HPB DAYHPB DAY

Plan todayPlan today

•4 cases4 cases

•ImagesImages

•Present range of approachesPresent range of approaches

•DiscussionDiscussion

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

USS…USS…

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

USS…USS…

Lap chole…Lap chole…

Hepatobiliary PathologyHepatobiliary Pathology

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

Cholesterol StonesCholesterol 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) StonesPigment (haem) Stones

• Calcium bilirubinate

• Chronic haemolysis

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

•USS…USS…

•Lap chole…Lap chole…

5 days postop readmitted with severe 5 days postop readmitted with severe abdominal pain….. abdominal pain…..

•Why, what investigationsWhy, what investigations

USS (CT)USS (CT)

Unremarkable

What else …

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

44 year old female with 2 week history of 44 year old female with 2 week history of obstructive jaundiceobstructive jaundice

OK LFTs but so whatOK LFTs but so what

USS: USS:

68 year old female with 2 week history of 68 year old female with 2 week history of obstructive jaundiceobstructive jaundice

USS: CBD 16mm GB distended, no stonesUSS: CBD 16mm GB distended, no stones

CT scan – unresectable ca pancreasCT scan – unresectable ca pancreas

Palliative R….Palliative R….

Stent - route Stent - route

ERCP StentERCP Stent

Percutaneous transhepatic Percutaneous transhepatic cholangiographycholangiography

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

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

Palliative Treatment:Palliative Treatment:

(Biopsy) – including EUS(Biopsy) – including EUS

GemcitabineGemcitabine

Pancreatic CancerPancreatic 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…

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

Thoughts….Thoughts….

USS ….USS ….

Case 3Case 3

Case 3Case 3

Some other imagesSome other images

How to treat pseudocysts??How to treat pseudocysts??

Pancreatic AnatomyPancreatic 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 drainagePseudocyst drainage

Pancreatic CystsPancreatic Cysts

• Non-neoplastic– Pseudocysts– others

• Neoplastic– Mucinous (cystadenoma)– Papillary/cystic tumours– Cystadenocarcinoma– Degeneration in any cancer

• FNAC– Steep learning curve

PANCREATITIS, PANCREATITIS, attempts to clarifyattempts to clarify

MARSEILLESMARSEILLES

• Chronic Pancreatitis

• Acute Pancreatitis

Acute PancreatitisAcute Pancreatitis

Acute Pancreatitis

• Mild - 80% ?management

• Severe – 20% total – manage carefully

• 6% mortality – what of, operations?

• How to identify the severes

Acute PancreatitisAcute Pancreatitis

Requires:•Small stones•Wide cystic duct•Decent common channel

1

2

Chronic PancreatitisChronic 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 pancreatitisOk its chronic pancreatitis

Alcohol …Alcohol …

Pain …Pain …

Diabetes …Diabetes …

Steatorrhoea …Steatorrhoea …

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

Investigation …Investigation …

Case 4Case 4

Multiple Liver MetsMultiple Liver Mets

• Hunt the primary??

• Why??

• Most colorectal, upper GI, pancreas, lung

Inoperable liver mets.Inoperable liver mets.Hunting?Hunting?

• Clinical

• Imaging +/- biopsy

• Immunochemistry– Specific (ha ha) markers– Cytokeratin profiles

Tumours with specific therapiesTumours with specific therapies

• Breast

• Colorectal

• Other UGI

• (Prostate)

• (Thyroid)

• Oncology peer pressure

Potential treatments available for some Potential treatments available for some patientspatients

ResectionResection

Local treatments ….Local treatments ….

Case 5Case 5

Case 6Case 6

Case 6Case 6

A few messages to repeatA few messages to repeat::

• Don’t forget CBD stonesDon’t forget CBD stones

• ERCP is principally for therapy now ERCP is principally for therapy now

• Save time, do the right test, ask a radiologistSave time, do the right test, ask a radiologist

• Tissue diagnosis not always possible in Tissue diagnosis not always possible in pancreatic cancer pancreatic cancer

• Time is critical in obs jaundiceTime is critical in obs jaundice

• Good palliation from biliary decompression Good palliation from biliary decompression

• CA 19/9 for pancreatic cancer CA 19/9 for pancreatic cancer

• GEMCITABINE for pancreatic cancerGEMCITABINE for pancreatic cancer

Any questions about anythingAny questions about anything