5 - Hepatobiliary Flashcards

Question

If a patient presents with RUQ post-cholecystectomy, what is the likely pathology and what should you do?

Answer 1

- Retained CBD stone - Use US abdomen but if unremarkable do MRCP

Answer 2

- Mirizzi Syndrome - Gallbladder empyema - Chronic cholecystitis - Bouveret’s Syndrome - Gallstone ileus

Answer 3

- Stone located in **Hartmann's pouch** or the cystic duct, that **compresses the common hepatic duct** - Causes **obstructive jaundice** - Confirmed with **MRCP** and manage by **laparoscopic cholecystectomy**

Answer 4

**- Gallbladder filled with pus** - Patient unwell and **often septic**, same clinical picture as acute cholecystitis - Diagnose with **US** or **CT** - Manage with **laparoscopic** (often switches to open) **cholecystectomy** or p**ercutaneous cholecystotomy**

Answer 5

- History of recurrent or untreated cholecystitis - Ongoing RUQ or epigastric pain w/wo N+V **- Complications:** gallblader carcinoma, biliary enteric fistula **- Diagnose with CT** or often histologically post-cholecystectomy. - Treat with **elective cholecystectomy**

Answer 6

Inflammation of gallbladder can form **cholecystoduodenal fistula** allowing gallstones into small bowel, resulting in **bowel obstruction** **- Bouveret’s Syndrome –** stone impacts proximal duodenum, causing a gastric outlet obstruction **- Gallstone Ileus –** stone impacts terminal ileum (narrowest part of small bowel), causing a small bowel obstruction

Answer 7

**Infection of the biliary tract** due to **biliary outflow obstruction.** Obstruction causes stasis of fluid and increased intraluminal pressure that allows **bacteria to colonise the billiary tree** **_Common Causes:_** Gallstones, ERCP/Iatrogenic, Cholangiocarcinoma **_Rare causes:_** Pancreatitis, Primary Sclerosing Cholangitis, Ischaemic Cholangiopathy, and parasitic infections

Answer 8

- Escherichia Coli - Klebsiella species - Enterococcus

Answer 9

**- Charcot's Triad** **- Reynold's Pentad** **- Pruitis** **- Pale stool/Dark urine** - Tachycardia - History of gallstones, ERCP, meds like COCP and fibrates

Answer 10

**- Routine bloods:** FBC (raised WBC) and LFTs (raised ALT, gamma GT and bilirubin) **- Blood cultures:** take before broad spectrum abx **- US of biliary tract:** bile duct dilatation \>6mm **- ERCP:** gold standard diagnostic and therapeutic. May do MRCP before

Answer 11

- Sepsis 6 with I**V broad spectrum abx** (Co-amoxiclav) - Endoscopic biliary decompression with **ERCP** or percutaneous transhepatic cholangiograpy (**PTC**) 2nd line **- Elective cholecystectomy** if the cause was gallstones

Answer 12

- **Repeated cholangitis** - Pancreatitis - Bleeding (more common when sphincterotomy performed) - Perforation

Answer 13

- 5-10% for those given early abx therapy **- Increased mortality:** delayed diagnosis, liver failure, cirrhosis, CKD, hypotension, female, over 50

Answer 14

- Cancer in the biliary system but usually extrahepatic **- Common location**: bifurcation of right and left hepatic ducts (Klatskin tumour). Slow growing that invades locally and metastases to lymph nodes then peritoneal cavity, liver, lung **- Histology**: 95% adenocarcinoma, SCC, lymphoma, sarcomas, small cell cancers

Answer 15

- Primary sclerosing cholangitis - Ulcerative colitis - Infective (Liver flukes, HIV, hepatitis virus) - Toxins (Chemicals in rubber and aircraft industry) - Congenital (Caroli’s disease, choledochal cyst) - Alcohol excess - Diabetes mellitus

Answer 16

**- Usually asymptomatic until later disease** - Post hepatic jaundice - Pruitis - Pale stools/dark urine - Cachexia - Sometimes: RUQ pain, malaise, early satetity, weight loss

Answer 17

In the presence of **painless jaundice** and an **enlarged gallbladder/RUQ mass,** there is likely an **obstructing pancreatic or gallbladder malignancy** not gallstones Sign only present if tumour obstructing distal to cystic duct

Answer 18

Think of other causes of post-hepatic jaundice: - obstructive choledocholithiasis - bile duct strictures - external compression from extra-biliary tumour - benign biliary tumours - pancreatic tumours - primary biliary cirrhosis - primary sclerosing cholangitis.

