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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
Q

What is Mirizzi syndrome?

A

Gallstones impacted at end of cystic duct causing compression of bile duct
Will have jaundice in this case as blockage of bile duct

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26
Q

Differentials of cholecystitis

A 
Peptic ulcer
Dyspepsia
Pancreatitis
Perforated ulcer
Pneumonia
ACS
Pyelonephritis
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27
Q

Define biliary colic

A

Colicky pain due to gallstone temporarily blocking cystic or bile duct

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28
Q

Define colicky pain

A

Pain comes and goes in waves

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29
Q

Symptoms of biliary colic

A

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

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30
Q

Examination of biliary colic

A

RUQ pain

Or normal

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31
Q

Ix of biliary colic

A 
Bloods
- elevated ALP
- FBC, lipase, CRP, clotting normal
Imaging
- USS
- CT
- MRCP
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32
Q

Tx for biliary colic

A

Remove stones via ERCP

Remove cause of stones (cholecystectomy)

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33
Q

ERCP

A

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
Q

Risks of ERCP

A

Pancreatitis
Bleeding & Perforation
Cholangitis

35
Q

Obstructive Jaundice Causes

A

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
Q

Symptoms of obstructive jaundice

A 
JAUNDICE
Dark urine, pale stool
Itching
Nausea & Vomiting
With or without pain - normally pain if gallstones causing it but others not
37
Q

Examination of obstructive jaundice

A

Jaundice!
Excortiations = itching
Tenderness in RUQ if gallstones
Courvoisier’s Law

38
Q

Courvoisier’s Law

A

Painless obstructive jaundice with palpable gallbladder = pancreatic head mass
Palpable as excess bile in gall bladder = dilates

39
Q

Ix for obstructive jaundice

A 
Bloods
- elevated conjugated bilirubin
- high ALP & GGT
- FBC, CRP, clotting normal
Imaging
- USS
- CT
- MRCP
40
Q

Treatment for obstructive jaundice

A

Unblock! = ERCP/PTC

Stop blockage recurring = cholecystectomy if gallstones or treat mass (transect/chemo/radio)

41
Q

What is a PTC?

A

percutaneous transhepatic cholangiopancreatography

  • radiological
  • needle passed through skin and liver into bile ducts
  • inject contrast
42
Q

What is cholangitis?

A

Obstructive jaundice with infection

43
Q

Causes of cholangitis?

A

Same as obstructive jaundice

  • gallstones
  • extraluminal = pancreatic mass/cyst
  • intraluminal = strictures/cholangiocarcinoma
44
Q

What is Charcot’s triad?

A

Jaundice
Fevers/Rigors
RUQ Pain

Seen in cholangitis

45
Q

Symptoms of cholangitis

A

Charcot’s triad = fever/rigors, jaundice, RUQ pain
Itching
Dark urine, pale stools
Nausea & Vomiting

46
Q

Examination of cholangitis

A

Jaundice
Fevers
Courvoisier Sign

47
Q

Ix of cholangitis

A 
Bloods
- bilirubin, ALP, GGT
- FBC - elevated WCC
- high CRP
- U&E, clotting should be normal
Imaging
- USS
- CT
- MRCP
48
Q

Tx of cholangitis

A
  • 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
Q

Define pancreatitis

A

Inflammation of the pancreas

50
Q

2 types of pancreatitis

A 
Acute = rapid onset inflammatory progress
Chronic = progressive inflammation and destruction of pancreatic secretory cells
51
Q

Role of pancreas

A 
Exocrine = digestive enzyme production into small bowel
Endocrine = producing circulating hormones (insulin)
52
Q

Causes of acute pancreatitis

A 
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
Q

Symptoms of acute pancreatitis

A

Upper abdominal pain
Radiates to back
N&V
Bloating

54
Q

Signs of acute pancreatitis

A

In pain - curled up
Very tender
With or without jaundice
With or without fevers/tachycardia

55
Q

Ix of acute pancreatitis

A
  • 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
Q

How do you diagnose acute pancreatitis?

