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Surgery > HPB > Flashcards

HPB Flashcards

1
Q

Causes of pre-hepatic jaundice?

A

Haemolytic anaemia
Gilbert’s syndrome
Criggler-Najjar Syndrome

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2
Q

Causes of hepatocellular jaundice?

A 
Alcoholic liver disease
Viral hepatitis
Iatrogenic eg medication
Hereditary haemochromatosis
Autoimmune hepatitis
Primary biliary cirrhosis and primary sclerosis cholangitis
Hepatocellular carcinoma
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3
Q

Causes of post-hepatic jaundice?

A

Intra-luminal causes eg gallstones
Mural causes eg cholangiocarcinoma, strictures, drug induced cholestasis
Extramural causes eg pancreatic cancer or abnormal masses (eg lymphomas)

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4
Q

How does observing the colour of urine and stool predict the type of jaundice present?

A

Conjugated bilirubin can be excreted via urine as it is water soluble, whereas unconjugated cannot. Dark urine is therefore in conjugated or mixed hyperbilirubinaemia.

Pale stools - obstructive jaundice due to reduced levels of stercobilin entering GI tract.

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5
Q

Blood Investigations for jaundice?

A 
LFTs
Coagulation studies
FBC and U&Es
ALP
Gamma-GT
Albumin
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6
Q

LFT results for pre-hepatic jaundice? (bilirubin, ALT/AST, ALP)

A

Bilirubin - normal or high
ALT/AST - normal
ALP - normal

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7
Q

LFT results for hepatic jaundice?

A

Bilirubin - high
ALT/AST - elevated
ALP - elevated

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8
Q

LFT results for post-hepatic jaundice?

A

Bilirubin - high to very high
ALT/AST - moderate elevation
ALP - High to very high

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9
Q

What is Gamma-GT a good marker of?

A

Biliary obstruction

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10
Q

What is the AST:ALT ratio for alcoholic liver disease and for viral hepatitis?

A

Alcoholic liver disease - AST/ALT >2

Viral hepatitis - AST:ALT around 1

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11
Q

Imaging investigations for jaundice?

A

First-line - US abdomen

MRCP - used to visualise biliary tree, typically performed if jaundice is obstructive but US was inconclusive.

Liver biopsy - when diagnosis has not been made despite above investigations

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12
Q

Management for jaundice?

A

Depends on underlying cause.

Obstructive causes may require ERCP to remove stones or stenting of CBD.

Symptomatic treatment - cholestyramine, anti-histamine.

Coagulopathy - may need vitamin K, FFP etc.

Hepatic encephalopathy - lactulose +/- rifaximin

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13
Q

Features, investigations and management of simple liver cysts?

A

Normally asymptomatic. Symptoms include abdominal pain, nausea, early satiety.

Ix -> LFTs normal, may have raised GGT. US remains modality of choice.

Management:
No intervention usually.
>4cm in size, follow-up US scans needed.
If symptomatic, US-guided aspiration or lap de-roofing.

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14
Q

What is polycystic liver disease and what is it caused by?

A

Presence of >=20 cysts within liver parenchyma, each of which are >=1cm in size.

Caused by either Autosomal dominant polycystic kidney disease (ADPKD) or Autosomal dominant polycystic liver disease (ADPLD)

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15
Q

Features, investigations and management of polycystic liver disease?

A

Asymptomatic, abdo pain. If large enough, can cause liver cirrhosis and portal hypertension.

Normal LFTs, U&Es can be affected if have renal cysts too.
US imaging is definitive.

If asymptomatic, leave alone and monitor.
Somatostatin analogues can give symptomatic relief by reducing cyst volume.

Indications for surgery -> intractable symptoms, inability to rule out malignancy on imaging alone, prevention of malignancy.
US-guided aspiration
Lap de-roofing of cysts.

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16
Q

Features of cystic neoplasms of liver?

A

Rare, <5% of liver cysts.
Most common are cystadenomas. They are premalignant.

