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Surgery Block > HPB - Liver and Gall Bladder > Flashcards

HPB - Liver and Gall Bladder Flashcards

1
Q

Which part of the biliary tree do cholangiocarcinoma’s tend to occur?

A

Predominantly in the extra hepatic biliary system

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2
Q

What is a Klatskin tumour?

A

Cholangiocarcinoma at the bifurcation of the right and left hepatic ducts

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3
Q

What type of cancers to cholangiocarcinomas tend to be?

A
  • Adenocarcinoma*
  • Squamous cell carcinoma
    (- Sarcoma
  • Lymphoma
  • Small cell cancer)
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4
Q

What are the risk factors for cholangiocarcinoma?

A
  • Primary sclerosing cholangitis
  • Ulcerative colitis
  • Infective eg. liver flukes, HIV, hepatitis
  • Toxins eg. rubber or aircraft chemicals
  • Congenital eg. Caroli’s, choldedochal
  • Excess alcohol
  • Diabetes mellitus
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5
Q

What are symptoms seen in cholangiocarcinoma?

A
  • Post hepatic jaundice
  • Pruritus
  • Pale stools
  • Dark urine
  • RUQ pain
  • Early satiety
  • Weight loss
  • Anorexia
  • Malaise
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6
Q

What is Courvoisier’s law?

A

Presence of jaundice + enlarged/palpable gallbladder —> likely malignancy of biliary tree or pancreas

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7
Q

What are the DDx to consider for post-hepatic jaundice?

A
  • Cholangiocarcinoma
  • Obstructive choledocholiathiasis
  • Bile duct stricture
  • Choledochal cyst
  • Compression of biliary tree
  • Pancreatic tumour
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
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8
Q

What tumour markers are raised for cholangiocarcinoma?

A
  • CEA

- CA19-9

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9
Q

What is the gold standard investigation for cholangiocarcinoma?

A

MRCP

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10
Q

What imaging is used to stage a cholangiocarcinoma? Why?

A

CT scan - locates distant metastases + evaluate level of biliary obstruction

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11
Q

What is the definitive management of a cholangiocarcinoma?

A

Complete surgical resection +/- radiotherapy

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12
Q

What palliative? management is there for a cholangiocarcinoma

A
  • Stenting - relieve obstructive symptoms
  • Surgical bypass procedures
  • Palliative radiotherapy
  • Chemotherapy
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13
Q

What complications are there in cholangiocarcinoma?

A
  • Increased risk of biliary tract sepsis

- Secondary biliary cirrhosis

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14
Q

Why is long term survival poor in cholangiocarcinoma?

A
  • Late presentation

- Majority of patients have unresectable disease at time of presentation

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15
Q

What is bile formed from?

A
  • Cholesterol
  • Phospholipids
  • Bile pigments
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16
Q

List the three main types of gallstones

A
  • Cholesterol stones
  • Pigment stones
  • Mixed stones
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17
Q

In which patients are pigment stones commonly seen?

A

Those with known haemolytic anaemia

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18
Q

What are the common risk factors for gallstone disease?

A 
5F's
- Female
- Fat
- Fertile
- Forty
- FHx
\+ Pregnancy, OCP, haemolytic anaemia, malabsorption
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19
Q

What is biliary colic?

A

Condition where there is pain due to the gallbladder neck becoming impacted by a gallstone - pain from contraction against the stone

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20
Q

Describe the presentation of biliary colic

A
  • Sudden, dull, colicky pain
  • RUQ pain
  • Precipitated by consumption of fatty foods
  • N+V
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21
Q

Describe the presentation of acute cholecystitis

A
  • RUQ pain
  • Fever
  • Murphy’s sign +ve
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22
Q

What is Murphy’s sign?

A

Ask the patient to inspire as you apply pressure in the RUQ - +ve when there is a halt in inspiration due to pain

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23
Q

What blood tests should be ordered in acute cholecystitis and what may they show?

A
  • FBC - Raised WCC + CRP
  • LFTs - raised ALP
  • U&E’s - dehydration
  • Amylase - check for pancreatitis
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24
Q

What imaging is first line for visualisation of gallstone disease?

A

Trans-abdominal USS

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25
Q

What may be seen on a US in gallstone disease?

A
  • Presence of gallstones or sludge
  • Gallbladder wall thickness
  • Bile duct dilatation
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26
Q

What is the gold standard imaging modality for gallstone disease?

A

MRCP

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27
Q

What is the definitive management for biliary colic? What is the timeframe for this?

A

Elective cholecystectomy - within 6wks of first presentation

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28
Q

What Abx are usually given in acute cholecystitis?

A

Co-amoxiclav +/- metronidazole

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29
Q

What is the definitive management for acute cholecystitis? What is the timeframe for this?

A

Laparascopic cholecystectomy - within 1wk (but ideally within 72hrs of presentation)

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30
Q

What treatment can be given if a patient with acute cholangitis isn’t fit for surgery?

