HEPATOBILIARY NOTES

ACUTE CHOLECYSTITIS

INTRO CF IX MX
Inflammation of the - Pain frequently begins in the • Fbc-leucocytosis • Conservative in delayed cholecystectomy
gallbladder that occurs most epigastric region and then • LFT-ALT,AST n bilirubin rise (Mildly elevated) -NBM, IV fluid
commonly because of localizes to the right upper • Amylase –tro pancreatitis -analgesics
obstruction of cystic duct by quadrant (RUQ)
• Transabdominal US (98% Sensitive) -abx: cefuroxime/gentamicin/cefazolin
gall stone - Fever, anorexia, nausea n (Against gramneg aerobes)
:thickened gall bladder (>4mm), Edema
vomiting
(Double wall sign), acoustic shadow, Murphy • Laparoscopic Cholecystectomy (standard
Types of gallstones - History of Biliary Colic
sign using US of care for surgical treatment of
• Pure cholesterol (10%). previously
Often solitary, large - Pain may Radiate to right • Abd x ray-tro other causes of acute abd (gas cholecystitis – AFTER 6 WEEKS OF ACUTE
(>2.5cm), round. shoulder n tip of scapula (Boas’ under diaphragm) EPISODE (Can be done within first week if
• Pure pigment (bile salts sign) • Abd n CT pelvic- gold standard but only use indicated). Complication : Conversion to
10%). Pigment stones are of - Jaundice (If in certain cases-In cases of emphysematous open, Bile duct injury, Bleeding, Bile leak
two types: Choledocholithiasis / Mirizzi cholecystitis, CT scanning may demonstrate • ERCP (If Stone at CBD)
• Black (associated with syndrome) intramural and intraluminal air within the • If pain and tenderness increased despite
haemolytic disease). - Positive murphy sign GB better than plain abdominal radiography tx -> Rapidly relieve symptoms by
• Brown (associated with (Temporary apnea during can Endoscopic ultrasound (EUS) -guided
chronic cholangitis and inhalation when deep transmural cholecystostomy + Consider
biliary parasites). palpation of RUQ) +/- Palpable Emergency Cholecystectomy
• Mixed (80%). Most tender gallbladder • Endoscopic gallbladder drainage
common; usually multiple.
• Percutaneous drainage

Etiology
Calculous Acalculous
• 90-95% 2ndry to gall stones • Related to bile stasis (critical illness,
• <1% due to tumour obstructing cystic prolong fasting, TPN, sepsis,major
duct surgery, severe burn /trauma)
• RF: 4F (female,fat,forty,fertile)

#MisiLegasi by Md Zaki MBBS240 UITM 11TH BATCH

CLINICAL PRESENTATION OF CHOLELITHIASIS
• Asymptomatic (80%)
- Most do NOT require treatment
- Consider cholecystectomy if: increased risk of malignancy (choledochal cysts, Caroli’s disease, porcelain or calcified gallbladder), sickle cell disease, pediatric patient,
bariatric surgery, and immunosuppression
• Biliary colic (10-25%)
• Cholecystitis
• Choledocholithiasis (8-15%)
• Cholangitis
• Gallstone pancreatitis
• Gallstone ileus (0.3-0.5%)
• Other: Empyema of the gallbladder, liver abscess, and gallbladder perforation with bile peritonitis
Complications of Acute Cholecyctitis
• Mirizzi syndrome: extra-luminal compression of CBD/CHD due to large stone in cystic duct
• empyema of gallbladder: suppurative cholecystitis, pus in gallbladder, and sick patient
• emphysematous cholecystitis: bacterial gas present in gallbladder lumen, wall, or pericholecystic space
(risk in diabetic patient); organisms involved in secondary infection: E. coli, Klebsiella, Enterococcus
• gangrenous gallbladder (20%), perforation (2%): result in abscess formation or peritonitis
• cholecystoenteric fistula, from repeated attacks of cholecystitis, can lead to gallstone ileus
 CHOLEDOCHOLITHIASIS

