Pancreatic and Hepatic Disorders Flashcards
Treatment for asymptomatic gallstones
Cholecystectomy is not recommended in asymptomatic pts. Only 10% of pts with asymptomatic gallstones develop sx in 5-yr period.
Exceptions include: immunocompromised pts, porcelain gallbladder, gallstones >3cm are a/w development of gallbladder CA
Treatment for asymptomatic gallstones
Cholecystectomy is not recommended in asymptomatic pts. Only 10% of pts with asymptomatic gallstones develop sx in 5-yr period.
Exceptions include: immunocompromised pts, porcelain gallbladder, gallstones >3cm are a/w development of gallbladder CA
DDx for acute RUQ pain + N/V, anorexia and guarding/tenderness in RUQ
Cholelithiasis, biliary colic, acute cholecystitis
DDx for RUQ pain
Gastroenteritis, PUD, acute hepatitis, renal colic, pleural based pneumonia, pyelonephritis
Risk factors for gallstones
- Increasing age
- FHx of gallstones
- Female sex
- Obesity
- Hx of recent pregnancy
- Previous hx of gallstones
US findings suggestive of gallstones
- Thickening of gallbladder wall
- Pericholecystic fluid
- Presence of gallstones
Treatment for sympomatic cholelithiasis
Cholecystectomy
Treatment for sympomatic cholelithiasis
Cholecystectomy
DDx for acute RUQ pain + N/V, anorexia and guarding/tenderness in RUQ
Cholelithiasis, biliary colic, acute cholecystitis
DDx for RUQ pain
Gastroenteritis, PUD, acute hepatitis, renal colic, pleural based pneumonia, pyelonephritis
Risk factors for gallstones
- Increasing age
- FHx of gallstones
- Female sex
- Obesity
- Hx of recent pregnancy
- Previous hx of gallstones
US findings suggestive of gallstones
- Thickening of gallbladder wall
- Pericholecystic fluid
- Presence of gallstones
Blood chemistries workup of cholelithiasis/findings suggestive of cholelithiasis
- CBC w/differential - mild leukocytosis 12-15K
- Amylase/Lipase
- LFTs - bilirubin 2-3mg/dL d/t inflammation and cholestasis (NOT D/T COMMON BILE DUCT OBSTRUCTION); elevated Alk phos and transaminases
Treatment for sympomatic cholelithiasis
Cholecystectomy
Indications for ABx in pts with symptomatic cholelithiasis
A single dose of 1st gen cephalosporin perioperatively is sufficient. Exceptions: 1. >70yo 2. Acute cholecystitis 3. History of obstructive jaundice 4. Common duct stones 5. Jaundice 6. Pts undergoing pre-op ERCP
Tx for acute cholecystitis with cholelithiasis
- obtain blood cultures
- Start ABx covering gram-neg rods and anaerobes (2nd gen cephalosporin against E. Coli, eneterobacter, klebsiella, enterococcus
- IV fluids
- NPO diet
- NG tube placement in the case of N/V
- Surgery in the next 48-72hrs
How does an elevated Alk phos AND elevated bili change the clinical picture/mgmt plan?
Suspect common bile duct obstruction in case of jaundice or elevated LFT’s. If US shows dilated bile ducts suspect obstruction of common bile duct. If common bile duct obstructed the stone MUST be cleared
Tx for common bile duct obstruction
- ERCP + lap chole
- Lap chole + intraoperative cholangiogram and common bile duct exploration
- lap chole + postop ERCP
Notes: stones <3mm in size only require observation b/c they may often pass
Mgmt of symptomatic cholelithiasis in a pregnant pt
- Gallstone pancreatitis and symptomatic cholelithiasis may be tx NONoperatively in most pregnant pts by hydration and pain mgmt.
