Upper GI and Hepatobiliary

Question 1

How do you treat the obstructive jaundice in a patient with pancreatic carcinoma, who cannot have a Whipple’s procedure?

Answer 1

Biliary stenting (done during ERCP) is the intervention of choice in paitents with malignant distal obstructive jaundice due to inresectable pancreatic carcinoma.

Question 2

Summarise the differences in LFTs (Bilirubin, ALT/AST and AlkP) between the different locations of jaundice.

Answer 2

In addition to the info in the table, in post-hepatic jaundice the stool is often pale, another key hint.

Question 3

What is Mirizzi syndrome?

Answer 3

Mirizzi syndrome is when a small gallstone compresses the common bile duct, leading to obstruction and jaundice.

It is one of the rare times that cholecystitis can present with jaundice.

Question 4

What is cholangitis?

Answer 4

Cholangitis describes the inflammation of the common bile duct.

This is due to stagnant bile which easily becomes infected (usually with E. coli).

It presents usually with obstructive symptoms and will have Charcot’s Triad.

Question 5

What is Charcot’s Triad?

Answer 5

Charcot’s Triad is the combination of:

• Jaundice
• Fever (±Rigors)
• RUQ abdominal pain

It occurs in ascending cholangitis.

(NB: when low BP and mental status changes also occur, this is Reynolds’ pentad)

Question 6

Why might someone in TPN develop jaundice?

Answer 6

TPN associated jaundice is a thing! It is painless, and no obstructive features.

This is thought to be due to hepatic dysfunction and fatty liver which may occur with long-term TPN usage.

Question 7

What is the most commonly first line test to diagnose jaundice?

Answer 7

An USS of the liver and biliary tree is most commonly used first line.

It will establish bile duct calibre, look for gallstones and also visualise other masses.

Question 8

What is the decision to use a metal or plastic stent for obstructive jaudice in a cancer patient usually based on?

Answer 8

Plastic stents are usually used if a surgical intervention is planned (as they are prone to displacement and blockaged, so not ideal for longer term).

Metal stents may compromise a surgical resection, but are less prone to displacement and blockage, so tend to be used more in patients not fit for surgery.

Question 9

What is the preferred diagnostic test for chronic pancreatitis?

Answer 9

Whilst abdominal radiographs show calcification ins ~30% of cases, CT pancreas with IV contrast is more sensitive at detecting pancreatic calcification (80% and 85% sensitivity and specificity, respectively).

If imaging is inconclusive, faecal elastase may be used to assess exocine function.

Question 10

What is a possible respiratory complication of acute pancreatitis?

Answer 10

Acute respiratory distress syndrome is a recognised complication of acute pancreatitis.

This is associated with a high mortality rate, of around 20%.

Question 11

What are the local complications of acute pancreatitis?

Answer 11

• Pseudocyst
  
  • collection is walled by fibrous or granulation tissue and typically occurs 4 weeks or more after an attach of acute pancreatitis.
  • Usually retrogastric
  • In ~25% of cases
• Pancreatic necrosis
• Pancreatic abscess (typically occurs as result of infected pseudocyst)
• haemorrhage (reason why one might get Grey-Turner and Cullen Sign)

Question 12

What score is used to assess severity of acute pancreatitis?

Answer 12

The modified Glasgow score.

If the score ≥ 3, severe pancreatitis likely - suggest refer to HDU/ICU and if the score < 3, severe pancreatitis is unlikely.

In terms of mortality:

• Score 0 to 2: 2% mortality
• Score 3 to 4: 15% mortality
• Score 5 to 6: 40% mortality
• Score 7 to 8: 100% mortality

Question 13

What domains make up the Modified-Glasgow Score?

Answer 13

The Modified-Glasgow Score is used to classify severity of pancreatitis. It consists of the following domains (note pneumonic PANCREAS):

P - PaO2 <8 kPa

A - Age >55

N - Neutrophilia (WCC >15x10^9/L)

C - Calcium < 2 mmol/L

R - Renal function: Urea >16 mmol/L

E - Enzymes: LDH >600iu, AST >200iu

A - Albumin < 32g/L (serum)

S - Sugar: blood glucose >10 mmol/L

Question 14

What does this CXR show?

Answer 14

This CXR shows surgical emphysema - this can be seen as you can see the Pec Major muscle (ginko leaf sign). This is a known complication of laparoscopic surgery.

Question 15

Summarise the management of a pancreatic pseudocyst.

Answer 15

Even when symptomatic, intial treatment should be conservative (i.e. analgesia + watch and wait).

If after 12 weeks there is still no improvement, then treat with endoscopic or surgical cystogastostomy or aspiration.

Question 16

What would you expect the amylase levels with a pancreatic pseudocyst to look like?

Answer 16

The amylase levels would be mildly raised in up to 75% of cases.

Question 17

What neurological complication can you commonly see after a gastrectomy?

Answer 17

Subacute combined degeneration of the spinal cord (aka. Lichtheim’s disease) due to B12 deficinecy.

Clinical features:

• Progressive onset of symptoms
• Motor problems: bilateral weakness of legs (and arms)
• Sensory problems: loss of vibration and touch sense
• Absent ankle reflexes (with normal or hyperreflexic knee-reflexes)

Question 18

What is the treatment for acute cholecystitis?

Answer 18

• Analgesia + IV Fluids
• IV Antibiotics
• Laparoscopic cholecystectomy within 1 week (NICE recently changed this, before it was after several weeks)

Question 19

What are 2 causes of jaundice that can be seen (and are related to) cholecystectomy for cholecystitis?

Answer 19

• Common Bile Duct injury:
  
  • Presents within the first few days after surgery
  • Inflammation and scarring post-OP lead to obstruction of the duct
• Common Bile duct stone:
  
  • Presents later usually (~2-4 weeks pos-OP)
  • A stone can travel into the end of the cystic duct during surgery and then later dislodge into the CBD
  • To prevent this, on-table cholangiograms are now usually performed after gallbladder removal

Question 20

Why are people suffering from Crohn’S more likely to develop jaundice?

Answer 20

Bile salts are absorbed int he terminal ileum. When this process is imapried (as in Crohn’s) the patien is more likely to develop gallstones; if they pass into the CBD, jaundive will develop.

Question 21

What would you expect the LFTs to be like in acute cholecystitis?

Answer 21

Usually they are normal.

Question 22

What are risk factors for choletlithiasis?

Answer 22

• Fair -> more prevalent in caucasians
• Fat -> BMI >30
• Female
• Fertile -> having children
• Forty -> being ≥40