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7: Digestive System > Chapter 95 Liver and Biliary System > Flashcards

Chapter 95 Liver and Biliary System Flashcards

1
Q

How many triangular ligaments are there?

A

Three:

One to R lateral, one to R medial, one to “L lobe”

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2
Q

Name the hepatic ligaments.

A

Coronary, tirangular, hepatorenal, lesser omentum (=hepatograstric + hepatoduodenal)

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3
Q

What % volume of blood does HA vs portal vein supply to liver?

And % oxygen supply each?

A

Portal vein supplied 80% of blood volume, HA 20%

Portal vein and HA supply 50% oxygen each

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4
Q

What artery does the cystic artery originate from?

A

Left branch of HA

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5
Q

What tributaries join the portal vein cranial proximal to the cofluence of cranial and caudal mesenteric veins?

A

Splenic vein and gastroduodenal vein (N.B. this is absent in cats).

Relevant re pringle manouvre - make sure to angle finger cranially to occlude gastroduodenal vein too).

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6
Q

The hepatic veins enter the CVC in a spiral fashion. Which side has the most caual entry?

A

R enter most caudal (usually within liver parenchyma)

L most cranial (usually close to where CVC passes through diaphragm)

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7
Q

Describe the borders of the epiploic formaen

A

Dorsal: CVC

Ventral: Portal vein and HA

Caudal: Mesoduodenum

Carnial: Liver

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8
Q

How many hepatic ducts are there in dogs?

A

2-8

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9
Q

When does cystic duct become CBD?

A

at entry of hepatic ducts

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10
Q

Where does the bile duct open?

What is the name of the sphincter?

A

Opens at major duodenal papilla

Sphincter of Oddi

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11
Q

How does feline CBD/pancreatic duct anatomy differ from dogs?

A

Dogs:

  • Separate opening of CBD vs pancreatic duct (Duct of Wirsung) at major duodenal papilla
  • Majority of pancreatic secretions via accessory pancreatic duct = Duct of Santorini (minor duodenal papilla)

Cats:

  • Conjoined CBD and pancreatic ducts at major duodenal papilla
  • Only 20% of cats have accessory duct (i.e. CBD disease/obstruction in cats may affect exocrin epancreatic secretions)
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12
Q

Where are the major and minor duodenal papillae located?

A

Major 3-6cm aboral to pylorus (usually 1-2cm distal to where CBD enters duodenum (i.e. 1-2cm intramural portion)

Minor 2cm aboral to major

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13
Q

List 6 broad functions of the liver

A
  1. Synthesis and clearance of plasma proteins:
  2. Carb and lipid metabolism
  3. Coagulation factor and anticoagulant synthesis: Almost all coagulation factors except vWf and VIII. Plasminigen, antithrombine etc
  4. Thrombopoetin synthesis
  5. Storage organ for vitamins fats, glycogen, zinc, copped
  6. Immune function: Reticuloendothelail function i.e. phagocytosis. Largest in body
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14
Q

How much hepatic function has to be lost before hypoalbuminaemia is evident?

A

70-80%

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15
Q

How much hepatic function capacity has to be lost for hypoglycaemia?

A

70-80%

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16
Q

How depleted do coag factors need to be before clotting time prolongation?

A

depleted to <15% of normal concentrations

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17
Q

What is the name of hepatic macrophages?

A

Kupffer cells

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18
Q

List 6 ‘ingredients; of bile

A

(BBBC…PW)

  • Bile salts
  • Bilirubin
  • Bicarb
  • Cholesterol
  • Phospholipids
  • Water
  • Other ions
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19
Q

Where does majority of bilirubin come from?

A

80% from Hb breakdown

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20
Q

What are bile salts made from?

A

Cholesterol

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21
Q

What are bile acids conjugated with in dogs?

And cats?

A

Taurine or glycine in dogs

Taurine in cats

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22
Q

What does cholecystokinin do (stimulated by food in duodenum, released by SI cells)?

A

Caused GB contraction and Sphincter of Oddi relaxation.

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23
Q

List 2 functions of bile salts

A
  1. Emulsify fats
  2. Bind endotoxin to preven absorbtion
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24
Q

How is bilirubin excreted?