A

Percuatnoes cholecystectomy - drains the infection

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31
Q

What are the main complications of gallstone pathology?

A
  • Obstructive jaundice
  • Ascending cholangitis
  • Acute pancreatitis
  • Gallbladder empyema
  • Chronic cholecystitis
  • Bouveret’s syndrome
  • Gallstone ileus
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32
Q

How is chronic cholecystitis often diagnosed?

A

CT scan

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33
Q

What is Bouveret’s syndrome?

A

Impaction of a gallstone to cause duodenal obstruction

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34
Q

What is gallstone ileus?

A

Impaction of a gallstone at the terminal ileum

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35
Q

What causes cholangitis?

A

Infection of the biliary tract - combination of biliary outflow obstruction + biliary infection –> stasis of fluid in obstruction allows for bacterial colonisation

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36
Q

What are the most common causes of cholangitis?

A
  • Gallstones
  • ERCP
  • Cholangiocarcinoma
  • Pancreatitis
  • Primary sclerosing cholangitis
  • Ischaemic cholangiopathy
  • Parasitic infections
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37
Q

What are the most common infective organisms involved in cholangitis?

A
  • Escherichia coli
  • Klebsiella spp
  • Enterococcus
38
Q

How does cholangitis most commonly present?

A 
Charcots triad
- Fever
- RUQ pain
- Jaundice
\+ pruritus, pale stools, dark urine
39
Q

What is Reynold’s pentathlon?

A
  • Jaundice
  • Fever
  • RUQ pain
  • Hypotension
  • Confusion
40
Q

At what diameter is the common bile duct said to be dilated?

A

> 6mm

41
Q

What is the gold standard investigation for cholangitis?

A

ERCP

42
Q

What is the definitive management for cholangitis?

A

Endoscopic biliary decompression - by ERCP or percutanoues transhepatic cholangiography

43
Q

What complications are there for ERCP?

A
  • Repeated cholangitis
  • Pancreatitis
  • Bleeding
  • Perforation
44
Q

What factors may increase mortality in cholangitis?

A
  • Delayed diagnosis
  • Liver failure
  • Cirrhosis
  • CKD
  • Hypotension
  • Female
  • > 50yrs
45
Q

What are simple liver cysts thought to be?

A

Congenitally malformed bile duct cells - failed to connect to extra hepatic ducts, leading to a local dilatation filled with bile-like fluid

46
Q

What symptoms may be seen in simple liver cysts (if any)?

A
  • Abdominal pain
  • Nausea
  • Early satiety
47
Q

What is the imaging modality of choice for suspected liver cysts?

A

USS

48
Q

What are the characteristics of liver cysts on USS?

A
  • Anechoic
  • Well defined
  • Thin walled
  • Oval/spherical lesions
  • Strong posterior wall acoustic enhancement
49
Q

What abnormal blood results may be seen in the case of a simple liver cyst?

A
  • Raised GGT

- CEA + CA19-9 may be raised

50
Q

What is the management for simple liver cysts?

A
  • No intervention
  • > 4cm –> follow up USS at 3, 6, 12 months post detection
  • Symptomatic –> USS guided aspiration or laparoscopic de-roofing
51
Q

Define polycystic liver disease

A

Presence of >20 cysts in the liver parenchyma, each of which are >1cm in size

52
Q

What is polycystic liver disease caused by?

A
  • Autosomal dominant polycystic kidney disease

- Autosomal dominant liver disease

53
Q

What seen on examination in polycystic liver disease?

A
  • Abdominal pain
  • Hepatomegaly
  • Urinary tract symptoms (if countercurrent renal disease)
  • Liver cirrhosis + portal hypertension (if severe)
54
Q

What is the definitive diagnostic tool for polycystic liver disease?

A

USS

55
Q

What medical treatment can be given for polycystic liver disease if needed?

A

Somatostatin analogues (short term benefit)

56
Q

What are the indications for surgery in polycystic liver disease?

A
  • Intractable symptoms
  • Inability to rule out malignancy on imaging alone
  • Prevention of malignancy
57
Q

What surgical options are there for management of polycystic liver disease? What is the benefit of each?

A
  • US guided aspiration –> relief of pain from cyst size
  • Laparoscopic de-roofing of cysts –> preferred if evidence of compression of surrounding structures
  • Resection
58
Q

What are cystadenomas?

A

Non-invasive mutinous cystic neoplasms of the liver - premalignant lesion

59
Q

What is the imaging indicated for suspected cystic neoplasms of the liver?

A

CT imaging with contrast - further delineation +/- evidence of metastasis

60
Q

Why should aspiration or biopsy be avoided if cystic neoplasms of the liver are suspected?

A

Can result in peritoneal seeding of malignancy

61
Q

What are the suspicious features for malignancy to look for on imaging of liver cysts?

