NMS Pancreas 1 (includes gallbladder) Flashcards
0
Q
annular pancreas
A
usually presents in infancy w duodenal obstruction (postprandial vomiting). caused by malrotation of ventral pancreas –> ring of pancreatic tissue around second portion of duodenum
pancreatitis and peptic ulcers also may result
1
Q
Pancreas divisum
A
due to failure of ventral and dorsal ducts to fuse, majority of pancreatic drainage is accomplished via accessory papilla and duct of Santorini.
–> most common congenital anomaly of pancreas (5% of population) but usually asymptomatic.
rarely chronic pain and recurrent pancreatitis result from inadequate drainage
2
Q
heterotopic pancreas
A
pancreatic tissue in an abnormal location (stomach, duodenum, Meckel’s diverticulum)
3
Q
why does resection of head of pancreas require resection of duodenum
A
bc they have shared blood supply (gastroduodenal –> pancreaticoduodenal artery)
4
Q
pancreatic ducts
A
- duct of wirsung is main duct; runs entire length of pancreas. it joins common bile duct and empties into 2nd part of duodenum at ampulla of vater
- duct of santorini (small duct) is an accessory duct often joining the duodenum more proximally than ampulla of vater
5
Q
blood supply of pancreas
A
- head: anterior and posterior superior pancreaticoduodenal arteries = branches of gastroduodenal artery;
anterior and posterior inferior pancreaticoduodenal arteries=branches of SMA - NECK, BODY, TAIL: splenic artery and branches (dorsal pancreatic artery)
6
Q
exocrine physiology of pancreas
A
secretion of 1-2L/d of clear, isosmotic alkaline fluid containing digestive enzymes.
exocrine pancreas makes up 85% of pancreatic volume;
endocrine pancreas accounts for only 2%, with the rest composed of extracellular matrix and vessels or ducts
7
Q
what kind of block can be done for pain control in pancreatic dz
A
celiac plexus block
8
Q
secretin
A
most potent endogenous stimulant for bicarbonate secretion
9
Q
endocrine function of pancreas
A
Islets of Langerhans make up 2% of pancreas by weigh:
1) insulin: from beta cells in islets of Langerhans (glucose absorption and storage);
2) glucagon: from islet alpha cells (glycogenolysis and release of glucose);
3) somatostatin: from islet delta cells (generally –> inhibitory function of GI tract)
10
Q
uses of somatostatin
A
- treat symptoms of neuroendocrine tumors (islet cell, carcinoid, gastrinoma, VIPoma, and acromegaly)
- convert high output fistulae to low output fistula (bc of its antimotility and antisecretory effects)
11
Q
acute pancreatitis
A
inflammation of pancreas due to parenchymal autodigestion by proteolytic enzymes
CAUSES: 1) alcohol abuse (40-50%); 2) gallstones (40%)
12
Q
Less common causes of acute pancreatitis
A
- hyperlipidemia
- hypercalcemia: 2/2 hyper PTH
- trauma
- post op and post ERCP
- pancreatic duct obstruction (tumor, pancreatic divisum)
- vasculitis
- scorpion venom
- viral infections
- drugs (azathioprine, INH, cimetidine)
13
Q
signs and symptoms of acute pancreatitis
A
- severe, constant epigastric pain radiating to the back. pain may be improved by sitting forward or standing
- nausea/vomiting
- low grade fever, tachypnea, tachycardia, upper abdominal tenderness with guarding but no rebound. bowel sounds may be absent due to adynamic ileus.
signs of hypovolemic shock may also be present due to massive retroperitoneal fluid sequestration and dehydration
14
Q
cullens sign
A
bluish discoloration of periumbilicus
hemorrhagic pancreatitis
15
Q
grey-turners sign
A
bluish discoloration of flank
hemorrhagic pancreatitis
16
Q
fox’s sign
A
bluish discoloration of inguinal ligament
hemorrhagic pancreatitis
17
Q
cullens, grey turners, fox’s sign
A
indicative of severe, hemorrhagic pancreatitis
18
Q
MEDVIPS: drug-induced pancreatitis
A
- methyldopa/metronidazole
- estrogen
- didanosine (inhibits HIV DNA polymerase reverse transcriptase)
- valproate
- INH
- pentamidine
- sulfonamides
19
Q
elevate lipase
A
only found in gastric and intestinal mucosa and liver, in addition to pancreas, so is more specific for pancreatitis than amylase
20
Q
elevated amylase
A
also found in salivary glands, small bowel, ovaries, skeletal muscle (+pancreas) so not specific marker for pancreatitis
21
Q
Ranson’s criteria : on admission
A
- age>55
- blood glucose>200
- AST>250
- LDH> 350
- WBC >16k
22
Q
Ranson’s criteria: after 48 h
A
- base deficit >4
- increase in BUN >5
- fluid deficit > 6L
- Calcium 10%
- PO2 < 60 mm Hg
23
Q
diagnostic choice for acute pancreatitis
A
CT scan: 90% sensitive, 100% specific.
