HEPATOBILIARY Flashcards
1
Q
MC bacteria isolated from gallbladder
A
E. coli (41%) Enterococcus (12%) Klebsiella (11%) Enterobacter (9%)
2
Q
Type IVa choledochal cyst
A
Intra and extra hepatic dilation, fusiform Type IV cysts are 2nd most common
3
Q
lowest risk of cholangio with what choledochal cyst
A
Type III
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
5
Q
type II choledochal cyst and tx
A
saccular diverticulum off CBD sac/cyst excision and primary closure alone
6
Q
type III choledochal cyst and tx
A
choledochocele or dilation of distal CBD
TRUE CYSTS
endoscopic sphincterotomy and cyst unroofing
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
8
Q
type IVb choledochal cyst
A
extra hepatic dilation only
9
Q
tx of gallbladder adeno invading muscularis propria
A
T1b - “extended chole”
10
Q
tx of gallbladder adeno invading perimsucular connective tissue
A
T2 - extended cholecystectomy
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
12
Q
Operation to perform if cystic duct margin is positive
A
Resection of CBD and Roux en Y hepaticojejunostomy reconstruction
13
Q
Chemo used in unresectable dz or distant metastatic gallbladder CA
A
gemcitabine and cisplatin vs capecitabine monotherapy
14
Q
Highest positive predictive value for choledocholithiasis
A
bilirubin
15
Q
Elevated ALT may indicate
A
viral hepatitis, diabetes, CHF, liver damage, bile duct problems, mono, myopathy
16
Q
Elevated AST may indicate
A
MI, acute pancreatitis, acute hemolytic anemia, severe burns, acute renal disease, MSK disesases, trauma
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.
18
Q
distal CBD injury
A
roux en Y choledochojejunostomy
19
Q
Proximal CBD injkury
A
Roux en Y hepaticojejunostomy
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
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
22
Q
Tx of advanced PSC
A
Liver transplant
23
Q
Most pts with PSC will have elevated what antibodies?
A
perinuclear antineutrophil cytoplasmic antibodies
24
Q
Abnormal bilirubin elevates MELD to …
A
12
25
Common signs of recurrence in gb cancer
jaundice and ascites
26
MC sites of recurrence after resection of GB cancer
carcinomatosis, intrahepatic mets or nodal recurrence in retroperitoneum
27
f/u imaging for surveillance after GB cancer resection
imaging every 6 months for 2 years and then annually for 5 years
28
most prevalent location of NET within small bowel
ileum
29
MC location for NET in pts between ages of 50-59 years
rectum
30
what bismuth classification is a tumor involving the hepatic duct bifurcation but not involving significant portions of right or left hepatic duct
tyoe II
31
What class tumor is a tumor involving the hepatic duct but not the bifurcation
type I
32
What class tumor involves conflucence of right and left hepatic ducts and extends to right hepatic duct
class IIIa
33
what class tumor involves confluence of right and left hepatic ducts and extends tgo the left hepatic duct
Class IIIb
34
what is the double duct sign
simultaneous dilation of common bile and pancreatic ducts
35
2 most common causes of double duct sign
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)
36
what is medial structure in portal triad
proper hepatic artery
37
what separates right and left lobes of liver
cantlies line (line between gallbladder fossa and IVC)
38
right posterior lateral esgments of liver
VI-VII
39
right superior anteromedial segment of liver
VIII
40
3 hepatic veins drain into
IVC
41
which two veins usually merge before draining into IVC
medial and left hepatic
42
replaced right hepatic - MC off? travels?
most commonly off SMA and travels behind pancreas and CBD
43
replaced left hepatic - MC off? travels?
MC off left gastric, travels in gastrohepatic ligametn
44
what if you cant visualize the hepatic ductso n IOC
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
45
What is Rigler triad
Bowel obstruction gallstone seen in intestine pneumobilia on imaging
46
GB polyps \> what size are consdiered cancer until proven otherwise
18 mm
47
portal HTN is defined as HVPG \>
6 mmHg
48
PBC and etiology of portal htn
presinusoidal and sinusoidal elements
49
name 4 sites of collateral circulation
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)
50
when to use selective shunt
decompress only part of portal venous system good for variceal bleeding but do NOT help ascites
51
what is a partial portosystemic shunt
type of side to side shunt where flow is calibrated by size of synthetic interposition graft placed bwten the portal vien and vena cava
52
most common non selective portosystemic shunt
side to side portocaval shunt
53
complications from non selective shunts
high rate of enecephalopathy, complicate later liver txp
54
ascites - what kind of shunt
non selective
55
double walled cyst on CT
echinococcal cyst (hydatid cyst)
56
what hepatic vein pressure gradient typically required for variceal rupture
12 mm Hg
57
What are components of child turcotte pugh score
bili albumin prothrombin time encephalopathy ascites
58
MELD at which pts have survival benefit for transplantation
15
59
etiology of choledochal cysts
anomalous biliary-pancreatic duct junction with reflux of pancreatic enzymes (long common BP duct)
60
positive sulfur colloid uptake
functioning kupffer cells FNH!
