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The Abdomen > Hepatobiliary > Flashcards

Hepatobiliary Flashcards

1
Q

What encases the liver

A

Glisson’s capsule

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2
Q

What exists between the diaphragm and superior surface of the liver

A

Subphrenic recesses (separated into right and left by the falciform ligament)

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3
Q

What divides the liver into right and left lobes

A
  • Falciform ligament (anteriorly and superiorly)

- Sagittal fissures (posteroinferiorly)

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4
Q

Associations of the visceral surface of the liver

A
  • Abdominal oesophagus
  • Stomach
  • Duodenum
  • Hepatic flexure
  • Right kidney
  • Right suprarenal gland
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5
Q

Where is the subhepatic space

A

Space between supracolic compartment and inferior surface of liver

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6
Q

What denotes the space between the right visceral surface of the liver and the right kidney

A

Morrison’s pouch (Hepatorenal recess)

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7
Q

Associations of superior surface of liver

A

Diaphragm

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8
Q

Where does the bare area exist

A

Between the two layers of the coronary ligament on the posterior surface

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9
Q

What forms the right sagittal fissure

A
  • Anteriorly = groove of the GB

- Posteriorly = IVC

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10
Q

What forms the left sagittal fissue

A
  • Anteriorly = fissure of the round ligament (ligamentum teres)
  • Posteriorly = ligamentum venosum (fetal remnant of ductus venosus)
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11
Q

Liver blood flow in L/min

A

1500

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12
Q

Liver blood flow contributors

A
  1. 30% from the hepatic artery (branch of the coeliac artery)
  2. 70% from the portal vein
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13
Q

Describe the course of the falciform ligament

A
  • Passes up from umbilicus
  • Runs over dome of the liver
  • Separates into upper leaf of coronary ligament (right part) and left triangular ligament
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14
Q

What is the fate of the left triangular ligament

A

Joins the lesser omentum in the fissure for the ligamentum venosum

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15
Q

Contents and orientation of free edge of lesser omentum

A
  1. Bile duct (right)
  2. Hepatic artery (left)
  3. Portal vein (posterior)
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16
Q

Contents and orientation of porta hepatis

A
  1. Common hepatic duct anteriorly
  2. Hepatic artery in the middle
  3. Portal vein posteriorly
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17
Q

What delineates the quadrate and caudate lobes

A
  • Left and right sagittal fissures

- Transverse porta hepatis

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18
Q

What forms the functional divide of the liver

A

Plane which passes through the GB fossa and IVC fossa

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19
Q

How many surgical liver segments are there

A

8

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20
Q

What supports the two functional lobes

A

Both lobes have their own:

  • Primary branch of the hepatic artery
  • Primary branch of the hepatic portal vein
  • Drained by its own hepatic duct
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21
Q

How do lipids bypass the liver

A

Via the lymphatic system

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22
Q

Where do the hepatic portal vein and hepatic artery divide into right and left branches

A

Level of the porta hepatis

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23
Q

Describe the course of the hepatic veins

A
  • Right, middle, and left
  • Intersegmental in their distribution
  • Drain into the IVC
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24
Q

Describe the vasculature of the caudate lobe

A

Has its own hepatic vein which drains directly into the IVC

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25
Q

What percentage of total lymph drained by the thoracic duct comes from the liver

A

25-50%

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26
Q

Where do the hepatic lymph nodes lie

A

Along the hepatic vessels and ducts in the lesser omentum

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27
Q

Describe the lymph journey from the liver

A
  1. Formed in the perisinusoidal spaces of Disse
  2. Drains to deep lymphatics in the intralobular triads
  3. Joined by superficial lymph from the visceral and diaphragmatic surfaces
  4. Drain into hepatic nodes
  5. Drain into colic nodes
  6. Drain into cisterna chyli
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28
Q

Posterior liver surface drainage

A
  • Phrenic and posterior mediastinal lymph nodes

- Join the right lymphatic and thoracic ducts

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29
Q

Define a portal system

A

One with capillaries at each end

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30
Q

What does the portal venous system drain

A
  • Abdominal part of the alimentary canal
  • Spleen
  • Pancreas
  • GB
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31
Q

