Hepatobiliary Gold Standard

Disease Gold Standard Diagnostic Tool Gold Standard Treatment

Symptomatic US: shows echogenic gall stones with acoustic Laparoscopic cholecystectomy: is the appropriate
Chronic shadows, target sign, little or no GB wall treatment for ALL patients with symptomatic with
calcular thickening or other evidence of cholecystitis gall stones, not for asymptomatic except 5
cholecystitis Lab: all normal (calcified, stone >3 cm, SS, DM
Acute Best diagnostic: HIDA scan Initial mx: hospitalization, IV fluids, antibiotics
calculous Most commonly done: US GB stones, GB wall If Mild\responsive: do either
cholecystitis thickening, peri-cholecystic fluid, sonographic 1-Early Approach: within 72 h. do LC
murphy sign 2-Delayed Approach: after 6 w. do LC
Note: CT done for acute abdomen is less If Complicated\failed medical treatment:
sensitive to detecting stones 1-Emergency cholecystectomy
Lab: leukocytosis 2-Percutaneous cholecystostomy
Acute HIDA scan
acalculous
cholecystitis
Choledoco- US GB stones, If dilated intrahepatic biliary TREAT THE CAUSE
lithiasis radicles proceed to MRCP 2ndry: cholecystectomy
Lab elevated Alk ph, bilirubin (total&direct), TREAT THE SYMPTOMS; STONES
slight increase LFT <1cm ERCP
>1cm CBD exploration, cholecystectomy
PREVENT STONE RECURRANCE IN BILIARY DILATAT
<1.5 cm: no bypass
>1.5 cm: Bypass; choledoco-jejunostomy
\duodenostomy (dilated=stasis=more stones) + I
bypassed sphincter of Oddi so, cholecystectomy
If 1ry usually large, single stone: due to stricture
CBD exploration, Bypass the stricture:
choledoco-duodenostomy, cholecystectomy
If 2ndry usually small, multiple stones:
ERCP or CBD explore ‫على حسب‬, cholecystectomy
Gall stone IO diagnosis Exploratory laparotomy remove the stone by
ileus milking it back to enterotomy, search for other
stones, cholecystectomy, close the fistula
Ascending Clinical: Charcot triad, Reynaud triad Initial: NPO, fluids, analgesic, ICU, IV antibiotics
cholangitis Lab: leukocytosis (ciprofloxacin and metronidazole OR tazocin) for
Definitive diagnosis: ERCP\PTC level of gram -ve bacteria
obstruction, bile culture, stone or foreign body If no improvement: ERCP\PTC
removal, draining catheter insertion If cause is stent: stent removal and replacement
US and CT: may reveal gall stones and biliary + Laparoscopic Cholecystectomy
dilatation
Biliary [MRCP] initial imaging of choice; identifies If diagnosed intra-operative: open and repair
stricture biliary anatomy and associated vascular injuries If simple injury: ERCP + stent
US initial imaging; collection\biliary dilatation If clip injury: proximal PTC decompression
CT/MRI bile collection for percutan. Drainage If delayed diagnosis: 8-week temporization, PTC
HIDA for ongoing biliary leaks nutrition and sepsis control meanwhile, repair.
OPERATIVE REPAIR= debridement + roux-en-Y
hepatico-jejunostomy + tension-free mucosa
anastomosis
Gall bladder Incidental in cholecystectomy specimens (1\3) Adjuvant chemotherapy +
cancer Stage I,II: gall stone symptoms If suspicious before LC: open cholecystectomy
Stage III,IV: weight loss, CBD obstruction If Tis \ T1a: LC with cystic duct -ve margins
 US thickening, irregularity, polypoid, porcelain
Cavernous US can tell the dx, if you want to make sure:
Hemangioma CT arterial phase: peripheral then central
enhancement venous phase: complete filling or
enhancement
MRI features as CT
Note: biopsy is contra-indicated
Focal nodular US+Doppler mass+ central feeding artery can
hyperplasia tell the dx, if you want to make sure:
CT arterial phase: enhancement (central artery)
but scar is hypodense venous phase: wash-out
MRI features as CT
Biopsy to reassure the patient
Liver cell MRI best tool: sensitive to fat & hemorrhage,
adenoma heterogeneity of single intensity
US or CT
HCC Triphasic CT
Early enhancement, early wash-out
US, MRI, metastatic workup by X-RAY & PET
AFP: >200: suggestive >2000: diagnostic
Liver US CT or MRI
metastasis
Autoimmune 1-CT or MRCP or ERCP
Pancreatitis + either
2-Positive serology: IgG, IgG4 OR
3-Pancreatico-biliary/extra-pancreatic findings
Sialadenitis, nephritis, pneumonitis
Acute Two of the following 3 criteria (Atlanta 2012)
Pancreatitis 1-Abdominal pain (its characteristic features)
2-Lipase/Amylase ≥ 3 times (lipase is better)
(BUT don’t indicate severity, prognosis,
complications) (1+2 are the mainstay of
diagnosis)
3-Imaging characteristic of acute pancreatitis
if mod to severe, unclear diagnosis, no
improvement, biliary pancreatitis
CT with IV: fluid collection, pseudocyst, necrosis
if mild, biliary pancreatitis (MRCP)
MRI with gadolinium: fluid collection,
pseudocyst, necrosis
US: Hyperechoic, enlarged, GB or CBD stones
(EUS can be used as tx to stones + ERCP at the
same time )
If T2: radical cholecystectomy; GB, GB liver bed,