A
  • Septations
  • Wall enhancement
  • Nodularity
62
Q

What are the suspicious features for abscess to look for on imaging of liver cysts?

A
  • Debris within the lesion

- Loculation

63
Q

What may be seen for a hydatid cyst on imaging of the liver?

A
  • Calcification

- Daughter cysts around the main lesion

64
Q

What is the management for cystadenomas and cystadenocarcinomas?

A

Liver lobe resection

65
Q

What is a hydatid cyst?

A

Cyst of the liver caused by infection by tapeworm Echinococcus granulosus

66
Q

How may hydatid cysts present?

A
  • Vague abdominal pain (mass effect)
  • Jaundice
  • Cholangitis
  • Vomiting
  • Dyspepsia
  • Early satiety
  • Anaphylaxis (if rupture)
67
Q

What is seen on the FBC in a hydatid cyst?

A

Eosinophilia

68
Q

What is seen on USS for a hydatid cyst?

A

Calcified, spherical lesion with multiple septations

69
Q

Why is aspiration not recommended for a hydatid cyst?

A

Risk of rupture leading to anaphylaxis

70
Q

What is the main treatment for hydatid cysts?

A

Cyst deroofing

+ adjunct anti microbial action

71
Q

What commonly causes liver abscess formation?

A
  • Cholecystitis
  • Cholangitis
  • Diverticulitis
  • Appendicitis
  • Septicaemia
72
Q

What organisms are most commonly isolated in liver abscesses?

A
  • E coli
  • Klebsiella pneumoniae
  • S constellatus
  • Fungal (immunocompromised)
73
Q

What are the clinical features of a patient with a liver abscess?

A
  • Fever
  • Rigors
  • Abdominal pain
  • Bloating
  • Nausea
  • Anorexia
  • Weight loss
  • Fatigue
  • Jaundice
  • O/E –> RUQ tenderness +/- hepatomegaly
74
Q

What abnormal results are seen on bloods for liver abscess?

A
  • Leucocytosis

- Deranged LFTs (usually raised ALP and ALT+bilirubin in proportion)

75
Q

What imaging modalities can be used for visualising a liver abscess?

A
  • USS

- CT with contrast

76
Q

What is the management for a liver abscess?

A
  • Fluid resuscitation
  • Abx therapy
  • US/CT guided aspiration of abscess
77
Q

What organism causes an amoebic abscess?

A

Entamoeba histolytica

78
Q

What are the main risk factors for hepatocellular carcinoma?

A
  • Viral hepatitis (B+C) ***
  • High alcohol intake
  • Smoking
  • > 70yrs
  • Hereditary haemochromatosis
  • Primary biliary cirrhosis
  • Aflatoxin exposure
  • FHx of liver disease
79
Q

What are the main symptoms of hepatocellular carcinoma?

A
  • Fatigue
  • Fever
  • Weight loss
  • Lethargy
  • Dull ache in RUQ
80
Q

What is felt on examination of hepatocellular carcinoma?

A

Irregular, enlarged, craggy + tender liver

81
Q

What are the main DDx for a patient presenting with liver failure/non specific liver signs?

A
  • Infectious hepatitis
  • Cardiac failure
  • Hepatocellular carcinoma
  • Benign hepatocellullar adenoma
  • Other causes of liver cirrhosis
82
Q

What lab test can be used to monitor hepatocellular carcinoma?

A

Alpha fetoprotein

83
Q

What imaging is used for hepatocellular carcinoma?

A
  • USS
  • Staging CT
  • MRI liver scan
84
Q

What may be seen on a CT angiogram for hepatocellular carcinoma?

A

Mass with arterial hypervascularisation

85
Q

What staging system is used for hepatocellular carcinoma?

A

Barcelona clinic liver cancer staging system

86
Q

What risk assessment tools are there for hepatocellular carcinoma? What do they indicate

A
  • Child Pugh score
  • MELD score
  • -> risk of mortality of cirrhosis + predict effectiveness from treatment options
87
Q

What curative options are there for hepatocellular carcinoma?

A
  • Surgical resection

- Transplant for liver

88
Q

What are the Milan criteria for transplantation?

A
  • One lesion smaller than 5cm or 3 lesions smaller than 3cm
  • No extra hepatic manifestations
  • No vascular infiltration
89
Q

What non-surgical management is available for hepatocellular carcinoma?

A
  • Image guided ablation
  • Alcohol ablation (best for small)
  • Transarterial chemoembolisation
90
Q

What is the median survival time from diagnosis in hepatocellular cancer?

A

~6months

91
Q

What are the most common cancers to metastasise to the liver?

A
  • Bowel
  • Breast
  • Pancreas
  • Stomach
  • Lung
92
Q

Why is biopsy not advisable in metastatic liver cancer?

A

If the tumour is operable - as needle tract can lead to seeding of the tumour

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