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Hepatobiliary Joshua Macarthur and Eric EaglesContents 1. Background anatomy and science 2. Jaundice 3. LFTs 4. Biliary colic 5. Acute cholecystitis 6. Acute cholangitis 7. Primary biliary cirrhosis 8. Primary sclerosing cholangitis 9. Malignancy 10.CasesBiliary Tract ● Functions: ○ Removes waste from the liver and delivers it to duodenum ○ Emulsifies fats ○ Transport for pancreatic enzymes ● Calot's triangle: ○ Borders ■ Medial - common hepatic duct ■ Inferior - cystic duct ■ Superior - inferior surface of the liver ○ Contents: ■ Right hepatic artery ■ Cystic artery ■ Lymph node of lundHaemaglobin Metabolism 1. Macrophages in spleen and bone phagocytose RBCs. 2. Haem is converted to biliverdin → unconjugated bilirubin. 3. UC bilirubin is released into the blood and binds to albumin. 4. In the liver, UC is conjugated with glucuronic acid to produce conjugated bilirubin. 5. Excreted into the bile and broken down by GI bacteria into urobilinogen. 6. 90% urobilinogen → stercobilin 7. 10% urobilinogen → urobilin 8. Stercobilin → excreted into (brown) faeces 9. Urobilin → excreted into (yellow) urineCauses of Jaundice ● Prehepatic: ○ Increased unconjugated bilirubin ○ Increase hb breakdown ● Intrahepatic: ○ Hepatocellular dysfunction ○ Chronic leads to biliary obstruction ● Posthepatic: ○ Biliary obstructionLiver Function Tests (LFTs) Pre-hepaticHepatic Post-hepatic 1. Is bilirubin high? (hepatocellular damage)(cholestasis) 2. Compare ALT and ALP: ALT/AST Normal ↑ normal/mi↑d ○ >10 fold-increase in ALT ALP/GGT Normal ↑ ↑↑ and <3 fold-increase in ALP = hepatocellular Conjugated bilirubiNormal ↑ ↑ injury Unconjugated bilirubin Normal ○ <10 fold-increase in ALT ↑ ↑ and >3 fold-increase in Albumin Normal Normal ↓ ALP = cholestasis Urobilinogen ↑ ↓ Absent 3. If ALT is increased, check GGT. Stercobilinogen ↑ ↓ AbsentCholelithiasis (Gallstones) Presentation Treatment Complications of Gallstones ● Biliary colic ● Analgesia (NSAID) ● Acute cholecystitis ● Triggered by eating ● 30 minutes - 8 hours duration ● Cholecystectomy ● Acute cholangitis ● ERCP ● Obstructive jaundice ● N/V ● Pancreatitis Risk factors (4 F’s) Post-cholecystectomy syndrome: ● Female ● Diarrhoea ● Nausea ● Fat ● Indigestion ● Intolerance of fatty foods ● Forty ● Epigastric/RUP pain ● Flatulence ● Fair Investigations ● Obs ● Abdominal examination - Murphy’s sign negative ● FBC, LFTs, CRP ● Abdominal USS Acute Cholecystitis Presentation ● RUQ pain (radiation to right shoulder) ● N/V ● Fever ● Tachycardia/tachypnoea Treatment Risk factors ● Nil by mouth ● Female ● IV fluids ● Fat ● Antibiotics ● Forty ● NG tube if required for vomiting ● Fair ● Cholecystectomy (within 72 hours of admission, 6-8 wks in cases Investigations of severe inflammation) ● Obs Complications ● Abdominal examination - Murphy’s sign positive ● FBC, U&Es, LFTs, CRP ● Sepsis ● Abdominal USS ● Gallbladder empyema/gangrene ● PerforationAcute Cholangitis Presentation Management: ● NIL by mouth Investigations: ● Sepsis six: ○ Senior input ● Obs ○ 3 in: ○ 3 out: ● Sepsis six ■ Oxygen ■ Bloods/cultures ● FBC, U&Es, LFTs, ABG, blood cultures, ■ IV abx ■ IV fluids (Hartmann’s) ■ Lactate CRP, coagulation panel ■ Urine ● Abdominal exam ● Imaging: ● ERCP: ○ Sphincterotomy ○ Biliary stenting ○ TA USS ○ Stone removal ○ CT ○ Biospy ○ MRCP ○ Balloon dilatationLots of similar sounding words…Round up ● Gallstones can cause “colicky pain” : BILIARY COLIC ○ This is a temporary obstruction of the gallbladder ● Prolonged obstruction of cystic duct : ACUTE CHOLECYSTITIS ● Obstruction of common bile duct : ACUTE CHOLANGITISPrimary Biliary Cirrhosis Presentation ● Abdo pain ● GI disturbance ● Xanthelasma & xanthoma ● Fatigue ● Pruritus (bile acids) ● Jaundice (bilirubin) ● Signs of cirrhosis/failure Risk factors ● Middle aged women Treatment ● Autoimmune disease ● Rheumatoid conditions ● Ursodeoxycholic acid Investigations ● Colestyramine ● Liver transplant at end stage ● Obs ● Abdo exam (ascites, splenomegaly, spider naevi) ● Immunosuppression ● FBC, LFT, U&E, ESR ● Autoantibodies: Anti-microbial & anti-nuclear Complications ● Liver biopsy for Dx & staging ● Advanced liver cirrhosis ● Portal hypertensionPrimary Sclerosing Cholangitis Risk factors ● Ulcerative Colitis ● 30-40 ● Male ● FHx Investigations ● Abdo exam: hepatomegaly & cirrhosis signs ● LFTs : cholestatic picture of deranged ALP ● MRCP GOLD STANDARD Dx Treatment ● Liver transplant ● ERCP: endoscopic retrograde cholangio-pancreatography ● Colestyramine Complications ● Acute bacterial cholangitis ● Cholangiocarcinoma in 10-20% ● Cirrhosis & liver failure ● Fat soluble vit. Deficiencies (biliary strictures)Malignancy: Cholangiocarcinoma Adenocarcinoma of bile ducts Treatment: ● ERCP to relieve obstruction Presentation ● Possibly curative surgery… ● Obstructive jaundice likely palliative (later stage when ○ Pale stools symptoms arise) ○ Dark urine ○ Pruritis ○ Chemo ● Weight loss (CA) ○ Radio ● RUQ pain ● Palpable gallbladder ● Hepatomegaly Risk factors ● UC→Primary sclerosing cholangitis→CC ● Liver flukes (parasite) Investigations ● CT/MRI imaging + histology = Dx ● CA 19-9 tumour marker ● MRCP assess any obstructionHave a go! A 63-year-old man is admitted with obstructive jaundice that has developed over the past 3 weeks. He was previously well and on examination has a smooth mass in his right upper quadrant. A) Carcinoma of the head of the pancreas B) Chronic cholecystitis C) Cholangiocarcinoma D) Primary biliary cirrhosis E) CholelithiasisHave a go! A 63-year-old man is admitted with obstructive jaundice that has developed over the past 3 weeks. He was previously well and on examination has a smooth mass in his right upper quadrant. A) Carcinoma of the head of the pancreas B) Chronic cholecystitis C) Cholangiocarcinoma D) Primary biliary cirrhosis E) Cholelithiasis Courvoisier's law: Pancreatic CA is more common than cholangiocarcinomaHave a go! A 51-year-old woman presents with recurrent episodes of epigastric pain radiating through to her back, typically brought on by eating a heavy meal. She drinks around 20 units of alcohol per week. During the current episode she noticed that her sclera were yellow. A) Chronic cholecystitis B) Common bile duct stones C) Primary biliary cirrhosis D) Acute cholangitis E) Primary sclerosing cholangitisHave a go! A 51-year-old woman presents with recurrent episodes of epigastric pain radiating through to her back, typically brought on by eating a heavy meal. She drinks around 20 units of alcohol per week. During the current episode she noticed that her sclera were yellow. A) Chronic cholecystitis B) Common bile duct stones C) Primary biliary cirrhosis D) Acute cholangitis E) Primary sclerosing cholangitis Tricky question! Epigastric pain throws people away from gallstones, don’t be fooled! Although there is jaundice, there is no fever and so this is not acute cholangitis. Hence this is BHave a go! A 72-year-old man is investigated for jaundice and weight loss. He has a history of ulcerative colitis and primary sclerosing cholangitis. Bloods show the following: A) Carcinoma of the head of the pancreas B) Acute cholecystitis C) Cholangiocarcinoma D) Primary biliary cirrhosis E) Bile duct strictureHave a go! A 72-year-old man is investigated for jaundice and weight loss. He has a history of ulcerative colitis and primary sclerosing cholangitis. Bloods show the following: A) Carcinoma of the head of the pancreas B) Acute cholecystitis C) Cholangiocarcinoma D) Primary biliary cirrhosis E) Bile duct stricture UC & PCS w/ weight loss heavily implies Cholangiocarcinoma. Bloods show and an obstructive pictureHave a go! A 55-year-old man with a history of gallstone disease presents with a two day history of pain in the right upper quadrant. He feels 'like I have flu' and his wife reports he has had a fever for the past day. On examination his temperature is 38.1ºC, blood pressure 100/60 mmHg, pulse 102/min and he is tender in the right upper quadrant. His sclera have a yellow-tinge. What is the most likely diagnosis? A) Biliary colic B) Acute cholecystitis C) Acute cholangitis D) Primary biliary cholangitis E) Primary sclerosing cholangitis F) Man-flu, classic psychosomatic illnessHave a go! A 55-year-old man with a history of gallstone disease presents with a two day history of pain in the right upper quadrant. He feels 'like I have flu' and his wife reports he has had a fever for the past day. On examination his temperature is 38.1ºC, blood pressure 100/60 mmHg, pulse 102/min and he is tender in the right upper quadrant. His sclera have a yellow-tinge. What is the most likely diagnosis? A) Biliary colic B) Acute cholecystitis C) Acute cholangitis D) Primary biliary cholangitis E) Primary sclerosing cholangitisThank you so much! Any questions?