Asymptomatic. Abdo pain, anorexia, nausea, fullness, bloating.

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17
Q

Investigations and management of cystic neoplasms of liver?

A

LFTs normal.
CT imaging with contrast.
Aspiration biopsy should be avoided.

Liver lobe resection is treatment of choice.

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18
Q

What are hyatid cysts of the liver and what are the features?

A

Results from infection by tapeworm Echinococcus granulosus.

Asymptomatic for many years. Vague abdominal pain caused by mass effect on surrounding structures or due to rupture.
Jaundice or cholangitis, vomiting, dyspepsia and early satiety

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19
Q

Investigations and management of hyatid cysts?

A 
LFTs are normal.
FBC - eosinophilia.
Echinococcal antibody titres positive.
USS will reveal calcified, spherical lesion with multiple septations.
CT with contrast for further assessment.

Surgical management - cyst deroofing.
Anti-microbials - albendazole, mebendazole +/- praziquantel.

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20
Q

Causes and Features of liver abscess?

A

Cholecystitis, cholangitis, diverticulitis, appendicitis, septicaemia.
Most common organisms are E. coli, K. pneumonia, S. constellatus.

Fever, riggers, abdominal pain. Bloating, nausea, anorexia, weight loss, fatigue, jaundice.
RUQ tenderness +/- hepatomegaly. shock if rupture.

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21
Q

Investigations of liver abscess?

A

FBC - leucocytosis
LFT - abnormal, raised ALP and deranged ALT and bilirubin.
Blood cultures
USS - shows poor defined lesions and hypo- and hyper-echoic areas with gas bubbles and septations.
CT with contrast.

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22
Q

Management of liver abscess?

A

Appropriate abx

Image-guided aspiration of abscess.

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23
Q

Features of amoebic abscess?

A

Most common extra-intestinal manifestation of amebiasis infection.

Vague abdo pain, nausea, fever, riggers, weight loss, bloating.
Suspected in recent travel history.

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24
Q

Investigations and management of amoebic abscess?

A

Leucocytotis and deranged LFTs.
Blood cultures.
Stool sample - E. Histolytica antibodies.
USS - poor-defined lesions which can be further characterised by CT imaging.

Abx - metronidazole.

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25
Q

Risk factors for hepatocellular carcinoma?

A 
Viral hepatitis - B and C
High alcohol intake
Smoking
Age >70
Primary biliary cirrhosis
Haemochromatosis
Aflatoxin exposure
Family history of liver disease
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26
Q

Features of hepatocellular carcinoma?

A

Vague symptoms - fatigue, fever, weight loss and lethargy.
Dull ache in RUQ uncommon but is characteristic.
Liver failure symptoms - ascites and jaundice.
Irregular, enlarged, craggy and tender liver on palpation.

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27
Q

Investigations and staging of hepatocellular carcinoma?

A

LFTs - deranged.
Platelets - low
Prolonged clotting
Alpha fetoprotein - raised in 70% of cases.

USS - if mass >2cm with raised AFP, virtually diagnostic.
CT/MRI scan for further evaluation.

If still in doubt - biopsy or percutaneous FNA

Staging - Barcelona Clinic Liver Cancer staging.
Risk assessment - Child-Pugh and MELD scores - risk of mortality from cirrhosis.

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28
Q

Management of hepatocellular carincoma?

A

Surgical - resection if no cirrhosis and good health status (early disease)
Transplantation - if fulfil Milan criteria.

Non-surgical:

  • image-guided ablation
  • ultrasound probes
  • alcohol ablation
  • trans arterial chemoembolisation (TACE) - infect high conc of chemotherapy into hepatic artery and embolising agent added to induce ischaemia.
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29
Q

Which cancers metastasise to liver commonly?

A

Breast, pancreas, stomach, lung

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30
Q

Causes of acute pancreatitis?

