“A “All Things Hepatobiliary…..and more!” MARK A TAYLOR PhD FRCSI FRCS(Eng) Consultant HPB Surgeon Belfast Health and Social Care Trust
“Just for Dr McEntee”
Disclaimer
Gallstones: Why so Serious!
Increasing prevalence with age • 12% men and 24% woman • 10 – 30% become symptomatic • Risk factors for mixed / cholesterol • calculi • Family history • Obesity • Diabetes • Ileal resection • Sudden weight loss
Gallstone Journey
Cholecystitis
Post Operative Problems Bleedingg Bile leak: bile peritonitis Choledocholithiasis Abscess/collection Ongoing pain/ shoulder pain Diarrhoea Bile duct injury POST CHOLECYSTECTOMY SYNDROME
Post Surgical Causes Choledocholithiasis Biliary Gastritis Remnant GB Cystic duct stone Dropped stones Peptic Ulcer Disease Pancreatitis GORD Wound Pain Neuritis Cardiac / respiratory causes Neuroma Taylor et al, Eur J Gastroenterol Hepatol. 2001 Feb;13(2):199-201
IBS and Gallstones 57000 cholecystectomies in England in 2012 700 000/ yr in USA Threshold for intervention / Sx rates. ◦ Johanning JM. The changing face of cholecystectomy . Am. Surg. 1998;64:643-64 25% have persistent symptoms after Sx. ◦ Tondelli P. Biliary tract disorders: postsurgical syndromes. Clin. Gastroenterol. 1983;12:231 Those with IBS have a higher prevalence of cholecystectomy. Kennedy TM et al. Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population BJS 2000;87:1658-63 Quality of life following Lap chole in patients with IBS symptoms (Belfast)
Loose bowel movement with onset of pain More frequent bowel movement with onset of pain Pain relieved by bowel movement Abdominal distension Mucous with bowel movement Sensation of incomplete evacuation Patients with symptoms of IBS indicated by the Manning criteria show significantly less improvement in QOL following LC. Prospective recruitment of patients with proven gallstones. Manning AP et al. Toward positive diagnosis of IBS. BMJ 1978;2:653-4 Detailed pro-forma of symptoms.
EUS EUS considerably lower risk than ERCP More invasive than MRCP Can detect small stones/microlithiasis missed by other imaging Causal finding for asymptomatic (normal LFT) CBD dilatation in 17% (prior non diagnostic CT/MRCP) Oppong K et al Scand J Gastoenterol 2014
Remnant GB Subtotal Cholecystectomy
Gallbladder Polyps Gallbladder polyps are common Gallbladder malignancy is rare ‘True’ gallbladder polyps have malignant potential Limited evidence base surrounding polyp management ESGAR 2017 guidelines addresses: ◦ Who needs cholecystectomy ◦ Who needs follow-up, frequency and duration
Gallbladder Polyps Benign – 95% ◦ Pseudopolyps – no strong evidence to say pre-malignant ◦ Cholesterol polyps ◦ Focal adenomyomatosis ◦ Inflammatory polyps ◦ ‘True’ (tumerous) polyps – do have malignant potential ◦ Adenomas - benign Malignant – 5% ◦ Adenocarcinoma – most common ◦ small cell, sarcoma, melanoma
ESGAR 2017
Taylor’s Logic Polyp > 1 cm: Refer for Lap Cholecystectomy Polyp <1cm >6mm: With Risks * Refer for Lap Cholecystectomy Poylp <1cm >6mm: No risks Serial USS (If increase Refer) Polyp<6mm Serial scan (change in size Refer) Polyp<6mm Serial Scan (no change Discharge) * Age >50, ethnic community, PSC, sessile with wall thickening> 4mm
Pancreatic Cysts
Pancreatic Pseudocyst Result of pancreatitis Can present with extreme volume
Serous Cystadenoma Predominantly benign, low risk malignancy. Vast majority incidental.
Mucinous Cystic Neoplasm Presentation includes ; • Abdominal Pain • Gastric outlet obstruction • Recurrent pancreatitis Resection based on size, signs of duct dilatation or mural nodules.
Intraductal Papillary Mucinous Neoplasm Jaundice New onset diabetes Weight loss Abdominal Pain / Pancreatitis
European Guidelines 2018
Pancreatic Cysts A common incidental finding with a wide variety of aetiology. REFER Risk of malignant potential and therefore need for surveillance; need for careful surgical selection due to high morbidity surgical interventions. Indications for surgical referral include main duct dilatation, jaundice, malignant cytology (conclusive across several guidelines ).
