Hepatobiliary Flashcards
1
Q
cholangio dx
A
can be clinical; no tissuee needed
2
Q
replace RHA
A
SMA > celiac or aorta.
posterior and lateral to the CBD and pancreas
palpation of a distinct pulse at this location should raise suspicion for this anatomical variant.
3
Q
Milan criteria for HCC
A
1 tumor < 5 cm or 3 tumors < 3 cm each
txp = survival benefit has been demonstrated for these patients
also eligible:
hilar cholangiocarcinomas a
epithelioid hemangioendothelioma
large hepatic adenomas
4
Q
UCSF criteria for liver txp in HCC
A
1 lesion < 6.5 cm or up to 3 lesions < 4.5 cm each and total < 8 cm
less restrictive
5
Q
contraindication to liver txp
A
INTRAhepatic cholangiocarcinoma
6
Q
arterial enhancement and delayed washouthepatic
A
HCC
7
Q
strong arterial enhancement with central scar persistent in delayed phase
A
FNHrim
8
Q
peripheral enhancing lesion in arterial phase
A
intrahpeatic cholangio
9
Q
peripehral nodular enhancement in arterial phase with central fillin centripetal in delayed
A
heamngioma
10
Q
adenoma resection lsize?
A
5cm
11
Q
early washout on portal phase; no stellate scar; peripheral enhancement centripetla
A
adenoma
12
Q
hyper T1
A
adenoma, FNH
13
Q
hypo T1
A
hemangioma
14
Q
dx bile leak after hepatectomy?
A
3x serum bili after POD 3
manage with drainage first
15
Q
normal liver functional remnant?
A
20-25%c
16
Q
childs a cirrhotic functional remnant?
A
40%
17
Q
for HCC presumed off CT scan, what additional imaging recommended?
A
MRI with contrast if 1-2 cm (smal)… to determine FLR
otherwise, <5cm (milan), wack it out.
18
Q
RCC met to liver tx
A
resection or perc radiofrequency or microwave ablation
19
Q
FNH mgmt
A
NTD
20
Q
left trisectionectomy = extended left
A
2, 3, 4, 5, 8
21
Q
rigth trisectionectomy = extended right
A
4, 5, 6, 7, 8
22
Q
falci
A
umbo vein remnant (extends to ligamentum teres) separates med/lat LEFT LOBE
23
Q
Cantlies
A
middle of fossa to IVC separates R and L lobes
24
Q
portal triad oritentation
A
CBD lateral
portal posterior
hepatic medial
25
composition of perfusion to liver
66% portal
33% hepatic aa
26
middle hepatic aa origin
from LHA
LHV and MHV also join before cava
27
what does middle vein drain
V and IVb
28
veins draining into IVC near top of liver
M/L, R, inferior phrenic, poss accessory RHV (medial R lobe), caudate vein (received R/L portal and arterial flow -- drains directly into IVC)
29
vits stored in liver
ADEK B12
30
bile salts
cholic and chenodeoxycholic
deoxycholic and lithocholic
conjugated to turine and glycine for water solubility
31
bilirubin clinically evident
>2.5 (under tongue first)
32
Gilbert disease
abnormal conjugation
glucuronyl transferase defect
indBil
33
Crigler Najjar disease
can't conjugte. severe gluruonyl transferase def; life tthreatning
indBil
34
newborn. jaundice normal
immautre glucuronyl transferase (high iBili)
35
Rotors syndrome
def in storange abililty; high Dbil
36
Dubin Johnson
def in secretion abiliyt; high DBil
37
fulminant hepatic failure 2/2 to what hepatitis viruses
B D E
38
chronic hepatitis/hepatoma 2/2 to what hepatitis viruses
B C D.
