Pancreatic and Hepatic disorders

Question 0

What blood chemistries would you expect to be abnormal with a diagnosis of cholelithiasis?

Answer 0

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

Question 1

Differential diagnosis for RUQ pain?

Answer 1

“GPARPP”

Gastroenteritis, peptic ulcer disease, acute hepatitis, renal colic, pleural based pneumonia, pyelonephritis

Question 2

Next step after a diagnosis of acute cholecystitis with cholelithiasis?

Answer 2

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

Question 3

Management for a woman who is six months pregnant with symptomatic cholelithiasis.

Answer 3

Symptomatic cholelithiasis and gallstone pancreatitis can be managed non-operatively the majority of pregnant patients with hydration and pain management

Question 4

Management of biliary pancreatitis?

Answer 4

Cholecystectomy and operative cholangiography. A cholangiogram is mandatory with biliary pancreatitis.

Question 5

What is a cholangiogram?

Answer 5

Imaging of the bile duct with x-rays. PTC and ERCP. Fluorescent fluids used as contrast

Question 6

Ultrasound of the gallbladder reveals extension of fluid that has internal echoes and gallstones. Next step?

Answer 6

empyema of the gallbladder. IV antibiotics and EMERGENT EXPLORATION with cholecystectomy.

Question 7

Acute cholecystitis with dilated common bile duct, and air in the biliary system. Management?

Answer 7

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

Question 8

What is an emphysematous gallbladder?

Answer 8

Air in the wall of the gallbladder, indicates that a gas forming organism has invaded tissues. Requires urgent surgery

Question 9

Elderly patient with hypothermia and leukopenia?

Answer 9

Signs of sepsis in an elderly patient

Question 10

Basic steps in a patient with acute cholangitis?

Answer 10

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.

Question 11

Retained stone

Answer 11

A common duct stone occurring within two years after a cholecystectomy

Question 12

What is a primary common bile duct stone?

Answer 12

Stone appearing two years after a cholecystectomy

Question 13

S/p a cholecystectomy the patient develops postoperative fever and abdominal pain. What is the appropriate management?

Answer 13

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.

Question 14

s/p Cholecystectomy fever and pain develops, leak on HIDA Scan and a cystic duct stop leak on ERCP. Next step in management?

Answer 14

Biliary drainage with a temporary stent placed during ERCP.

Biliary drainage procedure (choledochojejunostomy) if complete obstruction of bile duct.

Question 15

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?

Answer 15

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)

Question 16

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?

Answer 16

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

Question 17

Endoscopic ultrasound allows you to visualize a 2 cm mass in the head of the pancreas. Is biopsy of the mass appropriate?

Answer 17

Most experienced pancreatic surgeons are comfortable proceeding with pancreatic exploration without a preoperative pathologic diagnosis.

Question 18

What preoperative findings make a patient inoperable with a confirmed pancreatic cancer?

Answer 18

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.

Question 19

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?

Answer 19

Likely Cholangiocarcinoma

• ERCP or percutaneous transhepatic cholangiography to demonstrate level of obstruction.
• Biopsies and cytology

Question 20

Next step with a diagnosed cholangiocarcinoma?

Answer 20

• 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

Question 21

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?

Answer 21

The five-year survival rate is still 15% for patients undergoing curative resection.

Question 22

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?

Answer 22

-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

Question 23

50-year-old woman with jaundice. Diagnosed with ampullary adenocarcinoma. What is the treatment and prognosis?

Answer 23

– Most require a Whipple to remove the lesion

– Survival at five years as high as 65%

Question 24

A 3-cm polyp in the gallbladder. Next step in management?

Answer 24

– Observation for small polyps

– If polyp > 2cm cholecystectomy because of the 7% – 10% risk of developing adenocarcinoma of the gallbladder

Question 25

A calcified gallbladder. The step in management?

Answer 25

Porcelain gallbladder, 50% association with adenocarcinoma and should be removed.

Question 26

How do you assess the patient’s mortality with severe necrotizing pancreatitis?

Answer 26

Ranson criteria:
3+ = 28%
5-6 = 40%
7-8 = 100%

Question 27

Ranson criteria on admission

Answer 27

Age >55 years
WBC > 16000
Glucose > 200
LDH > 350 IU/L
AST > 250 IU/L

Question 28

A CT scan shows a peri-pancreatic collection. What is the next step?

Answer 28

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

Question 29

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?

Answer 29

pancreatic pseudocyst. Confirm with CT of the abdomen

Question 30

Next step if CT shows a pseudocyst and the lesser sac that is 8 cm in diameter

Answer 30

NPO Feeding,TPN, observation.

Question 31

Indications for surgery for treatment of a pseudocyst?

Answer 31

Fails to improve by six weeks

Question 32

Ultrasound of the liver shows cystic lesion with no internal echoes

Answer 32

Suggestive of a simple cyst. Usually asymptomatic. Simple cyst needs no further management.

Question 33

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

Answer 33

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

Question 34

U/S of liver shows cystic lesion. Dx?

Answer 34

Abscess. Hepatic abscess usually presents with fever, elevated WBC count, tenderness

Question 35

Treatment for a hepatic abscess?

Answer 35

IV antibiotics and CT guided drainage. Resection can be avoided. Amoebic abscess may be treated with metronidazole alone.

Question 36

Ultrasound of the liver shows a solid appearing lesion. What is the differential diagnosis?

Answer 36

Hemangioma, focal nodular hyperplasia, hepatic adenoma, metastatic cancer, hepatocellular carcinoma.

HHFAM

Question 37

How do you confirm the diagnosis of a hemangioma?

Answer 37

Hey labels RBC scan is highly reliable

Question 38

A central stellate scar on CT scan

Answer 38

Focal nodular hyperplasia. Require a liver biopsy to establish a diagnosis. No treatment is indicated.

Question 39

Should large hepatic adenomas be removed?

Answer 39

Reset the persistent or large lesions for two reasons:

(1) known to develop into hepatocellular carcinoma HCC
(2) risk of RUPTURE

Question 40

Next step in management for firmed hepatocellular carcinoma?

Answer 40

Determine whether metastatic disease exists:

CT scan of the chest and abdomen to examine for local mets

Question 41

CT scan reveals multiple low-density lesions within both lobes of the liver peripheral rim enhancement. Diagnosis? What treatment is appropriate?

Answer 41

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

Question 42

Treatment if abscess of the liver show serologies positive for E. histolytica?

Answer 42

Treatment for amoebic abscesses is metronidazole alone