Chronic pancreatitis

Chronic pancreatitis Compared to acute– Maybe painless, normal amylase and lipase, mononuclear infiltrate and fibrosis TIGARO– Toxin(ethanol, hypercalcemia, hyperlipidemia, acidosis, CRF), idiopathic, Genetic, autoimmune(Sjogren, IBD, PBC), Recurrent acute, Obstructive Etiology– alcohol, smoking, hereditary pancreatitis(before 20yrs old), ductal obstruction, tropical pancreatitis, systemic(cystic fibrosis, SLE), CFTR, SPINK1, PRSS1,  Presentation– pain(after meal 15~30mins), steatorrhea>protein deficiency, pancreatic diabetes(alpha and […]

Acute pancreatitis

Acute pancreatitis Etiology– Gallstone(<0.5cm), ethanol, hyperlipidemia, hypocalcemia, infection, drug, trauma, ERCP, vasculitis, ishemia, CFTR, PRSS1, SPINK1 Presentation– Epigastric pain. nausea, vomiting, knee-chest position relief pain, Cullen’s sign, Grey Turner’s sign Lab– Amylase(6~12hrs elevated, 3~5 days subsided), lipase(4~8hrs elevated, day 1 reach the peak, 8~14 days subsided), Trypsinogen activation peptide (TAP) KUB– Colon cut off sign(bowel […]


Cholangiocarcinoma, CCA Anatomy:  1.Intrahepatic- Proximal to the bifurcation of the right and left hepatic ducts, 10% 2.Extrahepatic a)Perihilar- Confluence+proximal to insertion of cystic duct into CBD, 50% b)Distal extrahepatic- Distal to insertion of cystic duct into CBD to ampulla of Vater(not included), 40%→ pancreaticojejunostomy, PD  Bismuth-Corlette classification for perihilar tumors Type I below confluence en […]


Cholangitis Charcot’s triad- fever, RUQ pain, jaundice Reynold’s pentad- Charcot’s triad + shock + conscious loss Diagnosis A. Systemic inflammation A‐1. Fever and/or shaking chillsA‐2. Laboratory data: evidence of inflammatory response B. Cholestasis B‐1. JaundiceB‐2. Laboratory data: abnormal liver function tests C. Imaging C‐1. Biliary dilatationC‐2. Evidence of the etiology on imaging (stricture, stone, stent […]

Acute cholecystitis

Acute cholecystitis Presentation- RUQ pain(4~6hrs), Murphy’s sign, leukocytosis, fever, Mirizzi syndrome(stone at cystic duct, compress common hepatic/common bile duct from external) Imaging Ultrasound- Wall>4~5mm, double wall sign Cholescintigraphy(HIDA scan)- 30~60 mins present at CBD, gallbladder. Positive if absent Morphine cholescintigraphy- Morphine increased sphincter of Oddi pressure, decreased false positive of HIDA scan MRCP- Detect stone […]

Hepatocellular carcinoma

Risk factor- HBV, HCV, nitrosamine, aflatoxin, senecio alkaloid, alcohol, metabolic syndrome, DM, iron overload, obesity, Alpha-1 antitrypsin deficiency, AIP, gallstone, cholecystectomy, red meat Protective factor- Statin, aspirin, NSAID, white meat CT- Arterial phase(early enhance, hyperdense), Venous phase(early washout, hypodense) Systemic effect and paraneoplastic syndrome- Painful gynecomastia, hypercalcemia, hypoglycemia, hyperlipidemia, hyperthyroidism, pseudo-porphyria Presentation- Abdominal pain, weight […]

Benign hepatic tumor

1.Hemangioma Risk factor- female, contraceptive Presentation- >5cm would pain X-ray- Calcified capsule Echo- well-defined, lobulation, homogenous, hyperechoic, hypoechoic(hemorrhage/fibrosis) CT- Arterial phase(contrast diffuse from outside into inside), venous phase(hemangioma light up), centripetal enhancement, cotton-wool enhancement Surgery indication- Kasabach-Merritt syndrome (exhausted Plt and coagulation factor, Microangiopathic hemolytic anemia), hemorrhage, suspect malignancy 2.Focal nodular hyperplasia(FNH) Risk factor- Female, […]

Liver abscess

Risk factor- DM, hepatobiliary disease, pancreatic disease, liver transplant, PPI, CGD Pathogenesis- Gallstone/malignant obstruction, penetrating wound, blood Pathogen- K.p, E.coli, Streptococcus milleri, Staphylococcus aureus, Streptococcus pyogenes Type Pyogenic (80%) Bile duct Multiple, DM, jaundice 1.Ceftriaxone + metronidazole2.Piperacillin + tazobactam3.Ampicillin + gentamicin + metronidazole Amebic (20%) Colon Focal, IHA>1:32 Metronidazole Manifestation- Fever, abdominal pain, nausea, vomiting […]