HPB - Liver and Gall Bladder Flashcards
Which part of the biliary tree do cholangiocarcinoma’s tend to occur?
Predominantly in the extra hepatic biliary system
What is a Klatskin tumour?
Cholangiocarcinoma at the bifurcation of the right and left hepatic ducts
What type of cancers to cholangiocarcinomas tend to be?
- Adenocarcinoma*
- Squamous cell carcinoma
(- Sarcoma - Lymphoma
- Small cell cancer)
What are the risk factors for cholangiocarcinoma?
- 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
What are symptoms seen in cholangiocarcinoma?
- Post hepatic jaundice
- Pruritus
- Pale stools
- Dark urine
- RUQ pain
- Early satiety
- Weight loss
- Anorexia
- Malaise
What is Courvoisier’s law?
Presence of jaundice + enlarged/palpable gallbladder —> likely malignancy of biliary tree or pancreas
What are the DDx to consider for post-hepatic jaundice?
- Cholangiocarcinoma
- Obstructive choledocholiathiasis
- Bile duct stricture
- Choledochal cyst
- Compression of biliary tree
- Pancreatic tumour
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
What tumour markers are raised for cholangiocarcinoma?
- CEA
- CA19-9
What is the gold standard investigation for cholangiocarcinoma?
MRCP
What imaging is used to stage a cholangiocarcinoma? Why?
CT scan - locates distant metastases + evaluate level of biliary obstruction
What is the definitive management of a cholangiocarcinoma?
Complete surgical resection +/- radiotherapy
What palliative? management is there for a cholangiocarcinoma
- Stenting - relieve obstructive symptoms
- Surgical bypass procedures
- Palliative radiotherapy
- Chemotherapy
What complications are there in cholangiocarcinoma?
- Increased risk of biliary tract sepsis
- Secondary biliary cirrhosis
Why is long term survival poor in cholangiocarcinoma?
- Late presentation
- Majority of patients have unresectable disease at time of presentation
What is bile formed from?
- Cholesterol
- Phospholipids
- Bile pigments
List the three main types of gallstones
- Cholesterol stones
- Pigment stones
- Mixed stones
In which patients are pigment stones commonly seen?
Those with known haemolytic anaemia
What are the common risk factors for gallstone disease?
5F's - Female - Fat - Fertile - Forty - FHx \+ Pregnancy, OCP, haemolytic anaemia, malabsorption
What is biliary colic?
Condition where there is pain due to the gallbladder neck becoming impacted by a gallstone - pain from contraction against the stone
Describe the presentation of biliary colic
- Sudden, dull, colicky pain
- RUQ pain
- Precipitated by consumption of fatty foods
- N+V
Describe the presentation of acute cholecystitis
- RUQ pain
- Fever
- Murphy’s sign +ve
What is Murphy’s sign?
Ask the patient to inspire as you apply pressure in the RUQ - +ve when there is a halt in inspiration due to pain
What blood tests should be ordered in acute cholecystitis and what may they show?
- FBC - Raised WCC + CRP
- LFTs - raised ALP
- U&E’s - dehydration
- Amylase - check for pancreatitis
What imaging is first line for visualisation of gallstone disease?
Trans-abdominal USS
What may be seen on a US in gallstone disease?
- Presence of gallstones or sludge
- Gallbladder wall thickness
- Bile duct dilatation
What is the gold standard imaging modality for gallstone disease?
MRCP
What is the definitive management for biliary colic? What is the timeframe for this?
Elective cholecystectomy - within 6wks of first presentation
What Abx are usually given in acute cholecystitis?
Co-amoxiclav +/- metronidazole
What is the definitive management for acute cholecystitis? What is the timeframe for this?
Laparascopic cholecystectomy - within 1wk (but ideally within 72hrs of presentation)
What treatment can be given if a patient with acute cholangitis isn’t fit for surgery?
Percuatnoes cholecystectomy - drains the infection
What are the main complications of gallstone pathology?
