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ABS > HEPATOBILIARY > Flashcards

HEPATOBILIARY Flashcards

1
Q

MC bacteria isolated from gallbladder

A

E. coli (41%) Enterococcus (12%) Klebsiella (11%) Enterobacter (9%)

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2
Q

Type IVa choledochal cyst

A

Intra and extra hepatic dilation, fusiform Type IV cysts are 2nd most common

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3
Q

lowest risk of cholangio with what choledochal cyst

A

Type III

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4
Q

type I choledochal cyst

A

fusiform dilation of extra hepatic duct MC (85%)

Treatment is with resection, Chole and roux en y hepaticojejunostomy

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5
Q

type II choledochal cyst and tx

A

saccular diverticulum off CBD sac/cyst excision and primary closure alone

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6
Q

type III choledochal cyst and tx

A

choledochocele or dilation of distal CBD

TRUE CYSTS

endoscopic sphincterotomy and cyst unroofing

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7
Q

type V choledochal cyst

A

dilation of intra hepatic ducts only

Unilobar: hepatic resection +/- Roux en y cholangiojejunostomy

Bilobar or cirrhosis/fibrosis -→ liver transplant

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8
Q

type IVb choledochal cyst

A

extra hepatic dilation only

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9
Q

tx of gallbladder adeno invading muscularis propria

A

T1b - “extended chole”

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10
Q

tx of gallbladder adeno invading perimsucular connective tissue

A

T2 - extended cholecystectomy

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11
Q

Tx of gallbladder adenoCA perforating the serosa and/or directly invading liver and/or one other adjacent organ or structure

A

Extended cholecystectomy with en bloc resection if feasible

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12
Q

Operation to perform if cystic duct margin is positive

A

Resection of CBD and Roux en Y hepaticojejunostomy reconstruction

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13
Q

Chemo used in unresectable dz or distant metastatic gallbladder CA

A

gemcitabine and cisplatin vs capecitabine monotherapy

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14
Q

Highest positive predictive value for choledocholithiasis

A

bilirubin

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15
Q

Elevated ALT may indicate

A

viral hepatitis, diabetes, CHF, liver damage, bile duct problems, mono, myopathy

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16
Q

Elevated AST may indicate

A

MI, acute pancreatitis, acute hemolytic anemia, severe burns, acute renal disease, MSK disesases, trauma

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17
Q

Elevated alk phos may be seen in

A

biliary obstruction, osteoblastic bone tumors, osteomalacia, osteoporosis, hepatitis, ciorrhosis, acute chole, myelofibrosis, leukemoid reaction, lymphoma, Paget diseae, sarcoidosis, hyperthyroidism, hyperPTH, myocardial infarction, pregnancy.

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18
Q

distal CBD injury

A

roux en Y choledochojejunostomy

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19
Q

Proximal CBD injkury

A

Roux en Y hepaticojejunostomy

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20
Q

Describe roux en Y hepaticojejunostomy

A

Dissection of remnant CBD or hepatic duct Divide small bowel and distal small bowel (ROUX limb) brought up and sutured to bile duct (end to side hepaticojejunostomy) End to side bowel-bowel anastomosis

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21
Q

How to mechanically flush stones from the duct?

A

For stones <3-4 mm in diameter can give IV admin of 1.0 mg of glucagon to help relax sphincter of Oddi Can then flush the cystic duct catehter with several 10 cc syringers of saline

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22
Q

Tx of advanced PSC

A

Liver transplant

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23
Q

Most pts with PSC will have elevated what antibodies?

