Download presentation
Published by十 何 Modified over 7 years ago
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!
Similar presentations
© 2025 SlidePlayer.com Inc.
All rights reserved.