Intro Clinical Features Investigations Management

Stone in CBD- obstructive • Intermittent abdominal st
1. 1 Line : Transabdominal Conservative- Hydration, stabilize the patient
jaundice (epigastric) pain US-Dilated CBD, Stone, Gall
• Jaundice (Obstructive) Bladder size Definitive: ERCP
Primary- bile stasis • Nausea 2. Gold standard: ERCP • Stenting
Secondary- from gallstone • Vomiting (Diagnostic and • Endoscopic sphincterotomy (ES)-> Endoscopic removal
• Pale stool Therapeutic) of stone-via basket (Dormia basket) or stone
(Hard to differentiate • Dark urine 3. MRCP (diagnostic only) destruction (Lithotripsy)
clinically Biliary colic and • Pruritis • Biopsy
Chole-docholithiasis) • Acute Cholangitis : Supportive : (Complication : Hemorrhage, Acute pancreatitis, Ascending
“Charcot’s Triad” - pain, • LFT-Total infection, Perforation)
Stones in the bile ducts are jaundice and fevers Bilirubin/AST/ALT/GGT
more often associated • Coagulation Profile If ERCP failed - Percutaneous transhepatic cholangiography
with infected bile (80 per PE : (PT/APTT) can be performed to provide drainage and subsequent
cent) than are stones in the - Tenderness in epigastrium and • RP (Bilirubin is nephrotoxic) percutaneous choledochoscopy.
gall bladder right hypochondrium
- Courvoisier’s Law : + PTBD (Percutaneous Transhepatic biliary drainage) –
‘If in the presence of jaundice, the Therapeutic (If jaundice not resolve/ failure of ERCP) but not
gall bladder is palpable, then the curative. Complication : sepsis, tube movement, leakage
cause around the tube, and dehydration
of the jaundice is unlikely to be due
to stone.’ This is due to the fact that Common bile duct exploration required at time of
CBD stones originate in the gall cholecystectomy (laparoscopic or open) if ERCP/PTC fail
bladder which is usually scarred and
fibrotic, preventing distension. Complications
• Pancreatitis
• Cholangitis
• Duodenal perforation
• Stricture
• Bleeding
 ASCENDING CHOLANGITIS

Intro Clinical Features Investigations Management

- Infection of biliary tree Charcot Triad : RUQ pain, Fever, FBC : Leukocytosis - Drainage (Ideally with ERCP) ->If not possible by
Jaundice (50-70%) LFT : Elevated ALP and Bilirubin percutaneous or surgical drainage
Etiology : Blood Culture
- Stasis in the biliary tract Reynolds Pentade (Suppurative Abdominal US : CBD Dilation, - IV Antibiotics : Broad spectrum to cover Gram-negatives,
due to obstruction (Stone) Cholangitis : + Hypotension with Stones Enterococcus, and anaerobes (ampicillin + sulbactam or
or stricture (usually from Altered mental status (High piperacillin/tazobactam)
previous cholecystectomy) mortality)
- Infection originates in the - Hydration (IV Drip)
duodenum or spreads Physical Examination : Tender
hematogenously from the hepatomegaly
portal vein
- E. coli, Klebsiella, Complciation : Septicemia -> Organ
Enterobacter, Enterococcus failure

MIRIZZI’S SYNDROME

- Rare cause of obstructive jaundice

- A gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common bile duct (CBD) or common
hepatic duct, resulting in obstruction and jaundice
- The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis
(inflammation). A cholecystocholedochal fistula can occur
- Occurs in 0.7 to 2.5 percent of cholecystectomies
- Tx: laparoscopic cholecystectomy

EMPYEMA OF GALLBLADDER
- GB fills with pus; sequel of acute cholecystitis or infected mucocele
- Tx: drainage, later cholecystectomy
- Acalculous cholecystitis → patients recovering from major surgery, trauma, burns
 ACUTE PANCREATITIS