demonstrates pseudocysts, phlegmon, abscess, or pancreatic necrosis
24
causes of elevated amylase levels
high amylase levels are seen in intestinal disease, perforated ulcer, ruptured ectopic pregnancy, salpingitis, salivary gland disorders, renal failure, and diabetic ketoacidosis
25
treatment of acute pancreatitis
1. aggressive hydration with electrolyte monitoring to maintain adequate intravascular volume
2. NG tube if vomiting
3. antibiotics if infection identified
4. NPO with nutritional support via post-pyloric feeding or TPN
5. avoid morphine-possible spasm of sphincter of Oddi (use IV fentanyl or hydromorphone; meperidine favored over morphine)
6. surgery indicated for either infected necrosis of pancreas or correction of associated biliary tract dz
26
chronic pancreatitis
chronic inflammation or recurrent acute pancreatitis causes irreversible parenchymal fibrosis, destruction, and calcification --> loss of endocrine and exocrine function
27
causes of chronic pancreatitis
1. EtOH abuse (70%)
2. idiopathic (20%)
3. other (10%): hyper PTH, HLD, congenital pancreatic abnormalities, hereditary, obstruction
28
signs and symptoms of chronic pancreatitis
1. recurrent or constant epigastric/back pain
2. malabsorption/malnutrition (exocrine dysfunction)
3. steatorrhea (exocrine dysfunction-fat soluble vitamin deficiency (ADEK)
4. Type 1 diabetes mellitus
5. polyuria
29
diagnosis of chronic pancreatitis
1. pancreatic calcifications
2. chain of lakes pattern on ERCP with ductal irregularities/dilatation/stenosis
3. pseudocysts with gland enlargement/atrophy, masses
30
Pseudocysts
nonepithelialized, encapsulated pancreatic fluid collections. up to 30% of pseudocysts resolve on their own with bowel rest (TPN and NPO). if after 6 wks they have not resolved and are > 6 cm in size, internal drainage of the mature cysts indicated via cyst gastrostomy or Roux-en-Y cyst jejunostomy.
31
pancreatic adenocarcinoma
1. originate in exocrine pancreas (ductal cells)
2. 2/3 occur in head of pancreas
risk factors:
1. male
2. african-american
3. tobacco user
32
Courvoisier's sign
jaundice with palpable gallbladder that is nontender
33
signs and symptoms of pancreatic adenocarcinoma
1. weight loss
2. (painless) jaundice
3. posterior epigastric pain radiating to the back
4. migratory thrombophlebitis (Trousseau's syndrome esp seen in tumors of body or tail)
34
diagnosis of pancreatic adenocarcinoma
1. elevated CEA or CA19-9
2. CT scan is study of choice
3. PTC and ERCP useful in periampullary lesions
35
treatment of pancreatic adenocarcinoma
1. tumors of head: Whipple procedure (pancreaticoduodenectomy)
2. tumors of body/tail: distal near-total pancreatectomy
3. if unresectable 2/2 liver or peritoneal mets, nodal mets beyond zone of resection, or tumor invasion of SMA, palliative procedures considered
36
Whipple procedure
removal of gallbladder, common bile duct, antrum of stomach, duodenum, proximal jejunum and head of pancreas (en bloc);
reconstruction with pancreaticojejunostomy , choledochojejunostomy, and gastrojejunostomy
37
prognosis for adenocarcinoma
median survival for patients who undergo successful resection is approximately 12-19 months, with 5y survival rate of 15-20%
38
pancreatic cystadenocarcinoma
1. commonly seen in females 40-60y
2. occurs in body/tail
3. accounts for <2% of all pancreatic exocrine tumors
4. prognosis better than adenocarcinoma
5. TREATMENT: distal/total pancreatectomy