61
negativfe sulfur colloid uptake
absent Kupffer cells from hepatocytes adenoma!
62
MC site of mets in HCC
lung
63
Milan criteria
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\*
64
ablation of liver tumors is best for
small lesions \<5 cm
65
TACE of liver tumors is best for
unresectable tumors \>5 cm
66
mgmt of intrahepatic cholangioCA
preop bx not necessary if radiographically and clinically suggested malignancy dx lap to rule out disseminated disease recommended
67
contraindications to resection for intrahepatic cholangioCA
LN mets past porta hepatis distant mets multifocal liver disease usually
68
hilar cholangiocarcinoma - in order to be resectable?
contralateral hemi-liver must have intact arterial/portal flow and biliary. drainage uninvolved with tumor
69
reconstructions for hilar cholangioCA
roux en Y hepaticojejunostomy
70
distal cholangioCA, how do you resect
Whipple
71
what kind of infection increases risk for gallbladder CA
typhoid
72
pt with CRC and isolated liver mets receives neoadjuvant FOLFOX. Restaging shows complete radiologic response. Next step?
still perform hepatic resection as complete pathologic response is rare
73
cholelithiasis + 5 mm GB polyp
cholecsyetectomy as risk of malignant transofrmation within gallbladder polyps linked to concurrent cholelithiasis
74
highest negative predictive value test for choledocho
GGT (normal GGT is 97% NPV)
75
marker for fibrolamellar variant HCC
neurotensin
76
isolated gastric varices
MCC by splenic vein thrombosis secondary to panmcreatitis
77
Tx of isolated gastric varices
splenectomy
78
extended left hepatectomy
segments 2-4 + 5 and 8
79
falciform ligament carries remnants of
umbilical vein
80
peritoneum that covers the liver
glisson's capsule
81
triangular ligaments are lateral and medial extensions of?
coronary ligament found on posterior surface of liver
82
portal triad enters which liver segments
IV and V
83
gallbladder lies under which liver segments
IV and V
84
what is the porta hepatis
hepatoduodenal ligament
85
borders of foramen of Winslow
entrance to lesser sac Anterior: portal triad Posterior: IVC Inferior: duodenum Superior: liver (caudate lobe)
86
left portal vein supplies
segments II, III and IV
87
right portal vein supplies
segments V, VI, VII, and VIII
88
middle hepatic artery MC a branch off of
left hepatic a
89
most primary and secondary liver tumors are supplied by
hepatic artery
90
left hepatic vein drains
II, III, and superior IV
91
middle hepatic vein drains
V and inferior IV
92
Right hepatic vein drains
VI, VII and VIII
93
inferior phrenic vv drain into
IVC
94
accessory right hepatic veins drain
medial aspect of R lobe directly into IVC
95
alk phos located in which membrane
canalicular
96
nutrient uptake occurs in which membrane
sinusoidal
97
usual energy source for liver
ketones glucose converted to glycogen and stored
98
where is urea synthesized
liver
99
which two coag factors not made in the liver
vWF and factor VIII (endothelium)
100
only water soluble vitamin stored in the liver
B12
101
which hepatocytes most sensitive to ischemia
central lobular (acinar zone III)
102
how much of normal liver can be safely resected
75%
103
How does hgb get to bilirubin
hgb --\> heme --\> biliverdin --\> bilirubin
104
what is bilirubin conjugated to in the liver? what does this improve?
glucuronic acid (via glucuronyl transferase) which improves water solubility
105
describe process of urobilinogen
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
components of bile
bile salts (85%), proteins, phospholipids (lecithin), cholesterol and bilirubin
107
final bile composition determined by
passive Na/K ATPase reabsorption of water in gallbladder
108
bile salts are ocnjugated to
taurine or glycine (improves water solubility)
109
primary bile acids
cholic and chenodeoxycholic
110
secondary bile acids
deoxycholic and lithocholic (dehydroxylated primary bile acids by bacteria in gut
111
main biliary phospholipid
lecithin emulsifies fat, solubilzies cholesterol
112
where is jaundice first evident
under the tongue
113
jaundice occurs when total bili \>
2.5
114
elevated unconjugated bilirubin indicates casue is
prehepatic (hemolysis), hepatic deficincies of uptake or conjugation
115
elevated conjugated bilirubin indicates what etiology
secretion defects into bile ducts (e.g. hepatitis) or excretion defects into GI tract (obstructive jaundice; e.g., gallstones, cancer, benign stricture)
116
hepatitis LFTs and alk phos
very high LFTs modest alk phos
117
obstructive jaundice LFTs and alk phos
modest LFTs very high alk phos
118
Gilberts disease
abnormal conjugation mild defect in glucuronyl transferase
119
crigler najjar disease
inability to conjugate severe deficiency of glucuronyl transferase high unconjugated bili --\> life threatening disease
120
physiologic jaundice of newborn
immature glucuronyl transferase high unconjugated bili
121
rotors syndrome
deficiency in storage ability, high conjugated bili
122
dubin-johnson syndrome
