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Year 3 - Met3a > Pancreatico-biliary diseases > Flashcards

Pancreatico-biliary diseases Flashcards

1
Q

what markers do the liver function tests include

A
  • Bilirubin
  • AST/ALT - produced by hepatocytes
  • ALP and GGT - produced by the biliary epithelium
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2
Q

What are the two types of bilirubin can you measure

A
  • unconjugated (indirect - measure of prehepatic)

- conjugated (direct - measure post hepatic)

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3
Q

what are the types of gallstones

A
  • pigment stones - small, friable and irregular, caused by haemolysis
  • Cholesterol stones - large, often solitary; caused by male, age and obesity
  • Admirand’s triangle - increase risk of stone if decreased lecithin, decreased bile salts and increased cholesterol
  • mixed stones - faceted (calcium salts, pigment and cholesterol)
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4
Q

What are the risk factors of gallstones

A
  • 5Fs - fat, 40s, fair, female, fertile
  • family history
  • drugs - Oral Contraceptive Pill, fibrates
  • associated conditions - sickle cell disease, cirrhosis, Crohn’s
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5
Q

What are the complications of gallstones in the..

  • in the gallbladder and cystic duct
  • in the bile duct
  • in the gut
A

In the gallbladder and cystic duct

  • Acute and chronic cholecystitis
  • Mucocoele
  • Empyema
  • Carcinoma
  • Mirizzi’s sindrome
  • biliary colic

In the bile duct

  • cholangitis
  • obstructive jaundice
  • pancreatitis

in the gut
- Gallstone ileus

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6
Q

What imaging do you use for gallstones

A
  • abdominal X ray - only done in 20% of cases - therefore not used
  • CT
  • Ultrasound
  • MRCP
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7
Q

What is Chronic cholecystitis

A
  • Chronic inflammation and biliary colic
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8
Q

What are the symptoms of chronic cholecystitis

A
  • flatulent dyspepsia = vague abdominal discomfort, distension, nausea, flatulence and fat intolerance
  • fat stimulates cholecystokinin release and gallbladder contraction
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9
Q

What does examination of cholecystitis feel like

A
  • tender in RUQ due to gallbladder inflammation
  • exhibit murphy’s sign
  • febrile
  • may have features of sepsis
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10
Q

what does the blood tests look like in cholecystitis

A
  • FBC - elevated WCC
  • CRP - elevated
  • LFT - Elevated ALT/ALP
  • patient should not be jaundice as there is no blockage to the flow of the bile
  • U&E, clotting and blood gas should be normal
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11
Q

What imaging should you use in cholecystitis

A
  • ultrasound scan

- CT scan

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12
Q

What is the treatment that is used in Chronic cholecystitis

A
  • cholecystectomy
  • ERCP and sphincterotoy before surgery - if US shows a dilated CBD with stones
  • if symptoms persist post-op consider hiatus hernia/IBS/peptic ulcer/chronic pancreatitis/tumour
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13
Q

What are the complications of cholecystitis

A
  • chronic cholecystitis
  • gallbladder empyema - if the gallbladder fails to drain at all

Fistula

  • cholecystoduodenal
  • cholecystojejunal
  • cholesystocolonic
  • mirizzi syndrome - gallstone is impacted at the end of the cystic duct causing compression of the bile duct - therefore due to the obstruction of the bile duct the patient will have jaundice
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14
Q

What are the differential diagnosis of GI causes and non GI causes of cholecystitis

A

GI causes

  • peptic ulcer
  • dyspepsia
  • pancreatitis
  • perforated ulcer

Non GI causes

  • pyelonephritis
  • pneumonia
  • ACS
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15
Q

What pain is experienced in biliary colic

A
  • colicky pain due to gallstone temporarily blocking the cystic or bile duct
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16
Q

What are the symptoms of biliary colic

A
  • colicky RUQ pain
  • radiation to the right shoulder
  • time - only last for hours as it is a temporary blockage of the bile or cystic ducts
  • repeated episodes
  • brought on after eating fatty foods
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17
Q

what does biliary colic look like on examination

A
  • might be RUQ pain

- or examination can be normal

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18
Q

What do the bloods look like in a biliary colic

A
  • LFTs - elevated ALP

- FBC, lipase, CRP, clotting normal

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19
Q

What imaging would you use for biliary colic

A
  • USS
  • CT
  • MRCP
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20
Q

what is the treatment for biliary colic

A
  • remove the stones (ERCP)

- Remove the cause of the stone - removal of the gallbladder - surgery - cholecystectomy

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21
Q

What does ERCP stand for

A

Endoscopic Retrograde Cholangio-Pancretography

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22
Q

What is the risk of ERCP

A
  • 5% pancreatitis
  • 1% bleeding and perforation
  • cholangitis
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23
Q

