Pancreatic & Hepatic Disorders Flashcards Preview

NMS Casebook > Pancreatic & Hepatic Disorders > Flashcards

Flashcards in Pancreatic & Hepatic Disorders Deck (60)
Loading flashcards...
1
Q

When to take out a gallbladder in an asymptomatic patient

A

Porcelain gallbladder (50% risk of adenocarcinoma) and stones > 3cm. Otherwise less than 10% of patients with asymptomatic gallstones develop symptoms requiring surgery over 5 years.

2
Q

In a patient presenting with RUQ pain, what biliary dx is less likely if the patient does NOT have a fever?

A

Acute cholecystitis

3
Q

Differential of RUQ pain in a young female?

A

Gastroenteritis, PUD, acute hepatitis, renal colic, pleural-based pneumonia, gallstone disease and pyelonephritis.

4
Q

Boaz sign and Murphey sign

A

Boaz = pain radiates to right scapula. Murphey: inspiratory arrest during deep RUQ palpation. Both indicate gallstone disease.

5
Q

Labs to order in patients with suspect gallstone disease?

A

CBC (mild leukocytosis is prevalent in uncomplicated cholelithiasis), LFTs (20% may have bili of 2-3, alk phos may also be elevated), amylase and lipase (check for pancreatic occlusion).

6
Q

What classification does a cholecystectomy fall under as far as sterility goes?

A

Clean-contaminated, patients get a single preop dose of 1st generation cephalosporin.

7
Q

Who receives more than the single pre-op dose of 1st generation cephalosporin for a lap chole?

A

Age > 70, acute cholecystitis, hx of obstructive jaundice, choledocolithiasis or jaundice. These patients all have a higher risk of developing septic complications.

8
Q

2 major complications of lap chole

A

CBD injury (may result in chronic strictures, infection, cirrhosis) and proper hepatic artery ligation (may result in hepatic ischemic injury, bile duct ischemia, stricture)

9
Q

A patient presents with RUQ pain, fever, elevated WBC, elevated alk phos and gallstones on RUQ u/s w/inflamed GB wall and pericholecystic fluid. How do you manage her?

A

IVF resuscitation, NPO, +/- NG if nausea/vomiting, preop abx, lab chole within 48-72 hours and post op abx for 24 hours.

10
Q

Bugs and drugs for acute cholecystitis with cholelithiasis

A

Bugs: E. coli, Enterobacter, Klebsiella, Enterococcus. Drug: 2nd generation cephalosporin pre-op and for 24 hours post-op

11
Q

How do you manage a patient presenting with symptomatic cholelithiasis, elevated AST/ALT, gallstones on RUQ u/s and a bilirubin of 4 mg/dL?

A

The presence of jaundice and elevated liver enzymes with gallstones likely indicates choledocolithiasis. In this patient it is essential to clear the CBD of stones w/ERCP followed by lap chole OR lap chole + intraop cholangiogram + CBD exploration OR lap chole + postop ERCP. Note that some surgeons are okay with observation for stones < 3mm.

12
Q

How many pregnant women typically have gallstones?

A

3-11%, asymptomatic in most cases, this is due to increased estrogen causing cholestasis.

13
Q

When to operate on a pregnant woman with symptomatic cholelithiasis or gallstone pancreatitis.

A

Recurrent episodes, acute cholecystitis, obstructive jaundice or peritonitis -> surgery or ERCP w/sphincterotomy, most preferably in 2nd trimester. Otherwise, hydration and pain management is appropriate with lap chole after delivery.

14
Q

A patient presents with symptomatic cholelithiasis, gallstones on RUQ u/s and a mildly elevated serum amylase. How do you manage this patient?

A

Cholecystectomy + operative cholangiogram (mandatory w/biliary pancreatitis) if the patient has mild pancreatitis. If the patient has fluid sequestration, hypocalcemia, oliguria, hypotension or pulmonary complications secondary to pancreatitis, the cholecystectomy should be delayed, the patient should be resuscitated and ERCP is warranted if CBD is dilated or there are stones in the distal CBD.

15
Q

What is the mechanism for the complications associated with pancreatitis?

A

Release of zymogens results in inflammation, PMN recruitment and release of cytokines (TNF-alpha and IL-1). This results in increased capillary permeability, hypovolemia, DIC, ARDS and eventually end-organ failure (esp. renal failure).

16
Q

Complications of gallstone disease that presents with fevers.

A

Acute cholecystitis, cholangitis, empyema or the gallbladder or pericholecystic abscesses.

