NMS. Casos Clínicos

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Chapter 7 ♦ Pancreatic and Hepatic Disorders

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◆ ◆ If no biliary leak or collection is evident on ultrasound, and the scan reveals normal hepatic excretion, then it is appropriate to follow the patient. If a collection is found and it is of significant size, it should be drained completely. If a biliary leak or obstruction is seen, the patient should undergo an ERCP to define the biliary anatomy and place a biliary stent depending on where the bile duct injury is. Some surgeons also obtain a computed tomography (CT) scan to rule out a hepatic abscess proximal to hepatic duct obstruction. Case Variation 7.10.2. Jaundice ◆ ◆ The workup is similar to that previously described in Case Variation 7.10.1. Case Variation 7.10.3. A leak on HIDA scan and a cystic duct stump leak on ERCP (Fig. 7-12) ◆ ◆ Management usually involves biliary drainage with a temporary stent placed during ERCP (Fig. 7-13). Exploration is necessary in the patient who fails to improve rapidly. Q: How would the proposed management change if both the HIDA scan and the ERCP demonstrate complete obstruction of the bile duct? A: Re-exploration and some sort of biliary drainage procedure are necessary. Occasionally, primary repair of the ductal injury is possible, but more often, a new biliary-enteric anasto- mosis is essential. The typical operation is a Roux-en-Y choledochojejunostomy or hepati- cojejunostomy. Figure 7-11: Hepatobiliary iminodiacetic acid (HIDA) scans A. HIDA scan of a normal patient. HIDA makes use of the radionuclide 99mTc attached to bilirubin analogs bound to iminodiacetic acid. This compound is injected intravenously, processed by hepatocytes, and excreted into the bile. In a normal person, filling of the liver, gallbladder, and biliary tract occurs within 60 minutes after injection. Note the filling of the liver (L), gallbladder (GB), and common bile duct (CBD) within 60 minutes after injection. B. HIDA scan of a patient with acute cholecystitis. Note the absence of filling of the gallbladder (GB) minutes after morphine injection, which contracts the sphincter of Oddi and leads to a rise of biliary system pressure. Even after morphine injection, the gallbladder does not fill, which is diagnostic of a blockage. However, the liver (L) and common bile duct (CBD) are filled. Because most gallstones are composed of cholesterol (and therefore radiolucent), plain abdominal radiographic films are often of little value. Therefore, ultrasonography and HIDA are the methods of choice for diagnosis. CBD = common bile duct, CD = cystic duct, CHD = common hepatic duct, D = duodenum, GB = gallbladder, LHD = left hepatic duct, PD = pancreatic duct, and RHD = right hepatic duct. (From Dudek RW. High-Yield Gross Anatomy , 4th ed. Wolters Kluwer Health; 2010, Fig. 11-6D, E.) SAMPLE