RCSI: HepatobilIary Surgery Flashcards
What is jaundice?
Jaundice is the result of accumulation of bilirubin in the bloodstream and subsequent deposition in the skin, sclera and mucous membranes.
Normal serum bilirubin is 3–17 mmol/L. Jaundice is clinically present at >40 mmol/L.
What are the three main types of jaundice?
- Pre-hepatic
- Hepatocellular
- Post-hepatic
What causes pre-hepatic (haemolytic) jaundice?
- Autoimmune haemolytic anaemia
- Transfusion reactions
- Drug toxicity
- Congenital abnormalities of red cell structure or content (e.g. sickle cell disease, hereditary spherocytosis)
What are some causes of hepatocellular jaundice?
- Hepatic unconjugated hyperbilirubinaemia (e.g. Gilbert’s syndrome, Crigler-Najjar syndrome)
- Hepatic conjugated hyperbilirubinaemia (e.g. viral infections, bacterial infections, drugs, non-infective hepatitis)
What are the causes of post-hepatic (obstructive) jaundice?
- Intraluminal abnormalities
- Choledocholithiasis
- Biliary stricture
- Primary sclerosing cholangitis
- Extrinsic compression of the bile ducts (e.g. pancreatic cancer, Mirizzi’s syndrome)
What is the pathophysiology of jaundice?
Jaundice results from high levels of bilirubin in the blood due to excessive breakdown of red blood cells. Bilirubin undergoes conjugation in the liver, making it water soluble for excretion.
What is the difference between unconjugated and conjugated bilirubin?
- Unconjugated bilirubin: Not water soluble
- Conjugated bilirubin: Water soluble
What are the symptoms of jaundice?
- Itching due to bile salts
- Abdominal pain
- Lethargy and general malaise
- Fever/rigors
- Jaundice
- Scleral icterus
- Dark urine
- Pale/clay-coloured stool
What is Courvoisier’s Law?
A painless, palpable gallbladder in a patient with jaundice is unlikely to be due to gallstone disease and may suggest malignant obstruction of the ducts.
What are some differential diagnoses for jaundice?
- Alcoholic liver disease
- Choledocholithiasis
- Drug induced liver injury
- Ascending cholangitis
- Pancreatic carcinoma
- Haemolytic anaemia
- Hepatitis A, B, C, E, D
- Gilbert syndrome
- Primary sclerosing cholangitis
What liver function tests are significant in jaundice?
- Unconjugated bilirubin: ↑ in haemolytic
- Alkaline phosphatase (ALP): Raised in biliary obstruction
- Gamma GT (GGT): More specific for biliary obstruction
- Transaminases (AST, ALT): Markers of hepatocellular injury
- Albumin: Marker of liver synthesizing function
What investigations are used for jaundice?
- Urine dipstick for bilirubin
- Blood tests (FBC, LFTs, Urea, creatinine)
- Coagulation profile
- Amylase
- Imaging (US abdomen, MRCP, ERCP, CT)
- Liver biopsy
What is the management for jaundice?
- Correct dehydration
- Monitor urinary output
- Monitor for coagulopathy
- Ensure adequate nutrition
- Symptomatic treatment for itching
- Specific treatments based on presentation
What are adverse risk factors for jaundice prognosis?
- Age > 65 years
- Elevated plasma urea
- Elevated plasma bilirubin (>200 g/L)
- Uncontrolled sepsis and multiple organ dysfunction
- Underlying malignant disease
What percentage of people over 50 years of age have gallstones?
10%
What are the types of gallstones?
- Pure cholesterol (10%)
- Pure pigment (10%)
- Mixed (80%)
What are the risk factors for cholesterol stones?
- Fat
- Female
- Fertile
- Forty
- Family history
What is biliary colic?
Severe epigastric pain caused by a gallstone becoming impacted in Hartmann’s pouch or the cystic duct.
What is acute cholecystitis?
Inflammation of the gallbladder caused by a gallstone becoming impacted in Hartmann’s pouch or the cystic duct.
What is the treatment for obstructive jaundice?
- ERCP for asymptomatic uncomplicated stones
- Surgical drainage
True or False: Acute cholecystitis causes jaundice.
False
What can cause pancreatitis related to gallstones?
If the stone occludes the sphincter of Oddi, bile may reflux up the pancreatic duct triggering the cytokine cascade of pancreatitis.
What is the current practice regarding asymptomatic gallstones?
The majority of gallstones are asymptomatic, and surgery is performed only on symptomatic patients.
What symptoms may patients experience post-cholecystectomy?
Patients may continue to have symptoms and may attribute further symptoms to their cholecystectomy.
What is post-cholecystectomy syndrome?