A

2 of 3 of:

  • typical symptoms of severe epigastric pain with N&V
  • pancreatic enzymes >3x upper limit of normal
  • radiographic evidence
57
Q

Scoring the severity of acute pancreatitis

A 
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
Q

Treatment for acute pancreatitis

A

IV FLUIDS!!! (Up to 5L/day)
Analgesia
Antiemetics

Then treat cause and complications

  • Enteral feeding tube?
  • nil by mouth?
59
Q

Which causes of acute pancreatitis can you treat?

A

Gallstones - ERCP/cholecystectomy

Hypertriglyceridaemia = fibrates

60
Q

Acute complications of acute pancreatitis?

A

Intrabdominal haemorrhage (retroperitoneal)
Pancreatic necrosis - can become infected
Peritonitis
Biliary obstruction
ARDS
AKI

61
Q

Late complications of acute pancreatitis

A

Pancreatic pseuodocysts
Pancreatic pseudoaneurysms
Pancreatic abscess
Pancreatic ascites -> aspiration and drainage

62
Q

What are signs of retroperitoneal haemorrhage?

A

Cullens

Gray Turners

63
Q

Causes of chronic pancreatitis?

A 
Alcohol!
Smoking!
Blockage of pancreatic duct = congenital, stones, cysts, tumours
Autoimmune
Hereditary
Idiopathic
64
Q

Symptoms of chronic pancreatitis

A

Pain
Nausea/Vomiting
Malabsorption of exocrine failure = weight loss, steatorrhoea

65
Q

Signs of chronic pancreatitis

A

Low BMI

Abdominal tenderness

66
Q

Management of chronic pancreatitis

A

Bloods - may be normal
Stools - low faecal elastase as exocrine failure
Imaging - USS, CT, MRCP

67
Q

Tx of chronic pancreatitis

A 
Analgesia
Anti-emetics
Pancreatic enzyme replacement (CREON)
Treat pancreatic diabetes
Treat cause
Treat complications
68
Q

Complications of chronic pancreatitis

A

Same as acute

  • pseudocysts
  • CBD/duodenal obstruction
  • venous thrombosis
  • ascites
69
Q

What indicates pancreatic necrosis in acute pancreatitis?

A

CRP >200u/L

70
Q

Which pancreatic enzyme is better diagnostically?

A

Serum lipase = more specific and sensitive v. amylase

71
Q

What is seen on a CXR in acute pancreatitis?

A
  • 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
Q

What is seen on CT in acute pancreatitis?

A
  • pancreas enlargement
  • irregular contour
  • necrosis
  • pseudocysts
  • obliteration of peri-pancreatic fat
73
Q

What is the use of ERCP in acute pancreatitis?

A

Identify and remove stones if this is cause

74
Q

Antibiotic use in acute pancreatitis?

A
  • if symptomatic
  • if infection shown
  • use imipenem as good pancreatic penetration
75
Q

What surgery is done for acute pancreatitis?

A
  • cholecystectomy if due to gallstones

- early ERCP if obstructed biliary system due to stones

76
Q

Pseudocyst

A

Late acute pancreatitis complication

  • from peripancreatic fluid collection
  • > 4 weeks after acute attack
  • retrogastric mostly
  • amylase rise
  • endoscopic/surgical cystogastrostomy or aspiration
77
Q

Pancreatic necrosis

A
  • 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
Q

Pancreatic abscess

A
  • late complication of acute pancreatitis
  • intra-abdominal collection of pus
  • necrosis absence
  • due to infected pseudocyst mostly
  • trans gastric drainage/endoscopic drainage
79
Q

Haemorrhage

A
  • early complication of acute pancreatitis
  • infected necrosis involving vascular structures
  • Grey Turners = retroperitoneal haemorrhage
80
Q

What multi-organ failure complications are involved with pancreatitis?

MET3a (38 decks)

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