INTRO CF IX MX
- Acute condition presenting w - Severe epigastric PAIN (Or at Upper CLINICAL DIAGNOSIS (+ Elevated Mild – Conservative (IV fluid, NBM, Analgesia,
abdo pain, a threefold or greater quadrant or diffuse) -pt breathe shallowly serum amylase level) Antiemetic). NO antibiotic =/- analgesics and
rise in the serum levels of the (Rapidly developed – Within minutes and anti-emetics
pancreatic enzymes amylase or persist for hours, refractory to usual - Serum amylase↑3-4x (but only - Usually self limiting if stone as etiology but
lipase, and/or characteristics analgesic) lasts for 24h) Raised >1000 (If urine need to refer for cholecystectomy (On the same
findings of pancreatic - Radiates to the back (50%) amylase - >1200) admission) to prevent recurrence
inflammation on contrast-
- Exacerbate by movement (50% Relief by
enhanced CT - Serum lipase ↑ (has longer half If Severe
lean forward/ sitting)
life- plus it is more specific + 1. Admit pt
- Etiology : I GET SMASHED - Nausea, vomiting, retching (Can be severe sensitive) –> Mahal 2. Analgesia
✓ Idiopathic and recurrent)
3. Aggressive fluid rehydration
✓ Gallstone/ Biliary calculi - Usually pt drank large amount of alcohol Other test: 4. Oxygenation
(50—70%) be4 the pain develops (If alcoholic etiology) 1. FBC (leucocyte- Ranson 5. Monitor vitals
✓ Ethanol (25%) criteria) 6. Antibiotic prophylaxis can be
✓ Toxins/ Trauma PE : 2. Urine amylase considered
✓ Scorpion/ Snake Bites May appear well or very ill 3. RP 7. CT scan if have signs of organ failure
✓ Mumps/ CMV Tachypnic, Tachycardic 4. Serum Ca (tro
✓ Autoimmune dz (SLE) Mild icterus (Gallstone cause) 8. ERCP FOR SEVERE GALLSTONE
hypercalcemia) PANCREATITIS (within 72h)
✓ Hypercalcemia / Distension due to ileus
5. LFT (Transaminitis suggest 9. Nasogastric drainage
Hyperlipidemia Abdominal Guarding (Not marked rigidity)
gallstone etiology) 10. Supportive therapy
✓ ERCP
✓ Drugs (corticosteroids, If Bleeding (Autodigestion of blood vessel): 6. Serum glucose 11. Nutritional support
azathioprine, - Grey turner sign (Flank) Plain abd Xray (Absent psoas Surgical debridement – Only of proven infected
asparaginase, valproic - Cullens sign (Umbilicus) shadow, ‘Sentinel loop sign’(dilated pancreatic necrosis
proximal jejunal loop adjacent to pancreas
acid, thiazides,
because of local ileus’), ‘colon cut-off sign’
oestrogens) (distended colon to mid-transverse colonwith no
Complication : air distally)
PATHOPHYSIO Systemic (develop WITHIN 1st week) 7. CXR
Obstruction of pancreatic duct(In 1. Shock 8. Transabd USS (Stone,
gallstone) 2. Arrthymias Edematous pancreas)
As the biliary and pancreatic duct 3. ARDS 9. CECT (TRO Differential, in
join to share a common bile duct, 4. Renal failure severe pancreatitis, Organ failure,
obstruction in this passage may 5. DIC Complication )
lead to reflux of bile or activated 6. Ileus
pancreatic enzymes into
7. hypoCa, hyperglycemia, hyperlipid
pancreatic duct
8. Visual disturbances, Confusion
Injury to acinar cell 9. Encephalopathy
↓
Damage duct epithelium Local (develop AFTER 1st week)
↓
Delay enzymatic secretion (READ 1. Acute Peripancreatic fluid collection /
: AUTODIGESTION) Pleural effusion , pancreatitic ascites
↓ 2. Pancreatic abscess
Acute pancreatitis 3. Pancreatic necrosis (sterile and infected)
↓ 4. Haemorrhage
Pancreatic odema, haemorrhage, 5. Pancreatic Pseudocyst (>4 weeks)
necrosis (fat necrosis) 6. Splenic/ mesenteric/portal vessel
↓
thrombosis
Inflammatory mediator release
into circulation causing systemic
complication
How to access severity? 3 scoring type
1. RANSON SCORE
>3 : Severe
LEGAL (Leukocyte, Enzyme (AST), Glucose, Age , LDH),
C-HEPS (Calcium, Hematocrit, O –pco2, Sequestration, Po2

