Theme: Management of jaundice

A. ERCP
B. MRCP
C. Percutaneous transhepatic cholangiogram
D. Laparotomy
E. Laparotomy and formation of hepatico-jejunostomy
F. Laparoscopic biliary bypass
G. CT scan

For each of the following scenarios please select the most appropriate next stage of
management. Each option may be used once, more than once or not at all.

1. A 65 year old man is admitted with jaundice and investigations demonstrate a

carcinoma of the pancreatic head. An ERCP is attempted but the surgeon is
unable to cannulate the ampulla.

You answered Laparotomy and formation of hepatico-jejunostomy

The correct answer is Percutaneous transhepatic cholangiogram

Theme from September 2012 Exam

Cancer of the pancreatic head will cause and obstructed jaundice and
intrahepatic duct dilatation. When an ERCP has failed the most appropriate
option is to attempt a PTC. This procedure is always preceded by an ultrasound
(which presumably this patient has already had or they would not be undergoing
an ERCP). Prior to performing the PTC it is important to stage the disease and
establish resectability or not. This is because the PTC drains frequently dislodge
and fall out. It is usually desirable to pass a stent at the time of doing the PTC to
mitigate the effects of this problem.

2. A 48 year old lady is admitted with attacks of biliary colic and investigations
show gallstones. A laparoscopic cholecystectomy is performed. The operation is
technically challenging due to a large stone impacted in Hartmans pouch.
Following the operation she fails to settle and becomes jaundiced and has bile
draining into a drain placed at the surgical site.

You answered Percutaneous transhepatic cholangiogram

The correct answer is ERCP

In this scenario it must be assumed that the bile duct has been damaged. In most
cases an ERCP is the most appropriate investigation. This can also allow the
passage of a stent if this is deemed to be safe and sensible.
3. A 34 year old lady is admitted with jaundice and undergoes an ERCP. The
procedure is technically difficult and she is returned to the ward still jaundiced.
Unfortunately she now has severe generalised abdominal pain.

You answered Laparotomy

The correct answer is CT scan

There are two main differential diagnoses here. One is pancreatitis, repeated
trauma to the ampulla and duct (if partially cannulated) is a major risk factor for
pancreatitis. The second is the possibility that the duodenum has been
perforated. ERCP is performed using a side viewing endoscope, the
manipulation of which can be technically challenging for the inexperienced
operator in a patient with abnormal anatomy. A CT scan is the best investigation
to distinguish between these two differential diagnoses.

Surgical jaundice

Jaundice can present in a manner of different surgical situations. As with all types of
jaundice a carefully history and examination will often give clues as the most likely
underlying cause. Liver function tests whilst conveying little in the way of
information about liver synthetic function, will often facilitate classification as to
whether the jaundice is pre hepatic, hepatic or post hepatic. The typical LFT patterns
are given below:

Location Bilirubin ALT/ AST Alkaline phosphatase

Pre hepatic Normal or Normal Normal
high
Hepatic High Elevated (often very Elevated but seldom to very high
high) levels
Post hepatic High-very Moderate elevation High- very high
high

In post hepatic jaundice the stools are often of pale colour and this feature should be
specifically addressed in the history.

Modes of presentation

These are addressed in the table below:

Diagnosis Typical features Pathogenesis

Gallstones Typically history of Usually small calibre gallstones which
biliary colic or can pass through the cystic duct. In
episodes of Mirizzi syndrome the stone may
chlolecystitis. compress the bile duct directly- one of
 Obstructive type the rare times that cholecystitis may
history and test present with jaundice
results.
Cholangitis Usually obstructive Ascending infection of the bile ducts
and will have usually by E. coli and by definition
Charcots triad of occurring in a pool of stagnant bile.
symptoms (pain,
fever, jaundice)
Pancreatic cancer Typically painless Direct occlusion of distal bile duct or
jaundice with palpable pancreatic duct by tumour. Sometimes
gallbladder nodal disease at the portal hepatis may be
(Courvoisier's Law) the culprit in which case the bile duct
may be of normal calibre.
TPN associated Usually follows long Often due to hepatic dysfunction and
jaundice term use and is fatty liver which may occur with long
usually painless with term TPN usage.
non obstructive
features
Bile duct injury Depending upon the Often due to a difficult cholecystectomy
type of injury may be when anatomy in Calots triangle is not
of sudden or gradual appreciated. In the worst scenario the bile
onset and is usually of duct is excised and jaundice offers
obstructive type rapidly post operatively. More insidious
is that of bile duct stenosis which may be
caused by clips or diathermy injury.
Cholangiocarcinoma Gradual onset Direct occlusion by disease and also
obstructive pattern extrinsic compression by nodal disease at
the porta hepatis.
Septic surgical Usually hepatic Combination of impaired biliary
patient features excretion and drugs such as ciprofloxacin
which may cause cholestasis.
Metastatic disease Mixed hepatic and Combination of liver synthetic failure
post hepatic (late) and extrinsic compression by nodal
disease and anatomical compression of
intra hepatic structures (earlier)

Diagnosis
An ultrasound of the liver and biliary tree is the most commonly used first line test.
This will establish bile duct calibre, often ascertain the presence of gallstones, may
visualise pancreatic masses and other lesions. The most important clinical question is
essentially the extent of biliary dilatation and its distribution.

Where pancreatic neoplasia is suspected the next test should be a pancreatic protocol
CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the
preferred option. PET scans may be used to stage a number of malignancies but do
not routinely form part of first line testing.

Where MRCP fails to give adequate information and ERCP may be necessary. In
many cases this may form part of patient management. It is however, invasive and
certainly not without risk and highly operator dependent.

Management
Clearly this will depend to an extent upon the underlying cause but relief of jaundice
is important even if surgery forms part of the planned treatment as patients with
unrelieved jaundice have a much higher incidence of septic complications, bleeding
and death.

Screen for and address any clotting irregularities

In patients with malignancy a stent will need to be inserted. These come in two main
types; metal and plastic. Plastic stents are cheap and easy to replace and should be
used if any surgical intervention (e.g. Whipples) is planned. However, they are prone
to displacement and blockage. Metal stents are much more expensive and may
compromise a surgical resection. However, they are far less prone to displacement
and to a lesser extent blockage than their plastic counterparts.

If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has
failed, then an alternative strategy is to drain the biliary system percutaneously via a
transhepatic route. It may also be possible to insert a stent in this way. One of the
main problems with temporary PTC's is their propensity to displacement which may
result in a bile leak.

In patients who have a bile duct injury surgery will be required to repair the defect. If
the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to
be created (difficult!)

If gallstones are the culprit then these may be removed by ERCP and a
cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an
operative cholangiogram should be performed and bile duct exploration undertaken
where stones remain. When the bile duct has been formally opened the options are
between closure over a T tube, a choledochoduodenostomy or
choledochojejunostomy.

Patients with cholangitis should receive high dose broad spectrum antibiotics via the
intravenous route. Biliary decompression should follow soon afterwards and
instrumenting the bile duct of these patients will often provoke a septic episode (but
should be done anyway).
hich of the following is the most sensitive blood test for diagnosis of acute
pancreatitis?

A. Amylase

B. Lipase

C. C-peptide

D. Trypsin
 E. Trysinogen

The serum amylase may rise and fall quite quickly and lead to a false negative result.
Should the clinical picture not be concordant with the amylase level then serum lipase
or a CT Scan should be performed.

Management of Pancreatitis

Management of Acute Pancreatitis in the UK

Diagnosis

 Traditionally hyperamylasaemia has been utlilised with amylase being

elevated three times the normal range.
 However, amylase may give both false positive and negative results.
 Serum lipase is both more sensitive and specific than serum amylase. It also
has a longer half life.
 Serum amylase levels do not correlate with disease severity.

