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MET3a > Pancreatobiliary Disease > Flashcards

Pancreatobiliary Disease Flashcards

1
Q

Function of the gallblader

A

Stores and concentrates bile which is produced by liver

Excretes into bile duct when have fatty meals

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2
Q

Function of the pancreas

A

Productive of digestive enzymes (exocrine function)

Production of insulin (endocrine function)

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3
Q

LFTs

A

Bilirubin
ALT/AST = transaminases produced by hepatocytes so elevation = inflammation
ALP & GGT = by biliary epithelium so elevation = inflammation of any of biliary ducts

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4
Q

Pathways of bilirubin

A

RBC breakdown in spleen
Unconjugated form
Goes to liver to become conjugated
Travels in bile duct to intestines out to faeces
Travels in blood to kidneys and out in urine as urobilinogen

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5
Q

2 types of bilirubin

A 
Unconjugated/indirect = pre hepatic or hepatocellular abnormality
Conjugated/direct = post hepatic abnormality
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6
Q

Define chole

A

Gallbladder

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7
Q

Define cholang

A

Of the bile duct

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8
Q

Define itis

A

Inflammation

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9
Q

Define cholangitis

A

Inflammation of the bile duct

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10
Q

Define cholangiocarcinoma

A

Cancer of the bile duct

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11
Q

Types of gallstones

A

Cholesterol (80%)
Pigmented
Mixed

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12
Q

RF of gallstones

A

5Fs = fat, 40s, fair skin, female, fertile
FH
Drugs = OCP, fibrates
Conditions = Sickle cell, cirrhosis, Crohns

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13
Q

What proportion of gallstones are asymptomatic?

A

80%

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14
Q

Complications of gall stones

A

20% of patients

  • cholecystitis
  • biliary colic
  • cholangitis
  • obstructive jaundice
  • pancreatitis
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15
Q

Radiological Ix of gallstones

A

Abdominal US 1st line
CT scan
Abdominal X-ray not used but may see incidentally
MRI (MRCP)

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16
Q

MRCP

A

Magnetic Resonance CholangioPancreatography

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17
Q

What table to use to differentiate 4 common biliary conditions?

A

Acute cholecystitis, biliary colic, obstructive jaundice, cholangitis down column
Pain, WCC/CRP/fever, jaundice on row

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18
Q

Symptoms of cholecystitis

A

RUQ pain - increases in intensity over time and does not settle without treatment
Radiate to right shoulder
Fevers
Nausea and vomiting
NO JAUNDICE - limited to gallbladder not causing blockage to flow of bile from liver to intestine

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19
Q

Examination of cholecystitis

A

RUQ tenderness
Murphy’s sign
Febrile
Septic

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20
Q

Murphy’s Sign

A

Ask patient to exhale
Place hand below costal margin on the right side at mid clavicular line
Instruct patient to expire
Positive = stops breathing and winces with a catch in breath as inflamed gallbladder palpated as it descends on inspiration

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21
Q

Ix of cholecystitis

A 
Bloods
- FBC elevated WCC
- elevated CRP
- elevated ALT/ALP
- not jaundiced
- U&E, clotting, blood gas
Imaging
- USS
- CT
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22
Q

Tx for cholecystitis

A

ABs
IV fluids
Analgesia
Surgery - cholecystectomy

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23
Q

Complications of cholecystitis

A

Chronic cholecystitis
Gallbladder empyema
Fistula
Mirizzi Syndrome

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24
Q

What fistulae can you get in cholecystitis?

