resident teaching conference 10/16/09 rondi kauffmann ... · necrotizing pancreatitis with...
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Resident Teaching Conference 10/16/09Rondi Kauffmann‐Resident presenter
William Nealon‐
Faculty presenter
KC59 year old male Referred to Surgery clinic for incidentally‐discovered 5cm x 3cm pancreatic cyst
HPI: ‐Pancreatic cyst incidentally discovered‐
Denies nausea, emesis or abdominal pain‐No weight loss, fever, chills‐
No jaundice, normal bowel movements‐
No history of pancreatitis
ROS: negative
PMHHtnPulmonary noduleDyslipidemiaHeart murmurDiverticulosis
PSHTonsillectomyvasectomy
FHLung cancer‐
fatherHtn‐mother, sister, brother
MedsBenicarVitamin BZocorOmeprazoleAspirin
SHMarriedRetiredSmoked 1.5 ppd
X 15‐20 years, quit
1993
Heavy etoh
drinker 15 years ago,
but now only drinks 6 pack
every other week
Physical ExamP: 76 BP: 176/92 RR: 18 bpm Temp: 98.1General: A&O, no jaundice, no lymphadenopathyAbdomen: soft, nontender, no masses,normal rectal exam
Labs138 103 84.4 27 0.8
7.5 29342
LDL 150Cholesterol 208Triglycerides 132HDL 32
Total protein 7.5Albumin 4.4Total bilirubin 0.7Alk phos 67ALT 37AST 35Amylase 13Lipase 19
Ca19‐9 108
EUS with biopsyBody with normal echotexturePancreatic duct measures 1.1 mm in diameterLarge, well‐circumscribed, anechoic lesion measuring 2.5 cm x 4.7 cm arising from body
No septationsNormal pancreatic duct without stricture or stone
FNAPathology: mixed lymphoid population, granular debris, negative for malignancyCEA: 674.9Cyst fluid amylase <10
TreatmentCentral pancreatectomy, omental pedicle flap, serosalpatchFinal pathology: pancreatic lymphoepithelial cyst, negative for malignancy
RR63 year old maleReferred to Surgery clinic with “abdominal fullness”and pain
HPI:3 months duration of symptomsWeight loss of 32 lbs. in 10 weeksNo fever, chills, nausea, melena, steatorrhea, jaundice
ROS‐ negative except for HPI
PMHType 2 diabetesThyroid cystHypertriglyceridemia
PSHTonsillectomy/adenoidectomyCystoscopyEGD/colonoscopy 2008
FHType 2 diabetes‐
father
MedsProtonixCaptoprilSynthroidCrestorTylenolNaproxenMVIEchinaceaGarlicLantusHumalog
Physical ExamP: 120 BP 154/95 RR 18 bpm temp 98.1General: A&O, no jaundice, no wastingAbdomen: soft, mild tenderness, no masses
Labs
133 97 12353
3.6 16 1.34
Total protein 7.1Albumin 4.3Total bilirubin 1.8Alk phos 120ALT 20AST 20
CEA 458.5Ca 19‐9 29, 245
EUS with FNA and cyst aspirationLarge loculated cystic lesion arising from neck of pancreas
Contained septations2.5 x 3.0 cm
Difficulty passing the scope into duodenum
CytopathologyCyst FNA: Degenerated cells with amorphous debris, not diagnostic of malignancy
No mucinCyst amylase 1209Cyst CEA >50,000
Pancreas neck FNA: adenocarcinomaDuodenal bulb biopsy: involved by moderate to poorly differentiated adenocarcinoma
PETIntense uptake corresponding to masses in right colon and pancreasThree low‐density lesions within the liverMultiple mesenteric lymph nodes with moderate FDG uptakeMild‐to‐moderate uptake in left supraclavicular lymph nodes
A 40 year old man with no co‐morbidities presents with diffuse abdominal pain and
distention and a 2‐day history of nausea and vomiting. He is afebrile and hemodynamically
normal, but is anuric and serum creatinine is 3.0 mg/dL. A CT scan confirms necrotizing
pancreatitis with a large peripancreatic phlegmon. There is no evidence of cholelithiasis or
cholecystitis. He has had no prior episodes of pancreatitis. The
next step in management
should be
A.