- If pain is recurrent or if there is biliary colic/acute cholecystitis/obstructive jaundice/peritoninits then an ERCP or surgery is justified (surgery is safest in the second tri)
- Gallbladder should be removed after delivery
Air in the walls of the gallbladder
Emphysematous gallbladder d/t invasion of gallbladder by gas-forming bacteria
Mgmt of biliary pancreatitis
- Cholangiogram is MANDATORY
- In case of significant complications from pancreatitis (high fluid req, hypocalcemia, oliguria, hypotension, pulmonary complications) then cholecystectomy must be DELAYED
- Dilated common bile duct or stone in distal duct then ERCP must be performed to relieve the obstruction
DDx for RUQ pain, gallstones on US, and fever w/hypotension
High fever is indicative of acute cholecystitis or complication of gallbladder disease (cholangitis, empyema or gallbladder, pericholecystic abscess)
What does a “distended gallbladder with fluid that has internal echoes and gallstones” suggest? Mgmt?
Empyema of the gallbladder.
Tx = IV ABx and EMERGENT exploration with cholecystectomy or percutaneous cholecystotomy (if pt is in poor general health…lower risk procedure)
Implications of air in biliary system and dilated common bile duct in pt with hx of cholecystectomy. Mgmt?
Suppurative cholangitis resulting from bacterial infxn by gas-forming organisms with bile duct obstruction. Pt may have jaundice.
1.Emergent ERCP w/sphincterotomy
2. Decompression of biliary tree
3. Stone removal
OR
Transhepatic cholangiogram w/stone extraction
OR
Cholecysteectomy w/common bile duct drainage
Pt presenting with RUQ pain and has very high fever, hypotension, and WBC >20K. Same thing in an elderly pt?
Acute biliary sepsis requires emergent eval, ABx, and IV fluids. Elderly pts may present with sx of sepsis with hypothermia and leukopenia!
Tender 3cm palpable mass in the RUQ w/fever and mental obtundation
Inflamed gallbladder and surrounding omentum requires emergent cholecystectomy b/c of risk of gallbladder rupture. The obtundation is a sx of sepsis
If distal CBD obstruction present but no mass on US
Contrast abd CT to visualize the distal common duct area b/c of better visualization than US b/c intestinal gas obscures the view
Jaundice w/elevated bili, fever, RUQ pain/tenderness. Mgmt?
Acute cholangitis req resuscitation, ABx, urgent US of biliary tree w/ERCP and biliary decompression
Differentiating pancreatic CA from acute cholangitis
Pancreatic CA is a/w abd/back pain, wt loss, and jaundice
Jaundice w/elevated bili, fever, RUQ pain/tenderness AND recent cholecystectomy
Retained stone in common bile duct (within 2yrs of surgery). Requires RUQ US and possible ERCP and/or bile duct exploration.
If no stone found then consider biliary stricture d/t injury from previous surgery. Tx = surgical exploration w/bypass of stricture w/choledochojejunostomy
Workup for postoperative fever/pain OR jaundice after lap chole.
Infection vs. biliary leak. Abd US and hepatobiliary nuclide scan (HIDA scan) for detection of biliary leaks and acute cholecystitis (fails to visualize). If no biliary leak or collection is evident on US then following the pt is appropriate. If leak/collection detected then it should be drained AND an ERCP should be ordered
Workup for postop leak on HIDA scan and cystic duct stump leak on ERCP
Biliary drainage w/temporary stent placed during ERCP. If HIDA scan and ERCP show COMPLETE obstruction of bile tract then biliary drainage procedure is necessary w/possible new anastamosis w/GI tract (choledochojejunostomy)
Painless jaundice w/pruritis and elevated conjugated bilirubin and alk-phos (6x nl) but normal AST and ALT
Obstrucion of biliary tree d/t CA of the pancreatic head, periampullary CA, cholangioCA (Klatskin tumor), stricture of the common bile duct, common bile duct stone impaction in the ampulla (usually INTERMITTENT abd pain, jaundice, fever, and chills)
If distal CBD obstruction present but no mass on US
Contrast abd CT to visualize the distal common duct area b/c of better visualization than US b/c intestinal gas obscures the view
If Abd CT does not visualize any mass in the case of painless jaundice
Perform endoscopic US through duodenal wall b/c of excellent visualization of pancreatic head
Prognosis for unresectable cholangioCA following palliative stenting of hepatic ducts
<5% 5yr survival. Death is mostly d/t locally invasive disease. Radiation and CTX are not helpful
What preop findings make pancreatic surgery inoperable?