BREXIT NEW 50p
Pancreatic cancer 1. Head of Pancreas 2. Body and Tail
Pancreatic Cancer Number of predicted deaths Male Female for various cancers in 2013 in Europe 60 20 Both sexes Deaths per 100,000 population Deaths per 100,000 population Lung 269,610 50 15 Colorectal 167,111 40 Breast 88,886 30 10 Pancreas 80,266 Pancreas 80,266 20 Prostate 70,347 5 Stomach 56,213 10 Leukaemia 40,941 0 0 1970 1980 1990 2000 2010 2020 1970 1980 1990 2000 2010 2020 All Cancers 1,314,236 Lung Colorectal Pancreas Breast Stomach Leukaemia Prostate Uterus Adapted from Malvezzi et al Ann Oncol 2013;24:792-800
Pancreatic Cancer (C25): 2014 Proportion of Cases Diagnosed at Each Stage, All Ages
Pancreatic Cancer (C25): 1971-2011 Age-Standardised One-Year Net Survival, England and Wales Prepared by Cancer Research UK
Risk Factors Baseline ~ 10/100,000 population/year Risk Proportion of cancers Smoking x 2 30 Genetic factors x 5-10 10 Chronic Pancreatitis x 10-20 1 Hereditary Pancreatitis x 35-70 <1 Age >70 x 5 - Type II DM x 1.5-2 - Obesity x 1.7 - High fat diet x 1.7 - Previous gastric surgery x 1.8 - Sclerosing Cholangitis x 14 - Helicobacter Pylori x 1.8 -
‘Classic’ symptoms Obstructive Jaundice ◦ 50% ◦ Truly ‘painless’ in about 10%, most will have some pain, but not biliary colic Pain ◦ 70% ◦ Back / epigastrium ◦ Relieved by sitting forward Nausea / Vomiting Weight Loss Anorexia Fatigue
Other symptoms New onset type 2 diabetes mellitus ◦ underweight or normal weight patient, not associated with weight gain Resistant dyspepsia/persistent epigastric pain IBS like symptoms in those >45 years ◦ very rare as a new onset symptom at this age Altered bowel habit ◦ Increased bowel movement frequency and offensive smelling stools ◦ Suggestive of exocrine insufficiency Venous Thromboembolism ◦ may be a manifestation of an underlying abdominal malignancy
NG12: Suspected Cancer referral guideline for pancreatic cancer Refer people using a suspected cancer pathway referral for pancreatic cancer if they are aged 40 and over and have jaundice. Consider an urgent direct access CT scan, or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following: ◦ diarrhoea ◦ back pain ◦ abdominal pain ◦ nausea ◦ vomiting ◦ constipation ◦ new-onset diabetes.
Ca19-9 Not useful as diagnostic High in Biliary Obstruction Main use in disease relapse (surveillance) May be normal!
Whipples Procedure
Diabetes Of 1165 patients who underwent pancreatic resectional surgery 41.8% had preexisting diabetes Out of the remaining 678, at a median of 3.6 months, 40.4% developed diabetes Elliott IA et al. Perm J 2017;21:16
Malnutrition Poor dietary intake Malabsorption – exocrine/endocrine/vitamin deficiency Increased catabolism – acute inflammation/infection Surgical effects – ileus/DGE/Pancreatic fistula/Chylous ascites
Low bone mineral density in chronic pancreatitis patients is a consequence of vitamin D deficiency, secondary to PEI Low bone mineral density may result in a significantly higher risk of low trauma fractures, especially in the vertebrae, hip and wrist Fractures Treatment of PEI are more prevents common reduction in bone in mineral density conditions with PEI Adapted from Tignor AS et al . Am J Gastroenterol. 2010 Adapted from Sikkens ECM et al . Pancreatology 2013
As a result of malnutrition, patients can develop Treating PEI reduces the nutritional deficiencies, especially of fat soluble prevalence of vitamin deficiencies vitamins such as vitamins A, D, E, and K. Vitamin deficiency can lead to serious health problems: ‒ Decreased immune competence (Vitamin A) ‒ Osteopenia/osteoporosis (Vitamin D) ‒ Neurological disorders (Vitamin E) ‒ Blood coagulation disorders and osteopenia/osteoporosis (Vitamin K)
Management of malabsorption Frequent small meals Fluids separate from meals Limit avoid high fat foods Pancreatic enzyme supplements ◦ Creon 75 – 80 000 Units with meals, 25 – 50 000 Units with snacks
Pancreatic Cancer Unusual presentation Type 3C diabetes, Upper back pain with unexplained weight loss Ca19-9 not good for diagnosis [ANXIETY] Post operative: Creon 75 – 80 000 Units with meals, 25 – 50 000 Units with snacks PPI Monitor for Diabetes Onset
Finally Mr Tom Diamond CCG Mr Lloyd McKie MATER HOSPITAL HPB SURGERY Mr Mark Taylor Mr Gareth Kirk Mr David Vass Ms Claire Jones
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