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Theme: Management of jaundiceA.ERCPB.MRCPC.Percutaneous transhepatic cholangiogramD.LaparotomyE.Laparotomy and formation of hepatico-jejunostomyF.Laparoscopic biliary bypassG.CT scanFor each of the following scenarios please select the most appropriate next stage of management. Each option may be used once, more than once or not at all. 1. A 65 year old man is admitted with jaundice and investigations demonstrate a carcinoma of the pancreatic head. An ERCP is attempted but the surgeon is unable to cannulate the ampulla.You answered Laparotomy and formation of hepatico-jejunostomy The correct answer is Percutaneous transhepatic cholangiogramTheme from September 2012 ExamCancer of the pancreatic head will cause and obstructed jaundice and intrahepatic duct dilatation. When an ERCP has failed the most appropriate option is to attempt a PTC. This procedure is always preceded by an ultrasound (which presumably this patient has already had or they would not be undergoing an ERCP). Prior to performing the PTC it is important to stage the disease and establish resectability or not. This is because the PTC drains frequently dislodge and fall out. It is usually desirable to pass a stent at the time of doing the PTC to mitigate the effects of this problem.2. A 48 year old lady is admitted with attacks of biliary colic and investigations show gallstones. A laparoscopic cholecystectomy is performed. The operation is technically challenging due to a large stone impacted in Hartmans pouch. Following the operation she fails to settle and becomes jaundiced and has bile draining into a drain placed at the surgical site.You answered Percutaneous transhepatic cholangiogram The correct answer is ERCPIn this scenario it must be assumed that the bile duct has been damaged. In most cases an ERCP is the most appropriate investigation. This can also allow the passage of a stent if this is deemed to be safe and sensible. 3. A 34 year old lady is admitted with jaundice and undergoes an ERCP. The procedure is technically difficult and she is returned to the ward still jaundiced. Unfortunately she now has severe generalised abdominal pain.You answered Laparotomy The correct answer is CT scanThere are two main differential diagnoses here. One is pancreatitis, repeated trauma to the ampulla and duct (if partially cannulated) is a major risk factor for pancreatitis. The second is the possibility that the duodenum has been perforated. ERCP is performed using a side viewing endoscope, the manipulation of which can be technically challenging for the inexperienced operator in a patient with abnormal anatomy. A CT scan is the best investigation to distinguish between these two differential diagnoses.Surgical jaundiceJaundice can present in a manner of different surgical situations. As with all types of jaundice a carefully history and examination will often give clues as the most likely underlying cause. Liver function tests whilst conveying little in the way of information about liver synthetic function, will often facilitate classification as to whether the jaundice is pre hepatic, hepatic or post hepatic. The typical LFT patterns are given below:Location Bilirubin ALT/ ASTAlkaline phosphatasePre hepaticNormal or high Normal NormalHepatic HighElevated (often very high)Elevated but seldom to very high levelsPost hepatic High-very highModerate elevation High- very highIn post hepatic jaundice the stools are often of pale colour and this feature should be specifically addressed in the history.Modes of presentationThese are addressed in the table below:Diagnosis Typical features PathogenesisGallstonesTypically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundiceCholangitisUsually obstructive and will have Charcots triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law)Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre.TPN associated jaundice Usually follows long term use and is usually painless with non obstructive featuresOften due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive typeOften due to a difficult cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury.Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.Metastatic disease Mixed hepatic and post hepaticCombination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier)DiagnosisAn ultrasound of the liver and biliary tree is the most commonly used first line test. This will establish bile duct calibre, often ascertain the presence of gallstones, may visualise pancreatic masses and other lesions. The most important clinical question is essentially the extent of biliary dilatation and its distribution. Where pancreatic neoplasia is suspected the next test should be a pancreatic protocol CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the preferred option. PET scans may be used to stage a number of malignancies but do not routinely form part of first line testing. Where MRCP fails to give adequate information and ERCP may be necessary. In many cases this may form part of patient management. It is however, invasive and certainly not without risk and highly operator dependent. ManagementClearly this will depend to an extent upon the underlying cause but relief of jaundice is important even if surgery forms part of the planned treatment as patients with unrelieved jaundice have a much higher incidence of septic complications, bleeding and death.Screen for and address any clotting irregularitiesIn patients with malignancy a stent will need to be inserted. These come in two main types; metal and plastic. Plastic stents are cheap and easy to replace and should be used if any surgical intervention (e.g. Whipples) is planned. However, they are prone to displacement and blockage. Metal stents are much more expensive and may compromise a surgical resection. However, they are far less prone to displacement and to a lesser extent blockage than their plastic counterparts.If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has failed, then an alternative strategy is to drain the biliary system percutaneously via a transhepatic route. It may also be possible to insert a stent in this way. One of the main problems with temporary PTC's is their propensity to displacement which may result in a bile leak.In patients who have a bile duct injury surgery will be required to repair the defect. If the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to be created (difficult!)If gallstones are the culprit then these may be removed by ERCP and a cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an operative cholangiogram should be performed and bile duct exploration undertaken where stones remain. When the bile duct has been formally opened the options are between closure over a T tube, a choledochoduodenostomy or choledochojejunostomy. Patients with cholangitis should receive high dose broad spectrum antibiotics via the intravenous route. Biliary decompression should follow soon afterwards and instrumenting the bile duct of these patients will often provoke a septic episode (but should be done anyway).hich of the following is the most sensitive blood test for diagnosis of acute pancreatitis?A.AmylaseB.LipaseC.C-peptideD.TrypsinE.TrysinogenThe serum amylase may rise and fall quite quickly and lead to a false negative result. Should the clinical picture not be concordant with the amylase level then serum lipase or a CT Scan should be