HPB Flashcards
hyperbilirubinaemia occurs at bilirubin levels roughly greater than what?
50 umol/L
what are the three main types of jaundice?
pre-hepatic
hepatocellular
post-hepatic
what occurs in pre-hepatic jaundice?
excessive red cell breakdown
liver is overwhelmed and cannot conjugate bilirubin-this causes unconjugated hyperbilirubinaemia
what occurs in hepatocelluar jaundice?
dysfunction of the hepatic cells
liver loses ability to conjugate bilirubin as well as habing some degree of obstruction
what occurs in post hepatic jaundice?
obstruction of biliary drainage
bilirubin is not all excreted
what happens to the levels of unconjugated and conjugated bilirubin in pre-hepatocellular and post- hepatic jaundice?
pre-hepatic: inc in unconjugated bilirubin
hepatocellular: inc in both unconjugated and conjuagted bilirubin
post-hepatic: inc in conjugated bilirubin
causes of pre-hepatic jaundice?
haemolytic anaemia
gilberts syndrome
criggler-najjar syndrome
causes of hepatocellular jaundice?
alcoholic liver disease
viral hepatitis/ autoimmune hepatitis
hereditary haemochromatosis
primary biliary cirrhosis/ primary sclerosing cholangitis
hepatocellular carcinoma
causes of post- hepatic jaundice?
gallstones
cholangiocarcinoma
strictures
pancreatic cancer
abdo masses
unconjuagted or conjugated bilirubin is excreted via the urine?
conjugated as it is water soluble
darker urine will be seen in which kind of jaundice?
hepatocellular or post-heaptic
normal urine is seen in unconjugated disease
pts presenting with jaundice should have which routine bloods done?
LFTS
coag studies
FBC
U&Es
pts presenting with jaundice should have which specialist bloods done? what do they indicate?
Bilirubin- degree of jaundice
Albumin- liver synthesis function
AST/ ALT- hepatocellular injury
ALP- raised in biliary obstruction
which blood marker is more specific for biliary obstruction than ALP but not routinely carried out?
Gamma-GT
which imaging is performed when investigating liver obstruction or gross pathology?
US abdo
Magnetic Resonance Choliangography (MRCP)
if bleeding or rapid coagulopathy presents in a pt with jaundice which management is required promptly?
Vitamin K or FFP
which complications are importnant to look for when dealing with a jaundiced patient?
coagulopathy
encephalopathy
infection (bowels)
what forms bile?
cholesterol, phospholipids, bile pigments (haem)
what are the three main types of gallstone?
Cholesterol stones
Pigment stones
Mixed stones
what are the risk factors for gallstone disease? (5 Fs)
Fat
Female
Fertile
Forty
Family History
of those who are symptomatic with gallstones how do these people present?
50% with biliary colic (impacted stone in neck of gallbladder)
35% as acute cholecystitis (inflammatory)
how does the pain differ in biliary colic and acute cholecystitis?
biliary colic- sudden, dull and colicky (can be precipitated by fatty foods)
acute cholecystitis- constant pain, signs of inflammation
what is murphys sign?
Apply pressure to RUQ and ask patient to inspire- Murphys sign +ve if this causes pain
indicates inflammed gallbladder
what are some differentials for RUQ pain?
Cholecystitis
GORD
peptic ulcer disease
acute pancreatitis
IBD
which blood tests should be carried out in suspected cholecystitis?
FBC and CRP (inflammation)
LFTs (raised ALP likely)
Amylase (rule out pancreatitis)
what imaging should be performed in suspected gallstone pathologies?
trans-abdominal ultrasound
MRCP
how is biliary colic managed?
lifestye advice- wgt loss, no fatty foods
elective laparoscopic cholecystectomy
how are cases of acute cholecystitis managed?