Answer 19

**_Bloods_** **_-_** Raised ALP, Gamma GT, Bilirubin - Tumour markers **CEA/CA19-9** **_Imaging_** - US **- MRCP GOLD STANDARD** will show strictures in biliary tree - ERCP (can take biopsies) - CT for staging as can look for distant metastases - Angiography for pre-op planning of hepatic arteries

Answer 20

**Intrahepatic or Klatskin tumour:** partial hepatectomy and reconstruction of the biliary tree **- Distal common duct tumour:** pancreaticoduodenectomy (termed a Whipple’s procedure). **- Radiotherapy** as neo/adjuvant therapy

Answer 21

**Stenting:** with ERCP to relieve obstructing symptoms but may need to be replaced every few months as prone to occlusion **Surgical bypass:** if obstruction not relieved by stenting **Palliative radiotherapy and chemotherapy** to slow tumour growth e.g cisplatin

Answer 22

- Increased risk of **biliary tract sepsis** due to obstruction **- Secondary biliary cirrhosis** - Prognosis 12-18 months to live after diagnosis - Distal tumours better prognosis than proximal

Answer 23

**Fluid-filled epithelial-lined sacs** within the **liver**, most commonly occurring in the right lobe Though to be **congenitally malformed bile duct cells**, failing to connect to the extrahepatic ducts **Symptoms:** mostly asymptomatic and found on imaging, some have ab pain, nausea and early sateity due to mass effect

Answer 24

**Bloods:** LFTs normal but may have raised gamma GT and tumour markers CEA/CA19-9 **US**: imaging modality of choice. well defined, thin walled, spherical lesions with no septation and strong posterior wall acoustic enhancement

Answer 25

**- \<4cm asymptomatic:** no intervention - \>**4cm asymptomatic:** follow up US scans at 3,6,12 months to check for growth. If size of cyst remains unchanged for 2-3 years no intervention unless becomes asymptomatic **- Symptomatic:** ultrasound-guided aspiration or laparoscopic de-roofing (lower rates of recurrence)

Answer 26

Presence of **≥20 cysts** in **liver parenchyma**, each of which are **≥1cm in size.** Caused by **ADPCKD** or **ADPLD** Structures are **not connected to intrahepatic bile ducts** so **do not drain** and lead to dilatation and cyst formation filled with bile fluid

Answer 27

**- Asymptomatic** **- Abdominal pain** and **hepatomegaly** as increases in size - May have urinary symptoms if kidneys involved - Eventual liver cirrhosis and portal hypertension

Answer 28

**Bloods:** normal LFTs **Imaging:** US with \>20 cysts that have the same morphology as simple cysts

Answer 29

- Can be **left alone** whilst asymptomatic **- Somatostatin analogues e.g Ocreatide** for short term relief of symptoms as reduces cyst volume **_- Surgery:_** * Laparoscopic de-roofing of cysts * US-Guided Aspiration (high recurrence so not done) * Resection of liver * Transplant

Answer 30

(1) intractable symptoms (2) inability to rule out malignancy on imaging alone (3) prevention of malignancy.

Answer 31

**Features:** asymptomatic as grow very slowly, abdominal pain, anorexia, bloating, fullness, nausea **Histology:** cystadenomas (non-invasive mucinous cystic neoplasms). Premalignant biliary epithelium that can become cystadenocarcinomas

Answer 32

**- Bloods:** normal LFTs but may have mildly raised CEA, ALP, CA19-9 **- US:** can tell the different between simple and complicated cysts **- CT imaging with contrast:** to diangose and look for metastases **- Management:** liver lobe resection whether adenoma or adenocarcinoma and histological diagnosis

Answer 33

Aspiration or biopsy should be avoided as can cause peritoneal seeding

Answer 34

**Malignancy:** septations, wall enhancement, nodularity **Abscess:** debris within cyst, loculation (also malignant sign) **Hyatid Cyst:** calcification, daughter cysts around main lesion