39
MC hepatitis worldwide
HBV
40
MC hepatitis causing cirrhosis in Western world
HCV
41
best marker of synthetic function in cirrhosis
prothrombin TIME
42
Kings College Criteria for poor prognosis ACUTE LIVER FAILURE
pH < 7.3 or
INR 6.5, Cr 3.4, grade III+ encephalopathy
with tylenol toxicity
or if not tylenol, then INR 6.5 or
<10 YO, > 40 YO, 7 days jaundice, INR .3.5, bili 17
43
SBP dx
PMN > 250 in fluid
44
SBP ppx indication
Ascites total protein < 1 g/dL
or previous hx of SBP
ppx = cipro (vs tx of SBP is CTX), or cipro x 7 days only if active GI bleed
45
portal hypertension dx
portal vein pressure > 10-12 mm Hg
portal - wedge >6
46
indication for splenorenal shunt
Chids A with bleeding (can worsen asictes)
47
chids C mortaility after shunt
50%
48
budd chiari tx
porta caval shunt
If acute, consider catheter directed TPA
49
splenic VT presentation an dmgmt
gastric varices bleed
splenectomy
50
PVT treatment
heparin
but if bleeding, maybe just shunt
51
amebic liver abscess location
RIGHT mostly usually single (from colon)
52
risk factor amebic (entamoeba histolytica)
Mexico
53
dx amebic
E. histlytica serology; aspiration is negative (protozoa on rim)
54
mgmt amebic
flagyl only
surgery if free rupture only
55
echinococcal cyst dx
positive serology ELISA, Casoni skin test, indirect hemagglutinin, latex agglutination, indirect immunofluorescence ab teset
E. granulosus, multilocularis, vulgari
don’t aspirate (anaphylaxis)
DOG (definitive) > sheep hx
CT double walled cyst
56
echinococcal cyst location
RIGHT, multiple
57
mgmt echinococcal
preop albendazole 2 wks
intraop injection of alcohol PAI
resect ALL of the cyst wall
58
schistosomiasis suspicion
presinusoidal portal hypertension (variceal bleeding without LFT issues) + maculopapular rash + Eosinophils
hx water contact
59
schisto mgmt
praziquantel and UGIB tx
60
pyogenic abscess
MC
MC from E.coli
61
pyogenic abscess location
RIGHT
62
hepatic adenoma risk of...
80% pain, 50% RUPTURE, 5% malignancy
63
hepatic adenoma location
RIGHT
64
hepatic adenoma Kupffer/sulfur colloid scan...
won't show up (no Kupffer cells in adenoma)
65
hepatic adenoma CTA findings
CTA arterial enhancement with washout portal z
66
mgmt hepatic adenoma
< 4cm: stop OCP
> 4cm or sx: resect (preop angioembolization considered)
ruptured? angioembolize. recover. then resect.
67
focal nodular hyperplasia imaging findings
CTA hyperintense arterial, washout with stellate scar
will light up on sulfur colloid
68
mgmt FNH
no resection
69
hemangioma MC what
MC benign tumor in liver
70
dx heamngioma
CT peripheral to central enhancement****; hypervascular; nodular enhancement peripherally
71
complication of hemangioma (not rupture)
consumptive coagulopathy = Kasabach - Merritt syndrome and CHF
72
MC cause HCC worldwide
HBV
73
best and worse prognosis HCC
best: fibrolamellar (young peopel)
worst: diffuse nodular
74
fibrolamellar variant HCC
best px but recurs often.... NEUROTENSIN biomarker
75
AFP correlates with what
HCC SIZE
76
5 yr survival with resectoin HCC
30%
77
margin required for HCC
1 cm
78
intrahepatic cholangio dx
CT scan: peripheral arterial and venous enhancement involving DUCTS
don’t need to Bx
79
dx lap role in intrahepatic cholangio
for staging
80
mgmt of cholangio
resectable if no LN past porta hepatis and no multifocal disease
just resect for negative margin
81
mgmt of hilar cholangiocarcinom
contralateral hemi liver must have intact arterial/portal flow and biliary drainage uninvolved
then, RNY HJ
82
varices
distal esophagus = esophageal submucosa - proximal gastric (pyloric (right gastric) and coronary (left gastric)
rectum = IMV - pudendal
umbilicus = vestigial umbilical V - epigastric veins to L portal V
RP = mesenteric - ovarian
83
portal HTN bleeding Rx acute vs ppx
acute = octreotide/vasopressin, EGD, TIPS
ppx = B blockers
84
what may TIPS WORSEN*
encephalopathy
85
mgmt of esophgeal variceal bleeding
1. resuscitate
2. transfuse
3. Abx
4. intubate for airway and EGD
5. EGD
6. octreotide, vasopressin
7.* TIPS if EGD fails
8. Senstaken Blakemore if EGD fails
86
surgical options for portal HTN decompression
(not TIPS)
1. gastroesophageal devascularization
2. esopahgeal transection and re-anastomosis
3. portosystemic shunts
87
types of portosystemic shunts done surgically
selective (I.e.: distal splenorenal WARREN shunt) - will not help ascites
partial nonselective: side to side via interposition graft between portal vein and cava
nonselective portocaval side to side without interposition ... high rate encepholaphty and complicated liver txp in the future
88
PET scan for HCC?
