HPB the Spleen and Gallbladder Flashcards
Functions of the spleen
Breakdown erythrocytes
Immunological defence
Infections –> splenomegaly (6)
Infective endocarditis Bacterial sepsis EBV TB Malaria Schistosomaisis
Non-infective causes of splenomegaly (3)
Inflammation
Portal HTN
Haemolytic disease
Haemolytic diseases –> splenomegaly (4)
Haemolytic anaemia
Leukaemia
Lymphoma
Myeloproliferative disorders
where is massive splenomegaly palpable?
RIF
Which conditions can cause massive splenomegaly? (6)
Myelofibrosis Lymphoma CML Malaria Leishmaniasis Gaucher's
Causes splenic rupture (7)
Blunt trauma Penetrating ribs Malaria Mononucleosis Haematological disease Iatrogenic Pre-existing illness
PS splenic rupture
Immediate massive bleed
Or peritonism + eventual shock
When can splenic rupture present late?
If massive expanding haematoma beneath capsule
Adverse consequences splenectomy
Incr risk fulminant/sepsis
Neutrophilia
Decr prod Ig
Reactive thrombocytosis
Preventing post-splenectomy sepsis
Elective surgery - 2 weeks before vaccinate
Low dose heparin 4 w post op
Annual flu vaccine
Lifelong pen V
Contents of bile (5)
Cholesterol Phospholipids Bile salts H2O Conjugated bilirubin
Role of bile
Break up + emulsify fats in the gut
When does bile flow into the Gall bladder /
When sphincter of oddi is CLOSED
What causes the gall bladder to contract and bile to be released?
Presence of FFA or AA in the duodenum
Which leads to the release of CCK (cholecystokinin)
Do most gall stones produce symptoms?
No
What is cholelithiasis
Formation of gallstones in gall bladder
What are the 2 types of gall stones?
Cholesterol gallstones
Bile pigment stones
How are cholesterol gallstones formed?
Cholesterol crystallises in bile
B/c XS cholesterol secretion in to bile or loss bile salt content
RF cholesterol gallstones (11)
Age Obesity High fat diet Rapid W loss Female Multiparity Pregnancy OCP DM Ileal disease/resection Liver cirrhosis
What compound do bile pigment stones contain?
Calcium bilirubinate
What are black pigment gallstones associated with?
Haemolytic conditions
What are brown pigment gallstones due to?
Biliary stasis/infection
Complications of gallstones in the gallbladder (5)
Biliary colic Acute cholecytstitis Empyema Perforation Carcinoma
Complications of gallstones in the bile ducts (3)
Biliary obstruction
Acute cholangitis
Acute pancreatitis
Complications of gallstones in intestines
Gallstone ileus
What is biliary colic due to?
Impaction of gallstone in gall bladder
What is choledocolithiasis
Stone impaction in common bile duct
What can choledcocolithiasis predispose to?
Ascending cholangitis
Or
Acute pancreatitis
What is Mirizzi’s syndrome
Gallstone impacted in cystic duct/Hartmann’s pouch –> compression common hepatic duct
What is a Gallstone ileus?
When a large gallstone erodes through the gall bladder lumen –. fustula into adjacent duodenum
AXR findings gallstone ileus
Small bowel obstruction
GAll stone
Aerobilia
What is Aerobilia
Air in the biliary tree
Def biliary colic
Pain assoc w/ temp obstruction of cystic duct or CBD by a stone migrating from the GB
SOCRATES biliary colic
S - epigastric/RUQ pain O - peaks 2hrs after eating C - sharp, crescendo, constant R - R shoulder/subscapular A - N+V T - hr E - fatty foods, lying down, insp R - opiates S - severe
what is acute cholecystitis?
Obstruction of gall bladder from emptying
Why is there a 2’ inflamm response in acute cholecystitis?
B/c H2O = still reabsorbed from bile
Bile becomes highly concentrated
Sx acute cholecystitis (once inflamm component develops)
Localised RUQ pain
Assoc w/ guarding + rigidity, vom + systemic upset
Murphy’s sign
What is Murphy’s sign
Continuous P over GB when pt is inhaling will cause pt to catch their breath at point of max inhalation
What is chornic cholecystitis?
Repeated eps of inflamm due to gallstones –> fibrosis + thickening GB wall
Sx chronic cholecysitis
;
Recurrent bouts of abdo pain
Discomfort + flatulence after fatty meals
What is common bile duct obstruction usually due to?
CHoledocholithiasis
Couviosiers’ law
In the presence of jaundice the GB is palpable but non-tender - then jaundice = unlikely due to a stone
what is ascending cholangitis?
Infection of the CBD –> sepsis
What does ascending cholangitis usually occur 2’ to?
Choledocholeithiasis
Charcot’s triad in ascending cholangitis
Obstructive jaundice
High fever
RUQ pain
What may happen to the liver in ascending cholangitis
May become dotted with small mutliple abscesses
Blood Ix in diagnosing gallstones
WBC/inflamm markers LFTs Amylase Prothrombin time (pre-intervention) GLucose
Imaging Ix gallstones
ABDO USS = 1st line
MRCP
What 3 things are you looking for - abdo USS gallstones
Stones in GB
Thickened GB wall
Incr diameter CBD (>7mm)
Mx asymp gallstones
Watch + wait
Cholecystectomy if co-morbiditis or v young
Mx biliary colic
Admit + supportive
Laparoscopic cholecystectmy
what is a hot cholecystectomy
Done within 72hrs of admission
What is a cold cholecystectomy
done 6w after admission
Risks of biliary surgery (5)
Perf Gallstone ileus Aerobilia Obstruction CBD injury
Med Mx of biliary colic
chenodeoxycholic acid
Who can have med Mx of biliary colic
If have small, non-calcified stones
Mx acute biliary sepsis
A-E analgesia IV f+ electrolytes Catheterise IV tazocin +/- gentamicin
Mx acute cholecystitis
As per biliary colic
+ IV cefuroxime
Mx chronic cholecystitis
Laparoscopic cholecystectomy + chonagiogram
Mx obstructive jaundice due to stones
ERCP + sphincterectomy
Vit K beforehand
electic lap chole
Who gets carcinoma of the gallbladder?
Elderly
w/ longstanding gallstones
how does carcinoma of the GB spread?
Direct invasion of liver
Lymphatics
Sx carcinoma of the GB (6)
RUQ pain
N+V
W loss
Obstructive jaundice + palp mass
Tx carcinoma GB
Radical cholecystectomy +/- liver resection
Prognosis carcinoma GB
Poor - usually presents too late for therapy