Differential causes of hyperamylasaemia

Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis

Assessment of severity

 Glasgow, Ranson scoring systems and APACHE II

 Biochemical scoring e.g. using CRP

Features that may predict a severe attack within 48 hours of admission to hospital
Initial assessment  Clinical impression of severity
 Body mass index >30
 Pleural effusion
 APACHE score >8

24 hours after admission  Clinical impression of severity

 APACHE II >8
 Glasgow score of 3 or more
 Persisting multiple organ failure
 CRP>150

48 hours after admission  Glasgow Score of >3

 CRP >150
  Persisting or progressive organ failure

Table adapted from UK guidelines for management of acute pancreatitis. GUT 2005,
54 suppl III

Management

Nutrition

 There is reasonable evidence to suggest that the use of enteral nutrition does
not worsen the outcome in pancreatitis
 Most trials to date were underpowered to demonstrate a conclusive benefit.
 The rationale behind feeding is that it helps to prevent bacterial translocation
from the gut, thereby contributing to the development of infected pancreatic
necrosis.

Use of antibiotic therapy

 Many UK surgeons administer antibiotics to patients with acute pancreatitis.

 A recent Cochrane review highlights the potential benefits of administering
Imipenem to patients with established pancreatic necrosis in the hope of
averting the progression to infection.
 There are concerns that the administration of antibiotics in mild attacks of
pancreatitis will not affect outcome and may contribute to antibiotic resistance
and increase the risks of antibiotic associated diarrhoea.

Surgery

 Patients with acute pancreatitis due to gallstones should undergo early

cholecystectomy.
 Patients with obstructed biliary system due to stones should undergo early
ERCP.
 Patients who fail to settle with necrosis and have worsening organ dysfunction
may require debridement, fine needle aspiration is still used by some.
 Patients with infected necrosis should undergo either radiological drainage or
surgical necrosectomy. The choice of procedure depends upon local expertise.

References
www.bsg.org.uk/pdfworddocs/pancreatic.pdf

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in

acute pancreatitis Villatoro et al Cochrane Library DOI:
10.1002/14651858.CD002941.pub3. 2010 version.
Which of the following is the most sensitive blood test for diagnosis of acute
pancreatitis?
 A. Amylase

B. Lipase

C. C-peptide

D. Trypsin

E. Trysinogen

The serum amylase may rise and fall quite quickly and lead to a false negative result.
Should the clinical picture not be concordant with the amylase level then serum lipase
or a CT Scan should be performed.

Management of Pancreatitis

Management of Acute Pancreatitis in the UK

Diagnosis

 Traditionally hyperamylasaemia has been utlilised with amylase being

elevated three times the normal range.
 However, amylase may give both false positive and negative results.
 Serum lipase is both more sensitive and specific than serum amylase. It also
has a longer half life.
 Serum amylase levels do not correlate with disease severity.

Differential causes of hyperamylasaemia

Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis

Assessment of severity

 Glasgow, Ranson scoring systems and APACHE II

 Biochemical scoring e.g. using CRP

Features that may predict a severe attack within 48 hours of admission to hospital
Initial assessment  Clinical impression of severity
 Body mass index >30
 Pleural effusion
 APACHE score >8
24 hours after admission  Clinical impression of severity
 APACHE II >8
 Glasgow score of 3 or more
 Persisting multiple organ failure
 CRP>150

48 hours after admission  Glasgow Score of >3

 CRP >150
 Persisting or progressive organ failure

Table adapted from UK guidelines for management of acute pancreatitis. GUT 2005,
54 suppl III

Management

Nutrition

 There is reasonable evidence to suggest that the use of enteral nutrition does
not worsen the outcome in pancreatitis
 Most trials to date were underpowered to demonstrate a conclusive benefit.
 The rationale behind feeding is that it helps to prevent bacterial translocation
from the gut, thereby contributing to the development of infected pancreatic
necrosis.

Use of antibiotic therapy

 Many UK surgeons administer antibiotics to patients with acute pancreatitis.

 A recent Cochrane review highlights the potential benefits of administering
Imipenem to patients with established pancreatic necrosis in the hope of
averting the progression to infection.
 There are concerns that the administration of antibiotics in mild attacks of
pancreatitis will not affect outcome and may contribute to antibiotic resistance
and increase the risks of antibiotic associated diarrhoea.

Surgery

 Patients with acute pancreatitis due to gallstones should undergo early

cholecystectomy.
 Patients with obstructed biliary system due to stones should undergo early
ERCP.
 Patients who fail to settle with necrosis and have worsening organ dysfunction
may require debridement, fine needle aspiration is still used by some.
 Patients with infected necrosis should undergo either radiological drainage or
surgical necrosectomy. The choice of procedure depends upon local expertise.

References
www.bsg.org.uk/pdfworddocs/pancreatic.pdf
Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in
acute pancreatitis Villatoro et al Cochrane Library DOI:
10.1002/14651858.CD002941.pub3. 2010 version.
Theme: Jaundice

A. Gilberts syndrome
B. Crigler Najjar syndrome
C. Hepatocellular carcinoma
D. Mirizzi syndrome
E. Hepatitis A
F. Hepatitis E
G. Bile duct stones
H. Multi cystic liver disease

Please select the most likely cause of jaundice for the scenario given. Each option
may be used once, more than once or not at all.

5. A 22 year old man returns to the UK from holiday in India. He presents with
painless jaundice. On examination he is not deeply jaundiced and there is no
organomegaly.

Hepatitis A

Infective hepatitis is the most likely cause. In the UK, foreign travel is a
common cause of developing infectious hepatitis, of which hepatitis A is the
most common.

6. A 56 year old man presents with jaundice. He has a long history of alcohol
misuse. On examination he is jaundiced and ultrasound shows multiple echo
dense lesions in both lobes of the liver. His alpha feto protein is elevated 6 times
the normal range

Hepatocellular carcinoma

HCC may complicate cirrhosis. AFP is often raised in HCC.

7. A 32 year old man who has suffered from Crohns disease for many years
presents with intermittent jaundice. When it occurs it is obstructive in nature. It
then usually resolves spontaneously.

You answered Mirizzi syndrome

The correct answer is Bile duct stones

 Bile salts are absorbed in the terminal ileum. When this process is impaired as
in Crohns the patient may develop gallstones, if these pass into the CBD then
obstructive jaundice will result.

Surgical jaundice

Jaundice can present in a manner of different surgical situations. As with all types of
jaundice a carefully history and examination will often give clues as the most likely
underlying cause. Liver function tests whilst conveying little in the way of
information about liver synthetic function, will often facilitate classification as to
whether the jaundice is pre hepatic, hepatic or post hepatic. The typical LFT patterns
are given below:

Location Bilirubin ALT/ AST Alkaline phosphatase

Pre hepatic Normal or Normal Normal
high
Hepatic High Elevated (often very Elevated but seldom to very high
high) levels
Post hepatic High-very Moderate elevation High- very high
high

In post hepatic jaundice the stools are often of pale colour and this feature should be
specifically addressed in the history.

