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MBBS IV - Junior Clerkship WCS > JC63A (Surgery) - Gallstones, Pancreatitis, Cholangiocarcinoma, RPC, Liver abscess, Pancreatic cancer > Flashcards

JC63A (Surgery) - Gallstones, Pancreatitis, Cholangiocarcinoma, RPC, Liver abscess, Pancreatic cancer Flashcards

1
Q

Gallstones /

  • Types
  • Risk factors
A

Types:

  • Cholesterol - Cholesterol monohydrate
  • Black pigment - calcium bilirubinate
  • Brown pigment - Calcium bilirubinate, palmitate, sterate
  • Mixed - Cholesterol + calcium salts

RF:

  • Cholesterol: “4F”, Excessive cholesterol secretion and Gallbladder stasis
  • Black pigment: Increase heme turnover/ hemolysis, Bile acid malabsorption, GB stasis
  • Brown pigment: Bacterial infection of biliary tree
  • Mixed: All of the above
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2
Q

Screening for risk factors of gallstone disease in history taking *

A

Female, Middle age
Obesity
Gallbladder stasis: Pregnancy or high estrogen state, Previous gastrectomy/ truncal vagotomy, low enteric intake/ Long-term parenteral nutrition
Liver cirrhosis
Hemolytic conditions
Diabetes mellitus: excessive cholesterol secretion
BM/ solid organ transplant

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3
Q

4 diseases stages of gallstone disease /

A
  1. Lithogenic state: risk factors cause Microlithiasis suspended in bile
  2. Asymptomatic GS: incidental finding on imaging
  3. Symptomatic GS: Biliary colic +/- fat intolerance, dyspepsia
  4. Complicated GS: Cholecystitis, CA gallbaldder, Cholangitis, Gallstone pancreatitis and ileus …etc
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4
Q

Brief investigation and workup plan for Gallstone disease *

A

P/E + blood tests: should be normal in uncomplicated GS disease

First-line: Trans-abdominal US: most sensitive modality for GB stones
- Stones: echogenic foci that casts an acoustic shadow

Second-line:
MRCP: usually as 2nd line if TAUS -ve
EUS ± bile collection: identify small stones missed on TAUS

CT scans: look for complications

ERCP/ PTBD: therapeutic intervention

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5
Q

Surgical treatment options of gallstone disease *

A

Laparoscopic cholecystectomy: Early or delayed LC

Gallbladder drainage:
Percutaneous transhepatic cholecystostomy
Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD)
Endoscopic transpapillary drainage by ERCP (ETGBD)

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6
Q

Combination of surgical treatment options for CBD stone + Gallstones *

A

Pre-operative ERCP + Cholecystectomy: Most common

Laparoscopic cholecystectomy + Exploration of CBD: Emergency

Laparoscopic cholecystectomy + on-table ERCP

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7
Q

Complications of gallstone disease *

A

Acute cholangitis, gallstone pancreatitis

Cholecystoenteric/ Choledoduodenal fistula + Gallstone ileus

Gangrenous cholecystitis - Sepsis

Emphysematous cholecystitis - secondary infection of the gallbladder wall with gas-forming organisms such as Clostridium perfringens

Gallbladder perforation: usually contained in the subhepatic space by the omentum, perforation into adjacent organs

Gallbladder Mucocele

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8
Q

Acute pancreatitis /

Mild, moderate and severe presentation

A

Mild
• Absence of organ failure and local or systemic complications

Moderately severe
• Transient organ failure resolving within 48 hours
• Local or systemic complications without persistent organ failure > 48 hours

Severe
• Persistent organ failure involving one or multiple organs

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9
Q

Scoring system for severity of acute pancreatitis *

A

Ranson’s criteria (11 criteria)
Most commonly utilized predictor of mortality associated with acute pancreatitis

GALL ETOH
Glucose, Age, Lymphocyte, LFT, Electrolytes, Third spacing BUN, Oxyghen, Hematocrit

o Score < 3: Mortality = 0 – 3% (Mild acute pancreatitis)
o Score ≥ 3: Mortality = 11 – 15%
o Score ≥ 6: Mortality = 40%

