NMS Surgery Pancreatic and Hepatic Disorders Flashcards

bile duct
Terms Definitions
What 3 groups need asymptomatic gallstones removed?
1. Immunocompromised
2. Porcelain gallbladder (chronic cholecystitis, at risk for adenocarcinoma of the gallbladder)
3. Larger than 3cm
6 factors that predispose to gallstones?
1. Age over 40
2. Family history of gallstones
3. Female
4. Obesity
5. Recent preg
6. Prev diag of gallstones
RUQ due to cholithiasis can radiate to where?
R subscapular
Most efficient way to dx cholithiasis?
US
Lab values to expect with cholithiasis
Mild leukocytosis, mild jaundice, elevated bilis, alk phos and transaminases can also be elevated
In uncomplicated cholithiasis, what's the abx regimen?
1 dose of preop first gen cephalosporin: Cefalexin, Cefazedone, Cefazolin
Who needs abx in cholithiasis?
high riskers for sepsis: over 70, acute cholecystitis, history of obstructive jaundice, common duct stones, jaundice, those with preop ERCP done
What's the major complication of lap chole?
Common bile duct injury: chronic biliary strictures, infection, cirrhosis
Injury to hepatic A: hepatic ischemic injury, bile duct ischemia, strictures
Most common species for acute cholecystitis?
1. E Coli
2. Enterobacter, Klepsiella, Enterococcus
Abx regimen for acute cholecystitis after blood cultures?
second gen cef for GNRs and Anaerobes: Cefotetan, Cefoxitin
- give preop and 24 hours postop
When bili and/or liver enzymes are elevated, what to suspect? What to do?
Common duct stone, preop or postop ERCP
How should gallstone pancreatitis and symptomatic cholithiasis be managed in pregs?
IV hydration and pain mgmt. Avoid surg till after deliv. But safest to do in 2nd trimester. ERCP and sphincterotomy generally safe.
When biliary pancreatitis suspected, what procedure is necessary operatively?
Operative cholangiogram. But delay surgery until complications from pancreatitis relieved: high fluid requirements, hypocal, oliguria, hypotension, pulmonary complications
Causes of pancreatitis mnemonic?
I GET SMASHED.
Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps (paramyxovirus and other viruses like epstein barr and cmv), Autoimmune (PAN/SLE), Scorpion sting, Hypercal (or hyperlip, hypertri, hypotherm), ERCP, Drugs (steroids, sulfonamides, azathioprine, nsaids, diuretics, duodenal ulcers)
clinical signs of pancreatitis
* Grey-Turner's sign (hemorrhagic discoloration of the flanks)
* Cullen's sign (hemorrhagic discoloration of the umbilicus)
* Grünwald sign (appearance of ecchymosis around the umbilicus due to local toxic lesion of the vessels)
* Körte's sign (pain or resistance in the zone where the head of pancreas is located (in epigastrium, 6–7 cm above the umbilicus)
* Kamenchik's sign (pain with pressure under the xiphoid process)
* Mayo-Robson's sign (pain while pressing at the top of the angle lateral to the Erector spinae muscles and below the left 12th rib (left costovertebral angle (CVA))[2]
RUQ pain and high fever would be suspicious for?
Acute cholecystitis and complication like cholangitis, empyema of gallbladder, pericholecystic abscess
What US signs would you see with empyema of gallbladder?
distended gallbladder with fluid that has internal echoes and gallstones
Tx for empyema of gallbladder?
emergent exploration, cholecystectomy, IV abx. If general health is poor: perctaneous cholecystostomy to drain
What does air in the biliary system mean? Tx?
Pneumobilia: suppurative cholangitis: gas forming organisms. Emergent ERCP w/ sphincterotomy, decompression of biliary tree, stone removal is feasible. If unsuccessful: transhepatic cholangiogram and stone extraction, or cholecystectomy and CBD drainage
Definition of SIRS/sepsis?
1. Temp >38(100.4) or <36(96.8)
2. HR >90
3. RR>20 or PaCO2<38
4. WBC>12000 or <4000 or >10%bands