39
pancreatic cystadenoma
1. seen in older/middle aged women
two types:
a. serious: benign
b. mucinous: generally benign, but potential to be malignant
2. treatment: surgical resection
40
insulinoma
beta cell neoplasm with overproduction of insulin
1. MC islet cell tumor
2. 90% are benign
3. most are solitary lesions with even distribution in head/body/tail of pancreas
4. if associated with MEN I (<10% of all cases), then multiple insulinomas may be present
41
diagnosis of insulinoma
1. fasting serum insulin level >10 uU/mL [nL is 0.3
| 3. prosinulin or C-peptide levels should be measured to rule out surreptitious exogenous insulin administration
42
treatment for insulinoma
1. surgical enucleation/resection usually curative
| 2. diazoxide can improve hypoglycemic symptoms by inhibiting pancreatic insulin release
43
what is Whipple's triad
characterizes insulinoma
1. symptoms of hypoglycemia with fasting
2. fasting glucose <50 mg/dL
3. relief of symptoms after eating (glucose)
44
gastrinoma
neoplasm associated with overproduction of gastrin; aka Zollinger-Ellison syndrome
45
epidemiology of gastrinomas
1. second most common islet cell tumor
2. 90% are located in gastrinoma triangle bordered by junction of second and third part of duodenum, cystic duct, and SMA under the neck of the pancreas
3. 25% of gastrinomas are associated with MEN-1
46
signs and symptoms of gastrinomas
1. signs mimicking peptic ulcer dz
2. epigastric pain most prominent after eating
3. profuse, watery diarrhea
47
diagnosis of gastrinoma
1. fasting serum gastrin level > 500 pg/mL [nl: <100 pg/mL]
2. secretin stimulation test will cause paradoxical increase in gastrin in patients with Zollinger-Ellison syndrome
3. ulcers in unusual locations (ie, 3rd part of duodenum or jejunum) is highly suggestive
4. octreotide scan to localize tumor
48
treatment of gastrinoma
1. PPI
2. surgical resection
3. chemotherapy
49
VIPoma
overproduction of VIP; aka Verner Morrison syndrome or WDHA syndrome (Watery Diarrhea, Hypokalemia, Achlorhydria);
most are malignant and majority have metastasized to lymph nodes and the liver at time of dx
10% extrapancreatic
50
signs and symptoms of VIPoma
1. severe, watery diarrhea
| 2. signs of hypokalemia-palpitations/arrhythmias, muscle fasciculations/tetany, paresthesias
51
treatment of VIPoma
fasting serum VIP>800 pg/mL (normal<200 pg/mL) with exclusion of other causes of diarrhea
52
glucagonoma
rare alpha cell neoplasm resulting in overproduction of glucagon
53
signs and symptoms of glucagonoma
1. mild diabetes (hyperglycemia)
2. anemia
3. mucositis
4. weight loss due to low amino acid levels
5. severe dermatitis: often a red psoriatic like rash with serpiginous borders over trunk and lower limbs
54
skin condition associated with glucagonoma
necrolytic migratory erythema
55
diagnosis of glucagonoma
1. fasting serum level glucagon > 1000 pg/mL
| 2. skin bx to confirm presence of necrolytic migratory erythema
56
common bile duct forms in which pancreatic bud
ventral
57
which pancreatic bud migrates to fuse with other
ventral
58
what does ventral pancreatic bud form in adult
uncinate process and inferior aspect of pancreatic head
59
what does dorsal bud form
superior aspect of head, body, tail
60
from which pancreatic bud does small accessory pancreatic duct of santorini form
from dorsal bud
61
main duct of wirsung forms from entire ventral pancreatic duct which fuses with ...
