Hepatobiliary, Pancreatic and Splenic Disease
Hepatobiliary, Pancreatic and Splenic Disease tests liver anatomy and function, biliary obstruction, pancreatitis, splenic indications, and portal hypertension. Numbers and severity scores drive decisions.
Core rules
- Couinaud: eight segments by hepatic veins and portal pedicles; segment I is the caudate. Calot triangle: cystic duct, common hepatic duct, inferior liver edge; the critical view of safety prevents bile duct injury.
- Acute pancreatitis: Atlanta criteria; diagnose with 2 of 3 (pain, lipase >3× upper limit, imaging). Early care is fluids, analgesia, and antiemetics; antibiotics only for infected necrosis. ERCP for cholangitis or persistent biliary obstruction.
- Splenectomy: trauma with hemodynamic instability, immune thrombocytopenia, hereditary spherocytosis; vaccinate against pneumococcus, meningococcus, and Haemophilus before elective surgery.
- Portal hypertension: Child-Pugh and MELD; acute variceal bleed = octreotide + ceftriaxone + endoscopic band ligation.
Worked example: A cirrhotic patient has bilirubin 2.5 mg/dL, albumin 3.2 g/dL, INR 1.8, mild ascites, and grade I encephalopathy. Child-Pugh: bilirubin 2, albumin 2, INR 2, ascites 2, encephalopathy 2 = 10, class C. Reasoning: each variable scores 1–3; class C predicts high operative risk and poor survival, so avoid elective major surgery and optimize.
Traps: calling pancreatitis idiopathic without ultrasound; giving prophylactic antibiotics in sterile necrosis; forgetting vaccination after splenectomy; misreading Child-Pugh class B as low risk.