Hepatobilier dan Pankreas
Core concepts
Separate hepatocellular from cholestatic injury using the ratio of aminotransferases to alkaline phosphatase, then build a differential. Know viral hepatitis serology (HBsAg, anti-HBs, anti-HBc IgM, HCV RNA), the natural history of cirrhosis, and its complications: ascites, varices, encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome. Understand gallstone disease from biliary colic to cholecystitis to cholangitis (Charcot's triad, Reynolds' pentad) and the role of ERCP. Recognise autoimmune and metabolic liver disease, and pancreatic pathology beyond acute pancreatitis, including chronic pancreatitis and pancreatic cancer presenting with painless jaundice.
Traps
Examiners test the distinction between cholestasis and obstruction: a dilated duct on ultrasound implies obstruction, whereas a non-dilated duct with raised alkaline phosphatase suggests intrahepatic cholestasis. Do not attribute ascites to cirrhosis without diagnostic paracentesis - a polymorphonuclear count above 250 cells/mm³ defines spontaneous bacterial peritonitis. Remember that acute cholangitis needs biliary drainage plus antibiotics, not antibiotics alone.
Worked example
A 62-year-old with fever, right upper quadrant pain, and jaundice has a raised bilirubin and alkaline phosphatase with a dilated common bile duct on ultrasound. Diagnosis: acute cholangitis. Rule of thumb: antibiotics and urgent ERCP for drainage; Charcot's triad plus hypotension or confusion (Reynolds' pentad) mandates immediate decompression.