- Obstructive jaundice
- Ascending cholangitis
- Acute pancreatitis
- Gallbladder empyema
- Chronic cholecystitis
- Bouveret’s syndrome
- Gallstone ileus
How is chronic cholecystitis often diagnosed?
CT scan
What is Bouveret’s syndrome?
Impaction of a gallstone to cause duodenal obstruction
What is gallstone ileus?
Impaction of a gallstone at the terminal ileum
What causes cholangitis?
Infection of the biliary tract - combination of biliary outflow obstruction + biliary infection –> stasis of fluid in obstruction allows for bacterial colonisation
What are the most common causes of cholangitis?
- Gallstones
- ERCP
- Cholangiocarcinoma
- Pancreatitis
- Primary sclerosing cholangitis
- Ischaemic cholangiopathy
- Parasitic infections
What are the most common infective organisms involved in cholangitis?
- Escherichia coli
- Klebsiella spp
- Enterococcus
How does cholangitis most commonly present?
Charcots triad - Fever - RUQ pain - Jaundice \+ pruritus, pale stools, dark urine
What is Reynold’s pentathlon?
- Jaundice
- Fever
- RUQ pain
- Hypotension
- Confusion
At what diameter is the common bile duct said to be dilated?
> 6mm
What is the gold standard investigation for cholangitis?
ERCP
What is the definitive management for cholangitis?
Endoscopic biliary decompression - by ERCP or percutanoues transhepatic cholangiography
What complications are there for ERCP?
- Repeated cholangitis
- Pancreatitis
- Bleeding
- Perforation
What factors may increase mortality in cholangitis?
- Delayed diagnosis
- Liver failure
- Cirrhosis
- CKD
- Hypotension
- Female
- > 50yrs
What are simple liver cysts thought to be?
Congenitally malformed bile duct cells - failed to connect to extra hepatic ducts, leading to a local dilatation filled with bile-like fluid
What symptoms may be seen in simple liver cysts (if any)?
- Abdominal pain
- Nausea
- Early satiety
What is the imaging modality of choice for suspected liver cysts?
USS
What are the characteristics of liver cysts on USS?
- Anechoic
- Well defined
- Thin walled
- Oval/spherical lesions
- Strong posterior wall acoustic enhancement
What abnormal blood results may be seen in the case of a simple liver cyst?
- Raised GGT
- CEA + CA19-9 may be raised
What is the management for simple liver cysts?
- No intervention
- > 4cm –> follow up USS at 3, 6, 12 months post detection
- Symptomatic –> USS guided aspiration or laparoscopic de-roofing
Define polycystic liver disease
Presence of >20 cysts in the liver parenchyma, each of which are >1cm in size
What is polycystic liver disease caused by?
- Autosomal dominant polycystic kidney disease
- Autosomal dominant liver disease
What seen on examination in polycystic liver disease?
- Abdominal pain
- Hepatomegaly
- Urinary tract symptoms (if countercurrent renal disease)
- Liver cirrhosis + portal hypertension (if severe)
What is the definitive diagnostic tool for polycystic liver disease?
USS
What medical treatment can be given for polycystic liver disease if needed?
Somatostatin analogues (short term benefit)
What are the indications for surgery in polycystic liver disease?
- Intractable symptoms
- Inability to rule out malignancy on imaging alone
- Prevention of malignancy
What surgical options are there for management of polycystic liver disease? What is the benefit of each?
- US guided aspiration –> relief of pain from cyst size
- Laparoscopic de-roofing of cysts –> preferred if evidence of compression of surrounding structures
- Resection
What are cystadenomas?
Non-invasive mutinous cystic neoplasms of the liver - premalignant lesion
What is the imaging indicated for suspected cystic neoplasms of the liver?
CT imaging with contrast - further delineation +/- evidence of metastasis
Why should aspiration or biopsy be avoided if cystic neoplasms of the liver are suspected?
Can result in peritoneal seeding of malignancy
What are the suspicious features for malignancy to look for on imaging of liver cysts?
- Septations
- Wall enhancement
- Nodularity
What are the suspicious features for abscess to look for on imaging of liver cysts?