A 
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune disease, SLE
Scorpion venom
Hypercalcaemia
ERCP
Drugs - azathioprine, NSAIDs, diuretics
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31
Q

What is the pathophysiology of acute pancreatitis?

A

Autodigestion of pancreatic tissue by pancreatic enzymes leading to necrosis.

32
Q

Features of acute pancreatitis?

A

Sever epigastric pain, radiates through back
Vomiting
Tenderness, ileus, low-grade fever
Cullen’s sign (Periumbical discolouration)
Grey-Turner’s sign (flank discolouration)

33
Q

Investigations of acute pancreatitis?

A

Serum amylase - diagnostic if 3x upper limit of normal.
LFTs - ALT >150
Serum lipase - more accurate, but not commonly available.

Abdo USS if cause unknown.

34
Q

Scoring system for acute pancreatitis?

A

Modified Glasgow criteria: PANCREAS

pO2 <8kPa
Age >55
Neutrophils >15
Calcium <2mmol/L
Renal function (urea) >16
Enzymes LDH or AST
Albumin <32
Sugar >10
35
Q

Management of acute pancreatitis?

A 
High-flow oxygen
IV fluid resuscitation
NG tube if patient vomiting profusely
Catheterise
Opioid analgesia
Broad-spectrum abx - imipenem.

Treat underlying cause - eg ERCP or cholecystectomy if gallstones

36
Q

Local complications of acute pancreatitis?

A

Peripancreatic fluid collections: may resolve or develop into pseudocysts or abscesses. Resolve with no treatment.

Pseudocysts:
Collection of fluid containing pancreatic enzymes, blood and necrotic tissue. Usually seen in lesser sac.
50% resolve spontaneously. If present longer than 6 weeks, unlikely to resolve spontaneously.
Treat with surgical debridement or endoscopic drainage.

Pancreatic necrosis:
Confirm with CT scan.
Treat with necrosectomy.

Pancreatic abscess:
Treat with trans gastric drainage or endoscopic drainage.

Haemorrhage

37
Q

Systemic complications of acute pancreatitis?

A 
DIC
Acute respiratory distress syndrome
Hypocalcaemia
Hyperglycaemia
Hypovolaemic shock and multi organ failure.
38
Q

Causes of chronic pancreatitis?

A

Alcohol
Cystic fibrosis
Haemochromatosis
Ductal obstruction: tumours, stones, structural abnormalities

39
Q

Features of chronic pancreatitis?

A

Pain worse 15-30 minutes following meal
Steatorrhoea - symptoms of pancreatic insufficiency usually develop between 5 and 25 years after onset of pain.
Diabetes - 20 years after symptom begins.

40
Q

Investigations of chronic pancreatitis?

A

Abdominal x-ray - pancreatic calcification in 30% of cases
CT scan - more sensitive at detecting pancreatic calcification
Functional tests - faecal elastase
Amylase and lipase levels rarely significantly raised.

41
Q

Management of chronic pancreatitis?

A

Initial:
Analgesia
Pancreatic enzyme supplements.

Definitive:
Avoid alcohol
ERCP - if stones present
EUS - drain pseudocysts
Endoscopic pancreatic sphincterotomy - if have high sphincter pressures.
42
Q

Complications of chronic pancreatitis?

A 
Pseudocyst
Steatorrhoea and malabsorption
Diabetes
Effusions - ascites, pleural
Pancreatic malignancy
43
Q

What is the most common type of pancreatic cancer?

A

Adenocarcinoma.

44
Q

Risk factors for pancreatic cancer?

A 
Smoking
Chronic pancreatitis
Recent onset DM
Age
Multiple endocrine neoplasia
BRCA2 gene
45
Q

Features of pancreatic cancer?

A 
Classically painless jaundice
Courvoisier's law - presence of painless obstructive jaundice, palpable gallbladder, unlikely to be gallstones.
Abdominal pain radiating to back
Weight loss
Acute pancreatitis
Thrombophlebitis migrans 
Steatorrhoea
DM
46
Q

Investigations of pancreatic cancer?