2. GLASGOW IMRIE SCALE

3. REVISED ATLANTA CLASSIFICATION

4. Others include APACHE, SAPS, SOFA and MODS

CHRONIC PANCREATITIS

INTRO CF IX MX
- Progressive inflammatory disease in I) Features of chronic - Serum Amylase : Elevated (in Supportive :
which there is IRREVERSIBLE inflammation : early stages only) - Tx addiction : Stop alcohol and smoking
destruction of pancreatic tissue and • Recurrent/chronic abdominal - Tests of pancreatic function only - Nutrition :
fibrosis (6 WEEKS) PAIN: confirms pancreatic insufficiency ✓ low in fat, high in protein & carbohydrates
- 13 per 100000 prevalence - Site : Epigastric (head of or more than 70% of gland ✓ Pancreatic Enzyme supplement with meals
- M>F (4:1) pancreas), left subcostal and back destroyed ✓ Correct malabsorption of fat-soluble vitamins and
- Mean age of onset : 40 y/o pain (left side of pancreas) vitamin B12
- Dull and gnawing (distressing/ - AXR → pancreatic calcifications
- Etiology : (maybe normal) ✓ Micronutrient therapy (Vitamin C & E,
✓ High ALCOHOL consumption (60- Constant) -> Need opiates
Methionine)
- Worse with food, alcohol - Endoscopic US / Sonographic
70%)
- Assoc with nausea and vomiting
✓ MCT in severe fat malabsorption
✓ Pancreatic duct obstruction from Findings : Presence of stones,
- Can have severe flare up - Abdominal pain (Analgesia- opiate/ celiac nerve block
stricture (post surgery, ERCP), or Visible side branches, cysts,
for intractable pain, eliminate obstructive factor – bile
 pancreatic carcinoma of lobularity, irregular main duct, pancreatic duct obstruction by endoscopic/ surgery)
head/cyst II) Features of exocrine failure pancreatic duct, hyperechoic foci - Correct malabsorption of the fat-soluble vitamins and
✓ Recurrent acute pancreatitis (30%) : and strands, dilatation of main vitamin B12
✓ Tropical pancreatitis : young age, • Anorexia and weight loss (due to pancreatic duct and hyperechoic - Treat DM (Insulin)
DM, Stone formation, in protein malabsorption + margins of main pancreatic duct
developing country Malnutrition).
✓ Autoimmune pancreatitis
(Present of 4 or more highly Surgical :
• Steatorrhoea (due to fat suggestive of chronic pancreatitis) - Tx reversible cause (Eg Whipple for pancreatic ca)
(Primary biliary cirrhosis, Primary malabsorption) : soft, greasy, foul-
sclerosing cholangitis) : diffuse - To overcome obstruction and remove mass lesions
smelling stools that typically float
enlargement of pancreas, - CT/MRI → Cause, outline of the (Relief pain)
on water.
irregular narrowing of main gland, main area of damage / (Eg.
pancreatic duct -> Fibrosis and extent of disease, pre-op planning - Pancreatic duct stricture → stent (used less than 4-6 wks)
stricture
III) Features of endocrine failure - Mass in head of pancreas -> pancreatoduodenectomy or a
: Insulin-dependent DM (due to loss - MRCP/ ERCP → biliary
Beger procedure (duodenum-preserving resection of the
of β islet cells) -> Infection obstruction, state of pancreatic pancreatic head
duct, stricture - If duct marked dilated -> longitudinal pancreatojejunostomy
+ All the complications of acute or Frey procedure)
pancreatitis can occur with
chronic pancreatitis

Hx : Number of Hospital
Treatment (Severity)
Complication :
- Biliary Obstruction
- Gastroduodenal obstruction
- Pancreatic cancer
- Opioid addiction
- Pseudocyst
 PANCREATIC CANCER