Modes of presentation

These are addressed in the table below:

Diagnosis Typical features Pathogenesis

Gallstones Typically history of Usually small calibre gallstones which
biliary colic or can pass through the cystic duct. In
episodes of Mirizzi syndrome the stone may
chlolecystitis. compress the bile duct directly- one of
Obstructive type the rare times that cholecystitis may
history and test present with jaundice
results.
Cholangitis Usually obstructive Ascending infection of the bile ducts
and will have usually by E. coli and by definition
Charcots triad of occurring in a pool of stagnant bile.
symptoms (pain,
fever, jaundice)
Pancreatic cancer Typically painless Direct occlusion of distal bile duct or
jaundice with palpable pancreatic duct by tumour. Sometimes
gallbladder nodal disease at the portal hepatis may be
 (Courvoisier's Law) the culprit in which case the bile duct
may be of normal calibre.
TPN associated Usually follows long Often due to hepatic dysfunction and
jaundice term use and is fatty liver which may occur with long
usually painless with term TPN usage.
non obstructive
features
Bile duct injury Depending upon the Often due to a difficult cholecystectomy
type of injury may be when anatomy in Calots triangle is not
of sudden or gradual appreciated. In the worst scenario the bile
onset and is usually of duct is excised and jaundice offers
obstructive type rapidly post operatively. More insidious
is that of bile duct stenosis which may be
caused by clips or diathermy injury.
Cholangiocarcinoma Gradual onset Direct occlusion by disease and also
obstructive pattern extrinsic compression by nodal disease at
the porta hepatis.
Septic surgical Usually hepatic Combination of impaired biliary
patient features excretion and drugs such as ciprofloxacin
which may cause cholestasis.
Metastatic disease Mixed hepatic and Combination of liver synthetic failure
post hepatic (late) and extrinsic compression by nodal
disease and anatomical compression of
intra hepatic structures (earlier)

Diagnosis
An ultrasound of the liver and biliary tree is the most commonly used first line test.
This will establish bile duct calibre, often ascertain the presence of gallstones, may
visualise pancreatic masses and other lesions. The most important clinical question is
essentially the extent of biliary dilatation and its distribution.

Where pancreatic neoplasia is suspected the next test should be a pancreatic protocol
CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the
preferred option. PET scans may be used to stage a number of malignancies but do
not routinely form part of first line testing.

Where MRCP fails to give adequate information and ERCP may be necessary. In
many cases this may form part of patient management. It is however, invasive and
certainly not without risk and highly operator dependent.

Management
Clearly this will depend to an extent upon the underlying cause but relief of jaundice
is important even if surgery forms part of the planned treatment as patients with
unrelieved jaundice have a much higher incidence of septic complications, bleeding
and death.

Screen for and address any clotting irregularities

In patients with malignancy a stent will need to be inserted. These come in two main
types; metal and plastic. Plastic stents are cheap and easy to replace and should be
used if any surgical intervention (e.g. Whipples) is planned. However, they are prone
to displacement and blockage. Metal stents are much more expensive and may
compromise a surgical resection. However, they are far less prone to displacement
and to a lesser extent blockage than their plastic counterparts.

If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has
failed, then an alternative strategy is to drain the biliary system percutaneously via a
transhepatic route. It may also be possible to insert a stent in this way. One of the
main problems with temporary PTC's is their propensity to displacement which may
result in a bile leak.

In patients who have a bile duct injury surgery will be required to repair the defect. If
the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to
be created (difficult!)

If gallstones are the culprit then these may be removed by ERCP and a
cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an
operative cholangiogram should be performed and bile duct exploration undertaken
where stones remain. When the bile duct has been formally opened the options are
between closure over a T tube, a choledochoduodenostomy or
choledochojejunostomy.

Patients with cholangitis should receive high dose broad spectrum antibiotics via the
intravenous route. Biliary decompression should follow soon afterwards and
instrumenting the bile duct of these patients will often provoke a septic episode (but
should be done anyway).
heme: Surgical jaundice

A. Carcinoma of the head of the pancreas

B. Bile duct stricture
C. Mirizzi syndrome
D. Bile duct stones
E. Chronic cholecystitis
F. Peri hilar lymphadenopathy
G. Fitz - Hugh Curtis syndrome

Please select the most appropriate cause of the jaundice scenario given. Each option
may be used once, more than once or not at all.

8. A 63 year old man is admitted with obstructive jaundice that has developed
over the past 3 weeks. He was previously well and on examination has a
smooth mass in his right upper quadrant.

Carcinoma of the head of the pancreas

Carcinoma of the pancreas (Courvoisiers law!). The development of jaundice

 in association with a smooth right upper quadrant mass is typical of distal
biliary obstruction secondary to pancreatic malignancy. A bile duct stricture
would not present in this way, all the other choices are related to gallstones
and Fitz Hugh Curtis syndrome is a complication of pelvic inflammatory
disease.

9. A 41 year old lady is admitted with colicky right upper quadrant pain. On
clinical examination she has a mild pyrexia and is clinically jaundiced. An
ultrasound scan is reported as showing gallstones and the patient is taken to
theatre for an open cholecystectomy. At operation, Calots triangle is almost
completely impossible to delineate.

You answered Chronic cholecystitis

The correct answer is Mirizzi syndrome

In Mirizzi syndrome the gallstone becomes impacted in Hartmans pouch.

Episodes of recurrent inflammation occur and this causes compression of the
bile duct. In severe cases this then progresses to fistulation. Surgery is
extremely difficult as Calots triangle is often completely obliterated and the
risks of causing injury to the CBD are high.

10. A 72 year old man undergoes a distal gastrectomy for carcinoma of the
stomach. He presents with jaundice approximately 8 months post operatively.
Ultrasound of the liver and bile ducts shows no focal liver lesion and normal
calibre common bile duct with intra hepatic duct dilatation.

You answered Mirizzi syndrome

The correct answer is Peri hilar lymphadenopathy

Unfortunately metastatic disease is the most likely event. Peri hilar

lymphadenopathy would be a common culprit.

Courvoisiers Law:
Obstructive jaundice in the presence of a
palpable gallbladder is unlikely to be due to
stones.
This is due to the fibrotic effect that stones
have on the gallbladder. Like all these laws
there are numerous exceptions and many
cases will not present in the typical manner.

Bile duct injury

 Inadvertent bile duct injury during
laparoscopic surgery should be referred to a
specialist hepatobiliary surgeon. Outcomes
are far worse when repair in undertaken by a
non specialist surgeon in a district hospital.

Surgical jaundice

Jaundice can present in a manner of different surgical situations. As with all types of
jaundice a carefully history and examination will often give clues as the most likely
underlying cause. Liver function tests whilst conveying little in the way of
information about liver synthetic function, will often facilitate classification as to
whether the jaundice is pre hepatic, hepatic or post hepatic. The typical LFT patterns
are given below:

Location Bilirubin ALT/ AST Alkaline phosphatase

Pre hepatic Normal or Normal Normal
high
Hepatic High Elevated (often very Elevated but seldom to very high
high) levels
Post hepatic High-very Moderate elevation High- very high
high

In post hepatic jaundice the stools are often of pale colour and this feature should be
specifically addressed in the history.

Modes of presentation

These are addressed in the table below:

Diagnosis Typical features Pathogenesis

Gallstones Typically history of Usually small calibre gallstones which
biliary colic or can pass through the cystic duct. In
episodes of Mirizzi syndrome the stone may
chlolecystitis. compress the bile duct directly- one of
Obstructive type the rare times that cholecystitis may
history and test present with jaundice
results.
Cholangitis Usually obstructive Ascending infection of the bile ducts
and will have usually by E. coli and by definition
Charcots triad of occurring in a pool of stagnant bile.
symptoms (pain,
fever, jaundice)
Pancreatic cancer Typically painless Direct occlusion of distal bile duct or
jaundice with palpable pancreatic duct by tumour. Sometimes
gallbladder nodal disease at the portal hepatis may be
 (Courvoisier's Law) the culprit in which case the bile duct
may be of normal calibre.
TPN associated Usually follows long Often due to hepatic dysfunction and
jaundice term use and is fatty liver which may occur with long
usually painless with term TPN usage.
non obstructive
features
Bile duct injury Depending upon the Often due to a difficult cholecystectomy
type of injury may be when anatomy in Calots triangle is not
of sudden or gradual appreciated. In the worst scenario the bile
onset and is usually of duct is excised and jaundice offers
obstructive type rapidly post operatively. More insidious
is that of bile duct stenosis which may be
caused by clips or diathermy injury.
Cholangiocarcinoma Gradual onset Direct occlusion by disease and also
obstructive pattern extrinsic compression by nodal disease at
the porta hepatis.
Septic surgical Usually hepatic Combination of impaired biliary
patient features excretion and drugs such as ciprofloxacin
which may cause cholestasis.
Metastatic disease Mixed hepatic and Combination of liver synthetic failure
post hepatic (late) and extrinsic compression by nodal
disease and anatomical compression of
intra hepatic structures (earlier)

Diagnosis
An ultrasound of the liver and biliary tree is the most commonly used first line test.
This will establish bile duct calibre, often ascertain the presence of gallstones, may
visualise pancreatic masses and other lesions. The most important clinical question is
essentially the extent of biliary dilatation and its distribution.

