A All Things Hepatobiliary..and more! MARK A TAYLOR PhD FRCSI - - PowerPoint PPT Presentation

“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)

Prospective recruitment of patients with proven gallstones. Detailed pro-forma of symptoms.

Patients with symptoms of IBS indicated by the Manning criteria show significantly less improvement in QOL following LC.

Manning AP et al. Toward positive diagnosis of IBS. BMJ 1978;2:653-4

Loose bowel movement with onset of pain More frequent bowel movement with

• nset of pain

Pain relieved by bowel movement

Abdominal distension

Mucous with bowel movement Sensation of incomplete evacuation

EUS

EUS considerably lower risk than ERCP More invasive than MRCP Can detect small stones/microlithiasis missed by

• ther 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

Number of predicted deaths for various cancers in 2013 in Europe Both sexes Lung 269,610 Colorectal 167,111 Breast 88,886 Pancreas 80,266 Prostate 70,347 Stomach 56,213 Leukaemia 40,941 All Cancers 1,314,236

Pancreatic Cancer

Male Female

60 30 Deaths per 100,000 population 50 40 20 10

1970 1980 1990 2000 2010 2020

20 5 Deaths per 100,000 population 15 10

1970 1980 1990 2000 2010 2020

Lung Colorectal Pancreas Stomach Leukaemia Prostate Uterus Breast

Pancreas 80,266

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

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.

NG12: Suspected Cancer referral guideline for pancreatic cancer

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 are more common in conditions with PEI Treatment of PEI prevents reduction in bone mineral density

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 nutritional deficiencies, especially of fat soluble 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

• steopenia/osteoporosis (Vitamin K)

Treating PEI reduces the prevalence of vitamin deficiencies

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

Management of malabsorption

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 Mr Lloyd McKie Mr Mark Taylor Mr Gareth Kirk Mr David Vass Ms Claire Jones CCG MATER HOSPITAL HPB SURGERY