1
Q
What are the 3 types of gall stones and what causes each to form?
A
- cholesterol stones (from excess cholesterol- poor diet, obesity)
- pigment stones (from bile pigment, seen in haemolytic anaemia)
- mixed stones (from cholesterol and bile pigment)
2
Q
give 5 risk factors for gall stones
A
fat forty fertile female familly history pregnancy oral contraceptives haemolytic anaemia malabsorbtion
3
Q
Describe the clinical features of biliary colic
A
- sudden dull colicky pain in RUQ/ epigastric region
- may radiate to the back
- precipitated by consumption of fatty food
- may get N+V also
- no inflammatory signs
- symptoms settle quickly when pain relief started
4
Q
What is biliary colic and acute cholecystitis?
A
Biliary colic is where the gall stone gets stuck in the bladder neck, no inflammatory response.
Acute cholecystitis is when the gall stone is impacted in the cystic duct or common bile duct and causes an inflammatory response.
5
Q
Describe the clinical features of acute cholecystitis
A
- initially may present similarly to biliary colic
- constant epigastric/ RUQ pain
- persists despite pain relief
- signs of inflammation: fever, raised WCC and CRP
- LFT derangement, jaundice, perforation, hepatomegaly if common bile duct blocked
- O/e= RUQ tenderness and murphys sign (pain on inspiration when pressing on RUQ)
6
Q
give 3 differentials for biliary colic and cholecystitis
A
- GORD
- peptic ulcer
- acute pancreatitis
- IBD
- ascending cholangitis
7
Q
How should biliary colic/ cholecystitis be investigated?
A
- FBC and CRP
- U&E (assess for dehydration secondary to reduced oral intake, AKI from sepsis etc)
- LFTs: likley show raised ALP, may get liver failure due to obstruction
- amylase: pancreatitis as differential
- trans abdo USS 1st
- magnetic resonance cholangiopancreatograph (MRCP) if USS inconclusive
8
Q
how is biliary colic managed?
A
- analgesia
- low fibre diet, weight loss and increase exercise
- elective (laparoscopic) cholecystectomy should be offered within 6 weeks of first presentation due to change of recurrence with more severe complications such as pancreatitis
9
Q
How is acute cholecystitis managed?
A
- IV abx: co amoc +/- metronidazole
- fluid resus
- full sepsis 6 if appropriate
- NG tube if pt vomiting
- NBM
- analgesia: usually opioid
- laparoscopic cholecystectomy needed within 1 week but ideally in 3 days
- if unfit for surgery and nor responding to abx, percutaneous cholecystotomy to drain infection
- lifestyle management as recurrence rate is high
10
Q
name and describe 7 complications of biliary colic?
A
- gall bladder empyema: abscess forms following infection, seen on USS or CT, needs laparoscopic cholecystectomy
- Chronic cholecystitis: recurrent or untreated cholecystitis + ongoing RUQ pain, treat w. elective cholecystectomy
- Gall stone ileus: inflammation of gall bladder wall causes fistula to form between gall bladder and duodenum, stone moved into duodenum and obstructs at terminal ileum
- bouvertes syndrome: gall stone moves into duodenum via fistula and causes duodenal obstruction
- obstructive jaundice
- ascending cholangitis
- acute pancreatitis
11
Q
What is cholangitis and what causes it?
A
This is infection of the biliary tract, caused by biliary outflow obstruction (due to gall stone, ERCP or cholangiocarcinoma) and subsequent infection due to fluid stasis and elevated intraluminal pressure. Most common infective organism is e coli, klebsiella and enterococcus
12
Q
Describe the clinical features of cholangitis
A
- RUQ pain + fever + Jaundice = Charcots triad
- RUQ pain + fever + jaundice + hypotension + confusion= Reynolds Pentad
- May also have pruritus (from bile accumulation in tissues), pale stool (bile cannot emulsify the fats), dark urine (conjugated bilirubin not leaving in bile so peed out)
- Often PMH gall stones, ERCP
- Pyrexia, rigors, jaundice, RUQ tenderness, confusion, hypotension and tachy may be present on examination
13
Q
how should cholangitis be investigated?
A
- routine bloods: fbc (often leukocytosis), lft
- blood cultures
- uss shows dilation
- ERCP is diagnostic and therapeutic but many will want an MRCP first anyway
14
Q
How should cholangitis be managed?
A
- sepsis 6
- ERCP with or without spincterotomy and stenting- done ASAP if pt deteriorating
- percutaneous trans hepatic cholangiograph may be used if too sick to tolerate ERCP
15
Q
Give 4 complications of ERCP
A
cholangitis
pancreatitis
bleeding
perforation
16
Q
Where do most cholangiocarcinomas arise from?
A
the bifucation of the left and right hepatic duct
17
Q
Give 3 riskfactors for cholangiocarcinomas
A
- primary sclerosing cholangitis
- UC
- toxins
- alcohol
- diabetes
18
Q
describe the clinical features of cholangiocarcinoma
A
- post hepatic jaundice
- pruritis
- pale stools
- dark urine
- sometimes RUQ pain, weight loss, anorexia and malaise
19
Q
Give 3 differentials for cholangiocarcinoma
A
- obstructive choledochilithiasis
- bile duct strictures
- choledochal cysts
- pancreatic tumours
- primary sclerosing cholangitis
20
Q
How is cholangiocarcinoma diagnosed?
A
- USS
- MRCP for difinative diagnosis
- CT for staging and looking for mets
21
Q
How are cholangiocarciomas managed?
