlusion of splenic artery

  • haematological disease
    • leukaemia or lymphoma
    • sickle cell disease
  • embolic disease
    • AF
    • endocarditis
89
Q

Features of splenic infarct

A

LUQ pain - radiating to shoulder
Fever, N+V
Asymptomatic

90
Q

Investigations for splenic infarct

A

CT abdominal scan with IV contrast

91
Q

Management of splenic infarct

A

Analgesia and IV hydration

Identify and treat cause

92
Q

Complications of splenic infarct

A

Abscess

Auto-splenectomy

93
Q

Features of splenic rupture

A

Abdominal pain - radiating to left shoulder due to free blood irritating diaphragm
Hypovolaemic shock
LUQ tenderness

94
Q

Investigations for splenic rupture

A

Immediate laparotomy - haemodynamically unstable pts with peritonism
Urgent CT chest-abdo-pelvis with IV contrast

95
Q

Management of splenic rupture

A

Urgent lapartomy
Conservative - strict bed rest and repeat CT scan at 1-week
Prophylactic vaccinations

96
Q

Complications of treatment of splenic rupture

A

Ongoing bleeding
Splenic necrosis
Splenic abscess or cyst formation
Thromboyctosis

97
Q

Define OPSI

A

Overwhelming post-splenectomy infection

  • asplenic patients are unable to mount normal immunological response -> overwhelming sepsis
  • prophylactic vaccinations against
    • pneumococcus
    • meningococcus
    • H.influenzae
  • prophylactic penicillin

Yr3 - General Surgery (17 decks)

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