distal pancreatic duct of dorsal bud
62
what abnormality arises if ventral pancreatic bud migrates posteriorly AND anteriorly to fuse with dorsal pancreatic bud
annular pancreas
63
name parts of pancreas
head, neck, body, tail
64
on what structure does pancreatic head rest
IVC, renal vessels
65
on what structure does uncinate process rest
aorta
66
what lies behind pancreatic neck
SMA
67
how is blood supplied to head of pancreas from celiac axis
gastroduodenal artery branches into SUPERIOR posterior and anterior pancreaticoduodenal artery
68
how is blood supplied to pancreatic head from celiac axis (2)
SMA branches into INFERIOR posterior and anterior branches of pancreaticoduodenal
69
which arteries supply body and tail of pancreas
splenic --> dorsal pancreatic --> joining branch from SMA --> forming inferior pancreatic
also multiple branches from splenic + inferior pancreatic arteries supply tail
70
into which veins do pancreatic veins drain
splenic vein into portal vein
71
which nodal groups drain pancreas
head: subpyloric, portal, mesocholic, aortocaval
body and tail: retroperitoneal in splenic hilum
to mesocolic, mesenteric, aortocaval
72
what do islet cells make
insulin (beta)
glucagon (alpha)
somatostatin (delta)
73
type of cells in exocrine pancreas
acinar, centroacinar, intercalated ductal, ductal
74
pH of pancreatic secretions
8
75
enzymes from pancreas
peptidases, trypsin, chymotrypsin, elastase, kallikrein, carboxypeptidase A and B
76
what stimulates exocrine secretion
bicarb: vagal efferents and secretin
enzymes: cholecystokinin and acetylcholine
77
what GI hormone is structurally similar to CCK
gastrin
78
what activates peptidases
enterokinase
79
what % acute pancreatitis is idiopathic
10%
80
metabolic causes of pancreatitis
hyperlipidemia, hypercalcemia
81
other surgical dzs causing pancreatitis
perforating peptic ulcer, Crohn dz of duodenum
82
diagnostic GI test that can cause pancreatitis
ERCP
83
arachnid bite that can cause pancreatitis
scorpion
84
worms that can cause obstructive pancreatitis
Ascaris, clonorchis sinensis
85
tests for diagnosing acute pancreatitis
amylase in serum, peritoneal fluid and urinary amylase
serum lipase, WBC, total bilirubin, LFT
AXR, US, CT
86
what is a sentinel loop
adynamic, dilated loop of small bowel associated with a focal area of inflammation initially described in relation to pancreatitis-associated ileus
87
when can patients with pancreatitis be fed
NOT early; this causes reactivation
| but i saw that early enteral feeds is good...what??
88
should abx be used in treatment of acute pancreatitis
yes, necrotizing pancreatitis
| this is controversial i think?
89
which abx to use for necrotizing pancreatitis
imipenem/cilastatin
90
how many patients with acute pancreatitis need surgery
10%
91
does early use of minidose heparin prevent intravascular thrombosis during acute pancreatitis or alter the course of pancreatitis
prob not
92
does peritoneal lavage alter clinical course of severe or necrotizing pancreatitis
controversial
recent study showed that patients with 5 or more of Ranson's criteria had reduced sepsis/death (with peritoneal lavage)
93
how should patients with severe pancreatitis be nourished
TPN;
but when peristalsis returns, nasoenteric or enteric feeding tubes (early enteral feeds?) may offer better nutrition without worsening pancreatitis (beyond ligament of Treitz)
94
what causes gallstone pancreatitis
- bile reflux into pancreas
- reflux of duodenal succus from a loose sphincter of Oddi
- stone blockage of pancreatic duct
95
if surgically untreated, what % of patients with gallstone pancreatitis will have recurrence within 8 weeks
33%
96
what other causes of pancreatitis must be ruled out in a patient with gallstones?
alcohol abuse, medications, hyperlipidemia, hypercalcemia
97
appropriate treatment of mild gallstone pancreatitis
laparoscopoic cholecystectomy; intraoperative cholangiogram on HD 3-5 if pancreatitis resolves
98
definition of chronic pancreatitis
recurrent bounts of acute, chronic pain, exocrine and endocrine dysfunction, irreversible parenchymal fibrosis
99
signs and symptoms of chronic pancreatitis
abdominal pain, diabetes, steatorrhea, pancreatic calcification
100
anatomic pancreatic changes in chronic pancreatitis
sclerosis with duct stenosis and dilatation
loss of acinar tissue
101
most common cause of chronic pancreatitis
alcohol abuse
102
CT findings with chronic pancreatitis
dilated pancreatic duct, calcifications, parenchymal atrophy (pseudocyst)
103
findings associated with chronic pancreatitis on CT
| she may have meant ERCP
chain of lakes
| did she mean ERCP?