Answer 35

Liver cysts formed by infection by the **tapeworm** Echinococcus granulosus. Eggs are passed **faeco-orally** (dogs) and **pass into the hepatic portal system** where they form cysts High prevalence in South America, North Africa, Central Asia

Answer 36

**- Asymptomatic** for years as slow growing **- Vague abdominal pain** due to mass effect or rupture - May cause jaundice, cholangitis, vomiting, dyspepsia **_- Bloods:_** LFTs normal, eosinophillia, positive antibody titre **_- US:_** calcified, spherical lesion with multiple septations. Anechoic with snowflake inclusions **_- CT Imaging with contrast_**

Answer 37

- If asymptomatic can monitor **- Surgical cyst deroofing** **- Antiparasitics** e.g albendazole, mebendazole and/or praziquantel - DO NOT ASPIRATE AS RUPTURE CAN CAUSE ANAPHYLAXIS

Answer 38

**Polymicrobial bacterial infection** spreading from the **biliary o**r **gastrointestinal tract**, either via contiguous spread or seeding from portal and hepatic veins **Common organsims:** E. Coli, K. pneumoniae, and S. constellatus, Fungal in immunocompromised **_Causes:_** cholecystitis, cholangitis, diverticulitis, appendicitis, or septicaemia

Answer 39

**- Fever, rigors, abdominal pain** - Bloating, nausea, anorexia, weight loss, fatigue and jaundice - On examination will have **RUQ pain** with **hepatomegaly** - If ruptures may have signs of sepsis

Answer 40

**- Bloods:** raised WBC, raised ALP **- Blood and fluid cultures:** should be sent off **- US:** poor defined lesions with hypo- and hyper-echoic areas, with gas bubbles and septations **- CT with contrast:** similar findings to US with surrounding oedema

Answer 41

DEPENDS ON SIZE - Fluid resuscitation **- Antibiotics** **- US/CT guided aspiratio**n w or w/o catheter drainage **- Cyst deroofing** - Surgery if ruptures TREAT ANY UNDERLYING CAUSE TOO

Answer 42

Most common extra-intestinal manifestation of **Entomoeba Histiolytica** (from spread via portal system) Spreads faeco-oral and once in colon invades mucosa to get to portal system. Common in developing world e.g South America, India

Answer 43

**- Vague symptoms** of abdominal pain, nausea, fever or rigors, weight loss, and bloating - May have prodrome of **abdominal pain** and **diarrhoea** **- History of recent travel (**\<6 months) to an endemic area

Answer 44

**_Ix:_** - Bloods: raised WBC, deranged LFTs, E.Histolytica antibodies - Blood cultures - Stool samples: for antibodies - US/CT: poor defined lesions **_Mx:_** - Antibiotics (***Metronidazole*** or ***Tinidazole***) - Surgical drainage for large cysts that do not respond to abx - Luminal agent (***Paromycin***) to clear colon of amoebiasis

Answer 45

6th most common cancer due to chronic inflammatory processes: **- Viral hepatitis** (most common) - Chronic alcoholism - Hereditary haemochromatosis - PBS - Aflatoxin (cereals and nuts)

Answer 46

- Viral hepatitis (Hep B and C) - Smoking - \>70 - Aflatoxins - Family history of liver disease

Answer 47

**- Main symptom:** liver cirrhosis **- Irregular enlarged craggy tender liver** - Dull ache in RUQ - Fatigue, fever, weight loss, lethargy **- Late:** ascites and jaundice **_Differentials:_** infectious hepatitis, cardiac failure (smooth liver), benign hepatocellular adenoma, other causes of liver cirrhosis

Answer 48

**- LFTs:** ALP, AST, ALT, Bilirubin all deranged **- Low platelets** and **prolonged clotting** **- Alpha-Fetal Protein (AFP)** may be raised and can be used to monitor progression

Answer 49

**- US:** inital imaging of choice. Mass \>2cm with raised AFP is diagnostic **- MRI liver scanning** or **percutaneous fine-needle aspiration** may be used if US suggestive but not sure. Be careful of seeding **- CT staging scan**

