Liver and Biliary Notes

B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)

Week 6 Liver, Bile Duct, Gallbladder, Pancreas M 08.05.13

A 40 year old obese female presents to the Emergency Department at University Hospital with 12 hour history of fever, right upper quadrant pain, nausea and vomiting. The pain developed 30 minutes after a large meal and remains persistent. The patient has a history of type II diabetes mellitus and hypertension. She takes glucophage and enalapril. On examination she appears moderately ill. The vital signs are temp 102, P 110, RR 26 and BP 100/70. The lungs have decreased breath sounds bilaterally. The heart has tachycardia but no gallops, rubs or clicks. The abdomen has distension, decreased bowel sounds and tenderness in the right upper quadrant which radiate to the back. The patient has a positive Murphys sign. The rectal examination is guaiac negative.

DDx: acute cholecystitis, acute pancreatitis, gastritis, esophagitis, hepatitis, duodenitis [Case Workup] WBC 17, LFT Nl, Amylase/Lipase Nl, bhcG (-)

o Order IVF, NPO, IV abx; then do cholecystectomy Dx: Acute cholecystitis

o Inflammation of GB caused by obstruction of cystic ducto Mucosa of GB continues to secrete mucous, GB becomes distended, results in venous congestion

and eventual impediment of arterial inflow and ischemiao 4 Fs (Female, Fertile, Fat, Forty)

Estrogen production directly influences production of gallstoneso Low grade fevers, mild tachycardia, RUQ TTPo Murphys sign: inspiratory arrest on deep palpation of RUQo [Suspect with incr WBC, incr Tbili, incr obstructive

enzymes, possibly acidotic or hypoglycemic, septic VS; incr Tbili possible even if stone only obstructs cystic duct]

What if very high WBC?o Perforation, empyemia in GB, gangrenous GB (older

diabetic pt), emphysematous GB, cholangitis, pancreatitiso White count can be normal w cholecystitiso Does NOT change plan to go to OR, but case may take longer

Work-up RUQ sonogram, HIDA scano U/S can show gallbladder wall thickening (GBWT), peri-

cholecystic fluid (PCCF), Stones/sludge, common bile duct size/dilation (usually < 6-7 mm, but w age can incr to 9 mm)

Calcification = chronic cholecystitiso HIDA scan can show filling of GB within 30 minutes, no filling at

4 hoursMost sensitive test to rule in acute cholecystitisIV injection of radionucleotide-labeled material taken up by Kupffer cells in liver, excreted into bile ductIf GB fails to fill at 4 h, 95% certainty pt has nonpatent cystic duct (poss obstruction) and cholecystitisIf liver not visualized no uptake = liver dying, fulminant failure or poor injection (technical problem)If no contrast seen in duodenum stone or tumor in CBD or non-functioning sphincter (give glucagon)If radionucleotide in abdomen perforation in bile duct leakage

o Order IVF, NPO, IV abxo Can give pain control, BZ to release pressure on sphincter


Treatmento Cholecystectomy on admission (not elective)

Do under general anesthesia; clamp off GB first; routine intra-operative cholangiogram to visualize CBD; then clip cystic artery; electrocautery off GB from liverConversion rate to open: 1-2%Complications: injury to R hepatic artery (MC variant is R hepatic artery off SMA look for pulsation off CBD); CBD injury (stricture, clip, Bovie); trocar injury into R iliac artery or aorta; injury to ducts of Luschka (accessory ducts draining into GB)During operation, look at mucosa, because 1% of timeinflammation causes cancer

o Complications of untreated gallstone disease: gallstone ileus (bile obstruction), acute cholangitis, biliary pancreatitis, cancer

Case Scenario: POD#3 pt initially doing well but now presents w low grade fever, worsening RUQ paino DDx: post-op abscess, cystic duct leak (clip falls off), leaking from artery (trend H&H), CBD

injury, retained CBD stoneo Workup: abd ultrasound, HIDA (will see contrast leak into tube/drain), do percutaneous drain to

see type of fluid Case scenario: If see a bowel leak, do ERCP because diagnostic and therapeutic Case scenario: if incr LFTs, could be retained stone (do ERCP or MRCP [to find biliary anatomy]) or CBD

obstruction (do HIDA) Case scenario: Chronic cholecystitis present with colicky pain (comes/goes after a few hours, afebrile, Nl

