Ranson criteria on admission
- Age
- WBC
- Blood glucose
- Serum AST
- Serum LDH
Branches of SMA
- Inferior pancreaticoduodenal artery (supplies head of the pancreas and to the ascending and inferior parts of the duodenum)
- Intestinal arteries (branches to ileum, branches to jejunum)
- Ileocolic artery (supplies last part of ileum, cecum, and appendix)
- Right colic artery (to ascending colon)
- Middle colic artery (to the transverse colon)
Branches of Celiac trunk
- Left gastric a.
- Common hepatic a.
- Splenic a.
- Esophageal branch, stomach branch
- Hepatic a. proper, Gastroduodenal a., Right gastric a.
- Dorsal pancreatic a., Short gastric a., Left gastro-omental a., Greater pancreatic a.
RLQ pain DDx (14)
JC WCS
- Acute appendicitis
- Cecal diverticulitis
- Ureteric colic
- Ruptured ectopic pregnancy
- Mesenteric adenitis
- Torsion of ovarian cyst
- Ileitis
- Meckel’s diverticulum
- Cecal ischemia
- CA Cecum
- Inguinal/Femoral hernia
- Testicular pathology
- PPU
- Acute cholecystitis
LLQ pain DDx (7)
JC WCS
- Sigmoid diverticulitis
- CA Sigmoid
- Torsion of ovarian cyst
- Ruptured ectopic pregnancy
- Ureteric colic
- Inguinal/Femoral hernia
- Testicular pathology
Central abdominal pain -
Periumbilical pain DDx (7)
JC WCS
- SB obs
- GE
- Early acute appendicitis
- Bowel ischemia
- IBS
- Ruptured AAA
- Acute pancreatitis
Central abdominal pain -
Hypogastrium pain DDx (4)
JC WCS
- Cystitis
- PID
- LB obs
- AROU
Child-Pugh score
ABCDE
Albumin Bilirubin PT Ascites (distension) Encephalopathy
A - 5-6 (compensated, normal liver function)
B - 7-9 –> can go for transplant
C - 10-15
MELD score (Model for end stage liver disease)
BICE
Bilirubin
INR
Creatinine
Etiology
Causes of Portal HT
IT
Pre-hepatic cause (20%)
- Thrombophlebitis of umbilical v.
- Congenital absence of PV
- Malignant invasion of PV (PV thrombosis usu by CA head of pancreas; HCC usu causes ipsilateral PV thrombosis, not usu causing main trunk thrombosis)
Intrahepatic cause (80%)
- Cirrhosis
- Drug
- Chronic hepatitis (8% HBV carrier in HK now)
- Cardiac cirrhosis
- Congenital hepatic fibrosis
Post-hepatic cause
- Budd-Chiari syndrome (affect the main hepatic v.?)
- Constrictive pericarditis
Spread of HCC
IT
Local invasion
- PV
- Hepatic v.
- Bile duct
Lymphatic spread (25% of patients)
Transperitoneal spread (Rare)
Hematogenous spread
- Lung, Bone
Presentation of HCC
IT
- Subclinical (50% cases are asymptomatic)
- Vague epigastric distension
- Sharp pain due to bleeding
- Abd mass
- Abd distension due to ascites
- Secondaries in Lung, Bone
- Paraneoplastic syndrome
- Diarrhea, hypo/hyperglycemia, hyperCa, polycythemia (tumor produces EPO) - LOW
- GIB
Indication of partial hepatectomy for HCC
IT
- Uni-lobar involvement
- No invasion into IVC or PV (actually in QM also do invasion to PV)
- Acceptable liver fx for major hepatectomy
- Child A
- ICG retention 15 min <14%
Indication of liver transplant for HCC
IT
- HCC <5cm single (or HCC <3cm up to 3 nodules)
2. Child C
Indication of TACE for HCC
IT
- Bi-lobe involvement, no distant spread / complete PV obs / IVC involvement
- Uni-lobar involvement but liver fx not acceptable for hepatectomy
Indication for RFA for HCC
IT
- HCC <5cm
- Satisfactory liver fx reserve
- Laparoscopic or open approach for HCC near to viscera
Etiology of HCC
IT
- Hep B (80% of HCC in HK)
- Hep C (in Japan)
- Cirrhosis
- Aflatoxin (in 1960s Africa when food not well preserved)
Milan criteria
1 lesion <5 cm
Up to 3 lesions, each <3 cm
No extrahepatic manifestations
No evidence of gross vascular invasion