A

Bacteria convert bilirubin to urobilinogen

Urobilinogen converted to urobilin or stercobilin

90% excreted in faeces (small amoiunt in urine)

10% re-absorbed

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25
Q

What gives faeces the brown colour

A

Stercobilin

i.e. acholic faeces due to reduced bile flow

N.B. sterco means faeces!

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26
Q

What volume of of liver can be removed acutely?

A

70%

84% –> death (due to portal hypertension avoid portal pressure >16mmHg - create portocaval shunt if so)

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27
Q

How long does it take for near complete regeneration after 70% hepatectomy?

A

7 days on average (can be up to 10 weeks

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28
Q

List 2 factors that have been associated with reduced hepatic regeneration

A

Biliary obstruction and diabetes mellitus (reduced insulin. Insulin = potent hapatotrophic factor)

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29
Q

How long does it take for US detectable CBD dilation after obstruction?

And for intrahepatic dilation?

A

1-2 days for CBD dilation

1 weeks for intrahepatic ducts

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30
Q

List 7 pathophysiological consequences of EHBTO

A
  1. Hypotension
  2. Decreased myocardial function
  3. Coagulopathy: Lack of fat + fat soluble vitamin absorbtion (i.e. Vit K)
  4. Endotoxaemia: Absence of bile salts –> bacterial overgrowth + endotoxin absorbtion
  5. ARF: Endotoxin = potent vasoconstrictor –> tubular necrosis
  6. GI haemorrhage: Endotoxin mediated ischaemia
  7. Delayed wound healing: Decreases fibroplasia and angiogenesis
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31
Q

What are the 3 most common canine caused of bile peritonitis?

A

Trauma, ruptured GB mucocoele, necrotising cholecystitis

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32
Q

What % of canine and feline choleliths are radiopaque?

What are they most commonly made up of?

A

Dogs:

50% radiopaque

Calcium carbonate or calcium bilirubinate

Cats:

80% radiopaque

Calcium carbonate (mostly)

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33
Q

List 6 imaging modalities that can be used to investigate hepatobiliary disease

A
  • Radiography
  • US (+ US guided cholecystograpthy - not described in cases of obstruction)
  • CT
  • MRI
  • Scintigraphy: Technetium 99 iminodiacetic acid derivates. Iv injection –> biliary excretion
  • Endoscopic retrograde cholangiopancreatography
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34
Q

In scintigraphy for EHBTO, what duration is consitent with EHBTO

A

>3 hours for compounds to accumulate in SI

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35
Q

What is normal CBD diameter in dogs?

And cats?

A

3 mm in dogs

4 mm in cats

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36
Q

An option to evaluate GB emptying is to inject synthetic cholecystikinin (Saincalinde).

What % of Gb volume is emptied in normal dogs vs obstructed?

A

Normal = 40% emptied within 1 hour

Abnormal = <20% emptied within 1 hour

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37
Q

What % liver resection –> inc ammonia?

A

>60% hepatectomy –> inc ammonia

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38
Q

name hepatotoxic inhalation agent

A

halothane

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39
Q

What 4 organisms are most commonly cultured from liver?

A

Clostridium, E. coli, Enterococcus, Bacteroides

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40
Q

How do hepatic cultures relate to bile cultures?

A

No positive hepatic cultures with negative bile culture.

41
Q

List 6 methods to improve hepatic exposure

A
  • Release triangular ligaments
  • Induce pneumothorax
  • Pack swabs in front of liver
  • Gastric stay sutures
  • Caudal sternotomy
  • Paracostal approach
42
Q

List the 3 ways that hepatic vasulcar occlusion techniques are classified i.e. for control of extensive haemorrhage

A
  1. Control of CVP (<5cm H2O)
  2. Liver inflow occlusion i.e. Pringle manouvre)
  3. Liver inflow and outflow occlusion (i.e. Pringle + pre- and post-hepatic CVC)

CVP doesnt really make sense as a vascular occlusion technique but this is how its classified in tobias

43
Q

What is the time limit for Pringle manouver?

A

20 mins

44
Q

How does liver tumour blood supply differ from normal liver parenchyma?

A

95% perfusion from hepatic artery (c.f 20% from HA in normal parenchyma)

45
Q

What was the cause of death in experimental dogs undergoing HA ligation?