How does the portal vein enter the free edge of lesser omentum

A

Via foramen of Wilmslow

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32
Q

Describe the course of the portal vein

A
  1. Formed via SMV and splenic vein
  2. Enters free edge of lesser omentum
  3. Ascends to porta hepatis
  4. Divides into right and left hepatic branches
  5. Breaks into capillaries running between the lobules of the liver
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33
Q

List the 5 sites of porto-systemic anastomoses

A
  1. Oesophageal branch of left gastric vein and oesophageal tributaries of the azygous
  2. Superior rectal branch of IMV and inferior rectal vein
  3. Portal tributaries of the mesentery and the retroperitoneal veins
  4. Portal veins of the liver and veins of the abdominal wall
  5. Portal branches in the liver and veins of the diaphragm
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34
Q

What is bile composed of

A
  1. Bile acid
  2. Bile salts
  3. Bile pigments
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35
Q

How are bile pigments formed

A
  1. Hb is broken down in the spleen
  2. Bilirubin is transported to the liver bound to albumin
  3. Bilirubin is conjugate to glucuronic acid in the hepatocytes
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36
Q

What stimulates contraction of the GB

A

CCK

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37
Q

What is glycogenesis

A

Conversion of glucose to glycogen

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38
Q

What is glycogenolysis

A

Conversion of glycogen back to glucose

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39
Q

What is gluconeogenesis

A

Production of glucose from amino acids

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40
Q

How does glucose become stored as fat

A
  1. Converted to FFAs
  2. FFAs transported to adipose tissue
  3. Combined with glycerol
  4. Stored as triglycerides
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41
Q

What role does the liver play in vitamin D activation

A

Forms the first hydroxylation to form 25-hydroxycholecalciferol

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42
Q

What are the two stages of detoxification

A
  1. Increase in water solubility of the substrate

2. Reduction in biological activity and toxic activity

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43
Q

What vitamins are stored in the liver

A

A, D, E, K, B12

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44
Q

What is the role of Kuppfer cells

A
  • Phagocytic cells

- Removes bacteria, debris, and old RBCs

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45
Q

When does bilirubin become detectable as jaundice

A

> 40

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46
Q

What happens to bilirubin in the bile

A
  1. Converted to urobilinogen by intestinal bacteria (absorbed, recirculated, excreted in urine)
  2. Some urobilinogen remains in the bowel as Stercobilinogen
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47
Q

Pre-hepatic jaundice hyperbilirubinaemia type

A

Unconjugated

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48
Q

Associated laboratory findings with pre-hepatic jaundice

A
  • No bilirubin in the urine
  • Raised urobilinogen in the urine
  • Reticulocytosis
  • Anaemia
  • Raised LDH
  • Reduced haptoglobin
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49
Q

Name the two congenital unconjugated hyperbilirubinaemias

A
  • Gilbert’s syndrome

- Crigler-Najar syndrome

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50
Q

Name the two congenital conjugated hyperbilirubinaemia

A
  • Dubins-Johnson syndrome

- Rotor’s syndrome

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51
Q

Causes of intrahepatic cholestasis

A
  • Hepatitis
  • Drugs
  • Cirrhosis
  • PBC
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52
Q

Laboratory tests to support cholestatic jaundice

A
  • Bilirubin in the urine (dark)
  • No urobilinogen in the urine (no bilirubin enters the bowel)
  • Raised ALP and GGT
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53
Q

Describe the course of bile through the liver

A
  1. Hepatocytes secrete bile into the bile canaliculi
  2. Canaliculi drain into interlobular biliary ducts
  3. Drain into the large collecting bile ducts of the intrahepatic portal triad
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54
Q

Components of the portal triad

A
  1. Portal vein
  2. Hepatic artery
  3. Bile duct
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55
Q

What forms the common hepatic duct

A

Joining of the right and left hepatic ducts which drain the right and left livers