deficiency in secretion ability, high conjugated bilirubin
123
hep A is what kind of virus
RNA
124
hep B is what kind of virus
DNA
125
MC hepatitis worldwide
hep B
126
which antibody is elevated in first 6 months of hep B
anti-HBc-IgM (c=core) IgG then takes over
127
hep b vaccine antibodies
anti-HBs antibodies (s=surface)
128
increased anti-HBc and increased anti-HBs antibodies and NO HBsAg
pt had infection with recovery and subsequent immunity
129
Hep C is what kidn of virus
RNA
130
Tx of hep C
sovaldi (95% cure rate)
131
Hep D and E are what kind of viruses
RNA
132
which hepatitis leads to fulminant hepatic failure in pregnancy
E most often in 3rd trimester
133
MCC liver failure
cirrhosis
134
best indicator of synthetic function in pt with cirrhosis
PT
135
how does lactulose help in hepatic encephalopathy
cathartic that gets rid of bacteria in the gut and acidifies colon preventing NH3 uptake by converting it to ammonium
136
Dietary tx for hepatic encephalopathy
limit protein \<70 g/day BCAAs Neomycin gets rid of ammonia producing bacteria from gut
137
how muc halbumin replacement after paracentesis
1 g for every 100 cc removed
138
aldosterone is elevated with liver failure secondary to
impaired hepatic metabolism
139
tx for hepatorenal syndroeme
volume challenge does NOT work stop diuretics, give volume mnidodrine and octreotide no good therapy other than liver txp
140
post partum liver failure with ascites
hepatic v thrombosis from ovarian vein source has infectious component tx: heparin and abx
141
type I HRS
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
type 2 HRS
less rapid renal function deterioration mainly presents with refractory ascites median survival without tx 4-6 months
143
SBP - how many PMNs diagnostic?
\>250
144
#1 bug in SBP
E coli
145
SBP - mono or poly organism
mono (if not need to worry about bowel perf)
146
RF for SBP
prior SBP UGI bleed (variceal hemorrhage) low protein ascites childhood nephrotic syndrome
147
tx of SBP
3rd gen cephalosporin or flluoroquinolone
148
how does octreotide help esophageal varices
decreases portal pressure by decreasing blood flow
149
pts with history of CAD on vasopressin for esophageal varices should also receive
nitroglycerin
150
refractory variceal bleeding
TIPS
151
collaterals between portal vein and systemic venous system of lower esophagus (azygous vein)
coronary veins
152
child's A that just has bleeding as symptom, what kind of shunt?
consider splenorenal (more durable) otherwise TIPS
153
portal HTN in children usually from
extra hepatic portal vein thrombosis
154
Tx of budd chiari
porta caval shunt (needs to connect to IVC above obstruction) can try catheter directed tPA if acute
155
MCC massive hematemesis in children
esophageal varices (2/2 portal vein thrombosis)
156
acute PVT - tx?
heparin but avoid if UGI bleeding present may eventually need a shhunt
157
why are cultures of amebic abscesses often sterile
protozoa only exist in peripheral rim
158
adenoma vs HCC on CT, how to distinguish?
BOTH enhance on arterial phase Adenomas do NOT show delayed washout
159
diffuse hepatic hemangiomas a/w
acquired hypothyroidism
160
MC cancer worldwide
HCC
161
#1 cause of HCC worldwide
Hep B
162
worst prognosis HCC
diffuse nodular type
163
AFP level and HCC
correlates with tumor size
164
margins when resecting HCC
1 cm
165
RF for hepatic sarcoma
PVC, thorotrast, arsenic
166
primary liver tumors vs metastatic, which is hypovascular?
metastatic = hypo primary=hyper
167
168
cystic veins drain into
R branch of portal vein
169
lymphatics are on what side of CBD?
right
170
parasympathetic fibers to GB come from
left trunk of vagus
171
gallbladder lacks which layer
submcuosa
172
mucosa is made up of what kidn of epithelium
columnar
173
morphine does what to sphincter of oddi
contracts
174
glucagon does what to sphincter of oddi
relaxes
175
normal pancreatic duct is
\<4 mm
176
where is highest concentration of CCK and secretin cells
duodenum
177
rokitansky aschoff sinuses are formed from
increased GB pressure epithelial invaginations in gallbladder wall
178
5 factors that deter from transcystic CBD exploration
friable cystic duct
numerous (**\>8**) stones in CBD
Large stones (**\>10 mm**)
Stones proximal to cystic duct/CBD junction
179
Chole is recommended for polyps 6-9 mm with other risk factors including (4)
Age \>50
Sessile morphology
Concomitant gallstones
Symptomatic polyps of any size
180
Most prevalent location for NET within the small bowel
Ileum
181
Second most common location of NETs
Small bowel
182
MC location for NET
GI tract
RECTUM
183
Why should pts with sickle cell be offered cholecystectomy?
Chronic hemolysis with hyperbilirubinemia is associated with formation of bile stones, usually containing more pigment (black)
184
What size stone should you consider prophylactic cholecystectomy
\>3 cm
185
Highest PPV for choledocholithiasis
Total bilirubin
186
Double duct sign typically caused by cancers where?
ampulla or pancreatic head