hepato-duodenal ligament, para-duodenal,
peripancreatic, hepatic artery, caeliac LN
If metastatic\T3\T4N: more radical resection
If jaundice: palliation by endosc. Or surgical stent
If duodenal obstruction: bypass
NO TREATMENT
NO malignant potential
Stop contraceptive pills
If severe symptoms/complications/to exclude
malignancy = surgical resection
NO TREATMENT
NO malignant potential
Stop contraceptive pills
If severe symptoms/complications/to exclude
malignancy in doubtful patients = surgical
resection for frozen section biopsy
Stop contraceptive pill: can causetumor regression
If <3 cm: follow up, stop OCP & pregnancy
If >4 cm, doubtful, symptomatic: liver resection
If child A: liver resection
If Milan criteria: liver transplant
If solitary <3 sm: local ablation
If inoperable: palliative; TACE(best), local radio,
targeted chemo(sorafenib), systemic chemo,
ethanol, arterial ligation
If inoperable (usually): palliat chemo; syst. or local
If Colon, GIST, Neuroenocrine: resection
If Mild to Mod: Supportive measures, nothing per
mouth for 1-2 days, hydration and IV fluids (in
absence of CVS disease), pain (meperidine
>morphine), ERCP (in CBD stones), correct alcohol
+ Ca + triglycerides + drugs affecting the pancreas
If more severe: peripancreatic fluid, peripancreatic
pseudocysts, pancreatic necrosis, renal,
respiratory, circulatory complicatons
Aggressive mx, ICU admission, parenteral feeding,
ERCP in biliary pancreatitis
OTHERS
If necrosis: parenteral not enteral feeding, surgical
debridement, percutaneous pus drainage
If systemic inf. response syndrome or sepsis,
MSOF, extra\pancreatic infection, increased CRP:
Antibiotics; imipenem, meropenem, fluoroquinolo
If cyst = <4w: percutaneous drain not? VARD
>4w: EUS drainage ± ERCP (look book algorhithm)
If biliary pancreatitis: LC to prevent recurrence
Pancreatic Lab Routine, bilirubin (total/direct), APh & GGT, CANCER HEAD PANCREAS
cancer CA19 – 9, CEA, CA 125 Whipple Operation only hope for cure
Imaging to assess lesion cancer head & tail We remove6: distal stomach, duodenum, proximal
Multi-detector computed tomography (MDCT) jejunum, head of pancreas, ampulla of Vater, CBD
pancreatic protocol = gold standard dx & stage + pancreatico/hepatico/gastro-jejunostomy
Resectability: invasion of PV, SMV, SMA, CA If Resectable no distant mets, no SMA contact, no
Staging: liver mets, LN invasion SMV or portal contact
+If cancer head, assess jaundice by =Whipple
US then can do CT, MRCP If Borderline no distant mets, SMA contact <180 ,
Note: no role for biopsy except If metastatic/ reconstructable SMV or portal contact
unresectable before chemo not percutaneous =Neoadj Chemo, reassess by MDCT then Whipple
but by: ERCP or EUS guided biopsy If Unresectable distant mets, SMA contact >180 ,
If extra-pancreatic mets are questionable= PET non-reconstructable SMV or portal contact
‫ﻣن اﻻﺧر‬ =Palliate: Pain by narcotics or caeliac neurolysis
Cancer Head: US for jaundice then MRCP Biliary obstruction by ERCP, PTC
MDCT pancreatic protocol for the tumor Gastric outlet obst. by stent\gastro-jejunostomy
Cancer Tail: CANCER BODY AND TAIL PANCREAS
MDCT pancreatic protocol for the tumor Distal pancreatectomy and splenectomy
Pancreatic Surgical resection
Neuroendocri
Simple liver May be slight LFT elevation If asymptomatic: observation
cyst US or CT homogenous, uniform, thin-wall If symptomatic: laparoscopic deroofing
Polycystic More LFT elevation, RFT elevation If asymptomatic: observation
liver US or CT multiple cysts If symptomatic: laparoscopic deroofing +
fenestration OR involved segment resection
Rare: transplantation
Choledochal MRCP most diagnostic Segmentectomy or Lobectomy
liver cyst CT or US If cholangitis: antibiotics
If large cyst: US or CT guided aspiration
(temporary)
Can do liver transplantation
Hydatid cyst Eosinophilia 40% Surgery definitive treatment + peri-operative
US larger cyst, daughter cysts, scolices medical treatment (roof top incision)
CT monolocular cyst + peripheral calcifications If small, accidentally discovered: Medical by
+ attenuation , (water lily sign) albendazole, mebendazole can be curative
X-Ray, cansoni test: not used If unfit for surgery, recurrent: PAIR; controversial
PAIR contraindications: very superficial cyst,
inaccessible + medical 4d before and after surgery
(1m albendazole, 3m mebendazole)
Amoebic liver Anemia, increased WBC and bilirubin, amoeba If early: Metronidazole 800, 3 per day, 10 days
abscess in stool If pus: US guided aspiration
US, CT, sigmoidoscope (lesion specific for
ameba)
Pyogenic liver US or CT multilocular cystic lesion Broad spectrum antibiotics until the result of C&S
abscess Aspiration; pus : culture and sensetivity US guided aspiration, if failed: open drainage

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