hpb day. plan today 4 cases4 cases imagesimages present range of approachespresent range of...
TRANSCRIPT
HPB DAYHPB DAY
Plan todayPlan today
•4 cases4 cases
•ImagesImages
•Present range of approachesPresent range of approaches
•DiscussionDiscussion
38 year old female, 6 month history of 38 year old female, 6 month history of recurrent attacks of severe epigastric pain recurrent attacks of severe epigastric pain -> back. Possibly dark urine at times-> back. Possibly dark urine at times
USS…USS…
38 year old female, 6 month history of 38 year old female, 6 month history of recurrent attacks of severe epigastric pain recurrent attacks of severe epigastric pain -> back. Possibly dark urine at times-> back. Possibly dark urine at times
USS…USS…
Lap chole…Lap chole…
Hepatobiliary PathologyHepatobiliary Pathology
Or how I learned to stop worrying Or how I learned to stop worrying and love the gallstone…and love the gallstone…
Cholesterol StonesCholesterol Stones
• Hypersecretion of cholesterol
• Decreased bile salt secretion
• Odd gallbladder
• Old, female, pregnant, obesity, rapid weight loss, ethnicity,impaired GB motility e.g. parenteral nutrition
Pigment (haem) StonesPigment (haem) Stones
• Calcium bilirubinate
• Chronic haemolysis
38 year old female, 6 month history of 38 year old female, 6 month history of recurrent attacks of severe epigastric pain -> recurrent attacks of severe epigastric pain -> back. Possibly dark urine at timesback. Possibly dark urine at times
•USS…USS…
•Lap chole…Lap chole…
5 days postop readmitted with severe 5 days postop readmitted with severe abdominal pain….. abdominal pain…..
•Why, what investigationsWhy, what investigations
USS (CT)USS (CT)
Unremarkable
What else …
How might we identify preop which How might we identify preop which patients may harbour CBD stones….patients may harbour CBD stones….
44 year old female with 2 week history of 44 year old female with 2 week history of obstructive jaundiceobstructive jaundice
OK LFTs but so whatOK LFTs but so what
USS: USS:
68 year old female with 2 week history of 68 year old female with 2 week history of obstructive jaundiceobstructive jaundice
USS: CBD 16mm GB distended, no stonesUSS: CBD 16mm GB distended, no stones
CT scan – unresectable ca pancreasCT scan – unresectable ca pancreas
Palliative R….Palliative R….
Stent - route Stent - route
ERCP StentERCP Stent
Percutaneous transhepatic Percutaneous transhepatic cholangiographycholangiography
Indications
•Determination of obstructive jaundice
•Level of obstruction
•Persistent pain after GB removal
Contraindications
Close to 100% sensitivity and specificity in identifying cause and level of obstruction
Self-expanding stent placed in the CBD of patient with non-resectable pancreatic tumour
Palliative Treatment:Palliative Treatment:
(Biopsy) – including EUS(Biopsy) – including EUS
GemcitabineGemcitabine
Pancreatic CancerPancreatic Cancer
• Adenocarcinoma
• Exocrine Pancreas
• Older, males > females, fags, booze, fat, carbs. BRACA-2, PJS
• 60, 10, 10% (Head, body, tail)
• 80% outside pancreas at diagnosis
• CA 19/9.
If it had been operable…If it had been operable…
47 year old male. 3 year history of 47 year old male. 3 year history of epigastric pain -> back. Rather constant. epigastric pain -> back. Rather constant. Worsening over 6 months. Stools recently Worsening over 6 months. Stools recently rather loose.rather loose.
Thoughts….Thoughts….
USS ….USS ….
Case 3Case 3
Case 3Case 3
Some other imagesSome other images
How to treat pseudocysts??How to treat pseudocysts??
Pancreatic AnatomyPancreatic Anatomy
• Consists of head, ucinate process, meck, body and tail
• Head lies within C shaped concavity of the duodenum
• Ucinate process passes posterior to the superior mesenteric vessels
• Neck is anterior to superior mesenteric vessels
• Tail ends as it passes between the layers of the splenorenal ligament
• Pancreatic duct- begins at tail and passes right through the body to the head where joins CBD at A of V.
• Also accessory pancreatic duct reflects the embryological origin of the pancreas from dorsal and ventral processes.
Pseudocyst drainagePseudocyst drainage
Pancreatic CystsPancreatic Cysts
• Non-neoplastic– Pseudocysts– others
• Neoplastic– Mucinous (cystadenoma)– Papillary/cystic tumours– Cystadenocarcinoma– Degeneration in any cancer
• FNAC– Steep learning curve
PANCREATITIS, PANCREATITIS, attempts to clarifyattempts to clarify
MARSEILLESMARSEILLES
• Chronic Pancreatitis
• Acute Pancreatitis
Acute PancreatitisAcute Pancreatitis
Acute Pancreatitis
• Mild - 80% ?management
• Severe – 20% total – manage carefully
• 6% mortality – what of, operations?
• How to identify the severes
Acute PancreatitisAcute Pancreatitis
Requires:•Small stones•Wide cystic duct•Decent common channel
1
2
Chronic PancreatitisChronic Pancreatitis
Chronic Pancreatitis
• Usually alcoholic aetiology
• Slowly progressive (1/4 if abstain)
• Will not recover
• Fibrosis, stone protein, calcification
• Some have pain
• Some have episodes of pancreatitis
Ok its chronic pancreatitisOk its chronic pancreatitis
Alcohol …Alcohol …
Pain …Pain …
Diabetes …Diabetes …
Steatorrhoea …Steatorrhoea …
69 year old male referred with an inguinal 69 year old male referred with an inguinal hernia. Looks terrible. Admits to 3 months hernia. Looks terrible. Admits to 3 months of anorexia, lethargy and weight loss.of anorexia, lethargy and weight loss.
Investigation …Investigation …
Case 4Case 4
Multiple Liver MetsMultiple Liver Mets
• Hunt the primary??
• Why??
• Most colorectal, upper GI, pancreas, lung
Inoperable liver mets.Inoperable liver mets.Hunting?Hunting?
• Clinical
• Imaging +/- biopsy
• Immunochemistry– Specific (ha ha) markers– Cytokeratin profiles
Tumours with specific therapiesTumours with specific therapies
• Breast
• Colorectal
• Other UGI
• (Prostate)
• (Thyroid)
• Oncology peer pressure
Potential treatments available for some Potential treatments available for some patientspatients
ResectionResection
Local treatments ….Local treatments ….
Case 5Case 5
Case 6Case 6
Case 6Case 6
A few messages to repeatA few messages to repeat::
• Don’t forget CBD stonesDon’t forget CBD stones
• ERCP is principally for therapy now ERCP is principally for therapy now
• Save time, do the right test, ask a radiologistSave time, do the right test, ask a radiologist
• Tissue diagnosis not always possible in Tissue diagnosis not always possible in pancreatic cancer pancreatic cancer
• Time is critical in obs jaundiceTime is critical in obs jaundice
• Good palliation from biliary decompression Good palliation from biliary decompression
• CA 19/9 for pancreatic cancer CA 19/9 for pancreatic cancer
• GEMCITABINE for pancreatic cancerGEMCITABINE for pancreatic cancer
Any questions about anythingAny questions about anything