Pancreatic And Hepatic 2

Question 0

55-year-old male with recent painless jaundice and marked pruritus. Bilirubin of 6, markedly elevated alkaline phosphatase. Suspected process? Differential? Next step?

Answer 0

Obstructive process to biliary tree

1. Cancer of pancreatic head
2. Periampullary carcinoma
3. Cholangiocarcinoma
4. Stricture of biliary tree
5. common bile duct impacted in ampulla (but this usually presents with fever and chills and PAIN)

Abdominal ultrasound

Question 1

Choledochojejunostomy? Performed when?

Answer 1

Repair of ductal injury requires new anastomoses with gastrointestinal tract

Complete obstruction of the bile duct necessitating biliary drainage procedure

Question 2

55-year-old male with recent painless jaundice and marked pruritus. Bilirubin of 6, markedly elevated alkaline phosphatase. Abdominal ultrasound shows dilated common bile duct but no gallstones or pancreatic masses – next step? (Why?). If unremarkable, following step?

Answer 2

CT of abdomen (transcutaneous abdominal ultrasound not good for visualizing distal bile duct and pancreatic head because intestinal gas obscures view)

Endoscopic ultrasound through duodenal wall to assess pancreatic head

Question 3

Pancreaticoduodenectomy?

Answer 3

Remove pancreatic head, first portion of the duodenum, jejunum at the ligament of Treitz

Question 4

Patient with cancer to the head of the pancreas – tumor resection is successful with negative margins and no local metastatic disease – cure rate in five years? Survival rate?

Mean survival for palliative biliary gastric bypass after finding unresectable pancreatic adenocarcinoma?

Answer 4

5-10%; 33-50%

8 months

Question 5

60-year-old man with painless jaundice . Abdominal ultrasound shows dilated Intrahepatic ducts but no dilation of common bile duct – suspected diagnosis? next steps?

Answer 5

Cholangiocarcinoma

ERCP or percutaneous transhepatic cholangiography (preferred because the better visualization of proximal hepatic ducts)

Question 6

Cholangiocarcinoma – prognosis?

If exploration shows no local metastatic disease and mass is resected. Prognosis?

If unresectable cholangiocarcinoma – five-year prognosis?

Answer 6

Poor – high rate of vascular invasion, metastatic disease

Five-year survival 15%

Less than 5%

Question 7

Effect of radiation on unresectable cholangiocarcinoma?

Answer 7

No effect on survival

Question 8

Management of ampullary adenocarcinoma?

Cure rate versus other pancreatic cancers? five-year survival?

Answer 8

1. Exploration for local or distant metastases
2. Whipple (pancreaticoduodenectomy)

Higher cure rate than other pancreatic cancers with 65% five year survival

Question 9

Duodenal adenocarcinoma – management? Relative prognosis?

Answer 9

Depends on location and size

1. If involves ampulla – Whipple
2. If in first or fourth part of the duodenum, segmental resection

Prognosis usually poor because of involvement of nearby structures

Question 10

Patient with mass in the gallbladder fossa visible on ultrasound – suspected diagnosis? Management? Metastases most likely to extend into?

Answer 10

Gallbladder adenocarcinoma –

1. CT for metastases
2. If no metastases, open cholecystectomy with wide resection of surrounding liver and hilar lymph node

Liver

Question 11

3 cm polyp found on gallbladder – management?

Answer 11

Cholecystectomy if polyp larger than 2 cm (observation if under 2 cm)

Question 12

Patient with the calcified gallbladder – management?

Answer 12

Removal – 50% association with adenocarcinoma

Question 13

Patient with suspected pancreatitis – test to rule out other common disorders? (Example?) Finding on test that supports pancreatitis? Unnecessary test in patients with uncomplicated pancreatitis?

Answer 13

Obstructive abdominal series to rule out other disorders (perforated ulcer with free air)

Generalized ileus and localized ileus second and third parts of the duodenum due to localized inflammatory process

CT not mandatory

Question 14

Treatment for uncomplicated pancreatitis?

Gallstone pancreatitis?

Answer 14

1. NPO
2. IV hydration
3. Pain control

Same way – when amylase decreases and patient improves, do laparoscopic cholecystectomy

Question 15

34-year-old male presents with abdominal pain and elevated Amy leads. After admission becomes severely ill with hypotension, hypoxia, multiorgan failure – suspected diagnosis? Mechanism?Treatment?

Answer 15

Severe necrotizing pancreatitis with systemic inflammatory response syndrome

Mediated by cytokine release and causes ARDS, multiorgan system failure, hemodynamic instability

1. Fluid resuscitation in ICU
2. CT of abdomen to assess the extent of information, other causes of decompensation (bowel perforation, abscess, biliary instruction)

Question 16

How to assess patient mortality with alcoholic pancreatitis?

Answer 16

Ranson criteria

On admission:

1. WBC over 16,000
2. Glucose over 200
3. AST over 250
4. LDH over 350
5. Age over 55

After 48 hours

1. Hematocrit decrease of 10%
2. Calcium less than 8
3. paO2 under 60
4. Base deficit over 4
5. BUN increase of 5
6. Fluid sequestration over 6 L

3 criteria – mortality 28%,
5/6 criteria mortality is 40%
7/8 criteria - mortality is 100%

Question 17

Correlation with amylase levels and severity of pancreatitis?

Answer 17

No correlation

Question 18

Patient presents with acute pancreatitis. Develops pulmonary failure and requires intubation and ventilation. Over next two days, develops fever, leukocytosis, and septic shock – most concerned about? Test? Management?

Answer 18

Pancreatic abscess

Dynamic CT scan

1. If CT shows peripancreatic collection – percutaneous sampling 2. CT ultrasound guidance
   Two. If a large amount of WBCs for bacteria, abscess – need to drain it

Question 19

Patient is recovering from percutaneous pancreatic abscess drainage when he becomes hypotensive and drainage becomes bloody – suspected condition? Management?

Answer 19

Solution of the catheter or absence into major artery (splenic, gastroduodenal, SMA, pancreatic vessels)

1. Angiography
2. Control with embolization

Question 20

Suspect Severe pancreatitis in 70-year-old patient – differential? difference in approach?

Answer 20

mesenteric ischemia or volvulus

Stronger need to confirm diagnosis - CT scan. If CT scan inconclusive, exploratory laparotomy.

Question 21

34-year-old alcoholic develops acute pancreatitis. Symptoms fail to resolve - continues to have moderate abdominal pain, persistent elevation in serum anylase, early satiety – presumptive diagnosis? Confirm with? Management?

Answer 21

Pancreatic pseudocyst (collection of fluid

He used to leakage

CT

1. If confirm pseudocyst: NPO, TPN, and observation
2. If it fails to improve by six weeks, surgical intervention