Pancreatic/Hepatic Surgery

Question 1

What is biliary disease progression?

Answer 1

Cholethiasis –> biliary colic –> acute cholecystitis

Choledocholitiasis –> ascending cholangitis or gallstone pancreatitis

Question 2

How does cholelithiasis present?

Answer 2

Presents as nausea, vomiting, RUQ pain without fever, only 15-20% are symptomatic
IN pregnancy: manage non-op i possible; elective lap chole can be done after delivery

Question 3

What is biliary colic?

Answer 3

Fatty meal –> CCK release –> gall bladder contraction against non-lodged stone resulting in transient RUQ pain for <6 hours; labs are usually normal if episode has passed

Question 4

How does cholecystitis present?

Answer 4

Presents as fever, WBC>15, RUQ pain >6 hours; MC bacteria are E. coli, bacteroides fragilis, Klebsiella, enterococcus

Question 5

How do you manage cholecystitis?

Answer 5

Dx abdominal u/s, order CBC and LFTs, tx lap chole within 72 hours

• elderly patients respond to sepsis with hypothermia and decreased WBC
• tx with cipro and metronidazole to cover GNR and anaerobes

Question 6

What are the indications for a cholecystecomy?

Answer 6

Symptomatic cholethiasis, acute cholecystitis, and cholangitis; do not operate on asymptomatic stones

Question 7

What are the complications of a cholecystectomy?

Answer 7

Nicking the CBD (jaundice) or right hepatic artery (hepatitis)

Question 8

How does a post-op biliary leak present?

Answer 8

Presents as Charcot’s triad; get an U/S and HIDA scan –> tx biliary drainage and temporary stent during ERCP

Question 9

How does choledocholithiasis present?

Answer 9

Presents as transient jaundice and an increase in alk phos; dx U/S shows dilated bile ducts +/- ERCP, tx lap chole with CBD exploration

Question 10

How does acute cholangitis present?

Answer 10

Presents as Charcot’s triad (jaundice, fever, RUQ pain) or Reynold’s pentad (shock, AMS) due to choledocolithiasis

Question 11

How do you manage acute cholangitis?

Answer 11

IVF, antibiotics, and U/S –> ERCP to compress biliary tree –> finally, lap chole with CBD exploration

Question 12

How do you manage gall bladder polyps?

Answer 12

2cm take it out due to risk of adenocarcinoma

Question 13

How does gall bladder adenocarcinoma present?

Answer 13

Presents as a mass in GB fossa; dx with CT scan, tx with open chole + hilar LN resection + liver resection with negative margins

Question 14

What is porcelain gall bladder?

Answer 14

Dystrophic calcification of gall bladder, has 50% risk of adenocarcinoma, take it out

Question 15

What is jaundice?

Answer 15

Elevated bilirubin and yellowing of skin

Three types: hemolytic, obstructive, and hepatocellular

Question 16

How do you manage hemolytic jaundice?

Answer 16

An increase in bilirubin (direct <20%), search for what is killing the RBCs

Question 17

How do you manage hepatocellular jaundice?

Answer 17

INcrease in bilirubin (direct 20-50%) and increase in AST/ALT, consider HBV/HCV and alcoholism

Question 18

How do you manage obstructive jaundice?

Answer 18

Increase in bilirubin (direct >50%) and increase in alk phos, caused by CBD stones and cancers

Question 19

What is painless jaundice caused by? How do you manage it?

Answer 19

Caused by biliary obstructive tumors (ampullary cancer, duodenal cancer, cholangiocarcinoma, pancreatic adenocarcinoma)
Manage by CT scan then ERCP, tx with Whipple if no mets or local invasion
If there is also an occult bleed, this indicated ampullary cancer. Whipple is still the procedure.

Question 20

How does pancreatic adenocarcinoma present?

Answer 20

Presents as obstructive jaundice, get a CT scan; cancer in head –> tx Whipple
in body or tail –> distal pancreatectomy,
mets or local invasion –> palliative care

Question 21

How does acute pancreatitis present?

Answer 21

Presents as epigastric pain boring through to the back with an increase in lipase and amylase; amylase levels do not correlate with severity

Question 22

What are the causes of pancreatitis?

Answer 22

idiopathic, gallstones, EtOH, trauma, steroids, mumps, autoimmune, scorpion sting, hypertriglyceridemia, hypercalcemia, ERCP, drugs
I GET SMASHED

Question 23

What are the types of pancreatitis and how do you treat them?

Answer 23

Edematous pancreatitis: get amylase/lipase, then NPO, IVF, pain meds
Hemorrhagic pancreatitis: presents as MSOF, ARDS, and hemodynamic instability; send to ICU for resuscitation and serial CTs
Ischemic pancreatitis: Dx no blood flow to the pancreas on contrast CT, tx IV abx and resection
Gallstone pancreatitis: if amylase returns to normal –> lap chole + cholangiogram; if complicated, ERCP to remove stone

Question 24

How do pancreatic abscesses present?

Answer 24

Presents as septic shock 2 weeks after acute pancreatitis; dx dynamic CT scan, tx perc drain + antibiotics

Question 25

How does a pseudocyst present?

Answer 25

Abdominal pain and early satiety 5 weeks after acute pancreatitis, tx cystogastrostomy only if it's symptomatic and has been present for 6+ weeks (must get bx with frozen epithelial section and see no epithelial lining before the ostomy since epithelium indicates cancer)

Question 26

How does chronic pancreatitis present?

Answer 26

Presents as constant epigastric pain, steatorrhea, and diabetes in a chronic alcoholic tx : insulin and pancreatic enzyme replacement

Question 27

What is an echinococcal cyst?

Answer 27

Multilocular cyst with calcified walls due to parasite echinococcus granulosus; inject hypertonic saline inside cyst and carefully excise it

Question 28

How do you treat a liver abscess?

Answer 28

Multiple/small bacterial abscesses--> IV antibiotics; single/large bacterial abscess --> perc drain; amebic abscess (Mexicans) --> metronidazole

Question 29

What are the types of liver cancers and how are they treated?

Answer 29

hepatic adenoma: often presents as hypovolemic shock and distended abdomen, related to OCPs and anabolic steroid abuse; tx d/c OCP, if it persists, resent due to possibility of rupture focal nodular hyperplasia: dx central stellate scar or sunburst pattern on CT scan, no OCP relationship, leave alone even if symptomatic hemangioma: leave alone hepatoma: presents as vague RUQ pain and mass related to HBV/HCV and cirrhosis with an increase in alpha FP; dx CT scan then tx resection with negative margins

Question 30

What do you see with portal HTN?

Answer 30

Sx esophageal varices, caput medusa, hemorrhoids | Tx with TIPS (connect portal vein to hepatic vein to relieve pressure) as a "bridge to liver transplant"