Hepatobiliary / Pancreatic Surgery - 4th Year Medic

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gtaang
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244880
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Hepatobiliary / Pancreatic Surgery - 4th Year Medic
Updated:
2013-11-05 14:55:35
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Liver Gallbladder pancreas surgery medicine revision
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HBP learning objectives for general surgery finals
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  1. Pathophysiology of gallstone formation
    • Cholesterol Supersaturation
    • Bile stasis - secondary to fasting, TPN or truncal vagotomy.
    • Increased bilirubin secretion in bile - ++ red cell lysis e.g. spherocytosis or sickle cell disease.
  2. Risk Factors for Gallstone disease
    • Age
    • Female sex
    • Obesity
    • Multiparity
    • Haemolytic disease
    • Long term TPN
    • Previous surgery / disease of distal small bowel
  3. Presentations of Gallstone disease
    • Biliary Colic:
    •              - Intermittent severe epigastric / RUQ pain ; associated with N+V. Resolves within hours.
    • Acute Cholecystitis:
    •              - Severe, continuous RUQ pain ; often radiates to right flank and back. Associated with anorexia and pyrexia. Classically Murphy's sign +ve.
    • Chronic Cholecystitis:
    •              - Repeated episodes of inflammation causes thickening and fibrosis of gallbladder wall.
  4. Investigation in gallbladder disease
    • Bloods:
    •     - FBC - infection
    •     - U+Es - dehydration 
    •     - LFTs - obstruction
    •     - Blood Cultures - infective agent
    •     - Amylase - rule out pancreatitis
    • AXR:
    •     - 10% of stones are radio-opaque
    • Abdominal USS:
    •     - Gold Standard. Identifies stones, determine wall thickness and assess ductal dilatation.
  5. Complications of Gallstone disease
    • Gallbladder:
    •    - Empyema
    •    - Mucocoele
    •    - Carcinoma
    •    - Perforation + Peritonitis
    •    - Carcinoma 
    •    - Fistula
    •    - Mirizzi Syndrome
    • Common Bile Duct:
    •    - Obstructive Jaundice
    •    - Cholangitis
    •    - Pancreatitis
    • Small Bowel:
    •    - Gallstone ileus
  6. Treatment of Gallstone Disease (Surgical)
    • Surgical = Cholecystectomy. Indications:
    •     - Symptomatic gallbladder stones
    •     - Asymptomatic patients at high risk e.g. diabetes, porcelain gallbladder, Hx of pancreatitis.
  7. Risks of Cholecystectomy
    • Conversion to open - 5-10%
    • Bile Duct injury - <1%
    • Bleeding - 2%
    • Bile leak - 1%
  8. Treatment of Gallstone Disease (non-surgical)
    • US/CT guided percutaneous drainage of gallbladder
    • Dissolution therapy*
    • Lithotripsy*
    • *rarely done due to side effects
  9. Anatomy of the Biliary Tree
    Picture
  10. Causes of Obstructive Jaundice
    • Intra-luminal - Gallstones
    • Luminal - cholangiocarcinoma, stricture
    • Extra-luminal - Pancreatitis, head of pancreas tumour, lymph nodes
  11. Investigation of obstructive jaundice
    • Bloods:
    •   - LFTs:
    •      - Bilirubin - raised in obstruction
    •      - ALP - Present in ductal cells, raised in obstruction
    •      - Transaminases - Hepatocellular, raised more typically in hepatitis.
    •   - Amylase - Rule out pancreatitis
    •   - Albumin and clotting factors - check liver synthetic function
    •   - AFP - HCC
    •   - Viral markers
    • Imaging:
    •   - Ultrasound - duct dilation
    •   - CT scan - unaffected by bowel gas or obesity
    •   - Cholangiography - MRCP provides good imaging of biliary tree
  12. Treatment of Obstructive Jaundice
    • Remove cause of obstruction
    •      - ERCP / Intra-operative CBD clearence
    •      - Tumour Resection
    • Stenting CBD
    • Palliative / Curative chemotherapy
  13. Causes of Acute Pancreatitis
    • G - Gallstones
    • E - Ethanol
    • T - Trauma
    • S - Steroids
    • M - Mumps
    • A - Autoimmune (PAN)
    • S - Scorpion Sting
    • H - Hyperlipidaemia / Hypercalcaemia / Hypothermia
    • E - ERCP
    • D - Drugs (Aziathioprine, thiazide diuretics , mercaptopurines)
  14. Classification of Pancreatitis
    • Oedematous (70%)
    • Necrotising / Severe (25%)
    • Haemorrhagic (5%)
  15. Assessing Severity of Pancreatitis
    • Glasgow Imrie Score
    • >2 positive criteria = severe attack
    • Criteria:
    • P - PaO2 <8kPa
    • A - Age > 55
    • N - Neutrophils / WCC > 15
    • C - Corrected Calcium < 2mmol/l
    • R - Raised Urea > 16mmol/l
    • E - Elevated Enzymes - AST > 200, LDH >600
    • A - Albumin <32g/L
    • S - Sugar / Glucose > 10mmol/L
  16. Investigations in Pancreatitis
    • Bloods:
    •      - FBC - check Hb and WCC
    •     - U+Es - check K and Na
    •     - LFTs - bilirubin, albumin and obstructive picture
    •     - Amylase - 3 x upper limit of normal (~300) is DIAGNOSTIC
    •     - Group and save - all surgical patients
    •     - Clotting - all surgical patients
    • Imaging:
    •     - AXR - non-specific
    •     - CT - may be required - shows necrotic / haemorrhagic changes
    •     - Abdominal USS - must be done in  first 48hrs to ID gallstone disease
  17. Treatment of Acute Pancreatitis
    • Urgent ERCP in proven gallstone disease
    • Prevent Complications:
    •     - IV antibiotics can be given in severe disease even in the absence of proven infection
    •     - Consider HDU / ITU
    • Surgical debridement is necessary if necrosis is proven.
  18. Complications of Pancreatitis
    • Local:
    •     - Pancreatic Pseudocyst (25% of cases)
    •     - infection +/- abscess formation
    •     - Haemorrhage
    •     - CBD obstruction
    •     - Progression to chronic pancreatitis
    •     - fistula
    • Systemic:
    •     - ARDS
    •     - MODS
    •     - DIC
    •     - Hypocalcaemia
    •     - Hyperglycaemia
  19. What preventitive measures can be taken in chronic pancreatitis
    • Stop Alcohol
    • Remove gallstones
    • Treat autoimmune disease
    • Encourage anti-oxidant rich diet (ACE vitamins and selenium)
  20. How to control symptoms / complications in chronic pancreatitis
    • Dietary modifications, reduce fat intake
    • Exocrine enzyme supplementation - Creon
    • Analgesia
    • Insulin control of diabetes - may be challenging

