Pancreatic/hepatic

Front 1

indications for chole in asymptomatic patients with gallstones?

Back 1

procelain (calcified) gallbladder, immunocompromised patients, GS > 3 cm (larger risk for CA), sickle cell

Front 2

predisposing factors for gallstones (5)?

Back 2

obesity, pregnancy, female gender, prev diag of gallstones, inc age

Front 3

what history might elicited that would make complaint of RUQ pain more llikely PUD than cholecystitis?

Back 3

hx of GERD, NSAID usage, smoking, alcohol abuse, tarry stools

Front 4

#1 diagnostic test for diagnosing cholecystitis and characteristic findings (3-4)?

Back 4

ultrasound; galldladder wall thickening, pericholecystic fluid, gallstones, sonographic murphy's sign

Front 5

does jaundice occur in cholecystitis?

Back 5

in 20% of patients, yes; NOT due to CBD blockage, but rather inflammation/cholestasis

Front 6

choleecystectomy: clean, clean-cont, or contanimated? antibiotics?

Back 6

clean-contaminated; preop antibiotic (eg cephalosporin) dose; usually no postop necessary unless inc age, acute cholecystitis, CBD stone, jaundice

Front 7

lap chole accepted standard - important parts of procedure?

Back 7

1. removing fundus from bed of liver
2. ligating cystic duct
3. ligating cystic artery
4. +/- operative cholangiogram

Front 8

major complications of cholecystectomy?

Back 8

common bile duct, hepatic artery injuries

Front 9

key feautres of acute cholecystitis (5) (not ultrasound findings)?

Back 9

RUQ pain, fever, leukocytosis, murphy's sign, N/V, elev Alk phos

Front 10

when, if at all, to start antibiotics in acute cholecystitis? what antibiotics?

Back 10

immediately after Blood Cxs are drawn; broad spectrum covering gram neg and anaerobes

Front 11

operate on acute cholecystitis when?

Back 11

after 48-72 hrs of antibiotics (called cool down period)

Front 12

39 yo males with five wks post-acute pancreatitis; epigastric pain, fevers, and pain - WBC 24, CT scan showing 6cmx6cm rim-enhancing fluid collection in bosy and tail of pancreas. what is proper managent?

Back 12

antibiotics and perc drain (same as IA abcess trtment)

Front 13

82 yo F with asymptomatic cholelithiasis. in addition to elev alk phosph and gallstones on US, here bilirubin is elev at 4.0.
1. Findings suggest what?
2. next steps (order of which is debated)?

Back 13

1. CBD obstruction
2. ERCP, lap chole OR lap chole with IOC

Front 14

management for symptomatic cholelithiasis (3-11% of preg patients)?

Back 14

usually with hydration and pain management; chole after delivery

Front 15

symptomatic cholelithiasis with elevated amylase -
1. diagnosis
2. course and management?

Back 15

1. mild (biliary) pancreatitis
2. amylase should come down, then chole with IOC

Front 16

pancreatitis secondary to stone in distal duct - management/order (2)

Back 16

ERCP (relieve obstruction) ---> allow for pancreatitis recovery ---> then chole

Front 17

60 yo M with marked RUQ pain and findings consistent with acute cholecystitis. U/S reveals GB distended with fluid and with internal echoes.
1. diagnosis?
2. management (2)?

Back 17

1. gallbladder emypema
2. abx and emergent exploration

Front 18

Patient presents with jaundice and RUQ pain. RUQ U/S post-chole with air in the biliary system.
1. diagnosis?
2. etiology?
3. management (3)?

Back 18

1. suppurative cholangitis
2. bacterial infection secondary to CBD obstruction
3. ERCP with sphincterotomy, emergent decompression of biliary tree, canulation of stone

Front 19

76 yo M in ED with 12 hr hx of RUQ pain and tenderness. appears quite ill. diagnosis/treatment for following:
1. temp 104, BP 90/60, WBC 20
2. temp 96 and WBC 3.9
3. 3cm palpable mass in RUQ, temp 103, obtunded
4. air in walll of GB

Back 19

1. acute biliary sepsis; resuscitation and emergent chole
2. acute biliary sepsis (can present in elderly with hypothermia and leukopenia) / same management as above
3. inflamed/palpable GB (emergent chole due to high risk of perf)
4. emphysematous GB / urgent surgery

Front 20

51 yo M to ED with recent onset of jaundice, fever, RUQ pain.
1. diagnosis?
2. initial steps in diagnosis/management (3)?
3. treatment?

