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ACVS Phase I Master Deck *Use This* > Chapter 95: Liver and Biliary System > Flashcards

Chapter 95: Liver and Biliary System Flashcards

1
Q

Name the branches of the hepatic artery. What lobes does each branch supply?

A
  1. Right lateral branch - caudate and R lateral lobes
  2. Right middle branch - Right medial
  3. Left branch - largest - left lateral, left medial, quadrate
    **Left branch gives off the Cystic artery to gallbladder
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2
Q

Name the branches of the portal vein. What lobes do they drain?

A
  1. Right branch: caudate, right lateral
  2. Left branch has a central and left branch
    - Central branch: Right medial and papillary
    - Left branch: Left lateral, left medial and quadrate lobes
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3
Q

How far away is the duodenal papilla from the pylorus?
How far is it from where the CBD appears to enter the duodenum on the serosal surface?

A

3-6cm aborad to the pylorus

1-2cm aborad from serosal entry point of CBD.

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4
Q

How far aborad from the major duodenal papilla is the minor duodenal papilla?

A

Minor is 2cm aborad from the major.

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5
Q

Which coagulation factors are NOT synthesized by the liver?

A

Factor 8 and von Willebrand factor.

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6
Q

Which coagulation factors are vitamin K dependent?

A

2,7,9,10

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7
Q

80% of bilirubin is made from the breakdown of what?

A

Hemoglobin

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8
Q

What substance gives feces its characteristic brown color?

A

Stercobilin

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9
Q

What substance stimulates the release of bile into the intestine?

A

Cholecystokinin.

Cholecystokinin is a hormone produced and secreted by the duodenal mucosa. It is the principal hormone responsible for stimulation of gallbladder contraction.

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10
Q

When a decrease in hepatic portal perfusion occurs, it causes an increase in arterial perfusion because of what response?

A

The hepatic arterial buffer response (HABR)
An intrinsic regulation to maintain hepatic oxygen delivery: the hepatic arterial blood flow increases when portal venous blood flow decreases.

The mechanism proposed for this relates to the synthesis and washout of adenosine (a potent vasodilator) from the periportal areas. When portal blood flow is diminished, adenosine accumulates, resulting in vasodilation of the hepatic arterioles and increasing blood flow. When venous blood flow is increased the adenosine is washed out, increasing resistance and resulting in a reduction in arterial flow.

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11
Q

What are the most common causes of EHBO (5)?

A

pancreatitis
neoplasia
mucocele
choleliths
cholecystitis

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12
Q

Consequences of EHBO that may affect a surgery patient (6)?

A

hypotension
decreased myocardial contractility
acute renal failure
coagulopathies
GI hemorrhage
delayed wound healing

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13
Q

Name three causes of bile peritonitis?

A

trauma
mucocele rupture
necrotizing cholecystitis

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14
Q

In a normal dog, after administration of cholecystokinin what % of the gallbladder empties after 1 hour?
What % in a dog with an obstruction?

A

Normal = 40%
less than 20% in that time if obstructed

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15
Q

What is the Pringle maneuver?
For how long can it be tolerated?

A

The Pringle maneuver, first described in 1908, is a technique to minimize blood loss during hepatic surgery. It involves clamping of the hepatoduodenal ligament and occluding the portal triad, which minimizes the blood inflow into the liver via the portal vein and hepatic artery. Blood outflow from the liver is not affected, therefore the Pringle maneuver cannot prevent backflow bleeding from the hepatic veins.

Tolerated for less than 20 mins.

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16
Q

Bleeding can still occur with Pringle maneuver - through which vessels?

A

Through gastroduodenal vein, backflow bleeding through hepatic veins, and retrograde arterial flow through the gastroduodenal artery.

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17
Q

Name three ways of stopping extensive hepatic bleeding?

A

Pringle maneuver
total hepatic vascular exclusion
hepatic artery ligation

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18
Q

Why can you perform hepatic artery ligation when removing a neoplastic tumor of the liver?

A

liver only gets 20% of blood from hepatic artery
tumors get 95% of blood from hepatic artery

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19
Q

What % of total liver volume do the left lateral and medial lobes make up?

A

44%

right medial and quadrate 28%
right lateral and caudate 28%

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20
Q

Name the three forms of hepatocellular carcinoma and what % of HCC are each type?

A

Massive 61%
Nodular 29%
Diffuse 10%

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21
Q

The massive form of hepatocellular carcinoma is most commonly located in which lobe? (percentages?)

A

Left lobe 67%

Central lobes 13-19%
Right lobes 12-20%

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22
Q

What % of massive hepatocellular carcinomas metastasize?

A

36%

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23
Q

What is the MST of massive hepatocellular carcinoma with surgery?

A

1460 days - much better than medical management

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24
Q

What does bilirubin get broken down into?

A

bilirubin -> urobilinogen -> urobilin or stercobilin

25
Q

How much of Urobilinogen is excreted/reabsorbed?

A

90% excreted in feces and 10% reabsorbed and excreted in bile

26
Q

What is total hepatic vascular exclusion?

A

Occluding both hepatic inflow and outflow by performing a Pringle maneuver and then clamping the inferior vena cava (IVC) above and below the liver.
Total hepatic vascular exclusion (THVE) was developed in an attempt to reduce the complications of the Pringle maneuver alone. However, it causes significant hemodynamic disturbance due to the interruption of venous blood flow in the IVC.

27
Q

What is the pathophysiology of coagulopathy associated with EHBO?

A

Bile salts enhance absorption of fat-soluble vitamins (i.e., vitamins A, D, E, and K). Decreased production, inactivation of bile salts, or biliary obstruction can contribute to a clinically important decrease in vitamin K-dependent coagulation factors.

