Hepatobiliary Disease

Transcription

1 Hepatobiliary Disease 大林慈濟綜合醫院 魏昌國 一般外科

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3 Cholelithiasis 膽道結石 Incidence (USA) 10% in adult 85% cholesterol stones 15% pigment stone Risk factors Cholesterol stones Age Female(2x, 25% versus 12% at age 60), Multiple pregnancies, oral pills Obesity Western diet Pigment stones Taiwan Black stones: hemolytic anemia, cirrhosis, ileal resection Brown stones: biliary stasis, infection >60% pigment stones Cirrhosis Infection

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5 Gallstones 膽囊結石 Nature history Asymptomatic: most Symptomatic: biliary colic 1-2% per year in aymptomatic pts Complications: acute cholecystitis, acute cholangitis, pancreatitis <0.5% per year in asymptomatic patients 3-5% per year in symptomatic patients Asymptomatic gallstones Diagnosis Incidental gallstones: ultrasonography Management No role for prophylactic cholecystectomy DM? High cancer risks: porcelain gallbladder(50%) Children with gallstones Gallstones discovered at laparotomy?

6 Gallstones 膽囊結石 Symptomatic gallstones Diagnosis Symptoms: biliary colic Location: epigastrium or RUQ, back pain Severity: severe Timing: within hours after meal, wake from sleep Sonography: echogenic structure & posterior acoustic shadows D/D: PUD, GERD, RLL pneumonia, inferior AMI Management Cholecystectomy Laparoscpic(L.C.) Open Medical dissolution of gallstones: Urso Nonobese, cholesterol gallstones, <10mm, about 6-12months to resolve <5mm(90%); 5-10mm(60%) Recurrent rate: 50-60% ESWL: Europe 10-20mm, single stone

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9 Acute cholecystitis 急性膽囊炎 Acute cholecystitis Thickening of GB wall =>Pericholecystic fluid =>Empyema of GB =>Gangrene of GB =>Emphysematous GB =>Perforation of GB Diagnosis of cholecystitis Symptoms: similar to bilary colic, but more severe, fever Murphy s sign Lab. Abnormalities: Leukocytosis ( ), WBC>20000 => gangrene or acute cholangitis GOT/GPT, ALP Bilirubin < 3 mg/dl Serum amylase Diagnostic imaging: Ultrasonography CT scan

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13 Acute cholecystitis 急性膽囊炎 Management of acute cholecystitis Initial management: Admission, NPO, IVF, systemic antibiotics G(-) & anaerobes Monitor fever curve, PE, lab. Data Most improving; if not => surgical intervention Cholecystectomy: timing Early cholecystectomy: within 48 hrs after onset, Laparoscopic/open Delayed cholecystectomy: 3 months later PTGBD: failing systemic therapy but are not candidates for cholecystectomy due to medical problems

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15 Acalculous cholecystitis 非結石性膽囊炎 Etiology: Major burns, major trauma Prolonged TPN Systemic sepsis, multiple organ failure After major abdominal or thoracic operation Symptoms & signs: Alert patient: RUQ pain & tenderness Elevated WBC, Bil., ALP Diagnostic imaging: Ultrasonography: inexpensive, done at bedside Abdominal CT scan: other intraabdominal problems Management: PTGBD: procedure of choice, nearly 100% effective Systemic antibiotics, NPO, treatment of concomitant illness Cholecystectomy after recovery

16 Choledocholithiasis 總胆管結石 Choledocholithiasis Gallstones pass through cystic duct into CBD Primary CBD stones: rare Symptoms: Jaundice: usually Bil. <10 Biliary colic Diagnosis: Ultrasonography, CT scan ERCP, PTC Management: Preoperative ERCP with sphincterotomy & retrieve CBD stones (1% mortality; 10% morbidity) Laparoscopic/open cholecystectomy after ERCP Laparoscopic/open choledocholithotomy with T-tube drainage