A

Cholecystoduodenal
Cholecystojejunal
Cholesystocolonic

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25
What is Mirizzi syndrome?
Gallstones impacted at end of cystic duct causing compression of bile duct Will have jaundice in this case as blockage of bile duct
26
Differentials of cholecystitis
``` Peptic ulcer Dyspepsia Pancreatitis Perforated ulcer Pneumonia ACS Pyelonephritis ```
27
Define biliary colic
Colicky pain due to gallstone temporarily blocking cystic or bile duct
28
Define colicky pain
Pain comes and goes in waves
29
Symptoms of biliary colic
Colicky to RUQ May radiate to R. shoulder NO JAUNDICE AS TEMPORARY BLOCKAGE Lasts for hours as temporary blockage of duct After fatty foods as matches peristalsis waves of bile Repeated episodes over weeks-months
30
Examination of biliary colic
RUQ pain | Or normal
31
Ix of biliary colic
``` Bloods - elevated ALP - FBC, lipase, CRP, clotting normal Imaging - USS - CT - MRCP ```
32
Tx for biliary colic
Remove stones via ERCP | Remove cause of stones (cholecystectomy)
33
ERCP
Endoscopic - through mouth down oesophagus into stomach into duodenum so adjacent to ampulla of Vater Retrograde Cholangio - bile duct Pancreatography Need x-ray screening to determine pathology Balloon inflated above any gallstones and dragged down through bile duct and pulls out stones below balloon
34
Risks of ERCP
Pancreatitis Bleeding & Perforation Cholangitis
35
Obstructive Jaundice Causes
Anything blocking normal drainage of bile At level of liver/common hepatic duct/common bile duct/ampulla of Vater Commonest - gall stones Others - benign/malignant masses in duct= pancreatic cancer/cysts - Strictures inside the lumen = cholangiocarcinoma
36
Symptoms of obstructive jaundice
``` JAUNDICE Dark urine, pale stool Itching Nausea & Vomiting With or without pain - normally pain if gallstones causing it but others not ```
37
Examination of obstructive jaundice
Jaundice! Excortiations = itching Tenderness in RUQ if gallstones Courvoisier's Law
38
Courvoisier's Law
Painless obstructive jaundice with palpable gallbladder = pancreatic head mass Palpable as excess bile in gall bladder = dilates
39
Ix for obstructive jaundice
``` Bloods - elevated conjugated bilirubin - high ALP & GGT - FBC, CRP, clotting normal Imaging - USS - CT - MRCP ```
40
Treatment for obstructive jaundice
Unblock! = ERCP/PTC | Stop blockage recurring = cholecystectomy if gallstones or treat mass (transect/chemo/radio)
41
What is a PTC?
percutaneous transhepatic cholangiopancreatography - radiological - needle passed through skin and liver into bile ducts - inject contrast
42
What is cholangitis?
Obstructive jaundice with infection
43
Causes of cholangitis?
Same as obstructive jaundice - gallstones - extraluminal = pancreatic mass/cyst - intraluminal = strictures/cholangiocarcinoma
44
What is Charcot's triad?
Jaundice Fevers/Rigors RUQ Pain Seen in cholangitis
45
Symptoms of cholangitis
Charcot's triad = fever/rigors, jaundice, RUQ pain Itching Dark urine, pale stools Nausea & Vomiting
46
Examination of cholangitis
Jaundice Fevers Courvoisier Sign
47
Ix of cholangitis
``` Bloods - bilirubin, ALP, GGT - FBC - elevated WCC - high CRP - U&E, clotting should be normal Imaging - USS - CT - MRCP ```
48
Tx of cholangitis
- First treat the infection = IV ABs, IV fluids - Unblock the blockage = ERCP/PTC - stop the blockage recurring = cholecystectomy if gallstones or treat mass (chemo/radio/resection)
49
Define pancreatitis
Inflammation of the pancreas
50
2 types of pancreatitis
``` Acute = rapid onset inflammatory progress Chronic = progressive inflammation and destruction of pancreatic secretory cells ```
51
Role of pancreas
``` Exocrine = digestive enzyme production into small bowel Endocrine = producing circulating hormones (insulin) ```
52
Causes of acute pancreatitis
``` GETSMASHED G - gallstones (at bottom of common bile duct joining pancreatic duct) E - ethanol T - trauma S - steroids M - mumps A - autoimmune S - scorpion bites H - hypertriglyceridemia E - ERCP D - Drugs (sodium valproate, azathioprine, opiates) ```
53
Symptoms of acute pancreatitis
Upper abdominal pain Radiates to back N&V Bloating
54
Signs of acute pancreatitis