Back 20

1. acute cholangitis
2. fluid resuscitation, antibiotics, and RUQ U/S
3. ERCP with GB decompression

Front 21

Stone in CBD <2 verus >2 yrs post-chole?

Back 21

1. <2 yrs: retained stone
2. >2 yrs: primary stone

Front 22

other option if ERCP fails in CBD stone extraction?

Back 22

perc transhepatic cholangiograpghy (PTC) with stone extraction

Front 23

what else can cause cholangitis besides CBD stone? name 2

Back 23

mass (pancreatic head CA), biliary structure

Front 24

post-op fever and adominal pain in patient after lap chole
1. likely diagnosis?
2. how to confirm (2 tests)?
3. management (2)?

Back 24

1. biliary leak
2. abdominal U/S, HIDA scan
3. drain any collections; ERCP to define biliary anatomy and look for cystic duct leak

Front 25

how is a cystic duct leak managed when seen on ERCP (1st and 2nd otions)?

Back 25

biliary drainage with a temporary stent (if that doesn't work, then reexploration and biliary drainage procedure, e.g. cholejejunostomy)

Front 26

55 yo M with jaundice of recent onset. NO pain, but marked pruritis. D bili of 6, normal AST/ALT, and an alk phosph 6x normal. differential diagnosis.
1. name 3
2. workup (3 modes of imaging)
3.

Back 26

1. pancreatic mass (head), cholangiocarcinoma (Klatskin tumor), CBD stricture, impacted stone (less common b/c usually produce symptoms)
2. abdominal ultrasound, CT abdomen, endoscopic US

Front 27

endoscopic ultrasound allows visulization of a 2cm mass in the head of pancreas. two possible ways to proceed?

Back 27

1. pancreatic exploration (establish tissue diagnosis perioperatively) versus endoscopic
2. transduodenal biopsy

Front 28

patient with pancreatic adenocarcinoma - name 4-5 factors that would require workup before being a surgical candidate.

Back 28

distant mets, abnormal CXR, neuro symptoms, bone pain, local invasion of tumor, liver mets

Front 29

perioperative plan for pancreatic adenocarcinoma?

Back 29

1. inspect for liver / omental mets
2. frozen section for possible paraaortic / celiac LN involvement (means tumor nonresectable)
3. resection via Whipple's

Front 30

1. what is whipple's procedure?
2. what is transected / detached; 3 main transection points.
3. what makes up anastamosis?

Back 30

1. pancreatoduodenectomy
2. jejunum at ligament of treitz transection, pancreas to uncinate process transected, 1st portion of duodenum (to preserve pyloris)
3. 1st part of duodenum to jejunum

Front 31

60 yo male with painless jaundice; abdominal u/s shows dilated intrahepatic ducts but no dilation of CBD.
1. most likely diagnosis?
2. evaluation?
3. prognosis and why?

Back 31

1. cholagniocarcinoma (Klatskin tumor)
2. ERCP or PTC (usually at CBD bifurcation)
3. poor prognosis (5-15% survival rate); most tumors unresectable at presentation

Front 32

1. what can mimic symptoms of gallstones, but reveals different findings on ultrasound?
2. is lap chole the correct treatment?
3. most discovered early or late?

Back 32

1. gallbladder adenocarcinoma;
2. no, open chole with wide rsx of surrounding liver and hilar lymph node resection
3. late, with large portion of liver involved

Front 33

what presents precursor (50% association) with gallbladder carcinoma?

Back 33

porcelain (calcified) gallbladder

Front 34

29 yo with acute episode of epigastric pain; amylase/lipase 3x normal, no gallstone on ultrasound
1. diagnosis?
2. what other diagnosis needs to be ruled out, and how?
3. management (4)?
4. may be necessary if acute pancreatitis not improving rapidly?

Back 34

1. acute pancreatitis
2. perfed ulcer; KUB (to look for free air)
3. NPO, aggressive IV fluids, pain control, observation
4. TPN

Front 35

gallstone pancreatitis has one additional management feature as opposed to non-gallstone pancreatitis. what is it?