- Acceptable general medical condition
- NO evidence of distant mets; no mets to nearby structures (liver) or local LN’s (paraaortic/celiac)
- normal CXR
- No neuro sx or bone pain
- Involvement of the IVC, aorta, SMA/SMV, portal vein
CT scan and endoscopic US have limited capacity to detect liver mets so what must be done
First phase of surgery involves assessing distant mets to the liver, peritoneal surfaces, periaortic/celiac LN’s w/bx of suspicious lesions for frozen section dx
Indicators of good prognostic value in pancreatic CA
- Tumor diameter <19%
- Negative resection margins
- Postop adjuvent chemo and rads
Painless jaundice with obstruction at the bifurcation of the common bile duct jxn with the left/right hepatic ducts. Workup?
Cholangiocarcinoma (Klatskin tumor). Best visualized with ERCP or percutaneous tranhepatic cholangiography (better for lesions higher up in the bile duct) + biopsies and cytology
Prognosis of Klatskin tumor
High rate of vascular invasion, unresectability, and metastasis and thus UNRESECTABLE mostly.
Workup for resectable Klatskin tumor
If no evidence of unresectability then exploration w/resection of bile ducts and gallbladder is appropriate.
If tumor extends into left/right hepatic duct then a hepatic lobectomy or trisegmentectomy is necessary
Prognosis for unresectable cholangioCA following palliative stenting of hepatic ducts
<5% 5yr survival. Death is mostly d/t locally invasive disease. Radiation and CTX are not helpful
Prognosis of ampullary vs. duodenal CA
Duodenal CA have worse prognosis b/c often involve nearby structures
Gallbladder CA presentation and tx
Sx similar to gallstones. CT is best tool for evaluation of mass and evaluation of mets. If no mets then an open cholecystectomy and wide resection of surrounding liver and hilar LN (2-3cm margin w/wedge resection of liver). Laparoscopy is not appropriate b/c cannot remove hepatic tissue that way.
DDx for elevated amylase AND lipase 3x normal but no gallstones on abd US
- Pancreatitis (pt may have generazlied or localized ileus of 2nd/3rd portion of duodenum d/t localized inflammation)
- Perforated ulcer w/free air (r/o w/obstructive series)
Tx for pancreatitis (uncomplicated) OR gallstone pancreatitis
- NPO
- IV hydration
- Pain control
- Observation
+ laparoscopic cholecystectomy after amylase decreases (for gallstone pacreatitis)
Presentation of severe necrotizing pancreatitis w/3rd space fluid loss d/t pancreatic inflammation with systemic inflammatory response
- Hypotension
- Hypoxemia (d/t ARDS)
- Multiorgan failure
- Ill-appearance
Workup for necrotizing pancreatitis w/systemic inflammatory response
r/o bowel necrosis/perforation, abscess formation, biliary obstruction w/infection
Labored breathing and 90% pulse ox’ in the context of necrotizing pancreatitis
- Pulmonary edema d/t overhydration
- ARDS from systemic inflammatory response to pancreatitis
- Atelectasis
- Pneumonia
Presentation of a pancreatic abscess
- S/s of sepsis
- Fever
- Leukocytosis
- Septic shock
Evaluation for pancreatic abscess
Dynamic CT scan is most reliable w/contrast to evaluate the vascularity of the pancreas
Implication and workup for peripancreatic collection
- Sample via percutanous route under CT/US guidance. If large amount of WBCs or bacteria then dx = abscess w/abscess drainage (via surgical vs. percutaneous catheter)
If percutaneous pancreatic abscess drainage becomes bloody with sudden onset hypotension
Most likely erosion of catheter or abscess into a major artery (splenic, gastroduodenal, SMA, pancreatic vessel). Dx via angiography and with embolization to control bleeding