17
Q

Fever and RUQ pain, RUQ u/s shows fluid with internal echoes and stones. What is your dx and how do you tx?

A

Empyema. Pt needs IV abx and emergent exploration with cholecystectomy. PTC to drain the gallbladder can be done if pt health is poor and cannot tolerate an operation.

18
Q

Fever, jaundice and RUQ pain, RUQ u/s shows prior cholecystectomy and dilation of CBD and air in the biliary system. What is your dx and how do you tx?

A

Suppurative cholangitis due to bacterial infection of gas-forming organisms proximal to biliary obstruction. Tx with rapid stabilization with IVFs/abx and emergent ERCP w/sphincterotomy to decompress biliary tree and remove stones. If ERCP is unsuccessful, you can call IR to do transhepatic cholangiogram w/stone extraction or go to the OR for cholecystectomy w/CBD drainage.

19
Q

Tx for acute biliary sepsis

A

IVF resuscitation/abx and urgent surgery.

20
Q

An elderly patient presents with a tender 3cm palapable mass in the RUQ, a temp of 103 and obtundation. How do you manage this patient? What if there was air seen in the gallbladder wall on RUQ u/s?

A

This patient has an inflamed gallbladder that is palpable because of omentum adhearing to it due to inflammation. As soon as this patient is resuscitated he needs emergent cholecystectomy due to high risk of GB rupture. Air in the GB wall indicates emphysematous GB and merits similar tx.

21
Q

A patient presents with recent onset of jaundice, fever and RUQ pain. RUQ u/s shows no gallstones, but dilation of the CBD is noted. How do you tx this patient?

A

IVFs/abx and ERCP for biliary decompression. This patient most likely has acute cholangitis.

22
Q

What differentiates a retained gallstone from a primary CBD stone?

A

Retained stones occur within 2 years of cholecystectomy. After 2 years = CBD stone.

23
Q

How do we get gallstones out of the CBD?

A

ERCP +/- sphincterotomy, PTC or operative duct exploration if the 1st 2 measures fail.

24
Q

How do you tx a patient with jaundice and RUQ pain secondary to biliary stricture after he had cholecystectomy?

A

Surgical bypass of the stricture with choledochojejunostomy. Endoscopic dilation can be considered but is less beneficial.

25
Q

Gallstones not well visualized by u/s

A

Distal CBD stones because intestinal gas gets in the way, use CT or ERCP. u/s is good for cystic duct and proximal CBD visualization.

26
Q

Your patient is POD 1 from lab chole and presents with fever and abdominal pain. What 2 things are you worried about and how do you rule them out at this point?

A

1) Biliary leak 2) Infection. 1) HIDA scan: patient must have bili < 8-10 for it to work, hepatoiminodiacetic acid is injected IV and is excreted along the biliary tract, it will show you leaks (and acute cholecystitis if the GB fails to visualize). RUQ u/s is also used to look for fluid collections. CT can be used to r/o hepatic abscesses proximal to old obstruction. 2) CBC should give you enough info to suspect infection.

27
Q

What do you do if your postop patient has a leakage on HIDA scan that was confirmed to be at the cystic duct stump seen on ERCP?

A

Biliary drainage with temporary stent placement. Exploration if the patient does not improve rapidly.

28
Q

What is your differential diagnosis in a 55 year old man with recent onset jaundice and pruritis w/labs: direct bili 6, AST 18, ALT 18 and alk phos 6x normal? ee

A

Obstructive jaundice: adenocarcinoma in pancreatic head (associated w/weight loss, vague back pain and tobacco), periampullary carcinoma, cholangiocarcinoma (associated w/weight loss, vague back pain and tobacco), CBD stricture (chronic alcoholism or prior biliary surgery) or CBD stone impacted in ampulla (sx are typically intermittent).

29
Q

What is a Klatskin tumor? How do you work one up? How do you treat it?

A

Cholangiocarcinoma at the bifurcation of the hepatic bile ducts. Dx w/PTC or ERCP to demonstrate the level of obstruction and get biopsies. Tx exploration and resection of bile ducts and gallbladder if there is no evidence of metastasis or local spread +/- hepatic lobectomy if tumor extends into hepatic ducts. Note however, that most tumors are unresectable and have a poor prognosis (5-15%) due to high rates of vascular invasion and mets and can be treated with palliative stenting.

30
Q

A 55 year old man presents with painless jaundice and vague back pain. CT of the abdomen reveals no masses in the head of the pancreas, no gallstones and dilation of the CBD. What is the next step?