104
most sensitive test for chronic pancreatitis
ERCP
105
factors indicating surgery for chronic pancreatitis
refractory, disabling pain; frequent recurrent acute exacerbations; possible malignancy; GI or biliary obstruction; splenic vein thrombosis with portal HTN
106
how are patients with chronic pancreatitis managed non-operatively
tx of pain; pancreatic exocrine replacement; insulin therapy
107
what are pseudocysts
pancreatic juice enclosed by a false capsule of fibrous or granulation tissue that arises as a consequence of pancreatitis or trauma
108
percentage of patients with acute pancreatitis forming pseudocysts
20%
109
what % of patients with chronic pancreatitis develop pseudocysts
20-40%
110
What % of ppl with acute pancreatitis develop persistent pseudocysts
4%
111
most common cause of pancreatic pseudocysts in kids
trauma
112
signs/symptoms of pancreatic pseudocysts
persistent pain, persistent n/v, weight loss, abdominal mass, persistent amylase elevation, jaundice, distension
113
% of patients with pseudocysts that have persistent abdominal pain
>90%
114
% of patients with pseudocysts that have abdominal mass
up to 50%
115
appropriate treatment of an infected pseudocyst
external drainage
no abx??
116
avg time for 4 cm pseudocyst to resolve
2-3 months
117
complications a/w pseudocyst
```
hemorrhage
infection,
leak
gastric outlet obstruction
bile duct obstruction
```
118
treatment of an unstable patient with hemorrhage into pseudocyst
arteriogram and possible embolization
119
what portion of pancreas gets carcinoma
exocrine
120
% of pop with pancreas divisum
6-10%
121
risk factors for pancreatic carcinoma
```
advanced age, smoking
diabetes (esp in women)
heavy alcohol use
exposure to benzidine and naphthylamine
partial gastrectomy
```
122
most common type of pancreatic carcinoma
90% adenocarcinoma
| others are cystadenoma and acinar
123
most common location of pancreatic carcinoma
2/3 in head
| 1/3 in body/tail
124
signs/symptoms of pancreatic carcinoma
pain, weight loss, nausea, anorexia, painless jaundice
125
tumor markers for pancreatic cancer
CA19-9, Ca50
126
diagnostic test for pancreatic carcinoma
CT
127
diagnostic test for patients with jaundice
ERCP
128
why is tissue dx important for pancreatic carcinoma
ddx includes lymphoma, sarcoidosis, TB, choledocolithiasis, pancreatitis
129
what is disadvantage of FNA
seeding
130
when should tissue dx of potentially resectable tumors be performed
in OR (FNA)
but is this still done
131
which patients are the best candidates for percutaneous needle bx of a periampullary tumor
nonoperative candidates
132
which primary tumor location is associated with the most major vessel tumor involvement
head of pancreas
133
what are main sites of metastasis for pancreatic cancer
liver, peritoneum
134
what contraindicates resection in pancreatic cancer
mets, even just to local nodes; tumor involvement of SMA, SMV
135
goal of pancreas surgery for carcinoma
cure
136
Kocher maneuver
to determine if SMA is involved in pancreatic carcinoma
--> hand needs to be able to identify a normal tissue plane between pancreas and SMA
137
what intraoperative maneuvers simplify visualization of portal vein
cholecystectomy, transection of common hepatic duct
138
what is appropriate treatment of distal pancreatic cancer
distal pancreatectomy with splenectomy
139
what is appropriate treatment of cancer of head
Whipple, if resectable
140
what is treatment option of unresectable pancreatic cancer
radiation and 5-fluoro
141
what is an option for post-op adjuvant treatment (pancreatic cancer)
5-fluoro and radiation
142
is pylorus preserving Whipple a/w any survival disadvantage
NO
143
what is current operative mortality rate with whipple
<3%
144
what is most common postop complication of whipple
delayed gastric emptying
145
appropriate treatment of delayed gastric emptying
metoclopramide
146
percent of patients who develop a postop pancreatic fistula
up to 20%
147
appropriate treatment of pancreatic fistula
