Pancreatic And Hepatic 3

Question 0

37 year-old woman seen for RUQ pain. Ultrasound shows no gallstones but does show a mass on right lobe of liver – most common diagnoses? Other possible diagnoses?

Answer 0

If cystic – simple cyst
If solid – hemangioma

Tumors – focal nodular hyperplasia and hepatic adenoma

Cancers – hepatocellular carcinoma, cholangiocarcinoma, metastases from other tumors

Question 1

Why wait seven weeks before surgical intervention for pseudocyst?

Type of procedure?

Answer 1

1. Many pseudocysts resolve in six weeks
2. Cyst wall must contain enough scar tissue for surgical suturing
3. Cystogastrostomy (drainage of fluid into G.I. tract)
4. Take biopsy to rule out cystadenoma or cystadenocarcinoma of the pancreas

Question 2

37 year-old woman seen for RUQ pain. Ultrasound shows no gallstones but does show a mass on right lobe of liver – relevant questions in history?

Answer 2

1. OPC use
2. Hepatitis B/C
3. Diabetes drugs
4. Pregnant

Question 3

37 year-old woman seen for RUQ pain. Ultrasound shows no gallstones but does show a mass on right lobe of liver – cystic lesion with no internal echoes. Suspected diagnosis? Possible complications? Management?

Answer 3

Simple cyst. Hemorrhage, secondary bacterial infection, obstructive jaundice

1. No further management
2. If symptoms persist, aspiration or simple excision

Question 4

37 year-old woman seen for RUQ pain. Ultrasound shows no gallstones but does show a mass on right lobe of liver – Multilocular cyst with calcifications in the wall with internal echoes. Suspected diagnosis? Management?

Answer 4

Echinococcal cyst

1. Serologic test for the echinococcus
2. Operative sterilization by injecting cyst with hypertonic saline followed by excision

Question 5

37 year-old woman seen for RUQ pain, fever, elevated WBC count. Ultrasound shows no gallstones but does show a mass on right lobe of liver – Suspected diagnosis? Management?

Answer 5

Hepatic abscess (fever, elevated WBC count and pain)

IV antibiotics and CT guided drainage

If amoebic abscess, metronidazole

Question 6

37 year-old woman seen for RUQ pain. Ultrasound shows no gallstones but does show a mass on right lobe of liver. Suspect hemangioma – diagnosed by? Appearance on imaging? Management?

Answer 6

Labeled RBC scan

Vascular lesion that fills from the periphery to the center

If asymptomatic, no removal

If symptomatic, high risk of rupture, and uncertain diagnosis, remove (Biopsy selectively, due to high risk of bleeding)

Question 7

37 year-old woman seen for RUQ pain. Ultrasound shows no gallstones but does show a mass on right lobe of liver – labeled RBC scan is negative for hemangioma. CT shows central stellate scar. Suspected diagnosis? Diagnosed with? Treatment?

Answer 7

Focal nodular hyperplasia; give her biopsy

No treatment (not premalignant)

Question 8

37 year-old woman seen for RUQ pain. Ultrasound shows no gallstones but does show a mass on right lobe of liver – biopsy indicate hepatic adenoma. Management? (Why?)

Answer 8

Resection because

1. Can develop into hepatocellular carcinoma
2. Associated with risk of rupture especially during pregnancy

Question 9

37 year-old woman seen for RUQ pain. Ultrasound shows no gallstones but does show a mass on right lobe of liver – biopsy indicates hepatocellular carcinoma – management?

Answer 9

1. CT to examine for metastases

2. If no metastases, resection

Question 10

Prognosis is favorable for patients with hepatocellular carcinoma if?

Answer 10

1. Solitary mass less than 5 cm
2. Non-cirrhotic liver
3. Without vascular invasion
4. Resectable with a 1 cm margin

Question 11

37-year-old male with history of IV drug use that is hospitalized for extremity abscess. Receives I&D and antibiotics. After three days, remains febrile to 103 – Possible causes?

Answer 11

1. Endocarditis
2. Intra-abdominal abscess
3. Pancreatitis
4. Pneumonia, UTI, infected indwelling catheter
5. HIV

Question 12

37-year-old male with history of IV drug use that is hospitalized for extremity abscess. Receives I&D and antibiotics. After three days, remains febrile to 103. Complains of tenderness in RUQ. WBC of 24,000 and elevated alkaline phosphatase differential? Test?

Answer 12

Symptoms suggest hepatobiliary condition

1. Gallstones
2. Infections – cholangitis or liver abscess

CT or ultrasound

Question 13

37-year-old male with history of IV drug use that is hospitalized for extremity abscess. Receives I&D and antibiotics. After three days, remains febrile to 103. CT scan shows multiple low-density lesions with both lobes of liver with peripheral rim enhancement indicative of abscess. Types of abscess? Treatment?

Answer 13

1. Pyogenic – caused by bacterial spread
2. Amebic – caused by Entamoeba

Broad-spectrum IV antibiotics for 4 to 6 weeks