Where pancreatic neoplasia is suspected the next test should be a pancreatic protocol
CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the
preferred option. PET scans may be used to stage a number of malignancies but do
not routinely form part of first line testing.

Where MRCP fails to give adequate information and ERCP may be necessary. In
many cases this may form part of patient management. It is however, invasive and
certainly not without risk and highly operator dependent.

Management
Clearly this will depend to an extent upon the underlying cause but relief of jaundice
is important even if surgery forms part of the planned treatment as patients with
unrelieved jaundice have a much higher incidence of septic complications, bleeding
and death.

Screen for and address any clotting irregularities

In patients with malignancy a stent will need to be inserted. These come in two main
types; metal and plastic. Plastic stents are cheap and easy to replace and should be
used if any surgical intervention (e.g. Whipples) is planned. However, they are prone
to displacement and blockage. Metal stents are much more expensive and may
compromise a surgical resection. However, they are far less prone to displacement
and to a lesser extent blockage than their plastic counterparts.

If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has
failed, then an alternative strategy is to drain the biliary system percutaneously via a
transhepatic route. It may also be possible to insert a stent in this way. One of the
main problems with temporary PTC's is their propensity to displacement which may
result in a bile leak.

In patients who have a bile duct injury surgery will be required to repair the defect. If
the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to
be created (difficult!)

If gallstones are the culprit then these may be removed by ERCP and a
cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an
operative cholangiogram should be performed and bile duct exploration undertaken
where stones remain. When the bile duct has been formally opened the options are
between closure over a T tube, a choledochoduodenostomy or
choledochojejunostomy.

Patients with cholangitis should receive high dose broad spectrum antibiotics via the
intravenous route. Biliary decompression should follow soon afterwards and
instrumenting the bile duct of these patients will often provoke a septic episode (but
should be done anyway).
heme: Management of biliary disease

A. Acute laparoscopic cholecystectomy

B. Delayed laparoscopic cholecystectomy
C. Percutaneous cholecystostomy
D. Elective cholecystectomy and intra operative cholangiogram
E. Endoscopic retrograde cholangiopancreatography
F. Choledochoduodenostomy
G. Bile duct excision and hepatico-jejunostomy
H. Operative cholecystostomy

For each scenario please select the most appropriate management option. Each option
may be used once, more than once or not at all.

11. A 72 year old lady underwent an open cholecystectomy 12 years previously.

She has been admitted since with 2 episodes of cholangitis and stones were
retrieved at ERCP. She has just recovered from a further episode of sepsis and
MRCP has shown further biliary stones.

You answered Bile duct excision and hepatico-jejunostomy

 The correct answer is Choledochoduodenostomy

A patient with long standing common bile duct stones is at risk of developing
duct fibrosis and ductal disproportion. This can result in impaired biliary
drainage. Not only may further stones be formed in the bile that is present, but
because of the ductal disproportion the tendency will be for the stones to
accumulate (rather than pass spontaneously, as would usually be the case post
ERCP and sphincterotomy). A biliary bypass procedure is the standard method
dealing with this and a choledochoduodenstomy is one procedure that can be
used.

12. A 26 year old women is admitted with acute cholecystitis of 24 hours duration.
LFT's are normal and Ultrasound shows a thick walled gallbladder containing
stones.

Acute laparoscopic cholecystectomy

This is an ideal case for an acute cholecystectomy, provided that surgery can
be undertaken promptly. After 48 -72 hours the patient should receive
parenteral antibiotics and delayed cholecystectomy performed.

13. A 32 year old lady is seen in the outpatients. She has had multiple episodes of
biliary colic and ultrasound shows thin walled gallbladder with multiple
calculi. Her ALT is slightly raised but other parameters are normal.

Elective cholecystectomy and intra operative cholangiogram

The easiest option is to perform an intraoperative cholangiogram. It is unlikely

to reveal any stones. If is does then either laparoscopic bile duct exploration or
urgent ERCP can be performed. An MRCP pre op is an alternative strategy.

Biliary disease

Diagnosis Typical features Pathogenesis

Gallstones Typically history of Usually small calibre gallstones which
biliary colic or can pass through the cystic duct. In
episodes of Mirizzi syndrome the stone may
chlolecystitis. compress the bile duct directly- one of the
Obstructive type rare times that cholecystitis may present
history and test with jaundice
results.
Cholangitis Usually obstructive Ascending infection of the bile ducts
 and will have usually by E. coli and by definition
Charcot's triad of occurring in a pool of stagnant bile.
symptoms (pain,
fever, jaundice)
Pancreatic cancer Typically painless Direct occlusion of distal bile duct or
jaundice with pancreatic duct by tumour. Sometimes
palpable gallbladder nodal disease at the portal hepatitis may
(Courvoisier's Law) be the culprit in which case the bile duct
may be of normal calibre.
TPN associated Usually follows long Often due to hepatic dysfunction and fatty
jaundice term use and is liver which may occur with long term
usually painless with TPN usage.
non obstructive
features
Bile duct injury Depending upon the Often due to a difficult laparoscopic
type of injury may be cholecystectomy when anatomy in Calots
of sudden or gradual triangle is not appreciated. In the worst
onset and is usually of scenario the bile duct is excised and
obstructive type jaundice offers rapidly post operatively.
More insidious is that of bile duct stenosis
which may be caused by clips or
diathermy injury.
Cholangiocarcinoma Gradual onset Direct occlusion by disease and also
obstructive pattern extrinsic compression by nodal disease at
the porta hepatis.
Septic surgical Usually hepatic Combination of impaired biliary
patient features excretion and drugs such as ciprofloxacin
which may cause cholestasis.
Metastatic disease Mixed hepatic and Combination of liver synthetic failure
post hepatic (late) and extrinsic compression by nodal
disease and anatomical compression of
intra hepatic structures (earlier)

A gallbladder may develop a thickened wall in chronic cholecystitis and

microscopically Roikitansky-Aschoff Sinsuses may be seen

Image sourced from Wikipedia

42 year old female presents with symptoms of biliary colic and on investigation is
identified as having gallstones. Of the procedures listed below, which is most likely to
increase the risk of gallstone formation?

A. Partial gastrectomy

B. Jejunal resection

C. Liver lobectomy

D. Ileal resection

E. Left hemicolectomy

Bile salt reabsorption occurs at the ileum. Therefore cholesterol gallstones form as a
result of ileal resection.

