Resident Teaching Conference 10/16/09 Rondi Kauffmann Resident presenter William Nealon Faculty presenter

Resident Teaching Conference 10/16/09 Rondi Kauffmann Resident presenter William Nealon Faculty presenter

KC 59 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

PMH Htn Pulmonary nodule Dyslipidemia Heart murmur Diverticulosis PSH Tonsillectomy vasectomy FH Lung cancer father Htn mother, sister, brother Meds Benicar Vitamin B Zocor Omeprazole Aspirin SH Married Retired Smoked 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 Exam P: 76 BP: 176/92 RR: 18 bpm Temp: 98.1 General: A&O, no jaundice, no lymphadenopathy Abdomen: soft, nontender, no masses, normal rectal exam

Labs 138 103 8 4.4 27 0.8 7.5 293 42 LDL 150 Cholesterol 208 Triglycerides 132 HDL 32 Total protein 7.5 Albumin 4.4 Total bilirubin 0.7 Alk phos 67 ALT 37 AST 35 Amylase 13 Lipase 19 Ca19 9 108

EUS with biopsy Body with normal echotexture Pancreatic duct measures 1.1 mm in diameter Large, well circumscribed, anechoic lesion measuring 2.5 cm x 4.7 cm arising from body No septations Normal pancreatic duct without stricture or stone

FNA Pathology: mixed lymphoid population, granular debris, negative for malignancy CEA: 674.9 Cyst fluid amylase <10

Treatment Central pancreatectomy, omental pedicle flap, serosal patch Final pathology: pancreatic lymphoepithelial cyst, negative for malignancy

RR 63 year old male Referred to Surgery clinic with abdominal fullness and pain

HPI: 3 months duration of symptoms Weight loss of 32 lbs. in 10 weeks No fever, chills, nausea, melena, steatorrhea, jaundice ROS negative except for HPI

PMH Type 2 diabetes Thyroid cyst Hypertriglyceridemia PSH Tonsillectomy/adenoidectomy Cystoscopy EGD/colonoscopy 2008 FH Type 2 diabetes father Meds Protonix Captopril Synthroid Crestor Tylenol Naproxen MVI Echinacea Garlic Lantus Humalog

Physical Exam P: 120 BP 154/95 RR 18 bpm temp 98.1 General: A&O, no jaundice, no wasting Abdomen: soft, mild tenderness, no masses

Labs 133 97 12 3.6 16 1.34 353 Total protein 7.1 Albumin 4.3 Total bilirubin 1.8 Alk phos 120 ALT 20 AST 20 CEA 458.5 Ca 19 9 29, 245

EUS with FNA and cyst aspiration Large loculated cystic lesion arising from neck of pancreas Contained septations 2.5 x 3.0 cm Difficulty passing the scope into duodenum

Cytopathology Cyst FNA: Degenerated cells with amorphous debris, not diagnostic of malignancy No mucin Cyst amylase 1209 Cyst CEA >50,000 Pancreas neck FNA: adenocarcinoma Duodenal bulb biopsy: involved by moderate to poorly differentiated adenocarcinoma

PET Intense uptake corresponding to masses in right colon and pancreas Three low density lesions within the liver Multiple mesenteric lymph nodes with moderate FDG uptake Mild 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 discharge C. Once her amylase is normal D. 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. Laparotomy B. Nasogastric tube decompression and broad spectrum antibiotics C. 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 debridement B. Cystgastrostomy C. Roux en Y cystjejunostomy D. Enteral feeding distal to the ligament of Treitz E. CT guided percutanous drainage

Pseudocysts Develop in 5 10% of patients with acute pancreatitis and 50% of patients with chronic pancreatitis Suspect if patient does not recover with one week of medical therapy, or when symptoms return after period of improvement

Pseudocysts Acute fluid collection Irregular in shape Frequently resolve Debridement reserved for necrotizing pancreatitis with infection or abscess Follow with serial CT Treatment: expectant management Pseudocyst Require 6 12 weeks to mature Caused by disruption of pancreatic duct Usually seen in setting of chronic pancreatitis May cause obstruction of gastric outlet or biliary tree

Complications of Pseudocysts Obstruction Infection Pain Hemosuccus pancreaticus

Treatment of Pseudocysts Open Laparoscopic Endoscopic

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 dialysis B. Exploratory laparotomy C. Needle aspiration D. 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. ERCP B. Surgical decompression C. Percutaneous aspiration D. 14 day course of antibiotics E. Repeat CT scan in 30 days

Treatment of pseudocysts MUST send biopsy of cyst wall to exclude malignancy