A

perinuclear antineutrophil cytoplasmic antibodies

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24
Q

Abnormal bilirubin elevates MELD to …

A

12

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25
Q

Common signs of recurrence in gb cancer

A

jaundice and ascites

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26
Q

MC sites of recurrence after resection of GB cancer

A

carcinomatosis, intrahepatic mets or nodal recurrence in retroperitoneum

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27
Q

f/u imaging for surveillance after GB cancer resection

A

imaging every 6 months for 2 years and then annually for 5 years

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28
Q

most prevalent location of NET within small bowel

A

ileum

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29
Q

MC location for NET in pts between ages of 50-59 years

A

rectum

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30
Q

what bismuth classification is a tumor involving the hepatic duct bifurcation but not involving significant portions of right or left hepatic duct

A

tyoe II

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31
Q

What class tumor is a tumor involving the hepatic duct but not the bifurcation

A

type I

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32
Q

What class tumor involves conflucence of right and left hepatic ducts and extends to right hepatic duct

A

class IIIa

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33
Q

what class tumor involves confluence of right and left hepatic ducts and extends tgo the left hepatic duct

A

Class IIIb

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34
Q

what is the double duct sign

A

simultaneous dilation of common bile and pancreatic ducts

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35
Q

2 most common causes of double duct sign

A

CA of the head of the pancreas and ampullary tumors (though occasioanlly an impacted gallstone in distal duct can result in obstruction of pancreatic duct)

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36
Q

what is medial structure in portal triad

A

proper hepatic artery

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37
Q

what separates right and left lobes of liver

A

cantlies line (line between gallbladder fossa and IVC)

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38
Q

right posterior lateral esgments of liver

A

VI-VII

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39
Q

right superior anteromedial segment of liver

A

VIII

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40
Q

3 hepatic veins drain into

A

IVC

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41
Q

which two veins usually merge before draining into IVC

A

medial and left hepatic

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42
Q

replaced right hepatic - MC off? travels?

A

most commonly off SMA and travels behind pancreas and CBD

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43
Q

replaced left hepatic - MC off? travels?

A

MC off left gastric, travels in gastrohepatic ligametn

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44
Q

what if you cant visualize the hepatic ductso n IOC

A

oull catheter back and try flushing again trendelenburg to see if chagne in imaging (back filling using gravity) convert to open to investigate injury to hepatic duct

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45
Q

What is Rigler triad

A

Bowel obstruction gallstone seen in intestine pneumobilia on imaging

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46
Q

GB polyps > what size are consdiered cancer until proven otherwise

A

18 mm

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47
Q

portal HTN is defined as HVPG >

A

6 mmHg

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48
Q

PBC and etiology of portal htn

A

presinusoidal and sinusoidal elements

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49
Q

name 4 sites of collateral circulation

A

distal esophagus/proximal stomach (Esophageal submucosal veins to proximal gastric veins) rectum (IMV to pudendal vein) umbilicus (vestigial umbilical v to left portal vein) retroperitoenum (mesenteric and ovarian vv)

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50
Q

when to use selective shunt

A

decompress only part of portal venous system good for variceal bleeding but do NOT help ascites

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51
Q

what is a partial portosystemic shunt

A

type of side to side shunt where flow is calibrated by size of synthetic interposition graft placed bwten the portal vien and vena cava

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52
Q

most common non selective portosystemic shunt

A

side to side portocaval shunt

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53
Q

complications from non selective shunts

A

high rate of enecephalopathy, complicate later liver txp

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54
Q

ascites - what kind of shunt

A

non selective

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55
Q

double walled cyst on CT

A

echinococcal cyst (hydatid cyst)

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56
Q

what hepatic vein pressure gradient typically required for variceal rupture

A

12 mm Hg

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57
Q

What are components of child turcotte pugh score

A

bili albumin prothrombin time encephalopathy ascites

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58
Q

MELD at which pts have survival benefit for transplantation

A

15

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59
Q

etiology of choledochal cysts

A

anomalous biliary-pancreatic duct junction with reflux of pancreatic enzymes (long common BP duct)

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60
Q

positive sulfur colloid uptake

A

functioning kupffer cells FNH!

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61
Q

negativfe sulfur colloid uptake

A

absent Kupffer cells from hepatocytes adenoma!

