Hepato Biliary Flashcards
What are the high-risk features and worrisome features for IPMN
HIGH RISK FEATURES
- Jaundice
- Main duct >10mm diameter
- Enhancing solid component
WORRISOME FEATURES
- Pancreatitis
- cyst >3cm
- wall enhancement
- non-enhancing mural nodule
- Duct 5-9 mm
- abrupt calibre change in duct with distal pancreatic atrophy
- Lymphadenopathy
What are EUS features concerning for malignancy in IPMN?
Main duct IPMN
- duct >7 mm
- Mural nodule >10mm
BD-IPMN
- Cyst >3cm with thick septa
- Mural nodule >10 mm
These patients should then be considered for surgery
Imaging features of solid liver lesions
HEMANGIOMA
- Noncon - Hypoattenuating
- Arterial - peripheral filling in
- PV - centripetal fill in
FNH
- Central scar
- Feeding arteriole
Adenoma
- Non-con - Hypoattenuating / isointense
HCC
- Arterial phase - rapid enhancement
- PV phase - washout
- U/S duplex - peritumoral vessels
Cholangio/colorectal mets
- non-con- hypoattenuating
- PV - may have minor peripheral enhancement
What are the predictive factors for variceal bleeding?
Endoscopic factors
- Location - intragastric varices > gastroesophageal varices
- Size
- small (straight)
- Medium (<1/3rd of lumen)
- Large (>1/3rd of lumen)
- Presence of red signs (wale, cherry spot, blood blister)
- variceal pressure (>12mm hg, exponential risk increase after 15)
Patient factors
- Disease severity (Childs score / MELD)
- Previous bleeding
What are the features of liver cystadenomas? How would you treat it?
These are rare cysts that are filled with mucin and have a thick wall with nodularity/septations/projections.
Females in 50s (similar to mucinous cystadenomas in pancreas)
Diagnosis - CT/MR/US
Differential - hydatid cyst/ cystadenocarcinoma
Treatment - complete excision due to malignant potential
Outline the complications of acute pancreatitis
Early
- Local
- Peripancreatic fluid collection -> pseudocyst
- Necrotic collection -> WON
- Gastric outlet obstruction
- Splanchnic venous thrombosis (treat only symptomatic patients i.e. hepatic symptoms or SB symptoms with splenic V or SMV thrombus – optimise management of panc, start anticoagulation)
- Colonic necrosis
- Systemic
- Exacerbation of pre-existing disease
- Transient (<48hrs) and persistent organ failure (>48 hrs)
- SIRS
- DVT/PE
Late
- Pseudocyst
- Chronic pancreatitis
Causes of portal hypertension
Prehepatic
- PV thrombosis
- Splenic V thrombosis
- PV fibrosis
- PV blockage by infiltrative lesions
- Splanchnic AV fistula
Intrahepatic pre-sinusoidal
- Schistosomiasis
- Primary biliary cholangitis
- Primary sclerosing cholangitis
- Intrahepatic portal vein obstruction
- Sarcoidosis
Sinusoidal
- Cirrhosis
- Amiodarone
- NAFLD
Post Sinusoidal
- Budd-Chiari syndrome
- Radiation injury
- Sarcoidosis
- IVC obstruction
- constrictive pericarditis
NAFLD - types, management
Types
- NAFL - asymptomatic and no inflammation
- NASH - fatty liver with inflammation
Diagnosis
- confirm fatty liver with imaging
- rule out other causes - alcohol, chronic liver disease
Treatment
- lifestyle
- weight loss
- avoid alcohol
- prophylactic
- Immunize for hepatitis
- DM control
- specific
- lipid lowering
- Elastography to rule out fibrosis
- liver biopsy to rule out cirrhosis, monitor for HCC if cirrhosis and transplant
Salient features HC adenoma
HCA are benign tumours containing liver parenchymal tissue only (no biliary radicals, Kupffer cells, portal radicals)
aetiology and incidence
- females 20-40 yrs
- OCP use
- anabolic steroids
- metabolic disorder like DM, glycogen storage disorder
clinical features
- abdo pain
- may rupture (if >5cm)
- malignant transformation (male, metabolic disorder, beta catenin +, >5cm)
Investigation
- CT may show rim enhancement with centripetal enhancement. May be isodense in portal venous phase
- AFP -ve
- ?molecular testing for beta catenin if planning for surveillance – large beta catenin +ve may need excision
treatment
- resect if
- male
- metabolic disorder
- >5cm and beta catenin +
- not regressing despite cessation of ocp
- possibly resect
- women >5cm
- non-operative
- women <5cm - stop OCP and look for regression
- May present acutely with rupture and hemodynamic instability - attempt embolization followed by resection later.