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19 Acute cholangitis 急性胆管炎 Acute cholangitis: Obstruction of biliary tree with infection, sepsis Life-threatening Charcot s triad: fever, jaundice, RUQ pain Reynolds pentad: Charcot s triad, hypotension, mental status change Ultrasonography/CT scan ERCP with ENBD or PTCD Bile culture Management: Admission, NPO, IVF, systemic antibiotics Definitive diagnosis Decompression of biliary tree, remove stones Biliary stricture, biliary ductal injury, congenital biliary disease: preoperative careful studies needed Foreign body: biliary stents or parasites

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21 Oriental cholangiohepatitis Recurrent pyogenic cholangitis: Endemic to the Orient Multiple IHD stones Multiple biliary strictures, common in main ducts, and more frequent & severe in left side Repeated bacterial infection Symptoms & signs: Young and thin patients with recurrent cholangitis Diagnostic imaging: Ultrasonography CT scan ERCP & PTC Management: Acute episode: Biliary drainage, IVF, antibiotics Chronic setting: Multiple PTCS Biliary-enteric drainage above level of obstruction Liver resection

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23 Liver Adenoma 肝臟腺瘤 Adenoma: Oral contraceptive pill Pathology: Soft fleshy tumors with smooth surface & capsule Clinical: A mass in the liver 33% patients with intraperitoneal bleeding Diagnosis: Normal liver serology, AFP Ultrasonography, CT scan Needle biopsy Treatment: Small tumors will regress with stop oral contraceptive Small central located, or multiple, dispersed: f/u Resection: Large, >5cm Painful, or ruptured Anatomic segmentectomy or lobectomy Recurrence after resection has not occurred.

24 Focal nodular hyperplasia(fnh) Pathology: Reaction to an injury rather than a neoplasm Usually solitary and small Often near the edge of liver Resembles a regenerating nodule with a central scar Clinical: Incidental findings Palpable mass or pain: less common No bleeding Diagnosis: Normal serology, AFP Sonography: isodense tumor CT scan: a central scar, and stellate distribution of the blood vessels Angiography: hypervascular tumor with large arteries, 85% AV shunting Treatment: Resection is not indicated in asymptomatic patient D/D FNH v.s. malignant tumor

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26 Gallbladder carcinoma 膽囊癌 General considerations: Uncommon, poor prognosis 1% of all cholecystectomy Old age, peak at y/o Female : male = 3 : 1 >95% with gallstones Porcelain gallbladder: 50% Direct extension to GB fossa Lymphatic spread to CBD 1/3 incidentally found during cholecystectomy Treatment: In situ & early disease: Radical cholecystectomy (including liver resection and LN dissection) Extensive disease or meta.: Palliative procedure(ptcd, ERBD, Bypass) No effective C/T agents R/T: can decrease tumor bulk & temporarily relieve obstruction, no survival benefits

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28 Hepatocellular Carcinoma(HCC) 肝癌 Etiology: Liver cirrhosis HBV, HCV Aflatoxin(Aspergillus flavus) Parasite(Liver fluke) Polyvinylchloride(PVC) Anabolic steroids Alpha1-antitrypsin deficiency Pathology: Nodular(clusters of nodules) Massive(single large mass) Diffuse(wide spread nodules) Clinical: No s/s in early stage BWL, weakness 10% rupture & bleeding Nontender hepatomegaly Splenomegaly, ascites Diagnosis: Laboratory: Hepatitis, AFP, liver function, ICG test Ultrasonography CT scan Hepatic angiography Needle biopsy

29 Hepatocellular Carcinoma(HCC) 肝癌 Treatment: Only curative therapy: surgical resection Entail Lobectomy => anatomic segmentectomy Resection margin 1cm Liver transplantation TACE PEI (percutaneous ethanol injection) RFA (Radiofrequency ablation) R/T, C/T Prognosis: Unresected HCC: poor, rarely survive beyond 4 months 5-year survival rate after curative resection: 25-30% Liver transplantation: similar to resection, higher cure rate for small HCC Fibrolamellar carcinoma: favorable prognosis