Nms Surgery Pancreatic And Hepatic Disorders

Front 1

What 3 groups need asymptomatic gallstones removed?

Back 1

1. Immunocompromised
2. Porcelain gallbladder (chronic cholecystitis, at risk for adenocarcinoma of the gallbladder)
3. Larger than 3cm

Front 2

6 factors that predispose to gallstones?

Back 2

1. Age over 40
2. Family history of gallstones
3. Female
4. Obesity
5. Recent preg
6. Prev diag of gallstones

Front 3

RUQ due to cholithiasis can radiate to where?

Back 3

R subscapular

Front 4

Most efficient way to dx cholithiasis?

Back 4

US

Front 5

Lab values to expect with cholithiasis

Back 5

Mild leukocytosis, mild jaundice, elevated bilis, alk phos and transaminases can also be elevated

Front 6

In uncomplicated cholithiasis, what's the abx regimen?

Back 6

1 dose of preop first gen cephalosporin: Cefalexin, Cefazedone, Cefazolin

Front 7

Who needs abx in cholithiasis?

Back 7

high riskers for sepsis: over 70, acute cholecystitis, history of obstructive jaundice, common duct stones, jaundice, those with preop ERCP done

Front 8

What's the major complication of lap chole?

Back 8

Common bile duct injury: chronic biliary strictures, infection, cirrhosis
Injury to hepatic A: hepatic ischemic injury, bile duct ischemia, strictures

Front 9

Most common species for acute cholecystitis?

Back 9

1. E Coli
2. Enterobacter, Klepsiella, Enterococcus

Front 10

Abx regimen for acute cholecystitis after blood cultures?

Back 10

second gen cef for GNRs and Anaerobes: Cefotetan, Cefoxitin
- give preop and 24 hours postop

Front 11

When bili and/or liver enzymes are elevated, what to suspect? What to do?

Back 11

Common duct stone, preop or postop ERCP

Front 12

How should gallstone pancreatitis and symptomatic cholithiasis be managed in pregs?

Back 12

IV hydration and pain mgmt. Avoid surg till after deliv. But safest to do in 2nd trimester. ERCP and sphincterotomy generally safe.

Front 13

When biliary pancreatitis suspected, what procedure is necessary operatively?

Back 13

Operative cholangiogram. But delay surgery until complications from pancreatitis relieved: high fluid requirements, hypocal, oliguria, hypotension, pulmonary complications

Front 14

Causes of pancreatitis mnemonic?

Back 14

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)

Front 15

clinical signs of pancreatitis

Back 15

* 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]

Front 16

RUQ pain and high fever would be suspicious for?

Back 16

Acute cholecystitis and complication like cholangitis, empyema of gallbladder, pericholecystic abscess

Front 17

What US signs would you see with empyema of gallbladder?

Back 17

distended gallbladder with fluid that has internal echoes and gallstones

Front 18

Tx for empyema of gallbladder?

Back 18

emergent exploration, cholecystectomy, IV abx. If general health is poor: perctaneous cholecystostomy to drain

Front 19

What does air in the biliary system mean? Tx?

Back 19

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

Front 20

Definition of SIRS/sepsis?

Back 20

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)

Front 21

what does it mean when you have palpable gallbladder? What to do?

Back 21

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

Front 22

Charcot's triad? Meaning?

Back 22

1. RUQ pain
2. Fever
3. Jaundice
means cholangitis

Front 23

Tx of cholangitis?

Back 23

1. IVF
2. Abx
3. Ultrasound.
4. ERCP is obstruction or dilation of CBD is seen

Front 24

What's a retained stone?

Back 24

common duct stone within 2 years of cholecystectomy. after 2 years=primary CBD stone

Front 25

Post lap chole fever and pain might be?

Back 25

infection/ biliary leak/ hepatic (CT scan)abscess/hepatic duct obstruction

Front 26

HIDA scan is good for detecting what?

Back 26

Biliary leaks, cholecystitis, obstructions

Front 27

Post lap chole cystic duct stump leak on HIDA or ERCP requires what?

Back 27

Drainage and temporary stent

Front 28

If HIDA or ERCP shows complete CBD obstruction post cholecystectomy, what to do?

Back 28

1. Biliary drainage using percutaneous drain
2. choledochojejunostomy (CBD to jejunum)

Front 29

Differential for painless jaundic, pruritis, elevated liver enzymes?

Back 29

Biliary tree obstruction. Cancer at head of pancreas, periampullary carcinoma, Klatskin tumor, CBD stricture, CBD stone (unusual for this presentation)

Front 30

If you see CBD dilation but no stones in US, next steps?

Back 30

1. CT
2. Endoscopic ultrasound through duodenal wall to visualize head of pancreas
3. US guided biopsy

Front 31

What would stop you from resecting a pancreatic adenocarcinoma at the head of pancreas?

