Surgery - Hepatobiliary, Pancreas Flashcards
Acalculous cholecystitis
- seen in who?
- pathogenesis
- imaging shows
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
Tx acalculous cholecystitis
1) Abx
2) Percutaneous cholecystostomy
3) Cholecystectomy + drain abscesses after med condition improves
Most common causes of acute pancreatitis
Gallstones - if stable, should get cholecystectomy EtOH Hyper triglyceridemia Recent ERCP
Blood supply to pancreas
Splenic A - body + tail
SMA - head
What do you not want to do in pt w/ severe COPD + acute cholecystitis?
Laproscopy
- can get increased CO2 absorption into blood
Do open cholecystectomy or cholecystostomy
Results of a HIDA scan
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
What causes relaxation of sphincter of oddi?
CCK
Glucagon
What causes contraction of sphincter of oddi?
Morphine
Meperidine DOES NOT so use this for pain for cholecystitis
Best way to eval liver function in:
- acute Hep B
- chronic hep B
Acute
- LFTs
- viral serology
Chronic
- liver bx
Imaging pancreatic cancer
CT
Hepatic metabolism of bilirubin
Uptake from bloodstream
Store in hepatocyte
Conjugate w/ glucuronic acid
Biliary excretion
Gilbert’s syndrome
mildly decreased UDP glucuronyl transferases (glucornidate stuff)
- will have mildly increased unconj hyperbilirubinemia
Which chronic hepatitis is more likely to have waxing and waning transaminase levels and arthralgias?
Hep C
Extrahepatic sequelae of hep C
Cryoglobulinemia
Porphyria cutanea tarda
Glomerulonephritis
Tx primary biliary cirrhosis
Ursodeoxycholic acid (slows disease progression, relieves sx)
Methotrexate
Colchicine
Liver transplant in advanced
If CT of pancreas w/ IV contrast doesn’t have the pancreas show up, what happened?
Necrosis of pancreas
Do an FNA bx and gram stain
Tx w/ necrosectomy after waiting 4 weeks
Courvoisier-Terrier sign
In malignant obstruction
Large thin walled distended gallbladder
Tx peritonitis
abx
NOT SURGERY
Key to establishing edematous nature of acute pancreatitis
Elevated hematocrit
Tx for infected pancreatitis
IV imipenem or meropenem
How long before pancreatitc pseudocyst shows up?
5 weeks
CT or US to dx
Smaller cysts = observe
Bigger cysts = drain percutaneously or surgically into GI tract or endoscopically into stomach
Liver supplied by?
Drained by?
- Supplied by hepatic portal v + hepatic A
- Drained by hepatic vein
HCC
- description
- management
In ppl w/ cirrhosis
Vague RUQ discomfort + wt loss
a-fetoprotein marker
CT scan to show extent
Resection if ok
Mets to liver
- description
- management
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
Hepatic adenoma
- description
- management
Due to birth control pills
Can rupture and bleed inside ab
CT dx
Emergency surgery
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
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
Hemolytic jaundice - characteristics
Mildly elevated bilirubin
↑ Unconj bilirubin
Nl conj bilirubin
No bile in urine
Hepatocellular jaundice - characteristics
High unconj + conj bilirubin
High AST, ALT
Modest inc ALP
Ex: Hepatitis
Obstructive jaundice - characteristics
High uncoj + conj bilirubin
High ALP
Work up w/ US (dilatation of biliary ducts)
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
Asymptomatic gallstones
- description
- management
Usually benign, only < 10% get symptoms needing surgery
NO surgery
Biliary colic
- description
- management
Stone block cystic duct
Episodes self-limited, usually stopped w/ Anti-cholinergics
US = gallstones –> YES surgery (elective cholecystectomy)
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
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
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
Cholecystectomy complications
- Pneumoperitoneum
- Ligation of CBD —> liver damaged
What do you do with acute cholecystitis in preggers?
o Nonoperative management – hydration + pain management; can do surgery or ERCP though
Abx for acute cholecystitis?
Not needed
Clean contaminated surgery
o Do 1 preop dose of 1st gen cephalosporin
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
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
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
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
Hemobilia associations
Associated with Quincke triad:
- RUQ ab pain
- jaundice
- GI bleeding
Why do you get sweaty w/ hypoglycemia?
B/c epi release 2/2 hypoglycemia triggers sweating, weakness, tachy
Tx iatrogenic injury to CBD resulting in biliary stricture
Roux en Y choledochojejunostomy
Tx echinococcal liver cysts
+ silver nitrate or hypertonic saline into cyst
Resection
Be careful of leakage causing anaphylaxis!
Choledochoal cysts - what do you dp?
Resect using Roux en Y choledochojejunostomy as these congenital cysts can have malignant changes
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
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
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
