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
2
Q
What are the two types of bilirubin can you measure
A
- unconjugated (indirect - measure of prehepatic)
- conjugated (direct - measure post hepatic)
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)
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
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
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
7
Q
What is Chronic cholecystitis
A
- Chronic inflammation and biliary colic
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
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
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
11
Q
What imaging should you use in cholecystitis
A
- ultrasound scan
- CT scan
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
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
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
15
Q
What pain is experienced in biliary colic
A
- colicky pain due to gallstone temporarily blocking the cystic or bile duct
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
17
Q
what does biliary colic look like on examination
A
- might be RUQ pain
- or examination can be normal
18
Q
What do the bloods look like in a biliary colic
A
- LFTs - elevated ALP
- FBC, lipase, CRP, clotting normal
19
Q
What imaging would you use for biliary colic
A
- USS
- CT
- MRCP
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
21
Q
What does ERCP stand for
A
Endoscopic Retrograde Cholangio-Pancretography
22
Q
What is the risk of ERCP
A
- 5% pancreatitis
- 1% bleeding and perforation
- cholangitis
23
Q
Biliary colic only causes
A
Pain
- it does not cause WCC/CRP/fever or jaundice
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
25
What are the symptoms of obstructive jaundice
- Jaundice
- dark urine - increased bilirubin
- pale stool - decreased bilirubin
- itching
- Nausea & Vomiting
- +/- pain
26
What does obstructive jaundice look like on examination
- Jaundice
- excortiations
- tenderness in the right upper quadrant
Courvoisier sign
- painless jaundice
- palpable gallbladder
27
What do the blood look like in obstructive jaundice
LFTs
- elevated conjugated bilirubin
- elevated ALP/GGT
- FBC, CRP, clotting = may be normal
28
What imaging is used for obstructive jaundice
- USS
- CT
- MRCP
29
What is the treatment for obstructive jaundice
- Unblock the blockage - ERCP/PTC
stop the blockage recurring
- cholecystectomy - if gallstones causing the blockage
Treating the mass
- resection
- chemotherapy
- radiotherapy
30
what is cholangitis
- infection with bile duct
| - obstructive jaundice with infection
31
What are the symptoms of cholangitis
Charcots triad
- jaundice
- fevers/rigors
- RUQ pain
- itching
- dark urine/pale stool
- nausea and vomiting
32
What are the examination of cholangitis
- Jaundice
- fevers
Courvoisier sign
- painless jaundice
- palpable gall bladder
33
what do the blood look like in cholangitis
LFTs - elevated bilirubin, ALP/GGT
- FBC - elevated WCC
- CRP - elevated
- U&E, clotting = normal
34
What imaging do you use in cholangitis
- USS
- CT
- MRCP
35
What is the treatment for cholangitis
- 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
What is the definition of pancreatitis
inflammation of the pancreas
37
What is the difference between acute and chronic pancreatitis
- Acute: Rapid onset inflammatory process
| - Chronic: Progress inflammation and destruction of the pancreatic secretory cells
38
What are the two roles of the pancreas
- Exocrine: digestive enzymes into small bowel
| - Endocrine: circulating hormones such as insulin
39
What are the causes of pancreatitis
```
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
What are the symptoms of pancreatitis
- upper abdominal pain that radiates to the back
- nausea/vomiting
- bloating
41
What are the signs of pancreatitis
- In pain (curled up)
- abdomen is very tender
- +/- jaundice
- +/- fevers/tachycardia
42
What do the blood look like in pancreatitis
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
What imaging do you have in pancreatitis
- 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
What do you need to diagnose pancreatitis
2 out of 3 of:
- typical symptoms
- pancreatic enzymes > 3x upper limit of normal
- radiographic evidence
45
How do you score the severity of pancreatitis
Glasgow score
| Alanta score
46
How does the Glasgow score of pancreatits work
```
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
How does the Atlanta score of pancreatitis work
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
How do you treat acute pancreatitis
- IV fluids
- analgesia
- antiemetics
treat the cause
treat the complications
49
What are the complications for acute pancreatitis
- Intra-abdominal haemorrhage (retroperitoneal)
- pancreatic necrosis
- peritonitis
- biliary obstruction
Multiple organ failure
- actue respiratory distress syndrome (ARDS)
- Acute kidney injury
50
What are late complications for pancreatitis
- pancreatic pseudocyst
- pancreatic pseudo-aneurysm
- pancreatic abscess
- pancreatic ascites
51
what is the causes of chronic pancreatitis
- Alcohol
- smoking
- blockage of the pancreatic duct - congenital, tones, cysts, tumours
- autoimmune
- hereditary
- idiopathic
52
What are the symptoms of chronic pancreatitis
- pain
- nausea and vomiting
- malabsorption: weight loss, steatorrhoea
53
what are the signs of chronic pancreatitis
- low BMI
| - abdominal tenderness
54
How do you investigate chronic pancreatitis
Bloods
- may be normal
Stool
- low elastase
55
What is the imaging used for chronic pancreatitis
- USS
- CT
- MRCP
56
what is the treatment for chronic pancreatitis
- analgesia
- antiemetics
- pancreatic enzyme replacement
- treat the cause
- treat the complications - pseudocysts, CBD/duodenal obstruction, venous thrombosis, ascites
57
What is the presentation of acute cholecystitis
- 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
What is Murphy's sign
- 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
what is the difference between biliary colic, acute cholecystitis, cholangitis in ..
- RUQ pain
- fever and raised WCC
- jaundice
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
What do investigations show in acute cholecystitis
- 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
What is the treatment for acute cholecystitis
- 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
What is a mucocelele
- obstructed gallbladder that fills with mucus (secreted by gallbladder wall)/pus
63
What is gallstone ileus
- 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
How does a cholangiocarcinoma present
- It presents with jaundice, weight loss, pruritus and persistent biliary symptoms.
65
Name a complication of PSC
Cholangiocarcinoma is an important complication of primary sclerosing cholangitis (PSC) that affects up to 10% of PSC patients.
