Liver, Biliary System, Pancreas Flashcards
another name for main pancreatic duct?
Duct of Wirsung
runs from tail to ampulla, turns inferiorly in head
name of accessory duct of pancreas and where does it drain?
accessory duct of Santorini
drains into accessory ampulla
presentation of acute pancreatitis?
constant epigastric pain, may radiate around to back, aggravated by movement, relieved by sitting forward, assoc. nausea and vomiting
signs of acute pancreatitis?
grey turner's sign epigastric tenderness abdom distension cullen's sign fever and tachycardia jaundice- oedema of pancreatic head obstructing CBD
what may be a common factor underlying many of the causes of acute pancreatitis?
duodenal reflux- enterokinase from gut can enter pancreas to cause premature activation of pancreatic proenzymes.
enterokinase converts trypsingogen to trypsin which cleaves chymotrypsinogen to chymotrypsin.
trypsin- causes autodigestion of pancreas
lipase- fat necrosis
amylase- rise in serum level
investigations in acute pancreatitis?
FBC- moderate leucocytosis
CRP?
Us and Es-assess renal function-may use contrast in ERCP?, and urea more than 16mmol/L criterion in severity determination.
LFTs- serum bilirubin raised, ALP twice upper limit of normal may indicate high risk pt with CBD gallstones?
serum amylase- max. within 2 days, NOT prognostic marker or lipase
calcium-low Ca2+-less than 2mmol/L in modified Glasgow criteria for predicting severity, due to Ca2+ reacting with FA in the pancreatic tissue that have been released with lipase breakdown of fatty tissue, to form chalky deposits.
glucose and albumin and LDH to aid in determining severity with modified Glasgow criteria
ABG- hypoxia in severe cases
blood lactate?-sepsis?, blood culture if pyrexial?
AXR and CXR- exclude perforation, sentinel loop- single loop of dilated bowel due to a nearby ileus from localised inflammation.
?ECG if epigastric pain to rule out acute MI
USS- rule out GSs, check for pseudocysts
CT- assess for pancreatic necrosis
what is a pseudocyst?
coalescence of fluid secreted by pancreas during disease, containing digestive enzymes, and collects in lesser sac, commonly appearing from day 10 onwards.
pseudo= not a real cyst as not lined by epi/endothelium as collection in lesser sac poster. to stomach.
may cause jaundice, gastric outlet obstruction and heavy bleeding
risk of fistula formation if drain percutaneously
differentials for acute pancreatitis?
AAA MI perforated peptic ulcer cholecystitis/cholangitis mesenteric infarction
tment acute mild pancreatitis?
IV fluids, crystalloid and plasma expanders
analgesia
foley catheter- monitor urine output
correct electrolytes e.g. Ca2+
Hrly mon- BP, urine output, RR, blood glucose *EWS
can eat and drink
alcohol withdrawal prophylaxis
identify precip cause, if GSs- laparoscopic cholecystectomy- prevent recurrent episodes.
severe acute pancreatitis tment?
IV fluids, analgesia, central line
antibiotics e.g. co-amoxiclav
FEED!- oral if canm nasojejunal may be better than TPN if not and no ileus as reduce risk of septic complications, improved maintenance of gut mucosal integrity.
surgery- early ERCP
systemic complications of acute pancreatitis?
SIRS DIC shock pulmonary insufficiency metabolic- low Ca, Mg and albumin
how can pancreatic fistuale and duct strictures be treated?
pancreatic duct stenting
most common causes chronic pancreatitis?
alcohol
trauma
familial
presentation chronic pancreatitis?
recurrent epigastric pain radiating through to back
weight loss, anorexia
steatorrhoea and malabsorption- as pancreatic insufficiency
diabetic
narcotic abuse frequently seen
drugs which may cause acute pancreatitis?*
steroids
sodium valproate
drugs for DM-DPP4 inhibitors?
investigations to diagnose chronic pancreatitis?
fibrosis of pancreas- duct dilatation on MRCP- magnetic resonace cholangiopancreatography or CT
butter fat test or faecal elastase
medical tment chronic pancreatitis?
opioid analgesia, and celiac axis block
diabetic control
stop alcohol
creon (pancrelipase)-comprised of lipase, protease and amylase, with each meal for exocrine dysfunction
surgical tment chronic pancreatitis?
ERCP and pancreatic duct stent
resection
drainage surgery- Puestow: Small bowel anastomosed to pancreatic duct so whole length of duct drained into loop of intestine.
Frey’s combines this procedure, with “coring” out the pancreatic head
if pancreatitis in elderly, what surgical tment may be used?
ERCP and sphincterotomy
general complications of pancreatitis?
recurrent attacks
diabetes
pulmonary insufficiency
haemorrhage
renal failure due to inadequate perfusion- shock, SIRS
pseudocyst, abscesses, strictures, fistulae
causes other than acute pancreatitis for raised serum amylase?
acute cholecystitis bowel perforation perforated peptic ulcer disease mesenteric infarction-acute mesenteric ischaemia ruptured AAA ruptured ectopic preg (EP)
management of ascending cholangitis?
parenteral antibiotics
resuscitation
endoscopic biliary drainage
what is saint’s triad?
coexistence of GSs with diverticular disease and hiatus hernia
what 3 factors does formations of GSs revolve around?
lithogenic bile as increase in cholesterol relative to bile salts
stasis
a nidus e.g. provided by bacteria or FBs
in what region are GSs rarely visualised with an USS?
in distal CBD as overlying intraduodenal gas
signs of acute cholecystitis?
fever
tachycardia
murphy’s sign
rebound tenderness or guarding
what is seen on a plain abdom. X-ray of GB empyema?
an air-fluid level
what is Mirizzi type 1 syndrome and why should it be diagnosed pre-operatively?
