Surgery Marrow Pg 281-290 (GIT)
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What is the most appropriate IV antibiotic of choice for treating infected necrosis in severe pancreatitis?

  • Amoxicillin
  • Ciprofloxacin
  • Clindamycin
  • Meropenem (correct)

    • A pancreatic Balthazar grade score of 4 indicates severe pancreatitis.

    True

    What management step should be taken for a patient diagnosed with severe pancreatitis in the initial phase?

    Nil per oral (NPO)

    Biliary pancreatitis often requires ____________ and sphincterotomy for management.

    <p>ERCP</p> Signup and view all the answers

    Match the following pancreatic necrosis scores with their corresponding descriptions:

    <p>0 = No necrosis 2 = 1/3rd of pancreas 4 = 1/2 of pancreas 6 = &gt;1/2 of pancreas</p> Signup and view all the answers

    Which surgical procedure is typically used for a resectable distal CBD tumor?

    <p>Whipple's surgery</p> Signup and view all the answers

    Bilhemia is caused by bile leaking into blood vessels.

    <p>True</p> Signup and view all the answers

    What is the most common site of metastasis in non-resectable gastrointestinal cancers?

    <p>Liver</p> Signup and view all the answers

    The tumor marker associated with gastrointestinal tumors is S. Ca _____.

    <p>19-9</p> Signup and view all the answers

    Match the biliary complications with their appropriate management:

    <p>Hemobilia = CT angiography and embolization if bleeding Bilhemia = ERCP + stenting</p> Signup and view all the answers

    Which structure is associated with Whipple's surgery as indicated by the 'Tunnel of Love' line?

    <p>Pancreatic head</p> Signup and view all the answers

    Sphincter of Oddi consists of three sphincters.

    <p>False</p> Signup and view all the answers

    What complication can arise from poor functioning of the Sphincter of Oddi?

    <p>Improper drainage of bile and pancreatic secretions</p> Signup and view all the answers

    Type 1 Sphincter of Oddi Dysfunction is characterized by biliary pain, CBD dilatation, and _____ derangement.

    <p>enzyme</p> Signup and view all the answers

    Match the types of Sphincter of Oddi Dysfunction with their features:

    <p>Type 1 = Biliary pain + CBD dilatation + Enzyme derangement Type 2 = Pain + CBD dilatation Type 3 = Biliary pain Type 4 = None - not a recognized type</p> Signup and view all the answers

    What is the recommended time frame for performing a CECT in benign pancreatic conditions?

    <blockquote> <p>72 hours</p> </blockquote> Signup and view all the answers

    CECT stands for Contrast-Enhanced Computed Tomography.

    <p>True</p> Signup and view all the answers

    What does the abbreviation CECT refer to in medical imaging?

    <p>Contrast-Enhanced Computed Tomography</p> Signup and view all the answers

    In benign pancreatic conditions, CECT should ideally be done __________ hours after initial assessment.

    <blockquote> <p>72</p> </blockquote> Signup and view all the answers

    Match the following medical imaging types with their description:

    <p>CECT = A radiological technique using contrast material MRI = Imaging technique using strong magnetic fields X-ray = Radiation imaging for viewing bone and dense tissue Ultrasound = Imaging using sound waves to visualize soft tissue</p> Signup and view all the answers

    Which procedure is performed for Type I choledochal cysts?

    <p>Hepaticojejunostomy</p> Signup and view all the answers

    Choledochoceles belong to Type III choledochal cysts.

    <p>True</p> Signup and view all the answers

    What is one major clinical feature of choledochal cysts?

    <p>Jaundice</p> Signup and view all the answers

    The ___________ procedure is performed as a management step for Type II and III choledochal cysts.

    <p>Kasai</p> Signup and view all the answers

    Match the types of choledochal cysts with their characteristics:

    <p>Type I = Diffuse CBD dilatation Type II = Diverticulum of CBD Type III = Intraduodenal portion of CBD dilatation Type IVa = Intra &amp; extra hepatic tree dilatation Type V = Extrahepatic biliary tree and intrahepatic biliary radicals dilatation</p> Signup and view all the answers

    What is the most common cause of liver transplant in children?

