Flashcards in Pancreatic And Hepatic 2 Deck (22):
Choledochojejunostomy? Performed when?
Repair of ductal injury requires new anastomoses with gastrointestinal tract
Complete obstruction of the bile duct necessitating biliary drainage procedure
55-year-old male with recent painless jaundice and marked pruritus. Bilirubin of 6, markedly elevated alkaline phosphatase. Suspected process? Differential? Next step?
Obstructive process to biliary tree
1. Cancer of pancreatic head
2. Periampullary carcinoma
4. Stricture of biliary tree
5. common bile duct impacted in ampulla (but this usually presents with fever and chills and PAIN)
55-year-old male with recent painless jaundice and marked pruritus. Bilirubin of 6, markedly elevated alkaline phosphatase. Abdominal ultrasound shows dilated common bile duct but no gallstones or pancreatic masses – next step? (Why?). If unremarkable, following step?
CT of abdomen (transcutaneous abdominal ultrasound not good for visualizing distal bile duct and pancreatic head because intestinal gas obscures view)
Endoscopic ultrasound through duodenal wall to assess pancreatic head
Remove pancreatic head, first portion of the duodenum, jejunum at the ligament of Treitz
Patient with cancer to the head of the pancreas – tumor resection is successful with negative margins and no local metastatic disease – cure rate in five years? Survival rate?
Mean survival for palliative biliary gastric bypass after finding unresectable pancreatic adenocarcinoma?
60-year-old man with painless jaundice . Abdominal ultrasound shows dilated Intrahepatic ducts but no dilation of common bile duct – suspected diagnosis? next steps?
ERCP or percutaneous transhepatic cholangiography (preferred because the better visualization of proximal hepatic ducts)
Cholangiocarcinoma – prognosis?
If exploration shows no local metastatic disease and mass is resected. Prognosis?
If unresectable cholangiocarcinoma – five-year prognosis?
Poor – high rate of vascular invasion, metastatic disease
Five-year survival 15%
Less than 5%
Effect of radiation on unresectable cholangiocarcinoma?
No effect on survival
Management of ampullary adenocarcinoma?
Cure rate versus other pancreatic cancers? five-year survival?
1. Exploration for local or distant metastases
2. Whipple (pancreaticoduodenectomy)
Higher cure rate than other pancreatic cancers with 65% five year survival
Duodenal adenocarcinoma – management? Relative prognosis?
Depends on location and size
1. If involves ampulla – Whipple
2. If in first or fourth part of the duodenum, segmental resection
Prognosis usually poor because of involvement of nearby structures
Patient with mass in the gallbladder fossa visible on ultrasound – suspected diagnosis? Management? Metastases most likely to extend into?
Gallbladder adenocarcinoma –
1. CT for metastases
2. If no metastases, open cholecystectomy with wide resection of surrounding liver and hilar lymph node
3 cm polyp found on gallbladder – management?
Cholecystectomy if polyp larger than 2 cm (observation if under 2 cm)
Patient with the calcified gallbladder – management?
Removal – 50% association with adenocarcinoma
Patient with suspected pancreatitis – test to rule out other common disorders? (Example?) Finding on test that supports pancreatitis? Unnecessary test in patients with uncomplicated pancreatitis?
Obstructive abdominal series to rule out other disorders (perforated ulcer with free air)
Generalized ileus and localized ileus second and third parts of the duodenum due to localized inflammatory process
CT not mandatory
Treatment for uncomplicated pancreatitis?
2. IV hydration
3. Pain control
Same way – when amylase decreases and patient improves, do laparoscopic cholecystectomy
34-year-old male presents with abdominal pain and elevated Amy leads. After admission becomes severely ill with hypotension, hypoxia, multiorgan failure – suspected diagnosis? Mechanism?Treatment?
Severe necrotizing pancreatitis with systemic inflammatory response syndrome
Mediated by cytokine release and causes ARDS, multiorgan system failure, hemodynamic instability
1. Fluid resuscitation in ICU
2. CT of abdomen to assess the extent of information, other causes of decompensation (bowel perforation, abscess, biliary instruction)
How to assess patient mortality with alcoholic pancreatitis?
1. WBC over 16,000
2. Glucose over 200
3. AST over 250
4. LDH over 350
5. Age over 55
After 48 hours
1. Hematocrit decrease of 10%
2. Calcium less than 8
3. paO2 under 60
4. Base deficit over 4
5. BUN increase of 5
6. Fluid sequestration over 6 L
3 criteria – mortality 28%,
5/6 criteria mortality is 40%
7/8 criteria - mortality is 100%
Correlation with amylase levels and severity of pancreatitis?
Patient presents with acute pancreatitis. Develops pulmonary failure and requires intubation and ventilation. Over next two days, develops fever, leukocytosis, and septic shock – most concerned about? Test? Management?
Dynamic CT scan
1. If CT shows peripancreatic collection – percutaneous sampling 2. CT ultrasound guidance
Two. If a large amount of WBCs for bacteria, abscess – need to drain it
Patient is recovering from percutaneous pancreatic abscess drainage when he becomes hypotensive and drainage becomes bloody – suspected condition? Management?
Solution of the catheter or absence into major artery (splenic, gastroduodenal, SMA, pancreatic vessels)
2. Control with embolization
Suspect Severe pancreatitis in 70-year-old patient – differential? difference in approach?
mesenteric ischemia or volvulus
Stronger need to confirm diagnosis - CT scan. If CT scan inconclusive, exploratory laparotomy.