Answer 50

**Barcelona Clinic Liver Cancer staging system** (BCLC) Helps to decide which treatment is suitable

Answer 51

**Child-Pugh:** calculates prognosis of patients with liver cirrhosis. Looks at serum bilirubin, albumin, INR, degree of ascites, and evidence of encephalopathy **MELD:** calculates same prognosis but better and also predicts likelihood of patient tolerating a liver transplant. Looks at creatinine, bilirubin, INR, sodium, and the use of dialysis (at least twice per week)

Answer 52

**- Surgical resection:** if no cirrhosis and good baseline health. High 5 year recurrence rate **- Transplation:** only if fufill the Milan criteria. One lesion \<5cm or three lesions \<3cm, no extrahepatic manifestations, no vascular infiltration

Answer 53

_- **Image guided ablation:**_ if early stage BCLC 0 or A. Put US waves into tumour to cause necrosis _**- Alcohol ablation**:_ if small **_- Transarterial Chemoembolisation (TACE):_** BCLC stage B (a large multinodular tumour. High concentrations of ***chemotherapy*** are injected ***directly into hepatic artery*** and an ***embolising agent*** is then added to induce ischaemia. Radiological techniques used so only embolise branches of arteries supplyin tumour not whole liver

Answer 54

- Depends on extent of underlying malignancy - Median survival 6 months

Answer 55

- **Bowel** (via the portal circulation), **breast, pancreas, stomach,** and **lung** - Hepatomegaly and ascites - Jaundice and upper abdominal pain

Answer 56

**_Ix:_** **- Bloods:** derange LFTs with raised ALP **- US** and **CT** to find staging and source of metastases **- Biopsy** not advised due to seeding **_Mx:_** - Often palliative - Surgery if metastases confined to liver and primary tumour under control. Can do TACE or selective internal radiotherapy

Answer 57

**Limited damage to the secretory function** of the gland, with no gross structural damage developing. Repeated acute can lead to chronic

Answer 58

(See image) **Most common:** Excess alcohol consumption and Gall stones Cause not found in some patients

Answer 59

- Premature and **exaggerated activation of digestive enzymes** - **Pancreatic inflammatory response** (Increasing vascular permeability and fluid shifts, third spacing) - Pancreatic enzymes in blood stream cause fat autodigestion leading to **fat necrosis** and **hameorraghe** into retroperitoneal space - Free fatty acids react with calcium to form chalky deposits and **hypocalcaemia** - End stage is complete **necrosis of the pancreas**

Answer 60

- **Sudden onset severe epigastric pain** that can **radiate to back** - Nausea and vomiting - Guarding - Cullen's/Grey-Turners if retroperitoneal haemorraghe - Tetany from hypocalcaemia - Jaundice if gallstones aetiology

Answer 61

- AAA - Renal calculi - Chronic pancreatitis - Aortic disection - Peptic Ulcer disease

Answer 62

**Serum Amylase:** 3x upper limit of normal **LFTs:** to see if any cholecystic involvement. Raised ALT likely cause is gallstones **Serum Lipase:** more accurate than amylase as remains elevated for longer

Answer 63

- Bowel perforation - Ectopic pregnancy - DKA

Answer 64

**- Modified Glasgow Criteria** within 48 hours of admission **- Score of 3 or more** have severe pancreatitis and a high-dependency care referral is needed - PANCREAS mneumonic (see image) **Others:** APACHE II score, Ranson Criteria, and Balthazar score (CT scoring system)

Answer 65

**_- US Abdomen:_** to find cause **_- AXR:_** not routinely done but may have ***sentinel loop sign***. Do ***CXR*** to look for pleural effusion or ARDS **_- Contrast enhanced CT:_** done if complications or can't find underlying cause if 48 hours after admission there is ***pancreatic oedema and swelling***, or non-enhancing areas suggestive of ***pancreatic necrosis***. If signs of persistent inflammatory response/organ failure do not CT for severity till 6-10 days after admission

Answer 66

- Fluids - Analgesics - Nutrition support (enteral feeding)

Answer 67

**- Manage underlying cause** (e.g ERCP and spincterotomy/cholecystectomy for gallstones) **- Supportive treatment** (see image OI OI) **- ONLY Broad spectrum abx** (Imipenem) IF for prophylaxis against infection in cases with **confirmed pancreatic necrosis** - If severe case treat in high dependency unit

