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Upper GI/Hepatobiliary Flashcards

1
Q

Causes of acute pancreatitis?

A

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia/Hypercalcaemia
ERCP
Drugs (furosemide, thiazides, azathioprine, NSAIDs, mesalazine, sodium valproate)

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2
Q

Drugs which can cause acute pancreatitis?

A

steroids
NSAIDs
furosemide
thiazides
azathioprine
mesalazine
sodium valproate

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3
Q

Presentation of acute pancreatitis?

A

severe epigastric pain
radiation through to back
pain may be eased on leaning forward
nausea and vomiting
systemically unwell
dehydration

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4
Q

Investigations for acute pancreatitis?

A

FBC (WCC)
U&E (urea)
LFT (transaminases + amylase)
Calcium
ABG
amylase + lipase (3 times upper limit of normal)
CRP
US (gallstones)
CT abdo (complications)

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5
Q

Amylase vs Lipase in acute pancreatitis?

A

lipase more sensitive and specific and is raised for longer period of time
however amylase widely used in practice (cheaper)

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6
Q

What is the Glasgow score used for?

A

to assess and stratify the severity of the pancreatitis
>3 = severe pancreatitis

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7
Q

What score is used to assess the severity of pancreatitis?

A

Glasgow Score

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8
Q

Components of Glasgow score?

A

PaO2
Age
Neutrophils
Calcium
Renal (Urea)
Enzymes (LDH, AST/ALT)
Albumin
Sugar (Glucose)

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9
Q

Management of Acute Pancreatitis?

A

Assess Glasgow Score (moderate and severe pancreatitis to HDU or ICU)
ABCDE
Fluid resuscitation
Analgesia (opiates)
Anti-emetics
Treat underlying cause if possible (gallstones etc)
Antibiotics if specific infection
Treat complications

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10
Q

Local complications of acute pancreatitis?

A

necrosis of pancreas
infection in necrotic area
abscess formation
peripancreatic fluid collections
pseudocysts (4wks after)
chronic pancreatitis

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11
Q

Systemic complications of acute pancreatitis?

A

Disseminated intravascular coagulation
SIRS
ARDS
Hypocalcaemia
Hyperglycaemia
Hypovolaemia (third spacing)
Retroperitoneal Haemorrhage (Grey Turner’s sign, Cullen’s sign)

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12
Q

Presentation of pancreatic cancer?

A

painless obstructive jaundice
yellow skin
scleral icterus
pale stools
dark urine
pruritus
non-specific upper abdo or back pain
weight loss
palpable mass
change in bowel habit
nausea or vomiting
new-onset or sudden worsening on T2DM

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13
Q

When to refer for suspected pancreatic ca?

A

over 40 with jaundice - 2 week wait
over 60 with weight loss + symptom - direct CT abdo

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14
Q

What does Courvoisier’s law state?

A

palpable gallbladder with jaundice is unlikely to be caused by gallstones

(cholangiocarcinoma or pancreatic ca)

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15
Q

What does Trousseau’s sign of malignancy state?

A

that migratory thrombophlebitisI is a sign of malignancy, particularly pancreatic adenocarcinoma

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16
Q

Investigations for pancreatic cancer?

A

CT abdo
CT TAP for staging
CA 19-9 tumour marker
ERCP/MRCP
Biopsy

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17
Q

Management of pancreatic cancer?

A

often late presentation -> curative sx not possible
Sx options
stents to relieve obstruction
palliative chemo
palliative radiotherapy
end of life care with symptom controlS

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18
Q

Sx options for pancreatic cancer?

A

Total pancreatectomy
Distal pancreatectomy
Pylorus-preserving pancreaticoduodenectomy (Modified Whipple’s)
Whipple’s procedure

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19
Q

What is Whipple’s procedure?

A

pancreaticoduodenectomy

removal of:
head of pancreas
pylorus of stomach
1st and 2nd parts of duodenum
gallbladder
common bile duct
relevant lymph nodes

anastomose stomach, tail of pancreas and hepatic duct to the jejunum

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20
Q

RFs for gallstones?

A

6 Fs:
female
fat
fair
forty
fertile
FHx

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21
Q

Presentation of gallstones?

A

asymptomatic if gallstones in gallbladder
biliary colic:
severe, colicky, epigastric pain or RUQ pain
triggered by meals
lasting between 30 mins and 8 hrs
may be associated with N&V

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22
Q

Complications of gallstones?

A

acute cholecystitis
ascending cholangitis
obstructive jaundice
pancreatitis
gallstone ileus
gallbladder empyema
perforation
gangrene

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23
Q

What is biliary colic?

A

gallstones temporarily obstructing the drainage of the gallbladder
resolves when stones fall back into the gallbladder

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24
Q

Investigations for biliary colic?

