Hepatobiliary and Pancreatic

 

Gallbladder

Cholecystitis

  • Dx: Patients present with right upper quadrant abdominal pain, fever, leukocytosis, Murphy's sign (pain and cessation of respiration during inspiration with palpation over the gallbladder)
    • Ultrasound can show gallblader thickening (wall >3mm), gallstones with posterior accoustic shadows, pericholecystic fluid, sonographic murphy's sign.
      • US  Normal Values:
             Hepatomegaly: >15.5 cm in longitudinal length.
             Splenomegaly: > 12 cm in longitudinal length.
             Common Bile Duct:
             Below 50 years old: >6 mm is considered dilated.
             Above 50 years old: add 1 mm to the maximum CBD diameter of 5 mm for
             each decade above 50 years of age (example: For an 80-year-old
             patient, maximum CBD diameter = 8 mm).
             Post cholecystectomy: the common bile duct assumes a reservoir
             function, and therefore the above measurements do not apply; CBD
             diameter up to 10 mm may be normal.
             Normal Renal Size: 9-12 cm. 
             Kidney size < 8 cm, or > 2.5 cm difference between the two kidneys is
             abnormal.
             Normal Renal Cortical Thickness: > 8 mm.
      • Normal gallbladder wall < 4mm
      • HIDA scan can show lack of filling of gallbladder signifying cystic duct obstruction. It can also show biliary dyskinesia with ejection fraction < 40%.
    • Tokyo Guidelines 13 Diagnosis Criteria:
      • A. Local inflammation (Murphy's sign, RUQ mass/pain/tenderness)
      • B. Systemic inflammation (fever, inc CRP, inc WBC)
      • C. Imaging findings characteristic of acute chole
      • Suspect diagnosis with 1 in A AND 1 in B
      • Definate diagnoiss with 1 in A AND 1in B AND C
    • Grading of cholecystitis by Tokyo Guidelines 13:

  • Tx: Laparoscopic cholecystectomy is the treatment of choice.
    • Always resuscitate.
    • Antibiotics definately for moderate and severe acute cholecystitis (grade II and III)
    • Cholecystostomy tube can be used for complicated cholecystitis (grade III) and allow subsequent laparoscopic cholecystectomy. It can also be used for high risk patients to allow for optimization prior to cholecystostomy.
    • Intraoperative cholangiogram can be used routinely or selectively (pancreatitis, elevated bilirubin, dilated common bile duct (>10mm).
    • Common bile duct injury during cholecystectomy can be repaired with a T-tube placed above or below (not at site of injury) if < 50% transection. Will need a Roux-en-y hepatojejunostomy for complete transection.
    • Post-cholecystectomy jaundice is initially evaluated with history, CMP, CBC, lipase, hepatitis panel. Ultrasound can identify fluid in gallbladder fossa. ERCP can show a leak / stricture / obstruction. Biloma can be drained percutaneously. ERCP with stenting can treat a leak; however, if it doesn't improve in 3 weeks, it will need Roux-en-y choledochojejunostomy. Complete common bile duct occlusion will require PTC and delayed Roux-en-y choledochojejunostomy.

Choledocholithiasis

  • Dx: Patients can present with cholecystiits or with jaundice alone.
    • Labs show elevated bilirubin (direct bilirubin).
    • Ultrasound shows gallstones, a dilated common bile duct, possibly a stone in the bile duct.
    • Cholangiogram (ERCP or IOC) is the gold standard for diagnosis..
  • Tx: Cholecystectomy and clearance of the bile duct is standard of care. This can be done safely with ERCP after laparoscopic cholecystectomy with cholangiogram identifies choledocholithiasis.
    • Always resuscitate and give antibiotic coverage.
    • Common bile duct exploration is usually done if the stone cannot be removed endoscopically.
    • If choledocholithiasis is recognized during an open cholecystectomy, can proceed with common bile duct exploration.
    • Impacted stone in the common bile duct is managed first with ERCP. Can then try transhepatic stenting if unable to remove stone. Finally, choledochoduodenostomy can be performed with a low longitudinal 2cm incision on the common bile duct, longitudinal incision on the duodenum, and anastamose the two with 4-0 PDS.