Sepsis=Sirs + suspected infection
Severe sepsis=sepsis + organ dysfunction
Septic shock= sepsis induced hypotension not responsive to fluids
(elderly get hypothermic and leukopenic)
what does it mean when you have palpable gallbladder? What to do?
inflamed gallbladder walled off by omentum. Need emergent cholecystectomy when resuscitation occurs. High risk of rupture and mortality. Watch out for change in MS=sign of sepsis
Charcot's triad? Meaning?
1. RUQ pain
2. Fever
3. Jaundice
means cholangitis
Tx of cholangitis?
1. IVF
2. Abx
3. Ultrasound.
4. ERCP is obstruction or dilation of CBD is seen
What's a retained stone?
common duct stone within 2 years of cholecystectomy. after 2 years=primary CBD stone
Post lap chole fever and pain might be?
infection/ biliary leak/ hepatic (CT scan)abscess/hepatic duct obstruction
HIDA scan is good for detecting what?
Biliary leaks, cholecystitis, obstructions
Post lap chole cystic duct stump leak on HIDA or ERCP requires what?
Drainage and temporary stent
If HIDA or ERCP shows complete CBD obstruction post cholecystectomy, what to do?
1. Biliary drainage using percutaneous drain
2. choledochojejunostomy (CBD to jejunum)
Differential for painless jaundic, pruritis, elevated liver enzymes?
Biliary tree obstruction. Cancer at head of pancreas, periampullary carcinoma, Klatskin tumor, CBD stricture, CBD stone (unusual for this presentation)
If you see CBD dilation but no stones in US, next steps?
1. CT
2. Endoscopic ultrasound through duodenal wall to visualize head of pancreas
3. US guided biopsy
What would stop you from resecting a pancreatic adenocarcinoma at the head of pancreas?
Distant mets esp to liver, LN mets especially to periaortic or celiac region, bone pain, neuro sxs, involvement of vena cava, aorta, SMA, SMV, or portal veins
Procedure for resection of tumor at head of pancreas?
Pancreaticoduodenectomy
What would you do if you found unresectable pancreatic adenocarcinoma with local spread?
Palliative biliary and gastric bypass to prevent gastric outlet or duodenal obstruction or bile duct obstruction. Alcohol injection at celiac axis to decrease back and abdominal pain.
Painless jaundice+dilated intrahepatic ducts+no dilation of CBD =?
Cholangiocarcinoma or Klatskin tumor
How to visualize cholangiocarcinoma or Klatskin?
ERCP or Percutaneous Transhepatic Cholangiography, which is better for proximal hepatic ducts
Are Klatskins resectable?
Generally no, but may be able to do resection of gallbladder and bile ducts, hepatic lobectomy or trisegmentectomy.
5 year survival w/ Klatskins is 15% after curative resection
What should you do with an unresectable Klatskins or cholangiocarcinoma?
Palliative stenting of hepatic duct strictures
Type of biliary cancer with best prognosis?
Ampullary adenocarcinoma. Requires a Whipple (pancreatoduodenectomy)
What does a mass in the gallblader fossa mean?
Gallbladder adenocarcinoma. Do open chole and wide resection of surrounding liver with hilar LN resection
porcelain gallbladder associated with what?
50% assoc w adenocarcinoma
When you suspect pancreatitis, what imaging should you get to rule out other stuff?
Obstructive abd series to r/o perf ulcer. Will usually see generalized ileus
Tx for pancreatitis?
NPO, IVF, pain control, observation, TPN if necessary
Tx for gallstone pancreatitis?
IVF, NPO, pain control, observation, lap chole when stable
Tx of severe necrotizing pancreatitis?
Major fluid resuscitation, CT abd for additional causes of decompensation such as bowel necrosis, perfs, abscesses, biliary obstruction w infection
Ranson's Criteria?
Admission: Age >55, WBC>16000, Glucose >200, LDH>350, AST>250

48 hours: Hct Drop 10%, BUN increase 5, Ca<8, PaO2<60, Base deficit >4, fluid sequestration >6L

2 or less: <5% mort
3-4: 15-20% mort
5-6: 40% mort
7: 99% mort
What do you do for a person with labored breathing and a low pulse ox?
1. chest auscultation
2. ABG
3. CXR
4. Supp oxygen
Potential causes of resp distress in pancreatitis?
Pulm edema from overhydration, ARDS from response to pancreatitis, atelectasis, pneumonia
Do amylase levels correlate with severity or prognosis?
NO
If a person with pancreatitis goes into sepsis, what should you suspect? What to do?
Pancreatis abscess or other source of sepsis like PNA, IV access infection, UTI. Sample percutaneously under CT or US guidance, drain the abscess surgically or percutaneously. Culture. Give abx for GNR and anaerobes: Imipenem alone or fluoroquinolone plus metronidazole
Sxs of pancreatic pseudocyst?
pain, anorexia, elev serum amylase, Early Satiety
Tx of pancreatic pseudocyst?
Conservative: IVF, NPO, pain control, TPN, obervation. If not resolved by 6 weeks: surgery to drain with cystogastrostomy through posterior stomach wall, biopsy to ensure that it's not cystadenoma or cystadenocarcinoma
Hepatic mass differential?
Young: simple cyst, hemangioma
Older: metastatic carcinoma, primary hepatocellular carcinoma, cholangiocarcinoma
Appearance and tx of simple cysts?
No internal echoes,
Aspiration, excision
Appearance and tx of multilocular cysts?
Calc in wall, internal echoes, inject echincoccal cyst w hypertonic saline, excision. don't spill into peritoneum
Treatment of hepatic pyogenic abscess?
IV abx (Metro), CT guided drainage. Surgery avoided.
Solid liver lesion common in OCP users?
Hepatic adenoma
Solid liver lesion with history of HepB/C?
Hepatocellular carcinoma
Most common solid liver lesion? How to diagnose?
Hemangioma diagnosed by labeled RBC scan, CT, or MRI: looks like vascular lesion
Biopsy hemangioma?
Nope, high risk of bleeding
CT appearance of focal nodualar hyperplasia?
central sellate scar
Tx for FNH?
None. benign.
When do we remove solid liver lesions?
When they're symptomatic, at risk for rupture, or when there's uncertainty as to diagnosis
Hepatic adenoma tx?
Discont oral contraceptives, resect if persistent or large because they can dev into hepatocellular carcinoma and at risk for rupture esp during preg
Mgmt of hepatocellular carcinoma?
CT for mets. If no mets, surgical assessment: size<5cm, single lobe, low grade malignancy, noncirrhotic, non-involvement of critical structures, met from colon not rectum, margin >1cm are all favorable features for resection
2 etiologies of liver abscesses? Appearance on CT?
1. Bacterial (pyogenic)
2. Amoebic (Entamoeba histolytica)

Multiple low density lesions with peripheral ring enhancement, or single large abscess
Tx of liver abscesses?
IV abx 4-6 weeks if multiple, percutaneous drainage+IV abx if single. If serologies + for E. histolytica = Metronidazole
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