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10
Q

Causes of acute pancreatitis and pathophysiology of each cause (9)

A

Gallstone: Reflux of bile into pancreatic duct

Alcoholism: Increases synthesis of digestive and lysosomal enzymes by pancreatic acinar cells

Hypercalcemia: High PTH, Formation and deposition of calcified stones intraductally in pancreatic duct

Hypertriglyceridemia: Lipase is thought to liberate toxic fatty acids into the pancreatic microcirculation

Post-ERCP

Drug-induced: Steroids, Diuretics, Azathioprine, DDP-4 inhibitors, Valproate, Sulphonamides

Infections

Tumours: Pancreatic or periampullary tumors

Autoimmune diseases: SLE, Sjogren’s, PBC

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11
Q

Causative infective agents of acute pancreatitis *

A

Bacteria = Mycoplasma/ Legionella/ Leptospira

Virus = Mumps/ Coxsackievirus B/ HBV/ EBV/ CMV/ VZV/ HSV/ HIV

Fungi = Aspergillus

Parasites = Ascaris/ Clonorchis sinensis/ Toxoplasmosis/ Cryptosporidium

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12
Q

Describe the anatomical location of 4 sections of pancreas /

A

4 sections from right to left: Head/Uncinate  Neck  Body  Tail

o Head of pancreas is cradled by the C-loop of duodenum
o Neck of pancreas lies anterior to the mesenteric vessels and portal vein
o Body of pancreas begins at the left border of SMV
o Tail of pancreas sits close to the splenic hilum anterior to left adrenal gland

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13
Q

Arterial and venous supply of pancreas /

A

Arterial supply: Celiac trunk/ Superior mesenteric artery (SMA)
Head of pancreas
 Superior pancreaticoduodenal arteries (from GDA)
 Inferior pancreaticoduodenal arteries (from SMA)
Tail of pancreas
 Splenic artery branches

Venous drainage:
Superior and inferior pancreaticoduodenal veins (into SMV)
Splenic veins (into portal vein)
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14
Q

Complication of acute pancreatitis *

A
  • *Pseudocyst**
  • *Infected pseudocyst**
  • *Necrotizing** pancreatitis
  • *Hemorrhagic** pancreatitis

Pleural effusion

  • *Ascites**
  • *Splenic vein thrombosis**
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15
Q

Pathophysiology of acute pancreatitis /

A

Initial insult = Unregulated premature activation of pancreatic enzymes such as trypsin within pancreatic acinar cells

  • Autodigestion of pancreatic tissues leading to peripancreatic and pancreatic necrosis
  • Autodigestion extends beyond the pancreas into the retroperitoneum, causing fat necrosis and erosion of blood vessels with hemorrhage
  • Entry of enzymes into the bloodstream may cause respiratory and renal injury

Systemic events
• NFᴋB-dependent inflammatory pathway
• Inflammatory cells lead to further acinar cell injury

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16
Q

Acute pancreatitis /

S/S

A

Fever

Abdominal pain
• Site: Epigastric pain but can be in RUQ or rarely LUQ
• Onset: Rapid onset (gallstones)/ Less abrupt (alcoholism)
• Character: Severe
• Radiation: Radiates to the back
• Associated symptoms: Nausea and vomiting
• Time course: Persists for several hours to days
• Relieving factors: Sitting up or leaning forward

Dyspnea
• Diaphragmatic inflammation secondary to pancreatitis
• Pleural effusions
• Adult respiratory distress syndrome

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17
Q

Ddx acute pancreatitis /

A

Differential diagnosis
 Peptic ulcer disease
 Choledocholithiasis/ Cholangitis/ Cholecystitis
 Hepatitis
 Mesenteric ischemia
 Intestinal obstruction
 Myocardial infarction*

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18
Q

Diagnostic criteria of acute pancreatitis /

A

Diagnosis of acute pancreatitis required 2/3 of the following
• Acute onset of persistent, severe, epigastric pain often radiating to the back (Clinical)
• Elevation of serum amylase or lipase to ≥ 3x upper limit of normal (Biochemical)
• Characteristic findings of acute pancreatitis on imaging including transabdominal USG, contrast-enhanced CT and MRI (Radiological)