INTRO CF IX MX
Top 5 highest cause of cancer death Carcinoma of the head of FBC – Anemia, Thrombocytosis A. If Resectable – Stage 1&2 (10-20 percent
Constitutes 2-3 % of all cancer pancreas (65%) LFT – Elevated ALP, Conjugated only) :
M>F • Obstructive jaundice (90%) – 4P Bilirubin and GGT I) Pre-Requisite : No involvement of liver,
: Painless, Persistent, Pruritic, Serum Amylase can be elevated peritoneal mets, or vasculature (hepatic artery,
Risk Factor : Progressive: (Less than half) SMA, Celiac Artery), no distant LN metastasis
- Age (Peak incidence 65-75 y/o) - due to compression or invasion II) Procedure :
- Black ethnicity / African descent of the CBD U/S abdomen : Pancreatic mass, - Whipple procedure / Pancreatico-
- Cigarette smoking (2-5x), Alcohol - Pruritus, dark urine, pale stool, dilated ducts, liver mets duodenectomy (GB & cystic duct, CBD, head of
- Family history (1st degree relative), Familial steatorrhea pancreas, duodenum, regional LN +/- removal
conditions (Familial Adenomatous polyposis) • Nausea & Vague Epigastric Ca 19-9 (Serum Ca Marker ) : of gastric antrum*) -> Reconstruction (Child’s
- Chronic pancreatitis (5-15x) discomfort/ mild pain – Worsen at - As baseline (sensitivity 90%; operation/Triple Anastomosis):
- Pre-malignant lesion : Pancreatic Intra- night, radiate to back specifi city 70% ) - Pancreatojejunostomy
epithelial neoplasia (Retroperitoneal infiltration) - Response to treatment, Identify - Hepaticojejunostomy
-Others : Lynch syndrome (HNPCC), Peutz- • Constitutional Symptoms : recurrence - Gastrojejunostomy
Jeghers syndrome Anorexia, weight loss, fatigue,
malaise CECT – Extent of tumor and * Pylorus-Preserving Pancreatoduodenectomy
Histology Type : staging (PPPD)
- 90% : ductal adenocarcinoma Advance (Mets) : Upper
- 7% : mucinous cystic neoplasms (mucinous abdominal/back pain, Ascites If CT finding inconclusive : - If Ca of body and tail : distal pancreatectomy
cystadenoma/ cystadenocarcinoma), serous - ERCP with Biopsy +/- Bilary +/- Splenectomy
cystadenoma, and papillary cystic tumour Physical Examination stenting :provides biopsy, relieves
- 3% : Islet cell tumor • Jaundice, Palpable liver jaundice III) Post-op :
• Gall bladder is typically palpable - EUS with Biopsy - Complications → leak from anastomosis,
Location : (Courvoiser’s sign) delayed gastric emptying
- Head of pancreas (Most common) • Thrombophlebitis migrans aka Other test to consider : MRCP, - Adjuvant Chemotherapy with 5-FU
Trousseau sign (10%). Presents as ERCP, Staging laparoscopy - Pancreatic Enzyme replacement
Route : Infiltrate locally along nerve sheath, emboli; splenic vein thrombosis
along lymphatics and hematogenous may lead to splenomegaly in 10% B. Non resectable : Most body/tail tumours are
of patients -> Can lead to varices not resectable (due to late presentation)
Mets : Liver and Peritoneum and caput medusae - Palliative Chemotherapy
• Mets : Hepatomegaly, Sister - Other palliative care :
Mary Joseph Nodule Relieve jaundice - Surgical biliary bypass
(Paraumbilical subcutaneous & treat biliary (Gastrojejunostomy)
mets), Virchow’s Node sepsis - Endoscopic biliary Stent
placed by ERCP
- Percutaneous biliary drainage
+ Onset of DM within previous
by percutaneous transhepatic
year
cholangiography
Improve gastric - Surgical gastroenterostomy
Note : Only Ampulla Ca usually emptying - Duodenal stent
present early with biliary Pain relief - Analgesia (Oral Morphine)
obstruction(Intermittent Jaundice) - Percutaneous Celiac plexus
block
- Transthoracic
Carcinoma of the body (25%) and splanchnicectomy (Division of
tail (10%): splanchnic nerve)
• Usually asymptomatic in the Symptom relief - Enzyme replacement for
& quality of life steatorrhea (Pancreatic
early stages -> Thus present at
enzyme)
advanced stage
- Treat DM
• Unexplained Weight loss and
back pain (60%).
• Epigastric mass.
• Jaundice suggests spread to
hepatic hilar lymph nodes or
metastases.
• Thrombophlebitis migrans (7%).
• Diabetes mellitus (15%).
 PRIMARY BILLIARY CHOLANGITIS / CIRRHOSIS & PRIMARY SCLEROSING CHOLANGITIS

