Pancreas

Acute pancreatits
Work-up
If unsure of dx of acute epigastric pain, start with gastrograffin swallow to r/o perf'd ulcer, Boerhaave's, gastric volvulus. Could also be acute MI (EKG, enzymes), AAA (will be seen on the US/CT you are gonna do for pancreatitis), ischemic bowel.
abdominal films
EKG
US/CT

Treatment
NPO, NGT, maybe TPN
IVF
H2 blockers
Abx? - when ?
Early ERCP + sphincterotomy in severe cases can help, but has risks, so do only to decompress obstructed CBD in septic pt.
Somatostatin does not help

If pt doesn't get better ...
CT, if necrosis, then needle aspiration and G/S + culture
If sterile but still not getting better in 24h, or if infected, abx + laparotomy.
1. Debride devitalized tissue, lavage
2. Drains in lesser sac, or marsupialize
3. Feeding tube

If CT shows pancreatic fluid collection ...
FNA and culture to distinguisg pseudocyst, sterile fluid, or pancreatic abscess
If it's a pancreatic abscess, IR drain, or surgical external drainage + feeding tube

Pseudocyst
If under 4 cm and asymptomatic, follow with serial US
If 5-6 cm or symptomatic (pain, obstruction, bleeding, infection) ...
ERCP - communicating with pancreatic duct?
If non-communicating, larger than 4cm, not very symptomatic, can do IR aspiration (even repeatedly, 3-4x). If that doesn't work or things get worse, surgical internal drainage.

If larger than 6cm, symptomatic, and communicates with pancreatic duct, make sure it's 6wks old and do surgical internal drainage (not if infected or bleeding). Roux-en Y cystojej is usual choice. Can do distal pancreatectomy if cyst is in the tail. If it's sticking right into the appropriate organ, can do cysto-duo or cysto-gastostomy.

If you operate, biopsy cyst wall to look for CA.

If infected, external drainage (IR or surgery).
If bleeding (sudden pain, shock; CT with IV contrast for dx if stable), go to IR if stable, laprotomy if unstable. Ligate vessel, open cyst, pack, ligate bleeders, external drainage.
Bleeding in a pseudocyst patient can be into cyst (erosion into vessel), into bowel (cyst erodes thru bowel wall), from gastric varices (2/2/ splenic vein thrombosis - do splenectomy). Do A gram if you can!

Pancreatic true cyst
serous or mucinous cystadenoma or cystadenocarcinoma
Mucinous - body/tail, higher malig potl
Serous - head, low malig potl

If suspect true cyst, get FNA and send:
CEA - hi in mucinous, low in serous and pseudo
CA125 - hi in malig, low in pseudo, variable in benign
Amylase/lipase - hi in pseudo
Viscosity - hi in mucinous
Cytology - look for CA
Wall bx - no epithelial lining in pseudo

Treatment
Surgery even if mets

Pancreatic ascites
Pt with h/o pancreatitis/pseudocyst with abdominal distention, fluid wave.

Work-up
CT abdomen
Paracentesis - protein, glucose, amylase, bile, cells
If amylase hi, it's pancreatic ascites.

Conservative treatment
NPO + TPN
somatostatin 150mg sq q8
repeated paracentesis
ERCP to stent across leak (unless significant debris in cyst)
75% success in 4 wks
repeat ERCP in 6 wks if doing well - remove stent if healed

If conservative fails:
pancreatectomy (Whipple or distal)
internal drainage if leak from cyst
Peustow is rare

Chronic pancreatitis
Indicated for complications:
pseudocyst, biliary or GI obstruction, abscess, splenic vein thrombosis with L portal HTN, pain

Factors to consider:
size of duct - large: Peustow; small: pancreatic resection (Whipple better pain results than distal, and not-as-bad diabetes)
failure of drainage procedure: resection
ampullary stenosis: sphincteroplasty and septoplasty

Workup
ERCP/PTC

If biliary obstruction, can treat with choledocho-jej, drainage of pseudocyst, or resection, depending on cause.
GI obstruction can be treated by pseudocyst drainage, or gastro-jej if you know it's not tumor

To differentiate pancreatic CA from localized chronic pancreatitis:
Look for mets with imaging
Best test is ERCP with brushings, biopsies, and fluid cytology
If ERCP inclonclusive, explore and do multiple biopsies

Pancreas divisum

Biliary surgery

Post cholecystectomy jaundice
Work-up and algorithm
H&P - look for peritonitis
Labs - esp LFTs and amylase
Abdominal films
Start abx
U/S RUQ - bil dil, stones, biloma, abscess
HIDA
If CBD occluded, get ERCP. If ERCP shows stone, retrieve. If can't ERCP or shows iatrogenic occlusion, explore.
May repair over T-tube, remove clip, choledocho-jej
IF HIDA shows leak, get CT scan
Drain the biloma, if it's the cystic duct, should close in 1-2 wks. If CBD, get ERCP, stent. Wait 3 weeks (for things to cool down), then OR - repair over T-tube or choldocho-jej (if tissue unhealthy or a lot of tension)
If HIDA shows normal - CT scan. IF CT also normal, look for other causes of jaundice.