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56
Q

What forms the common bile duct

A
  1. Common hepatic duct

2. Cystic duct

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57
Q

Length of bile duct

A

9cm

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58
Q

Describe the course of the CBD

A
  1. Lies 4cm above duodenum
  2. Passes behind duodenum
  3. Runs in groove on posterior aspect of the head of pancreas
  4. Opens into medial aspect of 2nd part of duodenum
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59
Q

Outline the arterial supply of the CBD

A
  1. Cystic artery - supplies proximal part
  2. Right hepatic artery - supplies middle part
  3. Posterior superior pancreaticoduodenal and gastroduodenal artery - supply the retroduodenal part
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60
Q

Venous drainage of the CBD

A

Directly to the liver

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61
Q

Capacity of the GB

A

50ml

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62
Q

Position of the GB relative to the duodenum

A
  • Anterior to superior part

- Intimately related

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63
Q

Outline the 3 parts of the GB

A
  1. Fundus = wide blunt end related to tip of 9th costal cartilage in MCL
  2. Body = main portion that contacts liver/transverse colon/superior duodenum
  3. Neck = narrow end directed towards porta hepatis
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64
Q

What is Hartmann’s pouch

A

Pouch present on the ventral aspect of the GB just proximal to the neck

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65
Q

What is the valve of Heister

A

Spiral mucosal valve in the cystic duct

66
Q

Course of the cystic duct

A

Courses between the layers of the lesser omentum

67
Q

Arterial supply to cystic duct and GB

A

Cystic artery

68
Q

What forms Callot’s triangle

A
  1. Inferior liver
  2. Cystic duct
  3. Common hepatic duct
69
Q

Significance of Callot’s triangle

A

Cystic artery lies within

70
Q

Outline the innervation of the GB

A
  • Sympathetic = coeliac plexus
  • Parasympathetic = vagus
  • Somatic = right phrenic nerve
71
Q

Outline the physiological effects of cholecystectomy

A
  1. Loss of concentrating effect of the GB can lead to increased flow of bile
  2. Fat intolerance
72
Q

Role of Lecithin in bile

A

Aid solubility of cholesterol

73
Q

Role of bile salts

A

To emulsify fats

74
Q

Two main bile salts

A
  1. Cholic acid

2. Chenodeoxycholic acid

75
Q

Daily bile salt excretion

A

4g/day

76
Q

Most common type of gallstone

A

Mixed stones

77
Q

Cause of ‘strawberry’ GB

A

Cholesterosis of the GB (lipid-laden macrophages accumulate in the GB wall)

78
Q

In what situation is a mucocele formed in the GB

A

When a stone becomes impacted but the GB is empty and there is no super-added infection

79
Q

Cause of biliary colic

A

Gallstone impaction in the cystic duct

80
Q

Treatment of biliary colic

A
  • Analgesia, rehydration, NBM

- Elective cholecystectomy if imaging consistent with gallstones

81
Q

Management of acute cholecystitis

A

Cholecystectomy (preferably within 48 hours)

82
Q

Management of cholangitis

A
  1. Fluid resus
  2. Broad spectrum abx
  3. Early ERCP
83
Q

Management of gallstone ileus and important considerations

A
  • Laparotomy and removal of stone from small bowel

- Do NOT interfere with fistula between GB and duodenum

84
Q

How do gallstones cause pancreatitis

A

Transient blockage of the ampulla of vater

85
Q

Fistula seen in gallstone ileus

A

Cholecystoenteric fistula

86
Q

What is normal CBD dilatation

A

6mm plus 1mm for every decade after 60

87
Q

Risks of ERCP

A
  • Bleeding
  • Duodenal perforation
  • Cholangitis
  • Pancreatitis
88
Q

Contraindications to laparoscopic cholecystectomy

A
  • Jaundice
  • Cirrhosis
  • Previous upper abdominal surgery
  • Empyema/gangrene
  • Morbid obesity
  • Pregnancy
89
Q

Complication of cholecystectomy procedure

A
  • Haemorrhage from slipped tie of GB bed
  • Biliary leak
  • Missed stone
  • Biliary stricture
  • Wound complication
  • Post-site hernia
90
Q