performed.Management of PancreatitisManagement of Acute Pancreatitis in the UKDiagnosisTraditionally hyperamylasaemia has been utlilised with amylase being elevated three times the normal range.However, amylase may give both false positive and negative results. Serum lipase is both more sensitive and specific than serum amylase. It also has a longer half life.Serum amylase levels do not correlate with disease severity.Differential causes of hyperamylasaemiaAcute pancreatitisPancreatic pseudocystMesenteric infarctPerforated viscusAcute cholecystitisDiabetic ketoacidosisAssessment of severityGlasgow, Ranson scoring systems and APACHE IIBiochemical scoring e.g. using CRP Features that may predict a severe attack within 48 hours of admission to hospitalInitial assessmentClinical impression of severityBody mass index >30Pleural effusionAPACHE score >824 hours after admissionClinical impression of severityAPACHE II >8Glasgow score of 3 or morePersisting multiple organ failureCRP>15048 hours after admissionGlasgow Score of >3CRP >150Persisting or progressive organ failureTable adapted from UK guidelines for management of acute pancreatitis. GUT 2005, 54 suppl IIIManagementNutritionThere is reasonable evidence to suggest that the use of enteral nutrition does not worsen the outcome in pancreatitisMost trials to date were underpowered to demonstrate a conclusive benefit.The rationale behind feeding is that it helps to prevent bacterial translocation from the gut, thereby contributing to the development of infected pancreatic necrosis. Use of antibiotic therapyMany UK surgeons administer antibiotics to patients with acute pancreatitis. A recent Cochrane review highlights the potential benefits of administering Imipenem to patients with established pancreatic necrosis in the hope of averting the progression to infection. There are concerns that the administration of antibiotics in mild attacks of pancreatitis will not affect outcome and may contribute to antibiotic resistance and increase the risks of antibiotic associated diarrhoea.SurgeryPatients with acute pancreatitis due to gallstones should undergo early cholecystectomy.Patients with obstructed biliary system due to stones should undergo early ERCP.Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement, fine needle aspiration is still used by some.Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise.References.uk/pdfworddocs/pancreatic.pdfAntibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis Villatoro et al Cochrane Library DOI: 10.1002/14651858.CD002941.pub3. 2010 version.Which of the following is the most sensitive blood test for diagnosis of acute pancreatitis?A.AmylaseB.LipaseC.C-peptideD.TrypsinE.TrysinogenThe serum amylase may rise and fall quite quickly and lead to a false negative result. Should the clinical picture not be concordant with the amylase level then serum lipase or a CT Scan should be performed.Management of PancreatitisManagement of Acute Pancreatitis in the UKDiagnosisTraditionally hyperamylasaemia has been utlilised with amylase being elevated three times the normal range.However, amylase may give both false positive and negative results. Serum lipase is both more sensitive and specific than serum amylase. It also has a longer half life.Serum amylase levels do not correlate with disease severity.Differential causes of hyperamylasaemiaAcute pancreatitisPancreatic pseudocystMesenteric infarctPerforated viscusAcute cholecystitisDiabetic ketoacidosisAssessment of severityGlasgow, Ranson scoring systems and APACHE IIBiochemical scoring e.g. using CRP Features that may predict a severe attack within 48 hours of admission to hospitalInitial assessmentClinical impression of severityBody mass index >30Pleural effusionAPACHE score >824 hours after admissionClinical impression of severityAPACHE II >8Glasgow score of 3 or morePersisting multiple organ failureCRP>15048 hours after admissionGlasgow Score of >3CRP >150Persisting or progressive organ failureTable adapted from UK guidelines for management of acute pancreatitis. GUT 2005, 54 suppl IIIManagementNutritionThere is reasonable evidence to suggest that the use of enteral nutrition does not worsen the outcome in pancreatitisMost trials to date were underpowered to demonstrate a conclusive benefit.The rationale behind feeding is that it helps to prevent bacterial translocation from the gut, thereby contributing to the development of infected pancreatic necrosis. Use of antibiotic therapyMany UK surgeons administer antibiotics to patients with acute pancreatitis. A recent Cochrane review highlights the potential benefits of administering Imipenem to patients with established pancreatic necrosis in the hope of averting the progression to infection. There are concerns that the administration of antibiotics in mild attacks of pancreatitis will not affect outcome and may contribute to antibiotic resistance and increase the risks of antibiotic associated diarrhoea.SurgeryPatients with acute pancreatitis due to gallstones should undergo early cholecystectomy.Patients with obstructed biliary system due to stones should undergo early ERCP.Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement, fine needle aspiration is still used by some.Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise.References.uk/pdfworddocs/pancreatic.pdfAntibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis Villatoro et al Cochrane Library DOI: 10.1002/14651858.CD002941.pub3. 2010 version.Theme: JaundiceA.Gilberts syndromeB.Crigler Najjar syndromeC.Hepatocellular carcinomaD.Mirizzi syndromeE.Hepatitis AF.Hepatitis EG.Bile duct stonesH.Multi cystic liver diseasePlease select the most likely cause of jaundice for the scenario given. Each option may be used once, more than once or not at all.5. A 22 year old man returns to the UK from holiday in India. He presents with painless jaundice. On examination he is not deeply jaundiced and there is no organomegaly. Hepatitis AInfective hepatitis is the most likely cause. In the UK, foreign travel is a common cause of developing infectious hepatitis, of which hepatitis A is the most common. 6. A 56 year old man presents with jaundice. He has a long history of alcohol misuse. On examination he is jaundiced and ultrasound shows multiple echo dense lesions in both lobes of the liver. His alpha feto protein is elevated 6 times the normal rangeHepatocellular carcinomaHCC may complicate cirrhosis. AFP is often raised in HCC.7. A 32 year old man who has suffered from Crohns disease for many years presents with intermittent jaundice. When it occurs it is obstructive in nature. It then usually resolves spontaneously.You answered Mirizzi syndrome The correct answer is Bile duct stonesBile salts are absorbed in the terminal ileum. When this process is impaired as in Crohns the patient may develop gallstones, if these pass into the CBD then obstructive jaundice will result.Surgical jaundiceJaundice can present in a manner of different surgical situations. As with all types of jaundice a carefully history and examination will often give clues as the most likely underlying cause. Liver function tests whilst conveying little in the way of information about liver synthetic function, will often facilitate classification as to whether the jaundice is pre hepatic, hepatic or post hepatic. The typical LFT patterns are given below:Location Bilirubin ALT/ ASTAlkaline phosphatasePre hepaticNormal or high Normal NormalHepatic HighElevated (often very high)Elevated but seldom to very high levelsPost hepatic High-very highModerate elevation High- very highIn post hepatic jaundice the stools are often of pale colour and this feature should be specifically addressed in the history.Modes of presentationThese are addressed in the table below:Diagnosis Typical features PathogenesisGallstonesTypically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundiceCholangitisUsually obstructive and will have Charcots triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law)Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre.TPN associated jaundice Usually follows long term use and is usually painless with non obstructive featuresOften due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive typeOften due to a difficult cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury.Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.Metastatic disease Mixed hepatic and post hepaticCombination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier)DiagnosisAn ultrasound of the liver and biliary tree is the most commonly used first line test. This will establish bile duct calibre, often ascertain the presence of gallstones, may visualise pancreatic masses and other lesions. The most important clinical question is essentially the extent of biliary dilatation and its distribution. Where pancreatic neoplasia is suspected the next test should be a pancreatic protocol CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the preferred option. PET scans may be used to stage a number of malignancies but do not routinely form part of first line testing. Where MRCP fails to give adequate information and ERCP may be necessary. In many cases this may form part of patient management. It is however, invasive and certainly not without risk and highly operator dependent. ManagementClearly this will depend to an extent upon the underlying cause but relief of jaundice is important even if surgery forms part of the planned treatment as patients with unrelieved jaundice have a much higher incidence of septic complications, bleeding and death.Screen for and address any clotting irregularitiesIn patients with malignancy a stent will need to be inserted. These come in two main types; metal and plastic. Plastic stents are cheap and easy to replace and should be used if any surgical intervention (e.g. Whipples) is planned. However, they are prone to displacement and blockage. Metal stents are much more expensive and may compromise a surgical resection. However, they are far less prone to displacement and to a lesser extent blockage than their plastic counterparts.If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has failed, then an alternative strategy is to drain the biliary system percutaneously via a transhepatic route. It may also be possible to insert a stent in this way. One of the main problems with temporary PTC's is their propensity to displacement which may result in a bile leak.In patients who have a bile duct injury surgery will be required to repair the defect. If the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to be created (difficult!)If gallstones are the culprit then these may be removed by ERCP and a cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an operative cholangiogram should be performed and bile duct exploration undertaken where stones remain. When the bile duct has been formally opened the options are between closure over a T tube, a choledochoduodenostomy or choledochojejunostomy. Patients with cholangitis should receive high dose broad spectrum antibiotics via the intravenous route. Biliary decompression should follow soon afterwards and instrumenting the bile duct of these patients will often provoke a septic episode (but should be done anyway).heme: Surgical jaundiceA.Carcinoma of the head of the pancreasB.Bile duct strictureC.Mirizzi syndromeD.Bile duct stonesE.Chronic cholecystitisF.Peri hilar lymphadenopathyG.Fitz - Hugh Curtis syndromePlease select the most appropriate cause of the jaundice scenario given. Each option may be used once, more than once or not at all.8. A 63 year old man is admitted with obstructive jaundice that has developed over the past 3 weeks. He was previously well and on examination has a smooth mass in his right upper quadrant.Carcinoma of the head of the pancreasCarcinoma of the pancreas (Courvoisiers law!). The development of jaundice in association with a smooth right upper quadrant mass is typical of distal biliary obstruction secondary to pancreatic malignancy. A bile duct stricture would not present in this way, all the other choices are related to gallstones and Fitz Hugh Curtis syndrome is a complication of pelvic inflammatory disease.9. A 41 year old lady is admitted with colicky right upper quadrant pain. On clinical examination she has a mild pyrexia and is clinically jaundiced. An ultrasound scan is reported as showing gallstones and the patient is taken to theatre for an open cholecystectomy. At operation, Calots triangle is almost completely impossible to delineate.You answered Chronic cholecystitis The correct answer is Mirizzi syndromeIn Mirizzi syndrome the gallstone becomes impacted in Hartmans pouch. Episodes of recurrent inflammation occur and this causes compression of the bile duct. In severe cases this then progresses to fistulation. Surgery is extremely difficult as Calots triangle is often completely obliterated and the risks of causing injury to the CBD are high.10. A 72 year old man undergoes a distal gastrectomy for carcinoma of the stomach. He presents with jaundice approximately 8 months post operatively. Ultrasound of the liver and bile ducts shows no focal liver lesion and normal calibre common bile duct with intra hepatic duct dilatation.You answered Mirizzi syndrome The correct answer is Peri hilar lymphadenopathyUnfortunately metastatic disease is the most likely event. Peri hilar lymphadenopathy would be a common culprit.Courvoisiers Law:Obstructive jaundice in the presence of a palpable gallbladder is unlikely to be due to stones.This is due to the fibrotic effect that stones have on the gallbladder. Like all these laws there are numerous exceptions and many cases will not present in the typical manner.Bile duct injuryInadvertent bile duct injury during laparoscopic surgery should be referred to a specialist hepatobiliary surgeon. Outcomes are far worse when repair in undertaken by a non specialist surgeon in a district hospital.Surgical jaundiceJaundice can present in a manner of different surgical situations. As with all types of jaundice a carefully history and examination will often give clues as the most likely underlying cause. Liver function tests whilst conveying little in the way of information about liver synthetic function, will often facilitate classification as to whether the jaundice is pre hepatic, hepatic or post hepatic. The typical LFT patterns are given below:Location Bilirubin ALT/ ASTAlkaline phosphatasePre hepaticNormal or high Normal NormalHepatic HighElevated (often very high)Elevated but seldom to very high levelsPost hepatic High-very highModerate elevation High- very highIn post hepatic jaundice the stools are often of pale colour and this feature should be specifically addressed in the history.Modes of presentationThese are addressed in the table below:Diagnosis Typical features PathogenesisGallstonesTypically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundiceCholangitisUsually obstructive and will have Charcots triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law)Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre.TPN associated jaundice Usually follows long term use and is usually painless with non obstructive featuresOften due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive typeOften due to a difficult cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury.Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.Metastatic disease Mixed hepatic and post hepaticCombination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier)DiagnosisAn ultrasound of the liver and biliary tree is the most commonly used first line test. This will establish bile duct calibre, often ascertain the presence of gallstones, may visualise pancreatic masses and other lesions. The most important clinical question is essentially the extent of biliary dilatation and its distribution. Where pancreatic neoplasia is suspected the next test should be a pancreatic protocol CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the preferred option. PET scans may be used to stage a number of malignancies but do not routinely form part of first line testing. Where MRCP fails to give adequate information and ERCP may be necessary. In many cases this may form part of patient management. It is however, invasive and certainly not without risk and highly operator dependent. ManagementClearly this will depend to an extent upon the underlying cause but relief of jaundice is important even if surgery forms part of the planned treatment as patients with unrelieved jaundice have a much higher incidence of septic complications, bleeding and death.Screen for and address any clotting irregularitiesIn patients with malignancy a stent will need to be inserted. These come in two main types; metal and plastic. Plastic stents are cheap and easy to replace and should be used if any surgical intervention (e.g. Whipples) is planned. However, they are prone to displacement and blockage. Metal stents are much more expensive and may compromise a surgical resection. However, they are far less prone to displacement and to a lesser extent blockage than their plastic counterparts.If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has failed, then an alternative strategy is to drain the biliary system percutaneously via a transhepatic route. It may also be possible to insert a stent in this way. One of the main problems with temporary PTC's is their propensity to displacement which may result in a bile leak.In patients who have a bile duct injury surgery will be required to repair the defect. If the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to be created (difficult!)If gallstones are the culprit then these may be removed by ERCP and a cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an operative cholangiogram should be performed and bile duct exploration undertaken where stones remain. When the bile duct has been formally opened the options are between closure over a T tube, a choledochoduodenostomy or choledochojejunostomy. Patients with cholangitis should receive high dose broad spectrum antibiotics via the intravenous route. Biliary decompression should follow soon afterwards and instrumenting the bile duct of these patients will often provoke a septic episode (but should be done anyway).heme: Management of biliary diseaseA.Acute laparoscopic cholecystectomyB.Delayed laparoscopic cholecystectomyC.Percutaneous cholecystostomyD.Elective cholecystectomy and intra operative cholangiogramE.Endoscopic retrograde cholangiopancreatographyF.CholedochoduodenostomyG.Bile duct excision and hepatico-jejunostomyH.Operative cholecystostomyFor each scenario please select the most appropriate management option. Each option may be used once, more than once or not at all.11. A 72 year old lady underwent an open cholecystectomy 12 years previously. She has been admitted since with 2 episodes of cholangitis and stones were retrieved at ERCP. She has just recovered from a further episode of sepsis and MRCP has shown further biliary stones.You answered Bile duct excision and hepatico-jejunostomy The correct answer is CholedochoduodenostomyA patient with long standing common bile duct stones is at risk of developing duct fibrosis and ductal disproportion. This can result in impaired biliary drainage. Not only may further stones be formed in the bile that is present, but because of the ductal disproportion the tendency will be for the stones to accumulate (rather than pass spontaneously, as would usually be the case post ERCP and sphincterotomy). A biliary bypass procedure is the standard method dealing with this and a choledochoduodenstomy is one procedure that can be used.12. A 26 year old women is admitted with acute cholecystitis of 24 hours duration. LFT's are normal and Ultrasound shows a thick walled gallbladder containing stones.Acute laparoscopic cholecystectomyThis is an ideal case for an acute cholecystectomy, provided that surgery can be undertaken promptly. After 48 -72 hours the patient should receive parenteral antibiotics and delayed cholecystectomy performed.13. A 32 year old lady is seen in the outpatients. She has had multiple episodes of biliary colic and ultrasound shows thin walled gallbladder with multiple calculi. Her ALT is slightly raised but other parameters are normal.Elective cholecystectomy and intra operative cholangiogramThe easiest option is to perform an intraoperative cholangiogram. It is unlikely to reveal any stones. If is does then either laparoscopic bile duct exploration or urgent ERCP can be performed. An MRCP pre op is an alternative strategy.Biliary diseaseDiagnosis Typical features PathogenesisGallstonesTypically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundiceCholangitisUsually obstructive and will have Charcot's triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law)Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatitis may be the culprit in which case the bile duct may be of normal calibre.TPN associated jaundice Usually follows long term use and is usually painless with non obstructive featuresOften due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive typeOften due to a difficult laparoscopic? cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury.Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.Metastatic disease Mixed hepatic and post hepaticCombination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier)A gallbladder may develop a thickened wall in chronic cholecystitis and microscopically Roikitansky-Aschoff Sinsuses may be seenImage sourced from Wikipedia 42 year old female presents with symptoms of biliary colic and on investigation is identified as having gallstones. Of the procedures listed below, which is most likely to increase the risk of gallstone formation?A.Partial gastrectomyB.Jejunal resectionC.Liver lobectomyD.Ileal resectionE.Left hemicolectomyBile salt reabsorption occurs at the ileum. Therefore cholesterol gallstones form as a result of ileal resection.Biliary diseaseDiagnosis Typical features PathogenesisGallstonesTypically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundiceCholangitisUsually obstructive and will have Charcot's triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law)Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatitis may be the culprit in which case the bile duct may be of normal calibre.TPN associated jaundice Usually follows long term use and is usually painless with non obstructive featuresOften due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive typeOften due to a difficult laparoscopic? cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury.Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.Metastatic disease Mixed hepatic and post hepaticCombination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier)A gallbladder may develop a thickened wall in chronic cholecystitis and microscopically Roikitansky-Aschoff Sinsuses may be seenTheme: Management of pancreatitisA.Non Contrast enhanced CT scanB.USS abdomenC.ERCP aloneD.ERCP with Sphincterotomy and biliary drainageE.Fine needle aspiration of necrosisF.Pancreatic necrosectomyG.Contrast enhanced CT scanWhat is the next best step in management for the scenario given? Each option may be used once, more than once or not at all.15. A 56 year old man is admitted with an attack of severe acute pancreatitis. He is managed on the intensive care unit and is making progress. He then deteriorates and a CT scan shows extensive pancreatic necrosis (>40%). On return from the radiology department he remains febrile and tachycardic with falling urine output.Pancreatic necrosectomyIn patients with systemic features of sepsis and extensive necrosis a necrosectomy is usually indicated.An FNA will not change his immediate management.16. A 22 year old teacher is admitted with severe epigastric pain. Serum amylase is normal. You wish to exclude a perforated viscus, and determine whether pancreatitis is present.You answered Non Contrast enhanced CT scan The correct answer is Contrast enhanced CT scanAn ultrasound will not accurately answer this question. Therefore a CT scan is required. Oral and IV contrast would usually be given.17. A 55 year old accountant has jaundice and a temperature of 39oC. He is known to have gallstones. Blood cultures have grown a gram negative bacilli.ERCP with Sphincterotomy and biliary drainageYou should suspect cholangitis in a patient with fevers and jaundice. Charcot's triad may only be present in 20% of patients. This patient needs biliary drainage with an ERCP.Infected pancreatic necrosis is one of the few indications for surgery in pancreatitisManagement of PancreatitisManagement of Acute Pancreatitis in the UKDiagnosisTraditionally hyperamylasaemia has been utlilised with amylase being elevated three times the normal range.However, amylase may give both false positive and negative results. Serum lipase is both more sensitive and specific than serum amylase. It also has a longer half life.Serum amylase levels do not correlate with disease severity.Differential causes of hyperamylasaemiaAcute pancreatitisPancreatic pseudocystMesenteric infarctPerforated viscusAcute cholecystitisDiabetic ketoacidosisAssessment of severityGlasgow, Ranson scoring systems and APACHE IIBiochemical scoring e.g. using CRP Features that may predict a severe attack within 48 hours of admission to hospitalInitial assessmentClinical impression of severityBody mass index >30Pleural effusionAPACHE score >824 hours after admissionClinical impression of severityAPACHE II >8Glasgow score of 3 or morePersisting multiple organ failureCRP>15048 hours after admissionGlasgow Score of >3CRP >150Persisting or progressive organ failureTable adapted from UK guidelines for management of acute pancreatitis. GUT 2005, 54 suppl IIIManagementNutritionThere is reasonable evidence to suggest that the use of enteral nutrition does not worsen the outcome in pancreatitisMost trials to date were underpowered to demonstrate a conclusive benefit.The rationale behind feeding is that it helps to prevent bacterial translocation from the gut, thereby contributing to the development of infected pancreatic necrosis. Use of antibiotic therapyMany UK surgeons administer antibiotics to patients with acute pancreatitis. A recent Cochrane review highlights the potential benefits of administering Imipenem to patients with established pancreatic necrosis in the hope of averting the progression to infection. There are concerns that the administration of antibiotics in mild attacks of pancreatitis will not affect outcome and may contribute to antibiotic resistance and increase the risks of antibiotic associated diarrhoea.SurgeryPatients with acute pancreatitis due to gallstones should undergo early cholecystectomy.Patients with obstructed biliary system due to stones should undergo early ERCP.Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement, fine needle aspiration is still used by some.Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise.References.uk/pdfworddocs/pancreatic.pdfAntibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis Villatoro et al Cochrane Library DOI: 10.1002/14651858.CD002941.pub3. 2010 version.Theme: Liver tumoursA.RhabdomyosarcomaB.Yolk sac tumourC.Hepatocellular carcinomaD.Metastatic lesionE.HaemangioendotheliomaF.CholangiocarcinomaG.HepatoblastomaH.AngiosarcomaPlease select the most likely diagnosis for the scenario given. Each answer may be used once, more than once or not at all.18. A 56 year old man with long standing ulcerative colitis and a DALM lesion in the rectum is admitted with jaundice. On CT scanning the liver has 3 nodules in the right lobe and 1 nodule in the left lobe. Carcinoembryonic antigen levels are elevated.Metastatic lesionThis is likely to be due to metastatic lesions from a colonic primary. DALM lesions should be excised by oncological colectomy for this reason. This burden of metastatic disease is unlikely to precipitate jaundice directly and nodal disease at the porta hepatis is the most likely cause in this case.19. A 48 year old lady with chronic hepatitis B infection is noted to have worsening liver function tests and progressive jaundice. Her alpha feto protein levels are grossly elevated.Hepatocellular carcinomaThis is most likely to be hepatocellular carcinoma and markedly elevated AFP levels in association with a compatible risk factor should make this the diagnosis.20. A 55 year old man with long standing ulcerative colitis is admitted with cholangitis and weight loss. Blood tests reveal a markedly elevated Ca 19-9.CholangiocarcinomaThis is most likely a cholangiocarcinoma. UC with sclerosing cholangitis. Increases the risk of cholangiocarcinoma. CA19-9 is elevated in approximately 80% cases.Liver tumoursPrimary liver tumoursThe most common primary tumours are cholangiocarcinoma and hepatocellular carcinoma. Overall metastatic disease accounts for 95% of all liver malignancies making the primary liver tumours comparatively rare. Primary liver tumours include:CholangiocarcinomaHepatocellular carcinomaHepatoblastomaSarcomas (Rare)Lymphomas Carcinoids (most often secondary although primary may occur)Hepatocellular carcinomaThese account for the bulk of primary liver tumours (75% cases). Its worldwide incidence reflects its propensity to occur on a background of chronic inflammatory activity. Most cases arise in cirrhotic livers or those with chronic hepatitis B infection, especially where viral replication is actively occurring. In the UK it accounts for less than 5% of all cancers, although in parts of Asia its incidence is 100 per 100,000.The majority of patients (80%) present with existing liver cirrhosis, with a mass discovered on screening ultrasound. DiagnosisCT/ MRI (usually both) are the imaging modalities of choicea-fetoprotein is elevated in almost all casesBiopsy should be avoided as it seeds tumours cells through a resection plane. In cases of diagnostic doubt serial CT and aFP measurements are the preferred strategy. TreatmentPatients should be staged with liver MRI and chest, abdomen and pelvic CT scan.The testis should be examined in males (testicular tumours may cause raised AFP). PET CT may be used to identify occult nodal disease.Surgical resection is the mainstay of treatment in operable cases. In patients with a small primary tumour in a cirrhotic liver whose primary disease process is controlled, consideration may be given to primary whole liver resection and transplantation.Liver resections are an option but since most cases occur in an already diseased liver the operative risks and post-operative hepatic dysfunction are far greater than is seen following metastectomy. These tumours are not particularly chemo or radiosensitive however, both may be used in a palliative setting. Tumour ablation is a more popular strategy. SurvivalPoor, overall survival is 15% at 5 years.CholangiocarcinomaThis is the second most common type of primary liver malignancy. As its name suggests these tumours arise in the bile ducts. Up to 80% of tumours arise in the extra hepatic biliary tree. Most patients present with jaundice and by this stage the majority will have disease that is not resectable. Primary scelerosing cholangitis is the main risk factor. In deprived countries typhoid and liver flukes are also major risk factors.DiagnosisPatients will typically have an obstructive picture on liver function tests.CA 19-9, CEA and CA 125 are often elevatedCT/ MRI and MRCP are the imaging methods of choice.TreatmentSurgical resection offers the best chance of cure. Local invasion of peri hilar tumours is a particular problem and this coupled with lobar atrophy will often contra indicate surgical resection. Palliation of jaundice is important, although metallic stents should be avoided in those considered for resection. SurvivalIs poor, approximately 15% 5 year survival.A 45 year old man presents with an episode of alcoholic pancreatitis. He makes slow but steady progress. He is reviewed clinically at 6 weeks following admission. He has a diffuse fullness of his upper abdomen and on imaging a collection of fluid is found to be located behind the stomach. His serum amylase is mildly elevated. Which of the following is the most likely explanation?A.Early fluid collectionB.Pancreatic abscessC.Peripancreatic necrosisD.PsuedocystE.Sterile necrosisPsuedocysts are unlikely to be present less than 4 weeks after an attack of acute pancreatitis. However, they are more common at this stage and are associated with a raised amylase.Pancreatitis: sequelaePeripancreatic fluid collectionsOccur in 25% casesLocated in or near the pancreas and lack a wall of granulation or fibrous tissueMay resolve or develop into pseudocysts or abscessesSince most resolve aspiration and drainage is best avoided as it may precipitate infectionPseudocystsIn acute pancreatitis result from organisation of peripancreatic fluid collection. They may or may not communicate with the ductal system.The collection is walled by fibrous or granulation tissue and typically occurs 4 weeks or more after an attack of acute pancreatitisMost are retrogastric75% are associated with persistent mild elevation of amylaseInvestigation is with CT, ERCP and MRI or Endoscopic USSSymptomatic cases may be observed for 12 weeks as up to 50% resolveTreatment is either with endoscopic or surgical cystogastrostomy or aspirationPancreatic necrosisPancreatic necrosis may involve both the pancreatic parenchyma and surrounding fatComplications are directly linked to extent of parenchymal necrosis and extent of necrosis overallEarly necrosectomy is associated with a high mortality rate (and should be avoided unless compelling indications for surgery exist)Sterile necrosis should be managed conservatively (at least initially)Some centres will perform fine needle aspiration sampling of necrotic tissue if infection is suspected. False negatives may occur and the extent of sepsis and organ dysfunction may be a better guide to surgeryPancreatic abscessIntra abdominal collection of pus associated with pancreas but in the absence of necrosisTypically occur as a result of infected pseudocystTransgastric drainage is one method of treatment, endoscopic drainage is an alternativeHaemorrhageInfected necrosis may involve vascular structures with resultant haemorrhage that may occur de novo or as a result of surgical necrosectomy.When retroperitoneal haemorrhage occurs Grey Turners sign may be identifiedA 34 year old lady is admitted with pancreatitis. The aetiology is unclear and it is classified as an attack of moderate severity according to the Glasgow criteria. Her imaging shows no gallstones and fluid around the pancreas. Which of the following is the most appropriate initial management option?A.LaparotomyB.LaparoscopyC.Radiological aspiration of the fluidD.Active observationE.Administration of octreotideLEARN THIS!Mnemonic for the assessment of the severity of pancreatitis: PANCREAS(Ann R Coll Surg Engl 2000; 82: 16-17P a02 < 60 mmHgA ge > 55 yearsN eutrophils > 15 x 10/lC alcium < 2 mmol/lR aised urea > 16 mmol/lE nzyme (lactate dehydrogenase) > 600 units/lA lbumin < 32 g/lS ugar (glucose) > 10 mmol/l> 3 positive criteria indicates severe pancreatitis.Acute early fluid collections are seen in 25% of patients with pancreatitis and require no specific treatment. Attempts at drainage may introduce infection and result in pancreatic abscess formation.Management of PancreatitisManagement of Acute Pancreatitis in the UKDiagnosisTraditionally hyperamylasaemia has been utlilised with amylase being elevated three times the normal range.However, amylase may give both false positive and negative results. Serum lipase is both more sensitive and specific than serum amylase. It also has a longer half life.Serum amylase levels do not correlate with disease severity.Differential causes of hyperamylasaemiaAcute pancreatitisPancreatic pseudocystMesenteric infarctPerforated viscusAcute cholecystitisDiabetic ketoacidosisAssessment of severityGlasgow, Ranson scoring systems and APACHE IIBiochemical scoring e.g. using CRP Features that may predict a severe attack within 48 hours of admission to hospitalInitial assessmentClinical impression of severityBody mass index >30Pleural effusionAPACHE score >824 hours after admissionClinical impression of severityAPACHE II >8Glasgow score of 3 or morePersisting multiple organ failureCRP>15048 hours after admissionGlasgow Score of >3CRP >150Persisting or progressive organ failureTable adapted from UK guidelines for management of acute pancreatitis. GUT 2005, 54 suppl IIIManagementNutritionThere is reasonable evidence to suggest that the use of enteral nutrition does not worsen the outcome in pancreatitisMost trials to date were underpowered to demonstrate a conclusive benefit.The rationale behind feeding is that it helps to prevent bacterial translocation from the gut, thereby contributing to the development of infected pancreatic necrosis. Use of antibiotic therapyMany UK surgeons administer antibiotics to patients with acute pancreatitis. A recent Cochrane review highlights the potential benefits of administering Imipenem to patients with established pancreatic necrosis in the hope of averting the progression to infection. There are concerns that the administration of antibiotics in mild attacks of pancreatitis will not affect outcome and may contribute to antibiotic resistance and increase the risks of antibiotic associated diarrhoea.SurgeryPatients with acute pancreatitis due to gallstones should undergo early cholecystectomy.Patients with obstructed biliary system due to stones should undergo early ERCP.Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement, fine needle aspiration is still used by some.Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise.References.uk/pdfworddocs/pancreatic.pdfAntibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis Villatoro et al Cochrane Library DOI: 10.1002/14651858.CD002941.pub3. 2010 version.43 year old lady presents with an attack of acute pancreatitis. It is classified as a mild attack on severity scoring. Imaging identifies gallstones but a normal calibre bile duct, and a peripancreatic fluid collection. Which of the following management options is most appropriate?A.Intravenous octreotideB.Cholecystectomy within 4 weeksC.Nasogastric tube drainage of the stomachD.Insertion of a radiological drainE.Avoidance of enteral feedingPatients with gallstone pancreatitis should undergo early cholecystectomy.Enteral feeding helps minimise gut bacterial translocation and should be given to most patients with pancreatitis. Many studies have evaluated the role of octreotide in reducing pancreatic secretions and shown no benefit (Uhl W et al Gut 1999 45:97-104, McKay C et al. Int J Pancreatol 1997; 21: 13-19).The use of antibiotics in pancreatitis is controversial. However, a recent Cochrane review has presented reasonable evidence in favor of administration of imipenem to prevent infection in established necrosis. Management of PancreatitisManagement of Acute Pancreatitis in the UKDiagnosisTraditionally hyperamylasaemia has been utlilised with amylase being elevated three times the normal range.However, amylase may give both false positive and negative results. Serum lipase is both more sensitive and specific than serum amylase. It also has a longer half life.Serum amylase levels do not correlate with disease severity.Differential causes of hyperamylasaemiaAcute pancreatitisPancreatic pseudocystMesenteric infarctPerforated viscusAcute cholecystitisDiabetic ketoacidosisAssessment of severityGlasgow, Ranson scoring systems and APACHE IIBiochemical scoring e.g. using CRP Features that may predict a severe attack within 48 hours of admission to hospitalInitial assessmentClinical impression of severityBody mass index >30Pleural effusionAPACHE score >824 hours after admissionClinical impression of severityAPACHE II >8Glasgow score of 3 or morePersisting multiple organ failureCRP>15048 hours after admissionGlasgow Score of >3CRP >150Persisting or progressive organ failureTable adapted from UK guidelines for management of acute pancreatitis. GUT 2005, 54 suppl IIIManagementNutritionThere is reasonable evidence to suggest that the use of enteral nutrition does not worsen the outcome in pancreatitisMost trials to date were underpowered to demonstrate a conclusive benefit.The rationale behind feeding is that it helps to prevent bacterial translocation from the gut, thereby contributing to the development of infected pancreatic necrosis. Use of antibiotic therapyMany UK surgeons administer antibiotics to patients with acute pancreatitis. A recent Cochrane review highlights the potential benefits of administering Imipenem to patients with established pancreatic necrosis in the hope of averting the progression to infection. There are concerns that the administration of antibiotics in mild attacks of pancreatitis will not affect outcome and may contribute to antibiotic resistance and increase the risks of antibiotic associated diarrhoea.SurgeryPatients with acute pancreatitis due to gallstones should undergo early cholecystectomy.Patients with obstructed biliary system due to stones should undergo early ERCP.Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement, fine needle aspiration is still used by some.Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise.References.uk/pdfworddocs/pancreatic.pdfAntibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis Villatoro et al Cochrane Library DOI: 10.1002/14651858.CD002941.pub3. 2010 version.A 43 year old lady presents with jaundice and is diagnosed as having a carcinoma of the head of the pancreas. Although she is deeply jaundiced, her staging investigations are negative for metastatic disease. What is the best method of biliary decompression in this case?A.ERCP and placement of metallic stentB.ERCP aloneC.ERCP and placement of plastic stentD.CholecystostomyE.CholedochoduodenostomyMetallic stents are contraindicated in resectable biliary diseaseA plastic stent is the best option for biliary decompression in resectable disease. Surgical bypasses have no place in the management of operable malignancy as a bridge to definitive surgery.Pancreatic stentsBoth benign and malignant biliary obstruction may be treated by placement of stents. These may be either plastic tubes or self expanding metallic stents. They can be placed either percutaneously, at ERCP, or, less commonly now, open surgery. Complications include blockage, displacement and those related to the method of insertion.Metallic Vs Plastic stentsMetallic stentsPlastic stentsExpensiveCheapEmbed in surrounding tissuesDo not usually embedDisplacement rareDisplacement commonBlockage rareBlockage commonContraindicated in resectable malignant diseaseMay be used as a bridge to resectional surgeryTheme: Management of biliary diseasesA.Acute laparoscopic cholecystectomyB.Delayed laparoscopic cholecystectomyC.Percutaneous cholecystostomyD.LithotripsyE.Endoscopic retrograde cholangiopancreatographyF.CholedochoduodenostomyG.Bile duct excision and hepatico-jejunostomyH.Operative cholecystostomyPlease select the most appropriate management option for the scenario given. Each option may be used once, more than once or not at all.25. A 43 year old women is admitted with acute cholecystitis and fails to settle. A laparoscopic cholecystectomy is performed, at operation the gallbladder has evidence of an empyema and Calots triangle is inflamed and the surgeon suspects that a Mirizzi syndrome has occurred.You answered Bile duct excision and hepatico-jejunostomy The correct answer is Operative cholecystostomyThis will address the acute sepsis and resolve the situation. Attempts at completing the surgery at this stage, even in expert hands carries a very high risk of bile duct injury.26. Following a difficult cholecystectomy a surgeon leaves a drain. 