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62
Q

MC site of mets in HCC

A

lung

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63
Q

Milan criteria

A

one lesion <5 cm 3 or fewer lesions all <3 cm and NO gross vascular or extrahepatic spread *usually perform neoadjuvant chemo prior to txp*

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64
Q

ablation of liver tumors is best for

A

small lesions <5 cm

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65
Q

TACE of liver tumors is best for

A

unresectable tumors >5 cm

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66
Q

mgmt of intrahepatic cholangioCA

A

preop bx not necessary if radiographically and clinically suggested malignancy dx lap to rule out disseminated disease recommended

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67
Q

contraindications to resection for intrahepatic cholangioCA

A

LN mets past porta hepatis distant mets multifocal liver disease usually

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68
Q

hilar cholangiocarcinoma - in order to be resectable?

A

contralateral hemi-liver must have intact arterial/portal flow and biliary. drainage uninvolved with tumor

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69
Q

reconstructions for hilar cholangioCA

A

roux en Y hepaticojejunostomy

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70
Q

distal cholangioCA, how do you resect

A

Whipple

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71
Q

what kind of infection increases risk for gallbladder CA

A

typhoid

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72
Q

pt with CRC and isolated liver mets receives neoadjuvant FOLFOX. Restaging shows complete radiologic response. Next step?

A

still perform hepatic resection as complete pathologic response is rare

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73
Q

cholelithiasis + 5 mm GB polyp

A

cholecsyetectomy as risk of malignant transofrmation within gallbladder polyps linked to concurrent cholelithiasis

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74
Q

highest negative predictive value test for choledocho

A

GGT (normal GGT is 97% NPV)

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75
Q

marker for fibrolamellar variant HCC

A

neurotensin

76
Q

isolated gastric varices

A

MCC by splenic vein thrombosis secondary to panmcreatitis

77
Q

Tx of isolated gastric varices

A

splenectomy

78
Q

extended left hepatectomy

A

segments 2-4 + 5 and 8

79
Q

falciform ligament carries remnants of

A

umbilical vein

80
Q

peritoneum that covers the liver

A

glisson’s capsule

81
Q

triangular ligaments are lateral and medial extensions of?

A

coronary ligament found on posterior surface of liver

82
Q

portal triad enters which liver segments

A

IV and V

83
Q

gallbladder lies under which liver segments

A

IV and V

84
Q

what is the porta hepatis

A

hepatoduodenal ligament

85
Q

borders of foramen of Winslow

A

entrance to lesser sac Anterior: portal triad Posterior: IVC Inferior: duodenum Superior: liver (caudate lobe)

86
Q

left portal vein supplies

A

segments II, III and IV

87
Q

right portal vein supplies

A

segments V, VI, VII, and VIII

88
Q

middle hepatic artery MC a branch off of

A

left hepatic a

89
Q

most primary and secondary liver tumors are supplied by

A

hepatic artery

90
Q

left hepatic vein drains

A

II, III, and superior IV

91
Q

middle hepatic vein drains

A

V and inferior IV

92
Q

Right hepatic vein drains

A

VI, VII and VIII

93
Q

inferior phrenic vv drain into

A

IVC

94
Q

accessory right hepatic veins drain

A

medial aspect of R lobe directly into IVC

95
Q

alk phos located in which membrane

A

canalicular

96
Q

nutrient uptake occurs in which membrane

A

sinusoidal

97
Q

usual energy source for liver

A

ketones glucose converted to glycogen and stored

98
Q

where is urea synthesized

A

liver

99
Q

which two coag factors not made in the liver

A

vWF and factor VIII (endothelium)

100
Q

only water soluble vitamin stored in the liver

A

B12

101
Q

which hepatocytes most sensitive to ischemia

A

central lobular (acinar zone III)

102
Q

how much of normal liver can be safely resected

A

75%

103
Q

How does hgb get to bilirubin

A

hgb –> heme –> biliverdin –> bilirubin

104
Q

what is bilirubin conjugated to in the liver? what does this improve?

