Pancreatic and Hepatic disorders Flashcards
What blood chemistries would you expect to be abnormal with a diagnosis of cholelithiasis?
Mild leukocytosis - WBC 12,000-15,000
Mild Jaundice - bilirubin 2-3 mg/dL in 20% of patients
Alkaline phosphatase and transaminase may be elevated
Differential diagnosis for RUQ pain?
“GPARPP”
Gastroenteritis, peptic ulcer disease, acute hepatitis, renal colic, pleural based pneumonia, pyelonephritis
Next step after a diagnosis of acute cholecystitis with cholelithiasis?
Obtain blood cultures
Abx for gram-negative rods and anaerobes postoperatively and for 24 hours after surgery
Second-generation cephalosporin is adequate
IVF
NPO
NG tube if nausea or vomiting
Plan for laparoscopic cholecystectomy in the next 48-72 hours
Management for a woman who is six months pregnant with symptomatic cholelithiasis.
Symptomatic cholelithiasis and gallstone pancreatitis can be managed non-operatively the majority of pregnant patients with hydration and pain management
Management of biliary pancreatitis?
Cholecystectomy and operative cholangiography. A cholangiogram is mandatory with biliary pancreatitis.
What is a cholangiogram?
Imaging of the bile duct with x-rays. PTC and ERCP. Fluorescent fluids used as contrast
Ultrasound of the gallbladder reveals extension of fluid that has internal echoes and gallstones. Next step?
empyema of the gallbladder. IV antibiotics and EMERGENT EXPLORATION with cholecystectomy.
Acute cholecystitis with dilated common bile duct, and air in the biliary system. Management?
Suppurative cholangitis - urgent decompression of the bile duct. Quick stabilization with IV fluids and antibiotics is essential.
Emergent ERCP with sphincterotomy, decompression of the biliary tree, stone removal if feasible
What is an emphysematous gallbladder?
Air in the wall of the gallbladder, indicates that a gas forming organism has invaded tissues. Requires urgent surgery
Elderly patient with hypothermia and leukopenia?
Signs of sepsis in an elderly patient
Basic steps in a patient with acute cholangitis?
Resuscitation, antibiotics, and an urgent ultrasound study of the biliary tree. ERCP and biliary decompression if obstruction or dilation of the common bile duct are seen.
Retained stone
A common duct stone occurring within two years after a cholecystectomy
What is a primary common bile duct stone?
Stone appearing two years after a cholecystectomy
S/p a cholecystectomy the patient develops postoperative fever and abdominal pain. What is the appropriate management?
Fever or pain may indicate an infection or biliary leak: U/S + HIDA
Two most useful tests are an abdominal ultrasound study and hepatobiliary nuclide scan (HIDA scan), great test to detect biliary leaks and acute cholecystitis.
s/p Cholecystectomy fever and pain develops, leak on HIDA Scan and a cystic duct stop leak on ERCP. Next step in management?
Biliary drainage with a temporary stent placed during ERCP.
Biliary drainage procedure (choledochojejunostomy) if complete obstruction of bile duct.
55-year-old man with jaundice. No pain but marked pruritus. Direct bilirubin of 6 mg/dL, normal AST, ALT, alk phos is 6x normal. What is the differential diagnosis?
Cancer of the head of the pancreas Periampullary carcinoma Cholangiocarcinoma –Klaskin tumor Stricture of the common bile duct Common bile duct stone impacted in the ampulla (but these typically result in intermittent symptoms of abdominal pain, jaundice, fever, chills, thus they do not fit this picture)
55-year-old man with jaundice. No pain but marked pruritus. Direct bilirubin of 6 mg/dL, normal AST, ALT, alk phos is 6x normal. What is the next step in management?
Abdominal ultrasound study to visualize the common bile duct
CT of abdomen
Transcutaneous abdominal ultrasound is not the best method for visualizing the distal bile duct and pancreatic head area because intestinal gas obscures the view
Endoscopic ultrasound allows you to visualize a 2 cm mass in the head of the pancreas. Is biopsy of the mass appropriate?
Most experienced pancreatic surgeons are comfortable proceeding with pancreatic exploration without a preoperative pathologic diagnosis.
What preoperative findings make a patient inoperable with a confirmed pancreatic cancer?
Acceptable general medical condition, no evidence of distance metastasis in a normal chest x-ray and no neurologic symptoms pain. CT scan and EUS require careful evaluation to check for evidence of local invasion of the portal vein, nearby structures, local lymph nodes. The liver must be free of metastatic lesions.
60-year-old male with painless jaundice. An abdominal ultrasound shows dilated intrahepatic ducts but no dilation of the common bile duct. What is the next step?
