Pancreas, biliary and liver Flashcards
Acute cholecystitis
- Definition
- Causes
Inflammation of the gallbladder
Causes
- Gallstones: blocks bile flow, thickens bile in gallbladder, leading to bacteria infection. Stone is mainly of cholesterol.
- Without stones: vascuilitis,, chemo, trauma
Bacteria
- Gut bacteria: E.coli, bacteriodes
Complications of gallstones/ acute cholecystitis
Empyema/ mucocele
GB perforation
- Can escalate to peritonitis
GS ileus: stone obstructs bowel
Pancreatitis
Fistula- with bowel
Ascending cholangitis
- Definition
- Causes
- Symptoms
Inflammation of bile duct, typically caused by infection ascending from duodenum.
Causes
- Gallstones
- Strictures
- Malignancy
- ECRP
Symptoms
- Charcot’s triad: jaundice, abdominal pain, fever.
Surgery for gallstones, biliary colic
Surgery best done within 48 hrs of cholecystitis/ biliary colic
- Laparoscopic cholecystectomy + Antibiotics
- Biliary stones = ERCP.
+ Lap chole +
- If cholangitis= antibiotics
Cholecystectomy complications
Early
- Bleeding
- Bile duct injury
- Bile leak
Long term
- Adhesions
Post-surgery due to lack of bile
- Steatorrhea
- Abdominal discomfort
ERCP complications
Bleeding
Pancreatitis
Perforation
Gallstones risk factors
- 5 Fs
Female
Fertile (pregnant)
Fat
Fair (Caucasian)
Fifty (Age >50)
Causes of pancreatitis
I GET SMASHED
Idiopathic
Gallstones (common)
Ethanol (common)
Trauma
Steroids
Mumps
Autoimmune
Scorpion toxin
Hypertryglyceridaemia/ Hypothermia/ Hypocalcaemia
ERCP
Drugs
Management of pancreatitis
Initial
1. Large IV access: Fluids
2. Analagesia
3. O2 if needed
4. NBM, NGT?
Further
Complications of pancreatitis
Hypovolaemic shock
Haemorrhagic pancreatitis
Pseudocyst
- Made of pancreatic fluid
Infected necrosis
ARDS, SIRS
T2DM
Chronic pancreatitis
Multiorgan failure
Pneumoperitoneum
Air in the peritoneal cavity, can be within the abdominal cavity.
Causes
- Perforated duodenal/ peptic ulcer
- Bowel perf/ obstruction
- Post operation
Diagnosis
- Erect CXR
- CT (more information)
Murphy’s sign
Pressing on RUQ, asking Pt to breathe in.
- If painful= positive
- Cause= acute cholecystitis
GS ileus
Big stone gallstone enters the bowel and gets trapped in the ileocaecal junction.
Cholangiocarcinoma
Malignancy of bile duct
Pancreatic cancer categories
Adenocarcinoma
- Most common
- Exocrine tumour
Neoendocrine
- From endocrine source: insulinoma, glucagonoma etc
Tumour markers for pancreatic cancer
CA19-)
- Carbohydrate antigen 19.9
- Sensitivity= 80%, specificity 73%
Whipple’s surgery
Removal
- Gallbladder
- Antrum of stomach
- Head of pancreas
- Curve of duodenum
Bypasses food from stomach to jejunum
Jejunum loop attached to cystic duct to drain bile.
Prehepatic causes of jaundice
Haemolytic anaemia causes
- SCD
- Hereditary spherocytosis
- Autoimmune
- Transfusion reaction
- Drug toxicity
Hepatic causes of jaundice
Unconjugated hyperbilirubinaemia
- Gilbert’s syndrome
- Crigler Najjar
Conjugated
- Alcohol, chronic hepatatis
- Viral infection: Hepm EBV, BMV
- Bacterial infection: abscess
- Drugs: paracetamol, antibiotics
Post-hepatic jaundice causes
Biliary obstruction
- Gallstone
- Pancreatic cancer
- Stricture
- Blood clot
Cholangiocarcinoma
Sclerosing cholangitis
Investigations for jaundice
Blood
- Reticulocyte count (haemolytic)
- Clotting (hepatic)
- Hepatitis screen: Hep A, B, C, CMV, EBV
- ASM ab, AMA
- LFTs
Imaging
- USS
- MRCP
Liver biopsy
Gallstones types
- 3
Most common
- Mixed
Cholesterol
- Often large and solitary
Pure pigment (bile salts)
- Black (haemolytic disease)
- Brown (Chronic cholangiitis, biliary parasites)
Features of Acute cholecystitis
Biliary colic
- RUQ intermittent pain.
