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Surgery - Hepatobiliary, Pancreas Flashcards

1
Q

Acalculous cholecystitis

  • seen in who?
  • pathogenesis
  • imaging shows
A

Most often seen in pts chronically hospitalized in ICU w/

  • multiorgan failure
  • severe trauma
  • surgery
  • burns
  • sepsis
  • prolonged IV

Most likely due to cholestasis and gallbladder ischemia —> secondary infection by enteric organisms —-> edema of gallbladder serosa —> necrosis of gallbladder

Imaging shows:

  • gallbladder distention
  • wall thickening
  • presence of pericholecystic fluid
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2
Q

Tx acalculous cholecystitis

A

1) Abx
2) Percutaneous cholecystostomy
3) Cholecystectomy + drain abscesses after med condition improves

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3
Q

Most common causes of acute pancreatitis

A 
Gallstones
- if stable, should get cholecystectomy
EtOH
Hyper triglyceridemia
Recent ERCP
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4
Q

Blood supply to pancreas

A

Splenic A - body + tail

SMA - head

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5
Q

What do you not want to do in pt w/ severe COPD + acute cholecystitis?

A

Laproscopy
- can get increased CO2 absorption into blood

Do open cholecystectomy or cholecystostomy

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6
Q

Results of a HIDA scan

A

Normal.
A normal result means that the radioactive tracer moved freely along with the bile from your liver into your gallbladder and small intestine. No problems were detected.

Slow movement of radioactive tracer.
If the radioactive tracer moves through your bile ducts very slowly, this may indicate a blockage or obstruction, or a problem in liver function.

No radioactive tracer seen in the gallbladder.
If the radioactive tracer isn’t seen in your gallbladder, this may indicate acute inflammation (acute cholecystitis).

Abnormal low gallbladder ejection fraction.
If the amount of radiotracer leaving the gallbladder is low after giving the medication CCK, this may indicate chronic inflammation (chronic cholecystitis).

Radioactive tracer detected in other areas.
If the radioactive tracer is found outside of your biliary system, this may indicate a leak

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7
Q

What causes relaxation of sphincter of oddi?

A

CCK

Glucagon

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8
Q

What causes contraction of sphincter of oddi?

A

Morphine

Meperidine DOES NOT so use this for pain for cholecystitis

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9
Q

Best way to eval liver function in:

  • acute Hep B
  • chronic hep B
A

Acute

  • LFTs
  • viral serology

Chronic
- liver bx

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10
Q

Imaging pancreatic cancer

A

CT

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11
Q

Hepatic metabolism of bilirubin

A

Uptake from bloodstream
Store in hepatocyte
Conjugate w/ glucuronic acid
Biliary excretion

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12
Q

Gilbert’s syndrome

A

mildly decreased UDP glucuronyl transferases (glucornidate stuff)
- will have mildly increased unconj hyperbilirubinemia

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13
Q

Which chronic hepatitis is more likely to have waxing and waning transaminase levels and arthralgias?

A

Hep C

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14
Q

Extrahepatic sequelae of hep C

A

Cryoglobulinemia
Porphyria cutanea tarda
Glomerulonephritis

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15
Q

Tx primary biliary cirrhosis

A

Ursodeoxycholic acid (slows disease progression, relieves sx)

Methotrexate
Colchicine

Liver transplant in advanced

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16
Q

If CT of pancreas w/ IV contrast doesn’t have the pancreas show up, what happened?

A

Necrosis of pancreas

Do an FNA bx and gram stain

Tx w/ necrosectomy after waiting 4 weeks

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17
Q

Courvoisier-Terrier sign

A

In malignant obstruction

Large thin walled distended gallbladder

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18
Q

Tx peritonitis

A

abx

NOT SURGERY

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19
Q

Key to establishing edematous nature of acute pancreatitis

A

Elevated hematocrit

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20
Q

Tx for infected pancreatitis

A

IV imipenem or meropenem

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21
Q

How long before pancreatitc pseudocyst shows up?

A

5 weeks

CT or US to dx

Smaller cysts = observe

Bigger cysts = drain percutaneously or surgically into GI tract or endoscopically into stomach

22
Q

Liver supplied by?

Drained by?

A
  • Supplied by hepatic portal v + hepatic A

- Drained by hepatic vein

23
Q

HCC

  • description
  • management
A

In ppl w/ cirrhosis
Vague RUQ discomfort + wt loss
a-fetoprotein marker

CT scan to show extent
Resection if ok

24
Q

Mets to liver

  • description
  • management
A

Outnumbers primary liver ca 20:1
Suspected in ppl w/ previous colon ca and rising CEA

