HPB Flashcards
What is the tumour marker for pancreatic cancer?
CA19-9
What are some pre-hepatic causes of jaundice?
- Haemolytic anaemia
- Gilbert’s syndrome
What are some Intra-hepatic causes of jaundice?
- Alcoholic liver disease
- Viral hepatitis
- Haemochromatosis
- Autoimmune hepatitis
What are some post hepatic causes of jaundice?
Gallstones
Cholangiocarcinoma
What are the risk factors for gallstones?
Fat
Female
Fertile
Forty
Family history
How do patients with acute cholecystitis present?
- Constant RUQ pain
- Fever
- Lethargic
- Positive Murphy’s sign
What are some differentials to consider along with acute cholecystitis?
- GORD
- Peptic ulcer disease
- Acute pancreatitis
- IBD
What are the initial investigations for cholecystitis?
FBC and CRP (for inflammatory response)
LFTs (raised ALP - ductal occlusion)
Amylase (signs of pancreatitis)
What is the first line imaging for investigating gallstones, what will it demonstrate?
Ultrasound
- Gallstones
- Gallbladder wall thickness
- Bile duct dilatation
What is the gold standard for investigating gallstones?
MRCP
What is the management for biliary colic?
Analgesia (paracetamol / NSAIDs / opiate analgesia)
What should be offered within first 6 weeks of gallstone presentation?
Laparoscopic cholecystectomy
What is the management for acute cholecystitis?
IV antibiotics (co-amoxiclav and metronidazole)
Analgesia
Anti-emetics
Laparoscopic cholecystectomy (or percutaneous cholecystostomy to drain the infection)
What are some complications of gallstones?
Mirizzi syndrome (compression of common hepatic duct by stone in GB)
Gallbladder empyema
What is cholangitis?
Infection of the biliary tree
What are the most common causes of cholangitis?
Gallstones, ERCP, Cholangiocarcinoma
How can Acute and chronic pancreatitis be distinguished?
Limited damage to the secretory function of the gland
What are the most common infective organisms in cholangitis?
E. Coli
Klebsiella
What are the clinical features of cholangitis Charcot’ s triad?
Right upper quadrant pain
Fever
Jaundice
How is cholangitis and cholecystitis differentiable?
Presence of jaundice
What are the lab tests for cholangitis?
Routine bloods
LFTs (raised ALP)
Blood cultures
What is the imaging of choice for cholangitis?
• Ultrasound scan (bile duct dilatation)
What is the gold standard investigation for cholangitis?
ERCP
What is the management of cholangitis?
Manage sepsis
IV access
Fluid resuscitation
Routine bloods
Blood cultures
Broad spectrum IV Abx
What is the definitive management of cholangitis??
Endoscopic biliary decompression
PTC (percutaneous transhepatic cholangiography) is 2nd line
What are the complications of ERCP?
Repeated cholangitis
Pancreatitis
Bleeding
Perforation
What are some common causes of liver abscesses?
Cholecystitis
Cholangitis
Diverticulitis
Appendicitis
How does a liver abscess present?
Fever
Rigors
Abdo pain
Nausea
Jaundice
RUQ tenderness
What are the investigations for a liver abscess?
Leucocytosis
Abnormal LFTs
Raised ALP
Blood cultures
Ultrasound = poor-defines lesion
What is the management of a liver abscess?
Fluids
Abx
Drained: image guided aspiration
What causes liver cysts?
Congenital
What is the management of liver cysts?
Mostly no intervention or ultrasound-guided aspiration
Usually liver cysts are asymptomatic but otherwise how would they present?
Abdo pain as the cysts grow in size
Hepatomegaly
What is the mnemonic for remembering causes of acute pancreatitis?
GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune disease e.g. SLE
Scorpion bite
Hypercalcaemia
ERCP
Drugs (azathioprine)
What is the pathogenesis of acute pancreatitis?
Premature and exaggerated activation of digestive enzymes
Pancreas inflames
How does acute pancreatitis present?