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19
Q

Typical signs on abd. exam for acute pancreatitis /

A

• Inspection
o Abdominal distension
o Pancreatic panniculitis: Tender red nodules frequently occur in distal extremities
o Intra-abdominal bleeding: Cullen’s sign, Grey Turner sign

• Palpation
o Epigastric tenderness
o Hepatosplenomegaly (alcoholic pancreatitis)

• Auscultation
o Hypoactive bowel sounds (inflammation)

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20
Q

Biochemical tests for acute pancreatitis /

A

CBC with differentials
• Leukocytosis
• ↑ Hematocrit

Serum inflammatory markers
• ↑ CRP levels

LFT
• ↑ Conjugated bilirubin
• ↑ AST, ALT and ALP

RFT
• ↑ Creatinine and blood urea nitrogen (BUN)

Serum BG level
• Hyperglycemia or hypoglycemia

Serum Ca2+ level
Serum and urine amylase level ≥ 3x upper limit of normal
Serum lipase level ≥ 3x upper limit of normal

Cardiac markers ± ECG
• Troponin (TnI, TnT) to exclude myocardial infarction (MI)

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21
Q

Radiological tests for acute pancreatitis *

Features suggesting acute pancreatitis on each test

A

USG abdomen
• Pancreas appears diffusely enlarged and hypoechoic on ultrasound
• Presence of gallstones in gallbladder or bile duct
• Peripancreatic fluid collection appears as anechoic collection

Abdominal X-ray
• Sentinel loop - Localized ileus
• Colon cutoff sign - functional spasm of descending colon
• Ground-glass appearance - acute peri-pancreatic fluid collection

CT abdomen with contrast: for complications like pancreatic necrosis, biliary obstruction…etc

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22
Q

First-line treatment of acute pancreatitis *

A

General:

  • IV fluid resuscitation
  • O2 supplementation
  • Enteral* nutritional support with electrolyte and glucose correction
  • Foley catheter
  • NPO with NG tube suction

Medical:

  • *Analgesic: NSAID** (Not opioids to avoid sphincter of Oddi spasm)
  • *Antibiotics** for pancreatic necrosis >30% : Imipenem* or meropenem; carbapenems, fluoroquinolones and metronidazole
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23
Q

First-line Surgical treatment options for acute pancreatitis *

Surgical options for complications

A

Endoscopic retrograde cholangiopancreatography (ERCP)

Percutaneous transhepatic biliary drainage (PTBD)

Exploration of common bile duct (ECBD)

  • Necrosectomy:
    o Open = Laparotomy/ Retroperitoneal approach
    o Minimally-invasive = Endoscopic or percutaneous radiologic

Complications:

  • Pancreatic pseudocyst and walled-off necrosis >> surgical drainage by endoscopy, percutaneous catheter or surgical debridement
  • Infected necrosis; antibiotics + percutaneous catheter drainage or endoscopic drainage
  • Pseudoanerysm - ABSOLUTE contraindication to endoscopic drainage
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24
Q

Cholangiocarcinoma *

  • Definition
  • Histological types *
  • Possible anatomical sites
A

Cholangiocarcinoma: tumours of ductular epithelium of intra- or extrahepatic bile ducts

adenocarcinoma (>90%), SCC

Site:
□ Intrahepatic (<10%): above CHD bifurcation
□ Perihilar (Klatskin, 50%): from CHD bifurcation to cystic duct origin
□ Distal (40%): distal to cystic duct origin (i.e. CBD)

25
Q

Anatomical classification of Perihilar Cholangiocarcinoma /

A

Bismuth-Corlette classification for perihilar tumours:
□ Type I: below confluence of L/R hepatic ducts
□ Type II: reaching confluence
□ Type IIIa/b: involve CHD + R/L hepatic ducts
□ Type IV: multicentric or involve CHD + RHD + LHD

26
Q

Cholangiocarcinoma *

HPB risk factors

A
  • *Primary sclerosing cholangitis** and UC
  • *Recurrent pyogenic cholangitis** (hepatolithiasis)
  • *Parasitic infection:** Clonorchis, Opisthorchis
  • *Gallstones**
  • *Chronic liver disease**