A

glucuronic acid (via glucuronyl transferase) which improves water solubility

105
Q

describe process of urobilinogen

A

breakdown of conjugated bilirubin by bacteria in the TI occurs free bili is then reabsorbed, converted to urobilinogen and eventually released in urine as urobilin excess urobilinogen turns urine dark like cola

106
Q

components of bile

A

bile salts (85%), proteins, phospholipids (lecithin), cholesterol and bilirubin

107
Q

final bile composition determined by

A

passive Na/K ATPase reabsorption of water in gallbladder

108
Q

bile salts are ocnjugated to

A

taurine or glycine (improves water solubility)

109
Q

primary bile acids

A

cholic and chenodeoxycholic

110
Q

secondary bile acids

A

deoxycholic and lithocholic (dehydroxylated primary bile acids by bacteria in gut

111
Q

main biliary phospholipid

A

lecithin emulsifies fat, solubilzies cholesterol

112
Q

where is jaundice first evident

A

under the tongue

113
Q

jaundice occurs when total bili >

A

2.5

114
Q

elevated unconjugated bilirubin indicates casue is

A

prehepatic (hemolysis), hepatic deficincies of uptake or conjugation

115
Q

elevated conjugated bilirubin indicates what etiology

A

secretion defects into bile ducts (e.g. hepatitis) or excretion defects into GI tract (obstructive jaundice; e.g., gallstones, cancer, benign stricture)

116
Q

hepatitis LFTs and alk phos

A

very high LFTs modest alk phos

117
Q

obstructive jaundice LFTs and alk phos

A

modest LFTs very high alk phos

118
Q

Gilberts disease

A

abnormal conjugation mild defect in glucuronyl transferase

119
Q

crigler najjar disease

A

inability to conjugate severe deficiency of glucuronyl transferase high unconjugated bili –> life threatening disease

120
Q

physiologic jaundice of newborn

A

immature glucuronyl transferase high unconjugated bili

121
Q

rotors syndrome

A

deficiency in storage ability, high conjugated bili

122
Q

dubin-johnson syndrome

A

deficiency in secretion ability, high conjugated bilirubin

123
Q

hep A is what kind of virus

A

RNA

124
Q

hep B is what kind of virus

A

DNA

125
Q

MC hepatitis worldwide

A

hep B

126
Q

which antibody is elevated in first 6 months of hep B

A

anti-HBc-IgM (c=core) IgG then takes over

127
Q

hep b vaccine antibodies

A

anti-HBs antibodies (s=surface)

128
Q

increased anti-HBc and increased anti-HBs antibodies and NO HBsAg

A

pt had infection with recovery and subsequent immunity

129
Q

Hep C is what kidn of virus

A

RNA

130
Q

Tx of hep C

A

sovaldi (95% cure rate)

131
Q

Hep D and E are what kind of viruses

A

RNA

132
Q

which hepatitis leads to fulminant hepatic failure in pregnancy

A

E most often in 3rd trimester

133
Q

MCC liver failure

A

cirrhosis

134
Q

best indicator of synthetic function in pt with cirrhosis

A

PT

135
Q

how does lactulose help in hepatic encephalopathy

A

cathartic that gets rid of bacteria in the gut and acidifies colon preventing NH3 uptake by converting it to ammonium

136
Q

Dietary tx for hepatic encephalopathy

A

limit protein <70 g/day BCAAs Neomycin gets rid of ammonia producing bacteria from gut

137
Q

how muc halbumin replacement after paracentesis

A

1 g for every 100 cc removed

138
Q

aldosterone is elevated with liver failure secondary to

A

impaired hepatic metabolism

139
Q

tx for hepatorenal syndroeme

A

volume challenge does NOT work stop diuretics, give volume mnidodrine and octreotide no good therapy other than liver txp

140
Q

post partum liver failure with ascites

A

hepatic v thrombosis from ovarian vein source has infectious component tx: heparin and abx

141
Q

type I HRS

A

double serum Cr >2.5 mg/dL or 50% decrease in GFR to <20 in <2 weeks Frequently follows precip event median survival without tx is 2 weeks

142
Q

type 2 HRS

A

less rapid renal function deterioration mainly presents with refractory ascites median survival without tx 4-6 months

143
Q

SBP - how many PMNs diagnostic?