- With nausea/ vomtting
- Murphy’s sign= tenderness on gallbladder on inspiration
Gold standard bile stone investigation
USS
MRCP
- if US is inconclusive
Chronic pancreatitis
- Description
- Pathology
Irreversible destruction of pancreatic parenchyma
Pathology
- May be global or focal
- In chronic alcohol disease= head most affected
- Chronic inflammatory changes causing; glandular atrophy, duct ectasia, microcalcification, intraductal stone
Causes of chronic pancreatitis
Reurrent pancreatitis
Secondary to pancreatic duct obstruction
- Cyst
- Tumours
- Structuures
- CF
AI diseasse
- PBC, PSC
Congenital
Chronic pancreatitis presentation
Recurrent/ persistent abdominal pain
Signs of exocrine insuffiiciency
- malabsorption: weight loss, anorexia, steatorrhoea
Signs of endocrine insufficiency
- Dabetes
Treatment of chronic pancreatitis
Preventative management of further damage
- no OH
- Anti-oxidant rich diet
Control symptoms
- Diet: less fat
- Exocrine enzyme supplement
- Control DM
- Analgesia
Surgical
- Treat reversible cause (tumour, stone, stricture)
- Severe: pancreatectomy
Porto-systemic vascular anastomosis
Left gastric-Oesophageal veins
Superior rectal- inferior rectal veins
Umbilical vein- epigastric vein
Investigationns into liver cirrhosis
LFTs, clotting
- AST, ALT
Congential screen
- Ferrtin (haemochromatosis)
- Ceruloplasmin (Wilson’s)
- Alpha-1 antitrypsin
Autoimmune screen (AIH)
- Anti-mitochondrial antibodies
- Anti-smooth muscle antibodies
Viral Hepatitis screen
- Hep A-E
- EBV, CMV
Imaging
- Abdominal ultrasoudn
Liver biopsy
Pancreatic cancer
- Peak age
- Risk factors
Age: 60-70
Risk factor
- Smoking
- Age
- High fat diet
- DM
- Alcoholism
- Chronic pancreatitis
Pancreatic cancer
- Pathology types
Majority= ductal adenocarcinoma
- Mainly affects the head (then body and tail respectively)
Mucinous cyst neoplasms
Islet cell tumours
Carcinoma of head of pancreas
- Presentation
Obstructive jaundice
- Palpable gallbladder
Epigastric/ LUQ pain
General
- Nausea, vomitting
- Fatigue, malaise
- Anorexia
Mets
- Hepatomegaly
Carcinoma of body and tail of pancreas
- Presentation
Most common
- Weight loss
- Back pain
Epigastriic mass
DM
Pancreatic cancer investigations
Bloods
- Marker= CA 19-9 (70% specificity)
- Amylase
- U+Es
- Calcium
- Glucose
Imaging
- USS: transabdominal, endoscopic (better for smaller lesions)
- Doppler for portal vein and SMVessels
- ERCP if obstructive jaundice
Management of pancreatic cancer
- Curative
- Palliative
Curative
- Whipple’s: pancreatoduodenectomy
- Total/ distal pancreatomy
Palliative
- Relief jaundice: bilary stenting, drainage via PTC/ surgery
- Sugrical gastric bypass to relief duodenal obstruction
- Pain: morphine, chemical ablation of celiac ganglia
Commonest tumours that metastasize to the liver (5)
Pancreas
Bowel
Stomach
Breast
Oesophagus
Hepatocellular cancer
- Risk factors
Cirrhosis
Cholangocarcinoma
- Description
- Typical sites
Neoplasm of biliary tree
- Typically extrahepatic, diistal CBD/ common hepatic duct, confluence of hepatic ducts.
Adenocarcinoma of gallbladder
- Associations
- Presentation
Associations
- UC
- PSC
Presentation
- Gallbladder mass
- Obstructive jaundice
Classifications of acute pancreatitis
Oedematous
- Most common
- Simple/ associated with phlegmon formation
Severe/ necrotising
- May form pseudocyst (large peripancreatic fluid collection)
Haemorrhagic
Acute pancreatitis
- Investigations
Bloods
- FBC
- U+E: Na, K
- LFT
- Serum amylase: >1000 is diagnostic
- Group + save
Abdominal US
- Rules our gallstone obstruction
CT
- Pancreatic oedema, loss of fat planes
Glasgow Imrie criteria
Scoring criteria to assess the severity of acute pancreatitis.
PANCREAS:
P- PaO2 <8
A- Age >55
N- Neutrophils/ WCC >15
C- (Corrected) Calcium <2
R- Raised blood urea >16
E- Elevated enzymes (AST, LDH)
A-Albumin (hypo)
S- Blood glucose >10
What is the 2 week referral indication of suspected pancreatic cancer
Age >40 with unexplained jaundice
what is the urgent indication for CT/USS in suspected pancreatic cancer
> 60 with weight loss and:
- diarrhoea
- Back pain
- Abdominal pain
- Nausea
- Vomiting
- Constipation
- New diabetes
What is the Cullen’s sign and which condition is it associated with?
Oedema + bruising around the umbilicus within 24-48 hours of acute abdominal pain
- Associated with acute pancreatitis
What is the Grey-Turner’s sign and which condition is it associated with?
Bruising in the flanks (caused by retroperitoneal haemorrhage)
- Sign of acute pancreatitis