controlled drainage, with or without somatostatin
148
potential complications a/w standard whipple
```
delayed gastric emptying (1/3)
pancreatic fistula (1/5)
abscess (1/10)
wound infection (1/12)
bile leak (1/20)
pancreatitis (1/20)
```
149
what is prognosis for pancreatic cancer patients after resection
up to 20% are alive after 5 years
150
what are most important post resection prognostic factors
positive lymph nodes, need for blood transfusions, clear margins, vascular invasion by histology
151
various endocrine tumors of pancreas
insulinoma, glucagonoma, VIPoma, somatostatinoma, gastrinoma, calcitoninoma and neurotensin secreting tumors
152
what is most common pancreatic endocrine tumor
insulinoma
153
Whipple triad for insulinoma
fasting blood sugar <50
symptoms of hypoglycemia when fasting
symptomatic relief following glucose replacement
154
diagnosing insulinoma
72h fast with blood glucose and insulin levels; insulin/glucose ratio > 0.4; elevated C protein and proinsulin
155
do you image for pancreatic endocrine tumors
yes, CT with contrast
156
location for insulomas
1/3 in each part of pancreas
157
how to treat insulinomas
resection
| enucleation for small tumors
158
role of diazoxide for patients with unresectable dz (insulinoma)
can attenuate hypoglycemia (less insulin released)
159
Zollinger-Ellison syndrome
pancreatic endocrine tumor that secretes gastrin
160
how to dx gastrinoma
secretin stimulation test
161
where are gastrinomas usually located
gastrinoma triangle:
1. confluence of cystic and CBD
2. junction of 2nd and 3rd portions of duodenum
3. junction of neck and body of pancreas
162
what % of gastrinomas are malignant
60% at time of dx
163
treatment for gastrinoma
resection with medical anti-acid production therapy
164
how to localize gastrinomas
CT with contrast, intraoperative ultrasound, duodenotomy, somatostatin, indium scan
165
Verner-morrison syndrome (WDHA)
watery diarrhea, hypokalemia, achlorydiria
a/w VIPomas
166
where are VIPomas usually
body and tail
167
should VIPomas be resected
yes, though half have metastasized by dx
168
what action should be taken if no tumor is identified in a patient with watery diarrhea, hypokalemia, achlorydria syndrome
subtotal pancreatectomy, bc there can be diffuse islet-cell hyperplasia
169
what condition would a patient with diabetes and a migratory rash be likely to develop?
glucagonoma
170
which enzyme, when activated, is thought to initiate many of the deleterious events a/w pancreatitis
trypsin!
171
which lipolytic enzyme causes pancreatic necrosis in the presence of bile?
phospholipase A
172
which enzyme is responsible for creating intrapancreatic hemorrhage
elastase
173
what causes fat necrosis in pancreatitis
lipase, esp in presence of bile
174
most important risk factor for severe necrotizing pancreatitis
obesity = more lipase
175
% patients with cholelithiasis that develop gallstone pancreatitis
4-8%
176
peritoneal tap findings a/w severe necrotizing pancreatitis
dark brown, sterile, non-foul smelling fluid
177
do NG tubes reduce the length of hospital stay or decrease pain in cases of acute pancreatitis
NO
| just use for vomiting/ileus
178
is somatostatin helpful in acute pancreatitis
NO
but does decrease pancreatic fistula output
179
cause of coagulopathy in pancreatitis
release of proteases
180
appropriate treatment for coagulopathies
fresh frozen plasma as required
181
mxn for pulmonary dysfunction during pancreatitis
digestion of surfactant by phospholipase A
182
appropriate treatment for pulmonary problems in acute pancreatitis
mechanical ventilation
183
most common bacteria that infect necrotic pancreatic tissue
gram negative rods
184
appropriate treatment of infected pancreatic tissue
surgical debridement, antibiotics
185
presentation of acute pancreatitis
epigastric pain and tenderness, abdominal distension, fever, tachycardia, jaundice (when a/w gallstone pancreatitis)
186
most common causes of acute pancreatitis
alcoholism, gallstone
187
Ranson's criteria utility
mortality in pancreatitis