    <p>Extrahepatic Biliary Atresia</p> Signup and view all the answers

    CA 19-9 is used primarily for monitoring patients with extrahepatic biliary atresia.

    <p>False</p> Signup and view all the answers

    List one associated anomaly of extrahepatic biliary atresia.

    <p>Cardiac lesions</p> Signup and view all the answers

    Type III atresia involves the right and left hepatic ducts and the entire __________ biliary tree.

    <p>extrahepatic</p> Signup and view all the answers

    Match the types of extrahepatic biliary atresia with their descriptions:

    <p>Type I = Atresia restricted to the common bile duct Type II = Atresia of the common hepatic duct Type III = Atresia of the right and left hepatic ducts and entire biliary tree</p> Signup and view all the answers

    Which of the following is NOT a risk factor for cholangiocarcinoma?

    <p>Cirrhosis</p> Signup and view all the answers

    Sclerosing cholangitis is primarily an autoimmune disease associated with inflammatory bowel disease.

    <p>True</p> Signup and view all the answers

    What is the most common site for cholangiocarcinoma?

    <p>Hilum</p> Signup and view all the answers

    The management procedure for Type I bile duct obstruction is __________.

    <p>Roux-en-Y hepaticojejunostomy</p> Signup and view all the answers

    Match the following features with their corresponding descriptions:

    <p>Obstructive jaundice = Yellowing of the skin and eyes due to bile duct obstruction Klatskin tumors = Hilar cholangiocarcinoma presenting at the bile duct junction MRCP = Imaging technique showing beaded appearance of biliary tree Bismuth-Corlette classification = Assessment system for cholangiocarcinoma location</p> Signup and view all the answers

    What is the most common cause of acute pancreatitis?

    <p>Gall stones</p> Signup and view all the answers

    Acinar cell death is a later stage in the pathophysiology of acute pancreatitis.

    <p>False</p> Signup and view all the answers

    Name one benign condition associated with pancreatitis.

    <p>Hyperparathyroidism</p> Signup and view all the answers

    The activation of ____________ and other enzymes contributes to inflammation in pancreatitis.

    <p>trypsinogen</p> Signup and view all the answers

    Which of the following symptoms is commonly experienced in acute pancreatitis?

    <p>Radiating pain to the back</p> Signup and view all the answers

    Match the following causes of acute pancreatitis with their descriptions:

    <p>Gall stones = Most common cause Alcohol = Second most common cause Iatrogenic factors = Post-ERCP pancreatitis Scorpion bite = Uncommon cause</p> Signup and view all the answers

    Low pH and activated trypsin are part of the early stages of pancreatitis.

    <p>True</p> Signup and view all the answers

    What is the risk percentage of developing pancreatitis after an ERCP procedure?

    <p>5%</p> Signup and view all the answers

    Which sign is characterized by discoloration around the umbilicus in cases of acute hemorrhagic pancreatitis?

    <p>Cullen sign</p> Signup and view all the answers

    Serum lipase levels rise gradually and decline late, making it less specific than serum amylase.

    <p>True</p> Signup and view all the answers

    What is one of the characteristic imaging findings associated with pancreatitis?

    <p>Colon cut-off sign</p> Signup and view all the answers

    The _____ sign indicates discoloration around the inguinal region in acute hemorrhagic pancreatitis.

    <p>Fox</p> Signup and view all the answers

    Match the conditions with their corresponding amylase levels:

    <p>Acute pancreatitis = 3 to 4 times normal Mesenteric ischemia = Elevated, but less specific Bowel perforation = Elevated amylase Normal = Within normal limits</p> Signup and view all the answers

    What is the most common congenital anomaly of the pancreas?

    <p>Pancreas divisum</p> Signup and view all the answers

    Pancreas divisum is associated with an increased risk of pancreatitis due to ineffective drainage.

    <p>True</p> Signup and view all the answers

    What imaging technique is used to diagnose pancreas divisum?

    <p>Magnetic resonance cholangiopancreatography (MRCP)</p> Signup and view all the answers

    An annular pancreas is a condition arising from the malrotation of the ventral pancreatic bud, which encircles the __________.