It describes persistent symptoms despite cholecystectomy, but it is now rarely used.
What is the pathogenesis of biliary colic?
Gallstone transiently impacted in Hartmann’s pouch or the cystic duct.
What are the clinical features of biliary colic?
Severe, steady dull pain in epigastrium or RUQ lasting minutes to hours, often after a fatty meal, with possible radiation to the right scapula.
What laboratory tests are used to rule out acute cholecystitis?
- FBC (WCC elevation)
- CRP (elevation)
- LFTs (elevated ALP)
- Amylase (to rule out pancreatitis)
What is the first-line investigation for gallstone pathology?
Abdominal ultrasound.
What are the management options for biliary colic?
- Conservative: Pain management, rehydration, lifestyle advice
- Surgical: Elective cholecystectomy
What is acute cholecystitis?
Inflammation of the gallbladder which may begin as chemical cholecystitis but can become secondarily infected.
What are common signs of acute cholecystitis?
- Local peritonism in RUQ
- Murphy’s sign
- Palpable, tender gallbladder
- Tachycardia
- Jaundice
What is Murphy’s sign?
Pain and ‘catch’ of breath on inspiration when pressure is placed under the costal margin.
What are the indications for laparoscopic cholecystectomy?
- Symptomatic gallstones
- Asymptomatic patients at risk of complications (e.g., diabetes, history of pancreatitis)
What is a gallbladder empyema?
When the gallbladder bile becomes purulent.
What is the management for a perforated gallbladder?
- Fluid resuscitation and antibiotics
- Laparoscopic cholecystectomy if the patient is fit
- Percutaneous drainage if unfit
What is a mucocele of the gallbladder?
Occurs when a stone becomes impacted in the cystic duct, preventing bile from entering and mucus from leaving.
What is the primary cause of obstructive jaundice?
When a stone obstructs the common bile duct.
What is ascending cholangitis?
Inflammation of the bile duct caused by bacterial infection secondary to mucosal erosion by gallstone and raised biliary pressure.
What is Charcot’s Triad?
Constant severe right upper quadrant pain, obstructive jaundice, and fever.
What are common causes of ascending cholangitis?
- Choledocholithiasis
- Biliary stricture
- Neoplasm
What initial management is recommended for ascending cholangitis?
- IV fluid resuscitation
- Pain management
- IV antibiotics
What is the typical clinical presentation of gallstone ileus?
Patient presents with intestinal obstruction, which may be intermittent.
What imaging can confirm a diagnosis of gallstone ileus?
CT scan.
What is the management for obstructive jaundice?
Laparoscopic cholecystectomy is curative.
What is acute pancreatitis?
Inflammation of the pancreas
It can vary in severity from mild to severe.
What are the common causes of acute pancreatitis?
- Gallstones (60%)
- Ethanol (30%)
- Trauma (ERCP, post-surgery)
- Steroids
- Mumps
- Autoimmune disease
- Scorpion venom
- Hypercalcaemia
- Drugs (NSAIDs, Azathioprine, Thiazides)
The mnemonic ‘I GET SMASHED’ can help remember these causes.
What is the prognosis for acute pancreatitis?
Good with effective drainage and antibiotics in mild to moderate cases
High mortality in patients with Reynold’s Pentad.
What is the Modified Glasgow Criteria used for?
To assess severity of acute pancreatitis and indicate need for high-dependency care
Three or more positive criteria within 48 hours suggest a severe attack.
What are the components of the Modified Glasgow Criteria?
- PaO2 < 8 kPA
- Age > 55 years
- Neutrophils/WCC > 15,000 × 10⁹/L
- Corrected calcium < 2 mmol/L
- Raised blood urea > 16 mmol/L
- Enzymes elevated, AST > 200 U/L, LDH > 600 U/L
- Albumin < 32 g/L
- Sugar, blood glucose > 10 mmol/L
What is the mainstay of treatment for acute pancreatitis?
Supportive measures including IV fluid resuscitation and pain management.
What is a key symptom of acute pancreatitis?
Rapid onset of severe epigastric pain
Pain may radiate to the back and improve when leaning forward.
What imaging technique is used to identify gallstones in acute pancreatitis?
Abdominal ultrasound.
What does ERCP stand for?
Endoscopic Retrograde Cholangiopancreatography.
What is the role of ERCP in acute pancreatitis?
Both diagnostic and therapeutic, used to identify and remove stones.
What are common complications of acute pancreatitis?
- Disseminated intravascular coagulation (DIC)
- Systemic inflammatory response syndrome (SIRS)
- Acute respiratory distress syndrome (ARDS)
- Hypocalcaemia
- Hyperglycaemia
Local complications may include pancreatic necrosis, abscesses, and pseudocysts.
