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Surgery NBME > Pancreatic and Hepatic Disorders > Flashcards

Pancreatic and Hepatic Disorders Flashcards

1
Q

first test to do in pt with sx. of biliary colic

A

USG

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2
Q

USG finding of gallstones in asymptomatic pt - management?

A

elective cholecystectomy not recommended unless pt is IC, has porcelain gallbladder or stones > 3 cm in size

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3
Q

tx. of symptomatic gallstones

A

elective cholecystectomy

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4
Q

what USG findings are suggestive of gallbladder disease?

A

thickened gallbladder wall
pericholecystic fluid
presence of gallstones

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5
Q

what type of medications usually help the symptoms of biliary colic?

A

anti-cholinergic medications

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6
Q

does a patient with uncomplicated, symptomatic cholelithiasis require antibiotics?

A

no - just single preop dose of first gen. cephalosporin

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7
Q

major complication of cholecystectomy?

A

injury to common bile duct

- may result in chronic biliary strictures, infection and even cirrhosis

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8
Q

what symptoms will make you think of acute cholecystitis?

A

symptoms of biliary colic along with high WBC count, fever, elevated ALP and signs of peritoneal irritation

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9
Q

tx. approach in acute cholecystitis

A
  1. antibiotics after obtaining culture (2nd gen. cephalosporin)
  2. IVF, NPO and NGT (if nausea/vomiting)
  3. laparoscopic cholecystectomy in 48-72 hours
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10
Q

what is an alternate way to diagnose acute cholecystitis?

A

HIDA scan

- see uptake in liver, CBD and duodenum but no uptake of material in gallbladder

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11
Q

a patient with symptomatic cholelithiasis is admitted with elevated ALP and bilirubin - what do you suspect? what next test do you do?

A
  1. obstruction of CBD

2. USG - will show dilated bile ducts

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12
Q

tx. of common bile duct obstruction

A

ERCP followed by laparoscopic cholecystectomy

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13
Q

what do you do if a pregnant patient presents with symptomatic gallstones?

A

manage non-operatively with hydration and pain medication; cholecystectomy after pregnancy

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14
Q

pt with symptomatic gallstones has an elevated serum amylase?

A

biliary pancreatitis

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15
Q

tx. of biliary pancreatitis

A

conservative - NPO, NGT, IVF
- amylase usually returns to normal quickly and then cholecystectomy can be performed (with intraoperative cholangiogram)

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16
Q

USG examination shows a gallbladder that is distended with fluid that has internal echoes and gallstones - dx?

A

empyema of gallbladder

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17
Q

tx. of empyema of gallbladder

A

IV antibiotics
emergent exploration w/ cholecystectomy
- if risk of surgery too high, percutaneous cholecystostomy to drain gallbladder

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18
Q

USG shows previous removal of gallbladder, dilated CBD and air in the biliary system - dx?

A

suppurative cholangitis

- bacterial infection with bile duct obstruction

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19
Q

tx. of suppurative cholangitis

A

urgent decompression of bile duct (ERCP w/ spincterotomy)

IVF and antibiotics

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20
Q

how might elderly patients present with sepsis?

A

signs of hypothermia and leukopenia

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21
Q

palpable gallbladder in patient with high fever and signs of sepsis

A

inflamed gallbladder

- emergent cholecystectomy after resuscitation due to high risk of rupture (high mortality)

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22
Q

air in the wall of the gallbladder

A

emphysematous gallbladder

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23
Q

basic steps in evaluation and tx of acute cholangitis?

A
  1. resuscitation and antibiotics
  2. urgent USG
  3. ERCP and biliary decompression
  4. cholecystectomy once stable
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24
Q

CBD stone occuring w/in 2 years after a cholecystectomy

A

retained stone

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25
Q

CBD stone occuring after 2 years post cholecystectomy

A

primary CBD stone

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26
Q

tx, if biliary stricture

A

surgical exploration and bypass with choledochojejunostomy

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27
Q

post-op fever and abdominal pain in a pt after cholecystectomy

A

can be either infection or biliary leak

  • order an abdominal USG or HIDA scan
  • maybe CT scan to R/O hepatic abscess
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28
Q

what do you do if you find a biliary leak or obstruction following cholecystectomy?