    <p>duodenum</p> Signup and view all the answers

    Match the following congenital pancreatic conditions with their clinical features:

    <p>Pancreas Divisum = Ineffective drainage and risk of pancreatitis Annular Pancreas = Encircles duodenum and associated with Down's syndrome Pancreatic Agenesis = Absence of the pancreas Situs Inversus = Congenital condition where organs are reversed</p> Signup and view all the answers

    Which management strategy is preferred for treating annular pancreas?

    <p>Duodenoduodenostomy</p> Signup and view all the answers

    The double bubble sign is associated with annular pancreas.

    <p>True</p> Signup and view all the answers

    What is the clinical feature that associates annular pancreas with Down's syndrome?

    <p>Non-bilious vomiting</p> Signup and view all the answers

    Study Notes

    Modified Marshall Score

    • Score ≥2 indicates severe pancreatitis.

    CT Severity Index

    • A CT severity score of 26 or higher indicates severe pancreatitis.

    Balthazar Grade

    • A score of 0 indicates a normal pancreas.
    • Scores 1 and 2 represent mild abnormalities.
    • Scores 3 and 4 indicate increasing severity of pancreatitis with fluid collections and/or gas.

    Pancreatic Necrosis

    • A score of 0 indicates no necrosis.
    • A score of 2 indicates necrosis affecting 1/3rd of the pancreas.
    • A score of 4 indicates necrosis affecting 1/2 of the pancreas.
    • A score of 6 indicates necrosis affecting greater than 1/2 of the pancreas.

    Pancreatitis Management

    • Nil per oral (NPO) is recommended.
    • Intravenous (IV) fluids, primarily Ringer's lactate, are the preferred choice.
    • Analgesia is necessary to manage pain, with opioids being used for uncontrolled pain.
    • Antibiotics are indicated in cases of severe pancreatitis or infected necrosis. Meropenem is the IV antibiotic of choice.
    • Total parenteral nutrition is used during the initial phase of severe pancreatitis.
    • Early initiation of enteral nutrition reduces mortality and risk of infections.
    • Nasojejunal tube is the preferred method for enteral nutrition.

    ERCP & Sphincterotomy in Pancreatitis

    • Indications include documented common bile duct (CBD) stone and biliary pancreatitis.

    Cholecystectomy in Pancreatitis

    • Indicated in gallstone-induced pancreatitis.
    • Performed before discharge.

    Hemobilia

    • Bleeding from the biliary tree.
    • Characteristics include pain, jaundice, Quincke's triad, and melena.
    • Management typically involves CT angiography and embolization if bleeding persists.

    Bilhemia

    • Bile leaking into blood vessels.
    • Often occurs after ERCP or trauma.
    • Rapidly progressive jaundice is a feature.
    • Management involves ERCP and stenting.

    Tumor Marker for Pancreatic Cancer

    • Serum CA 19-9 is a tumor marker.

    Chemotherapy for Pancreatic Cancer

    • Gemcitabine-based chemotherapy is commonly used.

    Resectable Pancreatic Cancer

    • Whipple's procedure is performed for distal CBD tumors.
    • Choledochojejunostomy is used for supraduodenal tumors.
    • Hepaticojejunostomy is employed for CHD tumors.
    • Portoenterostomy is used for Klatskin tumors.

    Non-Resectable Pancreatic Cancer

    • Palliative management is required.
    • ERCP with stenting and percutaneous transhepatic biliary drainage are common palliative interventions.

    Surgical Anatomy

    • The "Tunnel of Love" represents the area between the pancreatic head and the uncinate process, relevant during Whipple's surgery.

    Sphincter of Oddi

    • Composed of four sphincters: superior choledochal, inferior choledochal, ampullary, and pancreatic sphincter.
    • Dysfunction of the Sphincter of Oddi leads to improper drainage of bile and pancreatic secretions.

    Sphincter of Oddi Dysfunction Types

    • Type 1: Biliary pain, CBD dilatation, and enzyme derangement.
    • Type 2: Pain and CBD dilatation.
    • Type 3: Biliary pain.

    Diagnosis of Sphincter of Oddi Dysfunction

    • Endoscopic retrograde cholangiopancreatography (ERCP) and manometry are used for diagnosis.
    • Pressure above 40 mmHg indicates dysfunction.