WC, no CBD dilation, no fluid, shrunken GB, no edema, may still have shadowing) and previous history can take care of outpatient

Case scenario: acidotic pts putting CO2 in abdomen not a problem if pt has nl respiratory fx, but pt should be resuscitated prior to surgery

A 72 year old male undergoes a difficult coronary artery bypass graft and recovers in the cardiac intensive care unit. He remains on vasopressor and respiratory support. He does not tolerate enteral nutrition and requires hyperalimentation. On the eighth postoperative day he complains of fever to 102 and significant right upper quadrant pain. The WBC is 16, 000/mm3. The total bilirubin, the alkaline phosphatase and the gamma glutaryl transferase are all elevated. A sonogram of the right upper quadrant reveals a distended edematous gallbladder with sludge in the gallbladder but no obvious gallstones.

Top 3 nosocomial infections: pneumonia, UTI, line infection Dx: Acute acalculous cholecystitis

o Occurs secondary to ischemia of the GB wall and subsequent ischemic damage from bile stasiso Often found in hospitalized acutely ill patients after trauma or burnso Also occurs frequently in patients who have experienced global ischemia, such as after cardiac

surgery or those surviving cardiac arrest Workup

o Resuscitate up front, broad spectrum abx, make NPO, trend labs (LFTs, TBili, alk phos, WBC), blood cultures

o Ultrasound [sludge common] if not helpful, get HIDA scano If U/S and HIDA scan (+) treatment of acalculous cholecystitis = lap cholecystectomy, but

need to weigh risks/benefits of surgery at this point [pt still on pressors, post-op resp distress, too sick]

Treatmento Percutaneous cholecystostomy tube Perk Drain

Do transhepatic (not transabdominal)


o Can be done bedside with local anesthetico High mortality rate even if operate immediately

Four weeks ago a 40 year old obese female was involved in a pedestrian vs motor vehicle accident. She came to the Emergency Department with complaints of mild right upper quadrant pain. The vital signs were temp 99, P 100, RR 20 and BP 140/88. She had clear mentation. The lungs were clear to auscultation and percussion. The abdomen was soft and slightly distended with mild right upper quadrant tenderness and decreased bowel sounds. She received a CT of the abdomen and pelvis which showed a small subcapsular hepatic hematoma but also showed asymptomatic gallstones. She never had symptoms of gallstone disease. She presents to the general surgery clinic for evaluation of asymptomatic gallstones.

Dx: Asymptomatic gallstoneso Estimated that 20 million people in the U.S. have asymptomatic gallstoneso Only 1-4% of asymptomatic patients will become symptomatico Of those that become symptomatic, only 3-5% will develop complicated gallstone disease

Biliary colic is MC presenting sx (30 min to 4 hrs after meal w sx) Workup

o H&P make sure asymvptomatic (ask about post-prandial pain, duration of sxacute cholecystitis > 4-6 h)

Treatmento Indications for prophylactic cholecystectomy

Gallstones >3cmGallbladder polyp(s) >1cmCalcified (porcelain) gallbladder [bright white GB d/t calcifications]Undergoing liver transplantation

In liver transplant, always take out GB bc loss of innervationo In this case, pt can go home and just observe for sx

A 65 year old male with a history of asymptomatic gallstones now presents to the Emergency Department at Santa Rosa Hospital with mental status changes, fever and chills, jaundice and mild right upper quadrant pain. He also describes one episode of nausea and vomiting. The fever was 103 at home. The vital signs are temp 103, P 110, RR 28 and BP 100/50. The patient has confusion. He is diaphoretic. The skin and sclerae are yellow. The lungs are clear. The heart has tachycardia. The abdomen is soft, slightly distended and moderately tender in the epigastrium with decreased bowel sounds.