A
- complete surgical resection
- most are inoperable at time of presentation
so palliate with radiotherapy, chemo, ERCP stenting and surgical bypass of obstructions
22
Q
What may cause a liver abscess?
A
- polymicrobial infection from biliary or GI tract (eg ecoli, klebsiella)
- general by contiguous spread or seeding from portal or hepatic veins
- cholecystitis, cholangitis, diverticulitis, appendicitis or septicaemia are commonest causes
- may be after an entamoeba histolytica infection
23
Q
Describe the clinical features of liver abscesses
A
- fever
- rigors
- abdo pain
- +/- boating, nausea, weight loss, fatigue, jaundice
- hepatomegaly and RUQ tenderness O/E
- if it presents with rupture (rare) itll present with septic shock
24
Q
How should suspected liver abscesses be investigated?
A
- fbc, lft (ALP usually raised)
- blood cultures as septicaemia may be cause
- USS initially but CT needed for more information
25
How are liver abscesses managed?
- fluid resus
- stabilisation
- sepsis 6
- iv abx
- drainage via image guided aspiration
- treat cause
- surgery is rarely indicated
- if amoebic abscess= give metronidazole
26
Why do simple liver cysts form
- Thought to be due to congenitally malformed bile ducts which fail to connect to the extra hepatic ducts causing local dilation filled w/ bile fluid
27
Describe the clinical features of liver cysts
- most are asymptomatic
| - may present with anorexia/ early satiety, abdo pain, nausea, hepatomegaly, bloating or fullness due to mass effect
28
How are simple liver cysts managed?
- USS for diagnosis
- cysts >4cm need follow up at 3,6 and 12 months to check for growth
- if unchanged after 2-3 yrs, leave it alone
- if symptomatic or diagnosis is uncertain you can treat with USS guided aspiration or laparoscopic deroofing
29
How is polycystic liver disease diagnosed and what causes it
- >20 cysts in the renal parenchyma that are >1cm
- can be caused by ADPKD (PKD1 mutation)
- or by ADPLD (other mutations, no renal involvement)
30
How is polycystic liver disease managed?
- somatostatin analogues can provide short term relief as they reduce cyst volume
- laparoscopic deroofing or even liver resection if intractable symptoms, inability to rule out malignancy on imaging or to prevent malignancy
- US guided aspiration not routinely done due to fluid re- accumulation
31
How are cystic neoplasms managed?
- LFTs usually normal
- ALP, CAE, CA19-9 may be mildly elevated
- USS can usually differentiate them from simple cysts
- aspiration biopsy should be avoided due to risk of peritoneal seeding
- managed with lobe resection
32
What caused hydatid cysts
tape worm infections
33
How are hydatid cysts managed?
- diagnosis is by FBC showing eosinophilia, positive antibody titres, USS reveals calcified spherical lesions with multiple septations
- asymptomatic and inactive cysts just need monitoring
- surgical deroofing
- anti parasitic dugs
- aspiration not recommended as rupture can cause anaphylactic reactions
34
Describe the aetiology of liver cancer
- 90% are mets from bowel breast pancreas stomach or lung
- 10% are hepatocellular carcinoma
- HPCC arises from chronic inflammation due to viral hepatitis, chronic alcoholism, hereditary haemochromatosis or primary biliary cirrhosis
35
Describe the clinical features of liver cancer
- cirrhosis
- weightloss
- fatigue
- fever
- lethargy
- dull ache in the RUQ is an uncommon presentation but is fairly characteristic of HPCC
- advanced disease may present with ascites, jaundice
- O/e: irregular, enlarged, craggy and tender liver
36
Give 2 differentials for liver cancer
- infectious hepatitis
- cardiac failure (smooth hepatomegaly)
- benign hepatocellular adenoma
- other causes of cirrhosis
37
How should suspected liver cancer be investigated?
- LFTs: AST: ALT>2= likely alcoholic liver disease, if around 1= viral hepatitis)
- FBC (low platelet), clotting (prolonged), alpha fetoprotein (raised in 70%)
- USS: if mass >2 cm and AFP raised-> diagnostic
- CT for further evaluation
- MRI if diagnosis still unsure
- Biopsy or percutaneous fine needle aspiration may be performed to confirm but last resort due to risks associated with tumour seeding and deranged clotting
- MELD and child- pugh scores can be used to predict likelihood of pt tolerating a liver transplant
38
describe management options for liver cancer
- surgical: liver resection if cirrhosis with good baseline health status, transplant if they fufil milan criteria
- image guided ablation: if early HPCC, ultrasound microwave probes are placed in tumour mass to induce necorsis
- alcohol ablation if small inoperable tumour
- transarterial chemoembolisation if large mutinodular tumour
- palliation
39
What factors make up the Glasgow score for acute pancreatitis?
```
pO2<8
Age >55
Wcc >15
Calcium <2
Urea >16
LDH and ast/ alt
Albumin (less than 32)
Glucose >10
```
40
What questions should you ask to assess someone’s dependence on alcohol?
Do you think you need to cut down on the amount you drink
Do you get annoyed when people question you about how much you drink
Do you feel guilt about the amount you drink
Do you need a drink to get you going in the morning
These are main four, 2 positive answers indicate need for further assessment:
Do you need to drink more do get drunk
Can you skip a meal if you’ve been drinking because you’re not hungry
Do you ever need a drink to stop shakes or tremors
Does alcohol affect your ability to remember parts of the day/ night do you drink to take your mind off things or to relax you
Do you drink to feel less lonely
Have you ever made rules to help cut down the amount you drink
Do you get hangovers
Do you underestimate how much you drink when talking to others?
How much do you drink per day
Y3 Surgery
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