HPB Flashcards
Hydatid cyst causative agent
Echinococcus granulosus
Focal modular hyperplasia
Focal nodular hyperplasia is benign
Biopsy is only needed if there is doubt about the diagnosis
Risk of injury to CBD in lap chole
CBD injury with laparoscopic cholecystectomy = 0.3-0.7%
HCC mets
Lungs most comman
Then lymphatic spread
Pancreatic division
In classic pancreatic divisum the Duct of Santorini drains via the minor papilla and the duct of Wirsung drains via the major papilla
Risk factors for pancreatic fistulas
• Pancreatic fistula are the single biggest cause of morbidity following pancreatic resection
• Incidence is approximately 15%, risk lower in distal pancreatectomy
•Clinically significant fistula will have amylase three times the serum amylase level and will give rise to symptoms such as fever and tachycardia
• Risk of fistula is increased if there is a soft pancreas (22%), age over 70 years, long period of jaundice (rather than severity), coronary artery disease and blood loss over 1doomi
How many liver segments need to remain post resection
2 segments on the ipsilateral size correlate approximately to 20-30% of liver volume.
Good outcome when >20% left if underlying problems >40%
Liver regeneration time
4-6months
Main duct IPMN
Lesions which are between 20-30 mm are considered moderate risk and should be further evaluated using US and blood tests for CEA and CA19-9. Percutaneous biopsy is not generally performed.
IPMN histology
Main duct - usually pancreatic-bilary differention
Branching ducts - usually gastric foveolar
Gallbladder polyps
Malignancy more likely in >1cm
Gb cancer
- Represents 2% of all cancers
• Up to 90% cases associated with gallstones
• A polyp - carcinoma sequence does not apply in the gallbladder
• Malignancy is more likely in a gallbladder polyp larger than 1cm diameter
• 60% are located in the fundus
• 6% of patients with porcelain gallbladder will be associated with malignancy
• Treatment of T1 (mucosal disease) is by open cholecystectomy and regional nodal sampling
• T2-T3 disease is managed by formal resection of segments IVb and V
• Overall survival is less than 10% at 5 years.
Hepatic cystadenomas
Up to 10% of cystadenomas are malignant and distinguishing between benign and malignant disease (even on biopsy is difficult). Surgical resection is therefore recommended. Note that in the question, cross sectional imaging has already suggested the diagnosis.
IPMN follow up
Concerning features: enhancing nodule <5mm, elevated ca19.9 increase in growth to >5mm over 2 years
If cystic lesion <1cm thrn CT/MRI every 2 hrs
If >3cm follow up EUS/MRI every 3-6months
IPMN malignancy risk
Main duct - 60-100%
Side duct 25%
Main duct IPMN resection
Mutal nodule
Main duct involvement
Malignant cells on cytology
>40mm
Side branch resection
Criteria for resecting branching duct IPMN:
The presence of jaundice, cytology positive for high-grade dysplasia or cancer, the presence of a contrast-enhancing mural nodule (>5mm) or solid mass should be considered as absolute indications for surgery
What percentage of procelain gallbladders are associated with cancer
6%
CBD stones
Brown pigment stones have the highest incidence of being located in the CBD. They are also the most prone to infective complications. Black pigment stones are more closely associated with an underlying metabolic disorder.
Location of cholangiocarcinomas
Most are located in the peri hilar region. The region between the upper border of the pancreas and the ampulla of vater is the next most common site.
What percentage of patients with gallstones and normal CBD diameter and LFTs will have CBD stones
In patients aged less than 55 years with normal CBD on USS and normal LFT’s the incidence of CBD stones is 5%.
Tpn and gallstones
TP is more typically associated with pigment rather than cholesterol gallstones.
Hepatocellular adenoma
• 90% develop in women in their third to fifth decade
• Linked to use of oral contraceptive pill
• Lesions are usually solitary
• They are usually sharply demarcated from normal liver although they usually lack a fibrous capsule
• On ultrasound the appearances are of mixed echoity and heterogeneous texture.
On CT most lesions are hypodense when imaged prior to administration of IV contrast agents
• In patients with haemorrhage or symptoms removal of the adenoma may be required
• Asymptomatic adenomas >5cm are usually excised
• Adenomas in males are likely to be smaller but have a greater risk of malignant transformation
- Risk of rupture is greater infesions larger than 5cm and those which are exophytic.
Mortality rates from spontaneous rupture are 5-10%.
Gallstone pancreatitis in pregnancy
Cholecystectomy performed in the second trimester is the safest option and that which is associated with the lowest morbidity for mother and child.
Abx post surgery in acute cholecystitis
Nil required
Biliary stents
Metallic stents now useable in respectable disease
Side branch IPMN
Follow up of BD-IPMN is required as progression of disease is expected in about 10–15% of patients during 3 to 5 years of follow up. Surveillance should also include the entire pancreatic gland because of an increased risk of new-onset cancer. Initially, MRI in 6 months should be performed. Absence of worrying features at follow up and slow or no growth may allow for annual MRI surveillance
