Hepatobiliary and Pancreatic

Gallbladder

Cholecystitis

• • Dx: Patients present with right upper quadrant abdominal pain, fever, leukocytosis, Murphy's sign (pain and cessation of respiration during inspiration with palpation over the gallbladder)

    • Ultrasound can show gallblader thickening (wall >3mm), gallstones with posterior accoustic shadows, pericholecystic fluid, sonographic murphy's sign.

      • US  Normal Values:

      •      Hepatomegaly: >15.5 cm in longitudinal length.

      •      Splenomegaly: > 12 cm in longitudinal length.

      •      Common Bile Duct:

      •      Below 50 years old: >6 mm is considered dilated.

      •      Above 50 years old: add 1 mm to the maximum CBD diameter of 5 mm for

      •      each decade above 50 years of age (example: For an 80-year-old

      •      patient, maximum CBD diameter = 8 mm).

      •      Post cholecystectomy: the common bile duct assumes a reservoir

      •      function, and therefore the above measurements do not apply; CBD

      •      diameter up to 10 mm may be normal.

      •      Normal Renal Size: 9-12 cm. 

      •      Kidney size < 8 cm, or > 2.5 cm difference between the two kidneys is

      •      abnormal.

      •      Normal Renal Cortical Thickness: > 8 mm.

      • Normal gallbladder wall < 4mm

      • HIDA scan can show lack of filling of gallbladder signifying cystic duct obstruction. It can also show biliary dyskinesia with ejection fraction < 40%.

    • Tokyo Guidelines 13 Diagnosis Criteria:

      • A. Local inflammation (Murphy's sign, RUQ mass/pain/tenderness)

      • B. Systemic inflammation (fever, inc CRP, inc WBC)

      • C. Imaging findings characteristic of acute chole

      • Suspect diagnosis with 1 in A AND 1 in B

      • Definate diagnoiss with 1 in A AND 1in B AND C

    • Grading of cholecystitis by Tokyo Guidelines 13:

• • Tx: Laparoscopic cholecystectomy is the treatment of choice.

    • Always resuscitate.

    • Antibiotics definately for moderate and severe acute cholecystitis (grade II and III)

    • Cholecystostomy tube can be used for complicated cholecystitis (grade III) and allow subsequent laparoscopic cholecystectomy. It can also be used for high risk patients to allow for optimization prior to cholecystostomy.

    • Intraoperative cholangiogram can be used routinely or selectively (pancreatitis, elevated bilirubin, dilated common bile duct (>10mm).

    • Common bile duct injury during cholecystectomy can be repaired with a T-tube placed above or below (not at site of injury) if < 50% transection. Will need a Roux-en-y hepatojejunostomy for complete transection.

    • Post-cholecystectomy jaundice is initially evaluated with history, CMP, CBC, lipase, hepatitis panel. Ultrasound can identify fluid in gallbladder fossa. ERCP can show a leak / stricture / obstruction. Biloma can be drained percutaneously. ERCP with stenting can treat a leak; however, if it doesn't improve in 3 weeks, it will need Roux-en-y choledochojejunostomy. Complete common bile duct occlusion will require PTC and delayed Roux-en-y choledochojejunostomy.

Biliary Dyskinesia

• Rome III criteria help discern who may benefit from cholecystectomy surgery

  • episode > 30min

  • severe pain that increases to a steady level

  • occurs at different intervals

  • not relieved with BM, change in position, or antacids

Gallbladder Polyps

• • 0-27% risk of malignancy

  • High risk get lap chole

    • >10mm size (>18mm should have open chole with partial liver resection)

    • age > 50

    • sessile polyp

    • increasing size (>2mm)

    • Symptoms

  • low risk polyps get surveilance.

Gallbladder Cancer

• • Usually in older women

  • mucosa (epithelium and lamina propria), muscular layer, serosa.

  • Tx

    • T1a= extends into lamina propria --> cholecystectomy alone

    • T1b to T3= radical resection, segment IVb and V, portal lymphadencectomy

    • T2 or T3 also get adjuvent 5FU

Choledocholithiasis

• • Dx: Patients can present with cholecystiits or with jaundice alone.

    • Labs show elevated bilirubin (direct bilirubin).

    • Ultrasound shows gallstones, a dilated common bile duct, possibly a stone in the bile duct.

    • Cholangiogram (ERCP or IOC) is the gold standard for diagnosis..

    • American Society of Gastrointestinal Endoscopy guidelines 2019, ERCP is recommended for:

      • or evidence of CBD stone on US or CT

      • or Total bili > 4mg/dL and CBD > 6mm on imaging

      • or the ascending cholangitis

      • If none of these but abnormal LFT, age >55, dilated CBD, consider MRCP or lap chole with IOC. 

