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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
Investigations for liver abcesses
``` FBC - leucocytosis Raised ALP Peripheral blood and fluid cultures USS - poor-defined lesions CT imaging with contrast ```
26
Management of liver abcesses
Appropriate antibiotic therapy | Image-guided aspiration of abcess
27
Are the majority of liver tumours primary or metastatic?
Metastatic 90%
28
How does hepatocellular carcinoma forms?
Chronic inflammatory process of the liver - viral hepatitis - chronic alcoholism
29
Risk factors for hepatocellular carcinoma
``` Viral hepatitis - B and C High alcohol intake Smoking Advanced age Aflatoxin exposure Family history of liver disease ```
30
Clinical features of hepatocellular cancer
Liver cirrhosis Dull ache in RUQ Irregular, enlarged, craggy and tender liver on examination
31
Investigations for hepatocellular cancer
``` LFTs Low platelets Prolonged clotting USS Staging CT Biopsy or percutaneous fine-needle aspiration ```
32
Management of hepatocellular cancer
Surgical resection Transplantation Image guided ablation Transarterial chemoembolisation - high concentrations of chemotherapy drugs injected directly into hepatic artery and embolising agent to induce ischaemia
33
Common cancers to metastasise to the liver
``` Bowel Breast Pancreas Stomach Lung ```
34
Causes of acute pancreatitis
``` Gallstones Alcohol Trauma Steroids Mumps Autoimmune disease - SLE Hypercalcaemia ERCP Drugs - azathioprine, NSAIDs or Diuretics ```
35
Pathogenesis of acute pancreatitis
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
36
Clinical features of acute pancreasitis
``` Severe epigastric pain - radiated to back N+V Epigastric tenderness Soft abdomen with normal bowel sounds Grey-Turner’s and Cullen’s sign ```
37
Investigations for acute pancreatitis
``` Serum amylase - 3x upper limit LFTs Serum lipase USS abdomen AXR - sentinal loop sign Contrast-enhanced CT scan - pancreatic oedema and swelling ```
38
Management of acute pancreatitis
``` High-flow oxygen IV fluid resuscitation Nasogastric tube - if vomiting profusely Catheterisation + fluid chart Opioid analgesia Broad spectrum antibiotic Treat underlying cause ```
39
Complications of acute pancreatitis
``` DIC ARDS Hypocalaemia Hyperglycaemia Hypovolemic shock and multiorgan failure Pancreatic necrosis Pancreatic pseudocyst ```
40
Define chronic pancreatitis
Chronic fibro-inflammatory disease of the pancreas with progressive and irreversible damage to the pancreatic parenchyma
41
Causes of chronic pancreatitis
``` 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
Forms of chronic pancreatitis
Large duct disease - dilation and dysfunction of pancreatic ducts Small duct disease - associated with normal imaging
43
Risk factors for chronic pancreatitis
Excess alcohol consumption | Smoking
44
Clinical features of chronic pancreatitis
``` Chronic pain - epigastruim radiating to the back - eased by leaning forward - a/w N+V Endocrine dysfunction - DM Exocrine dysfunction - steatorrhoea - malabsorption ```
45
Signs of physical examination of chronic pancreatitis
Epigastric tenderness | Fullness/mass in epigastrium - pseudocyst or inflammatory mass
46
Investigations for chronic pancreatitis
BM - raised glucose Serum calcium - hypercalaemia LFTs - abnormal Faecal elastase level - low
47
Imaging for chronic pancreatitis
Abdo USS CT abdo-pelvis MRCP - biliary obstruction ERCP
48
Management for chronic pancreatitis
``` Initial - simple analgesia plus opioid - pancreatic enzyme supplements Definitive - avoidance of precipitating factor - management of chronic pain - nutritional support ```
49
Surgical management of chronic pancreatitis
``` Endoscopic - ERCP - EUS - drainage of pseudocysts - Pancreatis sphincterotmy Surgical - lateral pancreaticojejunostomy - pancreaticoduodenectomy (Whipple's) - total pancreatectomy Steriods - reduce symptoms when autoimmune aetiology ```
50
Complications of chronic pancreatisis
``` Pseudocyst Steatorrhoea and malabsorption Diabetes Effusions Pancreatic malignancy ```
51
Pathophysiology of pancreatic cancer
Ductal carcinoma Spreads by direct invasion of local structures - spleen, transverse colon, adrenal glands Lymphatic metastasis - regional lymph nodes, liver, lungs and peritoneum
52
Risk factors for pancreatic cancer
``` Smoking Chronic pancreatitis Recent onset of diabetes mellitus Family history Late onset diabetes ```
53
Clinical presentation of pancreatic carcinoma
``` Depends on site of tumour Head of pancreas - obstructive jaundice - adbo pain - weight loss Cachectic, malnourished and jaundiced on examination Palpable abdominal mass ```
54
Courvoisier's Law
Presence of jaundice and an enlarged/palpable gallbladder - malignancy of the biliary tree or pancreas should be strongly suspected
55
Investigations for pancreatic cancer
``` Anaemia, thrombocytopenia, raised bilirubin, ALP and gamma-GT CA19-9 Abdo USS Pancreatic CT EUS - fine needle aspiration biopsy ```
56
Management of pancreatic cancer
``` Radical resection - Whipple's for head - distal pancreatectomy Chemotherapy - 5-flourouracil Palliative - chemotherapy - ERCP stent - enzyme replacement ```
57
Define pancreatic cyst
Collections of fluid that form within the pancreas
