Chapter 13 Flashcards by Deborah Karp

What is extremely prevalent?

Hepatic arterial anatomic variation

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Where are the liver and gallbladder located?

RUQ

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What does bile do?

Produced by the liver and stored in the gallbladder

Critical for the absorption of fats

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Function of CCK

Released by the intestine in response to ingested fats
Causes the gallbladder to contract and propel bile through the cystic duct, into the common bile duct, and eventually into the duodenum

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Central roles of the liver

Nutrient and drug metabolism
Synthesis of coagulation proteins
Detoxification of the blood

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Pathway of the blood supply of the liver in m.ost people

Arterial blood from the aorta reaches hepatobiliary system via the right and left hepatic arteries, which are terminal branches of the proper hepatic artery

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Blood supply of the gallbladder

Supplied by the cystic artery, which commonly arises from the right hepatic artery
Cystic artery courses through the triangle of Calot

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What is the triangle of Calot composed of?

Inferior border of the liver
Common hepatic duct
Cystic duct

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Pathway of replaced or recurrent left hepatic artery

Courses from the left gastric artery through the hepatogastric ligament

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Pathway of replaced or recurrent right hepatic artery

When it branches off the SMA, frequently travels to the right of the common bile duct in the lateral hepatoduodenal ligament

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Venous blood supply of the liver

70% of its blood supply via the portal vein

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How is deoxygenated blood from the liver drained?

Drained by three large intraparenchymal hepatic veins (right, middle, left) that empty in the IVC

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Where do veins of the gallbladder penetrate?

Penetrate the hepatic parenchyma in the vicinity of the gallbladder fossa

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Morphologic vs functional classification of the liver

Morphologic: Divides liver into four lobes; lobes are separated by external fissures or ligaments
Functional: Divides liver into eight segments that are supplied by distinct branches of the arterial and portal blood supply.

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How are segments of the liver separated according to the functional classification?

By the vertically oriented portal scissurae containing the hepatic veins and the transversely oriented portal pedicles containing the portal vein branches within the hepatic parenchyma

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In the functional classification of the liver, what constitutes the right hemiliver?
What constitutes the left hemiliver?

Segments 5-8

Segments 2-4

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What is the surgeon’s initial priority in evaluating the patient with hepatobiliary dz?

Determine whether pt has necrotic or infected tissue
If biliary obstruction with infection is present
If there is acute liver failure

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What are the two frequently utilized diagnostic modalities in the pt who is acutely ill in order to determine if infection, a bile leak or biliary obstruction is present?

Serum bilirubin level

HIDA or DISIDA scan

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RFs for the development of symptomatic gallstone dz

Obesity
Rapid weight loss or gain
Estrogen exposure

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Classification of gallstones

Classified by their composition:

Cholesterol stones
Pigment stones

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Further subdivision of pigment stones

Black or brown pigment stones

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When do gallstones become symptomatic?

When they obstruct ductal structures

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Presentation of biliary colic

RUQ pain, nausea and vomiting that commonly begins a few hours after a fatty meal but ultimately regresses spontaneously once the gallstone dislodges from the cystic duct

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What is the term when gallstones intermittently obstruct the cystic duct?

Biliary colic

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Tx of choice for cholelithiasis

Elective cholecystectomy

Sx of cholecystitis

Initially resemble those of biliary colic; however the pain persists for hours to days without resolution

PE of cholecystitis

Murphy's sign Febrile Leukocytosis

What is often diagnostic of cholecystitis?

U/s

How is cholecystitis definitively diagnosed?

HIDA scan

When can a HIDA scan be frequently falsely negative?

Acalculus cholecystitis

Emphysematous cholecystitis

Persistent cystic duct obstruction leads to increased intraluminal pressure in the gallbladder, which can lead to ischemia of the gallbladder wall with subsequent perforation or necrosis

When should laparoscopic cholecystectomy be performed?

Within 24-72 hrs of hospital admission

Pattern of complication rates with cholecystectomy

Increase with greater delays before cholecystectomy

What is a possible definitive therapy for acalculous cholecystitis?

