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What is the mechanism of hypotension in severe cases of acute pancreatitis?
Fluid sequesteration in the intestine and retroperitoneum, systemic vascular effects of kinins and TNF, vomiting, and bleeding
T/F: Idiopathic acute pancreatitis may be the result of occult biliary microlithiasis or biliary sludge
When and where is iatrogenic injury to the CBD most common?
During lap chole at the triangle of Calot
What is the most common lipid profile associated with pancreatitis?
Type V (increased triglycerides)
What is the optimal method of determining whether a pancreatic phlegmon is infected? What is the treatment if infected?
- CT to look for retroperitoneal air
- CT-guided aspiration of fluid
How does excess lipid promote pancreatitis?
Toxic action of fatty acids released by lipase in the pancreas
What is the role of abdominal US in pancreatitis?
Detection of biliary obstruction and evaluation of pseudocysts
What percentage of CBD stones pass spontaneously?
What should be the initial management of gallstone pancreatitis?
- Admission, NPO, IV hydration, trend liver enzymes for fist 24-36 hrs
- Lap chole in future
What are the management options for a CBD stone detected during IOC?
- Laparoscopic basket retrieval
- Fogarty balloon retrieval
- Forcible saline injection
- Postop ERCP
- CBD exploration
Ranson's Criteria @ 48 hrs?
- Fall in Hct >10%
- Rise in BUN >5%
- Ca <8
- PaO2 <60
- Base deficit >4
- Fluid sequestration >6L
Ranson's criteria @ admission?
- Age >70
- WBC >18
- Glucose >220
- LDH >400
- AST >250
Should abx be given epirically to pts with severe pancreatitis?
Yes, Imipenem most popular choice
What are the primary cystic masses of the pancreas?
- Serous cystadenoma
- Mucinous cystadenoma
- Intraductal papillary mucinous neoplasm
What features differentiate pancreatic pseudocysts from cystic neoplasms?
- Pseudocysts: h/o pancreatitis, no septations, high cyst amylase, connection to pancreatic duct, no epithelial layer
- Neoplasm: calcification, septations, solid components, epithelial layer, no h/o pancreatitis, cyst CEA
What is the treatment of mucinous cystadenoma of the pancreas?
Resection - have potential for malignant transformation
What are some differentiating features of mucinous cystadenomas from serous cystadenomas of the pancreas?
Mucinous cystadenomas are typically larger with septations and peripheral calcifications on CT. Fluid in mucinous is pos for tumor markers (CEA, CA 19-9) and low in glycogen (high in serous). Serous cystadenomas tend to have more central calcification with a "starburst" pattern of smaller cysts within a larger capsule
What are the features of intraductal papillary mucinous neoplasm (IPMN)?
Solitary cystic neoplasm near the head of the pancreas with mucin seen in the ampulla on ERCP. High rate of cyst malignancy, and oncologic resection is the treatment.
What is the surgical treatment for a large (7cm) pancreatic pseudocyst inducing pain that fails to regress after 12 weeks?
Enteric drainage wtih cyst gastrostomy or cystic jejunostomy
What is the clinical presentation of familial Mediterranean fever?
- Bouts of fever and abdominal pain as well as intermittent chest and joint pain.
- Inheritance is AD.
- Colchicine effective for prevention, anti-inflammatories during an acute attack
What are the most common variants in origin of hepatic arteries?
- Right hepatic - off SMA, 20%
- Left hepatic - off left gastric, 10%
What are the structures in the portal triad?
- Portal vein - posterior
- CBD - right anterior
- Hepatic aa - left anterior
What should be the steps when CBD injury is suspected in lap chole?
Cholangiogram for define anatomy and injury followed by CBD repair over a T-tube for partial transection or choledochojejunostomy for complete transection
What are the sonographic effects of gallstones on US?
Acoustic shadowing behind the stones
What bacteria are the most common agents of biliary sepsis?
E coli and Klebsiella
What artery is at risk in the crural dissection during lap Nissen?
Aberrant Left hepatic arising off the left gastric (when present)
T/F: The portal vein formed by the SMV and splenic vv sees highly regulated blood flow with its multiple valves
- Portal system is valveless
What pleuropulmonary abnormalities may be seen in patients with pancreatitis?
Elevated hemidiaphragm, atelectasis, pleural reaction or effusion, hypoxemia, acute lung injury
What is the treatment of traumatic pancreatic transection with an intact ampulla of vater?
- distal pancreatectomy with oversewing of the proximal pancreatic duct and drain placement.
- In stable pts consider ERCP with pancreatic duct integrity being the primary variable for attempted pancreatic preservation vs resection
When should surgical drainage of pancreatic pseudocyst be considered?
- Large cysts (>5cm)
- Cysts that do not resolve/decrease after 6 weeks
- Infected pseudocysts
What is the surgical option of a T1 adenocarcinoma found after lap chole?
Nothing - lap chole is sufficient
What is the treatment of a T3 adenocarcinoma of the gallbladder?
Cholecystectomy + regional lymphadenectomy and liver segment V removal, portal triad skeletonization
What is the triad of hemobilia?
GI bleed, jaundice, RUQ pain
What does Charcot's triad imply?
Fever, RUQ pain, and jaundice indicative of cholangitis
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