Pancreatic/Hepatic Surgery Flashcards
What is biliary disease progression?
Cholethiasis –> biliary colic –> acute cholecystitis
Choledocholitiasis –> ascending cholangitis or gallstone pancreatitis
How does cholelithiasis present?
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
What is biliary colic?
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
How does cholecystitis present?
Presents as fever, WBC>15, RUQ pain >6 hours; MC bacteria are E. coli, bacteroides fragilis, Klebsiella, enterococcus
How do you manage cholecystitis?
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
What are the indications for a cholecystecomy?
Symptomatic cholethiasis, acute cholecystitis, and cholangitis; do not operate on asymptomatic stones
What are the complications of a cholecystectomy?
Nicking the CBD (jaundice) or right hepatic artery (hepatitis)
How does a post-op biliary leak present?
Presents as Charcot’s triad; get an U/S and HIDA scan –> tx biliary drainage and temporary stent during ERCP
How does choledocholithiasis present?
Presents as transient jaundice and an increase in alk phos; dx U/S shows dilated bile ducts +/- ERCP, tx lap chole with CBD exploration
How does acute cholangitis present?
Presents as Charcot’s triad (jaundice, fever, RUQ pain) or Reynold’s pentad (shock, AMS) due to choledocolithiasis
How do you manage acute cholangitis?
IVF, antibiotics, and U/S –> ERCP to compress biliary tree –> finally, lap chole with CBD exploration
How do you manage gall bladder polyps?
2cm take it out due to risk of adenocarcinoma
How does gall bladder adenocarcinoma present?
Presents as a mass in GB fossa; dx with CT scan, tx with open chole + hilar LN resection + liver resection with negative margins
What is porcelain gall bladder?
Dystrophic calcification of gall bladder, has 50% risk of adenocarcinoma, take it out
What is jaundice?
Elevated bilirubin and yellowing of skin
Three types: hemolytic, obstructive, and hepatocellular
How do you manage hemolytic jaundice?
An increase in bilirubin (direct <20%), search for what is killing the RBCs
How do you manage hepatocellular jaundice?
INcrease in bilirubin (direct 20-50%) and increase in AST/ALT, consider HBV/HCV and alcoholism
How do you manage obstructive jaundice?
Increase in bilirubin (direct >50%) and increase in alk phos, caused by CBD stones and cancers
What is painless jaundice caused by? How do you manage it?
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.
How does pancreatic adenocarcinoma present?
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
How does acute pancreatitis present?
Presents as epigastric pain boring through to the back with an increase in lipase and amylase; amylase levels do not correlate with severity
What are the causes of pancreatitis?
idiopathic, gallstones, EtOH, trauma, steroids, mumps, autoimmune, scorpion sting, hypertriglyceridemia, hypercalcemia, ERCP, drugs
I GET SMASHED
What are the types of pancreatitis and how do you treat them?
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
How do pancreatic abscesses present?
Presents as septic shock 2 weeks after acute pancreatitis; dx dynamic CT scan, tx perc drain + antibiotics
How does a pseudocyst present?
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)
How does chronic pancreatitis present?
Presents as constant epigastric pain, steatorrhea, and diabetes in a chronic alcoholic
tx : insulin and pancreatic enzyme replacement
What is an echinococcal cyst?
Multilocular cyst with calcified walls due to parasite echinococcus granulosus; inject hypertonic saline inside cyst and carefully excise it
How do you treat a liver abscess?
Multiple/small bacterial abscesses–> IV antibiotics; single/large bacterial abscess –> perc drain; amebic abscess (Mexicans) –> metronidazole
What are the types of liver cancers and how are they treated?
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
What do you see with portal HTN?
Sx esophageal varices, caput medusa, hemorrhoids
Tx with TIPS (connect portal vein to hepatic vein to relieve pressure) as a “bridge to liver transplant”