Severe epigastric pain which radiates through to the back
Epigastric tendernesss
What ‘signs’ are elicited on examining for acute pancreatitis?
Cullen’s sign (bruising around umbilicus)
Grey Turner’s sign (bruising in the flanks - retroperitoneal haemorrhage)
What are the causes of abdo pain which radiates through to the back?
AAA
Renal calculi
Chronic pancreatitis
Aortic dissection
Peptic ulcer
What are the investigations for acute pancreatitis?
Routine blood tests
Serum amylase (3 x)
LFTs (for evidence of gallstones - ALT raised)
What scoring system is used for the severity of acute pancreatitis?
Modified Glasgow criteria
What imaging is used for acute pancreatitis?
Abdo ultrasound (look for gallstones)
CT (after 48hrs from presentation)
What will acute pancreatitis show on a CT?
Pancreatic oedema and pancreatic necrosis
What is the treatment for acute pancreatitis?
Supportive
What are the supportive measures for acute pancreatitis?
IV fluid resus
Nasogastric tube (if vomiting)
Catheterisation (monitor fluid balance)
Opioid analgesia
What are some systemic complications of acute pancreatitis?
DIC
ARDS
Hypocalcaemia (fat necrosis from released lipases result in free fatty acids which react with calcium to form chalky deposits)
Hyperglycaemia (Secondary to destruction of islets of Langerhans)
What are some local complications of acute pancreatitis?
Pancreatic necrosis (due to ongoing inflammation)
Pancreatic pseudocyst
How would pancreatic necrosis present?
Clinical deterioration in the patient with raised inflammatory markers
How is pancreatic necrosis definitively diagnosed?
FNA of necrosis
When do pancreatic pseudocysts appear?
Weeks after initial episode
When should acute pancreatitis be treated with Abx?
Prophylaxis in cases of confirmed pancreatic necrosis
What are the main causes of chronic pancreatitis?
Chronic alcohol abuse
Idiopathic
(Lesser causes = hyperlipaemia, hypercalcaemia, infection, CF)
What are the features of chronic pancreatitis?
Chronic pain
Nausea and vomiting
Endocrine insufficiency
What mass effects do pseudocysts have?
Biliary obstruction
Gastric outlet obstruction
What are the differentials for central abdo pain?
Peptic ulcer disease
Reflux disease
AAA
Biliary colic
Chronic pancreatitis
What investigations are there for chronic pancreatitis?
Urine dip
FBC and CRP (amylase / lipase not usually raised)
Low faecal elastase level (enzyme made in pancreas)
What is the imaging and results for chronic pancreatitis?
CT - pancreatic atrophy / calcification
How can chronic pancreatitis be treated?
Treat reversible, underlying cause (alcohol cessation / hyperlipidaemia)
Analgesia
Creon enzyme replacement
Replacement of fat soluble vitamins
NOT SURGERY usually due to limited symptomatic improvement
What can be used to treat pancreatitis with an autoimmune aetiology?
Steroids
What is a splenic infarct caused by?
Occlusion of the splenic artery
Haematological disorders contesting circulation
Embolism (AF, post MI mural thrombus)
Trauma
What are the clinical features of a splenic infarct?
Left upper quadrant pain
Fever
Nausea
What are the differentials for LUQ pain?
Peptic ulcer
Pyelonephritis
Splenic infarct
What is the gold standard investigation for a splenic infarct?
CT abdo scan with IV contrast
What is the management of splenic infarct?
No specific treatment
Analgesia
Fluids
What prophylaxis can be given post splenectomy?
Low does antibiotic cover (penicillin)
What are the complications from splenic infarct?
Splenic rupture
Splenic abscess
Pseudocyst formation
What typically causes splenic rupture?
Abdo trauma
How does splenic rupture present?
Abdo pain
Hypovolaemic shock
What are the investigations for splenic rupture?
Unstable = immediate laparotomy
Stable = CT chest-abdo-pelvis with IV contrast
What are the complications of splenic rupture?
Ongoing bleeding
Splenic necrosis
Splenic abscess