Back 35

lap chole when amylase normalizes

Front 36

34 yo M with severe abdominal pain progressively increasing over hours. amylase in elevated; he is ill, hypotensive, hypoxic and developing multi-organ failure
1. diagnosis?
2. management (2)?
3. criteria that can predict mortality, and 5 features on admission?

Back 36

1. necrotizing pancreatitis
2. fluid resuscitation in ICU; CT abdomen (to asses extent of inflammation)
3. Ranson's (age, WBC, AST, LDH, glucose)

Front 37

in managing acute pancreatitis, important to asess adequacy for resuscitation (especially if remaining hypotensive).
1. what is best way to do this?
2. what is indicated with O2 sat of 90% in evaluation? differential (3-4)?

Back 37

1. CVP
2. ABG, CXR
3. pulmonary edema (overrehydration), atelectasis, ARDS, pneumonia,

Front 38

two days after patient presents with acute pancreatitis, develops sepsis with fever, leukocytosis -
1. what is most likely cause?
2. management (3 steps)

Back 38

1. pancreatic abcess
2. perc sampling/analysis, then perc/surgical drainage and antibiotics

Front 39

change in workup of suspected severe pancreatitis in 70 yo patient? why?

Back 39

1. CT-scan, Xlap (if still unclear); reason is to r/o other processes that can present similarly (e.g. gastric volvulus, mesenteric ischemia)

Front 40

34 yo alcoholic male after acute pancreatitis initially improves, symptoms fail to respond with trtment. continue to have mod abd pain, pers elev of serum lipase, early satiety.
1. susp diagnosis?
2. confirm diagnosis how?
3. management (3)?
4. when is surgical interention appropriate?

Back 40

1. pancreatic pseudocyst
2. CT-scan
3. NPO, TPN, observation
4. if pseudocyst not improving after 6 weeks

Front 41

1. surigcal procedure of choice for pancreatic pseudocyst that has not resolved after 6 weeks? Why?
2. what is also performed during procedure?

Back 41

1. cystgastrostomy; cyst usually continuous with posterior wall of stomach
2. biopsy (rule out cystadenoCA of pancreas)

Front 42

37 yo F with vague RUQ pain - normal labs. RUQ U/S - no gallstones, but xx4 cm on right lobe of liver
1. most likely diagnoses (2) and difference between 2?
2. worry about what in older patients (3)?

Back 42

1. simple cyst, hemangioma
2. fluid-filled versus solid
3. mets, primary HCC, cholangioCA

Front 43

management for simple cystic lesion in liver (no nternal echoes)?

Back 43

no further management (unless pain, then can aspirate)

Front 44

CT of liver reveals a multilocular cyst with calcification of the wall and internal echoes
1. diagnosis?
2 etiology?
3. management?

Back 44

1. echinococal cyst
2. Echinococcus granulosus (GI parasite)
3. surgery - intraoperative sterilization (via injection) and excision

Front 45

1. differential diagnosis for solid liver lesion? name 4-5.
2. name 1 thing elicited on hx that would point to two of the above specific diagnoses
3. most likely incidental pickup?

Back 45

1. hemangioma, liver mets, HCC, hepatic adenoma, focal nodular hyperplasia
2. OCPs --> hepatic adenoma
HepB,C ---> HCC
3. hemangioma

Front 46

Solid liver lesion and positive RBC scan -
1. most likely diagnosis?
2. what should therefore be avoid as opposed to workup of other liver lesions?

Back 46

1. hemangioma
2. don't biopsy (high risk of bleeding)

Front 47

Name four indications for excision of hepatic mass

Back 47

1. symptomatic
2. unclear diagnosis
3. risk of spontaneous rupture
4. persistent or large lesions

Front 48

CT for liver mass suggestive of HCC; biopsy reveals HCC; next steps (2)?

Back 48

1 mestastatic workup (CT chest/abdomen)
2. surgical assessment (with resection if appropriate - highest rate of cure)

Front 49

37 yo M with hx of IV drug abuse hosp with UE abcess. Gets I&D, IV abx; On exam, RUQ pain, WBC 24, elev alk phosph. next steps in diff abcess from biliary dz?

Back 49

RUQ ultrsound (for biliary disease);
CT (for hepatic, IA abcess

Front 50

treatment for liver abcesses:
1. pyogenic (bacterial) multiple, small abcesses
2. large, single pyogenic
3 amebic (caused by Entamoebal histolytica)

Back 50

1. broad spectrum abx
2. perc drainage
3. metronidazole