24 hours later bile is seen to be accumulating in the drain and this fails to resolve over the next 48 hours. The patient is otherwise well.Endoscopic retrograde cholangiopancreatographyThis will delineate the presence of potential bile duct injury. Usually this is result of leakage from the cystic duct and placement of a stent will allow free biliary drainage and the leak should settle.27. A 40 year old woman is admitted with abdominal pain. She has suffered from repeated episodes of this colicky right upper quadrant pain. On examination she is pyrexial with right upper quadrant peritonism. Her blood tests show a white cell count of 23. However, the liver function tests are normal. An abdominal ultrasound scan shows multiple gallstones in a thick walled gallbladder, the bile duct measures 4mm.Acute laparoscopic cholecystectomyThis lady has acute cholecystitis and needs an acute cholecystectomy. This operation should usually be performed within 48 hours of admission. Delay beyond this timeframe will usually result in increased operative complications and most surgeons would administer antibiotics and perform and interval cholecystectomy if the early window for an acute procedure is missed. A bile duct measuring 4mm is usually normal.Biliary diseaseDiagnosis Typical features PathogenesisGallstonesTypically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundiceCholangitisUsually obstructive and will have Charcot's triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law)Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatitis may be the culprit in which case the bile duct may be of normal calibre.TPN associated jaundice Usually follows long term use and is usually painless with non obstructive featuresOften due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive typeOften due to a difficult laparoscopic? cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury.Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.Metastatic disease Mixed hepatic and post hepaticCombination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier)A gallbladder may develop a thickened wall in chronic cholecystitis and microscopically Roikitansky-Aschoff Sinsuses may be seenImage sourced from Wikipedia Theme: Pancreatitis managementA.Pancreatic necrosectomyB.Staging laparotomy to assess severityC.Endoscopic retrograde cholangiopancreatographyD.Emergency cystogastrostomyE.Cholecystectomy within 4 weeksF.Elective cystogastrostomyG.Parenteral nutritionPlease select the most appropriate next stage in management for the scenario given. Each option may be used once, more than once or not at all.28. A 34 year old women is admitted with cholangitis. Her bilirubin is 180 and alkaline phosphatase is 348. She becomes progressively more unwell and develops abdominal pain. The houseman checks her amylase which is elevated at 1080. Standard treatment is initiated and her Glasgow score is 3.Endoscopic retrograde cholangiopancreatographyShe requires urgent decompression of her biliary system. An ERCP is the conventional method of performing this. It is important to ensure that her coagulation status is normalised prior to performing this procedure.29. A 63 year old man is admitted to ITU with an attack of severe gallstone pancreatitis. He requires ventillatory support for ARDS. Over the past few days he has become more unwell and a CT scan is organised. This demonstrates an area of necrosis. His CRP is 400 and WCC 25.1.Pancreatic necrosectomyThis man requires necrosectomy as he has infected pancreatic necrosis and is haemodynamically unstable. A radiological drainage procedure is unlikely to be sufficient.30. A 53 year old alcoholic develops acute pancreatitis and is making slow but reasonable progress. He is troubled by persisting ileus and for this reason a CT scan is undertaken. This demonstrates a large pancreatic pseudocyst. This is monitored by repeat CT scanning which shows no resolution and he is now complaining of early satiety.Elective cystogastrostomyDrainage of this man's pseudocyst is required. This could be accomplished radiologically or endoscopically or surgically. As the other options are not on the list this is the best option from those available.Management of PancreatitisManagement of Acute Pancreatitis in the UKDiagnosisTraditionally hyperamylasaemia has been utlilised with amylase being elevated three times the normal range.However, amylase may give both false positive and negative results. Serum lipase is both more sensitive and specific than serum amylase. It also has a longer half life.Serum amylase levels do not correlate with disease severity.Differential causes of hyperamylasaemiaAcute pancreatitisPancreatic pseudocystMesenteric infarctPerforated viscusAcute cholecystitisDiabetic ketoacidosisAssessment of severityGlasgow, Ranson scoring systems and APACHE IIBiochemical scoring e.g. using CRP Features that may predict a severe attack within 48 hours of admission to hospitalInitial assessmentClinical impression of severityBody mass index >30Pleural effusionAPACHE score >824 hours after admissionClinical impression of severityAPACHE II >8Glasgow score of 3 or morePersisting multiple organ failureCRP>15048 hours after admissionGlasgow Score of >3CRP >150Persisting or progressive organ failureTable adapted from UK guidelines for management of acute pancreatitis. GUT 2005, 54 suppl IIIManagementNutritionThere is reasonable evidence to suggest that the use of enteral nutrition does not worsen the outcome in pancreatitisMost trials to date were underpowered to demonstrate a conclusive benefit.The rationale behind feeding is that it helps to prevent bacterial translocation from the gut, thereby contributing to the development of infected pancreatic necrosis. Use of antibiotic therapyMany UK surgeons administer antibiotics to patients with acute pancreatitis. A recent Cochrane review highlights the potential benefits of administering Imipenem to patients with established pancreatic necrosis in the hope of averting the progression to infection. There are concerns that the administration of antibiotics in mild attacks of pancreatitis will not affect outcome and may contribute to antibiotic resistance and increase the risks of antibiotic associated diarrhoea.SurgeryPatients with acute pancreatitis due to gallstones should undergo early cholecystectomy.Patients with obstructed biliary system due to stones should undergo early ERCP.Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement, fine needle aspiration is still used by some.Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise.References.uk/pdfworddocs/pancreatic.pdfAntibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis Villatoro et al Cochrane Library DOI: 10.1002/14651858.CD002941.pub3. 2010 version.What proportion of patients presenting for cholecystectomy for treatment of biliary colic due to gallstones will have stones in the common bile duct?A.10%B.30%C.2%D.50%E.25%Up to 10% of all patients may have stones in the CBD. Therefore, all patients should have their liver function tests checked prior to embarking on a cholecystectomy. Biliary diseaseDiagnosis Typical features PathogenesisGallstonesTypically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundiceCholangitisUsually obstructive and will have Charcot's triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law)Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatitis may be the culprit in which case the bile duct may be of normal calibre.TPN associated jaundice Usually follows long term use and is usually painless with non obstructive featuresOften due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive typeOften due to a difficult laparoscopic? cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury.Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.Metastatic disease Mixed hepatic and post hepaticCombination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier)A gallbladder may develop a thickened wall in chronic cholecystitis and microscopically Roikitansky-Aschoff Sinsuses may be seenImage sourced from Wikipedia ................
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