Hepatobiliary and Pancreatic Surgery
Liver and portal hypertension
Know the Couinaud segments and that the right lobe is drained by the right hepatic vein. Cirrhosis severity is scored by Child–Pugh (bilirubin, albumin, INR, ascites, encephalopathy) and MELD. Portal hypertension presents with varices, splenomegaly and ascites. Acute variceal bleeding: resuscitate, restrict transfusion, give terlipressin plus antibiotics, and perform endoscopic band ligation within 12 hours; TIPS is rescue or early in high-risk patients.
Biliary tree
Gallstones cause biliary colic, cholecystitis, choledocholithiasis, cholangitis and pancreatitis. Charcot's triad is fever, jaundice and right upper quadrant pain; Reynolds' pentad adds hypotension and confusion. Cholangitis with sepsis needs urgent biliary drainage (ERCP) within 24 hours, not just antibiotics. Mirizzi syndrome is extrinsic compression of the common hepatic duct by a stone in Hartmann's pouch. Post-cholecystectomy bile leak is investigated with MRCP and treated by ERCP stenting.
Pancreas and spleen
Acute pancreatitis is diagnosed by two of three: typical pain, lipase more than three times the upper limit, and imaging. Early management is fluids, analgesia and enteral nutrition; antibiotics are not routine. Necrosis becomes infected after 2–4 weeks; step-up drainage is preferred. Pancreatic head cancer causes painless jaundice and a palpable gallbladder (Courvoisier). Splenectomy indications include trauma, immune thrombocytopenia and hereditary spherocytosis; vaccinate against pneumococcus, Haemophilus and meningococcus.
Rule of thumb
In gallstone pancreatitis, if there is concurrent cholangitis, ERCP is urgent; without cholangitis, wait and treat the stone electively.