    Milwaukee Classification

    • A classification system for pancreatitis.

    CECT for Pancreatitis

    • Computed tomography (CT) with contrast enhancement (CECT) is performed more than 72 hours after onset.

    Acute Pancreatitis

    • Gallstones are the most common cause of acute pancreatitis. Alcohol is the second most common cause.
    • Trauma is a significant cause in children.
    • Iatrogenic pancreatitis can occur as a complication of ERCP. The risk is around 5%.
    • ERCP for therapeutic purposes carries a higher risk than diagnostic procedures.
    • Females are more susceptible than males.
    • Difficult cannulation during ERCP increases the risk.

    Co-localization Theory of Pancreatitis

    • Normal pancreatic acinar cells maintain proper function.
    • Acinar cell death occurs during pancreatitis.
    • The early stages involve leaky co-localized organelles, activated trypsin, and low pH.
    • Zymogen activation leads to pancreatic destruction and pancreatitis.

    Pathogenesis of Pancreatitis

    • Inactive pancreatic enzymes (zymogens) are activated.
    • Trypsinogen and other enzyme activation, increased calcium levels, and activation of NF-kB and PKC contribute to inflammation.
    • Inflammatory mediators (IL-1, 6, 10,TNF-α) cause systemic inflammation.

    Clinical Features of Pancreatitis

    • Epigastric pain.
    • Radiation to the back.
    • Pain relief when bending forward.
    • Symptoms often out of proportion to physical signs.

    Benign Pancreatic Conditions

    • Drug-induced pancreatitis: Thiazide diuretics, antiretrovirals, chemotherapeutic agents.
    • Hyperparathyroidism and hypercalcemia.
    • Elevated triglycerides.
    • Pancreas divisum.
    • Idiopathic pancreatitis.
    • Scorpion bite.

    Diagnosis of Benign Pancreatic Conditions

    • Fasting ultrasound is the gold standard.
    • MRCP is highly sensitive and specific.
    • Liver biopsy confirms diagnosis and differentiates from neonatal hepatitis.

    Differential Diagnosis of Benign Pancreatic Conditions

    • Neonatal hepatitis.
    • Alagille syndrome (characterized by biliary atresia, congenital heart disease, and skeletal abnormalities).

    Management of Benign Pancreatic Conditions

    • Hepaticojejunostomy is performed for Type I biliary atresia.
    • Kasai procedure (portoenterostomy & jejunal anastomosis at the porta hepatis) is used for Type II and III biliary atresia.

    Choledochal Cysts

    • Dilatation of the biliary tree leads to ineffective drainage, resulting in jaundice.
    • Increased risk (10%) of cholangiocarcinoma.

    Choledochal Cyst Classification - Todani / Alonso-Lej Modification

    • Type I: Diffuse dilatation of the CBD (most common).
    • Type II: Diverticulum of the CBD.
    • Type III: Dilatation of the intraduodenal portion of the CBD (Choledochocele).
    • Type IVa: Intra- and extrahepatic biliary dilatation.
    • Type IVb: Extrahepatic biliary tree dilatation.
    • Type V: Extrahepatic biliary tree dilatation with intrahepatic biliary radial dilatation (Caroli's disease).

    Clinical Features of Choledochal Cysts

    • Lump, pain, and jaundice.

    Investigation of Choledochal Cysts

    • MRCP is the gold standard.

    Management of Choledochal Cysts

    • Type I: Roux-en-Y hepaticojejunostomy.
    • Type IVb: Portoenterostomy.
    • Type IVa & V: Liver transplantation.
    • Type II: Cutting and repairing the CBD.
    • Type III: ERCP and sphincterotomy.

    Cholangiocarcinoma

    • Carcinoma of the bile duct.

    Risk Factors for Cholangiocarcinoma

    • Obesity, diabetes mellitus (DM), HBV/HCV infection, choledochal cysts, thorotrast exposure.
    • Abnormal pancreatobiliary duct junction.
    • Sclerosing cholangitis (an autoimmune disease associated with inflammatory bowel disease).
    • Females are more affected than males.
    • Association with HLA DR3/B8.
    • Presence of anti-smooth muscle antibodies and antinuclear antibodies.