CT scan to dx
Resection if 1 lobe only
Radioablation too

25
Hepatic adenoma - description - management
Due to birth control pills Can rupture and bleed inside ab CT dx Emergency surgery
26
Pyogenic liver abscess - description - management
Most often in biliary tract disease (eg acute ascending cholangitis) Fever + Inc WBC + Tender liver Sonogram or CT to dx Percutaneous drainage
27
Amebic abscess of liver - diagnosis - treatment
Dx: serology (amoeba doesn’t grow in pus) Tx: Metronidazole empirically No drainage needed unless no response to metronidazole
28
Hemolytic jaundice - characteristics
Mildly elevated bilirubin ↑ Unconj bilirubin Nl conj bilirubin No bile in urine
29
Hepatocellular jaundice - characteristics
High unconj + conj bilirubin High AST, ALT Modest inc ALP Ex: Hepatitis
30
Obstructive jaundice - characteristics
High uncoj + conj bilirubin High ALP Work up w/ US (dilatation of biliary ducts)
31
How to dx obstructive jaundice 2/2 obstructive tumor
o Endoscopy can show ampullary cancers | o Cholangiogram can show intrinsic tumors from duct or small pancreatic cancer pushing ducts from outside
32
Asymptomatic gallstones - description - management
Usually benign, only < 10% get symptoms needing surgery NO surgery
33
Biliary colic - description - management
Stone block cystic duct Episodes self-limited, usually stopped w/ Anti-cholinergics US = gallstones --> YES surgery (elective cholecystectomy)
34
Acute cholecystitis - description - management
Constant pain Fever + Inc WBC US - Thickening of gallbladder wall - Pericholecystic fluid - Presence of gallstones - Dilatation of cystic duct HIDA scan - No uptake in gallbladder Tx: NG suction, NPO, IV fluids, abx Start abx after get blood cx – usually Gn – rods and anaerobes (e. coli, enterobacter) so use 2nd gen cephalosporin Same day cholecystectomy (48-72 hrs) Emergency percutaneous drain if very sick
35
Ascending cholangitis - description - management
Stones in CBD Febrile, WBC, increased bilirubin and HIGH ALP IV abx + ERCP to decompress CBD - Can also do perc drain or surgery to decompress Surgery: T tube into duct Eventual cholecystectomy
36
Biliary pancreatitis - description - management
Stones in ampulla ---| pancreatic and biliary ducts US to see stones Tx: NPO, NGT, IVF - ERCP + sphincterotomy to dislodge stone Elective cholecystectomy later
37
Cholecystectomy complications
- Pneumoperitoneum | - Ligation of CBD ---> liver damaged
38
What do you do with acute cholecystitis in preggers?
o Nonoperative management – hydration + pain management; can do surgery or ERCP though
39
Abx for acute cholecystitis?
Not needed Clean contaminated surgery o Do 1 preop dose of 1st gen cephalosporin
40
Biliary neoplasms
Klatskin tumor = tumors of biliary tree at bifurcation of hepatic ducts o Do ERCP or percutaneous transhepatic cholangiography to demonstrate level of obstruction o Poor prognosis b/c lots of vascular invasion + usually unresectable Porcelain gallbladder (calcified) has 50% assoc w/ adenocarcinoma and should be removed
41
Tx pancreatitis
- Tx: NPO, IVF, pain control, observation - If 2/2 to gallstones, when amylase decreases and pt improves, to lap chole - Amylase does not correlate w/ severity of pancreatitis or prognosis - Many pseudocysts resove in 6 wks
42
Ranson's Criteria
Evaluates pancreatitis (2/2 gallstone) severity; >=3 is severe “WALLG 48 FOCHUB” - WBC >16 - Age >55yr - LDH >350 - Liver enzymes (AST > 250) - Glucose >200 After 48 hrs: - Fluid sequestration > 6L - pAO2 < 60 - Ca < 8 - Hct > 10% decrease - Urea increased by 5 or more after IV hydration - Base deficit > 4 mEq/L
43
6-8 week old baby + persistent progressively increasing jaundice What do you suspect?
Biliary atresia Serologies + sweat test to r/o HIDA scan after 1 wk of phenobarbital - if no bile reaches duodenum, even with phenobarbital, surgical exploration needed
44
Hemobilia associations
Associated with Quincke triad: - RUQ ab pain - jaundice - GI bleeding
45
Why do you get sweaty w/ hypoglycemia?
B/c epi release 2/2 hypoglycemia triggers sweating, weakness, tachy
46
Tx iatrogenic injury to CBD resulting in biliary stricture
Roux en Y choledochojejunostomy
47
Tx echinococcal liver cysts
+ silver nitrate or hypertonic saline into cyst Resection Be careful of leakage causing anaphylaxis!
48
Choledochoal cysts - what do you dp?
Resect using Roux en Y choledochojejunostomy as these congenital cysts can have malignant changes
49
Pancreatitis dx
2 of the following: - acute epigastric pain radiating to back - increased amylase/lipase > 3x nl - characteristic ab imaging findings Don't need imaging if you have the top 2
50
Tx hepatorenal syndrome
Midodrine Octreotide Hepatorenal is when liver disease --> systemic vasodilation (2/2 NO in splanchnic circulation b/c of portal HTN) --> renal hypoperfusion --> prerenal renal failure
51
Acute cholecystitis in elderly diabetic males - what is a common cause?
Emphysematous cholecystitis! Look for ab radiogrpah showing air fluid levels in gallbladder or US showing curvilinear gas shadowing in gallbladder

Surgery (12 decks)

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