Dx: Ascending cholangitiso Charcots Triad (1877)

RUQ pain, fevers, jaundiceo Reynauds Pentad (1959)

Charcots Triad PLUS hypotension and mental status changeso Infectious syndrome affecting the biliary tract; complication of gallstone in CBDo Risks factors

Age (50-60s)Biliary stasis and obstruction

U.S. choledocholithiasis; World primary ductal stoneso Iatrogenic biliary tract manipulation

Workupo Order supplemental O2, resuscitate, CBC, U/A, broad spectrum abx


o Ultrasound of RUQ: see stones in GB, chronic or acute changes in GB, dilated extra-hepatic bile duct [sonogram better than CT to visualize stones in CBD]

o ERCP more distal obstruction = easier to get to obstruction; done prone under general anesthesia; get cannula into distal bile duct, blade to do sphincterotomy put balloon catheter, basket to remove stone put in biliary stent drain pus (ERCP, PTC or via catheter) drain bile duct

Can you do ERCP in pt w gastric bypass? NO! Do PTC. (percutaneous transhepatic cholangiography)

o If ERCP fails, drain operatively control bile duct and insert T-tube into bile duct upper part of T tube goes into bile duct and drains to skin helps radiologists shoot cholangiograms if stone has passed, tie off T-tube; if stone still there > 6 wks tract of fibrin (fistula) has developed and radiologist can put instruments down to relieve obstruction

o Impacted stone put in T-tube to decompress bile duct bring pts back in 6 wks for inflammation to subside T-tubes for distal obstruction [in real world, if stone found on intra-operative cholangiogram call endoscopist for ERCP next day]

Treatment Resuscitate, IV antibiotics, biliary tree decompression TRUE SURGICAL/GI EMERGENCY!!!!![can rapidly progress to sepsis +/- shock]

A 65 year old male presents to your office with jaundice, vague right upper quadrant tenderness and significant pruritis. He has anorexia and has a 15 pound weight loss over 3 months. The vital signs are stable. The skin and sclerae are deeply jaundiced. The lungs are clear. The heart has a regular rate and rhythm with no gallops, rubs or clicks. The abdomen is soft and nondistended. The liver edge is mildly tender on deep palpation. There is a painless, fixed, firm mass in the epigastrium and right upper quadrant. The rectal examination shows no masses and is guaiac negative.

DDx: pancreatic, gallbladder, cholangiocarcinoma Workup

o CBC & chem panel unremarkable with anemiao Bili & alk phos higho AST/ALT slightly elevatedo Ultrasound shows intra- and extra-hepatic duct dilationo KUB shows nonspecific gas pattern

Imaging to view firm mass palpated in RUQ:o CT + contrasto MRIo Biopsy (by ERCP scope to 2nd part of duodenum [doesnt go to biliary tree] shoot dye to

visualize tree use brushing & FNA to biopsy) Dx: GB carcinoma

o Rare cancer 5000 new cases per yr in U.S.o 5-year survival < 5%o Risk factors

Gallstones >3cmAdenomatous polyps Calcification of gallbladder wall

o Choledochal cyst 5% lifetime risko PSC 5-15% lifetime risko Presentation: Indistinguishable from presentation of cholecystitis and cholelithiasis

> 50% of GB cancers are NOT diagnosed before surgery Work-up


o CT or MRI to determine extent of invasiono CA 19-9 has 79% sensitivity, 98% specificity; can be elevated in cholangitis or GI/Gyn neoplasms

Treatmento Cholecystectomy with resection of segment 4 & 5 of the livero Cholecystectomy only for T1 tumor (limited to muscularis)

Dx: Cholangiocarcinoma (Bile Duct Cancer)o Rare cancer as well; 3000 new cases annuallyo Prognosis

If resectable 5 year survival is between 10-30%If unresectable 5-8 month median survival

o Risk FactorsPrimary sclerosing cholangitis, choledochal cyst, ulcerative colitis, SE Asia risk factors liver flukes, chronic typhoid carriers.

o Presentation: painless jaundice is most common presentation; may have pruritis, mild RUQ pain, anorexia, fatigue, weight loss; cholangitis may be presenting symptom.

