Liver Cysts

It has been a while. And yes, it is time for me to post again.

Ever since I started my new job, life had been more fulfilling. I get to spend more time with my patients and educate them properly about their current condition. Not like how it was back then when I could only afford 5 minutes for each patient because of the amount of patients I had to see a day.

I was taught on how to do ultrasounds at my new workplace. It might turn out useful in the future, who knows?

So let’s start with liver cysts for today.

Both images are from 2 different individuals but with the same problem. So what are they?

Also known as hepatic cysts, apparently they are quite common. Although they are benign, some may turn malignant. There are a lot of factors that contribute to the rise of the hepatic cysts (sounds familiar?). Be it congenital, hereditary, parasitic infections or even cancer.

I was saw a Japanese man, who had cysts in his liver as well, and the amount of cysts on his liver is astounding. Just too bad I do not have the image with me right now. Seems like his dad has the same problem too. So I guess the hereditary point proves it.

And if you consume alcohol beyond the normal limits, you have the tendency to develop it as well.

So what can we do for these cysts? Well, like most cysts, are benign. So just let them be. Unless you’re extremely worried, you may opt to have the cyst surgically drained and inspected to give you a peace of mind.

ERCP

Endoscopic retrograde cholangiopancreatography.

This is my first time really taking the time to look at a radiograph taken during ERCP.

Images DO NOT belong to me. I take no credits for them. I found them randomly over Google.

Try naming the parts… Answers below.

1. Common bile duct
2. Common hepatic duct
3. Cystic duct
4. Endoscope
5. Gall bladder
6. Ampulla of Vater
7. Left hepatic duct
8. Neck of gall bladder
9. Pancreatic duct
10. Right hepatic duct

Here’s a gall stone.

And another.

The Dormia basket. A method to remove stones through an endoscope.

Yes la… I feel smarter by an inch.

0.9% Saline or Hartmann’s?

I had nothing else better to do so I went googling. These are a few interesting facts that might come in handy one day.

As we all know, 0.9% saline (normal saline) is a widely accepted choice for fluid resuscitation in most of the situations. Eg. hypovolaemic shock, septic shock, burns, etc etc.

However, nothing is perfect and there is a downside to it. When it is used especially in huge amounts during emergency resuscitation, it may sometimes cause hyperchloraemic metabolic acidosis.

So what is hyperchloraemic metabolic acidosis?

It’s pretty much the same as the usual metabolic acidosis except that it has a normal anion gap.

If you want more information about it, just go here. AnaesthesiaMCQ.com. It has better explanations.

Acidosis can happen because of shock. Tissue perfusion decreases. There is hypoxaemia. Lactic acidosis occurs. However, heavy administration of 0.9% saline may cause acidosis as well. So it’s an “either or” situation. So be careful not to get too indulged in resuscitating the patient without thinking what you’re giving. You may be the cause of the acidosis itself.

Hartmann’s solution is the best next choice.

At the end of the day, what fluid to use is entirely up to you. Just keep in mind that there’s a risk of acidosis when using 0.9% saline alone.

A mixture of both solution sounds pretty alright to me… no?

Fluid Therapy for the Needy

Fluid Resuscitation for Shock

First off… we need to guess roughly how much blood had the patient lost.

Just by looking at few simple things would give you a guide.

• Blood pressure
• Pulse rate
• Mental status

There are other parameters such as respiratory rate and urinary output but the 3 mentioned above are the easiest to assess. They take less time. I like short cuts.

Blood pressure

If blood pressure is within the normal range, estimated blood loss would be about 1.5L or less.

If it is lower than normal, then it is above 1.5L.

Pulse rate

If it is between <100 – 120 beats/min, it is less than 1.5L.

If it is above 120 beats/min, it is above 1.5L.

Mental status

If the patient looks normal with anxiety, it is less than 1.5L.

If the patient is confused and he/she starts scolding your father, mother, girlfriend or boyfriend, it is above 1.5L.

If estimated blood loss is above 1.5L, the patient may need blood transfusion. Get ready packed red blood cells.

Always keep in mind that the patient needs oxygen and glucose to be alive. So make sure the patient is breathing and his circulation is intact.

Make sure at least one large bore cannula is inserted.

Okay. Now you need to decide. Crystalloids or colloids? Make a decision and quick.

I’ll go with 0.9% saline since it’s the safest. Run it as fast as you can. Use your hands to pump the solution bag if it’s not fast enough.

How much to give? It depends. It’s between 1 – 2 litres. In young and healthy adults, 2 litres would be appropriate. In elderly patients, try not to overload their poor poor heart. Try 1 litre first.

Keep an eye on the patient’s blood pressure and pulse rate.

Once the patient’s status is stabilized, treat the cause.