Biliary disease

Diagnosis Typical features Pathogenesis

Gallstones Typically history of Usually small calibre gallstones which
biliary colic or can pass through the cystic duct. In
episodes of Mirizzi syndrome the stone may
chlolecystitis. compress the bile duct directly- one of the
Obstructive type rare times that cholecystitis may present
history and test with jaundice
results.
Cholangitis Usually obstructive Ascending infection of the bile ducts
and will have usually by E. coli and by definition
Charcot's triad of occurring in a pool of stagnant bile.
symptoms (pain,
fever, jaundice)
Pancreatic cancer Typically painless Direct occlusion of distal bile duct or
jaundice with pancreatic duct by tumour. Sometimes
palpable gallbladder nodal disease at the portal hepatitis may
(Courvoisier's Law) be the culprit in which case the bile duct
may be of normal calibre.
TPN associated Usually follows long Often due to hepatic dysfunction and fatty
jaundice term use and is liver which may occur with long term
usually painless with TPN usage.
non obstructive
features
Bile duct injury Depending upon the Often due to a difficult laparoscopic
type of injury may be cholecystectomy when anatomy in Calots
of sudden or gradual triangle is not appreciated. In the worst
onset and is usually of scenario the bile duct is excised and
obstructive type jaundice offers rapidly post operatively.
 More insidious is that of bile duct stenosis
which may be caused by clips or
diathermy injury.
Cholangiocarcinoma Gradual onset Direct occlusion by disease and also
obstructive pattern extrinsic compression by nodal disease at
the porta hepatis.
Septic surgical Usually hepatic Combination of impaired biliary
patient features excretion and drugs such as ciprofloxacin
which may cause cholestasis.
Metastatic disease Mixed hepatic and Combination of liver synthetic failure
post hepatic (late) and extrinsic compression by nodal
disease and anatomical compression of
intra hepatic structures (earlier)

A gallbladder may develop a thickened wall in chronic cholecystitis and

microscopically Roikitansky-Aschoff Sinsuses may be seen

Theme: Management of pancreatitis

A. Non Contrast enhanced CT scan

B. USS abdomen
C. ERCP alone
D. ERCP with Sphincterotomy and biliary drainage
E. Fine needle aspiration of necrosis
F. Pancreatic necrosectomy
G. Contrast enhanced CT scan

What is the next best step in management for the scenario given? Each option may be
used once, more than once or not at all.

15. A 56 year old man is admitted with an attack of severe acute pancreatitis. He is
managed on the intensive care unit and is making progress. He then
deteriorates and a CT scan shows extensive pancreatic necrosis (>40%). On
return from the radiology department he remains febrile and tachycardic with
falling urine output.
 Pancreatic necrosectomy

In patients with systemic features of sepsis and extensive necrosis a

necrosectomy is usually indicated.An FNA will not change his immediate
management.

16. A 22 year old teacher is admitted with severe epigastric pain. Serum amylase
is normal. You wish to exclude a perforated viscus, and determine whether
pancreatitis is present.

You answered Non Contrast enhanced CT scan

The correct answer is Contrast enhanced CT scan

An ultrasound will not accurately answer this question. Therefore a CT scan is

required. Oral and IV contrast would usually be given.

17. A 55 year old accountant has jaundice and a temperature of 39oC. He is known
to have gallstones. Blood cultures have grown a gram negative bacilli.

ERCP with Sphincterotomy and biliary drainage

You should suspect cholangitis in a patient with fevers and jaundice. Charcot's
triad may only be present in 20% of patients. This patient needs biliary
drainage with an ERCP.

Infected pancreatic necrosis is one of the

few indications for surgery in
pancreatitis

Management of Pancreatitis

Management of Acute Pancreatitis in the UK

Diagnosis

 Traditionally hyperamylasaemia has been utlilised with amylase being

elevated three times the normal range.
 However, amylase may give both false positive and negative results.
 Serum lipase is both more sensitive and specific than serum amylase. It also
has a longer half life.
  Serum amylase levels do not correlate with disease severity.

Differential causes of hyperamylasaemia

Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis

Assessment of severity

 Glasgow, Ranson scoring systems and APACHE II

 Biochemical scoring e.g. using CRP

Features that may predict a severe attack within 48 hours of admission to hospital
Initial assessment  Clinical impression of severity
 Body mass index >30
 Pleural effusion
 APACHE score >8

24 hours after admission  Clinical impression of severity

 APACHE II >8
 Glasgow score of 3 or more
 Persisting multiple organ failure
 CRP>150

48 hours after admission  Glasgow Score of >3

 CRP >150
 Persisting or progressive organ failure

Table adapted from UK guidelines for management of acute pancreatitis. GUT 2005,
54 suppl III

Management

Nutrition

 There is reasonable evidence to suggest that the use of enteral nutrition does
not worsen the outcome in pancreatitis
 Most trials to date were underpowered to demonstrate a conclusive benefit.
 The rationale behind feeding is that it helps to prevent bacterial translocation
from the gut, thereby contributing to the development of infected pancreatic
necrosis.

Use of antibiotic therapy

  Many UK surgeons administer antibiotics to patients with acute pancreatitis.
 A recent Cochrane review highlights the potential benefits of administering
Imipenem to patients with established pancreatic necrosis in the hope of
averting the progression to infection.
 There are concerns that the administration of antibiotics in mild attacks of
pancreatitis will not affect outcome and may contribute to antibiotic resistance
and increase the risks of antibiotic associated diarrhoea.

Surgery

 Patients with acute pancreatitis due to gallstones should undergo early

cholecystectomy.
 Patients with obstructed biliary system due to stones should undergo early
ERCP.
 Patients who fail to settle with necrosis and have worsening organ dysfunction
may require debridement, fine needle aspiration is still used by some.
 Patients with infected necrosis should undergo either radiological drainage or
surgical necrosectomy. The choice of procedure depends upon local expertise.

References
www.bsg.org.uk/pdfworddocs/pancreatic.pdf

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in

acute pancreatitis Villatoro et al Cochrane Library DOI:
10.1002/14651858.CD002941.pub3. 2010 version.
Theme: Liver tumours

A. Rhabdomyosarcoma
B. Yolk sac tumour
C. Hepatocellular carcinoma
D. Metastatic lesion
E. Haemangioendothelioma
F. Cholangiocarcinoma
G. Hepatoblastoma
H. Angiosarcoma

Please select the most likely diagnosis for the scenario given. Each answer may be
used once, more than once or not at all.

18. A 56 year old man with long standing ulcerative colitis and a DALM lesion in
the rectum is admitted with jaundice. On CT scanning the liver has 3 nodules
in the right lobe and 1 nodule in the left lobe. Carcinoembryonic antigen levels
are elevated.

Metastatic lesion
 This is likely to be due to metastatic lesions from a colonic primary. DALM
lesions should be excised by oncological colectomy for this reason. This
burden of metastatic disease is unlikely to precipitate jaundice directly and
nodal disease at the porta hepatis is the most likely cause in this case.

19. A 48 year old lady with chronic hepatitis B infection is noted to have
worsening liver function tests and progressive jaundice. Her alpha feto protein
levels are grossly elevated.

Hepatocellular carcinoma

This is most likely to be hepatocellular carcinoma and markedly elevated AFP

levels in association with a compatible risk factor should make this the
diagnosis.

20. A 55 year old man with long standing ulcerative colitis is admitted with
cholangitis and weight loss. Blood tests reveal a markedly elevated Ca 19-9.

Cholangiocarcinoma

This is most likely a cholangiocarcinoma. UC with sclerosing cholangitis.

Increases the risk of cholangiocarcinoma. CA19-9 is elevated in approximately
80% cases.

Liver tumours

Primary liver tumours

The most common primary tumours are cholangiocarcinoma and hepatocellular
carcinoma. Overall metastatic disease accounts for 95% of all liver malignancies
making the primary liver tumours comparatively rare.

Primary liver tumours include:

 Cholangiocarcinoma
 Hepatocellular carcinoma
 Hepatoblastoma
 Sarcomas (Rare)
 Lymphomas
 Carcinoids (most often secondary although primary may occur)

Hepatocellular carcinoma
These account for the bulk of primary liver tumours (75% cases). Its worldwide
incidence reflects its propensity to occur on a background of chronic inflammatory
activity. Most cases arise in cirrhotic livers or those with chronic hepatitis B infection,
especially where viral replication is actively occurring. In the UK it accounts for less
than 5% of all cancers, although in parts of Asia its incidence is 100 per 100,000.
The majority of patients (80%) present with existing liver cirrhosis, with a mass
discovered on screening ultrasound.