A

obstructive picture on LFTs
US
MRCP
ERCP (also treatment)

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25
Complications of ERCP?
pancreatitis excessive bleeding cholangitis
26
Mx of gallstones?
asymptomatic -> no treatment required symptoms or complications -> cholecystectomy
27
Complications of cholecystectomy?
bleeding, infection, pain, scars damage to bile duct stones left in bile duct damage to bowel, blood vessels, other organs anaesthetic risks VTE post-cholecystectomy syndrome
28
What is post-cholecystectomy syndrome?
group of non-specific symptoms that can occur after a cholecystectomy diarrhoea indigestion epigastric or RUQ pain nausea intolerance of fatty foods flatulence
29
What is acute cholecystitis?
inflammation of the gallbladder calculous (95%) acalculous (long periods of fasting leading to build up of pressure i.e., ICU)
30
Presentation of acute cholecystitis?
RUQ pain radiating to right shoulder fever nausea and vomiting tachycardia, tachypnoea RUQ tenderness Murphy's sign positive raised inflammatory markers
31
What is Murphy's sign?
place a hand on RUQ ask patient to take deep breath in during inspiration the gallbladder will move down, come in contact with your hand and cause cessation of inspiration due to tenderness
32
Investigations for acute cholecystitis?
LFTs raised inflammatory markers abdo US MRCP
33
Mx of acute cholecystitis?
nil by mouth IV fluids antibiotics NG tube if required ERCP to remove stones cholecystectomy (acutely or delayed)
34
Complications of acute cholecystitis?
sepsis gallbladder empyema gangrenous gallbladder perforation
35
Mx of gallbladder empyema?
IV antibiotics cholecystectomy cholecystostomy
36
What is ascending cholangitis?
infection and inflammation of the bile ducts surgical emergency high mortality rate due to rapid progression to sepsis
37
Causes of ascending cholangitis?
obstruction (gallstones) post-ERCP
38
Most common organisms in ascending cholangitis?
E coli Klebsiella Enterococcus
39
What is Charcot's triad?
fever jaundice RUQ pain (+hypotension and confusion = Reynold's pentad)
40
Mx of ascending cholangitis?
nil by mouth IV fluids blood cultures IV Abx (met + ceft) potential HDU or ICU ERCP for stone removal, balloon dilatation, biliary stenting Percutaneous transhepatic cholangiogram can be used where ERCP not suitable or failed
41
Investigations for ascending cholangitis?
raised inflammatory markers LFTs blood cultures US CT MRCP ERCP
42
RFs for cholangiocarcinoma?
PSC liver flukes (parasitic)
43
What is cholangiocarcinoma?
cancer originating from the bile ducts majority are adenocarcinomas
44
Most common site for cholangiocarcinoma?
perihilar region (where the right and left hepatic duct have joined to become the common bile duct after leaving the liver)
45
Presentation of cholangiocarcinoma?
painless jaundice pale stools dark urine general pruritus unexplained weight loss RUQ pain palpable gallbladder hepatomegaly
46
Investigations for cholangiocarcinoma?
CT/MRI + biopsy staging CT TAP CA 19-9 MRCP ERCP
47
Mx of cholangiocarcinoma?
MDT curative surgery may be possible in early cases adjuvant chemorads palliative: stents to relieve obstruction sx to improve symptoms palliative chemorads end of life care
48
Types of gallstones?
cholesterol (10%) bile salts (10%) mixed (80%)
49
US findings in gallstone disease?
presence of gallstones GB wall thickening bile duct dilatation
50
What is GORD?
excessive reflux of gastric contents into the oesophagus resulting in symptoms and/or mucosal injury
51
RFs for GORD?
FHx obesity alcohol use smoking pregnancy
52
Features of GORD?
heartburn acid reflux worse at night and after large meals dysphagia (if ulceration or stricture) globus pulmonary aspiration
53
Investigations for GORD?
clinical diagnosis oesophageal manometry OGD must be performed to rule out cancer if new cases >45, dysphagia or weight loss
54
Mx of GORD?
lifestyle modification medical -> PPI, Gaviscon surgical -> Nissen's fundoplication
55
Indications for surgery in GORD?
persistent symptoms despite maximal medical therapy risk of aspiration pneumonia strictures severe ulceration Barrett's oesophagus young patient with uncontrolled symptoms
56
Complications of GORD?
oesophagitis and ulceration peptic stricture Barrett's oesophagus oesophageal adenocarcinoma
57
What is Barrett's oesophagus?
metaplasia of stratified squamous epithelium of the distal oesophagus to columnar epithelium +/- dysplasia
58
RFs for Barrett's oesophagus?
consequence of prolonged severe GORD obesity
59
Risk associated with Barrett's oesophagus?
1% per year develop into adenocarcinoma
60
Mx of Barrett's oesophagus?
conservative -> lifestyle modifications medical -> PPI, Gaviscon, eradication of H pylori surgical -> OGD surveillance, endoscopic ablation, endoscopic mucosal resection, oesophagectomy
61
What is a hiatus hernia?
prolapse of the gastro-oesophageal junction of part of the stomach into the thoracic cavity through the oesophageal diaphragmatic hernia
62
Types of hiatus hernias?
