1. Dr Fraser Cameron SHO General Surgery, COCH 8th December 2016
HPB Surgery for Finals
Dr Fraser Cameron
SHO General Surgery, COCH
8th December 2016

2. Overview Gallstones Jaundice Pancreatitis HPB malignancy
Abdominal examination for Finals

3. Gallstones Overview Jaundice Pancreatitis HPB malignancy
Abdo examination for Finals

4. Gallstones - Epidemiology
“Fair, fat , fertile, female, 40”…ACCURATE?
F > M = 2:1
Increases with age
Ethnicity
Genetic predisposition
15% adults have Gallstone disease
80% asymptomatic
20% symptomatic

5. Gallstones – Pathogenesis (i)
Cholesterol Stones (20%)
Bile Pigment stones (5%)
Brown (a/w chronic cholangitis & biliary parasite)
Black (a/w haemolytic disease)
Mixed stones (75%)

6. Gallstones – Pathogenesis (ii)
Asymptomatic
Gallbladder obstruction:
Stone impacted in Hartmann’s pouch
Chemical cholecystitis (water absorbed from bile – becomes more concentrated)
Initially sterile – may become infected from organisms secreted from liver into bile stream.
Movement into CBD:
CBD obstruction – jaundice & proximal duct dilatation
Stone progresses to sphincter of oddi – may affect pancreatic duct causing pancreatitis.

7. Gallstones – Clinical Presentation?
Name this anatomical space?

8. Gallstones – Clinical Presentation
Biliary Colic
Acute Cholecystitis
Chronic Cholecystitis/”Gallbladder dyspepsia”
Obstructive jaundice
Acute Cholangitis
Gallst0ne pancreatitis
Gallstone ileus

9. Gallstones – Ix & Mx S&S Investigations Management Biliary Colic
RUQ pain, N&V
LFTs mildly deranged
US – Gallstones
Analgesia
Lifestyle advice
Lap Chole
Acute Cholecystitis
RUQ pain, Murphy’s +ve
SIRS
Raised CRP/WCC
LFTs normal/deranged
US – thickened GB wall
IV Antibiotics
IV fluids
?”Hot” Lap Chole
PTC
Obstructive Jaundice
Jaundice
Pale stoole/dark urine
+/- RUQ pain
Deranged LFTs
Coagulopathic US
MRCP
ERCP
Ascending Cholangitis
Charcot’s Triad
SIRS – sepsis!!
Deranged LFTS
US +/- MRCP
Lap Chole/PTC
Gallstone Pancreatitis
Epigastric pain
+/- obstructive jaundice
Raised Amylase
?CT
APACHE
Gallstone Ileus
Small bowel obstruction
Abdo X-ray CT
Laparotomy & retrieval of Gallstone

11. Overview
Gallstones
Jaundice
Pancreatitis
HPB malignancy

12. Jaundice - Physiology

13. Jaundice - Classification
Pre-hepatic (haemolysis)
Hepatic (Hepatocellular)
Post-hepatic (Obstructive/Cholestatic)

14. Pre-hepatic Jaundice Congenital abnormalities of RBC structure
Hereditary spherocytosis
Sickle cell disease
Autoimmune haemolytic anaemia
Transfusion reactions
Drug Toxicity

15. Hepatic Jaundice Unconjugated hyperbilirubinaemia
Gilbert’s syndrome
Crigler-Najjar syndrome
Conjugated hyperbilirubinaemia
Infection – viral, bacterial, parasitic
Drugs e.g. paracetamol OD, antipsychotics, Abx
Non-infective hepatitis - ETOH

16. Post-hepatic jaundice
Intraluminal
Gallstones
Blood Clot
Parasites (Flukes)
Mural
Cholangiocarcinoma
Congenital atresia
Sclerosing cholangitis
Biliary cirrhosis – primary (autoimmune), secondary (sepsis)
Traumatic/post-surgical stricture
Extrinsic
Pancreatitis
Tumour – pancreas, ampulla vater
Lymphadenopathy of porta hepatis nodes

17. Jaundice - History Pain? PMH & Family History Foreign travel
Medications/Recreational drug use
History of Gallstones
Alcohol intake

18. Jaundice - Investigations
Simple
Advanced
Reticulocytes, Blood film
Coagulation
Hepatitis Screen
Immunology – ASMA, AMA
LFTS
Ultrasound
MRCP
Liver Biopsy
ERCP

19. Jaundice - LFTS Pre-hepatic Hepatocellular Obstructive
Unconjugated Bili
Increased
Normal
ALP
Increased ++
GGT
Transaminases
LDH

20. Jaundice - Complications
Renal failure (Hepatorenal syndrome)
Biliary infection (Cholangitis)
Deranged Coagulation
Relative immunosuppression & delayed wound healing