A

ERCP

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29
Q

USG of pt with painless jaundice shows dilated intrahepatic ducts but no dilation of the common bile duct - what do you suspect?

A

cholangiocarcinoma - Klatskin tumor

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30
Q

Klatskin tumor

A

tumor of the biliary tree at the bifurcation of the hepatic ducts

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31
Q

next step after finding dilated intrahepatic bile ducts on USG?

A

ERCP or percutaneous transhepatic cholangiogram w/ biopsy and cytology

  • not CT
  • looking for cholangiocarcinoma
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32
Q

tx. of ampullary adenocarcinoma

A

Whipple’s procedure if resectable

- much better prognosis than pancreatic or biliary cancer

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33
Q

tx. of duodenal adenocarcinoma

A
  • if it involves ampulla - Whipple’s
  • if in first or fourth segment - segmental resection
  • usually have worse prognosis due to involvement of nearby structures
34
Q

you find a mass in the gallbladder fossa on USG - what test do you do next? what do you suspect?

A
  • should do a CT scan

- suspect malignant gallbladder adenocarcinoma

35
Q

tx. of gallbladder carcinoma

A
  • open cholecystectomy with wedge resection of liver (2-3 cm margin) and hilar node resection
36
Q

tx. of gallbladder polyps

A

> 2 cm = cholecystectomy

smaller polyps are usually observed

37
Q

patient with pancreatitis with a drain for pancreatic abscess suddenly becomes hypotensive and has blood in the drain - what do you suspect?

A

erosion of the catheter or abscess into a major artery (splenic, gastroduodenal or SMA)

  • dx. with angiography
  • tx. embolization
38
Q

cystic lesion with no internal echoes found in liver - what might this be? what do you do next?

A
  1. simple cyst

2. no further management required - usually asymptomatic

39
Q

liver USG finding of multilocular cyst with calcifications in the wall and internal echoes - what might this be? management?

A
  1. echinococcal cyst
  2. tx. operative sterilization with injection of hypertonic saline followed by excision of cyst taking extreme caution not to spill
40
Q

you suspect a cavernous hemangioma on USG - how can you confirm the diagnosis?

A
  1. labelled RBC scan

2. bolus enhanced CT or MRI scan - vascular lesion that fills from the periphery to the centre

41
Q

tx. of liver hemangioma

A

usually asymptomatic and found incidentally; removal is not warranted

42
Q

indications for surgical removal of benign hepatic masses

A
  1. symptomatic lesions
  2. lesions with high risk of spontaneous rupture
  3. lesions with uncertainty of diagnosis
43
Q

which two liver lesions have high risk of bleeding with biopsy?

A

hemangioma

hepatic adenoma

44
Q

CT scan shows a liver lesion with a central stellate scar - what do you do next? and what is your tx?

A
  1. liver biopsy to establish diagnosis of focal nodular hyperplasia
  2. no tx. indicated
45
Q

what is the tx. for hepatic adenoma?

A

surgical resection if large or persistent due to risk of rupture and HCC development

46
Q

preferred tx. for multiple, small pyogenic liver abscesses

A

broad spec. IV antibiotics for 4-6 weeks

47
Q

first test to do in suspected liver cancer?

A

CT scan of abdomen and chest

48
Q

diagnostic test to confirm ruptured hepatic adenoma?

49
Q

tx. of pyogenic liver abscess

A

drainage - either percutaneously or surgically

IV antibiotics

50
Q

tx of multiple, small pyogenic liver abscesses

A

IV antibiotics for 4-6 weeks

51
Q

tx. of amebic abscess

A

metronidazole

paromomycin - to eliminate intraluminal cysts

52
Q

features of hemolytic jaundice

A

bilirubin 6-8 - mostly UCB, no CB

no bile in urine

53
Q

management of obstructive jaundice- first test?