Type I - sliding Type II - para-oesophageal or rolling Type III - combined Type IV - complex
63
Investigations for hiatus hernia?
CXR Barium swallow - best OGD CT
64
Mx of hiatus hernia?
conservative/medical management surgical: indicated if persistent symptoms despite maximal medical therapy Nissen's fundoplication
65
Complications of hiatus hernia?
oesophageal: inflammation ulceration bleeding iron deficiency anaemia gastric volvulus gastric ischaemia and infarction
66
What is peptic ulcer disease?
breakdown of the mucosal layer of the stomach or duodenum typically secondary to excessive acid production of damaged barrier mechanisms
67
RFs for peptic ulcer disease?
H pylori NSAIDs or aspirin smoking alcohol stress steroids gastrinoma (Zollinger-Ellison syndrome)
68
Features of peptic ulcer disease?
dyspepsia nausea epigastric pain heartburn anaemia duodenal -> relieved by food, cyclical pain gastric -> worsened by food, less cyclical
69
Investigations for peptic ulcer disease?
H pylori: urease test urea breath test stool antigen test OGD biopsy to rule out malignancy
70
Mx of peptic ulcer disease?
H pylori -> triple therapy antacids PPIs
71
Complications of peptic ulcer disease?
bleeding perforation sepsis gastric outlet obstruction
72
Mx of peptic ulcer complications?
Bleeding: ABC IV fluids, transfusion, PPI infusion, tranexamic acid OGD Perforation: ABC IV fluids, broad spectrum ABx surgical -> Graham patch repair -> closure of ulcer followed by omental patch and fixation
73
What is upper GI bleeding?
bleeding above the ligament of Treitz oesophagus stomach duodenum
74
Mx of upper GI bleed?
ABD bloods, group and crossmatch NPO, IV fluids, transfusion correct clotting abnormalities IV PPI, IV tranexamic acid if variceal -> terlipressin, Sengstaken-Blakemore tube urgent OGD: sclerotherapy variceal banding adrenaline injection coagulation
75
What is the Rockall Score used for?
to estimate the risk of rebleeding or death in upper GI bleed performed after OGD
76
What is the Glasgow-Blatchford score used for?
to assess the severity of an upper GI bleed prior to OGD to assess if patient suitable for outpatient management
77
What is dysphagia?
difficulty swallowing
78
What is odynophagia?
painful swallowing
79
Causes of dysphagia?
congenital: oesophageal atresia luminal: foreign body oesophageal wall: oesophageal web Plummer-Vinson carcinoma stricture achalasia GORD oesophagitis scleroderma extramural: pouch compression neurological: stroke MG MND
80
Oesophageal motility disorders?
primary: achalasia diffuse oesophageal spasm secondary: scleroderma Chagas DM amyloid MG
81
What is achalasia?
loss of oesophageal peristalsis, incr. lower oesophageal sphincter tone and failure to relax
82
Features of achalasia?
progressive dysphagia to both liquids and solids risk of SCC
83
Investigations for achalasia?
upper GI endoscopy Barium swallow ('bird-beak') manometry
84
Complications of achalasia?
nocturnal aspiration bronchiectasis lung abscess SCC
85
Mx of achalasia?
balloon dilatation injection of Botox Heller's cardiomyotomy
86
Types of oesophageal cancer?
SCC adenocarcinoma
87
Features of oesophageal adenocarcinoma?
most common in Western world lower third of oesophagus reflux
88
Features of oesophageal SCC?
most common globally upper and middle parts of oesophagus carcinogens
89
RFs for oesophageal adenocarcinoma?
Barrett's GORD obesity high fat intake smoking alcohol
90
RFs for oesophageal SCC?
high alcohol intake smoking nitrosamines Vit A, C deficiency coeliac strictures and webs achalasia peptic ulcer disease
91
Presentation of oesophageal cancer?
dysphagia weight loss haematemesis screening mets local invasions (hoarseness, Horner's, SVC obstruction)
92
Investigations for oesophageal cancer?
OGD biopsies CT TAP/PET
93
Mx of oesophageal cancer?
MDT endoscopic ablation and resection in high-grade dysplasia oesophagectomy + neoadjuvant chemorads (SCC better response to rads)
94
Surgical options for oesophagectomy?
Ivor-Lewis (2-stage oesophagectomy) -> performed for distal tumours McKeown Procedure (3 stage for proximal tumours) transhiatal resection
95
Types of gastric cancer?
adenocarcinoma adenocarcinoma of GOJ GISTs neuroendocrine tumours (carcinoid) lymphoma (H pylori)
96
RFs for gastric adenocarcinoma?
chronic ulceration related to H pylori nitrosamines EBV FHx Blood type A
97
Investigations for gastric adenocarcinoma?
gastroscopy and biopsy CT TAP/PET
98
Mx of gastric adenocarcinoma?
gastrectomy (partial or total) neoadjuvant chemotherapy palliative gastrojejunostomy
99
Complications of partial/total gastrectomy?
Early: haemorrhage acute pancreatitis anastomotic leak duodenal stump disruption respiratory compromise Late: dumping syndrome bile reflux vomiting diarrhoea recurrent stomal ulceration metabolic abnormalities (iron def, B12 def)
100
Complications of OGD?
perforation bleeding damage to teeth sedation risks aspiration numbness, risk of scalds sore throat

Surgery (10 decks)

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