Multiple biliary papillomatosis

Fibropolycystic liver diseases

27
Q

Cholangiocarcinoma *

Extra-HPB risk factors

A

FAT:

  • *Diabetes mellitus**
  • *Obesity and metabolic syndrome**
  • *INFECTED:**
  • *HIV infection**
  • *H. pylori infection**

Lynch syndrome
Cystic fibrosis

28
Q

Compare symptoms and signs of Intra-hepatic and extra-hepatic Cholangiocarcinoma /

A
29
Q

Ddx intrahepatic cholangiocarcinoma

A

Benign:
 Hepatic adenoma
 Hepatic haemangioma
 Focal nodular hyperplasia
Malignant
 Hepatocellular carcinoma
 Metastasis to liver

30
Q

Ddx extra-hepatic cholangiocracinoma /

A

Benign:
 CBD stones
 Post-instrumentation strictures
 Sclerosing cholangitis (PSC, IgG4-related)
 Chronic pancreatitis (compress CBD)

Malignant
 CA ampulla and duodenum
 CA head of pancreas
 Malignant hilar nodes

31
Q

3 patterns of cholangiocarcinoma spread /

A
32
Q

List curative and palliative treatment options for cholangiocarcinoma *

A

Curative:
- Hepatectomy
- Bile duct excision + reconstruction
- Hilar/ Portal Lymph node clearance
- Pancreaticoduodenectomy (Whipple’s) if distal disease
± adjuvant chemo/RT

  • *Palliative:**
  • Radiotherapy
  • Chemotherapy: GP regimen: cisplatin + Gentamycin chemo irradiation
  • Metallic stenting: Plastic vs metallic
  • Surgical bypass: Hepaticojejunostomy (HJ)
  • Drainage: PTBD or ERCP
33
Q

Indication for portal vein embolization for cholangiocarcinoma /

A
  • Future left lateral section <30% of estimated total liver volume (Urata formula)
34
Q

Recurrent pyogenic cholangitis

definition *

Causes

A

Recurrent cholangitis caused by stone formation resulting in stricturing of biliary tree and biliary obstruction

Causes:

1. Bacterial infection: Gram -ve bacilli
• Escherichia coli
• Klebsiella sp.
• Proteus sp.
• Pseudomonas aeruginosa
Anaerobes

2. Parasitic infection
Major liver trematodes or flukes that infect humans
• Clonorchis sinensis
• Opisthorchis viverrini
• Fasciola hepatica

  • *Roundworms**
  • *• Ascaris lumbricoides**
35
Q

RPC /

Pathogenesis

A

Stasis + Stricturing + Recurrent infection

Infection of bile ducts
>> Inflammation of portal triad and hepatocyte necrosis
>> Cholangiohepatitis, fibrosis and cholangitis with abscess formation
>> Bilirubinate stones and stricture formation

36
Q

RPC

Demographics /

A

exclusively in people who live in Southeast Asia

equal frequency in males and females

peak prevalence in 30 – 40s

Lower socio-economic group

37
Q

RPC

Typical locations of stricture formation /

A

Left main heaptic duct, segmental ducts

38
Q

RPC *

S/S

A

Charcot’s triad
• Fever
o With or without chills

• Abdominal pain
o RUQ or epigastric pain

• Jaundice

39
Q

RPC

First-line investigations: *

A

USG abdomen/ Liver USG: stones, ductal dilatation, liver abscess

CT abdomen

MRCP/ MRI

ERCP/ PTC with prophylactic antibiotics to prevent cholangitis or sepsis

40
Q

RPC

Supportive and definitive treatment options *

Aims of definitive treatment

A
  • *- IV antibiotics**
  • *- Rehydration and analgesics**
  • *- Urgent biliary decompression by ERCP**: with sphincterotomy, stricture dilatation and placement of biliary endoprosthesis (stent)
  • Hepaticojejunostomy with anastomosis into small bowel/ Hepaticojejunostomy with cutaneous stoma**

Aims:

  • *Remove biliary stones**
  • *Enlarge strictures/ Bypass strictures** for adequate biliary drainage
  • *Permanent percutaneous access to biliary tract**
41
Q

RPC *

Complications

A

Liver abscess

Choiangiocarcinoma

Portal vein thrombosis

Biliary cirrhosis

Choledoduodenal fistula

Acute pancreatitis: passage of biliary stone into pancreatic duct

42
Q

Liver abscess *

Risk factors

A

RFs:
□ Diabetes mellitus: classically a/w Klebsiella pneumoniae

□ Underlying HBP disease, eg. recurrent pyogenic cholangitis, liver transplant, liver cirrhosis

□ Colorectal cancer

□ Others: chronic PPI use, immunocompromised state (eg. CGD)

43
Q

Liver abscess /

Potential routes of infection

A

Ascending biliary infection: Biliary tract disease, Ascending cholangitis, empyema of GB, gallstones, malignant obstruction…etc

Portal vein pyemia: Intestinal pathology, Acute appendicitis, diverticulitis, pylephlebitis, Crohn’s disease

External inoculation: Penetrating wounds or iatrogenic

Hematogenous seeding: systemic bacteremia

44
Q

Liver abscess

S/S *

Complications (3)

A

□ Fever (90%): spiking fevers with chills
□ RUQ pain (89-100%): due to liver capsule stretch, may radiate to shoulder
□ Other liver symptoms: jaundice (23-43%), hepatomegaly (51-92%)
□ Constitutional symptoms: anorexia, weight loss, malaise

Complications:
→ Abscess rupture (3.8%)
→ Pleuropulmonary Cx (15-20%)
→ Local compression: Budd-Chiari syndrome (IVC/hepatic vein)
→ Consult EYE for K. pneumoniae endophthalmitis

45
Q

Ddx fever + RUQ pain *

A

(1) Hepatitis
(2) Acute cholangitis
(3) Acute cholecystitis
(4) RLZ pneumonia
(5) :Liver abscess

46
Q

Liver abscess /

First-line investigations

A

Basic blooods: NcNc anaemia, leukocytosis + L-shift, ↑ALP/GGT (SOL pattern) ± ↑bilirubin/AST, ↑CRP
Blood culture
Stool/serology for Entamoeba histolytica

USG: round/ovoid hypo/hyperechoic mass with internal echoes

Contrast CT: irregular lesion with central hypodensity ± gas
Double target sign: central hypodensity with hyperdense rim (capsule) and surrounding hypodensity (oedema)

MRI: T1W hypointense, T2W hyperintense

47
Q

Liver abscess *

First-line treatment

A

Supportive: resuscitate, vitals..etc

  • *Percutaneous drainage: diagnostic + therapeutic****
  • needle aspiration (if small ≤5cm) or catheter placement (if large >5cm)
  • USG- (small/superficial) or CT-guided

Surgical drainage: can be open or laparoscopic (rarely done, high mortality)

Antibiotics: empirically give ceftriaxone + metronidazole

48
Q

Pancreatic Cancer *

Demographic
Risk factors - pancreatic and systemic RF

A

Demography:
Median age 65, slight Male predominance

Pancreatic risk factors:

  • *- Chronic pancreatitis**
  • Pancreatic premalignant conditions: e.g. Pancreatic intraepithelial neoplasia (PanIN), Intraductal papillary mucinous neoplasm (IPMN)
  • Familial Pancreatic CA (FPC)
  • Genetic predisposition: e.g. Hereditary pancreatitis (PRSS1, SPINK1), Hereditary breast-ovarian cancer (BRCA1/2)

Systemic risk factors:

  • *Lifestyle factors:** smoking, obesity, DM
  • *Infections: H.pylori, HBV/HCV**
49
Q

Pancreatic cancer /

Pathological subtypes

A

□ Ductal adenocarcinoma (85%): signet ring, adenosquamous, anaplastic, colloid
- Pancreatic intraepithelial neoplasia (PanIN)

□ Cystic neoplasms: malignant potential for IPMN/MCN

  • Serous cystadenoma
  • Mucinous cystic neoplasm (MCNs)
  • Intraductal papillary mucinous neoplasms (IPMN):
50
Q