  21. Surgical Resection of the Pancreas
    • Whipples - Pancreaticoduodenectomy 
    • Frey's procedure - partial pancreatectomy of head
    • Peustow / Duval - Pancreaticojejunostomy
  22. Risk Factors for Pancreatic Cancer
    • Smoking
    • Increasing age (6th + 7th decades most common)
    • High fat diet
    • Diabetes
    • Alcoholism
    • Chronic Pancreatitis
  23. Presentation of head of pancreas carcinoma
    • Obstructive Jaundice (90%) - Due to compression / invasion of CBD
    • Pain (70%) - Epigastric or LUQ, often vague and radiates to back
    • Hepatomegaly - secondary to metastasis
    • Acute Pancreatitis
    • Thrombophlebitis migrans (10%) - cancer is a hypercoaguable state
  24. Carcinoma of body and tail of pancreas:
    • Asymptomatic in early stages
    • Weight loss
    • Back pain
    • Epigastric Mass
    • Jaundice - secondary to spread to nodes or metastases
    • Diabetes Mellitus
  25. Pathological Classification of Pancreatic Cancer:
    • Ductal Adenocarcinoma (90%)
    • Mucinous Cystic neoplasms (7%)
    • Islet Cell Tumours (3%):
    •     - Insulinoma
    •     - Glucagonoma
    •     - Gastrinoma
  26. Investigating Pancreatic Cancer
    • Bloods:
    •    - FBC
    •    - LFTs
    •    - Blood Sugar
    •    - CA19-9 (tumour marker)
    • Imaging:
    •    - Transabdominal ultrasound
    •    - Helical CT scan of pancreas
  27. Treatment of Pancreatic Cancer
    • 95% are not suitable for surgical resection
    • Relief of jaundice:
    •    - Biliary stenting
    •    - Percutaneous biliary drainage
    •    - Surgical biliary drainage
    • Relief of duodenal obstruction:
    •    - Gastric bypass
    • Relief of pain:
    •    - Oral Morphine (oromorph / MST)
    •    - Chemical ablation of the coeliac ganglia

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