Answer 68

- DIC - ARDS - Hypocalcaemia - Hyperglycaemia as Islets of Langerhan's destroyed and insulin production halted

Answer 69

**_Pancreatic Necrosis_** - Suspect if patient has signs of persistent systemic inflammation for more than 7-10 days after onset - Necrosis prone to infection so suspect if ***patient deteriorates*** and ***raised inflammatory markers*** - Confirm by ***CT imaging*** then ***fine needle aspiration biopsy*** - Treat with ***pancreatic necrosectomy*** 3-5 weeks after onset so walled off necrosis **_Pancreatic Pseudocyst_** - ***Collection of fluid*** containing pancreatic enzymes, necrotic material and blood. ***Lack epithelial lining*** but surrounded by vascular and fibrous that's why psuedo - Often in lesser sac blocking gastro-epiploic foramen - Often found incidentally on image or mass effect e.g biliary or gastric outlet obstruction - Can ***haemorraghe, rupture*** or ***become infected*** - May ***resolve spontaneously*** but if still there after 6 weeks ***surgical debridement*** or ***endoscopic drainage***

Answer 70

Chronic fibro-inflammatory disease causing **progressive and irreversible damage** to the pancreatic parenchyma 4x more likely in men and more likely aged \>40 **Main causes:** chronic alcohol abuse or idiopathic **Rare causes:** metabolic (hyperlipidaemia, hypercalcaemia), infection (HIV, mumps, coxsackie), hereditary (CF), autoimmune (e.g. AIP or SLE), anatomical (malignancy or stricture formation), or congenital anomalies

Answer 71

**- Chronic Epigastric Pain** (radiating to back, eased by leaning forward) - Exocrine/endocrine insufficiency (see image - Type 3c DM) - Often pseudocysts present and may have mass effect e.g biliary obstrucution

Answer 72

**- Urine dip** **- Routine bloods:** FBC/CRP **- Serum amylase/lipase:** not raise **- LFTs:** for obstructive jaundice **- BM:** to see if endocrine dysfunction **- Faecael elastase:** low with exocrine dysfunction. Enzyme released from pancreas into bowel that is not degraded

Answer 73

**CT imaging:** may show pancreatic calcification or atrophy and any pseudocysts present. Can show malignancies that can cause chronic pancreatitis **US or MRCP:** image biliary tree and pancreas but if normal doesn't exclude chronic pancreatitis **Secretin Stimulation test** or **Endoscopic US (EUS)** if diagnostic uncertainty

Answer 74

**- Treat reversible underlying cause** e.g alcohol cessation or statins for hyperlipidaemia **- Analgesics** (neuropathic not opiates like acute) - Exocrine dysfunction give **enzyme replacement** (like Creon) and fat soluble vitamins - Endocrine dysfunction may need **insulin regimes** and annual check of HbA1c **- ERCP** for diagnostic and stone removal/sphincterotomy - Endosonography-guided celiac plexus blockade or thoracoscopic splanchnicectomy for analgesia **- Steroids** to reduce symptoms of autoimmune pancreas. High dose prednisolone then low dose maintenance

Answer 75

- Endocrine and exocrine insufficiencies - Pancreatic malignancy risk once had for over 20 years

Answer 76

- 90% are **ductal carcinoma of the pancreas.** - 10% Exocrine (Pancreatic Cystic Carcinoma) or Endocrine (Derived from Islet Cells of Pancreas) **- Direct invasion of local structures** typically involves the spleen, transverse colon, and adrenal glands. **- Lymphatic metastasis** typically involves regional lymph nodes, liver, lungs, and peritoneum and common at diagnosis

Answer 77

- Smoking - Chronic pancreatitis - FHx - Late onset DM (\>50)

Answer 78

Features depend on site of tumour, at tail insidious onset + not symptomatic until late * *- Obstructive Jaundice** * *- Abdo Pain** (Secondary to invasion of coeliac plexus) * *- Weight loss/**Cachetic - Acute Pancreatitis - Thrombophlebitis Migrans - Abdominal mass/enlarged gallbladder

