Gallstone obstruction of the cystic duct
Biliary Colic
- intermittent RUQ pain
- tender gallbladder
- no weight loss
Cholecystitis:
- RUQ pain
- leukocytosis
- fever
- tender gallbladder
- no weight loss.
Pyogenic liver abscess
Radiological investigation
* multiloculated, hypo-echoic hepatic lesions
Signs/symptoms:
- jaundice
- weight loss
Pseudocyst
Def:
- encapsulated peri-pancreatic fluid collection
- not located near biliary duct to cause obstruction
Causes:
* history of pancreatitis
Symptoms:
- asymptomatic
- epigastric pain
- early satiety
- no jaundice
- no gallbladder enlargement
Portal vein thrombosis (PVT)
PVT Most often associated with cirrhosis
Acute PVT:
* Abdominal pain
Chronic PVT:
* variceal bleeding
Congenital umbilicus hernia
Pathophysiology:
- incomplete closure of abdominal muscles
- can be associated with:
* Down syndrome
* Ehlers- Danlos
* Hypothyroidism
* Beckwith-Weidemann
Clinical feature:
- soft, non-tender bulge covered by skin at umbilicus
- protrudes with increased abdominal pressure (eg, crying baby, straining)
- the hernia may include part of omentum or small intestine
- typically reducible
Management:
- observe for spontaneous closure
- elective surgery around age 5
- complicated umbilicus hernia require urgent surgery
notes require immediate surgery:
- gastroschisis: intestinal protrusion with no covering lateral to the umbilicus
- omphalocele: covered by thin-membrane protrusion of abdominal contents
Groin hernia
Def:
* inguinal bulge above inguinal ligament can be direct or indirect
Sign:
- enlarged inguinal bulge that increases in size with Valsalva Maneuver
- reduced inguinal bulge in supine position
Symptoms:
*asymptomatic —> postpone surgery —> will eventually develop symptoms by 10 years (pain/limitation to activity or incarcerated) & require repair
- symptomatic:
* associated abdominal pain
* symptoms of incarceration (N/V, changes in bowel habits)
* inability to perform daily activities
Treatment:
Symptomatic hernia requires urgent surgical repair
Hepatic adenoma
Epidemiology:
- benign epithelial liver tumor
- primary young women on prolonged oral contraceptive
Manifestation:
- often benign & asymptomatic (incidentally found)
- episodic RUQ pain
Imaging:
- solitary, solid lesion in right lobe of liver
- multiple lesions occasionally occur
- free fluid (blood) in the abadomen
Treatment:
- Asymptomatic & <5 cm —> stop oral contraceptive
- Symptomatic & > 5cm —> surgical resection
Complication:
- malignant transformation
- rupture & hemorrhagic shock ( hypotension, tachycardia, syncope, poor capillary refill, cold extremities, & anemia; low-grade fever & leukocytosis may occur due to peritoneal irritation from blood in the abdomen cavity)
**NOTE:
Rupture causes severe RUQ pain with hemorrhagic shock
Hepatocellular carcinoma
Epidemiology:
- older patients
- long standing alcohol use or chronic viral infection
Symptoms:
- progressive, subacute RUQ abdominal pain
- decompensated cirrhosis
Hydatid cyst
Can rupture in the abdomen
Symptoms:
- sudden onset of RUQ pain
- fever
- leukocytosis
Imaging:
*US shows smooth round cyst in the liver (not a solid mass)
Acute cellular rejection (ACR)
- occurs in the first 3 months after transplant
- EX: result from immunity rejecting liver allograft
Symptoms:
- asymptomatic
- fever
- malaise
- lethargy
investigation:
- LFT abnormalities (elevation in: aminotransferase, bilirubin, alkaline phosphatase)
- liver biopsy:
- mixed inflammatory infiltration of the portal tracts involving: eosinophils, neutrophils, & lymphocytes
- endotheliitis (lymphocytic sub-endothelial invasion of the portal & hepatic veins
- interlobular bile duct destruction
Treatment:
- increase immunosuppressant (high-dose steroids): typically, reverse the rejection
- steroid-refractory cases: use other immunosuppressant —> thymoglobulin, sirolimus
- repeat transplant, if fail to respond to immunosuppressant
Primary benign cholangitis (PBC)
Histologic finding:
*florid duct lesion (inflammation limited to the bile duct)
Metronidazole
Drug used in:
- intra-abdominal abscess
- Other infection occur in the post-transplant period
* * Present with fever, elevated transaminase, leukocytosis
Ulcerative colitis
Def:
- chronic inflammatory disorder of the colonic mucosa
- either be : mild or moderate-to- severe
Mild UC: Clinical feature: *abdominal pain *chronic diarrhea (<4 watery bowel movement per day) * hematochezia is rare or intermittent
Laboratory findings:
- No anemia
- Normal CRP
- Normal ESR
Investigation:
*shallow ulceration & inflammation in the rectum & sigmoid colon on colonoscopy
Treatment:
- 5-amino-salicylic acid (5-ASA) agents (eg, mesalamine, sulfasalazine, Balsalazide)
- **suppositories or enemas are preferred & limited to recto-sigmoid
- ** oral therapy limited to more extensive disease
- acute flare or severe chronic disease: corticosteroid = topically (hydrocortisone enema), systemically (prednisone)
Moderate to severe UC:
Clinical features:
- abdominal pain
- chronic diarrhea (> 6 bowel movement per day)
- frequent hematochezia
Laboratory:
- anemia
- elevated CRP
- elevated ESR
Treatment:
- TNF-alpha Inhibitors (infliximab, adalimumab, golimumab)
- a total procto-colectomy with ileoanal anastomosis
Solid liver masses
Hepatic hemangioma:
- most common benign liver tumor
- found incidentally
- Tri-phasic CT scan shows: centripetal enhancement (eg, enhancement moving from periphery to center) & No central scaring
Focal nodular hyperplasia (FNH):
- second most common benign liver lesion after hemangioma
- associated with anomalous arteries
- arterial flow & central scar on imaging
- women 20-50
- found incidentally
- lesion well circumscribed, solitary, < 5cm in size
- does not: grow over time, malignant transform, or rupture
- treatment is rarely required
- contraceptive can be continued
Hepatic adenoma:
- benign liver tumor
- arise in the right lobe of the liver
- women on long-term oral contraceptive
- possible hemorrhage or malignant transformation
- Tri-phasic CT scan shows: centripetal enhancement & No central scaring
Regenerative nodules:
*acute or chronic liver injury (eg, cirrhosis)
Hepatocellular carcinoma:
- malignant liver tumor
- arise in the setting of chronic liver disease (cirrhosis, viral hepatitis)
- patient usually asymptomatic but can develop early satiety & weight loss
- systemic symptoms
- chronic hepatitis or cirrhosis
- elevated alpha fetoprotein (AFP)
- No central scaring
Note:
hepatic cirrhosis:
- consume excess alcohol
- non-specific symptoms (fatigue, weight loss)
- ascites
- hepatic encephalopathies
- jaundice
- marked by: hepatic fibrosis, distortion of normal hepatic architecture & regenerative nodules
- Imaging shows: shrunk & irregular liver with innumerable small nodules
Liver metastases:
- liver is common site for metastases from other tumors (eg, pancreatic, colorectal, breast ): known extra-hepatic malignancy
- single/ multiple lesions are most common
Severe acute pancreatitis
