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

University and Surgical Training 1985-1988: Cambridge University BA 1988-1991: Oxford University BM, BCh 1992-1995: Liverpool SHO Rotation FRCS 1995-1997: MD University of Liverpool MD 1997-2005: Edinburgh Surgical Rotation: General Surgery and HPB and Multi Organ Transplant Surgery (FRCS Gen Surg) 2005: Consultant General and HPB Surgeon, University Hospitals, Bristol

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

Positions of Responsibility Within NHS Lead Surgeon for HPB Surgery (2006 -2013) Patient Safety Lead for Surgery (2010 – 2013) Director of Surgery, UHB. (2013 -2014) 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

Right Upper Quadrant Pain

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

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.

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

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

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

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

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

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.

Laparoscopic Cholecystectomy and Intra Operative Cholangiogram

Laparoscopic Common Bile Duct Exploration

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

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

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

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)

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

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

Hepatobiliary Functional HIDA Scan: Normal Study

Hepatobiliary Functional HIDA scan: Gallbladder Dyskinesia

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

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

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

Large Central Biliary Cystadenoma / Adenocarcinoma

Central Liver Resection for Biliary Cystadenoma / Adenocarcinoma

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

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

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

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.

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

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

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

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

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

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

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

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

Gallbladder Carcinoma involving colon and duodenum

Re-resection for gallbladder carcinoma

Re-resection for gallbladder carcinoma

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

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

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