Total parenteral nutrition (TPN)
B.
Bowel rest, fluid resuscitation
C.
Surgical pancreatic debridement
D.
Fine‐needle aspiration of peripancreatic fluid
E.
Prophylactic antifungal agents
A 39 year old woman is admitted with gallstone pancreatitis and epigastric pain. Pertinent
data include amylase, 2000 U/L; bilirubin, 1.2 mg/dL; and WBC count 15,000. After 2 days of
medical management, her epigastric pain resolves. Her amylase is
340 U/L and her bilirubin
and WBC count have normalized. Laparoscopic cholecystectomy should be attempted
A.
After ERCP and sphincterotomy
B.
Prior to dischargeC.
Once her amylase is
normalD.
4‐6 weeks later to allow
for a “cooling down period”
E.
Only if the patient develops recurrent pancreatitis
A 35 year old male is admitted with acute pancreatitis secondary
to hypertriglyceridemia. Oral
intake is discontinued, and he is hydrated with IV fluids. He has minimal upper abdominal
tenderness. 72 hours after admission, he has worsening leukocytosis and elevated amylase
with RUQ rebound tenderness. The CT scan shown is obtained. The most appropriate
management would be
A.
LaparotomyB.
Nasogastric tube
decompression and broad‐spectrum
antibioticsC.
Somatostatin therapy
D.
Repeat CT scan in 48 to 72 hours
E.
Percutaneous drainage.
A 35 year old male has epigastric pain and emesis. Four week previously, he was discharged
after an admission for uncomplicated acute pancreatitis. He has been receiving corticosteroids
since a renal transplant 4 years ago. Pertinent data include: WBC 11,000; amylase 1000; and
normal creatinine. The CT scan shown is obtained. The most appropriate management is
A.
Open debridementB.
Cystgastrostomy
C.
Roux‐en‐Y cystjejunostomy
D.
Enteral feeding distal to the ligament of Treitz
E.
CT guided percutanous drainage
PseudocystsDevelop in 5‐10% of patients with acute pancreatitis and 50% of patients with chronic pancreatitisSuspect if patient does not recover with one week of medical therapy, or when symptoms return after period of improvement
PseudocystsAcute fluid collection
Irregular in shapeFrequently resolveDebridement reserved for
necrotizing pancreatitis with infection or abscess
Follow with serial CT Treatment: expectant
management
PseudocystRequire 6‐12 weeks to
matureCaused by disruption of
pancreatic ductUsually seen in setting of
chronic pancreatitisMay cause obstruction of
gastric outlet or biliary tree
Complications of PseudocystsObstructionInfectionPainHemosuccus pancreaticus
Treatment of PseudocystsOpenLaparoscopicEndoscopic
A 42 year old previously healthy man arrives in the Emergency Department with a 12‐
hour history of excruciating epigastric pain. He is afebrile and
not jaundiced. Pulse is
115/min, blood pressure 90/60, and WBC count is 16,400. The CT scan show is obtained.
Immediate management should include
A.
Peritoneal dialysisB.
Exploratory laparotomy
C.
Needle aspirationD.
Fluid resuscitation
E.
ERCP
Four weeks later, the patient returns to the Emergency
Department with abdominal fullness. Vital signs are normal. The
CT scan show is obtained. Treatment now should be
A.
ERCPB.
Surgical decompression
C.
Percutaneous aspirationD.
14‐day course of
antibioticsE.
Repeat CT scan in 30
days
Treatment of pseudocystsMUST send biopsy of cyst wall to exclude malignancy