A 
FBC
LFT
CA 19-9
Abdominal US
Pancreatic CT scan - most important.
CT CAP
Endoscopic ultrasound (EUS) to guide FNA biopsy.
47
Q

Management of pancreatic cancer?

A

Curative: Whipple’s procedure - removal of head of pancreas, antrum of stomach, 1st and 2nd parts of duodenum, CBD, gallbladder.

Adjuvant chemotherapy with 5-flurouracil

Palliative care: chemotherapy, ERCP biliary stent, enzyme replacement.

48
Q

Types of endocrine tumours of pancreas?

A

G cell Gastrinoma - Zollinger-Ellison syndrome

alpha cell Glucagonoma - hyperglycaemia, DM

beta cell insulinoma - hypoglycaemia

delta cell somatostatinoma - DM, steatorrhoea, gallstones, weight loss, achlorhydria

Non-islet cells VIPoma - secrete water and electrolytes into gut. Relaxation of enteric smooth muscle.

Treat all with somatostatin analogues.

49
Q

Risk factors of gallstone disease?

A 
Fat
Female
Fertile
Forty
Family history
Pregnancy
Oral contraceptive
Haemolytic anaemia
Malabsorption
50
Q

Features of biliary colic

A

Colicky RUQ pain
Worse postprandially, worse after fatty foods.
Pain may radiate to right shoulder
Nausea and vomiting

51
Q

Features of acute cholecystitis?

A

Constant pain in RUQ or epigastrium.
Fever
Lethargy
Positive Murphy’s sign

52
Q

Investigations of gall bladder disease?

A

FBC and CRP
LFTs - raised ALP, normal bilirubin and ALT
Amylase
Urinalysis - pregnancy test

Imaging:
Trans-abdominal US - can show presence of gallstones, gallbladder wall thickness, bile duct dilatation.
If US inconclusive, MRCP used.

53
Q

Management of biliary colic?

A

Analgesia
Low fat diet, weight loss, increasing exercise

Elective lap whole within 6 weeks of first presentation.

54
Q

Management of acute cholecystitis?

A

IV abx - co-amoxiclav +/- metronidazole.
Analgesia and anti-emetics

Lap chole within 1 week of presentation, but ideally within 72 hours.

If not fit for surgery - percutaneous cholecystostomy to drain infection.

55
Q

Complications of gall bladder disease?

A

Mirizzi Syndrome - stone in Hartmanns pouch or in cystic duct - obstructive jaundice.

Gallbladder empyema - gallbladder filled with pus. Septic patients.

Chronic cholecystitis

Bouveret’s syndrome and gallstone ileus - fistula forms between gallbladder wall and small bowel. Can cause bowel obstruction.

Bouveret’s syndrome - stone impacts in proximal duodenum causing gastric outlet obstruction.

Gallstone ileus - stone impacts terminal ileum causing small bowel obstruction.

56
Q

Causes of cholangitis?

A 
Gallstones
ERCP
Cholangiocarcinoma
Pancreatitis
Primary sclerosis cholangitis

Infective organisms - E. coli, Klebsiella species, enterococcus.

57
Q

Features of cholangitis?

A 
RUQ pain
Fever Jaundice
Pruritis
Pale stools
Dark urine
Hypotension
Confusion

Charcot’s Triad - Jaundice, RUQ pain, fever
Reynold’s Pentad - addition of hypotension and confusion.

58
Q

Investigations of cholangitis?

A

FBC
LFTs - raised ALP, GGT, bilirubin
Blood cultures

US biliary tract will show bile duct dilation. Usually less than 6mm.
Goldstandard is ERCP.

59
Q

Immediate management of cholangitis?

A

IV access, sepsis 6.

60
Q

Definitive management of cholangitis?

A

ERCP

Percutaneous transhepatic cholangiography (PTC) second line.