DDx for abdominal pain and elevated amylase in elderly patient
- Pancreatitis
- Mesenteric ischemia
- volvulus
Best approach to r/o pancreatitis
CT imaging shows edema of pancreas and surrounding tissue. If CT is not definitive then consider ex lap
Persistent sx of pancreatitis including elevated amylase, and early satiety
suspect pancreatic psuedocyst which may cause local compression on the posterior wall of the stomach causing early satiety. Best imaged via abd CT (small psuedocysts <8cm only req monitoring, NPO, and TPN). If patient improves then start feeding and continue to monitor amylase
Persistant pancreatic pseudocyst
Surgical intervention required if no resolution by 6wks. Cystogastrostomy (approach through the posterior stomach and drain the communicating pseudocyst) + biopsy to r/o cystadenoma or cystadenoCA of pancreas
DDx for RUQ mass
Simple cyst (cystic), hemangioma (solid), focal nodular hyperplasia, hepatic adenoma, metastatic CA, primary hepatocellular carcinoma, cholangiocarcinoma
Key history when assessing pt with RUQ mass
- Hx of OCP’s
- Environmental toxin exposure
- Hep B and C
- Hx of liver injury
- Primary liver tumors
- Sx of chronic liver disease (cirrhosis, polycystic kidney disease, primary kidney tumors)
Mgmt for simple liver cystic (no internal echoes)
Usually asymptomatic and does not require further mgmt. May cause hemorrhage, secondary bacterial infection, and obstructive jaundice.
If cysts persist then cyst may be aspirated and excised.
Mgmt for multilocular cyst w/calcifications in the wall AND internal echoes
Ecchinococcal cyst results from echinococcus granulosus. Inject the cyst with hypertonic saline followed by excision of the cyst (DO NOT allow contents to spill)
Mgmt of cystic lesion suggestive of abscess
IV ABx and CT-guided drainage.
Amebic abscess may be tx w/Metronidazole alone w/o surgery
DDx for SOLID liver lesion
- Hemangioma
- Focal nodular hyperplasia
- Hepatic adenoma (hx of OCP’s)
- Metastatic CA
- Hepatocellular CA (hx of hep B or C)
CT or MRI appearance of hemangioma
vascular lesion that fills from the periphery to the center
Labeled RBC scan indication
Dx of hemangioma - demonstrates a collection of ectatic vascular cavernous spaces lined by endothelium
Hepatic lesions with a high risk of bleeding and thus biopsy should be avoided
- Hepatic adenoma
2. Hemangioma
Focal nodular hyperplasia imaging and features
- Central stellate scar on CT
2. NOT premalignant
Mgmt of hepatic adenoma
- Discontinue OCP’s
- Resect persistent/large lesions d/t risk of hepatocellular CA and risk of rupture (esp during pregnancy - thus tx before pregnancy!)
Evaluation of extent of dz in HCC
- Chest and Abd CT to r/o lung mets and abd mets to the hepatic hilar LN’s, celiac nodes, and local extension into the diaphragm
Mgmt of HCC w/o mets
Surgical assessment of hepatic lesions.
Fever in IVDU pt
- Endocarditis
- Intra-abdominal abscess
- pancreatitis
- pneumonia
- UTI
Infected indwelling catheter
DDx for fever and RUQ pain + inc alk phos
- Complications of gallstones/
2. Complications of infxn such as cholangitis/liver abscess
Tools for studying liver masses
- Abdominal US reveals many hepatobiliary processes including liver abscesses and biliary obstruction or stone
- CT best identifies hepatic abscesses near the dome of the liver and visualizing other intra-abdominal lesions/abscesses and diverticulitis
Cause of liver abscesses
Partial/complete obstruction of the biliary system w/ or w/o spread of bacteria up the biliary tree
Indications for open drainage of abdominal abscesses
- Coexisting biliary pathology
- Failure of drained abscess to improve
- Surgery required for any other reason
