SCORE 4-6

High-protein low-fat diet
Low-fat diet with medium-chain triglyceride supplementation
Total parenteral nutrition and bowel rest

1. Endoscopic variceal bbanding / sclerotherapy wtih nonselective betablockers
Esophagogastroduodenoscopy (EGD) with EVB/S should be performed every 2 to 8 weeks until esophageal and esophagogastric varices are obliterated.

1. Complete blood count (CBC), Basic metabolic panel (BMP), LFTs, C-reactive protein (CRP), Blood cultures, Echinococcosis and Entamoeba histolytica serologies
2. CT with IV contrast

1. For a single, simple cyst that is smaller than 5 cm, initial treatment can be albendazole or mebendazole alone.
2. Surgical cyst excision can be considered for persistent cysts or larger cysts that are anatomically amenable to surgery.
Avoid spillage as this can lead to anaphylaxis and seeding.
3. For large or complex multicystic lesions without daughter cells, puncture-aspiration-injection-reaspiration (PAIR) is the procedure of choice.
4. PAIR consists of puncture and needle aspiration of the cyst, injection of a solution, cyst reaspiration, and then irrigation.
5. Periprocedural albendazole or mebendazole is given 4 hours before PAIR and for at least 28 days after the procedure.
Surveillance is adequate for inactive cysts.

1. Repeat imaging 1-2 weeks after drain placement is recommended or sooner if the drain output drops suddenly and catheter migration is suspected. If the catheter is clogged and unable to be flushed, the catheter has migrated or if the abscess is still persistent, upsizing the percutaneous drain is recommended.
2. If the patient’s symptoms resolve and the lesion on imaging remains stable or becomes smaller, no further procedure may be necessary. After clinical stabilization, IV antibiotics can be switched to oral.
3. abx for 2-6 weeks

1. Right hepatectomy involves resection of segments V to VIII.
2. Left hepatectomy involves resection of segments II to IV.
3. Extended right hepatectomy (or right trisegmentectomy) involves resection of all segments lateral to the umbilical fissure (IV-VIII).
4. Extended left hepatectomy (or left trisegmentectomy) involves resection of the left lobe plus the anterior sector of the right liver (segments II-IV, V, and VIII), with or without segment I.

1. CEA levels, LFTs
2. CT scan and liver MRI . PET
3. When to consider biopsy for liver met : patient has suspected metastatic lesions, or the primary site is unknown, biopsy can provide specimen for pathologic, immunohistochemistry, and molecular testing.

1. Pathologic
2. Immunohistochemistry
3. Molecular testing

1. On triphasic CT, these are characterized by peripheral and nodular enhancement on arterial phase followed by progressive centripetal fill-in on portal venous phase.
2. On precontrast MRI, these are hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging.

1. On CT, these are characterized by strong and homogenous enhancement on arterial phase, except for a commonly seen central scar that remains hypoattenuating in portal venous phase (lesions > 5 cm more commonly show this central fibrous scar)
2. On MRI, the central scar is hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging.

1. early arterial enhancement followed by isoattenuation during portal and delayed-phase imaging.

1. On ultrasound, they appear as anechoic lesions with irregular thick walls with internal septation. Mural nodules, thickening of septations, and papillary infoldings can also be seen.
2. On CT, size and anatomic relationships are better appreciated. Findings include an isodense tumor compared to water, enhancement of mural nodules, wall calcifications, and septations of the cyst.
3. On MRI, multiloculated, septated lesions are also apparent. MRI provides better anatomic characterization (such as communication with the biliary system). On T1, these lesions are hypointense, and on T2, they are hyperintense.

1. individuals with symptomatic adenomas or with lesions greater than 5 cm or for women who have larger adenomas with a previous complicated pregnancy.
2. those women who cannot discontinue hormonal therapy
3. women who are pregnant
4. men because of increased risk of malignancy.

Symptomatic large simple liver cysts may be fenestrated by resecting the cyst wall and perhaps placing an omental pedicle in the cyst space. The cyst wall is sent to pathology to confirm that it is a simple cyst (as opposed to a cystadenoma).

Cystadenomas should be completely resected with negative margins given their potential for malignant degeneration.

1. Labs : CBC, LFT, Coag, viral serologies, CEA, CA 19-9 , AFP
2. US (surveillance q6M) , CT liver / MRI liver protocol

“classic” imaging findings of an arterially enhancing mass with contrast washout in the portal venous phase. Lesions of 1 to 2 cm may require both contrast-enhanced triple-phase CT and MRI to differentiate them from other liver lesions

mass that shows peripheral or central enhancement on contrast-enhanced scans and may be associated with peripheral biliary ductal dilation.

appears similar to cystadenoma and can be difficult to differentiate with imaging modalities. It therefore requires tissue diagnosis (showing bile, mucin, and glandular cells). Nodular enhancement and papillary projections are more often correlated with a diagnosis of cystadenocarcinoma (as opposed to cystadenoma).