A

>250

144
Q

1 bug in SBP

A

E coli

145
Q

SBP - mono or poly organism

A

mono (if not need to worry about bowel perf)

146
Q

RF for SBP

A

prior SBP UGI bleed (variceal hemorrhage) low protein ascites childhood nephrotic syndrome

147
Q

tx of SBP

A

3rd gen cephalosporin or flluoroquinolone

148
Q

how does octreotide help esophageal varices

A

decreases portal pressure by decreasing blood flow

149
Q

pts with history of CAD on vasopressin for esophageal varices should also receive

A

nitroglycerin

150
Q

refractory variceal bleeding

A

TIPS

151
Q

collaterals between portal vein and systemic venous system of lower esophagus (azygous vein)

A

coronary veins

152
Q

child’s A that just has bleeding as symptom, what kind of shunt?

A

consider splenorenal (more durable) otherwise TIPS

153
Q

portal HTN in children usually from

A

extra hepatic portal vein thrombosis

154
Q

Tx of budd chiari

A

porta caval shunt (needs to connect to IVC above obstruction) can try catheter directed tPA if acute

155
Q

MCC massive hematemesis in children

A

esophageal varices (2/2 portal vein thrombosis)

156
Q

acute PVT - tx?

A

heparin but avoid if UGI bleeding present may eventually need a shhunt

157
Q

why are cultures of amebic abscesses often sterile

A

protozoa only exist in peripheral rim

158
Q

adenoma vs HCC on CT, how to distinguish?

A

BOTH enhance on arterial phase Adenomas do NOT show delayed washout

159
Q

diffuse hepatic hemangiomas a/w

A

acquired hypothyroidism

160
Q

MC cancer worldwide

A

HCC

161
Q

1 cause of HCC worldwide

A

Hep B

162
Q

worst prognosis HCC

A

diffuse nodular type

163
Q

AFP level and HCC

A

correlates with tumor size

164
Q

margins when resecting HCC

A

1 cm

165
Q

RF for hepatic sarcoma

A

PVC, thorotrast, arsenic

166
Q

primary liver tumors vs metastatic, which is hypovascular?

A

metastatic = hypo primary=hyper

167
Q
A
168
Q

cystic veins drain into

A

R branch of portal vein

169
Q

lymphatics are on what side of CBD?

A

right

170
Q

parasympathetic fibers to GB come from

A

left trunk of vagus

171
Q

gallbladder lacks which layer

A

submcuosa

172
Q

mucosa is made up of what kidn of epithelium

A

columnar

173
Q

morphine does what to sphincter of oddi

A

contracts

174
Q

glucagon does what to sphincter of oddi

A

relaxes

175
Q

normal pancreatic duct is

A

<4 mm

176
Q

where is highest concentration of CCK and secretin cells

A

duodenum

177
Q

rokitansky aschoff sinuses are formed from

A

increased GB pressure epithelial invaginations in gallbladder wall

178
Q

5 factors that deter from transcystic CBD exploration

A

friable cystic duct

numerous (>8) stones in CBD

Large stones (>10 mm)

Stones proximal to cystic duct/CBD junction

179
Q

Chole is recommended for polyps 6-9 mm with other risk factors including (4)

A

Age >50

Sessile morphology

Concomitant gallstones

Symptomatic polyps of any size

180
Q

Most prevalent location for NET within the small bowel

A

Ileum

181
Q

Second most common location of NETs

A

Small bowel

182
Q

MC location for NET

A

GI tract

RECTUM

183
Q

Why should pts with sickle cell be offered cholecystectomy?

A

Chronic hemolysis with hyperbilirubinemia is associated with formation of bile stones, usually containing more pigment (black)

184
Q

What size stone should you consider prophylactic cholecystectomy

A

>3 cm

185
Q

Highest PPV for choledocholithiasis

A

Total bilirubin

186
Q

Double duct sign typically caused by cancers where?

A

ampulla or pancreatic head

ABS (23 decks)

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