Pancreatic and Hepatic Disorders Flashcards
Cholecystectomies are NOT usually performed in ASYMPTOMATIC patients, with what 3 exceptions?
1) immunocompromised patients
2) patients with porcelain (calcified) gallbladder
3) gallstones >3cm (assoc. with gallbladder carcinoma)
T/F: A cholangiogram is mandatory with biliary pancreatitis.
True
A common duct stone occurring within __ years after a cholecystectomy is termed a retained stone, whereas one appearing after that timeframe is a primary common bile duct stone.
2 years
What is a good test for detecting biliary leaks? If a leak is found, what is the next step?
Hepatobiliary nuclide scan (HIDA scan)
Drain the leak. ERCP to define biliary anatomy; somteims a CT to rule out a hepatic abscess proximal to hepatic duct obstruction
How do you manage obstruction of the bile duct (post cholecystectomy) visulaized on HIDA and ERCP?
choledochojejunostomy
Why isn’t transcutaneous abdominal ultrasound the best method for visualizing the distal bile duct and pancreatic head area?
intestinal gas obscures the view
A pancreatic tumor is unresectable if it involves which 5 vessels? Which one cannot be assessed until later in the procedure after structures have been mobilized?
1) IVC
2) SMA (not always a contraindication)
3) SMV
4) aorta
5) portal vein (cannot be assessed until later in procedure)
Painless jaundice with dilated intrahepatic ducts but no dilation of the common bile duct:
Klatskin tumor (cholangiocarcinoma at the bifurcation of the haptic ducts). Diagnose via ERCP
Which has a higher cure rate: pancreatic adneocarcinomas or ampullary cancer?
Ampullary! Both treated with Whipple (pancreatoduodenectomy), as are duodenal tumors if it involves the ampulla
Why isn’t a laparoscopic cholecystectomy appropriate to treat gallbladder adenocarcinoma?
Doesn’t allow for the removal of hepatic tissue needed (need to have a resection of liver 2-3 cm margin around gallbladder as well as a hilar lymph node resection)
Cholecystectom yis warranted for removal of gallbladder polyps >__cm because of the 7-10% risk of developing adenocarcinoma of the gallbladder.
> 2 cm (smaller than that = observation)
If patients meet 3 Ranson criteria, mortality rate is ___
5 or 6, then rate ______-
7 or 8, then rate _________
3: 28%
5-6: 40%
7-8: 100%
Person with pancreatitis who initially improves but symptoms fail to resolve completely. Instead, continues to have moderate abdominal pain, anorexia, persistent elevation of serum amylase and inability to eat due to early satiety:
pancreatic pseudocyst
If a pseudocyst is present on CT and the patient fails to improve by __ weeks, surgical intervention is appropriate.
6 weeks
In addition to draining the pseudocyst (cystogastrostomy, for example), what is done in the treatment of a pancreatic pseudocyst that has lasted >6 weeks?
biopsy to make sure not a cystadenoma or cystadenocarcinoma
How does a simple cyst and a hydatid cyst look differently on ultrasound?
Simple = cystic lesion with no internal echoes Hydatid = multilocular with calcifications in the wall and internal echoes
What is the differential for a solid liver lesion?
hemangioma, FNH, hepatic adenoma, metastatic cancer, and HCC
A ________ is highly reliable in making the diagnosis of hemangioma, which is the most likely diagnosis in a solid liver lesion.
labeled RBC scan
If a labeled RBC scan is negative for hemangioma, what is the next step for diagnosis?
CT to distinguish between FNH, HCC, hepatic adenomas, and mets
A central stellate scar on CT is occasionally seen in what liver lesion?
FNH
HCC shoudl be resected with a __ cm margin.
1cm
Which have a worse prognosis: liver mets from colon cancer or from rectal cancer?
rectal
The treatment of multiple, small pyogenic liver abscesses is:
IV abx for 4-6 weeks. Larger abscesses are drained for 2-3 weeks while IV abx are given simultaneously
A single abscess in the right lobe is more likely to be (pyogenic/entamoebic)
entamoebic! treat with metronidazole
A history of diarrhea is more consistent with (pyogenic/entamoebic) liver abscesses.