IV antibiotics (co-amoxiclav +/- metronidazole)
laparoscopic cholescytectomy
what is important to exclude in any patient presenting with RUQ pain post cholecystectomy?
a retained CBD stone
what is Mirizzi syndrome?
stone in Hartmanns pouch or in cystic duct causes compression on common hepatic duct
results in obstructive jaundice- confirm diagnosis with MRCP
inflammation of the gallbladder (typically if recurrent) can cause a fistula to form between which structures?
gallbladder and small bowel
stones can pass directly into small bowel typically duodenum from gallbladder
fistula formation between the gallbladder and small bowel following inflammation can result in which two complications?
Bouverets syndrome- stone impacts in proximal duodenum causing gastric outlet obstruction
Gallstone Ileus- stone impacts in terminal ileum causing small bowel obstruction
inflammation of the biliary tract is referred to as?
cholangitis
combination of obstruction and subsequent infection
cuases of cholangitis?
galstones
ERCP
choliangocarcinoma
what are the most common causitive organisms of cholangitis?
E. coli
Klevsiella
enterococcus
what are the common presenting symptoms of cholangitis?
RUQ pain, fever, jaundice
(may also have pruritis)
what are the two syndromes associated with cholangitis?
Charcots triad: Jaundice, fever, RU pain
Retnolds Pentad: Jaundice, fever, RUQ pain, hypotension, confusion
which investigations should be carried out in suspected cholangitis?
Routine bloods: FBC, LFTs, Blood cultures
US scan
ERCP (therapeutic and diagnosis)
how are patients with cholangitis managed?
may present with spesis- sepsis 6
endoscopic biliary decompression or ERCP
cancers of the biliary system are termed what?
cholangiocarcinoma
where is the most common site for bile duct cancers?
bifurcation of right and left hepatic ducts
typically slow-growing and invade locally
cholangiocarcinoma occurs more frequently in which patient populations?
>65yr olds
south-east asia due to association with chronic endemic parasitic infections
cholangiocarcinomas arise from which cells?
95% are adenocarcinomas from cholangiocytes
rarer- sqaumous cells carcinomas
what are the main risk factors for cholangiocarcinoma?
Primary sclerosing cholangitis
UC
infective- hepatitis. HIV
TOxins
Congenital
alcohol excess
diabetes mellitus
liver abscesses typically result from what?
polymicrobial bacterial infection spreading from biliary or GI tract
list common causes of liver abscesses?
cholecystitis, cholangitis diverticulitis, appendicitis, septicaemia
what are the most commonly isolated organisms in liver abscesses?
E.coli
K. pneumoniae
S. constellatus
how do patients with a liver abscess typically present?
fever, abdo pain, rigors
also: bloating, anorexia, wgt loss, fatigue, jaundice
what shoul dbe considered in all pts presenting with pyrexia of unknown origin assoc with abdo pain or bloating?
pyogenic liver abscess
what blood results will be seen in a pt with a liver abscess?
FBC- leucocytosis
LFTS- abnormal
ALP- raised
in addition to routine bloods pts with suspected liver abscess should have which investigations sent for mictoscopy?
peripheral blood and fluid cultures
what will be seen on US in pt with liver abscess?
poor defined lesion with hypo and hyper echoic areas
similar pic seen on CT with contrast
how are patients with liver abscesses managed?
fluid resuscitation
start antibitoic therapy
image guided aspiration of abscess
what is the causitive organism of an amoebic abscess and how does this infection spread?
entamoeba histolytica
faecal- oral spread- once in colon the tropozite invade the mucosa and spread to liver via portal system
how do patients present with an amoebic abscess?
vague symtpoms of abdo pain, fever, rigors, wgt loss, bloating
when would you suspect an amoebic abscess in a patient?
history of recent travel (<6 months) to an endemic region
(South America, Indian subcontinent, Africa)
whta will bloods show in patients with an amoebic abscess?
leucocytosis with deranged LFTS
Peripheral blood and fluid culture should also be sent for microscopy
in addition to bloods and microscopy what else shoudl be tested in patients with suspected amoebic abscess?