Biliary colic only causes

A

Pain

- it does not cause WCC/CRP/fever or jaundice

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24
Q

What is the cause of obstructive jaundice

A
  • anything that blocks the drainage of bile
  • gallstones - commonest cause
  • extraluminal - malignant/benign, e.g. pancreatic cancer/pancreatic cysts
  • intraluminal/stricutres such as cholangiocarcinoma
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25
Q

What are the symptoms of obstructive jaundice

A
  • Jaundice
  • dark urine - increased bilirubin
  • pale stool - decreased bilirubin
  • itching
  • Nausea & Vomiting
  • +/- pain
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26
Q

What does obstructive jaundice look like on examination

A
  • Jaundice
  • excortiations
  • tenderness in the right upper quadrant

Courvoisier sign

  • painless jaundice
  • palpable gallbladder
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27
Q

What do the blood look like in obstructive jaundice

A

LFTs

  • elevated conjugated bilirubin
  • elevated ALP/GGT
  • FBC, CRP, clotting = may be normal
28
Q

What imaging is used for obstructive jaundice

A
  • USS
  • CT
  • MRCP
29
Q

What is the treatment for obstructive jaundice

A
  • Unblock the blockage - ERCP/PTC

stop the blockage recurring
- cholecystectomy - if gallstones causing the blockage

Treating the mass

  • resection
  • chemotherapy
  • radiotherapy
30
Q

what is cholangitis

A
  • infection with bile duct

- obstructive jaundice with infection

31
Q

What are the symptoms of cholangitis

A

Charcots triad

  • jaundice
  • fevers/rigors
  • RUQ pain
  • itching
  • dark urine/pale stool
  • nausea and vomiting
32
Q

What are the examination of cholangitis

A
  • Jaundice
  • fevers

Courvoisier sign

  • painless jaundice
  • palpable gall bladder
33
Q

what do the blood look like in cholangitis

A

LFTs - elevated bilirubin, ALP/GGT

  • FBC - elevated WCC
  • CRP - elevated
  • U&E, clotting = normal
34
Q

What imaging do you use in cholangitis

A
  • USS
  • CT
  • MRCP
35
Q

What is the treatment for cholangitis

A
  • IV antibiotics - Piperacillin/tazobactam 4.5g/8h IV and IV fluids
  • IV fluid

Unblock the blockage - ERCP/PTC

Stop the blockage recurring
- cholecystectomy - if gallstones causing the blockage

Treating the mass

  • resection
  • chemotherapy
  • radiotherapy
36
Q

What is the definition of pancreatitis

A

inflammation of the pancreas

37
Q

What is the difference between acute and chronic pancreatitis

A
  • Acute: Rapid onset inflammatory process

- Chronic: Progress inflammation and destruction of the pancreatic secretory cells

38
Q

What are the two roles of the pancreas

A
  • Exocrine: digestive enzymes into small bowel

- Endocrine: circulating hormones such as insulin

39
Q

What are the causes of pancreatitis

A 
GET SMASHED 
G- gallstones 
E - ethanol 
T - trauma 
S - steroids 
M - mumps
A - autoimmune 
S - scorpion bites 
H - hypertriglyceridaemia 
E - ERCP
D - drugs (sodium valproate, azathioprine, opiates)
40
Q

What are the symptoms of pancreatitis

A
  • upper abdominal pain that radiates to the back
  • nausea/vomiting
  • bloating
41
Q

What are the signs of pancreatitis

A
  • In pain (curled up)
  • abdomen is very tender
  • +/- jaundice
  • +/- fevers/tachycardia
42
Q

What do the blood look like in pancreatitis

A

FBC - elevated WCC/platelets

  • U&E - possible renal impairment
  • LFT - may have jaundice and ALP/ALT elevation
  • CRP - often elevated
  • blood gas - elevated lactate
  • pancreatic enzymes - lipase/amylase are elevated
43
Q

What imaging do you have in pancreatitis

A
  • CXR - to ensure there is no damage to the lungs
  • USS - check for gallstones that could have lead to the pancreatitis
  • AXR
  • CT/MRCP
44
Q

What do you need to diagnose pancreatitis

A

2 out of 3 of:

  • typical symptoms
  • pancreatic enzymes > 3x upper limit of normal
  • radiographic evidence
45
Q

How do you score the severity of pancreatitis

A

Glasgow score

Alanta score

46
Q

How does the Glasgow score of pancreatits work

A 
Glasgow score 
PANCREAS
P - po2 less than 8kpa 
A - age over 55
N - neutrophils greater than 15
C - calcium less than 2
R - renal function urea greater than 16
E - LDH greater than 600/AST greater than 200 
A - albumin less than 32g/dl 
S - sugar greater than 10
  • if you have greater than 3 of these then you have severe pancreatitis
47
Q