o Klaskin tumor: perihilar cholangiocarcinoma Work-up

o CT or MRI to determine extent of invasiono PTC/ERCPo CA 19-9

Treatmento Surgical excision with reconstruction (if resectable)o If perihilar resect bile duct, cholecystectomy, portal lymphadenectomy, and bilateral roux-y-

hepaticojejunostomyo If distal - Whipple

A 75 year resident from a nursing home presents to the Emergency Department at University Hospital with nausea, vomiting, abdominal distension and obstipation. She has no history of abdominal operation. She has had a history of chronic cholecystitis for which she refused cholecystectomy. The vital signs are temp 100, P 110, RR 20 and BP 110/68. The abdomen is distended and tympanic with decreased bowel sounds. There are no abdominal wall hernias. The rectal examination shows no masses and is guaiac negative. The obstructive series shows complete small bowel obstruction, a calcified mass in the right lower quadrant and air in the biliary tree.

Nursing home residents usually get sigmoid volvulus, Ogilvies syndrome, gallstone ileus, and incarcerated femoral hernia

Dx: Gallstone ileus o Mechanical ileus of GI tract from an impacted gallstoneo Usually in the terminal ileum (ileocecal valve)o Results from inflammatory changes and ischemia of

gallbladder wall leasing to fistula to duodenum, gastric antrum, or transverse colon

o Classic imaging findings of air in biliary tree and an ileusCalcified mass in RLQ and air in biliary tree in RUQCan also see air in biliary tree w emphysematous cholecystitis or recent GI tract manipulation

o Symptoms of obstruction Workup

o NPO, IVF, resuscitation, NGT


Treatment [take care of SBO first]o Exploratory laparotomy, proximal enterotomy to relieve obstruction and remove stone, removal of

impacted gallstoneo Do elective cholecystectomy after 6 wks

Deal with fistula at later time [leave GB because inflammation hinders visualization for surgery and has incr risk of injuring CBD]

A 9 year old Asian female presents to the Emergency Room at Santa Rosa Childrens Hospital with jaundice, right upper quadrant pain and a right upper quadrant mass. She has no previous medical or surgical history. The vital signs are stable. The skin and sclerae are yellow. The lungs are clear. The heart has a regular rate and rhythm with no gallops, rubs or clicks. The abdomen is soft and nondistended but has mild pain and a prominent mass in the right upper quadrant.

Jaundice at age 9? Very abnormal Workup

o Left side: PTC or intra-operative cholangiogram (probably not ERCP because dont see scope)

o Right side: MRCPo Imaging shows dilated CBD w no obstruction, dilated pancreatic and

cystic ducts Dx: Choledochal cyst

o Classic finding of RUQ mass, jaundice, abdominal paino Increased risk of malignancyo Top 2 congenital abnormality of biliary tree

Biliary atresiaCholedochal cyst [congenital dilation of CBD even if asymptomatic, want to fix because of possibility of malignancy]

o Variants

oo D

When both intra and extra-hepatic ducts dilated Carolis diseaseo Complication: stasis of bile with infection; malignant transformation to cholangiocarcinoma

Treatmento Resection and reconstruction excise whole distal CBD


Roux-en-Y choledochojejunostomyRoux-en-Y hepatic jejunostomy


You admit a 40 year old obese female with acute cholecystitis. With resuscitation, intravenous antibiotics and analgesics your patient improves remarkably. Your faculty surgeon decides to perform a laparoscopic cholecystectomy on this hospital admission. During the laparoscopic cholecystectomy your faculty surgeon performs an intraoperative cholangiogram which shows stones in the distal common bile duct.

Intra-operative cholangiogram (IOC) shows CBD stoneso Why not just do post-operative ERCP?

Failure rate of 4-10%o Laparoscopic common bile duct exploration

FlushingIV glucagon 1-2mg relaxation of SODBallon dilation of SOD (sphincter of Oddi)Helical stone basket retrieval

You admit a 40 year old obese female with acute cholecystitis. With resuscitation, intravenous antibiotics and analgesics your patient improves remarkably. Your faculty surgeon decides to perform a laparoscopic cholecystectomy on this hospital admission. Your faculty surgeon performs a laparoscopic cholecystectomy. There is a moderate amount of inflammation in the portal region.

