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HPB DAY. Plan today 4 cases Images Present range of approaches Discussion. 38 year old female, 6 month history of recurrent attacks of severe epigastric pain -> back. Possibly dark urine at times USS….

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Plan today 4 cases images present range of approaches discussion

Plan today

4 cases

Images

Present range of approaches

Discussion


38 year old female, 6 month history of recurrent attacks of severe epigastric pain -> back. Possibly dark urine at times

USS…


38 year old female, 6 month history of recurrent attacks of severe epigastric pain -> back. Possibly dark urine at times

USS…

Lap chole…


Hepatobiliary pathology

Hepatobiliary Pathology severe epigastric pain -> back. Possibly dark urine at times

Or how I learned to stop worrying and love the gallstone…


Cholesterol stones
Cholesterol Stones severe epigastric pain -> back. Possibly dark urine at times

  • 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 stones
Pigment (haem) Stones severe epigastric pain -> back. Possibly dark urine at times

  • Calcium bilirubinate

  • Chronic haemolysis


38 year old female, 6 month history of recurrent attacks of severe epigastric pain -> back. Possibly dark urine at times

USS…

Lap chole…

5 days postop readmitted with severe abdominal pain…..

Why, what investigations


Uss ct
USS (CT) severe epigastric pain -> back. Possibly dark urine at times

Unremarkable

What else …




68 year old female with 2 week history of obstructive jaundice

USS: CBD 16mm GB distended, no stones

CT scan – unresectable ca pancreas

Palliative R….

Stent - route


Ercp stent

ERCP Stent jaundice


Percutaneous transhepatic cholangiography
Percutaneous transhepatic cholangiography jaundice

  • 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



Palliative treatment biopsy including eus gemcitabine

Palliative Treatment: non-resectable pancreatic tumour

(Biopsy) – including EUS

Gemcitabine


Pancreatic cancer
Pancreatic Cancer non-resectable pancreatic tumour

  • 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… non-resectable pancreatic tumour


47 year old male. 3 year history of epigastric pain -> back. Rather constant. Worsening over 6 months. Stools recently rather loose.

Thoughts….

USS ….


Case 3
Case 3 back. Rather constant. Worsening over 6 months. Stools recently rather loose.


Case 31
Case 3 back. Rather constant. Worsening over 6 months. Stools recently rather loose.


Some other images back. Rather constant. Worsening over 6 months. Stools recently rather loose.


How to treat pseudocysts

How to treat pseudocysts?? back. Rather constant. Worsening over 6 months. Stools recently rather loose.


Pancreatic anatomy
Pancreatic Anatomy back. Rather constant. Worsening over 6 months. Stools recently rather loose.

  • 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 drainage
Pseudocyst drainage back. Rather constant. Worsening over 6 months. Stools recently rather loose.


Pancreatic cysts
Pancreatic Cysts back. Rather constant. Worsening over 6 months. Stools recently rather loose.

  • Non-neoplastic

    • Pseudocysts

    • others

  • Neoplastic

    • Mucinous (cystadenoma)

    • Papillary/cystic tumours

    • Cystadenocarcinoma

    • Degeneration in any cancer

  • FNAC

    • Steep learning curve


Pancreatitis attempts to clarify marseilles
PANCREATITIS, back. Rather constant. Worsening over 6 months. Stools recently rather loose.attempts to clarifyMARSEILLES

  • Chronic Pancreatitis

  • Acute Pancreatitis


Acute pancreatitis
Acute Pancreatitis back. Rather constant. Worsening over 6 months. Stools recently rather loose.

Acute Pancreatitis

  • Mild - 80% ?management

  • Severe – 20% total – manage carefully

  • 6% mortality – what of, operations?

  • How to identify the severes


Acute pancreatitis1
Acute Pancreatitis back. Rather constant. Worsening over 6 months. Stools recently rather loose.

1

2

  • Requires:

  • Small stones

  • Wide cystic duct

  • Decent common channel


Chronic pancreatitis
Chronic Pancreatitis back. Rather constant. Worsening over 6 months. Stools recently rather loose.

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 pancreatitis alcohol pain diabetes steatorrhoea

Ok its chronic pancreatitis back. Rather constant. Worsening over 6 months. Stools recently rather loose.

Alcohol …

Pain …

Diabetes …

Steatorrhoea …


69 year old male referred with an inguinal hernia. Looks terrible. Admits to 3 months of anorexia, lethargy and weight loss.

Investigation …


Case 4
Case 4 terrible. Admits to 3 months of anorexia, lethargy and weight loss.


Multiple liver mets
Multiple Liver Mets terrible. Admits to 3 months of anorexia, lethargy and weight loss.

  • Hunt the primary??

  • Why??

  • Most colorectal, upper GI, pancreas, lung


Inoperable liver mets hunting
Inoperable liver mets. terrible. Admits to 3 months of anorexia, lethargy and weight loss.Hunting?

  • Clinical

  • Imaging +/- biopsy

  • Immunochemistry

    • Specific (ha ha) markers

    • Cytokeratin profiles


Tumours with specific therapies
Tumours with specific therapies terrible. Admits to 3 months of anorexia, lethargy and weight loss.

  • Breast

  • Colorectal

  • Other UGI

  • (Prostate)

  • (Thyroid)

  • Oncology peer pressure


Potential treatments available for some patients resection local treatments

Potential treatments available for some patients terrible. Admits to 3 months of anorexia, lethargy and weight loss.

Resection

Local treatments ….


Case 5
Case 5 terrible. Admits to 3 months of anorexia, lethargy and weight loss.


Case 6
Case 6 terrible. Admits to 3 months of anorexia, lethargy and weight loss.


Case 61
Case 6 terrible. Admits to 3 months of anorexia, lethargy and weight loss.


A few messages to repeat terrible. Admits to 3 months of anorexia, lethargy and weight loss.:

Don’t forget CBD stones

ERCP is principally for therapy now

Save time, do the right test, ask a radiologist

Tissue diagnosis not always possible in pancreatic cancer

Time is critical in obs jaundice

Good palliation from biliary decompression

CA 19/9 for pancreatic cancer

GEMCITABINE for pancreatic cancer


Any questions about anything

Any questions about anything terrible. Admits to 3 months of anorexia, lethargy and weight loss.


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