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Flashcards in Surgery - Hepatobiliary, Pancreas Deck (51):
1

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

2

Tx acalculous cholecystitis

1) Abx

2) Percutaneous cholecystostomy

3) Cholecystectomy + drain abscesses after med condition improves

3

Most common causes of acute pancreatitis

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

4

Blood supply to pancreas

Splenic A - body + tail

SMA - head

5

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

6

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

7

What causes relaxation of sphincter of oddi?

CCK
Glucagon

8

What causes contraction of sphincter of oddi?

Morphine

Meperidine DOES NOT so use this for pain for cholecystitis

9

Best way to eval liver function in:
- acute Hep B
- chronic hep B

Acute
- LFTs
- viral serology

Chronic
- liver bx

10

Imaging pancreatic cancer

CT

11

Hepatic metabolism of bilirubin

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

12

Gilbert's syndrome

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

13

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

Hep C

14

Extrahepatic sequelae of hep C

Cryoglobulinemia
Porphyria cutanea tarda
Glomerulonephritis

15

Tx primary biliary cirrhosis

Ursodeoxycholic acid (slows disease progression, relieves sx)

Methotrexate
Colchicine

Liver transplant in advanced

16

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

17

Courvoisier-Terrier sign

In malignant obstruction

Large thin walled distended gallbladder

18

Tx peritonitis

abx

NOT SURGERY

19

Key to establishing edematous nature of acute pancreatitis

Elevated hematocrit

20

Tx for infected pancreatitis

IV imipenem or meropenem

21

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

22

Liver supplied by?

Drained by?

- Supplied by hepatic portal v + hepatic A
- Drained by hepatic vein

23

HCC
- description
- management

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


CT scan to show extent
Resection if ok

24

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

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