Cholecystotomy drainage | Also an option for inoperable cholecystitis pt

What is pathognomonic for gallstone ileus and should prompt exploratory laparotomy?

Plain radiograph demonstrating small bowel obstruction and air in the biliary system

What should be performed after the discovery of a gallstone ileus?

Enterolithotomy to remove the gallstone or resection of the affected intestinal segment

What is usually delayed in a gallstone ileus?

Cholecystectomy

Tx for suspected choledocholithiasis

Common duct stones may be retrieved via urgent ERCP | Alternatively, surgeon may explore the bile duct at time of either laparoscopic or open cholecystectomy

What may be useful in cases with complex ductal anatomy and to evaluate for choledocholithiasis and bile duct injury or pathology?

Intraoperative cholangiography

In a laparoscopic cholecystectomy, what should be done prior to division of structures?

Obtain the critical view of safety

When is conversion to open approach indicated in cholecystectomy?

When the delineation of ductal anatomy is difficult or if significant bleeding develops

Complications of laparoscopic cholecystectomy

Cystic duct stump leaks | Iatrogenic injury to surrounding ductal structures

Presentation of cystic duct stump leaks

Present 3 days after procedure with abd pain, fever, and/or vomiting

Confirmation of cystic duct stump leaks

HIDA scan | ERCP

Management of cystic duct stump leaks

ERCP stenting of the common bile duct as well as percutaneous drainage of the resulting biloma(s)

What are common iatrogenic complications of a cholecystectomy?

Injury to the common bile duct occurs more frequently during laparoscopic vs open approach Electrocautery injuries Inadvertent ligation of the common bile or hepatic duct

What should happen if the surgeon recognizes ductal injury intraoperatively?

Termination of the procedure and transfer of the pt to a tertiary care center for definitive management

What do 90% of bile duct injuries require?

Operative bile duct reconstruction via Roux-en-Y hepaticojejunostomy

How are gallbladder polypoid lesions commonly detected

U/s

Management of asymptomatic gallbladder lesions

Expectantly with ultrasonographic surveillance performed every 3-6 mos

When is laparoscopic cholecystectomy recommended in a pt with gallbladder polyps?

Any pt who has a gallbladder polyp that is >10 mm in size

When is open cholecystectomy recommended for gallbladder polyps?

Removal of larger lesions to avoid dissemination of malignancy

When are choledochal cysts more common?

Pts of Asian ethnicity

A minority of pts with choledochal cysts present with what sx?

Triad of jaundice, abd pain, and a RUQ mass

More common adult presentation of choledochal cysts

Complications such as cholangitis or pancreatitis

Imaging modality of choice for choledochal cysts

MRCP

Tx of choledochal cysts

Cyst excision with hepaticoenterostomy

Tx for type V choledochal cysts

These pts may require liver transplantation

Tx for type III choledochal cysts

Some authors advocate therapeutic transduodenal sphincteroplasty

What is the most common cause of biliary strictures?

Iatrogenic injuries

Tx of distal biliary strictures

Biliary-enteric bypass

Tx for primary sclerosing cholangitis

Biliary-enteric anastomosis

Characteristics of primary sclerosing cholangitis

Affects men more commonly than women | May progress to biliary cirrhosis and end-stage liver dz necessitating liver transplantation

Tx of biliary structures initially in pts with primary sclerosing cholangitis

Either ERCP or percutaneous biliary stenting

Presentation of pyogenic hepatic abscess

Most will have fever Only half of pts will have abd pain Jaundice is infrequent

What is the most sensitive and specific test for the dx of pyogenic hepatic abscess?

CT scan

What can help distinguish between pyogenic bacterial abscesses from parasitic abscesses?

Indirect hemagglutination or ELISA

When do iatrogenic pyogenic liver abscesses occur?

Following therapeutic interventions, such as: - Radiofrequency ablation (RFA) - Hepatic artery chemoembolization

Organisms of pyogenic liver abscess

``` Usually polymicrobial K. pneumoniae E. coli Streptococci B. fragilis ```

Tx of pyogenic liver abscess

Image-guided percutaneous drainage coupled with appropriate broad-spectrum abx therapy