NMS. Casos Clínicos

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Chapter 7 ♦ Pancreatic and Hepatic Disorders

Figure 7-21: CT scan of a gallbladder cancer ( arrows ). (From Yamada T, Alpers DH, Owyang C, et al. Textbook of Gastroenterology , 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1999:3037.)

◆ ◆ If CT reveals an infiltrating mass in the gallbladder with no evidence of metastatic dis- ease, it is advisable, if possible, to perform an open cholecystectomy, a wide resection of the surrounding liver, and a hilar lymph node resection . Most surgeons advocate a wedge resection of the liver with a 2–3-cm margin around the gallbladder. Laparo- scopic cholecystectomy is probably not appropriate because of the inability to remove sufficient hepatic tissue. ◆ ◆ The most common means of spread in carcinoma of the gallbladder is by direct extension into the liver. Unfortunately, the discovery of most of these cancers occurs late in their course, when they involve a large portion of the liver, making them unresectable . Case Variation 7.13.4. A 3-cm polyp in the gallbladder ◆ ◆ Observation of small polyps is usually appropriate. Cholecystectomy is warranted for re- moval of larger polyps (>2 cm) because of the 7%–10% risk of developing adenocarcinoma of the gallbladder. Case Variation 7.13.5. A calcified gallbladder ◆ ◆ A calcified gallbladder, also called a porcelain gallbladder, has an association with adeno- carcinoma and should be removed. SAMPLE Case 7.14 Acute Epigastric Pain with High Serum Amylase and Lipase You are following a 29-year-old who had an episode of epigastric pain. The serum amylase and lipase are three times normal, and no gallstones are visible on ultra- sound examination of the abdomen. Q: What management is appropriate? A: This patient most likely has pancreatitis based on initial assessment. To be certain that you are not missing other possible diagnoses, an obstructive abdominal series is necessary to