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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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Hpb day

HPB DAY


Plan today 4 cases images present range of approaches discussion

Plan today

4 cases

Images

Present range of approaches

Discussion


Hpb day

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

USS…


Hpb day

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


Hpb day

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 …


How might we identify preop which patients may harbour cbd stones

How might we identify preop which patients may harbour CBD stones….


44 year old female with 2 week history of obstructive jaundice ok lfts but so what uss

44 year old female with 2 week history of obstructive jaundice

OK LFTs but so what

USS:


Hpb day

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


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


Hpb day

Self-expanding stent placed in the CBD of patient with non-resectable pancreatic tumour


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.


If it had been operable

If it had been operable…


Hpb day

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


Case 31

Case 3


Hpb day

Some other images


How to treat pseudocysts

How to treat pseudocysts??


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.


Pseudocyst drainage

Pseudocyst drainage


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 …


Hpb day

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


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


Potential treatments available for some patients resection local treatments

Potential treatments available for some patients

Resection

Local treatments ….


Case 5

Case 5


Case 6

Case 6


Case 61

Case 6


Hpb day

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


Any questions about anything

Any questions about anything


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