Liver: Surgical Flashcards
Primary benign liver masses (4)
Cysts
Haemangioma
Focal nodular hyperplasia (has bile duct elements)
Hepatocellular adenoma
Primary malignant liver masses (3)
HCC (malignnat epithelial)
Cholangiocarcinoma
Angiosarcoma (vascular tumour, quite rare)
Hyatid cysts are caused by which organism?
Enchinococcus
Benign cyst
Common origin sites for secondary malignant liver tumour?
Much more common than primary cancer
From colon, lung, breast, stomach, pancreas, melanoma etc..
Difference between primary and secondary liver tumours?
Primary usually solitary, secondary usually multiple
Exceptions: eg solitary metastasis from colon
Aetiological factors of HCC?
Hepatitis B and C
Aflatoxins
Cirrhosis of any cause
Clinical features of HCC?
Rapid increase in liver size in cirrhotic patient
Worsening of ascites, fever, pain
Prognosis of HCC?
Usually incurable
Median survival is 7 months
Small lesions may be resectable
Embolisation of tumour may be used palliatively
Morphology of HCC
Can be unifocal, multifocal or diffusely infiltrative
Which liver tumour is most commonly associated with the use of OCP?
Hepatocellular adenoma
Risk factors for cholelithiasis and cholecystits
Female Fair Fat Forties Fertile
Also diabetes
What colour are cholesterol gallstones?
Pale
What colour are bile gallstones?
Dark green
Most stones are a mix of cholesterol and bile
Complications of gallstones
Can impact in Hartmann’s pouch or neck of gallbladder:
Cholecystitis Mucocele Biliary colic Obstructive jaundice Ascending cholangitis Pancreatitis
VERY RARE: GB carcinoma
Prognosis of gallbladder carcinoma?
Rare complication of gallstones
Usually elderly females
Advanced stage at presentation, poor prognosis
True/false: gallbladder papillomas are the most common benign tumours of the gallbladder
True
True/false: Cholangiocarcinoma is the commonest malignancy seen in the gallbladder
False, adenocarcinoma
Causes of extrahepatic biliary tract obstruction
Lumen: stones
Within wall: Stricture, tumour
Outsdie wall: Pancreas tumour, ampulla carcinoma, lymphoma, surgical ligation of bile duct
Clinical features of biliary obstruction
Obstructive jaundice (raised bili, pale stools, dark urine)
Raised ALP
Complications: cholangitis, abscesses
Radiology investigations for biliary tract obstruction
USS first line for gallstones
Percutaneous transhepatic cholangiogram (PTCA) to inject DYE
ERCP ?stone, benign or malignant stricture
Cytology of bile duct brushing ?malignancy
CT/MRI
What is a cholangiocarcinoma?
Adenocarcinoma of bile ducts (intra or extrahepatic)
Presents at early stage with obstructive jaundice
Risk factors for cholangiocarcinoma
Sclerosing cholangitis/UC
Liver fluke
Congenital biliary tree anomaly
How is cholangiocarcinoma diagnosed?
Diagnosis of exclusion (need to exclude primary tumours from pancreas or stomach which can closely mimic intrahepatic cholangiocarcinoma)
Where does an Ampullary carcinoma occur?
Ampulla of Vater, origin may be in duodenum, pancreas, bile duct, or ampulla itself
Important to distinguish from periampullary duodenal carcinoma or metastatic spread
Pathology of acute pancreatitis
- Due to acinar cell injury and inflammation
- Causes release of exocrine enzymes and autodigestion of pancreas
- Associated inflammatory response by cytokines, which leads to pancreas necrosis, surround FAT NECROSIS, and haemorrhage
Pathology of chronic pancreatitis
Repeated inflammation leads to loss of pancreas parenchyma and fibrosis
Also get inspissation of secretions in pancreas ducts, forming DUCTAL PLUGS
This results in calcification which can be picked up on imaging
Causes of pancreatitis (metabolic, mechanical, vascular, infectious)
Metabolic: alcohol, cholesterol, hypercalcaemia, drugs (THIAZIDES AND CICLOSPORIN)
Mechanical: Gallstones, trauma, post ERCP
Vascular: shock, embolism, vasculitis
Infectious: Mumps, mycoplasma, cocksackie virus
Presentation of acute pancreatitis
Epigastric pain radiating to back
Acute abdomen
Shock
ARDS, organ failure
Raised serum amylase
HYPOCALCAEMIA
Rarely jaundice
Hyperglycaemia
Clinical effects of chronic pancreatitis
Common cause: alcohol
Relapsing episodes of pain
Malabsorption due to enzyme loss
Exocrine more affected than endocrine
DM is late sign
Pseudocyst formation
How does chronic pancreatitis appear on imaging?
Calcification on CT/xray
Distorted ducts on ERCP
Risk factors fro pancreatic carcinoma
Smoking
Chronic pancreatitis
Genetic factors
Where is the most common site for carcinoma in the pancreas?
Head (60-70%)
Symptoms of pancreatic carcinoma
Painless jaundice (due to tumour on the head. Body and tail tumours present later)
Cachexia
Metastases
Thrombophlebitis
Serum markers for pancreatic cancer
CA19.9 most useful
CEA and CA125 may be elevated but are less specific
Diagnosis of pancreatic carcinoma
Definitive: needle/core biopsy under CT guidance
Prognosis of pancreatic cancer
<5% 5 year survival rate
What surgical procedure can be used to resect a pancreas head tumour?
Whipple’s pancreaticoduodenectomy
What are the 3 syndromes associated with pancreatic endocrine neoplasms (PENs)?
Insulinomas
Gastrinoma
MEN type 1
What is an insulinoma?
Syndrome of pancreatic endocrine neoplasm
Usually sporadic, single and benign
Secrete insulin, resulting in hypoglycaemia
Worsened by exercise or fasting
Can present with confusion
What are gastrinomas?
Syndrome linked to pancreatic endocrine neoplasm
Ofent multiple, can be malignant
Arise from G cells which secrete gastrin
Causes Zollinger Ellison syndrome (peptic ulceration)
WHich MEN type is associated with pancreatic endocrine neoplasms (PEN)?
MEN type 1
Autosomal recessive inherited condition.
Tumours in pancreas, pituitary gland, and parathyroid glands (remember PPP!!!!)