What are the definitions of variceal bleeding in terms of time line
Bleeding episode is defined as atleast 2 units transufusion plus:
- Systolic <100mm
- tachycardic >100
- Postural drop of 20 mm
Acute bleed - within 5 days of presentation
Treatment failure - rebleed <5days
Early rebleed - 5 days - 6 weeks
late rebleed - > 6 weeks
Outline the management of bleeding oesophageal varices
Management can be broadly classified under the following categories:
- Resuscitative and temporising measures
- Pharmacologic
- Endoscopic
- Interventional
- Surgical
RESUSCIATION AND TEMPORISING MEASURES
- Airway and O2
- hemodynamic resus
- correct coagulopathy
- Antibiotics (ceftriaxone 1g x 7 days)
- Balloon compression
- Intubate before starting
- Check position with fluoroscopy before full balloon inflation
- can be left in situ for 24-48 hrs before necrosis
- start with oesophageal pressure 35-40 mmhg, once bleeding stops bring down by 5 mm to 25 mm
- Can be repeated if bleeding restarts
Pharmacology
- Terlipressin 2mg iv q 4hrs
Endoscopy
- Within 12 hrs of admission
- EVL better than sclerotherapy
- Cyanoacrylate better for gastric varices
- If rebleeding occurs - repeat once more then go to TIPS or surgery
INTERVENTIONAL
- TIPS if no contraindication
- Attempt after 2 failed endoscopic attempts
SURGICAL (50% mortality due to encephalopathy, sepsis and renal failure - hence TIPS is favoured)
- Shunt
- Nonselective (portocaval shunt) - quickest but most encephalopathy
- Selective (distal splenorenal)
- Partial non-selective (portocaval interposition graft - decompresses portal system and allows hepatic flow)
- Non-shunt
- Oesophageal transection and reanastamosis after ligation of varices
- Devascularization of GEJ (Sugiura procedure)
features of hemangioma (liver)
females 40 50yrs
>4cm giant haemangioma
CT - hypodense precontrast - centripetal spread of enhancement post contrast
MRI better than CT
Do not biopsy - bleeding.
Kasabach-merritt syndrome - giant haemangioma with consumptive coagulopathy
Treatment -
- <4cm none
- >10 cm consider excision
- 4-10 cm weigh risk-benefit
- Acute presentation with bleeding is very rare - consider embolization
What are the contraindications for TIPS?
TIPS is used in to treat variceal bleeding.
Absolute contraindications
- Heart failure
- Pulmonary HTN
- TR
- Severe sepsis
Relative contraindications
- Liver cancer, particularly central
- thrombocytopenia / coagulopathy
- Portal vein thrombosis
for IPMN that are not being resected, how would you follow up?
Clinical follow-up
- yearly review
- abdo pain
- jaundice
- wt loss
- pancreatitis
Imaging
<1cm cyst - 2-3 yrly CT/MR
1-2 cm cyst - annual CT/MR x2 and then lengthen interval
2-3cm - 3-6 EUS then lengthen interval with alternating MR–> consider surgery instead
>3cm - 3-6 monthly EUS alternating with MR -> considr surgery instead
Note: tumor markers are currently not recommeded for follow up.
What are the rates of invasive cancer in IPMN?
Main duct IPMN - 50-70%
BD-IPMN - 10-15%
Investigation for portal hypertension
If a patient has risk factors for PH (cirrhosis) and clinical manifestations (e.g ascites, varices) then investigations are not needed. Otherwise:
- HVPG >5mmHg
- US scan
Ascites
splenomegaly
nodular liver
portal vein diameter >13 mm
Portal flow velocity <12cm/sec
porto-systemic collaterals
Transient elastography
PLUS tests to determine the cause
porto-systemic collaterals
Transient elastography
PLUS tests to detremine the cause
Indications for surgical intervention in IPMN
Must resect
- all IPMN with high risk features
- MD-IPMN 5-9mm with worrisome features
- MD/BD IPMN with EUS-FNA suggestive of malignancy
Probabaly resect
- BD-IPMN with worrisome features in young patient
- >2cm cyst in young patients
- BD_IPMN cyst enlarging by >2mm/yr
Surgical options depend on location of tumor(s), but intra-op frozen section confirming negative margin for high grade dyplasia/malignancy is needed.
options are enucleation (BD-IPMN), distal panc, pancreaticoduodenectomy, total panc (multiple tumor)
What are simple liver cysts, differentials, when and how would you treat them?