NO. NEED>
89
cholangio risk factors
PSC, choledocholithiasis, choledochal cysts, liver fluke infections, HBV, HCV
90
duodenal adenoma
soap bubble sign
91
hepatorenal syndrome types
1. acute/severe = sharp decline
2. chronic slow progression
92
HRS pathophys
portal HTN > splanchnic vasodilation > arterial decrease to kidney> RAAS activated> decreased GFR
93
HRS dx
is of exclusion
Lab findings can be: increased Cr and BUN
UNa < 10.
URBC < 50
Uprot < 500
94
HRS tx
1. octreotide - splanch vasoconstrictor
2. systemic vasoconstriction - midodrine, terlipressin, etc.
3. albumin
4. abx if infxn
5. HD
6. liver txp or TIPS
95
HBV vaccination efficacy
90% in immuncompetent; so don't wait
96
Wilsons disease
copper accumulation;
ATP7B AR
97
hcv tx medical
sofosbuvir
ribavirin
98
factors not made in the liver
vWF and Factor VIII
99
acinar zone III
CENTRALLOBAR = most sensitive to ischemia (closest to hepatic VEIN) and artery
100
bile salts conjugated to
taurine or glycine
101
primary bile acids (salts)
cholic and chenodeoxycholic
102
secondary bile acids (salts)
deoxycholic and lithocholic
(dehydroxylated primary bileacids by bacteria in gut)
103
bile components
bile salts 85%
protein
lecithin
cholesterol
bilirubin
104
lecithin
main biliary phospholipid (emulsifies fat, solubilizes chlesterol)
105
jaundice first place
under tongue
106
worst hepatitis prognosis overall
HBV + HDV
107
hep e
MC fulminant hepatic failure in pregnancy.... most often in 3rd trimester
108
BCAAs in cirrhosis
because metabolized in skeletal muscle
109
propranolol role in UGI bled
not much... may prevent asx varices from bleeding
110
splenorenal shunt
CHilds A with bleeding
CI: ascites
ligate: left adrenal, left gonadal, IMV, coronary vein, pancreatic branches of splenic
DON’T NEED SPLENECTOMY
111
if refractory ascites, what kind of shunt?
TIPS >>>>> OR for partial portosystemic (interposition graft between portal and iVC)
112
Childs score and shunt placement
correlates with mortality after shunt placement
113
MC cause of pedatric portal hypertension
extrahepatic portal vein thrombosis
114
size cut off for TACE first in HCC palliation or mets
5 cm (otherwise just ablate)
115
hepatic sarcoma RF
PVC
thorotrast (contrast)
arsenic
rapidly fatal
116
hmg coa to bile salts
hmg coa reductase to cholesterol.
cholesterol with 7-a-hydroxylase to bile salts
HGM COA REDUCTASE IS RATE LIMITING REACTION TO CHOLESTEROL SYNTHESIS
117
brown stone
secondary to infection // primary bile duct stones Ca-bilirubinate (E coli makes B-glucuronidase which deconjugates BR)
118
black and cholesterol stones in CBD are SECONDARY bile duct stones.... not like brown stones
yeah
119
RNY cholecystitis
if GB there, chole + intraop CBD exploration
if GB no there, lap G and ERCP through that
120
what is more common: GB adenoca or cholangio?
GB adenoca
121
risk factor infection for cholangio
C. sinensiso
122
other risk factors for cholangio
UC, choledochal cyst, PSC, chornic bile duct infection, HBV, HCV, inflammation
123
need bx for cholangio?
no. can just have MRCP + sx
124
diagnostic lap in cholangio
YES before resection!!!!!
125
resectability of gallbaldder ca
intrahepatic: no LN involvement past porta
extra: not involve SMA or celiac nodes
126
klatskin tumor
upper 1/3 extrahepatic cholangio; R0 may need lobectomy but hard to resect
127
GB polyp etiology
cholesterol > hyperplastic > adenoma
128