Post cholecystectomy cholangitis
Here, the patient is septic, and you need to drain the biliary tree.
Algorithm
ABCs, access, H&P.
Labs, plain films, abx.
Emergent ERCP to drain the CBD. Can remove stone, bx mass.
If that's a no go, PTCD.
If that's a no go, resuscitate patient and go to OR, with the goal of draining the biliary tree.
Explore CBD, extract stone (may use choledochoscope)
If having trouble, or unstabe, put a T-tube in CBD and close.
If patient is stable and you want to drain internally, do a choledochoduodenostomy if porta not too scarred (can leave stone). If porta is scarred, and duo won't mobilize, do sphincterotomy. If still can't get stone, do choledocho-jej.

Post-cholecystectomy syndrome
"Still has pain s/p CCY"
ddx:
GERD, PUD, pancreatitis, IBS
Biliary: CBD stone/stricture, SOD, biliary dyskinesia

Workup
H&P - characterize pain
Labs - including LFTs, amylase/lipase
Tests:
EGD/ERCP
CT if you suspect pancreas
RUQ U/S - CBD >12mm is abnormal
HIDA delayed emptying >2h c/w biliary dyskinesia (remember, there is no gallbladder, so no EF)

Treatment - direct to etiology
Pt may benefit fropm sphincterotomy (ERCP or surgical TDS) if:
HIDA emptying >2h
CBD >12mm
Good wendoscopist can't cannulate ampulla
Pain reproduced by injecting CBD

Choledochal cyst
Types
I - most common - involves CBD

Complications
Malignancy

Treatment
Excision and hepatico-jej
If the dissection is tough, you can enter the cyst and develop a subserosal or submucosal plane, leaving the outside intact.
Also do CCY

Primary sclerosing cholangitis
Associated with IBD, can be idiopathic
Diffuse or localized extrahepatic stenoses
Recurring cholangitis/jaundice
Pts die 2/2 cirrhosis

Treatment
IR stents (can be changed q3 months)
Surgical hepatico-jej or choldocho-jej (place stents pre-op for identification)
Liver transplant


Acalculous cholecystitis
Risk - TPN - biliary stasis
Diagnosis
Portable RUQ US (not HIDA - gotta move pt and could be false neg in acalculous cholecystitis)
Elevated SGPT raises suspicion

Treatment
If sick, percutaneous cholecystomsomy under US guidance by IR
If no IR, do minilaparotomy and open cholestostomy under local

Less sick types with biliary dyskinesia
HIDA with CCK: if GB EF <30%, elective CCY

Biliary cancer
Gallbladder cancer
Stage I Mucosa
Stage II infiltrates subserosal layer, but serosa is uninvolved
Stage III thru serosa (into liver), or lymph nodes I, but <2cm
Stage IV, thru serosa (into liver), or lymph nodes +, but >2cm

Treatment
If I/II - CCY
III/IV - radical CCY - resect 2 cm of liver bed, dissect porta and anterior/inferior panc nodes
Distant mets - no surgery
If you are gonna go back to radicalize the CCY, do mets w/u 1st!

Bile duct cancer
Proximal (Klatskin) - at bifurcation
Middle third - CBD, not intrapancreatic
Distal - intrapancreatic

Work-up
1. r/o other causes of obstructive jaundice (stones, extrinsic compression of CBD by nodes from other cancer, sclerosisng cholangitis)
2. r/o mets
CT abd/chest
ERCP/PTC (can also get bx or brushings)
(Angio)
MR/MRCP

Treatment
Can start with laporoscopy
Look at nodes, liver, surfaces, hepatic plate
If looks unresectable, think drainage - ERCP/PTC, hepatico-jej)
Distal - Whipple
Middle - CCY, resect CBD up to pancreas, hepatico-jej
Proximal - CCY, dissect out porta, may include caudate lobe if involved, hepatico-jej
Post-op - adjuvant XRT, 5-FU