21. Jaundice - Management General Medical Surgical Fluid balance
Correct Clotting
Treat infection
Nutrition
Medical
Remove causative agent
Steroids (autoimmune)
Surgical
ERCP
PTC
Resection (Whipples)/Splenectomy
Lap Chole

22. Overview
Gallstones
Jaundice
Pancreatitis
HPB malignancy

24. Pancreatitis - Pathophysiology

25. Pancreatitis - Aetiology
GET SMASHED…
Gallstones & biliary tract disease (40%)
Ethanol (40%)
Toxins & Drugs
Surgery/Trauma (ERCP)
Metabolic
Autoimmune & inherited
Snake bite & infections (Mumps)
Hypothermia
Duodenal obstruction

26. Pancreatitis – Clinical Features
S&S
Complications
Epigastric pain radiating to back
Acute abdomen
Jaundice
Ascites
Grey Turner’s & Cullen’s
Organ Failure:
Respiratory (ARDS)
Cardiovascular
Renal
Acute peripancreatic fluid collections
Pancreatic pseudocyst
Acute necrotic collections
Walled-off pancreatic necrosis

27. Pancreatitis - Diagnosis
Atlanta Classification – 2 of:
Abdominal pain (acute-onset, severe, epigastric, radiating to back)
Serum lipase/Amylase 3x upper limit of normal.
CT/MRI confirming Acute Pancreatitis

28. Pancreatitis –Ix & Mx Investigations Management Biochem/Haem CXR
FBC, CRP, U&E, Amylase, LFT
ABG - lactate
CXR
Ultrasound
MRCP CT
Fluid Resus
Analgesia/Antiemetics
APACHE II
Consider HDU/ICU
Complications – d/w tertiary centre ?drainage/surgery.

29. Overview
Gallstones
Jaundice
Pancreatitis
HPB malignancy

30. Pancreatic Ca. (Ca19-9) 90% ductal adenocarcinoma
Head of Pancreas (65%)
Obstructive jaundice (90%)
Pain (70%)
Anorexia, N&V, fatigue
Hepatomegaly
Body (25%) & Tail (10%)
Usually asymptomatic
Weight loss/back pain
Jaundice – mets/hilar lymph spread

31. Liver malignancy (AFP)
Commonest metastatic
HCC = 90% primary liver ca.
Common in Africa/Asia, M>F
Cirrhosis – chronic HBV/HCV, alcohol
p/w rapid deterioration cirrhosis
Other primary liver tumours:
Fibrolamellar carcinoma (FLC)
Angiosarcoma

32. Biliary Malignancy Cholangiocarcinoma Adenocarcinoma of GB
Usually extrahepatic
Distal CBD, common hepatic, Klatskin tumour
Adenocarcinoma of GB
a/w Gallstones 70%, UC & PSC
Often incidental finding at Lap Chole
Ampullary Ca.
Small & presents early with OJ
Best prognosis

33. HPB malignancy - Management
Curative
Radical resection
Adjuvant chemo
Palliative
Analgesia
Relieve Jaundice
ERCP - stenting
PTC
Relieve Duodenal obstruction - gastrojejunostomy
Embolisation

34. Overview Gallstones Jaundice Pancreatitis HPB malignancy
Abdominal Exam for Finals

35. Take a break…

36. The Perfect Abdo Exam for Finals
Introduction
Inspection
General
Hands
Head
Neck & Torso
Abdomen
To complete my examination….

37. Introduction Wash hands Introduce yourself Patient ID
Explain examination & get consent
Exposure & positioning

38. Inspection General Hands Head Neck & Torso
Clubbing, leuchonycia, koilonychia, palmar erythema, flapping tremor, Dupuytren’s
Head
Conjunctival pallor, jaundice sclera, glossitis/stomatitis, aphthous ulcers, breath odor
Neck & Torso
Virchow’s node, spider naevi (>5), gynaecosmastia, hirsutism

39. Abdomen - Inspection
5 Fs
Know your scars:

40. Abdomen Inspection
Stomas!!
Right/Left?
Contents?
Spouted?

41. Abdomen – Palpation Superficial palpation Deep palpation
Tenderness
Guarding
Rebound tenderness
Deep palpation
Masses
Deep tenderness – Rovsing’s/Murphy’s
Palpate organs
Liver
Spleen
Ballot kidneys
AAA

42. Abdomen - Auscultate Normal Tinkling = ?obstruction
Absent = paralytic ileus/peritonitis

43. To complete my examination…
Thank patient & cover them
“I would take a history, examine hernia orifices, external genitalia and perform DRE”
Urine dip
Summarise & suggest further investigations

44. Top Tips Keep calm & composed Communicate with the patient
Look like you’ve done it before (even if you haven’t!!)
Summarise your findings (hands behind back!!)
Structured answers
If you have a bad station move on & forget it!

45. Thankyou & Good Luck!