On the first postoperative day the patient describes right upper quadrant pain and shoulder pain.

Next step?o The serum bilirubin is 3.5 mg/dL. A sonogram of the right upper quadrant shows a

homogeneous fluid collection in the portal region. Dx: Post-cholecystectomy complications

o Cystic stump leako CBD injuryo Retained stone

Workup/Treatmento How do you ID these problems? POD#5 s/p cholecystectomy has RUQ pain different from pre-op

GB paino Sonogram shows 6x6 fluid collection in RUQ get IR to drain percutaneously

Pus suspect infectionBile suspect cystic stump leak

o HIDAo ERCP look for contrast leaking out of cystic stump into peritoneal cavity

Cystic stump leak tx w sphincterotomy w stent placement across duct (may have too much inflammation to get good closure) incr resistance across sphincter and decr pressure gradient divert flow of bile down CBD

A 47 year old male with a history of significant alcohol use comes to the Emergency Department at Valley Baptist Hospital with an 8 hour history of epigastric pain. The pain developed after a party where he consumed 16 beers and a whole pizza. The mid epigastric pain is persistent and radiates to the back. The pain improves slightly when he sits forward. He has had several episodes of nausea and vomiting. Food makes the pain worse. The pain has not improved after vomiting. OTC Pepcid and Tylenol have not improved the pain. His past medical history is significant for bilateral inguinal hernias at age 6 years old. The vital signs are temp 100.2, P 128, RR 36 and BP 110/60. The patient is uncomfortable and diaphoretic. He sits forward on the examination table. The left lung base is dull to percussion and has decreased breath sounds. The heart has tachycardia but no gallops, rubs or clicks. The abdomen has distension, diffuse tenderness in the epigastric region with decreased bowel sounds. There is voluntary guarding on deep


palpation in the epigastric region but no frank rigidity. The rectal examination shows no lesions and is negative for occult blood. There is mild peripheral edema.

DDx: acute episgastric pain = PUD, gastritis, MI (get cardiac enzymes and EKG) Dx: Acute pancreatitis

o Causes: #1/2 gallstone obstruction and alcoholism; hypertriglyceridemia, hypercalcemia, scorpion bite, medication-induced (sulfa, abx, steroids), iatrogenic (instrumentation), post-traumatic injury; pancreas divisum (anatomic anomaly in 10% but hardly causes pancreatitis)

o Initially at dx After 48 hAge > 55 Base deficit > 4WBC > 16 BUN incr > 5Glucose > 200 Serum Ca < 8LDH > 350 Hct decr > 10%AST > 250 Fluid sequestration > 6 L

o Ransons criteria doesnt change management; marker for prognosis (*note amylase NOT prognostic)# Criteria Mortality0-2 < 5%3-4 ~15%5-6 ~40%7-8 ~100%

o Signs

Turners sign: flank hemorrhageCullens sign: periumbilical hemorrhageFluid sequestration: retroperitoneal can third space require a lot of fluid resuscitation

o Why does patient have decr breath sounds and dullness to percussion in L lung field?Inflammation causes reactive inflammation across diaphragm pleural effusion

Workupo ICU admission, NPO, pain control, nutrition, abx if pt febrile (use imipenem)o AGGRESSIVE RESUSCITATION

How much? Look at CVP, UOP, wedge pressure; dont start pressors w/o adequately preloading the pt

o IV Fluids APPROPRIATE RATE!!!; Foley to assess resuscitative efforts; NGT if nausea/emesis Imaging

o CT will show pseudocyst (not typical for early presentation), r/o necrotizing pancreatitis; use if unsure of dx or looking for complications


o Ultrasoundo Obstructive series can show perforation, chronic pancreatitis w calcifications, air-fluid level to

show bowel obstruction, gastric outlet obstruction, pancreatic calcifications, colon cut-off sign (edema at root of mesentery)