58
Classification of pancreatic cysts
Serous - low malignancy risk | Mucinous - high malignancy risk
59
Presentation of pancreatic cysts
Asymptomatic Abdominal pain or back pain - mass effect and compression Post-obstructive jaundice Vomiting
60
Define pancreatic pseudocyst
Collection of fluid within the pancreatic tissue | Formed by inflammatory reaction producing necrotic space which fills with pancreatic fluid
61
Imaging of pancreatic cyst
Pancreatic protocol CT scan | Magnetic resonance cholangiopancreatography
62
Imaging features of low risk pancreatic cysts
Diameter < 3cm Cystic morphology with central calcification Asymptomatic
63
Imaging features of high risk pancreatic cysts
Cyst diameter > 3cm Main pancreatic duct dilation greater than 10mm Enhancing solid component Non-enhancing mural nodule
64
Pancreatic cyst management
Surveillance | Resection
65
Types of gallstones
``` Cholesterol stones - pure cholesterol - excess production - poor diet and obesity Pigment stones - bile pigments - excess production - haemolytic anaemia Mixed ```
66
Risk factors for gallstones
``` Fat Female Fertile Forty Family history Pregnancy Oral contraceptives ```
67
Clinical features of gallstones
Asymptomatic Biliary colic Acute cholecystitis
68
Features of biliary colic
Gallbladder neck becomes impacted by gallstone | - no inflammatory response
69
Presentation of biliary colic
Sudden, dull and colicky pain RUQ - radiated to epigastrium or back Precipitated by consumption of fatty foods N+V
70
Presentation of acute choecystitis
Constant pain - persistent despite pain relief Signs of infection - fever, raised WCC Derangement of liver function tests
71
Murphy's sign
Apply pressure to RUQ and ask patient to inspire | Positive when halt in inspiration due to pain -> inflamed gallbladder
72
Investigations for gallstones
``` FBC and CRP - inflammation U&Es - dehydration LFTs Amylase - pancreatitis Trans-abdominal USS - presence of gallstones - gallbladder wall thickness - bile duct dilation ```
73
Management of biliary colic
``` Analgesia - NSAIDs and PRN + anti-emetic Advised about lifestyle factors Elective cholecystectomy - high chance of recurrence - development of complications ```
74
Management of acute cholecystitis
``` IV antibiotics - co-amoxiclav +/- metronidazole Fluid resuscitation NG tube + NBM if vomiting Cholecystectomy - laparoscopic - percutaneous ```
75
Complications of gallstones
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
Define cholangitis
Infection of the biliary tract
77
Causes of cholangitis
Occlusion of biliary tree - gallstones - ERCP - cholangiocarcinoma
78
Common infective organisms of cholangitis
Escherichia coli Klebsiella species Enterococcus
79
Clinical features of cholangitis
``` Charcots Triad - RUQ pain - fever - jaundice Reynold's Pentad - jaundice - fever - RUQ pain - hypotension - confusion ```
80
Investigations for cholangitis
``` FBC - leucocytosis LFTs - raised ALP +/- GGT and raised bilirubin Blood cultures USS of biliary tract - bile duct dilation ERCP ```
81
Management of cholangitis
Sepsis 6 Endoscopic biliary decompression - ERCP
82
Define cholangiocarcinoma
Cancer of biliary system | - common site is bifurcation of right and left hepatic ducts
83
Risk factors for cholangiocarcinoma
``` Primary sclerosing cholangitis Ulcerative colitis Infective - HIV, hepatitis Toxins - rubber and aircraft industry Congential Alcohol excess Diabetes mellitus ```
84
Clinical features of cholangiocarcinoma
Asymptomatic till late stage Post-hepatic jaundice and pruritus Pale stools and dark urine
85
Investigations for cholangiocarcinoma
``` Blood for obstructive jaundice Tumour markers CEA and CA19-9 USS MRCP CT - staging ```
86
Management of cholangiocarcinoma
``` Surgery - complete surgical resection - partial hepatectomy and biliary tree reconstruction - pancreaticoduodenectomy (Whipple's) Radiotherpay Palliative - stenting - ERCP - surgery - bypass - medical - radio and chemotherapy ```
87
Complications of cholangiocarcinoma
Biliary tract sepsis | Secondary biliary cirrhosis
88
Causes of splenic infarct
Occlusion of splenic artery - haematological disease - leukaemia or lymphoma - sickle cell disease - embolic disease - AF - endocarditis
89
Features of splenic infarct
LUQ pain - radiating to shoulder Fever, N+V Asymptomatic
90
Investigations for splenic infarct
CT abdominal scan with IV contrast
91
Management of splenic infarct
Analgesia and IV hydration | Identify and treat cause
92
Complications of splenic infarct
Abscess | Auto-splenectomy
93
Features of splenic rupture
Abdominal pain - radiating to left shoulder due to free blood irritating diaphragm Hypovolaemic shock LUQ tenderness
94
Investigations for splenic rupture
Immediate laparotomy - haemodynamically unstable pts with peritonism Urgent CT chest-abdo-pelvis with IV contrast
95
Management of splenic rupture
Urgent lapartomy Conservative - strict bed rest and repeat CT scan at 1-week Prophylactic vaccinations
96
Complications of treatment of splenic rupture
Ongoing bleeding Splenic necrosis Splenic abscess or cyst formation Thromboyctosis
97
Define OPSI
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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