188
what 3 groups need asymptomatic gallstones removed
1. immunocompromised
2. porcelain gallbladder (chronic cholecystitis, at risk for adenocarcinoma of the gallbladder)
3. larger than 3 cm
189
6 factors that predispose to gallstones
1. age >40
2. fam hx of gallstones
3. female
4. obesity
5. recent pregnancy
6. prev dx gallstones
190
RUQ due to cholelithiasis can radiate to where
right subscapular
191
most efficient way to dx cholelithiasis
ultrasound
192
lab values to expect with cholelithiasis
mild leukocytosis, mild jaundice, elevated bilis, alk phos and transaminases can also be elevated
193
in uncomplicated cholelithiasis, what is abx regimen
1 dose preop 1G cephalosporin : cefalexin, cefazedone, cefazolin
194
who needs abx in cholelithiasis
high riskers for sepsis: over 70, acute cholecystitis, hx obstructive jaundice, common duct stones, those with preop ERCP done
195
whats major complication of lap chole
common bile duct injury: chronic biliary strictures, infection, cirrhosis;
injury to hepatic artery: hepatic ischemic injury, bile duct ischemia, strictures
196
most common species for acute cholecystitis
1. E. coli
| 2. enterobacter, klebsiella, enterococcus
197
abx regimen for acute cholecystitis after blood cultures
2G cephalosporin for GNRs and anaerobes: Cefotetan, Cefoxitin
--> give preop and 24h postop
198
when bili and/or liver enzymes are elevated, what to suspect? what to do?
common duct stone! preop or post op ERCP
199
how should gallstone pancreatitis and symptomatic cholelithiasis be managed in pregnant pts
IV hydration and pain mgmt. avoid surg until after delivery if possible but safest to do in 2nd trimester. ERCP and sphincterotomy generally save
--> i also read that chole is safer than peritonitis so sometimes better to do elective? or am i thinking of appy...
200
when biliary pancreatitis suspected, what procedure is necessary operatively?
operative cholangiogram. but delay surgery until complications from pancreatitis relieved: high fluid requirements, hypocalcemia, oliguria, hypotension, pulmonary complications.
201
causes of pancreatitis mnemonic
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps (paramyxovirus and other viruses like epstein barr and cmv)
Autoimmune (PAN/SLE)
Scorpion
Hypercalcemia (or hyperlipidemia, hypertriglyceridemia, hypothermia)
ERCP
Drugs (steroids, sulfonamides, azathioprine, NSAIDs, diuretics, duodenal ulcers)
202
clinical signs of pancreatitis
- grey-turners sign: hemorrhagic discoloration of flanks
- cullen's sign: hemorrhagic discoloration of umbilicus
- grunwald sign: appearance of ecchymosis around umbilicus due to local toxic lesion of vessels
- korte sign (pain or resistance in zone where head of pancreas is located in epigastrium, 6-7 cm above umbilicus)
- kamenchik's sign (pain with pressure under xiphoid process)
- mayo-robson sign (pain while pressing at top of angle lateral to erector spinae muscles and below left 12th rib =left costovertebral angle, CVA)
203
RUQ pain and high fever would be suspicious for
acute cholecystitis and complication like cholangitis, empyema of gallbladder, pericholecystic abscess
204
what ultrasound signs would you see with empyema of gallbladder
distended gallbladder with fluid that has internal echoes and gallstones
205
Tx for empyema of gallbladder
emergent exploration, cholecystectomy, IV abx.
if general health is poor: percutaneous cholecystostomy to drain
206
what does air in the biliary system mean? tx?
pneumobilia: suppurative cholangitis! gas forming organisms.
emergent ERCP w sphincterotomy, decompression of biliary tree, stone removal if feasible.
if unsuccessful: transhepatic cholangiogram and stone extraction, or cholecystectomy and CBD drainage
207
Definition of SIRS/sepsis
1. temp >38 (100.4) or 90
3. RR>20, or PaCO212 or 10% bands
sepsis = SIRS + suspected infection
severe sepsis = sepsis + organ dysfunction
septic shock = sepsis induced hypotension NOT RESPONSIVE TO FLUIDS
(elderly get hypothermic and leukopenic in sepsis!)
