HPB + Pancreas Flashcards
what is cholelithiasis
condition of having gallstones
what are the different types of gallstones & what are the main impt things to know about them
cholesterol stones (85%)
radiolucent
5Fs
pigment stones 15%
black sterile gallstones (hard)
radiopaque
brown infected gallstones (soft)
radiopaque
mixed (majority)
biliary sludge
what are the risk factors for gallstones
5Fs
fat
females
forty
fertile
fam Hx
what Ix order for cholelithiasis
US HBS Hepatobiliary system—- since 85% are radiolucent
CT TAP — r/o alternative diagnosis or assess for complications
MRCP/ERCP
ERCP can be therapeutic!!!
MRCP = magnetic resonance cholangiopancreatography
ERCP = endoscopic retrograde cholangiopancreatography
+/- PTC percutaneous transhepatic cholangiography
how can cholelithiasis present
asymptomatic
biliary colic
complications
in gallbladder
acute calculous cholecystitis
mucocele of GB
Pericholecystic abscess
Mirizzi’s Syndrome
in CBD
obstructive jaundice
ascending cholangitis
secondary biliary cirrhosis
gallstone pancreatitis
in gut
gallstone ileus
what causes biliary colic
present of gallstones within the gallbladder
gallbladder contracts in response to hormonal or neuronal stimulation —- forces stone against GB outlet or cystic duct opening — increased intra-GB P
how does biliary colic present
Pain
epigastric or RUQ pain
NOT true colic!! – wax & wanes but rarely has pain free intervals
distinct attacks lasting 30 mins to 6 hrs — resolves spontaneously
radiation to inferior angle of scapula or tip of right shoulder
aggravated by fatty meals
+/- N&V
+/- bloating, abdo distension
+/- epigastric or retrosternal burning sensation
+/- back or LUQ pain
management of biliary colic
conservative Tx
diet —- avoid fat + large meals
counsel about symptoms
surgical Tx = elective laparoscopic cholecystectomy
IV Vit K BEFORE ANY INTERVENTION!!! — lack of bile salts in gut = reduced absorption of fat soluble Vit K = reduced prothrombin = increased bleeding
presentation of acute calculous cholecystitis
symptoms (Hx)
pain
RUQ
constant + unremitting + severe — >6 hrs to days
vs biliary colic = max 6 hrs per ep
trigger: fatty food
fever
N&V
anorexia
signs (exam)
RUQ tenderness + guarding
murphy’s sign +ve — inspiratory arrest on deep palpation of RUQ
boas’ sign — hyperaesthesia to light touch below right scapula (increased or altered sensitivity)
palpable GB (30%)
Ix for suspected acute calculous cholecystitis
bloods
FBC
U&E
CRP
LFTs
amylase
US HBS
since 85% gallstones radiolucent
CXR + Xray KUB – r/o alternative diagnosis
diagnostic criteria for acute cholecysitis?
acc to Tokyo guidelines
1 local sign of inflammation + 1 systemic sign of inflammation + 1 imaging finding
local signs of inflammation
murphy’s sign
RUQ mass/pain/tenderness
systemic sign of inflammation
fever
elevated CRP
elevated WBC
imaging finding characteristic of acute cholecystitis
usually US
management of acute cholecystitis
medical Tx
ABCs — IV fluid resus if dehydrated
septic work up
analgesia
empirical IV Abx
NBM
monitor for signs of failure of medical Tx — peritonism, non-resolving fever or pain
surgical Tx = lap chole
early rather than late — within 7 days of symptom onset
alternative = PTC percutaneous transperitoneal/transhepatic cholecystostomy
what are some complications of cholecystitis & gallstones
hydrops
empyema of GB
emphysematous cholecystitis
gangrene & perforation of GB
cholecystoenteric fistula
gallstone ileus
obstructive jaundice
what is cholangitis
life-threatening ascending bacterial infection of the biliary tree
a/w partial/complete obstruction of ductal system
causes of cholangitis
choledocholithiasis
benign biliary strictures — PSC, post-infectious, congenital
malignancy – pancreatic, biliary, GB, duodenum
foreign bodies
prev instrumentation — eg ERCP
cholelithiasis vs choledocholithiasis
cholelithiasis: presence of gallstones, usually in GB
choledocholithiasis: presence of gallstones in CBD common bile duct
presentation of cholangitis
charcot’s triad = fever + jaundice + RUQ pain
reynold’s pentad = those 3 + hypotension + AMS altered mental state
Ix for suspected cholangitis
bloods
septic work up
FBC
U&Es
LFT — cholestatic pattern (ALP + GGT»_space; ALT + AST)
US HBS
recall: 85% gallstones radiolucent
management of cholangitis
ABCDs
“in view of cholangitis being a SURGICAL EMERGENCY, i will resus patient who may be in septic shock + deteriorate rapidly”
good IV access
fluid resus
close monitoring
IV Abx
emergent biliary decompression via ERCP
usually deferred (24-48 hrs post admission) — unless deteriorating or not improving w Abx
definitive Tx = lap chole or ERCP sphincterotomy w removal of biliary stones
what is acute pancreatitis
reversible pancreatic parenchymal damage of varying severity – sec to acute inflammatory disease of the pancreas
prognosis of acute pancreatitis
80% = mild presentation + low mortality (1%) + low morbidity
20% = srs presentation + high mortality (40%) + high morbidity
death
early (within 1 wk) — severe organ failure
late — infected pancreatic necrosis w resultant sepsis
aetiology of acute pancreatitis
I GET SMASHED
(note: gallstones + ethanol = 60-80% of cases)
I: Idiopathic (15-25%) Iatrogenic (10%)
G: gallstones (40-70%)
E: Ethanol (25-35%)
T: trauma
S: steroids
M: mumps + other infections
A: autoimmune
S: scorpion toxin
H: hypertriglyceridaemia, hyperCa
E: ERCP (2-5%)
D: Drugs (1-2%) — Ab, azothioprine, valproate, diuretics, ACEI
Ix for suspected acute pancreatitis
bloods
FBC
U&E
LFTs
CRP
ABG
serum amylase — >3x ULN
rises within a few hrs + normalises in 5 days
serum lipase — >3x ULN
rises within 4-8 hrs + stays elevated for 8-14 days
imaging
erect CXR
PFA
US HBS
CT TAP
diagnostic criteria for acute pancreatitis
JPN Guidelines
2/3 of following
abdominal pain
acute onset + persistent + severe + epigastric pain
often radiating around abdomen to back
serum lipase/amylase — >3x ULN
characteristic imaging — CT/MRI/US