Diagnosis

 CT/ MRI (usually both) are the imaging modalities of choice

 a-fetoprotein is elevated in almost all cases
 Biopsy should be avoided as it seeds tumours cells through a resection plane.
 In cases of diagnostic doubt serial CT and aFP measurements are the preferred
strategy.

Treatment

 Patients should be staged with liver MRI and chest, abdomen and pelvic CT
scan.
 The testis should be examined in males (testicular tumours may cause raised
AFP). PET CT may be used to identify occult nodal disease.
 Surgical resection is the mainstay of treatment in operable cases. In patients
with a small primary tumour in a cirrhotic liver whose primary disease process
is controlled, consideration may be given to primary whole liver resection and
transplantation.
 Liver resections are an option but since most cases occur in an already
diseased liver the operative risks and post-operative hepatic dysfunction are
far greater than is seen following metastectomy.
 These tumours are not particularly chemo or radiosensitive however, both may
be used in a palliative setting. Tumour ablation is a more popular strategy.

Survival
Poor, overall survival is 15% at 5 years.

Cholangiocarcinoma
This is the second most common type of primary liver malignancy. As its name
suggests these tumours arise in the bile ducts. Up to 80% of tumours arise in the extra
hepatic biliary tree. Most patients present with jaundice and by this stage the majority
will have disease that is not resectable.
Primary scelerosing cholangitis is the main risk factor. In deprived countries typhoid
and liver flukes are also major risk factors.

Diagnosis

 Patients will typically have an obstructive picture on liver function tests.

 CA 19-9, CEA and CA 125 are often elevated
 CT/ MRI and MRCP are the imaging methods of choice.
Treatment

 Surgical resection offers the best chance of cure. Local invasion of peri hilar
tumours is a particular problem and this coupled with lobar atrophy will often
contra indicate surgical resection.
 Palliation of jaundice is important, although metallic stents should be avoided
in those considered for resection.

Survival
Is poor, approximately 15% 5 year survival.

A 45 year old man presents with an episode of alcoholic pancreatitis. He makes slow
but steady progress. He is reviewed clinically at 6 weeks following admission. He has
a diffuse fullness of his upper abdomen and on imaging a collection of fluid is found
to be located behind the stomach. His serum amylase is mildly elevated. Which of the
following is the most likely explanation?

A. Early fluid collection

B. Pancreatic abscess

C. Peripancreatic necrosis

D. Psuedocyst

E. Sterile necrosis

Psuedocysts are unlikely to be present less than 4 weeks after an attack of acute
pancreatitis. However, they are more common at this stage and are associated with a
raised amylase.

Pancreatitis: sequelae

Peripancreatic fluid collections

 Occur in 25% cases

 Located in or near the pancreas and lack a wall of granulation or fibrous tissue
 May resolve or develop into pseudocysts or abscesses
 Since most resolve aspiration and drainage is best avoided as it may
precipitate infection

Pseudocysts

 In acute pancreatitis result from organisation of peripancreatic fluid collection.

They may or may not communicate with the ductal system.
  The collection is walled by fibrous or granulation tissue and typically occurs 4
weeks or more after an attack of acute pancreatitis
 Most are retrogastric
 75% are associated with persistent mild elevation of amylase
 Investigation is with CT, ERCP and MRI or Endoscopic USS
 Symptomatic cases may be observed for 12 weeks as up to 50% resolve
 Treatment is either with endoscopic or surgical cystogastrostomy or aspiration

Pancreatic necrosis

 Pancreatic necrosis may involve both the pancreatic parenchyma and

surrounding fat
 Complications are directly linked to extent of parenchymal necrosis and extent
of necrosis overall
 Early necrosectomy is associated with a high mortality rate (and should be
avoided unless compelling indications for surgery exist)
 Sterile necrosis should be managed conservatively (at least initially)
 Some centres will perform fine needle aspiration sampling of necrotic tissue if
infection is suspected. False negatives may occur and the extent of sepsis and
organ dysfunction may be a better guide to surgery

Pancreatic abscess

 Intra abdominal collection of pus associated with pancreas but in the absence
of necrosis
 Typically occur as a result of infected pseudocyst
 Transgastric drainage is one method of treatment, endoscopic drainage is an
alternative

Haemorrhage

 Infected necrosis may involve vascular structures with resultant haemorrhage

that may occur de novo or as a result of surgical necrosectomy.
 When retroperitoneal haemorrhage occurs Grey Turners sign may be
identified

A 34 year old lady is admitted with pancreatitis. The aetiology is unclear and it is
classified as an attack of moderate severity according to the Glasgow criteria. Her
imaging shows no gallstones and fluid around the pancreas. Which of the following is
the most appropriate initial management option?

A. Laparotomy

B. Laparoscopy

C. Radiological aspiration of the fluid

 D. Active observation

E. Administration of octreotide
LEARN THIS!

Mnemonic for the assessment of the

severity of pancreatitis: PANCREAS
(Ann R Coll Surg Engl 2000; 82: 16-17

P a02 < 60 mmHg

A ge > 55 years
N eutrophils > 15 x 10/l
C alcium < 2 mmol/l
R aised urea > 16 mmol/l
E nzyme (lactate dehydrogenase) > 600
units/l
A lbumin < 32 g/l
S ugar (glucose) > 10 mmol/l

> 3 positive criteria indicates severe

pancreatitis.

Acute early fluid collections are seen in 25% of patients with pancreatitis and require
no specific treatment. Attempts at drainage may introduce infection and result in
pancreatic abscess formation.

Management of Pancreatitis

Management of Acute Pancreatitis in the UK

Diagnosis

 Traditionally hyperamylasaemia has been utlilised with amylase being

elevated three times the normal range.
 However, amylase may give both false positive and negative results.
 Serum lipase is both more sensitive and specific than serum amylase. It also
has a longer half life.
 Serum amylase levels do not correlate with disease severity.

Differential causes of hyperamylasaemia

Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis
Assessment of severity

 Glasgow, Ranson scoring systems and APACHE II

 Biochemical scoring e.g. using CRP

Features that may predict a severe attack within 48 hours of admission to hospital
Initial assessment  Clinical impression of severity
 Body mass index >30
 Pleural effusion
 APACHE score >8

24 hours after admission  Clinical impression of severity

 APACHE II >8
 Glasgow score of 3 or more
 Persisting multiple organ failure
 CRP>150

48 hours after admission  Glasgow Score of >3

 CRP >150
 Persisting or progressive organ failure

Table adapted from UK guidelines for management of acute pancreatitis. GUT 2005,
54 suppl III

Management

Nutrition

 There is reasonable evidence to suggest that the use of enteral nutrition does
not worsen the outcome in pancreatitis
 Most trials to date were underpowered to demonstrate a conclusive benefit.
 The rationale behind feeding is that it helps to prevent bacterial translocation
from the gut, thereby contributing to the development of infected pancreatic
necrosis.

Use of antibiotic therapy

 Many UK surgeons administer antibiotics to patients with acute pancreatitis.

 A recent Cochrane review highlights the potential benefits of administering
Imipenem to patients with established pancreatic necrosis in the hope of
averting the progression to infection.
 There are concerns that the administration of antibiotics in mild attacks of
pancreatitis will not affect outcome and may contribute to antibiotic resistance
and increase the risks of antibiotic associated diarrhoea.

Surgery
  Patients with acute pancreatitis due to gallstones should undergo early
cholecystectomy.
 Patients with obstructed biliary system due to stones should undergo early
ERCP.
 Patients who fail to settle with necrosis and have worsening organ dysfunction
may require debridement, fine needle aspiration is still used by some.
 Patients with infected necrosis should undergo either radiological drainage or
surgical necrosectomy. The choice of procedure depends upon local expertise.