28
Q

What % of nodular and diffuse HCC will metastasize?

A

93%

29
Q

What is the proportion of volume in the Right:Left liver?

A

3:2

30
Q

Where is the gallbladder attached to the liver?

What other lobe forms part of the fossa?

A

Extensively attached to the right medial lobe.

Lateral aspect of the quadrate also forms the fossa.

31
Q

Name the lobes of the liver:

A

Left Lateral
Left Medial
Quadrate
Right Medial
Right lateral
Caudate (has papillary process on left and caudate on right (which is fused to right lateral))

32
Q

What is the porta hepatis?

A

The porta hepatis is the central portion of the liver to the right of midline where the portal vein, hepatic artery, and bile duct enter and exit the liver. The portal vein is the easiest structure of these 3 to identify.

33
Q

Besides coagulopathy, what can absence of bile salts in the GI from EHBO lead to?

A

Increased endotoxin absorption
- renal vasoconstriction / acute tubular necrosis
- gastric ischemia
- poor response to vasopressors

34
Q

Where would you find the hepatic artery and portal vein?

A

ventral to the epiploic foramen

35
Q

How much of hepatic blood supply comes from the hepatic artery?
How much of O2 supply?

A

Blood: 20%
O2: 50%

36
Q

How much of hepatic blood supply comes from the portal vein?
How much of O2 supply?

A

Blood: 80%
O2: 50%

37
Q

What is the portal vein?

A

A confluence of the cranial and caudal mesenteric veins with tributaries of the splenic and gastroduodenal vv.

38
Q

How many hepatic veins drain blood to the caudal vena cava?

A

6-8 hepatic vv.

39
Q

Describe flow of bile from the canaliculi to the major duodenal papilla:

A

Canaliculi -> interlobular ducts -> lobar/hepatic ducts -> CBD -> Sphincter of Oddi -> major papilla

40
Q

Describe the flow of bile from gallbladder to papilla:

A

GB stores, concentrates bile -> cystic duct -> CBD -> Sphincter of Oddi -> major duodenal papilla

41
Q

What is the species difference between dogs and cats regarding the duodenal papillae?

A

In dogs, the CBD and pancreatic duct run adjacent but not connected through sphincter of Oddi into major papilla, but most pancreatic enzymes enter in the minor duodenal papilla through accessory pancreatic duct.

In cats, CBD and pancreatic duct merge to pass into major papilla, and only 20% of cats have an accessory pancreatic duct.

42
Q

What percentage of cats have an accessory pancreatic duct?

A

20% - enters at minor duodenal papilla.

43
Q

What is the sphincter of Oddi?

A

smooth muscle that surrounds the CBD and pancreatic duct (or fused pair in cats) just above the major duodenal papilla.

44
Q

How much of total body protein production is from the liver?

A

20%

45
Q

All albumin is made in the liver. How much of functional liver mass must be lost to cause hypoalbuminemia?

A

70-80% must be gone (but other things can contribute to hypoalbuminemia)

46
Q

The liver has a central role in carb metabolism and maintains glucose through gluconeogenesis and glycogenolysis. How much of functional liver mass must be lost to cause hypoglycemia?

A

70-80%, just like albumin

47
Q

How low must reserves of coag factors get before clinically detectable coagulopathies are seen?
What % of dogs will bleed spontaneously?

A

Must get to <15% before coagulopathies occur. Less than 2% of dogs will bleed spontaneously.

48
Q

The liver contributes the most to reticuloendothelial function, what does the reticuloendothelial system do?

A

Phagocytosis of harmful endogenous and foreign substances. Kupffer cells are principle cell.

49
Q

What are Kupffer cells?

A

hepatic macrophages. the principle reticuloendothelial system cell.

50
Q

What are two functions of bile salts?

A

Emulsify fats for digestion and absorption

Bind endotoxin to prevent absorbtion

51
Q

What are the four most clinically important anticoagulants?

A

Antithrombin III, a2-macroglobulin, plasminogen, a2-antiplasmin

52
Q

How much liver can be removed? What is the cause of mortality if you take more?

A

70%

Portal hypertension causes mortality rather than liver failure.

53
Q

Liver regeneration begins within hours and complete compensation via hypertrophy/hyperplasia can be reached by when?

A

6 days! But may take 6-10 weeks.

54
Q

You can use the hepatic arterial buffer response and regenerative response to stimulate hypertrophy of the remaining liver prior to removal of part of the liver how?

A

Embolize the portal vein on that side to stimulate hypertrophy - can increase volume by 25-33%

55
Q

What do bile salts cause when released into peritoneum?

A

Inflammation, hemolysis, tissue necrosis

Also hyperosmolar so draw fluid into peritoneum and can cause hypovolemic shock

56
Q

What are the three major causes of bile peritonitis in dogs?

In cats?

A

Trauma, necrotizing cholecystitis, mucoceles

Rare in cats, but caused by trauma

57
Q

What (5) cytokines/factors increase liver regeneration?

A

IL-6
Growth factors
Prostaglandin E2
Nitrous Oxide
Insulin (very potent)
Estrogen

58
Q

What (6) factors decrease rate/ability to regenerate liver?

A

Biliary obstruction
Diabetes (through decreased insulin)
Pancreatectomy (insulin)
Malnutrition
Old age
Males

59
Q

Most bile is sterile, why is this important in leakage?

A

Sterile = mild chemical peritonitis.
Bacteria = can grow in peritoneal effusion, much worse prognosis.

ACVS Phase I Master Deck *Use This* (88 decks)

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