Entamoebic (treat with flagyl)
They penetrate the bowel, go to portal vein and then to liver
What is the pathway from bilirubin in the serum to excretion through the urine?
Serum bound bilirubin –> hepatic free bilirubin –> hepatic conjugated bilirubin (to glucuronic acid) –> bile conjugated bilirubin –> GI tract conjugated bilirubin –> GI tract free bilirubin –> (oxidation to) GI tract free urobilinogen –> serum free urobilinogen –> urine free urobilinogen
Treatment of hydatid cysts can be accomplished with which three antibiotics?
albendazole, mebendazole, praziquantel (antihelminthic therapy)
High direct bilirubin in infant 3 months old. Consider what diagnosis?
Choledochal cysts. Treatment is surgical excision (hepaticojejunostomy)
Or biliary atresia!
What is the maximum portal system pressure (before risk of bleeding complications)?
12 mm Hg
The most common cause of cirrhosis WORLDWIDE is _____
In the US, it is _________
worldwide: Hep B
US: Hep C
Describe the blood supply of the gallbladder starting with the celical trunk.
Celiac trunk = left gastric, splenic, common hepatic common hepatic = proper hepatic, right gastric, and gastroduodenal proper hepatic = right and left hepatic arteries cystic artery (to gallbladder) comes off right hepatic artery. Left hepatic supplies left lobe of liver.
_______ induces RELAXATION of the gallbladder.
VIP. Also serves to increase the amoutn of water and electrolytes secreted in the bowel lumen
_______- acts to increase the amount of water and bicarbonate released from the pancreas and bile duct epithelium in order to buffer the acidic gastric contents.
Secretin
What are the two main types of pigment stones (far less common than cholesterol stones)?
Black = due to hemolytic anemia, cirrhosis Brown = due to parasitic infections
What findings on MRCP would be characteristic of PSC?
Bile duct has alternating areas of dilation and stricture, appearing beaded
Chronic pancreatitis is associated with what findings on MRCP?
ectasia of branches of the pancreatic duct
What are risk factors for gallbladder cancer?
Polyps >2.5 cm, Native American, choledochal cysts, PSC, cholecystoenteric fistula
What is the first imaging test used to try to diagnose cholangiocarcinoma?
Abdominal CT
What would pancreatic divisum show on MRCP? What does this condition predispose to?
separately draining dorsal and ventral pancreatic ducts. Pancreatitis symptoms occur in 1% of patients (but most are asymptomatic and it’s only discovered on autopsy)
What is the most common and initial manifestation of pancreatic disease in cystic fibrosis?
Exocrine failure (exocrine functions = bicarb and digestive enzyme secretions). Patients with CF will almost always require pancreatic enzyme supplements to help maintain growth and development.
What is the most common complication of chronic pancreatitis?
diabetes mellitus
What are contraindications to Whipple (pancreaticoduodenectomy)?
1) liver serosa involvement
2) invasion of the colonic mesentery
3) liver metastasis
4) invasion of the hepatoduodenal ligaments
5) metastasis to the portal vein, aorta, or vena cava
6) fixation by the tumor of the duodenum to underlying structures
What are contraindications to nonnoperative management of splenic injury?
1) high grade splenic injuries (indicated by contrast extravasation)
2) hemodynamic instability
3) generalized peritonitis
4) patients with additional intrabdominal injuries that require surgical repair/exploration
What are causes of massive splenomegaly?
thalassemia, CML, CLL, lymphomas, myelofibrosis (spleen becomes the primary site for hematopoiesis), polycythemia vera, metabolic diseases (Gauchers, Niemann-Pick disease), sarcoidosis, autoimmune hemolytic anemia, and malaria (to produce IgM by the B lymphocytes in the spleen).
What is the development site for T lymphocytes?
thymus
What are physical exam findings associated with acute necrotizing pancreatitis?
Cullen sign (superficial bruising and edema in the subcutaneous tissues surrounding the umbilicus) and Grey-Turner sign (retroperitoneal hemmorhage and flank bruising). Subcutaneous nodules may also be seen = fat necrosis.
What is the Trousseau sign of malignancy?
visible swollen venous vessels that resolve and appear around the body: migrating thrombophlebitis