208
what does it mean when you have palpable gallbladder? what to do
inflamed gallbladder walled off by omentum. need emergent cholecystectomy when resuscitation occurs. high risk of rupture and mortality! watch out for change in mental status = sign of sepsis
209
Charcot's triad? meaning
1. RUQ pain
2. fever
3. jaundice
means cholangitis
210
tx of cholangitis
1. IVF
2. abx
3. ultrasound
4. ERCP if obstruction or dilatation of CBD seen
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what is a retained stone
common duct stone within 2 yrs of cholecystectomy. after 2 yrs = primary CBD stone
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post lap chole fever and pain might be?
infection/biliary leak/hepatic (CT scan) abscess/hepatic duct obstruction
213
HIDA scan is good for detecting what
biliary leaks, cholecystitis, obstructions
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post lap chole cystic duct stump leak on HIDA or ERCP requires what
drainage and temporary stent
215
if HIDA or ERCP shows complete CBD obstruction post cholecystectomy, what to do?
1. biliary drainage using percutaneous drain
| 2. choledochojejunostomy (CBD to jejunum)
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differential for painless jaundice, pruritus, elevated liver enzymes?
biliary tree obstruction, cancer at head of pancreas, periampullary carcinoma, Klatskin tumor, CBD stricture, CBD stone (unusual for this presentation)
217
if you see CBD dilation but no stones in ultrasound, what are next steps
1. CT
2. endoscopic ultrasound through duodenal wall to visualize head of pancreas
3. ultrasound guided bx
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what would stop you from resecting a pancreatic adenocarcinoma at the head of pancreas
distant mets esp to liver, LN mets esp to periarotic or celiac region, bone pain, neuro symptoms, involvement of vena cava, aorta, SMA, SMV or portal veins
219
procedure for resection of tumor at head of pancreas
pancreaticoduodenectomy
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what would you do if you found unresectable pancreatic adenocarcinoma with local spread
palliative biliary and gastric bypass to prevent gastric outlet or duodenal obstruction or bile duct obstruction. alcohol injection at celiac axis to decrease back and abdominal pain.
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painless jaundice + dilated intrahepatic ducts + no dilation of CBD
cholangiocarcinoma or Klatskin tumor!
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how to visualize cholangiocarcinoma or Klatskin
ERCP or percutaneous transhepatic cholangiography, which is better for proximal hepatic ducts
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are Klatskin tumors resectable
generally no, but may be able to do resection of gallbladder and bile ducts, hepatic lobectomy or trisegmentectomy
5yr survival with klatskins is 15% after curative resection
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what should you do with unresectable Klatskins or cholangiocarcinoma
palliative stenting of hepatic duct strictures
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type of biliary cancer with best prognosis
ampullary adenocarcinoma. requires a whipple (pancreaticoduodenectomy)
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what does a mass in the gallbladder fossa mean?
gallbladder adenocarcinoma. do open chole and wide resection of surrounding liver with hilar LN resection.
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porcelain gallbladder associated with what?
50% a/w adenocarcinoma
228
when you suspect pancreatitis what imaging should you get to rule out other stuff
obstructive abdominal series to r/o perforated ulcer. will usually see generalized ileus
229
tx for pancreatitis
NPO, IVF, pain control, observation, TPN if necessary
230
tx for gallstone pancreatitis
IVF, NPO, pain control, observation, lap chole when stable
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tx of severe necrotizing pancreatitis
major fluid resuscitation, CT abd for additional causes of decompensation such as bowel necrosis, performations, abscess, biliary obstruction with infection
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Ransons criteria
admission: age>55, wbc>16, glucose>200, LDH>350, AST>250
48h: hct drop 10%, BUN increase 5, Ca6L
2 or less <5% mortality
3-4 15-20%
5-6 40%
7+ 99% mortality
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what do you do for a person with labored breathing and low pulse ox
1. chest auscultation
2. ABG
3. CXR
4. supply O2
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potential causes of resp distress in pancreatitis
pulm edema from overhydration, ARDS from response to pancreatitis, atelectasis, pneumonia
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do amylase levels correlate with severity or prognosis
NO!
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if a person with pancreatitis goes into sepsis, what should you suspect? what to do?
pancreatic abscess or other source of sepsis like pneumonia, IV access infection, UTI.
sample percutaneously under CT or ultrasound guidance, drain abscess surgically or percutaneously.
culture. give abx for GNR and anaerobes: imipenem alone or fluoroquinolone plus metronidazole.