Cholangitis

  • Dx: Charcot's triad is jaundice, fever, and right upper quadrant pain. Reynold's pentad adds shock and altered mental status.
    • CBC shows leukocytosis
    • CMP can show hyperbilirubinemia, elevated AST/ALT and alk phos, and even an elevated creatnine.
    • Ultrasound can show findings of choledocholithiasis.
    • Tokyo Guidelines 13:

  • Tx: These patient require emergent resuscitation and antibiotic coverage.
    • Decompress biliary system urgently for grade II, emergently for grade III. This can be with ERCP, PTC, or common bile duct exploration and drainage.
    • Cholecystectomy will be needed once stabalized.

Pancreas

Acute Pancreatitis

  • Dx: Patients present with epigastric pain radiating to the back, nausea, vomiting, elevated lipase. Causes include gallstones, alcohol, medications, ERCP, pancreatic divisum, ideopathic.
    • Ranson's criteria is best used to determine severity of alcoholic pancreatitis . Mortality 0-2 is 2%, 3-4 is 15%, 5-7 is 40%, 7-8 is 100%.
       Presentation  48hrs
       Glucose > 200  Ca++ < 8
       AST > 250  Hct fall > 10%
       LDH > 350  PO2 < 60
       Age > 55  BUN rise > 5
       WBC > 16  Base deficit > 4
         Fluid sequestration > 6L
    • Gallstone pancreatitis does not follow this criteria. Will need MRCP, ERCP, or IOC to clear bilie duct.
    • CT can be reserved for > 3 ranson's criteria to look for necrotizing pancreatitis.
  • Tx: Start with fluid resuscitation and keeping NPO.
    • Emergent necrosectomy is indicated for infected pancreatitis and hemorrhagic pancreatitis.
    • ERCP is benificial for gallstone pancreatitis that doesn't improve after ~2 days with ongoing biliary obstruction.
    • Antibiotics are used for infected pancreatitis only (along with debridement).
    • Cholecystectomy with IOC is needed for gallstone pancreatitis to prevent recurrance. This should be done before discharge unless the patient has severe pancreatiits (> 3 ranson criteria is one definition of severe).

Chronic Pancreatitis

  • Dx: Patients present with epigastric pain radiating to the back, a history of pancreatitis, weight loss, and malabsorption.
    • CT can show calcifications, dilated pancreatic ducts, masses.
    • MRCP or ERCP can identify ductal anatomy.
  • Tx: Start by eliminating causative factors (see acute pancreatitis) and pain control.
    • Whipple
    • Lateral pancreaticojejunostomy
    • Fry Procedure
    • Distal Pancreatectomy
    • Pseudocysts should have treatment delayed for at least 6 weeks to allow maturation (want 1cm wall on CT). ERCP should be done for ductal anatomy. Consider treatment for symptoms or cyst > 6cm. In non communicating cysts, cystgastrostomy may be required. In communicating cysts, ERCP with sphincterotomy may allow for drainage; otherwise, will require cystgastrostomy. Biopsy cyst wall to rule out cancer.

Pancreatic Pseudocyst

  • Dx: 
    • Biopsy cyst to ensure not Ca (can be done during surgery)
    • ERCP to look for ductal communication
  • Tx: 
    • indications for Tx:
      • >6cm
      • symptomatic
    • Communicating:
      • ERCP with sphincterotomy
      • internal drainage
      • surgical drainage
    • Non communicating:
      • internal drainage
      • percutaneous drainage
      • surgical drainage
    • Chronic pancreatitis with pseudocyst and enlarged duct may benefit from lateral pancreaticojejunostomy