A

CT can miss tumors in the head of the pancreas. Endoscopic u/s through the duodenum can visualize the head of the pancreas well and can be combined with ERCP for biopsy and further assessment.

31
Q

Why can biopsy of the pancreas looking for pancreatic cancer be misleading?

A

A thickened and scarred area in the head of the pancreas can feel like cancer when it is just chronic pancreatitis. Additionally, pancreatic cancer can cause local areas of the pancreas to scar due to inflammation and biopsy will look like chronic pancreatitis even though cancer is present.

32
Q

What type of pancreatic cancer can you proceed to treat with pancreaticoduodenectomy?

A

No metastasis, no spread to or beyond periaortic/celiac LNs and no local invasion. Note that the 1st phase of the surgery involves biopsy and frozen section of liver lesions and regional LNs to confirm that disease is truly confined to the pancreas. If this is the case, the surgeon can proceed with pancreaticoduodenectomy.

33
Q

How is a pancreaticoduodenectomy performed?

A
34
Q

What do you tell your patient about their 5 year survival rate after you do your Whipple?

A

35-48% in patients with negative nodes and no mets. Average rates are 5-10%. Things that improve prognosis are size < 3cm, negative nodes, diploid DNA, S-phase fraction < 19%, negative nodes/margins and use of postop chemorads.

35
Q

An older woman presents with obstructive jaundice. ERCP and biopsy result in diagnosis of ampullary carcinoma. How do you manage this patient?

A

Complete evaluation for local and distant spread followed by Whipple. Note that Whipple has 5 year survival around 65% for this type of cancer.

36
Q

When is segmental resection of duodenal carcinoma acceptable?

A

In parts 1 and 4. Parts 2 and 3 can involve the ampulla of Vater and merit a Whipple or surrounding structures.

37
Q

A patient presents with RUQ pain following greasy meals. RUQ u/s reveals a mass in the gallbladder fossa that is infiltrating the gallbladder wall and cystic duct. CT reveals gallbladder adenocarcinoma but no metastasis. How do you manage this patient?

A

Open cholecystectomy, resection of surrounding liver with 2-3cm margins and hilar LN resection. Note that recurrent cancer can occur at the trochar sites and most cancers are unresectable at dx due to large hepatic involvement.

38
Q

Why do we take out gallbladders with polyps > 2cm and gallbladders that are calcified?

A

Polyps > 2cm have a 7-10% risk of becoming malignant. Porcelain gallbladders are associated with adenocarcinoma 50% of the time.

39
Q

A patient presents with epigastric pain and serum amylase and lipase 3x normal levels. How do you manage this patient?

A

Check RUQ u/s for gallstones. For simple uncomplicated pancreatitis you don’t need CT, just put them on pancreatic rest (NPO, IVFs, pain control observation +/- TPN depending on length of recovery). If gallstones are present, wait for amylase and lipase to drop with pancreatic rest then perform lap chole.

40
Q

A patient presents with boaring epigastric pain that radiates to his back, he is hypotensive, ill-appearing and hypoxemic. He has elevated amylase/lipase. How do you manage this patient?

A

He is presenting with sx of necrotizing pancreatitis and SIRS/ARDS secondary to cytokine release from inflammation. You should aggressively resuscitate w/IVFs and order CT to check for any other areas that could contribute to his decompensation.

41
Q

What are Ranson’s criteria?

A

3 criteria = 28% mortality. 5-6 criteria = 40% mortality. 7-8 criteria = 100% mortality

42
Q

Differential for labored breathing in a patient with acute pancreatitis?

A

ARDS, pulmonary edema from overhydration, atelectasis or pneumonia

43
Q

A patient in the ICU being treated for acute pancreatitis develops ARDS and sepsis. How do you manage this patient?

A

Consider pancreatic abscess, IV access site infection, UTI and pneumonia. If pancreatic abscess is likely, get CT w/contrast to look for abscess. If abscess if present, sample/drain percutaneously or sample percutaneously and drain surgically if fluid is too much to drain from a catheter. Give abx that cover gm negs and anaerobes.

44
Q

Major complication to look out for after placing a perc drain for pancreatic abscess? How do you dx and tx this?

A

Erosion through major arteries like the splenic, gastroduodenal, SMA or pancreatic. If this does happen, dx w/angiography and tx w/embolization.

45
Q

Considerations to take in elderly or obtunded patients with epigastric pain and elevated serum amylase

A

Mesenteric ischemia and volvulus can present similarly to pancreatitis and need to be ruled out with CT in this patient population.

