Indications for surgery in Crohn’s disease
Acute complications (abscess, perforation) Persistent local Ileal disease Enterocutaneous fistulae, or internal fistulae Intolerable long term obstructive and other symptoms
Local complications of acute pancreatitis (7)
Fluid collection Pancreatic necrosis Abscess Effusion Pseudocyst Haemorrhage Portal/splenic vein thrombosis
Causes of acute pancreatitis
Idiopathic Gallstones EtOH Trauma Steroids Mumps Autoimmune (PAN) Scorpion Hyperlipidaemia ERCP Drugs
Primary liver tumours
HCC Cholangiocarcinoma Hepatoblastoma Lymphoma Carcinoid Sarcoma
Stuff resected in whipples procedure (x4)
Extrahepatic bile ducts
Duodenum
Distal stomach
Pancreatic head
Teratoma tumour markers (x3)
beta-HCG
CEA
AFP
(ABC in teratoma)
Function of bile
Emulsification of fat into fatty acids for reabsorption, which mainly happens in distal ileum (enterohepatic circulation).
Excretes bilirubin byproduct
Excretes cholesterol
Bilirubin pathway from production to excretion （7)
- Breakdown of Hb in kupffer cells of liver （biliverdin become bilirubin)
- Unconjugated form travels to liver bound to ALBUMIN
- Conjugation with GLUCURONIC ACID, using glucuronyl transferase
- Secreted into gut with bile
- Gut bacteria produce UROBILINOGEN
- Reabsorbed urobilinogen can become urobilin in urine
- Further down gut urobilinogen becomes stercobilin
Bile salts
- What is primary bile salt
- What is secondary bile salt
- What does bile salt do
- Surfactant, produced from cholesterol in the liver by conjunction with GLYCINE or TAURINE. Secreted with bile in duodenum. Cholic Acid and Chenodeoxychic acid.
- Primary bile salts that are deconjugated by bacteria in gut.
- Reabsorbed FA and fat soluble vitamins (forms micelles with FA to facilitate reabsorption at brush border.)
- Average bile flow per day
- Average bilirubin produced per day
- Average bile production per day
- 600-800ml
- 300mg
- 500-1500ml
Effect of right hemicolectomy on bile metabolism
Terminal ileum resected
Reduced bile salt absorption.
- Excess cholesterol in bile, more likely to get gallstones
- Bile salt diarrhoea (colestyramine can chelate bile salts to help this. Cholestatic pruritis is due to bile salt in skin rather than bilirubin)
Ways of draining pseudocyst
- Radiology guided, percutaneous
- Endoscopic through posterior wall of stomach
- Open. Connect pseudocyst with stomach, or jejunum
Complications of chronic pancreatitis
Pancreatic fluid collections Pseudocyst Abscess Fistula Biliary tree obstruction
Malnutrition
Diabetes
2 types of gastric carcinomas
Intestinal - looks like colonic ACC
Diffuse - signet rings, gastric mucous cells
Ulcer definition
Breach in mucosa into submucosa or deeper. Erosion = breach in epithelium only
Pancreatic enzymes
HCO3 - neutralise gastric acid
Lipase - digest fat
Amylase - starch
Peptidases - protein (usually activated by enterokinase in bowel lumen)
