1. Right Upper Quadrant Pain and Abnormal LFTs
Mr Ian Pope, BA, MD FRCS (Gen Surg)
Consultant Hepato-Pancreatico-Biliary (HPB) and General Surgeon
Bristol Royal Infirmary; Spire Hospital, Bristol

2. University and Surgical Training
: Cambridge University BA
: Oxford University BM, BCh
: Liverpool SHO Rotation FRCS
: MD University of Liverpool MD
: Edinburgh Surgical Rotation: General Surgery and HPB and Multi Organ Transplant Surgery (FRCS Gen Surg)
2005: Consultant General and HPB Surgeon, University Hospitals, Bristol

3. Clinical Interests
Liver Cancer (HCC), Colorectal Liver Metastases, Bile Duct Cancer, Gallbladder Cancer, Pancreatic Cancer
Gallstones, Pancreatitis, Liver Cysts, Pancreatic Cysts, Bile Duct injury, Liver and Pancreatic Trauma
Advanced Laparoscopic Surgery, Hernia Surgery, Abdominal Pain

4. Positions of Responsibility Within NHS
Lead Surgeon for HPB Surgery ( )
Patient Safety Lead for Surgery (2010 – 2013)
Director of Surgery, UHB. ( )
South West Clinical Senate (2014)
Council Great Britain and Ireland HPB Association (GBIHPBA)
Association of Upper GI Surgeons (AUGIS) Panel for prospective randomised trials in gallbladder disease

5. Right Upper Quadrant Pain

6. Investigations Radiology Biochemistry Ultrasound LFTs CT
MRCP
Liver Specific MRI
Secretin MRCP
Fibroscan
Biochemistry
LFTs
Non Invasive Liver Screen
Endoscopy
Endoscopic Ultrasound
ERCP
Spyglass
Biliary Manometry

7. Liver Function Tests
Bilirubin: Obstructive Jaundice, Gilbert’s, Haemolytic Jaundice.
ALT: Hepatitis / Acute Liver injury, Biliary Obstruction.
Alk P: Biliary Obstruction, Liver regeneration, Skeletal Pathology.
Gamma GT: Biliary Obstruction, Alcohol.
Albumin: Synthetic Function, Nutrition, Protein Loss.

8. Non-Invasive Liver Screen
Viral Hepatitis Screen: A, B, C, E, EBV, CMV
Auto-Antibodies:
Anti Nuclear Antibody,
Anti Smooth Muscle Antibody
Anti Mitochondrial Antibody
Immunoglobulins
Ferritin
Caeruloplasmin
Alpha 1 anti trypsin
CRP
Lipids, Glucose
INR

9. Ultrasound Findings Liver Liver Cysts, Focal Liver Lesion
Liver Metastases / HCC / Cholangiocarcinoma
Biliary Gallstones
Gallbladder Polyp
Common Bile Duct (CBD) Dilatation (No Gallstones)
Intra Hepatic Duct Dilatation
Choledochal Cyst
Pancreatic Pancreatic Mass
Pancreatic Cyst
Pancreatic Duct Dilatation

10. Biliary Pain / Colic
6 – 8 hour history of severe epigastric and RUQ pain
Radiation to back and shoulder
Associated nausea and vomiting
Worse pain ever had, nearly called an ambulance
Previous milder attacks over last 12 months
Tends to come on after eating, cheese, diary
Likely Biliary Colic
Plan U/S and LFTs

11. Ultrasound: Gallstones
U/S has 98% sensitivity for gallstones
Filling defect with acoustic shadow
Gallbladder wall thickness
CBD calibre (3-4mm)
CBD: normal is 1mm per decade age eg 8mm and 80yrs
Impaction of stone in neck of gallbladder
LFTs normal
Abnormal LFTs with cholecystitis or CBD stones

12. Complications of Gallstones
Biliary colic
Acute cholecystitis
Mucocoele
Empyema
Perforation
Mirrizzi Syndrome
Obstructive jaundice
Cholangitis
Acute Pancreatitis
Gallbladder cancer
Gallstone Ileus

13. Laparoscopic Cholecystectomy
98% Laparoscopic Operation
Conversion: adhesions, biliary anatomy, bleeding
Day Case / Overnight Stay
Median time to recovery 12 days
Possible need for CBD exploration
Complications: bleeding, infection,
bile leak (1:200),
bile duct injury (1:300),
long term diarrhoea.

