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Senior - Surgery 1 > 6 - Hepato-Biliary Surgery > Flashcards

6 - Hepato-Biliary Surgery Flashcards

1
Q

Cholecyst means

A

Gallbladder

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2
Q

Cholecystitis means

A

Inflammation of the gallbladder (infection)

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3
Q

Cholecystectomy means:

A

Gallbladder removal

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4
Q

Cholelithiasis means

A

Stones in the gall bladder

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5
Q

Choledocho means

A

Bile duct

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6
Q

Choledocholithiasis means

A

Stones in bile duct

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7
Q

Common patient type for gallstones

A

Fat
Fair
Female
Forty

Obsese pt’s who rapidly lose weight

Unusual in children

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8
Q

Most gallstones are made of:

A

Cholesterol

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9
Q

How does estrogen cause gallstones?

A

Its causes increased cholesterol secretion, liver can’t keep up with bile salts to emulsify the cholesterol

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10
Q

How does progesterone lead to gallstones?

A

Decreases bile acid secretion, leading to decreased emulsification of cholesterol

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11
Q

Why are pregnant patients more likely to get gallstones?

A

Increased estrogen and progesterone

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12
Q

Pt presentation for cholelithiasis

A

Many are asymptomatic

Classic: crampy RUQ pain, possible correlated with meals, N/V, anorexia

Severe - jaundice, fever, chills, increased t. bili, LFT’s, WBC’s

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13
Q

Valuable and easy diagnostic tool to look for gallstones and cholecystitis?

A

Ultrasound

Add’l workup tests include the usual shit - CBC, CMP, amlyase/lipase, PT/INR, UA c HCG

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14
Q

What is biliary colic?

A

Stones obstruct the neck of the gallbladder and it cannot expel bile -> transient, post-prandial RUQ pain

(Food intake -> CCK secretion -> gall bladder contraction)

Usually treated with pain management and anti-emetics

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15
Q

How does cholecystitis present?

A

Persistent, colicky, RUQ pain, fever, chills, N/V

Murphy’s Sign (RUQ pain rebound tenderness)

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16
Q

Labs - tests for cholecystitis?

A

Leukocytosis c left-shift
Normal t. bili
Normal amy/lip

US - thickened gallbladder wall (>4mm)

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17
Q

Plan for cholecystitis

A

Admit

NPO
IV ABX (GNR coverage)

Surgery (usually within 24 hours but can wait up to 72)

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18
Q

What is acalculous cholecystitis?

A

Gall bladder infection not caused by stones (normally 2/2 stasis in gallbladder)

Long-term hospitalized patients
NPO
Starvation

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19
Q

What is the imaging study of choice for cholecystitis?

A

Ultrasound

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20
Q

What is the normal thickness for a gallbladder?

A

Less than 4mm

Add 1mm for every decade after 60yrs

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21
Q

What is a sonographic Murphy’s sign?

A

RUQ rebound tenderness / pain elicited by using transducer

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22
Q

What is Mickey Mouse sign?

A

Portal vein (head)

Common bile duct and hepatic artery (ears)

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23
Q

Common bile duct (CBD) obstruction - describe

A

Stone blocks duct shared by pancreas, gallbladder, and liver (YIKES!)

Obstructive jaundice quickly develops

Acholic stools (white)

Pancreatitis possible

Bacteria form duodenum ascends to the liver (ascending cholangitis)

So much badness!!!

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24
Q

Labs for CBD obstruction?

A

Leukocytosis c left-shift
Elevated LFTs and t. bili
Amy/lip elevated if pancreas involved
Prolonged PT/INR

US - dilated CBD/intrahepatic ducts

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25
Q

Plan for CBD obstruction

A

NPO
IV ABX

Urgent GI consult for ERCP

OR

Surgery for percutaneous drainage

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26
Q

What is ERCP?

A

Endoscopic Retrograde Cholangio-Pancreatogram

An upper endoscopy performed by GI

Locate and cannulate the Ampulla of Vater

Inject contrast and obtain imaging to evaluate CBD

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27
Q

Describe sphincterotomy

A

Performed with ECRP

Allows for passage of large stone to be delivered

May cause injury to pancreas, duodenum, or bleeding

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28
Q

Applicability of Magnetic Resonance Cholangio-Pancreatogram (MRCP)

A

Diagnostic only

Non-invasive

Performed by radiologist in MRI suite

Good test for CBD obstruction or CBD injury after cholecystectomy

29
Q

What is Hepatobiliary IminoDiacetic Acid (HIDA) Scan?

A

Nuclear med study

Series of images taken at timed intervals

Radioactive tracer

Gamma camera

Evaluates for obstruction

30
Q

What is cholangitis?

A

CBD obstruction with infection

31
Q

What is the most serious complication of cholelithiasis?

A

Cholangitis (CBD obstruction with infection)

Lethal if not treated ASAP

32
Q

Cholangitis presentation?

A

Charcot’s Triad (fever, jaundice, RUQ pain)

Reynolds Pentad (fever, jaundice, RUQ pain, confusion, shock)

33
Q

Labs for cholangitis?

A

Leukocytosis c left shift

Increased LFT’s, t. bili, PT/INR, possibly amy/lip

34
Q

Txt for cholangitis

A

ICU ADMISSION

IV ABX
ERCP
Percutaneous trans-hepatic drainage
Cholecystectomy with inraoperative choplangiogram

35
Q

Indications for cholecystectomy

A

Symptomatic cholelithiasis (biliary colic)

Cholecystitis (infection)

Cholangitis (CBD obstruction with infection - worst complication of stones)

Cholangiocarcinoma (gallbladder CA is rare)

36
Q

What is Intra-Operative Cholangiogram (IOC) used for?