Treatment [treat underlying process]o Debridement of pancreas is a difficult procedure and ends up requiring multiple re-operations w

wide drainage AVOID OPERATING ON PANCREAS!!!o Indications to operate

Biliary pancreatitisInfected necrotizing pancreatitisPancreatic pseudocystAlso stricture of pancreatic duct, hemorrhagic pancreatitis, abscess, refractory to medical management

o Keep resuscitating, no further imaging Case scenario: Chronic pancreatitis from alcohol use (exocrine and endocrine malfunction)

o Best test: CT scan to confirm atrophic pancreas or chain of lakeso Obstructive series shows calcified pancreaso RUQ sonogram shows atrophic calcified pancreas; pancreatic duct may show chain of lakeso Dealing with food fear (pain after eating) operate with sonographer to ID course of pancreatic

duct (dilated, stricture, dilated stricture) filet open duct longitudinally and do roux limb from jejunum to pancreatic duct lay open side-by-side = lateral pancreaticojejunostomy may have to resect pancreas

A 35 year old female recovers from gallstone pancreatitis, undergoes a laparoscopic cholecystectomy and is discharged to home. Three weeks later she returns to the emergency room with early satiety, vomiting, mild epigastric pain and an epigastric mass. The vital signs are temp 100, P 98, RR 22 and BP 130/80. The lungs are clear to auscultation and percussion. The heart has a regular rate and rhythm with no gallops, rubs or clicks. The abdomen is soft, slightly distended with a prominent mass in the upper right quadrant. The rectal exam shows no masses and is guaiac negative. An abdominal sonogram shows a 6 cm, homogenous fluid collection posterior to the stomach in the lesser sac.

DDx: simple pancreatic cyst, pseudocyst, cystic neoplasm Dx: Pancreatic pseudocyst

o Incidence15% after acute pancreatiits35% after chronic pancreatitis

o Most pseudocyst resolve by 6 weeksEspecially if 6 cm, let wall calcify before draining

o Transmural drainage, transpapillary drainage, surgical drainageDrain through stomach cystgastrostomy or endoscopically (endoscope can only get a 1 cm window, but operative can get larger window in fluid collection)


If abutting duodenum drain into duodenumIf free in body do roux limb to drain into jejunumDo not percutaneously drain a pseudocyst

o Send part of wall to pathology normal pseudocyst wall = fibrin, platelets, protein if see epithelium, cancer until proven otherwise resect

A 12 year old female with a history of pancreas divisum has had multiple episodes of recurrent acute pancreatitis. She now presents to the Emergency Room at Christus Santa Rosa Childrens Hospital with massive hematemesis. The vital signs are temp 98, P 130, RR 30 and BP 80/50. She is pale and diaphoretic. The lungs are clear. The heart has tachycardia and a soft holosystolic murmur. The abdomen is soft and nondistended with mild epigastric tenderness and decreased bowel sounds. The liver edge is smooth but the spleen is very prominent. After resuscitation you perform an esophagogastroduodenoscopy which reveals gastric varices. You perform an abdominal sonogram which reveals splenic vein occlusion and marked splenomegaly.

Dx: Isolated gastric varices o Etiology

Splenic vein thrombosis (MCC of isolated gastric varices) Treatment

o Splenectomy decr venous load and remove source of veins prevent dev of gastric varices Ann Surg. 2004 June; 239(6): 876882.

o The Natural History of Pancreatitis-Induced Splenic Vein Thrombosiso Results: Gastrosplenic varices were identified in 41

patients (77%) with varices evident on computed tomography (CT) in 40 of 53 patients, on esophagogastroduodenoscopy (EGD) in 11 of 36 patients, and on both CT and EGD in 10 of 36 patients. This risk of variceal bleeding was 5% for patients with CT-identified varices and 18% for EGD-identified varices. Overall, only 2 patients (4%) had gastric variceal bleeding and required splenectomy. Functional quality of life was better than historical controls surgically treated for chronic pancreatitis.

o Conclusion: Gastric variceal bleeding from pancreatitis-induced splenic vein thrombosis occurs in only 4% of patients; therefore, routine splenectomy is not recommended.


