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 duct
o Mucosa of GB continues to secrete mucous, GB becomes distended, results in venous congestion
and eventual impediment of arterial inflow and ischemia
o 4 Fs (Female, Fertile, Fat, Forty)
Estrogen production directly influences production of gallstones
o Low grade fevers, mild tachycardia, RUQ TTP
o Murphys sign: inspiratory arrest on deep palpation of RUQ
o [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, pancreatitis
o White count can be normal w cholecystitis
o Does NOT change plan to go to OR, but case may take longer
Work-up RUQ sonogram, HIDA scan
o 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 cholecystitis
o HIDA scan can show filling of GB within 30 minutes, no filling at
4 hours
Most sensitive test to rule in acute cholecystitis
IV injection of radionucleotide-labeled material taken up by Kupffer cells in liver,
excreted into bile duct
If GB fails to fill at 4 h, 95% certainty pt has nonpatent cystic duct (poss obstruction) and
cholecystitis
If 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 abx
o Can give pain control, BZ to release pressure on sphincter
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
Treatment
o 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 liver
Conversion 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 pain
o DDx: post-op abscess, cystic duct leak (clip falls off), leaking from artery (trend H&H), CBD
injury, retained CBD stone
o 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 stasis
o Often found in hospitalized acutely ill patients after trauma or burns
o 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 scan
o 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]
Treatment
o Percutaneous cholecystostomy tube Perk Drain
Do transhepatic (not transabdominal)
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
o Can be done bedside with local anesthetic
o 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 gallstones
o Estimated that 20 million people in the U.S. have asymptomatic gallstones
o Only 1-4% of asymptomatic patients will become symptomatic
o 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)
Treatment
o Indications for prophylactic cholecystectomy
Gallstones >3cm
Gallbladder polyp(s) >1cm
Calcified (porcelain) gallbladder [bright white GB d/t calcifications]
Undergoing liver transplantation
In liver transplant, always take out GB bc loss of innervation
o 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 cholangitis
o Charcots Triad (1877)
RUQ pain, fevers, jaundice
o Reynauds Pentad (1959)
Charcots Triad PLUS hypotension and mental status changes
o Infectious syndrome affecting the biliary tract; complication of gallstone in CBD
o Risks factors
Age (50-60s)
Biliary stasis and obstruction
U.S. choledocholithiasis; World primary ductal stones
o Iatrogenic biliary tract manipulation
Workup
o Order supplemental O2, resuscitate, CBC, U/A, broad spectrum abx
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
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 anemia
o Bili & alk phos high
o AST/ALT slightly elevated
o Ultrasound shows intra- and extra-hepatic duct dilation
o KUB shows nonspecific gas pattern
Imaging to view firm mass palpated in RUQ:
o CT + contrast
o MRI
o Biopsy (by ERCP scope to 2
nd
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 >3cm
Adenomatous polyps
Calcification of gallbladder wall
o Choledochal cyst 5% lifetime risk
o PSC 5-15% lifetime risk
o Presentation: Indistinguishable from presentation of cholecystitis and cholelithiasis
> 50% of GB cancers are NOT diagnosed before surgery
Work-up
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
o CT or MRI to determine extent of invasion
o CA 19-9 has 79% sensitivity, 98% specificity; can be elevated in cholangitis or GI/Gyn neoplasms
Treatment
o Cholecystectomy with resection of segment 4 & 5 of the liver
o Cholecystectomy only for T1 tumor (limited to muscularis)
Dx: Cholangiocarcinoma (Bile Duct Cancer)
o Rare cancer as well; 3000 new cases annually
o Prognosis
If resectable 5 year survival is between 10-30%
If unresectable 5-8 month median survival
o Risk Factors
Primary 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 invasion
o PTC/ERCP
o CA 19-9
Treatment
o Surgical excision with reconstruction (if resectable)
o If perihilar resect bile duct, cholecystectomy, portal lymphadenectomy, and bilateral roux-y-
hepaticojejunostomy
o 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 gallstone
o 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 ileus
Calcified mass in RLQ and air in biliary tree in RUQ
Can also see air in biliary tree w emphysematous cholecystitis or recent GI tract
manipulation
o Symptoms of obstruction
Workup
o NPO, IVF, resuscitation, NGT
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
Treatment [take care of SBO first]
o Exploratory laparotomy, proximal enterotomy to relieve obstruction and remove stone, removal of
impacted gallstone
o 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: MRCP
o Imaging shows dilated CBD w no obstruction, dilated pancreatic and
cystic ducts
Dx: Choledochal cyst
o Classic finding of RUQ mass, jaundice, abdominal pain
o Increased risk of malignancy
o Top 2 congenital abnormality of biliary tree
Biliary atresia
Choledochal cyst [congenital dilation of CBD even if
asymptomatic, want to fix because of possibility of
malignancy]
o Variants
o
o D
When both intra and extra-hepatic ducts dilated Carolis disease
o Complication: stasis of bile with infection; malignant transformation to cholangiocarcinoma
Treatment
o Resection and reconstruction excise whole distal CBD
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
Roux-en-Y choledochojejunostomy
Roux-en-Y hepatic jejunostomy
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
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 stones
o Why not just do post-operative ERCP?