- Debris within the lesion
- Loculation
What may be seen for a hydatid cyst on imaging of the liver?
- Calcification
- Daughter cysts around the main lesion
What is the management for cystadenomas and cystadenocarcinomas?
Liver lobe resection
What is a hydatid cyst?
Cyst of the liver caused by infection by tapeworm Echinococcus granulosus
How may hydatid cysts present?
- Vague abdominal pain (mass effect)
- Jaundice
- Cholangitis
- Vomiting
- Dyspepsia
- Early satiety
- Anaphylaxis (if rupture)
What is seen on the FBC in a hydatid cyst?
Eosinophilia
What is seen on USS for a hydatid cyst?
Calcified, spherical lesion with multiple septations
Why is aspiration not recommended for a hydatid cyst?
Risk of rupture leading to anaphylaxis
What is the main treatment for hydatid cysts?
Cyst deroofing
+ adjunct anti microbial action
What commonly causes liver abscess formation?
- Cholecystitis
- Cholangitis
- Diverticulitis
- Appendicitis
- Septicaemia
What organisms are most commonly isolated in liver abscesses?
- E coli
- Klebsiella pneumoniae
- S constellatus
- Fungal (immunocompromised)
What are the clinical features of a patient with a liver abscess?
- Fever
- Rigors
- Abdominal pain
- Bloating
- Nausea
- Anorexia
- Weight loss
- Fatigue
- Jaundice
- O/E –> RUQ tenderness +/- hepatomegaly
What abnormal results are seen on bloods for liver abscess?
- Leucocytosis
- Deranged LFTs (usually raised ALP and ALT+bilirubin in proportion)
What imaging modalities can be used for visualising a liver abscess?
- USS
- CT with contrast
What is the management for a liver abscess?
- Fluid resuscitation
- Abx therapy
- US/CT guided aspiration of abscess
What organism causes an amoebic abscess?
Entamoeba histolytica
What are the main risk factors for hepatocellular carcinoma?
- Viral hepatitis (B+C) ***
- High alcohol intake
- Smoking
- > 70yrs
- Hereditary haemochromatosis
- Primary biliary cirrhosis
- Aflatoxin exposure
- FHx of liver disease
What are the main symptoms of hepatocellular carcinoma?
- Fatigue
- Fever
- Weight loss
- Lethargy
- Dull ache in RUQ
What is felt on examination of hepatocellular carcinoma?
Irregular, enlarged, craggy + tender liver
What are the main DDx for a patient presenting with liver failure/non specific liver signs?
- Infectious hepatitis
- Cardiac failure
- Hepatocellular carcinoma
- Benign hepatocellullar adenoma
- Other causes of liver cirrhosis
What lab test can be used to monitor hepatocellular carcinoma?
Alpha fetoprotein
What imaging is used for hepatocellular carcinoma?
- USS
- Staging CT
- MRI liver scan
What may be seen on a CT angiogram for hepatocellular carcinoma?
Mass with arterial hypervascularisation
What staging system is used for hepatocellular carcinoma?
Barcelona clinic liver cancer staging system
What risk assessment tools are there for hepatocellular carcinoma? What do they indicate
- Child Pugh score
- MELD score
- -> risk of mortality of cirrhosis + predict effectiveness from treatment options
What curative options are there for hepatocellular carcinoma?
- Surgical resection
- Transplant for liver
What are the Milan criteria for transplantation?
- One lesion smaller than 5cm or 3 lesions smaller than 3cm
- No extra hepatic manifestations
- No vascular infiltration
What non-surgical management is available for hepatocellular carcinoma?
- Image guided ablation
- Alcohol ablation (best for small)
- Transarterial chemoembolisation
What is the median survival time from diagnosis in hepatocellular cancer?
~6months
What are the most common cancers to metastasise to the liver?
- Bowel
- Breast
- Pancreas
- Stomach
- Lung
Why is biopsy not advisable in metastatic liver cancer?
If the tumour is operable - as needle tract can lead to seeding of the tumour