Fluid Therapy for the Needy

Crystalloids or Colloids?

In an emergency setting, which one would be the better choice?

Seriously, I can’t be bothered with all the statistics that researchers produce in their papers about which is superior than the other.

Every individual is different and their needs should be tailored. Decision is not made based on some research papers who knows nuts about your patient more than you do.

I’ll list down the advantages and disadvantages of both the solution.

Cystalloids

Advantanges:

• It’s cheap.
• Easily available.
• No anaphylactic effects.

Disadvantages:

• Stays for a short period of time in the intravascular compartment.
• More is needed to achieve euvolaemic status. 3 times more as compared to colloids.

Colloids

Advantages:

• Stays longer in the intravascular compartment.
• Less amount is needed.

Disadvantages:

• More expensive.
• Produce anaphylatic effects in certain individuals.
• Interferes with blood grouping and cross-matching.

Points to take note…

1. If someone has sepsis or burns… do not resuscitate with colloids. Both sepsis and burns produce leaky capillaries. The colloid molecules would just leak into the interstitial space. It does not play its role as an intravascular volume expander. It produces an osmotic effect in the interstitial space instead and causes oedema.
2. If blood has not been taken for grouping and cross-matching, don’t bother using colloids.
3. If patient is severely in shock, giving crystalloid may not be fast enough. Use colloids instead. It’ll buy you some time.

Fluid Therapy for the Needy

Bladder Cancer

Someone presents with painless haematuria. Suspect bladder cancer until proven otherwise.

The following steps to be taken:

To Diagnose.

Determine the presence of the tumour. Do an intravenous urethrogram first to confirm any mass in the bladder as well as any that’s located along the urinary tract.

Followed by cystourethroscope under general anaesthesia. You get a better view by sticking in the scope.

Locate the site of tumour, the numbers present and appearance.

To Stage.

During the scope, do a biopsy. Then followed by transurethral resection of bladder tumour (TURT) if needed.

CT scan to determine affected lymph nodes and local invasion of the tumour.

To Treat.

Few choices available.

If bladder tumour is superficial (Ta, T1), then just by endoscopic diathermy.

If larger (T1, T2), then proceed to TURT.

If it is invasive (T2, T3), just remove the bladder by doing a cystectomy.

Complications of TURT.

Blood clots forming in the bladder after the procedure.

Bladder perforation.

Aftermath.

Those with bladders, of course you follow up with them with regular cystourethroscopy to detect any recurrence.

Those without bladders, there will be 2 choices:

To make a new bladder, or so called neobladder. Continence is retained. Uses colon or small bowel. Or… an internal reservoir is made to contain the urine, and is connected to the body surface. Urine is drained at regular intervals by catheter.

To create a passage for urine output without any storeroom. Incontinence. Ureters are implanted on the ileum. Ileum opens on to the abdominal wall. A urine stoma is created.

Chemotherapy?

Intravesical epirubicin or mitomycin C reduces recurrent rates.

Cisplastin and methotrexate are useful as well.

Waseh… I tired liao. That’s pretty much it la.. got anything I add later la…

Composition of Colloid Solutions

The less frequent road travelled. Not many use colloid solution as a primary form of fluid resuscitation. However, it’s good to know what are they, and when are they need.

Natural colloid, albumin, has very limited usage these days. I won’t be talking about it. And besides, I’m lazy.

I’ll be mentioning these 3 synthetic colloids:

• Dextrans
• Gelatin
• Hetastarch

Dextrans

There are 2 types available. The 40 and 70. Each represents the molecular weight (MW) of the polysaccharides present. 40000 and 70000 respectively.

They are actually sugar water… so to say. The dextrans are polysacs in solution with either 0.9% saline or 5% dextrose solution.

Dextran 40 lasts about 6 hours. Dextran 70 last 4 times more, 24 hours.

Gelatin

Also present in 2 types. The Haemaccel and Gelofusine.

Molecular weight for Haemaccel is 35000. As for Gelofusine, it’s 30000.

Lasts about 2 hours in the circulation.

They are made from pigs. So be careful when you’re giving them in certain cultures.

Contents of Haemaccel:

• 145 mmol/L of Na
• 145 mmol/L of Cl
• 5 mmol/L of K
• 6.25 mmol/L of Ca
• pH 7.4

Contents of Gelofusine:

• 154 mmol/L of Na
• 125 mmol/L of Cl
• 0.4 mmol/L of K
• 0.4 mmol/L of Ca
• pH 7.4

Hetastarch

Also also known as hydroxyethyl starches.

Again, 2 types available. Elohes 6% (MW of 200000) and Hespan (MW of 450000).

Very good but very expensive. So don’t bother using them unless it’s really necessary.

Fluid Therapy for the Needy