How is this prevented?

A

Gangrenous necrosis

Abx

Consider propylactic cholecystectomy if time (cystic artery from left HA)

46
Q

How does liver cytology compare to histo?

A

FNA 48% accurate

47
Q

What was minor (PCv drop by 10% or more) and major (transfusion or death) of hepatic tru-cut biopsy.

What was greatest risk factor for bleeding?

A

22% minor, 6% major

Thrombocytopaenia

48
Q

Name a cat specific complication of hepatic tru cut biopsy

A

Vagotonic shock

49
Q

What is conversion rate of lap liver biopsies?

A

2-4%

50
Q

How can life threatening portal hypertension be managed after e.g. liver lobectomy?

What options are available if staged resection feasible?

A

create portocaval shunt

Selective portal vein branch embolization/ligation to stimulate hepatic regenration of remnant liver before definitive lobectomy.

51
Q

List the % volume of respective liver lobes

A

Caudate + R lateral = 28%

Central division = 28%

Left medial + lateral = 44%

52
Q

List 3 benefits of selective arterial embolization/chemoembolization/chemo delivery.

What feature of hepatic tumours make them particulary suitable to these techniques.

A
  • Increased local chemo concentrations (x10-50) and dwell times
  • Reduced systemic toxicities
  • Reduced tumour blood supply/oxygenation

Hepatic tumours receive 95% blood supply from HA (vs 20% in normal parenchyma)

53
Q

What product is added to chemo for embolization?

Why

A

Iodized poppy seed oil (Lipiodol)

–> slurry + improved radiopacity (tumours lack Kupffer cells i.e. no clearance of fatty substances so chemo mixture is concentrated in tumour.

54
Q

What is a complication of embolization?

A

Post-embolization syndrome (malaise, fever, pain)

55
Q

Above what serum tbil level is icterus clincially visible

A

25-35 umol/L (= 1.5 - 2.0 mg/dL)

56
Q

How long after EHBTO can it take fo rcoag tests to become abnormal?

A

10d

57
Q

How is bile effusion diagnosed?

A

Effusion tbil >x2 serum tbil

Bile crystals/pigment on cyto

58
Q

What is the Vit K dose

And ffp/whole blood volume?

A

1 mg/kg sc bid

FFP or whole blood at 10 ml/kg

59
Q

What % of EHBTO dogs have positive bile culture?

And cats?

What organisms most common?

A

17 - 39% dogs

30 - 50% cats

E. coli, Clostridium, Enterococcus, Enterobacter, Bacteroides

60
Q

List 2 options for management of ‘transient’ biliary obstruction

A

Stent of cholecystostomy tube

61
Q

What is the main concern if need to do cholecystojejunostomy instead of CCD?

A

Gastric ulceration due to gastric acid oversecretion

(normally presence of bile in duodenum inhibits gastric acid secretion)

62
Q

What is the recommended stoma lenght in cholecystoenterostomy?

A

>2.5cm

63
Q

List 5 potential complications of cholecystoenterostomy

A

Stricture, ascending cholagitis, dehiscence, gastric ulceration, haemorrhage

64
Q

What is shown in this image?

A

Human (Cotton-Huibregtse) polyethylene stent over a 0.03-inch hydrophilic guide

65
Q

What were the 2 main complications of lap-assissted cholecystostomy tube placement?

A

Obstruction and early dislodgement (recommend tsi 3-4 weeks)

66
Q

Comment re histo of canine hepatic abcesses

And feline?

A

No underlying neoplasia in dogs

25% neoplasia in cats (n.b. very few cases)

67
Q

List some possible predisposing factors for canine hepatic abcesses

A

DM, recurrent UTI, Pancreatitis, pneumonia, GB rupture, long term pheno or corticosteroids

N.B. NOT neoplasia

68
Q

What bacteria was most commonly identified in canine hepatic abcess?

A

E. coli

69
Q

List 4 management options for canine hepatic abcess

A
  1. Surgery
  2. medical
  3. US drainage
  4. US drainage + ablation (half of volume drained 95% ethanol injected and left there for 3 mins - also reported for hepatic and renal cysts)
70
Q

List some concurrent conditions with whihc liver lobe torsion has been seen

A

Hepatic abcess

Hepatic tumour

Diaphragmatic hernia

Septic peritonitis

GDV

71
Q

Which liver lobe is most comonly affected in llt

A

left lateral

72
Q

What is prognosis for LLT managed surgically?