Pancreatic Cancer

  • Dx: Patients present with painless jaundice and weight loss with masses at the pancreatic head. Pancreatic tail masses can present late with vague symptoms.
    • Workup includes CBC, CMP, CA 19-9, CEA, CT pancreatic protocol, CT chest.
    • Can use ERCP and endoscopic ultrasound for tissue diagnosis. Do not place biliary stent if the patient is an operative candidate.
  • Tx: Contraindications to surgical cure include SMA involvement, distal metastasis, or portal vein involvement (relative).
    • Palliation can include ERCP with metal stent placement, transhepatic stent, roux-en-y choledochojejunostomy with gastrojejunostomy, celiac plexus block, chemo-XRT.
    • Start with laparoscopy, because 75% may be unresectable.
    • Whipple give 10% 10yr cure.
    • Distal pancreatectomy
    • Postoperative chemo-XRT (gemcitobine and 5FU) is indicated for node positive or inadequate margins.
    • Complications of whipple
      • pancreatic fistula --> drain, octreotide
      • gastric outlet obstruction

Liver

  • The liver is divided into segments by the left, right, and middle hepatic veins

Liver Mass 

  • Dx: CT differentiates the type of mass.
 Lesion CT Finding
 Hemangioma  Peripheral nodular enhancement
 FNH  Central scar
 Adenoma  Mixed fat, hemorrhage, necrosis
 HCC  Venous washout
  • Tx:
    • Hemangioma is a benign vascular tumor associated with high estrogen states (female > male). They do not bleed. Observe.
    • Focal nodular hyperplasia (FNH) can also be identified with a wheel pattern on angiogram or nuclear medicine scan. Resect only for symptoms or diagnostic uncertainty.
    • Adenoma is associated with oral contraceptive (OCP) use and can rupture and bleed. Biopsy reveals hepatocytes. Stopping OCPs may be effective if < 5cm adenoma. Re-image in 6mo and during pregnancy. Resect with 2cm margin. Can use hepatic artery embolization preoperatively (or while pregnant).
    • Hepatocelluar carcinoma (HCC) treatment includes OLT (single tumor up to 5cm or < 3 tumors each < 3cm), segmental resection, locoregional therapy, and chemotherapy. HCC does not usually require biopsy if:
      • AFP > 400 with >2cm lesion and arterial hypervascularization.
      • AFP <400 with >2cm lesion on 2 separate imaging modalities.

Liver Abscess

  • Dx: Patients present with fevers and abdominal pain. Patients with amebic abscess (enterameba histolytica) may have foreign travel and have srology positive..
    • CT scan cannot determine pyogenic from amebic abscess.
    • Technecium 99 scan only lights up with pyogenic abscess.
  • Tx:
    • Broad spectrum antibiotics and drainage are used for pyogenic abscess. They may require surgical drainage.
    • Flagyl alone is treatment for enterameba histolytica (can use aspiration to rule out pyogenic abscess). Surgery is reserved for free rupture or peritonitis.

Liver Cyst

  • Dx: Cysts are easily seen on ultrasound, can use CT. Hydatid cysts (echinococcal) can cause anaphylactic shock if they rupture. Simple cysts can cause pain, bleed, or get infected.
    • Echinococcal cysts show positive echinococcal serology. CBC gives an eosinophilia. Ultrasound shows thick walls, calcifications, debris, sepatations, daughter cysts.
    • Cystadenomas have malignant potential and CT shows multiloculated, septated, irregular, calcified syst with mural nodules.
  • Tx:
    • Simple cysts can be observed if asymptomatic and < 8cm. If symptomatic and >5cm, they can be unroofed. If <5cm and symptomatic, they can be aspirated.
    • Hydatic cysts should be completely enucleated while controling for any leakage. This is done with evaculation, sterilization with hypertonic saline, and pericystectomy. Use Mebendazole as adjuvant treatment.
    • Cystadenoma needs cyst wall enucleation and hepatic resection for cystadenocarcinoma.