14. Laparoscopic Cholecystectomy and Intra Operative Cholangiogram

15. Laparoscopic Common Bile Duct Exploration

16. Gallstones and Abnormal LFTs
Pre-Operative ERCP / Duct Clearance was routine (70% no stones)
Complications: Bleeding,
Acute Pancreatitis,
Perforation
Mortality 1%
Sphincter Stenosis
Cholangiocarcinoma
Pre-Operative Imaging: MRCP
Intra-Operative Imaging: Cholangiogram, Laparoscopic Ultrasound
Reserve ERCP for Elderly, Unfit, Cholangitis, Deep Jaundice

17. NICE Guidance: Acute Cholecystitis, 2014
Superimposed infection and GB wall thickening on U/S
Hospital admission or A and E attendance
Optimal management is early laparoscopic cholecystectomy which should be within 7 days of presentation
Associated: lower rates conversion
shorter hospital stay
Delayed cholecystectomy:
6-8 weeks following acute attack
repeated admissions
higher complication rates

18. No Improvement following Cholecystectomy
Retained CBD Stones
LFTs
MRCP
EUS
Surgical Complications
Subtotal Cholecystectomy
Sphincter of Oddi Dysfunction
Other Pathology

19. No Gallstones Seen on UltraSound Scan
Typical Biliary Pain
Precipitated by fatty meals
Recurrent / prolonged duration of symptoms
Abnormal LFTs associated with pain
Acute pancreatitis (Idiopathic)
Absence of alarm symptoms / suspicion of cancer
Consider: Microlithiasis
Biliary Dyskinesia (Gallbladder / SOD)

20. Endoscopic Ultrasound (EUS): Microlithiasis
‘Starry Night’ Sign
Stone debris below resolution of ultrasound seen on agitation with EUS scope.
Causes biliary colic, transient CBD stones, acute pancreatitis
Indication for laparoscopic cholecystectomy

21. Biliary Dyskinesia
Motility Disorder affecting Gallbladder and / or Sphincter of Oddi
Gallbladder Dyskinesia: diagnosed by gallbladder ejection fraction on HIDA scan
Abnormal value <40%
90% Patients pain free following cholecystectomy
Biliary Sphincter of Oddi Dysfunction:
May result in pain, abnormal LFTs and biliary Dilatation on U/S
Diagnosis on HIDA, Manometry or Secretin MRCP
Long term relief of symptoms in 80% patients following ERCP and ES
Pancreatic Sphincter of Oddi Dysfunction is a cause of recurrent acute pancreatitis and pancreatic pain
Improves with pancreatic sphincterotomy

22. Hepatobiliary Functional HIDA Scan: Normal Study

23. Hepatobiliary Functional HIDA scan: Gallbladder Dyskinesia

24. Secretin MRCP: Sphincter of Oddi Dysfunction
Pre Secretin
Post Secretin
Pancreatic duct 3mm
Pancreatic duct dilated to 8mm

25. Other U/S Findings: Gallbladder Polyps
Gallbladder polyps often reported on U/S if do not cast an acoustic shadow
Many are stones and so offer cholecystectomy if symptomatic
Require surveillance due to risk of carcinoma (16%)
< 4mm 2-3 years
4 - 10mm annual
Cholecystectomy if > 10mm
or if age > 50, single polyp, sessile
Asymetrical GB wall thickening = GB Cancer

26. Liver U/S: Cysts and Biliary Cystadenoma
Small cysts under 5cm unlikely to be a cause of pain
Larger cysts cause pain due to pressure / mass effect (early satiety / SOB)
Treatment : Laparoscopic De-roofing, Resection, Transplantation
Complex Cysts: wall thickening, solid content, multiple septations, suggestive of Biliary Cystadenoma / Carcinoma

27. Large Central Biliary Cystadenoma / Adenocarcinoma

28. Central Liver Resection for Biliary Cystadenoma / Adenocarcinoma

29. Focal Liver Lesions on U/S
Usually an incidental finding on U/S or CT
Characterisation often requires Liver MRI
Adenoma: risk of bleeding and malignant transformation, stop OCP and refer to HPB, biopsy and genetic subtyping
Focal Nodular Hyperplasia (FNH): Asymptomatic, Benign
Haemangioma: Asymptomatic, Benign
Liver Abscess: Pain, Sepsis, raised CRP / WBC, low albumin
HCC: risk in chronic liver disease
Liver metastases

30. U/S: Intra Hepatic Biliary Dilatation; Normal CBD = Hilar Cholangiocarcinoma
Alk Phos may be only LFT abnormality
Jaundice occurs when complete obstruction occurs
Isolated duct dilatation may be intrahepatic cholangiocarcinoma
Differential autoimmune cholangiopathy (IgG4 disease)
ERCP / Spyglass / Biopsy

31. Biliary U/S: Choledochal Cysts
Dilated bile duct on U/S may represent a choledochal cyst if no distal obstruction.
Associated with abdominal pain and recurrent cholangitis
Risk of cholangiocarcinoma
Anomalous junction of pancreatic and biliary duct insertion
Diagnosis on U/S and MRCP
Surgery required to excise extra hepatic component and reduce risk of malignancy

32. Pancreatic Carcinoma Pain is a late presentation
Abnormal LFTs / Jaundice
U/S: Dilated CBD
Possible Early Symptoms:
New onset or worsening diabetes
Pancreatic Exocrine Insufficiency: diarrhoea, pale motions, weight loss
‘Double Duct’ on U/S or CT is pancreatic / periampullary carcinoma until proven otherwise.
Pancreatic Duct Dilatation requires referral to exclude pancreatic cancer.