    Features of Cholangiocarcinoma

    • Obstructive jaundice.
    • Distal CBD tumor presents as periampullary cancer.
    • Most common site: Hilum.
    • Klatskin tumors: Hilar cholangiocarcinoma (classified using the Bismuth-Corlette classification).

    Investigaton of Cholangiocarcinoma

    • MRCP is used to diagnose.

    Post-Cholangiocarcinoma Surgery

    • Gemcitabine-based chemotherapy is used.
    • Tumor depth and T-staging are important prognostic factors.
    • CA 19-9 level is monitored.

    Extrahepatic Biliary Atresia

    • Inflammatory fibrosis of the biliary system seen in children.
    • Most common cause of liver transplant in children.
    • Classified based on the Japanese and Anglo-Saxon classifications.

    Extrahepatic Biliary Atresia Classifications

    • Type I: Atresia restricted to the CBD.
    • Type II: Atresia of the CHD:
      • IIa: Patent gallbladder with CBD.
      • IIb: Obliterated gallbladder, cystic duct, and CBD.
    • Type III: Atresia of the right and left hepatic ducts and the entire extrahepatic biliary tree.

    Extrahepatic Biliary Atresia Associated Anomalies

    • Cardiac lesions, polysplenia, and situs inversus.

    Clinical Features of Extrahepatic Biliary Atresia

    • Jaundice at birth.
    • Rapidly progressive liver failure and cirrhosis.

    Investigation of Extrahepatic Biliary Atresia

    • Blood tests: Increased serum bilirubin and alkaline phosphatase.

    Management of Extrahepatic Biliary Atresia

    • Type I: Roux-en-Y hepaticojejunostomy.
    • Type II: Cut and repair the CBD.
    • Type III: ERCP + sphincterotomy.
    • Type IVb: Portoenterostomy
    • Type IVa & V: Liver transplantation.

    Pancreatic Divisum

    • The most common congenital anomaly of the pancreas.
    • Failure of fusion of the dorsal and ventral pancreatic buds.
    • Increased risk of pancreatitis due to ineffective drainage.
    • Magnetic resonance cholangiopancreatography (MRCP) is used for diagnosis.
    • Management: ERCP + Sphincterotomy.

    Annular Pancreas

    • Malrotation of the ventral pancreatic bud, encircling the second part of the duodenum.
    • Commonly associated with Down syndrome.
    • Clinical features: Non-bilious vomiting (may also be associated with duodenal atresia, presenting with bilious vomiting).
    • Investigation: CECT and x-ray (double bubble sign).
    • Management: Duodenoduodenostomy.

    Signs of Acute Hemorrhagic Pancreatitis

    • Cullen's sign (discoloration around the umbilicus).
    • Grey Turner's sign (discoloration around the flanks).
    • Fox's sign (discoloration around the inguinal region).

    Signs of Severe Pancreatitis

    • Peritonitis (deposition of chalky white material; no perforation).

    Diagnosis of Acute Pancreatitis

    • Two out of three criteria:
      • Abdominal pain consistent with acute pancreatitis.
      • Three-fold or high elevation of serum amylase or lipase levels.
      • Characteristic imaging findings.

    Serum Amylase and Lipase in Pancreatitis

    • Amylase has a shorter half-life, rising early and declining early. It is sensitive but not specific for severity.
    • Lipase has a longer half-life, with a gradual rise and late decline. It is more specific and does not predict pancreatitis severity.

    Conditions with Raised Amylase

    • Acute pancreatitis (3 to 4 times normal).
    • Mesenteric ischemia.
    • Bowel perforation.

    X-ray Findings in Pancreatitis

    • Gasless abdomen.
    • Ileus.
    • Colon cut-off sign (dilated colonic loop with incomplete haustrations).
    • Sentinel loop (focal dilated proximal jejunal loop in the left upper quadrant).

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    Description

    This quiz covers the assessment and management strategies for severe pancreatitis, including scoring systems such as Modified Marshall Score, CT Severity Index, Balthazar Grade, and Pancreatic Necrosis. Understand the interventions and treatments typically recommended for managing this condition effectively.

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