References
www.bsg.org.uk/pdfworddocs/pancreatic.pdf

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in

acute pancreatitis Villatoro et al Cochrane Library DOI:
10.1002/14651858.CD002941.pub3. 2010 version.
43 year old lady presents with an attack of acute pancreatitis. It is classified as a mild
attack on severity scoring. Imaging identifies gallstones but a normal calibre bile duct,
and a peripancreatic fluid collection. Which of the following management options is
most appropriate?

A. Intravenous octreotide

B. Cholecystectomy within 4 weeks

C. Nasogastric tube drainage of the stomach

D. Insertion of a radiological drain

E. Avoidance of enteral feeding

Patients with gallstone pancreatitis should undergo early cholecystectomy.

Enteral feeding helps minimise gut bacterial translocation and should be given to most
patients with pancreatitis. Many studies have evaluated the role of octreotide in
reducing pancreatic secretions and shown no benefit (Uhl W et al Gut 1999 45:97-
104, McKay C et al. Int J Pancreatol 1997; 21: 13-19).
The use of antibiotics in pancreatitis is controversial. However, a recent Cochrane
review has presented reasonable evidence in favor of administration of imipenem to
prevent infection in established necrosis.

Management of Pancreatitis

Management of Acute Pancreatitis in the UK

Diagnosis

 Traditionally hyperamylasaemia has been utlilised with amylase being

elevated three times the normal range.
 However, amylase may give both false positive and negative results.
  Serum lipase is both more sensitive and specific than serum amylase. It also
has a longer half life.
 Serum amylase levels do not correlate with disease severity.

Differential causes of hyperamylasaemia

Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis

Assessment of severity

 Glasgow, Ranson scoring systems and APACHE II

 Biochemical scoring e.g. using CRP

Features that may predict a severe attack within 48 hours of admission to hospital
Initial assessment  Clinical impression of severity
 Body mass index >30
 Pleural effusion
 APACHE score >8

24 hours after admission  Clinical impression of severity

 APACHE II >8
 Glasgow score of 3 or more
 Persisting multiple organ failure
 CRP>150

48 hours after admission  Glasgow Score of >3

 CRP >150
 Persisting or progressive organ failure

Table adapted from UK guidelines for management of acute pancreatitis. GUT 2005,
54 suppl III

Management

Nutrition

 There is reasonable evidence to suggest that the use of enteral nutrition does
not worsen the outcome in pancreatitis
 Most trials to date were underpowered to demonstrate a conclusive benefit.
 The rationale behind feeding is that it helps to prevent bacterial translocation
from the gut, thereby contributing to the development of infected pancreatic
necrosis.
Use of antibiotic therapy

 Many UK surgeons administer antibiotics to patients with acute pancreatitis.

 A recent Cochrane review highlights the potential benefits of administering
Imipenem to patients with established pancreatic necrosis in the hope of
averting the progression to infection.
 There are concerns that the administration of antibiotics in mild attacks of
pancreatitis will not affect outcome and may contribute to antibiotic resistance
and increase the risks of antibiotic associated diarrhoea.

Surgery

 Patients with acute pancreatitis due to gallstones should undergo early

cholecystectomy.
 Patients with obstructed biliary system due to stones should undergo early
ERCP.
 Patients who fail to settle with necrosis and have worsening organ dysfunction
may require debridement, fine needle aspiration is still used by some.
 Patients with infected necrosis should undergo either radiological drainage or
surgical necrosectomy. The choice of procedure depends upon local expertise.

References
www.bsg.org.uk/pdfworddocs/pancreatic.pdf

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in

acute pancreatitis Villatoro et al Cochrane Library DOI:
10.1002/14651858.CD002941.pub3. 2010 version.
A 43 year old lady presents with jaundice and is diagnosed as having a carcinoma of
the head of the pancreas. Although she is deeply jaundiced, her staging investigations
are negative for metastatic disease. What is the best method of biliary decompression
in this case?

A. ERCP and placement of metallic stent

B. ERCP alone

C. ERCP and placement of plastic stent

D. Cholecystostomy

E. Choledochoduodenostomy
Metallic stents are contraindicated
in resectable biliary disease

A plastic stent is the best option for biliary decompression in resectable disease.
Surgical bypasses have no place in the management of operable malignancy as a
bridge to definitive surgery.

Pancreatic stents

Both benign and malignant biliary obstruction may be treated by placement of stents.
These may be either plastic tubes or self expanding metallic stents. They can be
placed either percutaneously, at ERCP, or, less commonly now, open surgery.
Complications include blockage, displacement and those related to the method of
insertion.

Metallic Vs Plastic stents

Metallic stents Plastic stents
Expensive Cheap
Embed in surrounding tissues Do not usually embed
Displacement rare Displacement common
Blockage rare Blockage common
Contraindicated in resectable malignant May be used as a bridge to resectional
disease surgery
Theme: Management of biliary diseases

A. Acute laparoscopic cholecystectomy

B. Delayed laparoscopic cholecystectomy
C. Percutaneous cholecystostomy
D. Lithotripsy
E. Endoscopic retrograde cholangiopancreatography
F. Choledochoduodenostomy
G. Bile duct excision and hepatico-jejunostomy
H. Operative cholecystostomy

Please select the most appropriate management option for the scenario given. Each
option may be used once, more than once or not at all.

25. A 43 year old women is admitted with acute cholecystitis and fails to settle. A
laparoscopic cholecystectomy is performed, at operation the gallbladder has
evidence of an empyema and Calots triangle is inflamed and the surgeon
suspects that a Mirizzi syndrome has occurred.

You answered Bile duct excision and hepatico-jejunostomy

The correct answer is Operative cholecystostomy

This will address the acute sepsis and resolve the situation. Attempts at
completing the surgery at this stage, even in expert hands carries a very high
risk of bile duct injury.
26. Following a difficult cholecystectomy a surgeon leaves a drain. 24 hours later
bile is seen to be accumulating in the drain and this fails to resolve over the
next 48 hours. The patient is otherwise well.

Endoscopic retrograde cholangiopancreatography

This will delineate the presence of potential bile duct injury. Usually this is
result of leakage from the cystic duct and placement of a stent will allow free
biliary drainage and the leak should settle.

27. A 40 year old woman is admitted with abdominal pain. She has suffered from
repeated episodes of this colicky right upper quadrant pain. On examination
she is pyrexial with right upper quadrant peritonism. Her blood tests show a
white cell count of 23. However, the liver function tests are normal. An
abdominal ultrasound scan shows multiple gallstones in a thick walled
gallbladder, the bile duct measures 4mm.

Acute laparoscopic cholecystectomy

This lady has acute cholecystitis and needs an acute cholecystectomy. This
operation should usually be performed within 48 hours of admission. Delay
beyond this timeframe will usually result in increased operative complications
and most surgeons would administer antibiotics and perform and interval
cholecystectomy if the early window for an acute procedure is missed. A bile
duct measuring 4mm is usually normal.