1. Staging is performed preoperatively with cross-sectional imaging to identify occult metastases, multifocal tumors, or extension into adjacent vascular structures or the main biliary confluence.
2. With a liver mass on imaging or liver biopsy consistent with adenocarcinoma, it is important to rule out other sources of a gastrointestinal primary malignancy with upper and lower endoscopy or positron emission tomography because the most common adenocarcinoma lesion in the liver is a metastatic lesion.
3. The American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) classification stages tumors based on size, number of tumors, invasion of blood vessels, and involvement of regional nodes and presence of distant metastasis. Stage IV is considered unresectable disease.

hepatic tumors less than 3 cm who are poor surgical candidates or as a bridge for liver transplant. Complications include bleeding, vascular thrombosis, abscess, and injury to surrounding structures and organs such as the gallbladder and colon.

effective in patients with hepatic neoplasms who are poor surgical candidates or as a palliative liver-directed therapy to control tumor growth. Chemotherapy is injected into the tumor through blood vessels and is combined with an embolic agent to cut off the blood supply to the tumor.

Radioembolization using yttrium-90 embedded particles can be used for larger unresectable HCC tumors to halt tumor growth and potentially increase time to progression

1. Adjuvant chemotherapy with oral capecitabine
2. monitored with cross-sectional imaging and tumor markers every 3 to 6 months for the first 2 to 3 years and then every 6 months for up to 5 years.

AFP and CT or MRI every 3 to 6 months for 2 years. Following this period, they are monitored with AFP and imaging every 6 to 12 months.

1. Position the patient supine with the right hand under the head.
2. Identify the lesion of interest with percussion and ultrasound guidance.
3. Inject lidocaine over the upper border of the rib to avoid the subcostal vessels.
4. Use a scalpel to create a small skin incision and then pass the needle through the skin and subcutaneous tissue into the lesion of interest under ultrasound guidance.
5. Obtain the biopsy using a core or Tru-Cut needle while the patient is holding his or her breath.

1. Depending on the location of the lesion, make a right subcostal or upper midline laparotomy incision with placement of appropriate retractors (Thompson, Bookwalter).
2. After the round and falciform ligaments are taken down, they may be used for retraction. Depending on location, it may be necessary to divide the triangular and coronary ligaments to aid in exposure.
3. After adequately exposing the lesion, biopsy it, usually with a Tru-Cut or core needle or wedge resection. Attempt to identify all relevant anatomic structures, including the hepatic veins, inferior vena cava, porta hepatis, and so on.

include invasion of main portal vein or common hepatic artery, extrahepatic adjacent organ invasion and metastatic disease.
diagnostic laparoscopy is advised to rule out extrahepatic involvement or locally advanced disease

1. Laparoscopic inspection for cholangiocarcinoma and high-risk cases
2. Incision (eg, upper midline, subcostal, Chevron, J-type)
3. Liver mobilization and Pringle if appropriate
4. Control of inflow vessels for right and left hepatectomy
5. Control of outflow vessels for right and left hepatectomy
6. Parenchymal transection
7. Closure and drainage for biliary reconstruction

1. CT scan
2. EUS
3. Octreotide scan
4. Intraop : EGD - transillumination, IOUS

Pancreaticoduodenectomy for the head of the pancreas and distal for body and tail (location of dominant disease)
Frozen section intraoperatively to rule out high-grade dysplasia or invasive cancer
Total pancreatectomy in some cases of diffuse IPMN

obstructive jaundice, enhancing solid component, and main duct greater than 1 cm

cysts greater than 3 cm, thickened enhancing cyst walls, main duct 5 to 9 mm, nonenhancing mural nodules, abrupt caliber change, lymphadenopathy, and pancreatitis. These require EUS. Then resect for symptoms, solid component, and increasing size.

Laboratory studies, measured during a spontaneous episode of hypoglycemia: glucose, insulin level, C-peptide, proinsulin, and beta-hydroxybutyrate, and screening for oral hypoglycemic use
Confirmatory test: 72-hour monitored fast

Laboratory studies: fasting serum somatostatin level greater than 160 pg/mL

Laboratory studies: overnight fasting VIP level of 225 to 2000 pg/mL

Laboratory studies: overnight fasting VIP level of 225 to 2000 pg/mL

1. CT: PNETs are hypoattenuating in early and late contrast phases. They are enhancing in the arterial phases because of hypervascularity. This differentiates PNET from pancreatic adenocarcinoma, which is hypovascular in the arterial phase.
2. MRI: PNET has low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. PNET may have ring-like enhancement on early and late contrast images, which may differentiate it from other pancreatic tumors.
3. Localization may be performed through multiple modalities, including angiography, endoscopic ultrasound, or 68Ga-DOTATATE PET if CT and MRI are unable to identify the location of the lesion.
4. Somatostatin receptor scintigraphy may also be helpful in the localization of PNETs. However, insulinomas rarely express somatostatin; therefore, this modality is not as useful in detecting insulin-secreting tumors.
5. Arterial stimulated and venous sampling (ASVS) may be performed with an insulinoma or gastrinoma that is difficult to locate, with the selective arterial administration of calcium or secretin to stimulate the release of insulin or gastrin, respectively. Measurement of portal venous or right hepatic venous hormone levels facilitates localization of the tumor.

Patients with recurrent, severe pancreatitis should be evaluated for endoscopic or surgical therapy. (Success rates are similar.)
Endoscopic therapy consists of an endoscopic minor papilla sphincterotomy.
Surgical options include minor papilla sphincterotomy or sphincteroplasty. Patients with dilated dorsal ducts may be candidates for a Puestow procedure.
Severely symptomatic patients who fail other options can be considered for pancreatic denervation or resection, both of which are associated with significant morbidity.