Failure rate of 4-10%
o Laparoscopic common bile duct exploration
Flushing
IV glucagon 1-2mg relaxation of SOD
Ballon 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 leak
o CBD injury
o Retained stone
Workup/Treatment
o How do you ID these problems? POD#5 s/p cholecystectomy has RUQ pain different from pre-op
GB pain
o Sonogram shows 6x6 fluid collection in RUQ get IR to drain percutaneously
Pus suspect infection
Bile suspect cystic stump leak
o HIDA
o 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
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
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 h
Age > 55 Base deficit > 4
WBC > 16 BUN incr > 5
Glucose > 200 Serum Ca < 8
LDH > 350 Hct decr > 10%
AST > 250 Fluid sequestration > 6 L
o Ransons criteria doesnt change management; marker for prognosis (*note amylase NOT
prognostic)
# Criteria Mortality
0-2 < 5%
3-4 ~15%
5-6 ~40%
7-8 ~100%
o Signs

Turners sign: flank hemorrhage
Cullens sign: periumbilical hemorrhage
Fluid 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
Workup
o 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
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
o Ultrasound
o 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 pancreatitis
Infected necrotizing pancreatitis
Pancreatic pseudocyst
Also 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 lakes
o Obstructive series shows calcified pancreas
o RUQ sonogram shows atrophic calcified pancreas; pancreatic duct may show chain of lakes
o 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 Incidence
15% after acute pancreatiits
35% after chronic pancreatitis
o Most pseudocyst resolve by 6 weeks
Especially if <6cm
Diagnosis
o CT
Treatment
o Do nothing, provide supportive care, r/o recurrent pancreatitis
o Wait for 6 weeks [no matter the size or duration of sx] because cyst does not have a defined wall
Anterior border (stomach), medial border (duodenum), inferior border (mesocolon)
If < 6 cm, likely will resolve on own; but if > 6 cm, let wall calcify before draining
o Transmural drainage, transpapillary drainage, surgical drainage
Drain through stomach cystgastrostomy or endoscopically (endoscope can only get a 1
cm window, but operative can get larger window in fluid collection)
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
If abutting duodenum drain into duodenum
If free in body do roux limb to drain into jejunum
Do 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 Thrombosis
o 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.
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
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 carcinoma
o Cancers can arise from: Ampulla of Vater,
duodenum, pancreas, bile duct
o Complaints of jaundice, icterus, itching
o Mass may be palpable, esp in cachectic pts
o Distended, dilated, NT GB
Workup
o CT scan to confirm
o ERCP w biopsy [note: biopsy may cause
hematoma then unresectable]
o Ultrasound helpful to look at portal nodes, duodenum
Dx: Pancreatic adenocarcinoma
o 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 liver
o EUS
Treatment
o 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)
Chemotherapy
Bypass 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
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
If surgery not possible, radiotherapy +/- chemotherapy to shrink cancer, decr sx, prolong
life
o Contraindication to Whipple procedure
Metastatic disease
Involvement of SMA or Celiac Axis
Involvement 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: Insulinoma
o Most common type of pancreatic islet cell tumor
o Whipples triad of hypoglycemic symptoms, low blood glucose (<40), relieved by giving glucose
o Serum C-peptide will be elevated (rules out exogenous insulin administration)
o Majority are small (<2cm), solitary, and benign (90%)
Imaging
o CT/MRI only 50% sensitivity (do first)
o Endoscopic ultrasound 80% sensitivity (more invasive)
o Intraoperative ultrasound near 100%
Other neuroendocrine tumors of pancreas
o Gastrinoma: Peptic ulcer disease, diarrhea
o Glucagonoma: Dermatitis, diabetes, DVTs
Classic rash necrolytic migratory erythema
o VIPOMA: Watery diarrhea, hypokalemia, achlorydia
o Somatostatinoma: Diabetes, gallstones, steatorrhea
An otherwise previously healthy 22 year old female complains of sudden right upper quadrant pain and
collapses in the kitchen while she is cooking supper. EMS technicians arrive, place two large bore IV lines
and transfer the patient to University Hospital. Her previous medical history is unremarkable. She has had
no previous abdominal operations. She has not traveled in the last year. Her only medication is oral birth
control. Her vital signs are temp 99, P 140, RR 30 and BP 86/60. She is diaphoretic and confused. Her
mucous membranes and skin are pale. The lungs are clear to auscultation and percussion and the heart has
tachycardia. Her abdomen has distension, dullness to percussion, diffuse tenderness but no frank peritoneal
signs. The hematocrit is 15%.