Back 31

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

Front 32

Procedure for resection of tumor at head of pancreas?

Back 32

Pancreaticoduodenectomy

Front 33

What would you do if you found unresectable pancreatic adenocarcinoma with local spread?

Back 33

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.

Front 34

Painless jaundice+dilated intrahepatic ducts+no dilation of CBD =?

Back 34

Cholangiocarcinoma or Klatskin tumor

Front 35

How to visualize cholangiocarcinoma or Klatskin?

Back 35

ERCP or Percutaneous Transhepatic Cholangiography, which is better for proximal hepatic ducts

Front 36

Are Klatskins resectable?

Back 36

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

Front 37

What should you do with an unresectable Klatskins or cholangiocarcinoma?

Back 37

Palliative stenting of hepatic duct strictures

Front 38

Type of biliary cancer with best prognosis?

Back 38

Ampullary adenocarcinoma. Requires a Whipple (pancreatoduodenectomy)

Front 39

What does a mass in the gallblader fossa mean?

Back 39

Gallbladder adenocarcinoma. Do open chole and wide resection of surrounding liver with hilar LN resection

Front 40

porcelain gallbladder associated with what?

Back 40

50% assoc w adenocarcinoma

Front 41

When you suspect pancreatitis, what imaging should you get to rule out other stuff?

Back 41

Obstructive abd series to r/o perf ulcer. Will usually see generalized ileus

Front 42

Tx for pancreatitis?

Back 42

NPO, IVF, pain control, observation, TPN if necessary

Front 43

Tx for gallstone pancreatitis?

Back 43

IVF, NPO, pain control, observation, lap chole when stable

Front 44

Tx of severe necrotizing pancreatitis?

Back 44

Major fluid resuscitation, CT abd for additional causes of decompensation such as bowel necrosis, perfs, abscesses, biliary obstruction w infection

Front 45

Ranson's Criteria?

Back 45

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

Front 46

What do you do for a person with labored breathing and a low pulse ox?

Back 46

1. chest auscultation
2. ABG
3. CXR
4. Supp oxygen

Front 47

Potential causes of resp distress in pancreatitis?

Back 47

Pulm edema from overhydration, ARDS from response to pancreatitis, atelectasis, pneumonia

Front 48

Do amylase levels correlate with severity or prognosis?

Back 48

NO

Front 49

If a person with pancreatitis goes into sepsis, what should you suspect? What to do?

Back 49

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

Front 50

Sxs of pancreatic pseudocyst?

Back 50

pain, anorexia, elev serum amylase, Early Satiety

Front 51

Tx of pancreatic pseudocyst?

Back 51

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

Front 52

Hepatic mass differential?

Back 52

Young: simple cyst, hemangioma
Older: metastatic carcinoma, primary hepatocellular carcinoma, cholangiocarcinoma

Front 53

Appearance and tx of simple cysts?

Back 53

No internal echoes,
Aspiration, excision

Front 54

Appearance and tx of multilocular cysts?

Back 54

Calc in wall, internal echoes, inject echincoccal cyst w hypertonic saline, excision. don't spill into peritoneum

Front 55

Treatment of hepatic pyogenic abscess?

Back 55

IV abx (Metro), CT guided drainage. Surgery avoided.

Front 56

Solid liver lesion common in OCP users?

Back 56

Hepatic adenoma

Front 57

Solid liver lesion with history of HepB/C?

Back 57

Hepatocellular carcinoma

Front 58

Most common solid liver lesion? How to diagnose?

Back 58

Hemangioma diagnosed by labeled RBC scan, CT, or MRI: looks like vascular lesion

Front 59

Biopsy hemangioma?

Back 59

Nope, high risk of bleeding

Front 60

CT appearance of focal nodualar hyperplasia?

Back 60

central sellate scar

Front 61

Tx for FNH?

Back 61

None. benign.

Front 62

When do we remove solid liver lesions?

Back 62

When they're symptomatic, at risk for rupture, or when there's uncertainty as to diagnosis

Front 63

Hepatic adenoma tx?

Back 63

Discont oral contraceptives, resect if persistent or large because they can dev into hepatocellular carcinoma and at risk for rupture esp during preg

Front 64

Mgmt of hepatocellular carcinoma?

Back 64

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

Front 65

2 etiologies of liver abscesses? Appearance on CT?

Back 65

1. Bacterial (pyogenic)
2. Amoebic (Entamoeba histolytica)

Multiple low density lesions with peripheral ring enhancement, or single large abscess

Front 66

Tx of liver abscesses?

Back 66

IV abx 4-6 weeks if multiple, percutaneous drainage+IV abx if single. If serologies + for E. histolytica = Metronidazole