61
Q

Risk factors for cholangiocarcinoma?

A 
Primary sclerosis cholangitis
UC
Infective - Liver flukes, HIV, hepatitis
Toxins 
Congenital - Caroli's disease
Alcohol excess
DM
62
Q

Features of cholangiocarcinoma?

A

Asymptomatic until later stages.
Post-hepatic jaundice, pruritus, pale stools, dark urine.
RUQ pain, satiety, weight loss, anorexia, malaise.

63
Q

Investigations of cholangiocarcinoma?

A

High bilirubin, ALP, GGT.
CEA and CA19-9 may be elevated.

USS initially
MRCP definitive
ERCP
CT for staging.

64
Q

Management of cholangiocarcinoma?

A

Klatskin tumours (at bifurcation of right and left hepatic ducts) - partial hepatectomy and reconstruction of biliary tree

Distal CBD tumours - Whipple’s procedure.

Radiotherapy for adjunct or neoadjunct therapy.

Palliative: most cases
Stenting ERCP
Surgical bypass
Palliative radiotherapy

65
Q

Features, investigations and management of primary biliary cholangitis?

A

Chronic liver disorder, middle-aged females.

Associations - Sjogren’s, RA, systemic sclerosis, thyroid disease.

Features:
Pruritus, fatigue, jaundice, hyperpigmentation, RUQ pain, xanthelasmas, xanthomata, clubbing, hepatosplenomegaly, may progress to liver failure.

Diagnosis - AMA, smooth muscle ab, raised serum IgM

Management -
pruritus - cholestyramine
fat-soluble vitamin supplementation
Ursodeoxycholic acid
Liver transplantation
Complications:
Osteomalacia, coagulopathy
Sicca syndrome
Portal hypertension - ascites, variceal haemorrage
Hepatocellular cancer
66
Q

Features, investigations and management of primary sclerosing cholangitis?

A

Inflammation and fibrosis of intra and extra-hepatic bile ducts.

Associations - US, Crohn’s, HIV

Features - cholestatis, jaundice and pruritus, RUQ pain, fatigue.

Investigations - ERCP/MRCP, ANCA positive, liver biopsy

Complications - cholangiocarcinoma, increased risk of colorectal cancer.

67
Q

Causes of splenic infarct?

A

Leukaemia, lymphoma, myelofibrosis, sickle cells disease, CML, polycythaemia rubra vera, hyper coagulable states.

Embolic disorders - endocarditis, AF, infected aneurysm, grafts, post-MI mural thrombosis.

68
Q

Features of splenic infarct?

A

LUQ pain, radiating to left shoulder.
Fever
N + V
Pleuritic chest pain

69
Q

Investigations and management of splenic infarct?

A

CT abdo scan with IV contrast.
FBC, U&Es, LFTs, coagulation screen.

Analgesia, IV hydration.
Long-term anticoagulation.

Splenectomy should be avoided.

Vaccinations - pneumococcus, N. meningitidis, H. influenza

70
Q

Features of splenic rupture?

A

Abdo pain, hypovolemic shock, LUQ tenderness.

71
Q

Investigations of splenic rupture?

A

Immediate laparotomy if harm-dynamically unstable

Urgent CAP with IV contrast

72
Q

Management of splenic rupture?

A

Conservative - resuscitated. Best rest and repeat CT at 1 week.

Prophylactic vaccinations.

Higher grade ruptures - embolisation

73
Q

Complications of splenectomy?

A

Haemorrhage
Pancreatic fistula
Thrombocytosis - give prophylactic aspirin
Encapsulated bacteria infection

74
Q

Causes of hyposplenism?

A 
Splenectomy
Sickle cell
Coeliac disease
Graves disease
SLE
Amyloid
75
Q

Causes of splenomegaly?

A 
Myelofibrosis
CML
Visceral leishmaniasis
Malaria
Gaucher's syndrome

Surgery (9 decks)

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