Management of cystic stump bile leak

A
  1. ERCP
  2. Sphincterotomy
  3. Stent
91
Q

Indication for CBD exploration

A
  • Failure of ERCP

- Intraoperative cholangiography confirms stones

92
Q

What is used to drain the CBD following CBD exploration

A

14G T-tube

93
Q

Describe the falciform ligament

A

Two-layered fold of peritoneum ascending from umbilicus to anterior and superior aspects of the liver

94
Q

What is the ligamentum teres

A

Obliterated remains of the left umbilical vein which, in utero, brings blood from the placenta back to the fetus

95
Q

What is the ligamentum venosum

A

Fibrous remnant of the fetal ductus venosus that shunts blood from the left umbilical vein to the IVC

96
Q

Describe the left triangular ligament

A

Formed from the left leaf of the falciform ligament and is continuous with the lesser omentum

97
Q

What proportion of PSC patients have UC

A

50-70%

98
Q

Method of stone removal in gallstone ileus

A

Proximally sited terminal ileal enterotomy and leave the GB

99
Q

Aschoff-Rokitansky sinuses

A

The result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the gallbladder wall in chronic cholecystitis

100
Q

Most common bacterial cause of liver abscesses

A

Klebsiella and E.coli most common - both gram -ve rods

101
Q

What percentage of laparoscopic cholecystectomy should be day case

A

60%

102
Q

What percentage of gallstones are radio-opaque

A

15%

103
Q

Most common site of porto-systemic bleeding

A

Between left gastric veins and azygous system

104
Q

Preceding symptom in primary biliary cholangitis

A

Pruritus (precedes jaundice)

105
Q

Cause of amoebic liver disease

A

Entamoeba histolytica

106
Q

Cause of liver fluke (Fasciola hepatica)

A

Parasitic trematobe

107
Q

Treatment of liver fluke

A

Triclabendazole

108
Q

At what spinal level does the pancreas cross

A

L1-2

109
Q

Posterior relations of the head of the pancreas

A

IVC, right renal artery and vein, left renal vein

110
Q

Describe the uncinate process

A

Projects from the inferior aspect of the head and lies between the aorta and SMA

111
Q

Orientation of pancreatic neck to portal vein

A

Lies anterior to its origin (SMV joins splenic vein)

112
Q

Spinal level of pancreatic body

A

L2

113
Q

Where does the tail of the pancreas lie

A

Within the splenorenal ligament and in close relation to the splenic hilum

114
Q

Describe the course of the main pancreatic duct

A
  1. Begins in the tail
  2. Runs through the gland parenchyma to the head
  3. Unites with the CBD to form the ampulla of vater
115
Q

Describe the course of the accessory pancreatic duct

A

Opens into the duodenum at the summit of the minor duodenal papilla

116
Q

Blood supply to the tail of the pancreas

A

Splenic artery

117
Q

Pancreatic exocrine daily fluid volume

A

1.5L

118
Q

Where are the proteolytic enzymes secreted from

A

Acinar cells

119
Q

How is trypsinogen activated to trypsin

A

By enterokinase in the duodenum and the alkaline environment

120
Q

Which three enzymes does trypsin activate

A
  1. Chymotrypsin
  2. Proelastase
  3. Procarboxypeptidase
121
Q

Describe the 3 phases of pancreatic exocrine secretion

A
  1. Cephalic - under vagal control
  2. Gastric - under vagal control
  3. Intestinal - CCK and secretin
122
Q

Where is somatostatin secreted from

A

Delta-cell of the pancreas

123
Q

Where is pancreatic polypeptide secreted from

A

F-cells of the pancreas

124
Q

What is the half-life of insulin

A

5-10 minutes

125
Q

Inhibitors of insulin secretion

A
  • Sympathetic stimulation
  • Dopamine
  • Serotonin
  • Somatostatin
126
Q

Role of insulin in carbohydrate metabolism

A
  • Promotes glucose uptake
  • Promotes glycogenesis
  • Stimulates glycolysis
127
Q