How does the Atlanta score of pancreatitis work

A

Mild acute pancreatitis

  • no organ failure
  • no local complications
  • no systemic complications

moderate acute pancreatitis

  • transient organ failure less than 48 hours
  • local complications
  • exacerbation of comorbidity

Severe acute pancreatitis
- persistent organ failure - greater than 48 hours

48
Q

How do you treat acute pancreatitis

A
  • IV fluids
  • analgesia
  • antiemetics

treat the cause
treat the complications

49
Q

What are the complications for acute pancreatitis

A
  • Intra-abdominal haemorrhage (retroperitoneal)
  • pancreatic necrosis
  • peritonitis
  • biliary obstruction

Multiple organ failure

  • actue respiratory distress syndrome (ARDS)
  • Acute kidney injury
50
Q

What are late complications for pancreatitis

A
  • pancreatic pseudocyst
  • pancreatic pseudo-aneurysm
  • pancreatic abscess
  • pancreatic ascites
51
Q

what is the causes of chronic pancreatitis

A
  • Alcohol
  • smoking
  • blockage of the pancreatic duct - congenital, tones, cysts, tumours
  • autoimmune
  • hereditary
  • idiopathic
52
Q

What are the symptoms of chronic pancreatitis

A
  • pain
  • nausea and vomiting
  • malabsorption: weight loss, steatorrhoea
53
Q

what are the signs of chronic pancreatitis

A
  • low BMI

- abdominal tenderness

54
Q

How do you investigate chronic pancreatitis

A

Bloods
- may be normal
Stool
- low elastase

55
Q

What is the imaging used for chronic pancreatitis

A
  • USS
  • CT
  • MRCP
56
Q

what is the treatment for chronic pancreatitis

A
  • analgesia
  • antiemetics
  • pancreatic enzyme replacement
  • treat the cause
  • treat the complications - pseudocysts, CBD/duodenal obstruction, venous thrombosis, ascites
57
Q

What is the presentation of acute cholecystitis

A
  • continuous epigastric or RUQ pain (referred to the right shoulder) - irritation of the underside of the diaphragm by an inflamed gallbladder or a subphrenic abscess refers pain to dermatomes C3-C5
  • vomiting
  • Fever
  • local peritoneum
  • GB mass
  • Murphy’s sign is positive
  • Phlegmon (RUQ mass of inflamed adherent momentum and bowel) may be palpable
58
Q

What is Murphy’s sign

A
  • Lay 2 fingers over the RUQ, ask patient to breathe in
  • This causes pain and arrest of inspiration as an inflamed gallbladder impinges on your fingers
  • It is only positive if the same test in the LUQ does not cause pain
59
Q

what is the difference between biliary colic, acute cholecystitis, cholangitis in ..

  • RUQ pain
  • fever and raised WCC
  • jaundice
A

Biliary Colic

  • RUQ pain = Yes
  • fever and raised WCC = no
  • jaundice = np

Acute Cholecystitis

  • RUQ pain = yes
  • fever and raised WCC = yes
  • jaundice = No

Cholangitis

  • RUQ pain = yes
  • fever and raised WCC = yes
  • jaundice = yes
60
Q

What do investigations show in acute cholecystitis

A
  • raised WCC

US

  • thick-walled, shrunken gallbladder
  • pericholecystic fluid
  • stones
  • CBD dilated if >6mm

Plain AXR = only shows - 10% of gallstones, may identify a porcelain gallstone

61
Q

What is the treatment for acute cholecystitis

A
  • NBM, Analgesia, IVI, antibiotics (e.g. Co-amoxiclav 625mg/8 hour IV)
  • Laparoscopic cholecystectomy - treatment choice for all patients fit for GA
  • open surgery - required if there is GB perforation
  • percutaneous cholecystostomy - if elderly or high risk/unsuitable for surgery cholecystectomy can be done later or in acalculous cholecystitis
62
Q

What is a mucocelele

A
  • obstructed gallbladder that fills with mucus (secreted by gallbladder wall)/pus
63
Q

What is gallstone ileus

A
  • stone erodes through the gallbladder into the duodenum and may then obstruct the terminal ileum (ileocaecal valve)
  • AXR - air in the CBD, small bowel fluid levels and a stone
  • duodenal obstruction rarer (Bouvert’s syndrome)
64
Q

How does a cholangiocarcinoma present

A
  • It presents with jaundice, weight loss, pruritus and persistent biliary symptoms.
65
Q

Name a complication of PSC

A

Cholangiocarcinoma is an important complication of primary sclerosing cholangitis (PSC) that affects up to 10% of PSC patients.

Year 3 - Met3a (43 decks)

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