DX PRIMARY SCLEROSING CHOLANGITIS PRIMARY BILLIARY CIRRHOSIS

INTRO - Narrowing of biliary tree (intra and/or extrahepatic bile ducts) from scarring - Chronic inflammation and fibrous obliteration of
intrahepatic bile ductules
Etiology
• Primary/idiopathic (most common) Etiology :
- associated with IBD, more commonly UC, in up to 70% of patients (usually male)
- one of the most common indications for liver transplant Primary : likely autoimmune (associated with Sjögren’s
syndrome, scleroderma, CREST syndrome, RA, thyroiditis)
• Secondary (less common) • affects mainly middle-aged women (M:F = 1:9)
- long-term choledocholithiasis
- cholangiocarcinoma Secondary :
- surgical/traumatic injury (iatrogenic) • Acquired: post-operative strictures, chronic pancreatitis,
- contiguous inflammatory process sclerosing cholangitis, stone in bile duct
- post-ERCP • Congenital: CF, congenital biliary atresia, choledochal
- associated with HIV/AIDS (“HIV cholangiopathy”) cysts
- IgG4-related disease
CF - Often insidious, may present with fatigue and pruritus (Young Adult with mild, non-specific • Often asymptomatic or non-specific symptoms such as
symptoms) pruritus, fatigue
- May present with signs of episodic bacterial cholangitis secondary to biliary obstruction • Chronic: jaundice and melanosis (darkening skin) and
other signs of cholestasis
Complication : Recurrent cholangitis -> Biliary Cirrhosis -> Hepatic Failure , Increased risk of • Osteoporosis
Cholangiocarcinoma • Complication : hepatocellular failure, portal HTN with
variceal bleed, ascites
IX - LFT : Elevated ALP. Others : Elevated bilirubin, AST - LFT : Elevated ALP, GGT -> Bilirubin
- Autoimmune : p-ANCA, Elevated IgM - Autoimmune : Positive anti-mitochondrial antibodies
- MRCP, ERCP (Diagnostic) : Narrowing and dilatations of bile ducts that may result in “beading”, (AMA), Elevated IgM
both intrahepatic and extrahepatic bile ducts. If finding equivocal -> Liver Biopsy (Fibrous - Liver Biopsy (Diagnostic)
obliterationof bilairy tracts) - MRCP : NO bile duct obstruction

- Others : Elevated Serum Cholesterol

MX Endoscopic Sphicterotomy, biliary stent in dominant CBD Stricture • Drugs that treat the underlying disease:
Cholangitis : Antibiotics , Drainage of pus in CBD for Suppurative cholangitis - Ursodiol (usual first line treatment)
 (No specific treatment that can reverse the ductal changes) - Obeticholic acid (particularly if inadequate response to
urosiol)
Definitive : Liver Transplantation • Cholestyramine (for pruritus and hypercholesterolemia)
MRCP at least annually for early detection of cholangiocarcinoma • Calcium and vitamin D for low bone density;
bisphosphonates if osteoporosis severe
• Definitive : Liver transplant