Role of glucagon in lipid metabolism

A

Stimulates lipase activity to increase plasma FFAs and glycerol

128
Q

Effects of somatostatin

A
  • Inhibits release of insulin and glucagon

- Reduces GI motility, secretion, absorption

129
Q

Causes of pancreatitis

A
  • Gallstone
  • Ethanol
  • Toxins
  • Surgery or trauma
  • Metaboolic
  • Autoimmune
  • Snake bite
  • Hypothermia
  • ERCP
  • Duodenal obstruction
130
Q

Indication for pancreatic necrosectomy (what test must be performed)

A

Necrosis must be confirmed on FNA first

131
Q

Test on pancreatic exocrine function

A

Lundh meal

132
Q

Two scoring systems for pancreatitis

A
  1. Glasgow

2. Ranson’s criteria

133
Q

Glasgow score indicating severe disease

A

> 3

134
Q

Management of pancreatitis secondary to gallstones

A
  • Urgent ERCP with mandatory sphincterotomy
  • Cholecystectomy on same admission or within 2 weeks
  • Necrosectomy if proven
135
Q

Risk factors for pancreatic carcinoma

A
  • Age
  • Smoking
  • Diabetes
  • Chronic pancreatitis
136
Q

Microscopic and macroscopic appearance of pancreatic tumour

A
  • Mostly adenocarcinoma

- Large, white diffuse tumour

137
Q

Trousseau’s sign

A
  • Thrombophlebitis migrans

- Associated with visceral cancer including the pancreas

138
Q

Management of periampullary cancers

A

Whipple’s resection

139
Q

Management of cancer of the pancreatic body and tail

A
  • Resection rate <7%
  • Adjuvant therapy has no proven role
  • Prognosis is poor
140
Q

CA-19-9

A

Elevated in 75-90% of pancreatic cancers

141
Q

Metabolic picture in the presence of a pancreatic fistula

A

Hypokalaemic metabolic acidosis due to loss of HCO3

142
Q

When is a pancreatic pseudocyst likely to develop

A

3-6 weeks post pancreatitis

143
Q

Most common type of GB cancer

A

Adenocarcinoma

144
Q

Describe Mirizzi syndrome

A

Compression of the common hepatic duct causing obstructive jaundice secondary to a stone in the cystic duct or neck of the GB

145
Q

What are the three grades of pancreatic trauma

A
  1. Minor = injury does not involve the main ducts
  2. Intermediate = distal injury +/- duct disruption
  3. Major = injury to the head of the pancreas or pancreaticoduodenal artery
146
Q

AXR features of pancreatic trauma

A

Air bubbles:

  • Along the right psoas margin
  • Upper pole of right kidney
  • Lower mediastinum
  • Obliteration of psoas shadow - Ground glass appearance of lesser sac
147
Q

Most common bacteria associated with cholangitis

A

E.coli

148
Q

Cause of Hydatid cyst

A

Echinococcus granuosus which initiates a type 1 hypersensitivity reaction

149
Q

Appearance of Hydatid cyst on imaging

A

Calcified liver lesion

150
Q

Biliary disease associated with HIV

A

Sclerosing cholangitis

151
Q

In whom is acalculous cholecystitis common

A

T2DM

152
Q

Why is Callot’s triangle obliterated in Mirizzi syndrome

A

Repeated inflammation caused by the stone in the cystic duct

153
Q

In whom is hepatocellular adenoma most common

A

30-50 year old women on the COCP

154
Q

How should hepatocellular adenomas be managed in males

A

Superficial resection due to higher risk of malignant transformation

155
Q

Lap chole wound infection rate

A

3-5%

156
Q

How is biliary atresia treated

A

Roux-en-Y

157
Q

What must be performed if ERCP fails in pancreatic cancer

A

Percutaneous transhepatic cholangiogram and drain

158
Q

Describe a Klatskin tumour

A

Hilar cholangiocarcinoma

159
Q

What must be done if a gallstone cannot be removed during surgery

A

Construct choledocoduodenostomy

160
Q

What skin condition is associated with Glucagonoma

A

Necrolytic migratory erythema

161
Q

What is the most sensitive test for pancreatitis

A

Serum lipase

162
Q

How is insulinoma managed

A

Enucleation (mostly benign)

The Abdomen (8 decks)

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