A

excellent (11/12 survived)

73
Q

What is the underlying lesion if GB mucocoele?

A

Cystic mucosal hyperplasia

74
Q

Deficiency of what gene has been found in dogs with Gb mucocoele?

A

ABCB4 gene

75
Q

What is the magnitude of risk factor for the following for having GB mucocoele:

Hypothyroidism

Hypoadrenocorticism

A

Hypothyroidism –> x3

Hypoadrenocorticism –> x29

76
Q

What bacteria are most commonly isolated form Gb mucocoele?

A

E coli and Enterococcus

77
Q

IN what % of GB mucocoele has concurrent EHBTO been documented?

A

30%

i..e ensure GB patency!

78
Q

What is mortality rate following sx for GB mucocoele?

A

16 - 40%

79
Q

Comment on Gb rupture vs mortality

A

No association unless septic

80
Q

What 5 of canine choleliths had +ve culture (aerobic vs anaerobic)?

A

70% cultured positive for aerobic

55% for anaerobic

81
Q

What is post-op mortality rate for cholelithiasis in dogs?

What factro was assocated with increased mortality

A

10%

Presence of EHBTO

82
Q

What are the 4 general types of hepatic tumour?

A

Hepatocellular, cholangiocellular, neuroendocrine, mesenchymal

83
Q

What are the most common hepatic tumour ‘type’

A

metastatic (haemoatopoetic and lymphoid)

84
Q

Name a parneoplastic syndrome seen with hepatic masses

A

Hypoglycaemia

85
Q

List the 3 types and (% occurence) of hepatocellular carcinomas

A
  • Massive (61%)
  • Nodular (29%)
  • Diffuse (10%)
86
Q

where does massive hepatocellular carcinoma most frequently occur and in what % of cases?

A

L lobe, 67% of cases (about 20% in middle vs R)

87
Q

What is the met rate in massive vs diffuse or nodular hepatocellular carcinoma?

What are 3 most common sites?

A

Massive = 36% metastasis vs 93% in nodular/diffuse

LN (40/%), lungs (40%), peritoneum (20%),

88
Q

What is the MST in surgicall yve medically managed canine massive hepatocellular carcinoma?

What factor was associated with poorer prognosis?

A

Surgery –> 1500d MST

Medical –> 270d MST

R sided tumour (n.b. NOT associated with completeness of excision)

89
Q

What are the most common locations of bile duct carcinoma in dogs (intrahepatic ducts vs extrahepatic vs GB)

A

Intrahepatic (90%) > extrahepatic (10%) > GB (1%)

90
Q

What factors has been associated with cholangiocellular carcinoma in humans (and found in 1 dog)?

A

Chinese liver fluke

91
Q

What is the most common type of primary hepatic neoplasm in cats?

A

Bile duct tumours (benign bile duct adenoma (aka biliary cystadenoma) > carcinomas)

92
Q

What was periop mortality for feline malignant biliary tumours?

And met rate?

A

100% periop mortality

67% metastasis

93
Q

What are the two most common body sites for neuroendocrine carinomas?

A

GI and lungs

94
Q

In canine hepatic neuroendocrine carcinoma, what % had diffuse disease?

And mets?

A

100% diffuse

93% mets

i.e. terribele prognosis. Sx not recommended

95
Q

List 8 canine mesenchymal hepatic tumours

A

Haemangioma

Haemangiosarcoma

Leiomyosarcoma

Osteosarc

Chondrosarc

Fibrosarc

Mesenchymoma

(Rhabdosarc in cats. Not chodro in cats).

96
Q

What was MST for cats undergoing spelnectomy for MCT (even with mets)

A

19 months

97
Q

What was MST for dogs with histiocytic sarcoma managed with lomustine?

A

100d

98
Q

What % of malignancies metastasise to liver?

A

30% i.e. most common site for mets.

99
Q

What is the most common metastatic neoplasm of liver?

A

Lymphoma (60%) > carcinoma (20%) > sarcoma (15%)

7: Digestive System (12 decks)

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