A

To make sure your cholecystectomy went well before you close up

Contrast injected to look for extravasation, obstruction, etc

37
Q

Complications of cholecystectomy

A 
Bleeding
Injury to surrounding structures 
Infection
Retained CBD stones
Bile leak
Incisional hernia
38
Q

Follow-up for cholecystectomy

A 
NPO initially
Track WBC’s, electrolytes
IV ABX until afebrile
LMWH (DVT prophylaxis) and ambulate as soon as possible
Pulm toilet 
Control pain
Discharge when criteria met 
Normal activity in 6-8 weeks
39
Q

What is percutaneous gallbladder drainage?

A

Reserved for patients with CBD obstruction refractory to ERCP/IOC

Tube comes out the abd through the skin, drains into bag

Temporary measure

40
Q

What does the liver synthesize?

A

Factors V and VII
Prothrombin
Acute phase proteins
Bile

41
Q

Imaging for the liver:

A

US - evaluates the biliary tree

CT/MRI - good detail of small soft tissue masses

Nuclear med

Angiography

Biopsies

42
Q

Non-operative management of liver trauma

A

Frequent abd exams

Ensure hemodynamically stable

R/o other visceral injuries

43
Q

If hepatic hematoma becomes infected s/p trauma:

A

Requires drainage

44
Q

What is hemobilia?

A

Blood in the biliary tree

Think bad infection, gas-producing bacteria

45
Q

What pneuomobilia?

A

Air in the biliary tree

Rare with trauma

May occur if infected with gas-producing bacteria

46
Q

How does liver abscess typically present?

A

RUQ pain with radiation to right shoulder

Fever, chills, leukocytosis

Hepatomegaly with TTP

47
Q

Causes of liver abscess?

A

Pyogenic abscess (90%)

  • intra-abdominal infection (IBD flare, Crohn’s, appendicitis)
  • liver trauma

Fungal
Hydatid cyst
Entameboae histolytica

48
Q

Txt for liver abscess

A

Abx if solitary, small, or scattered

If large and amendable - percutaneous drainage

Surgery (last resort)

49
Q

MC primary liver malignancy?

A

Hepatocellular Carcinoma (HCC)

50
Q

MC CA of the liver?

A

Malignant CA (usually from colon)

51
Q

Describe congenital liver cysts:

A

Smooth-walled, well-circumscribed and homogeneous fluid on US

Normally small and found incidentally on US or CT

Can be symptomatic if larger

52
Q

Describe neoplastic liver cysts

A

Irregular cysts

Aspiration of fluid necessary but not always diagnostic (inconclusive)(need follow-up with surgery to confirm or rule out malignancy)

53
Q

What is polycystic liver dz?

A

Congenital (AD)

Large, multiple cysts invade / replace normal hepatocytes

  • results in liver failure
  • need liver transplant

*should also check for polycystic kidneys

54
Q

What is the MC solid hepatic tumor?

A

Hepatic hemangioma

Normally asymptomatic and no intervention req’d

55
Q

Hepatic adenoma - what is it?

A

Benign proliferation of non-functioning hepatocytes (cold nodules)

Associated with estrogen therapy

Mostly asymptomatic unless encroaching on surrounding organ

Loses signal in T2 image

Bleeding risk > benefit of percutaneous Bx and FNA

Not dysplastic
Don’t rupture

56
Q

When would you do surgery on hepatic adenoma?

A

If its a large, invasive lesion which is not responding to estrogen cessation

57
Q

What is focal nodular hyperplasia? (FNH)

A

Hyperplasia of FUNCTIONING hepatocytes

“Hot” on nuclear med scan

Most asymptomatic

Surgery indicated only on large, invasive lesions

58
Q

What is MC cause of new liver dysfunction in the US?

A

Non-Alcoholic Steato Hepatitis (NASH)

59
Q

Describe NASH

A

Fatty liver -> fibrosis -> cirrhosis and can progress to HCC

60
Q

Risk factors for NASH

A 
Older age
DM
Serum transferases > 2 times normal 
Hepatocellular ballooning + Mallory hyaline/fibrosis on Bx
BMI > 28 
Visceral adipose deposits
61
Q

Management of NASH

A

Weight loss
Control underlying co-morbidities
Limited role of Vit E, Olristat, statins

62
Q

HCC is associated with:

A

Hep B/C
Cirrhosis
Aflatoxins

63
Q

Workup of HCC

A

Screen high-risk patients
Alpha-fetoproteins elevated
MRI/CT
Bleeding risk outweighs benefit of percutaneous Bx

64
Q

Study of choice for HCC workup?

A

MRI/CT

65
Q

Txt for HCC

A

Resection - smaller lesions and patients with adequate functional reserve

Liver transplant

RFA for small tumors, non-mets

66
Q

Acute liver failure presentation

A

Jaundice
Encephalopathy
Coagulopathy

67
Q

Chronic liver dz presentation

A 
Ascites
Esophageal varices
Hemorrhoids
Caput medusae
Ascites 
Jaundice (2/2 elevated unconjugated t. bili
Encephalopathy 
Coagulopathy
68
Q

Txt for chronic liver dz

A

Admission, resuscitation, nutritional support

TIPA procedure for portal HTN (transjugular intrahepatic portosystemic shunt)

BB’s

Lactulose (to bind free NH3)

69
Q

There was a sign on the lawn at a drug rehab center that said

A

“Keep off the Grass”

Senior - Surgery 1 (8 decks)

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