Liver Functions Digestion processing digested food breaking down food and turning it into energy Homeostasis controlling levels of fats, amino acids and glucose in the blood storing iron, vitamins and other essential chemicals manufacturing, breaking down and regulating numerous hormones including sex hormones Immune combating infections in the body clearing the blood of particles and infections including bacteria neutralising and destroying drugs and toxins Blood manufacturing bile Enzymes and proteins - those involved in blood clotting and tissue repair.
Bile Water, Electrolytes, Bile acids, Cholesterol, Phospholipids Conjugated Bilirubin
Liver Function Tests and Bile Albumin General synthetic function + severity of Liver disease Clotting Also synthetic - Prothrombin time (INR) Total Bilirubin Processing function Aminotransferases (AST+ALT) Mitochondrial and cytosolic enzymes – ALT more specific ALP Enzyme in the cells lining the biliary ducts of the liver γ Glutamyl-transpeptidase (GGT) A rough marker of alcohol consumption if ALP is normal
Gallstones 80% - “Cholesterol” Stones Cholesterol supersaturation of bile Proportion to bile salts and phospholipids Crystallisation-promoting factors Bile salt loss in terminal Ileum in Crohn’s Disease Motility of gall bladder 20% - “Pigment” Stones Calcium Bilirubinate Haemolytic Diseases Cause of recurrent stones post cholecystectomy
Risk Factors Increasing age Rapid weight loss Drugs – OCP Ileal disease or resection Diabetes
Presentations/Complications Asymptomatic – Incidental finding In the Gall bladder Chronic Cholecystitis Biliary Colic Acute Cholecystitis Empyema of the gallbladder Biliary peritonitis Abcess Mucocoele Carcinoma of the gallbladder In the common bile duct Obstructive jaundice Cholangitis Pancreatitis
Biliary Colic Spasm pain when the gallbladder contracts against a stone in the Hartmann’s Pouch Epigastrium or RUQ Constant, not in waves Extremely severe – sweaty, writhe around Important Differentials: Perforated peptic ulcer, pancreatitis, ruptured aneurysm
Acute Cholcystitis Usually progression of biliary colic Increased glandular secretion Distension – possible impeding vascular supply Chemical Inflammation Bacterial Infection Murphy’s sign Patients lie still Local Peritonitis Important Differentials: Basal Pneumonia, Intrahepatic Abcess, Perforated peptic ulcer, pancreatitis, ruptured aneurysm
Cholecystectomy Complications General Bleeding Infection Pneumoperitoneum – vagus nerve – decereased cardiac output Specific Bleeding from cystic artery is more difficult to stop haemodynamically Common Bile Duct Injury or stone movement. Bowel Perforation
Common Bile Duct RUQ Pain Fever/Rigors Jaundice
Triad only present in minority Pain is the most common In comparison to jaundice from malignancy the Jaundice fluctuates Fever indicates biliary sepsis
Mild: Enzymatic spillage Inflammatory cascade activation and Localized oedema. Local exudate may also lead to increased serum levels of pancreatic enzymes. Moderate: Increasing local inflammation bleeding, fluid collections and spreading local oedema involving the mesentery and retroperitoneum other organs. Severe: Necrosis Profound localized bleeding and fluid collections Spread to local structures mesenteric infarction, peritonitis and intra- abdominal fat ‘saponification’. A persisting accumulation of inflammatory fluid, usually in the lesser sac, is a pseudocyst, i.e. does not have an epithelial lining.
At admission: Age in years > 55 years White blood cell count > 16x10/l Blood glucose > 11 Serum AST > 200 Serum LDH > 500 Within 48 hours: Calcium < 2 Hematocrit fall > 10% Oxygen PO2 < 8kPa BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration Base deficit (negative base excess) > 4 Sequestration of fluids > 6 L
ERCP Risks Bleeding – especially if Sphincterotomy is concerned Infection – cholangitis in the bile duct. Pancreatitis – 5% Younger patients, Previous post-ERCP pancreatitis Females Procedures that involve cannulation or injection of the pancreatic duct Patients with sphincter of Oddi dysfunction Gut perforation Additional risk if a sphincterotomy is performed. D2 is anatomically retroperitoneal, perforations due to sphincterotomies are also retroperitoneal. Oversedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting. There is also a risk associated with the contrast dye in patients who are allergic to compounds containing iodine.
MRCP Magnetic resonance cholangiopancreatography (MRCP) is a medical imaging technique that uses magnetic resonance imaging to visualise the biliary and pancreatic ducts in a non-invasive manner
3 things I want you to take away 1 2 3 Complications/Presentations Investigations Ranson’s Criteria