Likely Cholangiocarcinoma
- ERCP or percutaneous transhepatic cholangiography to demonstrate level of obstruction.
- Biopsies and cytology
Next step with a diagnosed cholangiocarcinoma?
- Klatskin tumors are associated with a poor prognosis – high rate of vascular invasion, unresectability, and metastatic disease.
- If no evidence for unresectability or metastasis is evident on CT, exploration with resection of the bile ducts and gallbladder.
- most tumors are unresectable
You perform a complete resection of the primary cholangiocarcinoma at the hepatic duct bifurcation. The patient recovers and asks about his prognosis. What is your response?
The five-year survival rate is still 15% for patients undergoing curative resection.
Patient diagnosed with primary cholangiocarcinoma. You perform only palliative stenting of the hepatic duct strictures after finding unresectable cholangiocarcinoma with local spread. What is the prognosis?
-Five-year survival rate is less than 5%.
m/c cause of death is locally invasive disease.
Neither radiation nor chemotherapy has any proven long-term benefit
50-year-old woman with jaundice. Diagnosed with ampullary adenocarcinoma. What is the treatment and prognosis?
– Most require a Whipple to remove the lesion
– Survival at five years as high as 65%
A 3-cm polyp in the gallbladder. Next step in management?
– Observation for small polyps
– If polyp > 2cm cholecystectomy because of the 7% – 10% risk of developing adenocarcinoma of the gallbladder
A calcified gallbladder. The step in management?
Porcelain gallbladder, 50% association with adenocarcinoma and should be removed.
How do you assess the patient’s mortality with severe necrotizing pancreatitis?
Ranson criteria:
3+ = 28%
5-6 = 40%
7-8 = 100%
Ranson criteria on admission
Age >55 years WBC > 16000 Glucose > 200 LDH > 350 IU/L AST > 250 IU/L
A CT scan shows a peri-pancreatic collection. What is the next step?
Sampling by a percutaneous route under CT scan or ultrasound guidance
WBC or bacteria, diagnosis of an abscess is appropriate, abscess drainage is essential.
– Drain either surgically or percutaneously with a catheter
34-year-old alcoholic man who has developed acute pancreatitis initially improves but continues to have moderate abdominal pain, anorexia, persistent elevation of serum amylase, inability to eat due to early satiety. Diagnosis?
pancreatic pseudocyst. Confirm with CT of the abdomen
Next step if CT shows a pseudocyst and the lesser sac that is 8 cm in diameter
NPO Feeding,TPN, observation.
Indications for surgery for treatment of a pseudocyst?
Fails to improve by six weeks
Ultrasound of the liver shows cystic lesion with no internal echoes
Suggestive of a simple cyst. Usually asymptomatic. Simple cyst needs no further management.
Multilocular cyst with calcifications in the wall and internal echoes of ultrasound of the liver
Treatment is aimed at operative sterilization by injecting hypertonic saline followed by excision
echinococcal cyst from echinococcus granulosis, a GI parasite.
Serologic tests usually positive
Treatment is aimed at operative sterilization of the system by injecting hypertonic saline followed by excision of the cyst
U/S of liver shows cystic lesion. Dx?
Abscess. Hepatic abscess usually presents with fever, elevated WBC count, tenderness
Treatment for a hepatic abscess?
IV antibiotics and CT guided drainage. Resection can be avoided. Amoebic abscess may be treated with metronidazole alone.
Ultrasound of the liver shows a solid appearing lesion. What is the differential diagnosis?
Hemangioma, focal nodular hyperplasia, hepatic adenoma, metastatic cancer, hepatocellular carcinoma.
HHFAM
How do you confirm the diagnosis of a hemangioma?
Hey labels RBC scan is highly reliable
A central stellate scar on CT scan
Focal nodular hyperplasia. Require a liver biopsy to establish a diagnosis. No treatment is indicated.
Should large hepatic adenomas be removed?
Reset the persistent or large lesions for two reasons:
(1) known to develop into hepatocellular carcinoma HCC
(2) risk of RUPTURE
Next step in management for firmed hepatocellular carcinoma?
Determine whether metastatic disease exists:
CT scan of the chest and abdomen to examine for local mets
CT scan reveals multiple low-density lesions within both lobes of the liver peripheral rim enhancement. Diagnosis? What treatment is appropriate?
Liver abscesses may be either pyogenic (bacterial spread) or amebic (entamoeba histolytica)
Preferred treatment of multiple, small pyogenic abscesses is broad-spectrum IV antibiotics for 4–6 weeks.
Large, single pyogenic liver abscess – percutaneous drainage via radiologic guidance
Treatment if abscess of the liver show serologies positive for E. histolytica?
Treatment for amoebic abscesses is metronidazole alone