Blood and stool samples sent for Entamoeba histolytica antbodies
how are patients with an amoebic abscess managed?
most pts treated with antibiotics alone
surgivcal drainage may be required in larger cysts
what are the only two antimicrobials of choice to treat an Entamoeba histolytca in amoebic abscess?
metronidazole
tinidazole
how do simple liver cysts appear on US imaging?
anechoic (no echo, black on US), well-defined, thin-walled, oal/spherical lesions
define a simple liver cyst and where they msot commonly occur?
fluid-filled epithelial-lined sacs withint the liver most commonly the right lobe
what may be raised in pts with simple liver cysts?
rasied GGT
LFTs are typically normal
how are simple liver cysts managed?
most require no intervention
>4cm, follow up US at 3, 6, 12 months
US aspiration if symptomatic
how is polycystic liver disease characterised?
presence of >20 cysts of which each are >1cm
which two autosomal dominant conditions cause polycystic liver cysts?
autosomal dominant polycystic kidney disease (ADPKD)
autosomal dominant polycystic liver disease (ADPLD)
what % of liver cysts are true cystic neoplasms?
5%- most common type are cystadenomas, premalignant lesions
why should aspiration/ biopsy be avoided in suspected cystic neoplasms?
risk of seeding
what is the management choice for cystadenomas and cystadenocarcinomas of the liver?
liver lobe resection
samples then sent to histopathology for diagnosis confirmation
hydatid cysts result from which infection?
tapeworm, Echnococcus granulosus
what will show in US if Hydatid cyst?
calcified, spherical lesion with multiple septations
Cyst deroofing to manage
how does hepatocellular carcinoma arise?
result of chronic inflammation affecting the liver
most common causes include: viral hepatitis, chronic alcoholism
what are the risk factors for hepatocellular carcinoma?
in developing countries what accounts for around 90% of HCC cases?
Viral hepatitis
HCC much more common in asian individuals secondary to hep B infections in childhood
what are the main presenting symtpoms of HCC?
similar to that of liver cirrhosis: vague symtpoms such as fatigue, wgt loss, fever
dull ache in RUQ is uncommon but if present should raise suspicion in those with known cirrhosis
what will be seen on examination that is highly suggestive of liver malignancy i.e. HCC?
irregular, enlarged, craggy and tender liver
Ascites if indicator of late stage liver disease also
differtials for pt presenting with liver failure or non-specific liver signs?
infectious hepatitis
cardiac failure (smooth hepatomegaly)
benign hepatocellular adenoma
lother causes of liver cirrohsis
how sre suspected cases of liver malignancy investigated?
LFTs- may be deranged
FBC- may show low platelets
AFP (raised in 70% cases)
US scan
which ratio of AST:ALT is suggestive of alcoholic liver disease rather than viral hepatitis?
AST:ALT >2 alcoholic liver disease
AST:ALT around 1 viral hepatitis
what on US combined with raised AFP is virtually diagnostic of liver malignancy?
mass >2cm
Biopsy can be perfromed if still unsure
what system is used to stage liver cancers?
Barcelona Clinic Liver cancer staging system
which score isused to asses pts with liver cirrhosis and calculate prognosis?
Child-Pugh score
MELD score also used to predict mortality and likelihood of pt tolerating transplant
what is the surgical management for liver cancer?
surgical resection
transplantation
(limited by tumour size and liver function alongside comorbidities)
liver transplant in liver cancer pts can only be carried out if they fulfill which criteria?
Milan Critera
one lesion is <5cm or three lesions <3cm
no extrahepatic manifestations
no vascular infiltration
what non-surgical management options are available for liver cancer?
image guided ablation
TACE- transarterial chemoembolisation
what is the median survival time of pts with HCC from time of daignosis?
aroudn 6 months
extent of underlying cirrhosis is main prognostic factor
what are the most common cancers to metastise to the liver?
bowel, breast, pancreas, stomach, lung
can you biospy liver mets secondary to a primary cancer originiating elsewhere in the body?
no- risk of seeding cancer
what is the GET SMASHED mneumonic?
