Sam Alderson Alina Serafin FY1s SJUH

HPB DISEASE: IN COUNTDOWN TO FINALS

AIMS AND OBJECTIVES

Anatomy Common presentations of RUQ pain and the differential list Management Quiz Help you pass finals!

WHAT IS UNDER THE RUQ??

ANATOMY

CASE 1

45 year old female comes into the Surgical Assessment Unit with acute onset RUQ pain, radiating to the back

What else do you want to know? What could it be?

CASE 1 CONTD

Temp 36.6 Constant Severe pain 3/3 Writhing in pain Similar pain 2/12 ago Examination unremarkable

Investigations? FBC, U&Es, LFTs, Clotting

NAD

AXR, CXR ECG USS

RUQ PAIN

Cholecystitis Duodenal ulcer Hepatitis Pyelonephritis Appendicitis Pneumonia PE

Pancreatitis MI Perforated oesophagus ANYTHING!

BILIARY COLIC
Pain due to gallstones in gallbladder neck Continuous Usually pain settles +/- jaundice

Management: Analgesia USS Elective cholecystectomy

GALLSTONES

What are they made from

Cholesterol

(75%) Pigment: from broken down Hb (<10%) Mixed

Who gets them?

FAT,

FORTY, FEMALE, FERTILE But also: Haemolytic anaemia, Hyperlipidaemia, Crohns

CASE 2
42 year old lady with epigastric, right shoulder and RUQ pain in A&E Lying very still, breathing shallow breaths Sweaty and pale, nauseated

What else do you want to know?

CASE 2 CONTD
Temp 38.0 HR 102, BP 120/80 On examination, focal tenderness RUQ in inspiration RUQ mass palpable WCC 21 CRP 150

What could it be?

ACUTE CHOLECYSTITIS
Obstruction and inflammation of common bile duct Unwell patient with raised inflammatory markers, signs of infection Murphys sign positive

Management: ABC NBM, Access, fluids, analgesia, antibiotics, antiemetics, ?surgery

CASE 3
47 year old lady with RUQ pain, febrile and unwell Shaking in resus Jaundiced

What does she have? What do you need to do?

CHOLANGITIS
Ascending infection of the bile duct Iv fluid resusciation and iv antibiotics

Cefuroxime

and Metronidazole

High mortality

CASE 4
55 year old man comes to A&E, dishevelled and disorientated. Severe epigastric pain radiating to the back Vomiting Sweaty

What more do you need to know? What could it be?

CASE 4 CONTD
Drinker: 70 units/week Never had this before Sitting up relieves pain Jaundiced

PANCREATITIS: CAUSES

GET SMASHED!

GET SMASHED!

Gallstones Ethanol Trauma Steroids Mumps Autoimmune

Scorpion Venom

DO NOT SAY IN OSCE

Hyperlipidaemia, hypothermia, hypercalcaemia ERCP Drugs

PANCREATITIS: SEVERITY
P A N C R E A S
PaO2 <8kPa Age >55 Neutrophils >15 Calcium <2 mmol/L Renal Function (Urea) >16 mmol/L Enzymes: LDH> 600 iu/L, AST >200 Albumin <32 g/L Sugar >10 mmol/L

OH DEAR

You can and review our gentleman:

Lying

still Rigid abdomen, with bruises along his flanks BP 80/50 P 130 RR 30 Sats 98% on air

What do you do?

ABC, ABC, ABC

A B C
Are they talking Vomit? Drowsy, needing adjunct? Rate, sats Trachea, chest sounds

Blood pressure, pulse, temperature, cap refill Urine output

WHAT DO YOU DO?

Nil by mouth Fluids: LOTS! Catheter and strict fluid balance chart Likely to need NG tube Analgesia, antiemetic, LMWH Regular observations ABG USS, ERCP, CT GET HELP

GALLSTONE COMPLICATIONS

Gallbladder
Biliary colic Cholecystitis Mucocele Carcinoma

Common bile duct

Obstructive jaundice Cholangitis Pancreatitis

Gut

Gallstone ileus

QUIZ TIME!

QUESTION 1

What is this? What causes it?

QUESTION 2
What can you see? What % of people have this on X-ray? Name 2 complications

QUESTION 3
What is this syndrome? What duct is being compressed? What causes it?

QUESTION 4

What are they? (1) What are they most commonly made of? (1) What is the most useful diagnostic investigation? (1)

QUESTION 5

What abnormality is shown? (1) How do patients commonly present? (1) What is the prognosis? (1)

QUESTION 6

What is this called? (1) When would you insert this? (1) How could you check correct position? (1)

ANSWER 1
Cullens sign Causes: Acute pancreatitis, ruptured AAA, ruptured ectopic, trauma

ANSWER 2
Gallstones 10% Colic, Cholecystitis, Cholangitis, Pancreatitis, Obstructive jaundice, Mucocoele, Gallstone ileus

ANSWER 3
Mirrizzis syndrome Hepatic duct Chronic cholecystitis, large gallstones

ANSWER 4

Gallstones (1) Cholesterol (1) USS (1)

ANSWER 5

Head of pancreas tumour (1) Painless obstructive jaundice (1) Mean survival < 6 months (1)

ANSWER 6

Nasogastric tube ryles/wide bore (1) Acute pancreatitis/ bowel obstruction (1) Aspirate pH below 6, bilious fluid, CXR (1)