A 67 year old male presents to your outpatient clinic with a 3 month history of vague epigastric discomfort. The patient also describes that his skin and eyes have become yellow. The patient also describes anorexia and a 30 lb weight loss over 3 months. He also notes that his stool is light in color and malodorous. He has rare alcohol use. The vital signs are temp 98, P 100, RR 14 and BP 128/82. The patient appears malnourished. The eyes have scleral icterus. The skin has jaundice, pruritis and rare scattered angiomas. There is no palmar erythema or gynecomastia. The lungs are clear. The heart has a regular rate and rhythm with no gallops, rubs or clicks. The abdomen is soft, and nondistended with mild epigastric tenderness. The liver edge is palpable 2 cm below the right costal margin and the liver span is 12 cm. The spleen is not palpable. The rectal examination shows no masses and is guaiac negative. There is mild peripheral edema. The right upper quadrant sonogram reveals intra- and extra-hepatic biliary ductal dilatation and an ill defined mass in the head of the pancreas.

DDx: cirrhosis (palmar erythema, gynecomastia, shrunken liver, so unlikely)

Dx: Periampullary carcinomao Cancers can arise from: Ampulla of Vater,

duodenum, pancreas, bile ducto Complaints of jaundice, icterus, itchingo Mass may be palpable, esp in cachectic ptso Distended, dilated, NT GB

Workupo CT scan to confirmo ERCP w biopsy [note: biopsy may cause

hematoma then unresectable]o Ultrasound helpful to look at portal nodes, duodenum

Dx: Pancreatic adenocarcinomao Poor prognosis

5 yr survival = 4%5 yr survival = 20% even in those w local dz who undergo Whipple

o CA 19-9 and CEA may be elevated Workup

o CT/MRI stage cancer by looking at livero EUS

Treatmento Whipple procedure (pancreaticoduodenectomy): even if benign (dont need biopsy prior to

surgery) when resect head of pancreas, must also resect duodenum b/c share common blood supply

o Kocher maneuver: expose structures in retroperitoneum behind duodenum and pancreas look for erosion into vena cava, make sure portal vein not involved resect stomach, bile duct, duodenum, and pancreas as one unit then reconstruct w jejunum

Must know if tumor is resectable 15% develop duodenal obstruction

o +celiac nodes palliative care (very poor prognosis; Whipple contraindicated)ChemotherapyBypass all w large loop jejunum connected to stomach (bypass obstructed duodenum)

Extremely high mortality b/c dying of bulk tumor Treatment

o Indication for surgery: early stage, but most cases advanced at time of dx


If surgery not possible, radiotherapy +/- chemotherapy to shrink cancer, decr sx, prolong life

o Contraindication to Whipple procedureMetastatic diseaseInvolvement of SMA or Celiac AxisInvolvement of celiac or portal lymph nodes

A 45 year old female complains of tachycardia, diaphoresis and tremulousness. She notes that these symptoms improve with eating food and she has a 35 lb weight gain over 6 months. On exam the vital signs are stable. The lungs are clear. The heart has tachycardia. The abdomen is soft, obese, nondistended and nontender with normal bowel sounds. In the evaluation the serum blood glucose level is 45 mg/dL. You perform simultaneous serum C peptide levels and fasting serum blood glucose levels. There is an inappropriately high C peptide level in relation to the fasting blood glucose level.

Dx: Insulinomao Most common type of pancreatic islet cell tumoro Whipples triad of hypoglycemic symptoms, low blood glucose (


DDx for child-bearing age, non-traumatic female: ruptured splenic artery aneurysm (another cause of intraabdominal hemorrhage in women of childbearing years, especially prone to rupture and hemorrhage during pregnancy), ectopic pregnancy (bHcG), hepatic adenoma, hemangioma, FNH (focal nodular hyperplasia) (look for central scar on CT or MRI), hepatic cyst,

Dx: Hepatic adenomao Woman aged 20-40o Strong association with oral contraceptive useo Risk of spontaneous rupture, especially if >5cm