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
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 adenoma
o Woman aged 20-40
o Strong association with oral contraceptive use
o Risk of spontaneous rupture, especially if >5cm
Workup
o 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 margins
o 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 cyst
o Echinococcus flat tapeworm
Life cycle alternates between carnivores and herbivores Dog is definitive host
Tapeworm eggs pass in feces of infected dog, eaten by interm host such as sheep or cattle
Humans eat contaminated vegetables or are in contact with infected animals/soil
Ova hatch in small intestine, travel via portal circulation to liver
Diagnosis
o CT shows cystic lesion
o ELISA assay for echinococcal antigens
Results positive in 85% of infected patients
o Eosinophilia
Treatment
o Surgical due to high risk of secondary infection and
rupture.
o If cysts are small or patient not suitable candidate for
surgical resection medical treatment
o 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
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
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 Abscess
o E. Histolytica
o 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 choice
o 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: Hemobilia
o Typically occurs after major liver injury
o 4-14 days post-trauma, contained hematoma decompresses into biliary tree
o 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 embolization
o 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.
B. Belingon Notes from case session slides, Annas notes (Dr. Esterl), Beckys notes (Dr. Nguyen)
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 <20 ng/mL).
Dx: Hepatocellular carcinoma
A 60 year old male underwent a sigmoid resection for adenocarcinoma 9 months ago. He now comes to your office
with anorexia, fatigue and a 20 pound weight loss over 3 months. He also complains of jaundice and vague right
upper quadrant pain. The vital signs are stable. The lungs have decreased breath sounds in the bases. The heart
has a regular rate and rhythm with no gallops, rubs or clicks. The abdomen is soft and slightly distended with mild
tender ness in the right upper quadrant and normal bowel sounds. The liver edge is firm and nodular and the spleen
is not palpable. The rectal exam shows no masses and is guaiac negative.
Dx: Metastatic lesions to liver
A 60 year old male develops end stage liver disease from Hepatitis C that he contracted from IV drug abuse
during the Vietnam War. He waits on the UNOS liver list for a cadaveric orthotopic liver transplant. He has not
abused alcohol or IV drugs for nearly 40 years. He presents to the Emergency Room at University Hospital with
massive upper gastrointestinal hemorrhage. He states that his stomach became distended and then he vomited
bright red blood. The vital signs are temp 98, P 120, RR 26 and BP 110/60. He is pale. The skin has jaundice, easy
bruisability and multiple spider angiomas. The right chest is dull to percussion with decreased breath sounds. The
heart has tachycardia. The abdomen has distension, a fluid wave, shifting dullness, a small reducible umbilical
hernia and decreased bowel sounds. The lower extremities have mild peripheral edema.
Dx: Cirrhosis
A 15 year old male undergoes an appendectomy for perforated appendicitis. The abdominal wall fascia is closed
but the subcutaneous tissue is open to heal by secondary intention. Three weeks after appendectomy the patient
complains of fever and chills, anorexia, lethargy, vague shoulder pain and right upper quadrant pain. The vital signs
are temp 102, P 110, RR 20, and BP 110/70. The lungs are clear. The heart has tachycardia. The abdomen is soft,
slightly distended, and moderately tender in the right upper quadrant with decreased bowel sounds.
Dx: Liver abscess