33. Chronic Pancreatitis
Central upper abdominal pain with radiation to back, exacerbated by eating / alcohol
Investigation to exclude pancreatic cancer, U/S, CT, MRCP, EUS.
Exocrine Insufficiency: Check Faecal Elastase. Replacement therapy can improve pain
Pain Management: Opiates, Coeliac Plexus Block
Dilated Pancreatic duct: suitable for surgery or pancreatic duct stent.
Radiological Findings (U/S, CT, MRCP, EUS: Heterogenous pancreas, pancreatic calcification, side duct ectasia, dilated PD, PD stones

34. Chronic Pancreatitis and Pancreatic Cancer
Chronic pancreatitis is a risk factor for pancreatic cancer
Deterioration in symptoms of pain may be due to development of cancer
Obstructive jaundice due to chronic inflammation or pancreatic cancer
Worsening of diabetic control due to progressive PD obstruction

35. U/S or CT: Pancreatic Cysts: Cause of Pain or Incidental Finding?
Pancreatic Pseudocyst:
Risk of abscess, bleeding, rupture.
Require intervention if >6cm or symptomatic
Cystic Pancreatic Tumours:
Serous Cyst Adenoma (Benign)
Mucinous Cystadenoma (potentially malignant)
Intraductal Papillary Mucinous Neoplasia (IPMN)
Main Duct (high risk of malignancy)
Side Branch (30% cancer risk when >3cm)
Increased risk of malignancy if symptomatic

36. CT Assessment of Pancreatic Cysts
Pancreatic Pseudocyst
Serous Cyst Adenoma
Mucinous Cyst Adenoma
Intra-ductal Papillary Mucinous Neoplasia (IPMN)

37. EUS: Diagnosis of Cystic Pancreatic Lesions
Morphology
EUS guided fine needle aspiration (FNA)
Cyst fluid for Amylase, CEA and Cytology
CEA greater than 200 suggests mucinous lesion
Diagnosis, surveillance or surgery

38. MRCP: Multifocal Side Branch IPMN
Asymptomatic
Incidental finding of pancreatic cysts on U/S
3 areas of side branch IPMN
Largest lesion 2cms
Suitable for surveillance

39. Main Duct IPMN of Tail of Pancreas
Theatre
Main Duct IPMN of Tail of Pancreas
Solid Pseudo Papillary Tumour
69 yr old man, upper abdominal pain
U/S: Cyst in tail of Pancreas
CT: 3cm Cystic lesion tail of Pancreas
Operation: Distal Pancreatectomy, Splenectomy, Colectomy.
17 yr old girl, upper abdominal pain
U/S: Mass tail of pancreas
MRI: 7cm mass body pancreas
Operation: Spleen preserving distal pancreatectomy

40. Gallbladder Cancer Presentation similar to hilar cholangiocarcinoma
Abnormal Gallbladder with associated hilar mass on CT
Incurable if presenting with obstructive jaundice at time of diagnosis
Treatment is stent placement by PTC
Very poor prognosis

41. Gallbladder Carcinoma involving colon and duodenum

42. Re-resection for gallbladder carcinoma

43. Re-resection for gallbladder carcinoma

44. Major Bile Duct Injury 1 in 300 lap cholecystectomies
50,000 cholecystectomies performed in UK annually
Requires biliary reconstruction
Long term risk cholangitis
Long term risk secondary biliary cirrhosis
Long term risk cholangiocarcinoma

45. Major Bile Duct Injury: Unlawful Killing
Right portal vein injury
Right hepatic artery injury
Infarction of right liver
Repatriated to UK
Post operative liver failure
Rupture of IVC (filter)
Death

46. Ultrasound Findings Liver Liver Cysts Focal Liver Lesion
Liver Metastases / HCC / Cholangiocarcinoma
Biliary Gallstones
Gallbladder Polyp
Common Bile Duct (CBD) Dilatation (No Gallstones)
Intra Hepatic Duct Dilatation
Choledochal Cyst
Pancreatic Pancreatic Mass
Pancreatic Cyst
Pancreatic Duct Dilatation