A

USG - look for dilated intrahepatic ducts

54
Q

next test after USG in obstructive jaundice?

A

ERCP - possibly w/ stone removal if due to gallstones

55
Q

pt comes in with progressive obstructive jaundice and weight loss; on USG you see dilated intra/extrahepatic ducts and a very distended, thin-walled gallbladder - dx?

A

malignant obstructive jaundice

- MCC is adenoca of head of pancreas, ampulla of vater or cholangiocarcinoma

56
Q

Courvoisier-Terrier sign

A

dilated intrahepatic and extrahepatic ducts with a very distended, thin-walled gallbladder

57
Q

an USG finding shows thin-walled, distended gallbladder in pt with jaundice - next steps?

A

CT scan

ERCP - if CT scan is not diagnostic

58
Q

pt with obstructive jaundice also has postive FOBT and anemia - dx?

A

likely ampullary carcinoma - can bleed into lumen of duodenum

59
Q

dx. of ampullary carcinoma

60
Q

in addition to obstructive jaundice and distended gallbladder on USG, what are the characteristic pain findings in pancreatic cancer?

A

persistent, nagging mild pain deep in epigastrium and upper back

61
Q

you suspect pancreatic cancer, you do a CT scan and no mass is seen - what is the next step?

A

upper endoscopy with EUS

62
Q

what features deem a pancreatic cancer unresectable?

A

distant mets
local invasion of visceral vessels
LN mets in periaortic or celiac nodes

63
Q

indications for removal of gallbladder in asymptomatic patients?

A

immunocompromised patients
porcelain gallbladder
stones > 3 cm

64
Q

pt has signs of biliary colic along with sx of peritoneal irritation, fever and elevated WBC count - dx?

A

acute cholecystits

65
Q

when do you suspect acute cholangitis?

A

signs of biliary colic, peritoneal irritation, high fever, elevated WBC count, elevated bilirubin and ALP

66
Q

Reynold’s pentad

A 
RUQ pain
high fever
jaundice
confusion (neuro sx.)
hypotension (shock)
67
Q

how do you confirm dx of acute cholangitis?

A

USG - will show dilated ducts

68
Q

tx of acute cholangitis

A

IV antibiotics and emergent decompression with ERCP –> follow with cholecystectomy once pt stable

69
Q

tx of biliary pancreatitis if pt does not improve or deteriorates on conservative tx

A

ERCP w/ sphincterectomy

70
Q

older patient presents with abdominal pain and increased amylase levels - next step?

A

must R/O other causes such as mesenteric ischemia or volvulus
- order CT scan

71
Q

signs of acute pancreatitis, elevated amylase and high hematocrit

A

acute edematous pancreatitis

72
Q

management of hemorrhagic pancreatitis

A

intensive support in ICU

serial CT scans daily

73
Q

about 10 days after onset of pancreatitis, patient begins to spike fever and has leukocytosis - what are you considering? what test do you order?

A

pancreatic abscess

- order CT scan with contrast

74
Q

tx of pancreatic abscess

A

drainage

imipenem or meropenem (pts with seizures)

75
Q

2 most common ways of presentation of pancreatic pseudocyst

A
  • can occur few weeks after tx of pancreatitis OR after blunt trauma to the abdomen in a car accident for ex
76
Q

CF in pancreatic pseudocyst

A 
vague upper abdominal discomfort
early satiety (pressure symptoms)
ill-defined epigastric mass
77
Q

diagnostic test of choice for pancreatic pseudocyst

78
Q

approach to management of pancreatic pseudocyst

A

smaller than 6 cm - observe for spontaneous resolution

> 6 cm or 6 weeks - surgical intervention

79
Q

best surgical tx. for pancreatic pseudocysts

A

endoscopic cystogastrostomy

- always take biopsy to ensure it is actually inflammatory

80
Q

best diagnostic test in chronic pancreatitis

A

ERCP - chain of lakes appearance

Surgery NBME (16 decks)

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