Hepatobiliary, Pancreatic and Transplant Surgery
Core concepts
Hepatobiliary and pancreatic disease includes gallstones, choledocholithiasis, cholangitis, pancreatitis, pancreatic cancer, liver trauma, and transplant. Acute cholecystitis is usually managed with antibiotics and early laparoscopic cholecystectomy; choledocholithiasis requires biliary imaging and usually ERCP. Acute cholangitis presents with fever, jaundice, and right upper quadrant pain; treatment is antibiotics and biliary drainage, usually ERCP, not immediate surgery. Acute pancreatitis is managed with fluids, analgesia, early enteral nutrition when tolerated, and treatment of the cause; routine antibiotics are not indicated without infection. Pancreatic head cancer often causes painless jaundice and a double-duct sign. Liver trauma ranges from observation in stable patients to operative or angiographic control in unstable patients. Transplant recipients require immunosuppression and vigilance for rejection, infection, and drug toxicity.
Traps
Do not miss choledocholithiasis because liver enzymes are only mildly elevated. Do not give prophylactic antibiotics for sterile necrotizing pancreatitis. Do not delay drainage in cholangitis with sepsis. In transplant patients, fever may be blunted; rejection can present with rising liver enzymes or creatinine. Avoid nephrotoxic drugs when possible.
Worked example
A patient with fever, jaundice, RUQ pain, and dilated bile ducts has ascending cholangitis. Resuscitate, give antibiotics, and arrange urgent ERCP for drainage. Rule of thumb: cholangitis equals drainage plus antibiotics; surgery is reserved for failed drainage or specific complications.