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune disease i.e. SLE
Scorpion venom
Hypercalcaemia
ERCP
Drugs (azathioprine, NSAIDs, Diuretics)
what happens pathologically in acute pancreatitis?
exaggerated inflammatory response causing inc in vascular permeability and subsewuent fluid shifts
enzymes released from pancreas causing autodigestion of fats (fat necrosis) and blood vessels which could lead to haemorrhage
fat necrosis in pancreatitis releases fatty acids which eventually causes which biochemical abnormality?
hypocalcaemia
fatty acids react with serum calcium to form chalky depositis in fatty tissue
how do patients with pancreatitis typically present?
severe epigastric pain which can radiate to the back
nausea and vomiting
which bruising signs can sometimes be seen in pancreatitis?
Cullens sign-bruising around umbilicus
Grey Turners sign- bruising in the flanks
differentials for acute abdominal pain that radiates to the back other than pancreatitis?
AAA
renal calculi
chronic pancreatitis
aortic dissection
peptic ulcer disease
in addition to rountine bloods which investigations are specific to acute pancreatits?
serum amylase- 3x upper limit is diagnostic
LFTs- if raised can indicate gallstones as cause
serum lipase- more accurate than amylase but not routinely available
what are the current UK guidelines for CT imaging used to asses severity of a disease i.e. pancreatitis?
should be performed 6-10 days after admission in patients with features of persistent inflammatory response
how is acute pancreatits managed?
IV fluid resuscitation
Nasogastric tube
Cathetirisation + fluid balance chart
Opioid analgesia
broad spectrum antibiotic if pancreatic necrosis
what are the potential systemic complications of pancreatitis?
Disseminated Intravascular Coagulation (DIC)
Acute Respiratory Distres Syndrome (ARDS)
Hypocalcaemia (from fat necrosis)
Hyperglycaemia (islet destruction and subsequent insulin disturbance)
what are the potential local complications of pancreatitis?
pancreatic necrosis- persistent inflammation for >7/10 days, confirm with CT
pancreatic pseudocyst- collection of fluid containg pancreatic enzymes blood and necrotic tissue (usually found couple of weeks later)
what imaging is used in suspected cases of acute pancreatitis?
US to investigate underlying cause i.e. gallstones
CT only used if complications are suspected or diagnosis uncertain
what are the two most common causes of acute pancreatitis?
gallstones
alcohol
which level of serum amylase is daignostic of acute pancreatitis?
3x upper limit of normal
what is the M:F ratio of chronic pancreatitis?
4:1
average onset > 40yrs
what are the main causes of chronic pancreatitis?
chronic alcohol abuse (60%)
idiopathic (30%)
in addition to the typical epigastric pain and N&V pts with chronic pancreatits what may patients may also present with?
endocrine insufficiency- damage to islet of langerhans cells causes insulin disruption and impaired glucose regulation
exocrine insufficiency- damage to acinar cells causes failed digestive enzyme production leading to malabsoprtion
in addition to routine bloods and investigations which two tests can be helpful in diagnosing chronic pancreatitis?
blood glucose- second to endocrine insufficiency
faecal elastase- will be low second to exocrine insufficiency
how are cases of chronic pancreatitis managed?
analgesia
enzyme replacement if exocrine dysfunction i.e. Creon
vitamin supplements (fat soluble: A, D, E, K)
what makes up 90% of pancreatic cancers?
ductal carcinoma of the pancreas
exocrine tumours and endocrine tumours make up remainder
direct invasion of pancreatic cancers involves which structures?
spleen, transverse colon, adrenal glands
lymphatic invasion: regional lymph nodes, liver, lungs, peritoneum
*metastasis is common at time of diagnosis*
risk factors for pancreatic cancer?
smoking, chronic pancreatitis
late onset diabetes, diagnosis >50yrs = 8x greater risk of developing carcinoma
what % of cases of pancreatic cancer are unresectable at diagnosis?
