E2: Hepatobilliary (incl PSS) Flashcards
Between which liver lobes is the gallbladder? In which division?
Quadrate and right medial lobe
Central division
What is the Pringle maneuver? When is it used?
Blocking, digitally or with clamp, the portal vein and hepatic artery (main blood supply to liver) in the epiloic foramen
Way to occlude blood flow to the liver temporarily (for max 10-15 min) to control bleeding
What is a choledolchotomy?
Incision into the gall bladder duct
When could you use the Guillotine technique for a liver biopsy?
When want to biopsy the periphery/margin of a liver lobe
When suspect generalzed disease and want to obtain a large sample
What biopsy techniques would you use for a focal lesion, such as a tumor?
Percutaneous
FNA
What should you make sure is fairly normal in texture and consistency before taking a liver biopsy via Parenchymal Fracture? What is a major disadvantage of this technique?
Liver parenchyma
Disadvantage: if bleeding occurs after hemostats are removed, it can be difficult to control; technique generally associated with greatest amount of blood loss of all biopsy techniques
What type of biopsy would you take if the lesion is more centrally located on the liver lobe? Which surface of the liver should biopsies be taken and why?
Punch biopsy
Convex surface (across from diaphragm), larger vessels are closer to the concave surface
Also do not penetrate more than half the thickness of the lobe
What can you use to control the bleeding after a small biopsy of the liver?
Absorbable gelatin sponge
What techniques can you use to prevent bleeding after a partial lobectomy?
Overlapping sutures
Staples
Surgities
What are some common indications for a partial or complete lobectomy?
Trauma
Infection
Neoplasia
Arteriovenous fistula
What are the 4 main types of neoplasms that are found in the liver?
Hepatocellular
Cholangiocellular
Mesenchymal
Neuroendocrine
What is the most common benign liver neoplasia in the dog? Cat?
Dogs: Hepatoma
Cats: Cholangiocellular adenoma
What malignant neoplasm of the canine liver caries the best prognosis? Worst?
Massive adenocarcinoma of LEFT lobes
Worst: Diffuse
T/F: Metastatic tumors, such as HSA, are more common than primary tumors in the liver.
True
What is the most common cause of extrahepatic biliary tract obstruction in dogs?
Pancreatitis
What dog breeds are predisposed to the development of gallbladder mucoceles?
Shelties
Cocker Spaniels
What are the steps for performing a cholecystectomy?
- Confirm patency of bile duct before removing the GB: Perform duodenostomy and catheterize major duodenal papilla (2cm distal to pylorus) and flush
- Mobilize GB from hepatic fossa
- Ligate cystic artery and cystic duct, remove GB
- Flush common bile duct again and check for leakage
What are the complications associated with cholecystectomy?
Bile peritonitis- failure to adequately ligate bile duct or small ducts entering cystic duct
Bleeding- failure to ligate cystic artery
T/F: Incision into the common bile duct, choledochotomy, is only performed when the duct is dilated. Choleliths are often pushed into the gallbladder and a cholecystectomy is performed.
True
What procedure is done to temproarily relieve obstruction due to extraluminal compression? How is this done?
Bile duct stenting
Place red rubber catheter and suture into common bile duct (keeping the duct open from the inside) using an absorbable suture to the intestinal wall
When the suture disolves it dislodges the catheter into the intestines
What procedure can you perform if you do not have a patent bile duct, such as due to an obstruction or significant stricutre? What are complications in dogs? Cats? Who has a worse prognosis?
Biliary diversion- Cholecystoduodenostomy
Make corresponding incisions into the duodenum and the gallbladder, then suture together so bile would flow from gallbladder into intestines
Complications- both: Leakage
Complications-Dogs: Ascending infections, bleeding at stoma site
Complications-Cats: High morbidity and mortality, chronic vomiting
When performing biliary surgery, what diagnostic samples should be obtained?
Bile (for culture)
How do you diagnose a bile peritonitis?
Compare fluid and serum bilirubin
If fluid >2x serum then have bile peritontis
What is performed if a cholecystoduodenostomy is not possible?
Cholecystoenterostomy (attach to jejunum as far proximally as possible)
What are the classifications for congenital PSS?
Macrovascular - intra or extrahepatic
Microvascular- intrahepatic
What are the classifications for acquired PSS? How are they caused?
Single shunt- trauma or iatrogenic
Multiple shunts- diseases causing portal hypertension
What is the classic signalment for extra vs intrahepatic PSS?
Extra: Small dogs and cats
Intra: Large breed dogs
Extrahepatic shunts occur when veins that should join the ____ vein, enter the __________ or ________ vein instead.
Portal
Caudal vena cava
Azygous
Which veins are most commonly involved with extrahepatic PSS?
Left gastric and splenic/gastrosplenic veins
An intrahepatic shunt is usually a patent ____ _____.
Ductus venosus
What clinical sign is more common with portal vein atresia than with other types of congential shunts?
Ascites due to hypoproteinemia
What cause of microvascular shunting within the liver will when assessed with nuclear scintigraphy show a near normal shunt fraction?
Portal vein hypoplasia
What are some physical exam findings specific to cats with PSS?
Copper colored irises
Hypersalivation
Aggressive behavior
What type of shunt does a Protein C activity <70% indicate?
Microvascular shunt
What types of stones can occur in dogs with PSS?
Biurate crystals
What type of shunt can consistently be indentified with ultrasound?
Intrahepatic
What modality can definitively determine the presence and location of a PSS?
CT Angiography
What is the disadvantage of using Portography?
It is an open procedure
What procedures can be done to gradually occlude a PSS?
Ameroid constrictor
Cellophane banding (not for cats)
What can acute significant pain and diarrhea +/- blood post-operatively after PSS surgery indicate?
Portal hypertension