In pain - curled up Very tender With or without jaundice With or without fevers/tachycardia
55
Ix of acute pancreatitis
- elevated WCC and platelets - renal impairment? - U&Es - high ALP and ALT - CRP elevated - elevated lactate - pancreatic enzyme (lipase, amylase) - bone profile - LDH - blood sugar Imaging - CXR - any lung damage - USS - AXR - CT/MRCP
56
How do you diagnose acute pancreatitis?
2 of 3 of: - typical symptoms of severe epigastric pain with N&V - pancreatic enzymes >3x upper limit of normal - radiographic evidence
57
Scoring the severity of acute pancreatitis
``` GLASGOW SCORE Pancreas mnemonic P - PO2<8kPa A - Age >55 N - neutrophils >15 C - calcium <2 R - renal function >16 urea E - enzymes LDH>600/AST>200 A - albumin <32g/dl S - sugar >10 ``` need 3 or more for severe Atlanta Score is another one - severe if >48 hour organ failure - mild -= no organ failure or complications - moderate - organ failure <48 hours or some local complications
58
Treatment for acute pancreatitis
IV FLUIDS!!! (Up to 5L/day) Analgesia Antiemetics Then treat cause and complications - Enteral feeding tube? - nil by mouth?
59
Which causes of acute pancreatitis can you treat?
Gallstones - ERCP/cholecystectomy | Hypertriglyceridaemia = fibrates
60
Acute complications of acute pancreatitis?
Intrabdominal haemorrhage (retroperitoneal) Pancreatic necrosis - can become infected Peritonitis Biliary obstruction ARDS AKI
61
Late complications of acute pancreatitis
Pancreatic pseuodocysts Pancreatic pseudoaneurysms Pancreatic abscess Pancreatic ascites -> aspiration and drainage
62
What are signs of retroperitoneal haemorrhage?
Cullens | Gray Turners
63
Causes of chronic pancreatitis?
``` Alcohol! Smoking! Blockage of pancreatic duct = congenital, stones, cysts, tumours Autoimmune Hereditary Idiopathic ```
64
Symptoms of chronic pancreatitis
Pain Nausea/Vomiting Malabsorption of exocrine failure = weight loss, steatorrhoea
65
Signs of chronic pancreatitis
Low BMI | Abdominal tenderness
66
Management of chronic pancreatitis
Bloods - may be normal Stools - low faecal elastase as exocrine failure Imaging - USS, CT, MRCP
67
Tx of chronic pancreatitis
``` Analgesia Anti-emetics Pancreatic enzyme replacement (CREON) Treat pancreatic diabetes Treat cause Treat complications ```
68
Complications of chronic pancreatitis
Same as acute - pseudocysts - CBD/duodenal obstruction - venous thrombosis - ascites
69
What indicates pancreatic necrosis in acute pancreatitis?
CRP >200u/L
70
Which pancreatic enzyme is better diagnostically?
Serum lipase = more specific and sensitive v. amylase
71
What is seen on a CXR in acute pancreatitis?
- sentinel loop = gut dilatation next to pancreas - cut off sign = gas distended to right colon which suddenly stops in mid/left transverse colon - calcifications
72
What is seen on CT in acute pancreatitis?
- pancreas enlargement - irregular contour - necrosis - pseudocysts - obliteration of peri-pancreatic fat
73
What is the use of ERCP in acute pancreatitis?
Identify and remove stones if this is cause
74
Antibiotic use in acute pancreatitis?
- if symptomatic - if infection shown - use imipenem as good pancreatic penetration
75
What surgery is done for acute pancreatitis?
- cholecystectomy if due to gallstones | - early ERCP if obstructed biliary system due to stones
76
Pseudocyst
Late acute pancreatitis complication - from peripancreatic fluid collection - >4 weeks after acute attack - retrogastric mostly - amylase rise - endoscopic/surgical cystogastrostomy or aspiration
77
Pancreatic necrosis
- early complication of acute pancreatitis - parenchyma and surrounding fat - manage sterile necrosis conservatively - fine needle aspiration sampling of necrotic tissue to detect infection - try to avoid necrosectomy
78
Pancreatic abscess
- late complication of acute pancreatitis - intra-abdominal collection of pus - necrosis absence - due to infected pseudocyst mostly - trans gastric drainage/endoscopic drainage
79
Haemorrhage
- early complication of acute pancreatitis - infected necrosis involving vascular structures - Grey Turners = retroperitoneal haemorrhage
80
What multi-organ failure complications are involved with pancreatitis?
ARDS | AKI

MET3a (38 decks)

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