Answer 79

**_Lab_** ***- FBC*** (anaemia and thrombocytopenia) ***- LFTs*** (raised bilirubin, ALP and gamma GT showing obstructive jaundice) ***- CA19-9*** not to diagnose but to measure response **_Imaging_** - ***Initial USS*** to look for ***bile duct dilatation*** or ***pancreatic mass*** ***- CT to diagnose*** followed by ***chest-abdomen-pelvis CT scan*** or ***PET*** to stage ***- Endoscopic US*** for ***fine needle aspiration biopsy*** or ERCP for biopsy

Answer 80

**_Surgical resection:_** - Whipples Procedure (pancreaticduodenectomy) or - Distal Pancreatectomy (if tumour of tail) CONTRAINDICATED IF METASTASES **_Adjuvant chemotherapy:_** - Following surgery give 5-fluorouracil

Answer 81

Removal of the ***head of the pancreas,*** the ***antrum*** of the stomach, the **1st and 2nd parts of the duodenum**, ***common bile duct,*** and ***gallbladder.*** All share blood supply of ***gastroduodenal artery*** ***Tail of the pancreas*** and the ***hepatic duct*** are ***anastomosed to the jejunum*** to drain bile and ***stomach*** anastomosed too **_Complications:_** pancreatic fistula, delayed gastric emptying, and pancreatic insufficiency

Answer 82

**FOLFIRINOX** (folinic acid, 5-fluorouracil, irinotecan, and oxaliplatin) If not well enough to tolerate this give ***gemcitabine therapy***

Answer 83

**Percutaneous or ERCP _Biliary stent_:** to relieve obstructive jaundice and pruitis **Palliative chemotherapy:** gemcitabine based. used if good performance status **Enzyme replacements (inc Lipases e.g Creon):** for exocrine insufficiency to stop malnourishment and steatorrhea

Answer 84

Functional (symptoms due to secretion) or Non-functional (symptoms due to metastatic spread) - Gastrinoma (Zollinger-Ellison) - Insulinoma - Somatostatinoma - Glucagonoma - VIPoma

Answer 85

Hereditary condition associated with tumours of the endocrine. Used to be called Wermer syndrome - Hyperparathyroidism due to parathyroid tumours - Endocrine pancreatic tumours - Pituitary tumours

Answer 86

**_Ix:_** - Combination of CT, MRI and/or Endoscopic Ultrasound. - Intra-arterial calcium with digital subtraction angiography **_Mx:_** - If small non-functioning just observed - If large functioning then primary tumour and metastases resected - Somatostatin analgoues can help control effects of hormone oversecretion

Answer 87

Cysts identified by histology, risk of malignancy and secretions In general **mucinous cysts** are **high risk** and **serous cysts** are **low risk**

Answer 88

**- Mostly asymptomatic** - **Abdominal/back pain** (compression), **post obstructive jaundice, vomiting** - If turn malignant may have general features of malignancy such as weight loss, loss of appetite, change in bowel habits

Answer 89

Often following pancreatitis The inflammatory reaction produces a necrotic space in the pancreas that fills with pancreatic fluid, however this lacks an epithelial lining Often asymptomatic

Answer 90

Often picked up on imaging. If found do **pancreatic protocol CT scan** or **magnetic resonance cholangiopancreatography** to further assess. May then do **Endoscopic US scan with Fine Needle Aspiration (EUS-FNA)** to further assess and work out low risk/high risk

Answer 91

**_Low risk:_** left alone with ***surveillence*** every 5 years due to malignancy risk **_High risk:_** ***resection*** is first line with follow up MRI every 2 years If non-malignant excellent prognosis but if malignant 60% 5 year survivial

Answer 92

- Post ERCP due to sphincterotomy - Following passage of gallstone - Scarring from acute pancreatitis

Answer 93

Will not see them if they are largely cholesterol based as not calcified Will only see fluid and inflammation around the gallbladder

Answer 94

Gallstone stuck in Hartman's pouch which in turn chronically blocks the cystic duct. Gallbladder gets enlarged and creates mucus pouch Abdominal pain with palpable gallbladder without any signs of infection

Answer 95

Modified Glasgow Score. If \>3 suggest HDU/ITU input as severe P A N C R E A S

5 - Hepatobiliary Flashcards

(122 cards)