46
Q

An older man presents after improvement from acute pancreatitis. He now complains of moderate abdominal pain, anorexia due to early satiety and his serum amylase is still elevated. How do you manage this patient?

A

Get a CT to look for pancreatic pseudocyst. Pseudocysts are due to leakage of pancreatic fluid, edema and compression of local structures. If a pseudocyst is present, put the patient on pancreatic rest until symptoms resolve and begin feeding and monitoring serum amylase. If the patient is stable you can d/c. If the pseudocyst fails to improve by 7 weeks you’ve got to pull it out surgically.

47
Q

What is the surgical procedure for a pancreatic pseudocyst that has not resolved by 7 weeks?

A

By now the pseudocyst wall should have enough fibrous tissue to suture to. Cystogastrostomy involves opening of the stomach anteriorly and locating the cyst with a needle through the posterior stomach. Once found, you make a communication with the cyst and the stomach and take a biopsy to make sure it is not a cystadenoma or cystadenocarcinoma of the pancreas. The cyst can also be drained percutaneosly.

48
Q

What are common liver masses seen in younger people? Older people?

A

Younger: simple cysts, hemangiomas, focal nodular hyperplasia and hepatic adenomas. Older: metastatic carcinoma, primary hepatocellular carcinoma and cholangiocarcinoma.

49
Q

What are special aspects of the patient’s history you should ask if they have RUQ pain and a hepatic mass on RUQ u/s?

A

OCP use (hepatic adenomas and less frequently focal nodular hyperplasia), environmental toxins, hepatitis B and C or cirrhosis (HCC), previous liver injury and known primary tumors.

50
Q

How do we treat simple liver cysts?

A

Most need no further management once bad things are ruled out. If it really bothers the patient and does not resolve cyst aspiration followed by sclerosant or simple excistion can be done.

51
Q

A patient presents with RUQ. Abdominal u/s shows multilocular cysts with calcification in the wall and internal echos in the liver. What is your dx?

A

Echinococcal cysts, these are GI parasites and serologic testing should be done to confirm your dx. The cyst is treated by injecting the cyst with hypertonic saline (scolocidal) and then excision of the cyst…NEVER SPILL THE CYST CONTENT into the abdomen because it will infect ther peritoneal cavity.

52
Q

A 40 year old man presents with fever and RUQ tenderness. WBC is 15000. CT shows a simple fluid collection within the liver. How do you treat this patient?

A

He has a hepatic abscess. This should be treated with CT guided percutaneous drainage and IV abx for 4-6 weeks if bacterial and metronidazole if amebic. It is appropriate to leave the drainage catheter in for 2-3 weeks while the patient is on abx. Note that amebic abscesses typically don’t need any surgery.

53
Q

How do you confirm your diagnosis of a hepatic hemangioma in a 27 year old male?

A

Labeled RBC scan is highly reliable. Bolus-enhanced CT or MRI may also confirm the diagnosis (lesion will fill from periphery to the center).

54
Q

When is it appropriate to surgically remove a hemangioma?

A

If the patient is symptomatic. This typically means there is a risk of rupture.

55
Q

What hepatic lesions should you avoid biopsying

A

Hemangiomas and adenomas because they bleed like crazy. Ecchinococcal cysts because you don’t want to contaminate the peritoneal cavity.

56
Q

Patient has RUQ abdominal pain with a central stellate scar on CT. RBC scan is negative for hemangioma. How do you manage this patient?

A

One you r/o hemangiom or adenoma you can biopsy the lesion. If the patient has focal nodular hyperplasia you are done. If the patient has hepatic adenoma you have to resect large ones because they can develop into HCC and are at risk for rupture (especially during pregnancy)

57
Q

Next step when a patient gets a CT that suggests HCC

A

Get a biopsy, if the biopsy is positive for HCC, get a CT chest/abdomen to check for metastasis (esp in hepatic hilar LNs and celiac LNs) or local invasion (esp to diaphragm). If there are no mets the patient can go to surgery.

58
Q

What makes a patient with metastatic liver cancer have a more favorable prognosis?

A

Resectable w/1cm margins, solitary, < 5cm, noncirrhotic, no vascular invasion, colon primary (as opposed to rectal primary) and low-grade. Note that vascular invasion is a contraindication for surgery, but otherwise surgery should be tried whenever acceptable because it offers the highest cure rate.

59
Q

What is your differential for a fever in an IV drug abuser?

A

Endocarditis, intra-abdominal abscess, pancreatitis, pneumonia, UTI or infected injection site.

60
Q
A