80%- due to vague and non-specific symtpoms
what is Courvoisier’s Law?
in the presence of jaundice and an enlarged/ palpable gallbladder, malignancy of the biliary tree or pancreas fhould be strongly suspected
which tumour marker has a high sensitivity and specificty for pancreatic cancer?
CA19-9
assesses repsonse to treatment rather than initial diagnosis
what imaging is used for pancreatic cancer?
US for initial imaging
CT is most important for diagnosis and staging
*chest-abdomen-pelvis CT following diagnosis and potentialy PET-CT*
how are cases of pancreatic cancer managed?
only curative management is radical resection
whipples (pancreaticoduodenectomy)- tumour of head of pancreas
dital pancreatectomy
what is removed during a Whipples procedure?
head of the pancreas, antrum of stomach, 1st and 2nd parts of duodenum, the common bile duct and the gallbladder
all removed due to shared supply of gastroduodenal artery
adjuvant chemotherapy with which drug is commonly used following surgery in pancreatic cancer?
5-flourouracil
FOLFIRINOX and Gemcitabien therpay are alternatives
how are patients with pancreartic cancer palliatively managed?
palliative chemo i.e gemcitabine
enzyme replacements i.e. Creon for exocrine insificiency
what is the prognosis in pancreatic cancer?
5-year survival rate <5%
how can endocrine tumours of the pancreas be described?
functional- actively secreting enzymes with symtpoms related to this
non-functional- clinical features relate purely to malignant spread
endocrine tumours of the pancreas are associated with which syndrome?
MEN1 (multiple endocrine neoplasia 1)
what are the endocrine tumours of the pancreas?
Gastrinoma (G cells)
Glucagonoma (a cells)
Insulinoma (ß cells)
Somatostatinoma (σ cells)
VIPoma (non-islet cells)
how are pancreatic cysts divided?
true cysts (non-inflammatory)
pseudocysts (inflammatory)
name the parts of the pancreas?
how can true pancreatic cysts be classified?
secretions, histology, risk of malignancy
as a rule are serous or mucinous pancreatic cysts higher risk for malignancy?
serous cyst are low risk
muccinous are high risk
how are those with low and high risk pancreatic cysts typically followed up?
high risk- follow up MRI every 3 years
low risk- every 5 years
what are the msot common causes of splenic infarction?
Haematological disease*: lymphoma, sickle cell, CML
Thromboembolism
*cause infarction through congestion of splenic circulation by abnormal cells
what are important differentials of LUQ pain?
splenic rupture
peptic ulcer disease
pyelonephritis
left sided basal pneumonia
what is the gold standard investigation for splenic rupture?
CT abdo scan with IV contrast
segmental wedge of hypoattenuated tissue will be visible with the apex of the wedge pointign to hilum o fspleen from the segmental branchig of splenic artery
what are the complications of splenic infarction?
splenic rupture
splenic abscess
pseudocyst formation
Most cases will warrant splenectomy
what follows splenic rupture?
large intraperitoneal haemorrhage rapidly leading to haemorrhagic shock
msot cases of splenic rupture are secondary to what?
abdominal trauma- particularly blunt trauma
minority of cases are iatrogenic or second to underlying splenomegaly
how is splenic rupture managed?
those who are haemodynamically unstable or with grade 5 injury (shattered spleen) require urgent laparotomy
haemodynaically stable pts can be treated conservatively
what is OPSI?
Overwhelming Post-Splenectomy Infection
asplenic pts cannot mount normal immunological response
asplenic pts including those post-splenectomy shoudl receive vaccinations against which three organisms?
Pneumococcus
Meningococcus
H. Influenzae