Pancreatic cancer /

Possible anatomical locations

A

□ Head (60%): a/w better prognosis (earlier detection due to obstructive jaundice)
□ Body (15%) or tail (5%): a/w worse prognosis (late detection)
□ Diffuse (20%)

51
Q

Pancreatic cancer /

S/S specific to pancreatic head cancer vs pancreatic tail cancer

A

Head:

  • Painless progressive obstructive jaundice
  • Vague epigastric/RUQ discomfort
  • S/S of pancreatic insufficiency with New onset diabetes (Steatorrhoea, maldigestion, malabsorption)
  • S/S of Gastric outlet obstruction

Tail:

  • Severe epigastric pain radiating to the back (⸪ invasion of coeliac and mesenteric plexus)
  • S/S of pancreatic insufficiency with New onset diabetes (Steatorrhoea, maldigestion, malabsorption)
  • Constitutional symptoms and S/S of metastasis
52
Q

Pancreatic cancer /

Paraneoplastic manifestations

A

Paraneoplastic manifestations (notorious)
 Trousseau’s syndrome (6%): unexplained migratory superficial thrombophlebitis
 Paraneoplastic pemphigoid
 Panniculitis (rare): esp in acinar cell variant, usu on legs

Systemic metastasis: liver, peritoneum, lungs, bone (less common)

Constitutional symptoms: malaise, weight loss, anorexia

53
Q

Pancreatic cancer *

Diagnostic investigations and typical findings

A
  • *TAUS: i**nitial screening Ix
  • Pancreatic mass: focal hypoechoic hypovascular solid mass with irregular margins

CT abdomen with pancreas protocol
→ Ill-defined hypoattenuating mass
→ Double duct sign

ERCP
→ Findings: double duct sign, >1cm pancreatic duct stricture

MRCP: same as ERCP

Tissue biopsy: imaging guided, for non-operative/ neoadjuvant Tx

54
Q

DDx pancreatic mass *

A

Pancreatic neuroendocrine tumours

Pancreatic lymphoma

Focal chronic pancreatitis

Autoimmune pancreatitis

55
Q

Definitive surgical treatment options for Pancreatic cancer: head vs tail *

A
  • *Pancreatic Head:**
  • *- Radical Pancreaticoduodenectomy (Whipple’s operation) + Reconstruction by Roux-en-Y**
  • *Pancreatic Tail:**
  • *- Distal/central subtotal pancreatectomy ± splenectomy**

No safe resection margin
- Total pancreatectomy

56
Q

Detail of Whipple’s procedure and Roux-en-Y reconstruction: list all resections and anastomoses /

A

En-bloc resection of 6 structures:

  • Head of pancreas
  • SB: duodenum + first 15cm of jejunum
  • *- Common bile duct**
  • *- Gallbladder**
  • *- Stomach**: distal gastrectomy
  • Regional LNs

Reconstruction by roux-en-Y (3 anastomoses)

  • *- PJ/G:** distal pancreas to jejunum/stomach
  • HJ: hepatic duct to jejunum (45-60cm proximal to GJ)
  • GJ: stomach to jejunum
57
Q

Post-Whipple supportive treatment (check) /

A

Pancreatic drain
Broviac catheter
Parenteral nutrition

58
Q

Treatment options for unrectable pancreatic cancer *

A

Systemic therapy: radiotherapy, chemotherapy
→ Chemotherapy (1st line): FOLFIRINOX, gemcitabine monotherapy
→ Other options (2nd line): other chemotherapy

Palliative drain: Metallic drain

  • *Surgical bypass**
  • Biliary bypass for obstructive jaundice + Coeliac axis block: Gastrojejunostomy and Hepaticojejunostomy
  • Triple bypass if obstructive jaundice + GOO
59
Q

Tests to differentiate liver primary vs secondary metastasis /

A

IHC tests

Lung primary= TTF1
Colorectal primary = CDX2
Breast primary = BRST2
Gynaecological primary = CA125

MBBS IV - Junior Clerkship WCS (131 decks)

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