No septations, contain serous fluid, do not communicate with biliary tree.
Diagnosis - CT / US
Differential
- Cystadenoma (thick wall)
- Hydatid
- metastatic NET
Treatment - only if symptomatic or diagnostic uncertainty
- non-operative - aspiration/sclerosant injection
- Surgical - fenestration and deroofing of extrahepatic portion
Severity assessment of pancreatitis
There are several ways to assess severity of pancreatitis. I use the Multiple organ dysfunction score as advised in the consensus Atlanta classification. Other methods like Glasgow score, CRP are also widely used.
Timing - On admission, and then at 24 hrs, 48 hrs and 7 days)
Mild
- No organ failure
- No local complication
Moderate
- Transient organ failure (<48 hrs)
- Local complication present
Severe
- Persistent organ failure (>48 hrs) (single or multiple)
What is the pathognomonic ERCP sign of IPMN?
Mucin protruding from widely open papilla
Child Pugh score
classifies severity of liver disease according to the
- albumin
- bilirubin
- INR
- Ascites
- Encephalopathy
score of 5 to 6 is considered Child-Pugh class A (well-compensated disease);
7 to 9 is class B (significant functional compromise)
10 to 15 is class C (decompensated disease).
These classes correlate with one- and two-year patient survival: class A: 100 and 85%; class B: 80 and 60%; and class C: 45 and 35%
Classify liver incidentalomas
Congenital
- simple cysts
- Polycystic liver disease
- Haemangioma
Infective
- Pyogenic liver abscess
- Hydatid cyst
Neoplastic
- Benign
- FNH
- Adenoma
- Cystadenoma
- Haemangioma
- Malignant
- Primary
- HCC
- Intrahepatic Cholangiocarcinoma
- Cystadenocarcinoma
- Hemangiosarcoma
- Mets
- Lymphoma
- Melanoma
- Primary
Describe broadly the treatment of Gallbladder cancer
Staging investigations
- CT chest abdo pelvis for nodes, vascular and peritoneal disease
- MRI - for liver parenchyma and bile duct
- Blood to check for jaundice (poor prognostic indicator - do not offer surgery straight up without MDM discussion)
- Diagnostic laparoscopy
- PET CT - controversial, use only when CT/MRI findings equivocal
Regional nodes: cystic, hepatoduodenal, hepatic artery and portal vein nodes
Non- regional nodes - para-aortic, peri-caval, SMA, coeliac nodes - involvement of these denote metastatic disease and is unresectable
Margin = 2 cm, plus clear margin on cystic duct end.
Criteria for unresectabitly:
- unresectable hepatic mets
- Distant mets (including non-regional nodes)
- Peritoneal disease
- Extensive involvement of hepatic artery, portal vein or hepatoduodenal ligament.
Treatment: surgery is the only curative treatment, but it is only offered if curative surgery can be achieved with clear margins. There is no role for palliative debulking surgery. treatment depends on the stage of disease
T1a (invades lamina propria) - cholecystectomy only
T1b (invades Muscle layer) - Controversial. Although T1b means tumour not through muscularis propria, studies have reported up to 20% LN involvement. If patient is fit then extended cholecystectomy (2cm margin on liver with non-anatomical resection of segments IVb and V) + regional lymphadenectomy
T2-3 (T2 - invades perimuscular layer T3 perforates visceral peritoneum or invades into 1 surrounding organ) - Extended chole + regional lymphadenectomy +/- bile duct resection (if negative margins can’t be achieved with chole on cystic duct stump on frozen section)
T4 (invades 2 or more surrounding organs)- palliative chemo +/- radiation
Jaundiced patient - relative contraindication to surgery due to poor prognosis - should be discussed in MDM, jaundice can be relieved with stenting post staging.
Palliative chemo -
- gemcitabine
- capox
- folfox
Radio
- EBRT + 5FU
Biliary drainage
relieve bowel obstruction - palliative bypass
What are worrisome signs in pancreatitis secondary to hypertriglyceridemia? How does the treatment differ in presence of worrisome signs?
Worrisome signs
- hypocalcemia
- Lactic acidosis
- organ failure
- worsening inflammation (Temp >38.5/<35; Pulse >90, RR>20; Paco2 <32 mmHg; WCC >12 or <4)
Patients with worrisome signs need plasmapheresis.
patients without worrisome signs can be treated with insulin dextrose (.1-.3mg/kg/hr - same as DKA protocol)