GS impacted in Hartmann’s pouch can result in obstructive jaundice by impinging on CBD.
must be diagnosed pre-op as there is a risk of damage to CBD.
type 2= pressure on CBD can result in necrosis of intervening tissue, with a resultant fistula.
management of GB calculi if symptomatic?
elective cholecystectomy
how should bile ducts be screened prior to cholecystectomy following acute pancreatitis or obstructive jaundice, or abnormal LFTs or CBD dilated on USS?
by ERCP
how does GS ileus occur and present?
GS can erode into duodenum and impact at narrowest point of small bowel, typically 2 ft proximal to ileo-caecal valve or at an excistent pathological stricture.
presents as small bowel obstruction.
plain AXR may show obstructed small bowel, a large calcified GS in RIF, and air outlining biliary tree, but whole triad rarely seen.
why should an ECG always be performed in ptnt presenting with epigastric pain?
could be MI
drugs that can cause acute pancreatitis?
steroids
sodium valproate
thiazides
oestrogens
PAN in Imrie scorng system (modified glasgow)
PaO2 less than 8.0kPa
age over 55yrs
neutrophilia-WCC more than 15 X 10^9
CRE in Imrie scoring system?
Ca2+ is less than 2 milimol per litre
urea is raised to more than 16 milimol per litre
E- LDH more than 600U/L
AS in Imrie scoring system?
A- albumin is less than 32 grams per litre
glucose is more than 10 milimol per litre
3 or more= severe pancreatitis with high mortality, assess within 1st 48hrs.
why is albumin reduced in acute pancreatitis, and hence why is energetic fluid replacement the single most important therapeutic measure?
large volume of protein rich fluid sequestered in retroperitoneum
how is vol replacement guided in acute pancreatitis?
CVP measurement
how is pancreatic viability assessed in acute pancreatitis?
early CT scan with IV contrast
why is ABG measurement important in 1st 48 hrs of pancreatitis?
must know PaO2 and give oxygen by mask if hypoxaemia. resp failure can occur as systemic inflammatory response with lung capillary leak causing pulmonary interstitial oedema and so lengthened diffusion pathway.
when would giving Ca2+ in acute pancreatitis be necessary?
if tetany occurs
what are pseudocysts surrounded by?
granulation tissue
complications of pseudocyst?
haemorrhage- erosion into splenic artery
obstruction- GOJ, duodenum, CBD
infection
how does contrast determine pancreatic necrosis on CT?
necrosed area will not enhance
presentation of pancreatic carcinoma in 30-60% of ptnts?
obstructive jaundice- skin and sclera yellow, pale stools, dark urine, raised bilirubin and ALT, and very raised ALP
sign that may be found in ptnt unknown to have a pancreatic carcinoma?
Trousseau’s sign= migrating superficial thrombophlebitis
why is back pain in pancreatic carcinoma part. assoc. with a poor prognosis?
suggests erosion of malignancy into posteriorly related pre-vertebral structures
why should symptomatic hepatic masses NOT be biopsied if potentially resectable?
increase risk of tumour seeding and infiltration of diaphragm
commonest benign hepatic neoplasm?
haemangioma
CT scan with IV contrast shows characteristic peripheral enhancement with centripetal filling.
often asymptomatic- observation required
resection if symptomatic
people in which hepatic adenomas most commonly occur?
women who have used OCPs
presentation of hepatic adenomas?
abdominal pain
acute intraperitoneal bleeding from sudden rupture
hepatomegaly/ upper abdo mass
cold defect on radionuclide imaging
haemorrhage and necrosis on MRI scans
angiography= hypervascular lesion with peripheral blood supply
benign hepatic tumours?
haemangiomas
hepatic adenomas
focal nodular hyperplasia- angiography shows hypervascular lesion
bile duct adenomas
aetiology of HCC?
hep B and C infection
liver cirrhosis
aflatoxin B1
rarely= synthetic androgens, haemochromatosis, alpha 1 antitrypsin deficiency, type 1 glycogen storage disease
symptoms HCC?
RUQ pain and hepatomegaly jaundice weight loss anorexia fever
how are ptnts at high risk of HCC screened?
alpha fetoprotein measurements and liver US every 4 mtnhs e.g. in those with long-standing Hep B infection
pntns in which incidence of cholangiocarcinoma is higher?
sclerosing cholangitis
UC
cystic dilatation of biliary tree
only metastatic disease in which liver resection is established?
colorectal cancer
cholangiocarcinoma clinical features?
weight loss jaundice pruritis vague abdo pain nausea weight loss
best hope for a cure in cholangiocarcinoma?
resection
most common cause of hepatocellular carcinoma?
Hepatitis B virus