BENIGN LIVER TUMOR

HEMANGIOMAS (CAVERNOUS) FOCAL NODULAR HYPERPLASIA HEPATIC ADENOMA

Most common benign hepatic tumor Focal overgrowth of functioning liver tissue - Benign glandular epithelial tumor, Rare
Abnormal plexus of vessels from malformation of Unknown etiology - RF : Female, Age 20-50, Estrogen(OCP, Pregnancy),
angioblastic fetal tissue Female, Age 20-50 Obesity
F>M CF : Asymptomatic - Have malignant potential
CF : Asymptomatic, DIVC if giant Ix : CT Scan – Solid,vascular tumor mass with central - CF : Asymptomatic (25% - RUQ Pain, Mass)
IX : stellate scar (+MRI, biopsy). Can hard to distinguish - Ix : CECT / MRI (Well Circumscribed, vascular solid
- CECT (well-demarcated hypodense mass with with adenoma/ fibrolamellar HCC tumor, normal surrounding liver tissue), Liver biopsy if
peripheral enhancement on arterial phase with Tx : None in doubt
centripetal filling on delayed phases) - Tx : Stop steroid/ OCP, Excise if large (>5cm) -> Risk of
- U/S (homogenous hyperechoic mass) HCC and Bleed
- Avoid percutaneous biopsy (Bleeding)
Tx : None

HEPATOCELLULAR CARCINOMA

INTRO CF IX MX
rd
3 leading cause of cancer Commonest presentation : Rapid AFP : >500ng/mL CURATIVE
death worldwide deterioration in pre-existing cirrhosis LFT : Elevated ALP and bilirubin - Hepatic Resection (Partial Hepatectomy – remove
M>F (CLD symptoms + Weight loss) affected tissue with 1-2cm of normal tissue margin):
Risk Factors : US : Liver parenchyma High mortality rate in patient with liver cirrhosis
- Liver Cirrhosis - RUQ discomfort, right shoulder pain Needle Biopsy : Confirm HCC - Liver Transplant (May use bridging therapy while
- Aflatoxin exposure, - Jaundice, weakness, anorexia, Triphasic CT (enhancement on awaiting transplant)
Contraceptives weight loss arterial phase and washout on portal
- Hepatomgealy, Hepatic bruit/ venous phase) : Local spread, Lymph PALLIATIVE (Unresectable/Advanced)
Spread : Local invasion, Portal friction rub node, Metastasis - Non-surgical method/ Local ablative therapy :
vein , Hepatic vein (Distant - Ascites with blood radiofrequency ablation, percutaneous ethanol
mets – Lung,Bone, Brain) - Paraneoplastic syndrome Other ix : Bone scan, Indocyanine injection, transcatheter arterial chemoembolization
(hypoglycemia, hypercalcemia, Green (ICG) clearance test in cirrhosis (TACE), chemotherapy and radiotherapy
erythrocytosis, and watery diarrhea) patient
Metastatic Liver Cancer :
- Most common Liver ca
- Common organ : (GIT most common) pancreas, colon, stomach, oesophagus, and breast
- Tx depends on primary cancer site and prognosis (Often liver metastases are a manifestation of
Stage IV disease, and chemotherapy is indicated)
- Hepatic resection of metastatic colorectal liver mets is possible

Uncommon tumor : Fibrolamellar carcinoma (FLC).

• Usually affects younger patients (3rd and 4th decades).
• Does not occur on a background of liver disease.
• Presents as a large vascular mass.
 CARCINOMA OF THE GALL BLADDER

INTRO CF IX MX
Very Rare Late onset presentation (Come with advance disease) US : mural thickening, CURATIVE (<10%) :
- Non-specific RUQ pain, Palpable RUQ mass (Can mimic calcification, loss of interface - Surgical Resection + Regional
Risk Factors : chronic symptomatic symptoms of biliary colic / Cholecystitis -> Often diagnosed between gallbladder and liver lymph nodes dissection
gallstones (70% of cases), old age, incidentally as unexpected finding during or after
female, gallbladder polyps, porcelain cholecystectomy for ‘benign’ disease) CT Scan : polypoid mass, mural PALLIATIVE (Majority) :
gallbladder, chronic infection - Jaundice, Weight loss, malaise (Late) thickening, liver invasion, nodal - Obstructive jaundice can be
(Salmonella, Helicobacter), IBD involvement, and distant relieved by endoscopic and/or
Obey Courvoisier’s Law : Painless palpable Gall Bladder Metastases percutaneous methods
Majority type : Adenocarcinoma (90%) (Late sign)
MRI/MRCP : Benign vs Poor prognosis : Median
Local Invasion : Liver, stomach , duodenum Malignant Polyps survival less than 6 months
Distant Mets : Liver, Lung, Bone Percutaneous biopsy