What is chronic pancreatitis?
A chronic fibro-inflammatory disease of the pancreas with progressive damage.
What are the main causes of chronic pancreatitis?
- Chronic alcohol abuse (60%)
- Idiopathic (30%)
- Other causes include metabolic, infection, hereditary, autoimmune, and anatomical factors.
What is the typical presentation of chronic pancreatitis?
- Recurrent or chronic abdominal pain
- Nausea and vomiting
- Weight loss
- Diarrhoea (pale and bulky if exocrine failure)
- Diabetes mellitus (endocrine insufficiency)
What are the key investigations for chronic pancreatitis?
- CT pancreas protocol
- Ultrasound abdomen
- MRCP
- ERCP
- Faecal elastase
These tests help identify pancreatic atrophy, calcification, and ductal abnormalities.
What is the management approach for chronic pancreatitis?
- Conservative: Stop alcohol and dietary modifications
- Medical: Pancreatic exocrine supplements, analgesia, control diabetes
- Surgical: Endoscopic drainage, laparoscopic necrosectomy.
What is fat necrosis associated with in acute pancreatitis?
Release of free fatty acids reacting with serum calcium, leading to hypocalcaemia.
What signs indicate severe acute pancreatitis?
- Cullen’s sign: Bruising around the umbilicus
- Grey Turner’s sign: Bruising in the flanks.
What is the treatment for infected pancreatic necrosis?
Fine needle aspiration and interventional radiology drainage.
What is the difference between acute and chronic pancreatitis in terms of pancreatic function?
Acute pancreatitis has limited damage to the secretory function, while chronic pancreatitis leads to irreversible damage.
What may an abdominal X-ray show in the context of pancreatic issues?
Calcification
This can indicate chronic pancreatitis.
What is typically low in chronic pancreatitis with exocrine insufficiency?
Faecal elastase
This is a marker for pancreatic exocrine function.
What is a conservative management strategy for chronic pancreatitis?
Stop alcohol
Preventing the cause is crucial in managing the condition.
What dietary modifications are recommended for chronic pancreatitis?
Reduced fat diet, adequate carbohydrates and protein
These changes help manage symptoms and support nutrition.
What type of medical management is used for pancreatic exocrine insufficiency?
Pancreatic exocrine supplements: Creon
Creon helps to replace pancreatic enzymes.
Which vitamins are important for patients with pancreatic insufficiency?
Fat soluble vitamins: ADEK
These vitamins are crucial for various body functions.
What analgesic may be required for chronic pancreatitis?
Opiates
Pain management is essential in chronic pancreatitis treatment.
What is the surgical option for patients who fail medical therapy in chronic pancreatitis?
Surgery to decompress/drain an obstructed pancreatic duct
Surgery is considered only after medical options are exhausted.
What are some surgical options for chronic pancreatitis?
- Pancreaticoduodenectomy (Whipple’s procedure)
- Partial or distal pancreatectomy
- Pancreatojejunostomy
These options depend on the patient’s condition and pancreatic anatomy.
What is the most common form of pancreatic cancer?
Ductal carcinoma of the pancreas
This type comprises up to 90% of primary pancreatic malignancies.
What are the main risk factors for pancreatic carcinoma?
- Smoking
- Chronic pancreatitis
- Family history
- Late onset diabetes mellitus
These factors increase the risk of developing pancreatic cancer.
What is the prognosis for pancreatic cancer?
High mortality rate, with 80% being unresectable at diagnosis
Early detection is rare, leading to poor outcomes.
What are common symptoms of pancreatic cancer?
- Can be asymptomatic in early stages
- Loss of appetite
- Weight loss
- Nausea and vomiting
- Pruritus
- Pain: Epigastric or upper left quadrant
Symptoms may vary and can be vague.
What laboratory investigation is used to assess obstructive patterns in pancreatic cancer?
LFTs: Raised bilirubin, ALP, GGT
These tests help identify liver function and biliary obstruction.
What imaging technique is used to assess pancreatic masses?
CT pancreas using pancreatitis protocol
This imaging helps assess the size of lesions and vascular invasion.
What is the main goal of palliative management in pancreatic cancer?
Pain relief and management of symptoms
Most patients are not candidates for curative surgery.
What is the Whipple’s procedure?
Removal of the head of the pancreas, antrum of stomach, 1st and 2nd parts of the duodenum, common bile duct, and gallbladder
This surgery is performed for tumors located at the head of the pancreas.
What does Courvoisier’s Law state?
A palpable GB in a patient with jaundice is unlikely to be due to gallstones and suggests malignant obstruction
This law indicates the importance of gallbladder palpability in diagnosing biliary obstruction.