Workupo If stable, could do CT scan and sonogram free fluid in RUQ and pelvis go to OR for surgical

exploration Treatment

o Should be resected due to risk of spontaneous rupture enucleate with 2cm marginso If small and asymptomatic trial of discontinuation of OCP, follow up imaging

A 45 year old Palestinian male visits his daughter in San Antonio for an extended vacation. In Palestine he tends to a field of sheep for the mayor of a small town. He uses several border collie dogs to herd the sheep. He comes to the outpatient clinic with low grade fever, anorexia and right upper quadrant pain. The vital signs are stable. The lungs are clear to auscultation and percussion and the heart has a regular rate and rhythm. The abdomen is soft and nondistended but the liver is tender to deep palpation. The WBC is 12, 000/mm3 and there is eosinophilia on the smear. The right upper quadrant sonogram shows a 5 cm septated lesion in the right lobe of the liver.

Dx: Echinococcal cysto Echinococcus flat tapeworm

Life cycle alternates between carnivores and herbivores Dog is definitive hostTapeworm eggs pass in feces of infected dog, eaten by interm host such as sheep or cattleHumans eat contaminated vegetables or are in contact with infected animals/soilOva hatch in small intestine, travel via portal circulation to liver

Diagnosiso CT shows cystic lesiono ELISA assay for echinococcal antigens

Results positive in 85% of infected patients o Eosinophilia

Treatmento Surgical due to high risk of secondary infection and

rupture. o If cysts are small or patient not suitable candidate for

surgical resection medical treatmento Medical Albendazole (only 30% can expect resolution)o MUST avoid release of cyst content because can results in an acute anaphylactic reaction or

peritoneal implant of scolices


A 25 year old female goes to Cancun for Spring break. Two weeks after her vacation she complains of fever, nausea, vomiting and right upper quadrant pain. The vital signs are temp 101, P 100, RR 18 and BP 120/80. The abdomen is soft and slightly distended with moderate right upper quadrant pain. The sonogram of the liver shows a fluid filled collection in the right lobe of the liver.

Dx: Amebic Liver Abscesso E. Histolyticao Typical patient Young hispanic male 20-40 with history

of travel to endemic area or emigration from Mexico or SE Asia

o Content of abscess Anchovy paste Diagnosis

o Serologic tests enzyme immunoassay (EIA), ELISA, etc Treatment

o Flagyl is treatment of choiceo Drainage or surgery is rarely necessary

A 43 year old male was involved in a high speed motor vehicle accident and suffered blunt injury to the right lobe of the liver which as treated non-operatively. Three weeks after the injury he presents to the outpatient trauma clinic with fatigue and melanic bowel movements. The vital signs are temp 99, P 98, RR 22 and BP 110/70. The mucous membranes are pale. The lungs are clear to auscultation and percussion. The heart has a regular rate and rhythm. The abdomen is soft, nondistended and non tender with decreased bowel sounds. The rectal examination shows no masse but is strongly guaiac positive. You place a nasogastric tube which shows trace blood. You perform upper endoscopy which shows blood emitting from the sphincter of Oddi.

Dx: Hemobiliao Typically occurs after major liver injuryo 4-14 days post-trauma, contained hematoma decompresses into biliary treeo Hemobilia fistula from the vessel to the biliary tree presents as melena or upper GI bleed

Diagnostic test and treatment of choice?o Angiogram and embolizationo Not a frequent dx, need a high index of suspicsion

EXTRA CASES

A 53 year old male a history of Hepatitis B and C from IV drug abuse now complains of vague right upper quadrant pain, anorexia and 10 pound weight loss over 2 months. The vital signs are stable. The cardiopulmonary exam is normal. The abdomen is soft and nondistended with vague right upper quadrant pain and normal bowel sounds.


The liver edge is palpable and firm. The rectal exam shows no masses and is guaiac negative. The sonogram shows a solid, ill defined lesion in the right lobe of the liver. Serum AFP marker is 200 ng/mL (normal

Liver and Biliary Notes

Documents

Transcript of Liver and Biliary Notes