NMS. Casos Clínicos

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Chapter 7 ♦ Pancreatic and Hepatic Disorders

11. The most common solid liver masses are hemangioma, which usually do not require surgery. 12. The most common malignant tumor of the liver is metastatic carcinoma. The primary cancer should be sought. Resection of metastatic colonic carcinoma to the liver, with no metastasis outside the liver, can result in long-term survival. 13. Hepatocellular carcinoma, the most common primary liver cancer, is associated with cirrhosis and an elevated serum alpha fetoprotein level. 14. Liver failure has an elevated international normalized ratio (INR) due to deficiency of factors II, VII, IX, and X, which is corrected with fresh frozen plasma (FFP) or cryoprecipitate in an acute bleed and vitamin K. It also is associated with thrombocytopenia due to hypersplenism.

COMMON PANCREATICOBILIARY DISORDERS Critical Surgical Associations

If You Hear/See Jaundice—painful Jaundice—painless

Think

Gallstones

Pancreatic cancer

CA 19-9

Marker for pancreatic cancer

Ampullary cancer

Curative resection may be possible

Cholangiocarcinoma Acute pancreatitis “Chain of lakes” duct

Usually not resectable Gallstones or alcohol Chronic pancreatitis Small ones resolve

Pseudocyst

Symptomatic pseudocyst

Cyst-gastrostomy for internal drainage Endoscopic ultrasound for diagnosis

Question of pancreatic infection Q: How would you manage this patient? A: Generally, less than 10% of patients with asymptomatic gallstones develop symptoms requiring surgery over a 5-year period. For this reason, cholecystectomy is not generally recommended in asymptomatic patients except in certain individuals. Exceptions may include immunocom- promised patients because they are prone to more serious complications of gallstone disease; patients with a porcelain gallbladder (calcified gallbladder); and patients with gallstones larger SAMPLE Case 7.1 Asymptomatic Gallstones A 24-year-old woman with a family history of polycystic kidney disease is being screened by ultrasound to determine if she has the disease. She does not have the disease, but ultrasound examination shows several small gallstones (Fig. 7-1). Further history and review of symptoms find no evidence of symptomatic gallstone disease.