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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

slide3
38 year old female, 6 month history of recurrent attacks of severe epigastric pain -> back. Possibly dark urine at times

USS…

slide5
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

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

cholesterol stones
Cholesterol 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 stones
Pigment (haem) Stones
  • Calcium bilirubinate
  • Chronic haemolysis
slide18

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)

Unremarkable

What else …

slide41

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

percutaneous transhepatic cholangiography
Percutaneous transhepatic cholangiography
  • 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:

(Biopsy) – including EUS

Gemcitabine

pancreatic cancer
Pancreatic 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.
slide59

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

Thoughts….

USS ….

pancreatic anatomy
Pancreatic 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.
pancreatic cysts
Pancreatic Cysts
  • 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, attempts to clarifyMARSEILLES
  • Chronic Pancreatitis
  • Acute Pancreatitis
acute pancreatitis
Acute Pancreatitis

Acute Pancreatitis

  • Mild - 80% ?management
  • Severe – 20% total – manage carefully
  • 6% mortality – what of, operations?
  • How to identify the severes
acute pancreatitis1
Acute Pancreatitis

1

2

  • Requires:
  • Small stones
  • Wide cystic duct
  • Decent common channel
chronic pancreatitis
Chronic 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 pancreatitis alcohol pain diabetes steatorrhoea
Ok its chronic pancreatitis

Alcohol …

Pain …

Diabetes …

Steatorrhoea …

slide79

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

Investigation …

multiple liver mets
Multiple Liver Mets
  • Hunt the primary??
  • Why??
  • Most colorectal, upper GI, pancreas, lung
inoperable liver mets hunting
Inoperable liver mets.Hunting?
  • Clinical
  • Imaging +/- biopsy
  • Immunochemistry
    • Specific (ha ha) markers
    • Cytokeratin profiles
tumours with specific therapies
Tumours with specific therapies
  • Breast
  • Colorectal
  • Other UGI
  • (Prostate)
  • (Thyroid)
  • Oncology peer pressure
slide90

A few messages to repeat:

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

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