CARCINOMA OF THE BILE DUCT (CHOLANGIOCARCINOMA)

INTRO CF IX MX
Malignancy of extra- and intrahepatic bile duct Early : Non specific LFT : Obstructive features CURATIVE (<10%) :
Rare, but incidence increasing (abdominal pain, early (Elevated bilirubin, ALP, GGT) - Surgical Resection (excision of a
satiety, anorexia and weight lobe of the liver and reconstruction
Site : Billiary Confluence / Klatskin Tumor / Hilar loss) Ultrasound, MDR-CT or MRCP of the biliary tree)
Cholangiocarcinoma (60%), Distal Bile duct (20-30%), scanning : Define level of biliary
Intrahepatic (10-20%) Physical Examination : obstruction, determine PALLIATIVE (Majority) :
Jaundice, Cachexia, palpable locoregional extent of disease, - Obstructive jaundice can be relieved
Risk Factors : Gallstones, ulcerative colitis, primary sclerosing gall bladder mets by biliary stent endoscopic (ERCP)
cholangitis, choledochal cyst, Clonorchis sinensis & and/or percutaneous (PTC) methods
Opisthorchis Viverrini infection (liver fluke), chronic Direct cholangiography using ERCP
intrahepatic stones (hepatolithiasis) or PTC : Can place biliary stents Poor prognosis : 90 per cent dead in
one year from liver failure or biliary
Type : Adenocarcinoma sepsis
 SPLENECTOMY
INDICATION COMPLICATION
- Splenic trauma (most common reason for splenectomy), hereditary A. Short-term
spherocytosis, primary hypersplenism, chronic immune thrombocytopenic - Injury to surrounding structures (e.g. gastric wall, tail of pancreas)
purpura (ITP), splenic vein thrombosis causing esophageal varices, splenic - Post-operative thrombocytosis, leukocytosis
abscess, thrombotic thrombocytopenic purpura (TTP), and sickle cell - Thrombosis of portal, splenic, or mesenteric veins
disease - Subphrenic abscess

Mnemonic - SHIRTS B. Long-term

Splenic abscess/splenomegaly - Post-splenectomy sepsis (encapsulated organisms): 4% of splenectomized patients
Hereditary spherocytosis (highest risk in those <16 yr old) -> Need prophylaxis with vaccinations, ideally 2 wk pre-
Immune thrombocytopenic purpura or post-operative (pneumococcal, H. influenzae, and meningococcus)
Rupture of spleen - Splenosis: intra-abdominal “seeding” of splenic tissue during removal
Thrombotic thrombocytopenic purpura
Splenic vein thrombosis

LIVER ABSCESS
INTRO CF IX MX
A. Pyogenic : Pyogenic : Anorexia, fevers In general : Leukocytosis, Elevated liver enzymes Pyogenic - Antibiotics (Penicillin/ 3rd
and malaise, accompanied gen Cephalosporin, aminoglycoside
Risk Factors : elderly, diabetics and the by right upper quadrant A. Pyogenic : and metronidazole) and ultrasound-
immunosuppressed discomfort - US and CT Scan : multiloculated cystic mass guided aspiration

Etiological Agent : Streptococcus milleri, Amoebic : Dysentery + - Aspiration for culture and sensitivity : Amoebic : treated empirically with
Escherichia coli, S. faecalis, Klebsiella and Fever, anorexia and weight Confirmatory metronidazole (400–800 mg, three
Proteus vulgaris (mixed growths are common) loss + RUQ pain times a day, for 7–10 days). Open
B. Amoebic : isolation of the parasite from the drainage of abscess if fails to
B. Amoebic : Entamoeba Histolytica, spread via + Hepatomegaly, Jaundice liver lesion or the stool and confirming its nature response to antibiotics
fecal-oral route by microscopy. Liver US also can be done

“Great things happen to those who don't stop believing, trying, learning, and being grateful.”