  • Tx: Cholecystectomy and clearance of the bile duct is standard of care. This can be done safely with ERCP after laparoscopic cholecystectomy with cholangiogram identifies choledocholithiasis.

    • Always resuscitate and give antibiotic coverage.

    • Common bile duct exploration is usually done if the stone cannot be removed endoscopically.

    • If choledocholithiasis is recognized during an open cholecystectomy, can proceed with common bile duct exploration.

    • Impacted stone in the common bile duct is managed first with ERCP. Can then try transhepatic stenting if unable to remove stone. Finally, choledochoduodenostomy can be performed with a low longitudinal 2cm incision on the common bile duct, longitudinal incision on the duodenum, and anastamose the two with 4-0 PDS.

Cholangitis

• • Dx: Charcot's triad is jaundice, fever, and right upper quadrant pain. Reynold's pentad adds shock and altered mental status.

    • CBC shows leukocytosis

    • CMP can show hyperbilirubinemia, elevated AST/ALT and alk phos, and even an elevated creatnine.

    • Ultrasound can show findings of choledocholithiasis.

    • Tokyo Guidelines 13:

• • Tx:

    • Hemangioma is a benign vascular tumor associated with high estrogen states (female > male). They do not bleed. Observe.

    • Focal nodular hyperplasia (FNH) can also be identified with a wheel pattern on angiogram or nuclear medicine scan. Resect only for symptoms or diagnostic uncertainty.

    • Adenoma is associated with oral contraceptive (OCP) use and can rupture and bleed. Biopsy reveals hepatocytes. Stopping OCPs may be effective if < 5cm adenoma. Re-image in 6mo and during pregnancy. Resect with 2cm margin. Can use hepatic artery embolization preoperatively (or while pregnant).

    • HCC tumor rupture does not affect long term survival -- > IR, resuscitate, elective resection. 

    • Hepatocelluar carcinoma (HCC) treatment includes OLT (single tumor up to 5cm or < 3 tumors each < 3cm), segmental resection, locoregional therapy, and chemotherapy. 

      • Liver resection or transplant= curative intent

      • Liver directed therapy (microwave ablation, RFA, alcohol)= curative intent for advanced age or comorbidities

      • Palliative treatment= transarterial chemoembolization

• FNH

  • second most common liver tumor, usually women, 30-50yo

  • OCP use increases risk of FNH complications - bleeding (OCPs do not cause FNH). 

  • Tx:

    • observation until symptoms

    • recommend stop OCPs; if continuing OCP, need surveillance q6mo

Liver Abscess

• • Dx: Patients present with fevers and abdominal pain. Patients with amebic abscess (enterameba histolytica) may have foreign travel and have serology positive.

    • Enzyme immunoassay is test of choice, detects E. histolytica specific antibodies; follow with needle aspiration to confirm if Ab positive. 

    • E. histolytica serology: indirect hemagglutination, enzyme lined immunosorbent assay, indirect immunoflourescence, latex agglutination.  (combine 2 tests)

    • CT scan cannot determine pyogenic (bacterial) from amebic abscess.

    • Technecium 99 scan only lights up with pyogenic abscess.

  • Tx:

    • Broad spectrum antibiotics and drainage are used for pyogenic abscess. They may require surgical drainage.

    • Flagyl alone is treatment for enterameba histolytica (can use aspiration to rule out pyogenic abscess). Surgery is reserved for free rupture or peritonitis.

Liver Cyst

• • Dx: Cysts are easily seen on ultrasound, can use CT. Hydatid cysts (echinococcal) can cause anaphylactic shock if they rupture. Simple cysts can cause pain, bleed, or get infected.

    • Echinococcal cysts show positive echinococcal serology. CBC gives an eosinophilia. Ultrasound shows thick walls, calcifications, debris, sepatations, daughter cysts.

    • Cystadenomas have malignant potential and CT shows multiloculated, septated, irregular, calcified cyst with mural nodules, papillary growths, thickened walls.

    • Simple cysts are thin walled without septations. 

  • Tx:

    • Simple cysts can be observed if asymptomatic and < 8cm. If symptomatic and >5cm, they can be unroofed. If <5cm and symptomatic, they can be aspirated.

    • Hydatic cysts should be completely enucleated while controling for any leakage. This is done with evaculation, sterilization with hypertonic saline, and pericystectomy. Use Mebendazole as adjuvant treatment.

    • Cystadenoma needs cyst wall enucleation and hepatic resection for cystadenocarcinoma.