Biliary disease

Diagnosis Typical features Pathogenesis

Gallstones Typically history of Usually small calibre gallstones which
biliary colic or can pass through the cystic duct. In
episodes of Mirizzi syndrome the stone may
chlolecystitis. compress the bile duct directly- one of the
Obstructive type rare times that cholecystitis may present
history and test with jaundice
results.
Cholangitis Usually obstructive Ascending infection of the bile ducts
and will have usually by E. coli and by definition
Charcot's triad of occurring in a pool of stagnant bile.
symptoms (pain,
fever, jaundice)
Pancreatic cancer Typically painless Direct occlusion of distal bile duct or
jaundice with pancreatic duct by tumour. Sometimes
palpable gallbladder nodal disease at the portal hepatitis may
 (Courvoisier's Law) be the culprit in which case the bile duct
may be of normal calibre.
TPN associated Usually follows long Often due to hepatic dysfunction and fatty
jaundice term use and is liver which may occur with long term
usually painless with TPN usage.
non obstructive
features
Bile duct injury Depending upon the Often due to a difficult laparoscopic
type of injury may be cholecystectomy when anatomy in Calots
of sudden or gradual triangle is not appreciated. In the worst
onset and is usually of scenario the bile duct is excised and
obstructive type jaundice offers rapidly post operatively.
More insidious is that of bile duct stenosis
which may be caused by clips or
diathermy injury.
Cholangiocarcinoma Gradual onset Direct occlusion by disease and also
obstructive pattern extrinsic compression by nodal disease at
the porta hepatis.
Septic surgical Usually hepatic Combination of impaired biliary
patient features excretion and drugs such as ciprofloxacin
which may cause cholestasis.
Metastatic disease Mixed hepatic and Combination of liver synthetic failure
post hepatic (late) and extrinsic compression by nodal
disease and anatomical compression of
intra hepatic structures (earlier)

A gallbladder may develop a thickened wall in chronic cholecystitis and

microscopically Roikitansky-Aschoff Sinsuses may be seen

Image sourced from Wikipedia

Theme: Pancreatitis management

A. Pancreatic necrosectomy
B. Staging laparotomy to assess severity
C. Endoscopic retrograde cholangiopancreatography
D. Emergency cystogastrostomy
E. Cholecystectomy within 4 weeks
F. Elective cystogastrostomy
G. Parenteral nutrition

Please select the most appropriate next stage in management for the scenario given.
Each option may be used once, more than once or not at all.

28. A 34 year old women is admitted with cholangitis. Her bilirubin is 180 and
alkaline phosphatase is 348. She becomes progressively more unwell and
develops abdominal pain. The houseman checks her amylase which is elevated
at 1080. Standard treatment is initiated and her Glasgow score is 3.

Endoscopic retrograde cholangiopancreatography

She requires urgent decompression of her biliary system. An ERCP is the

conventional method of performing this. It is important to ensure that her
coagulation status is normalised prior to performing this procedure.

29. A 63 year old man is admitted to ITU with an attack of severe gallstone
pancreatitis. He requires ventillatory support for ARDS. Over the past few
days he has become more unwell and a CT scan is organised. This
demonstrates an area of necrosis. His CRP is 400 and WCC 25.1.

Pancreatic necrosectomy

This man requires necrosectomy as he has infected pancreatic necrosis and is

haemodynamically unstable. A radiological drainage procedure is unlikely to
be sufficient.

30. A 53 year old alcoholic develops acute pancreatitis and is making slow but
reasonable progress. He is troubled by persisting ileus and for this reason a CT
scan is undertaken. This demonstrates a large pancreatic pseudocyst. This is
monitored by repeat CT scanning which shows no resolution and he is now
complaining of early satiety.

Elective cystogastrostomy

Drainage of this man's pseudocyst is required. This could be accomplished

radiologically or endoscopically or surgically. As the other options are not on
the list this is the best option from those available.

Management of Pancreatitis
Management of Acute Pancreatitis in the UK

Diagnosis

 Traditionally hyperamylasaemia has been utlilised with amylase being

elevated three times the normal range.
 However, amylase may give both false positive and negative results.
 Serum lipase is both more sensitive and specific than serum amylase. It also
has a longer half life.
 Serum amylase levels do not correlate with disease severity.

Differential causes of hyperamylasaemia

Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketoacidosis

Assessment of severity

 Glasgow, Ranson scoring systems and APACHE II

 Biochemical scoring e.g. using CRP

Features that may predict a severe attack within 48 hours of admission to hospital
Initial assessment  Clinical impression of severity
 Body mass index >30
 Pleural effusion
 APACHE score >8

24 hours after admission  Clinical impression of severity

 APACHE II >8
 Glasgow score of 3 or more
 Persisting multiple organ failure
 CRP>150

48 hours after admission  Glasgow Score of >3

 CRP >150
 Persisting or progressive organ failure

Table adapted from UK guidelines for management of acute pancreatitis. GUT 2005,
54 suppl III

Management
Nutrition

 There is reasonable evidence to suggest that the use of enteral nutrition does
not worsen the outcome in pancreatitis
 Most trials to date were underpowered to demonstrate a conclusive benefit.
 The rationale behind feeding is that it helps to prevent bacterial translocation
from the gut, thereby contributing to the development of infected pancreatic
necrosis.

Use of antibiotic therapy

 Many UK surgeons administer antibiotics to patients with acute pancreatitis.

 A recent Cochrane review highlights the potential benefits of administering
Imipenem to patients with established pancreatic necrosis in the hope of
averting the progression to infection.
 There are concerns that the administration of antibiotics in mild attacks of
pancreatitis will not affect outcome and may contribute to antibiotic resistance
and increase the risks of antibiotic associated diarrhoea.

Surgery

 Patients with acute pancreatitis due to gallstones should undergo early

cholecystectomy.
 Patients with obstructed biliary system due to stones should undergo early
ERCP.
 Patients who fail to settle with necrosis and have worsening organ dysfunction
may require debridement, fine needle aspiration is still used by some.
 Patients with infected necrosis should undergo either radiological drainage or
surgical necrosectomy. The choice of procedure depends upon local expertise.

References
www.bsg.org.uk/pdfworddocs/pancreatic.pdf

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in

acute pancreatitis Villatoro et al Cochrane Library DOI:
10.1002/14651858.CD002941.pub3. 2010 version.
What proportion of patients presenting for cholecystectomy for treatment of biliary
colic due to gallstones will have stones in the common bile duct?

A. 10%

B. 30%

C. 2%
 D. 50%

E. 25%

Up to 10% of all patients may have stones in the CBD. Therefore, all patients should
have their liver function tests checked prior to embarking on a cholecystectomy.

Biliary disease

Diagnosis Typical features Pathogenesis

Gallstones Typically history of Usually small calibre gallstones which
biliary colic or can pass through the cystic duct. In
episodes of Mirizzi syndrome the stone may
chlolecystitis. compress the bile duct directly- one of the
Obstructive type rare times that cholecystitis may present
history and test with jaundice
results.
Cholangitis Usually obstructive Ascending infection of the bile ducts
and will have usually by E. coli and by definition
Charcot's triad of occurring in a pool of stagnant bile.
symptoms (pain,
fever, jaundice)
Pancreatic cancer Typically painless Direct occlusion of distal bile duct or
jaundice with pancreatic duct by tumour. Sometimes
palpable gallbladder nodal disease at the portal hepatitis may
(Courvoisier's Law) be the culprit in which case the bile duct
may be of normal calibre.
TPN associated Usually follows long Often due to hepatic dysfunction and fatty
jaundice term use and is liver which may occur with long term
usually painless with TPN usage.
non obstructive
features
Bile duct injury Depending upon the Often due to a difficult laparoscopic
type of injury may be cholecystectomy when anatomy in Calots
of sudden or gradual triangle is not appreciated. In the worst
onset and is usually of scenario the bile duct is excised and
obstructive type jaundice offers rapidly post operatively.
More insidious is that of bile duct stenosis
which may be caused by clips or
diathermy injury.
Cholangiocarcinoma Gradual onset Direct occlusion by disease and also
obstructive pattern extrinsic compression by nodal disease at
the porta hepatis.
Septic surgical Usually hepatic Combination of impaired biliary
patient features excretion and drugs such as ciprofloxacin
which may cause cholestasis.
Metastatic disease Mixed hepatic and Combination of liver synthetic failure
post hepatic (late) and extrinsic compression by nodal
 disease and anatomical compression of
intra hepatic structures (earlier)

A gallbladder may develop a thickened wall in chronic cholecystitis and

microscopically Roikitansky-Aschoff Sinsuses may be seen

Image sourced from Wikipedia