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btk book review > Hepatobiliary > Flashcards

Hepatobiliary Flashcards

1
Q

What structures are in the portal triad? What is their relationship to one another?

A
  • common bile duct laterally
  • proper hepatic artery medially
  • portal vein posteriorly
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2
Q

What separates the right and left lobes of the liver?

A

Cantile’s Line between the gallbladder fossa and IVC

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3
Q

Describe the venous drainage of the liver.

A
  • three hepatic veins that empty into the IVC

- the middle and left usually merge before draining into the IVC

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4
Q

What are the most common variations for liver vascular anatomy?

A
  • replaced right off the SMA, traveling behind the pancreas and CBD
  • replaced left off the left gastric, traveling in the gastrohepatic ligament
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5
Q

How is symptomatic cholelithiasis managed in pregnancy?

A
  • lap chole during the second trimester
  • place ports via Hassan technique, keep pneumoperitoneum as low as possible, and place a bump under the right side to offload the cava
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6
Q

How should you manage a CBD stone identified during IOC?

A
  • attempt to flush stone, can give glucagon twice
  • transcystic CBD exploration
  • laparoscopic CBD exploration
  • post-op ERCP
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7
Q

What should you do if you can’t visualize the hepatic ducts on IOC?

A
  • pull the catheter back and try flushing it again
  • put the patient in T-burg to promote back filling
  • convert to open to investigate an injury to the hepatic duct
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8
Q

When should cholecystectomy be performed for gallstone pancreatitis?

A
  • preferably during the index admission after clinical resolution of pancreatitis
  • may need to wait and do an interval chole at 6 weeks if there is a significant peripancreatic collection; perform ERCP with sphincterotomy then wait for collection to mature/regress
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9
Q

What is the Rigler triad?

A
  • bowel obstruction, gallstone seen in intestine, pneumobilia on imaging
  • which, together, suggest gallstone ileus
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10
Q

How is gallstone ileus treated?

A
  • enterotomy proximal to obstruction, milk stone back to remove
  • avoid cholecystectomy and fistula at the same time as a combined procedure has higher morbidity and recurrence rates are low
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11
Q

Most gallbladder polyps are what?

A

benign hyperplastic polyps

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12
Q

How are gallbladder polyps managed?

A
  • cholecystectomy if symptomatic, larger than 1cm, or associated with cholelithiasis
  • serial imaging if over 6mm
  • treat as cancer until proven otherwise if larger than 18mm
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13
Q

What is the hepatic vein pressure gradient?

A
  • the gradient between the wedged hepatic vein pressure and the free hepatic vein pressure
  • defines portal hypertension when > 6
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14
Q

How is portal hypertension defined?

A

as a hepatic vein pressure gradient greater than 6mmHg

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15
Q

What are the sites of collateral circulation that form in patients with portal hypertension?

A
  • distal esophagus (esophageal submucosal veins to proximal gastric veins)
  • rectum (IMV to pudendal vein)
  • umbilicus (vestigial umbilical vein to left portal vein)
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16
Q

How is portal hypertension treated?

A
  • splanchnic vasoconstrictors like vasopressin and octreotide in the acute setting
  • non-selective beta blockers like propanolol and nadolol for prophylaxis
  • esophageal banding
  • TIPS
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17
Q

What are the surgical options for patients with portal hypertension?

A
  • gastroesophageal devascularization (total of the greater curvature and upper ⅔ of lesser curvature; circumferential of lower 7.5cm of esophagus)
  • portosystemic shunts (selective, nonselective, partial)
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18
Q

Which patients with portal hypertension are most likely to benefit from gastroesophageal devascularization?

A

those with extensive portal venous thrombosis and no options for portosystemic shunts

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19
Q

What is a selective portosystemic shunt?

A
  • a surgical treatment of portal hypertension which decompresses only part of the portal venous system
  • good for variceal bleeding but does not help ascites
  • usually splenorenal (aka Warren shunt)
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20
Q

What is a partial portosystemic shunt?

A

a surgical treatment of portal hypertension in which a side to side anastomosis is created and calibrated by the size of the interposition graft placed between the portal vein and vena cava

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21
Q

What is a nonselective portosystemic shunt?

A
  • one that decompresses the entire portal venous system
  • most commonly a side-to-side portocaval shunt
  • cons: high rate of encephalopathy and makes transplant more difficult
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22
Q

What are the differences between a selective and nonselective portosystemic shunts?

A
  • selective (e.g. splenorenal) decompress only part of the portal venous system whereas nonselective (e.g. portocaval) decompress it all
  • selective treat variceal bleeding while nonselective treat ascites
  • nonselective are more often complicated by encephalopathy and make transplant more difficult
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23
Q

What is the most common pathogen found in a pyogenic liver abscess?

A

E. coli

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24
Q

What is the treatment of a pyogenic liver abscess?

A

perc drain and antibiotics

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25
Q

What is the treatment of an amebic liver abscess?

A
  • diagnose with serology

- treat with metronidazole, usually don’t require drainage

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26
Q

How is an echinococcal liver cyst diagnosed and treated?

A
  • usually see a double walled cyst on CT
  • diagnose with serology
  • treat with albendazole followed by surgical excision
  • if you aspirate or spill you can cause anaphylaxis
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27
Q

What hepatic vein pressure gradient is typically required for variceal rupture? What pressure is used to define portal hypertension?

A
  • hypertension is defined as pressure gradient > 6mmHg

- rupture occurs at a pressure gradient > 12mmHg

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28
Q

What are the components of the Child-Turcotte-Pugh score?

A
  • bilirubin
  • albumin
  • prothrombin time
  • encephalopathy
  • ascites
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29
Q

What are the components of the MELD-Na score?

A
  • INR
  • Na
  • bilirubin
  • creatinine
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30
Q

What MELD score suggests that a patient would have a survival benefit following transplant?

A

MELD > 15

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31
Q

How are umbilical hernias managed in cirrhotics with ascites?

A
  • control ascites medically first
  • if this doesn’t work, can use intermittent paracentesis, temporary PD catheter, or TIPS
  • okay to use mesh in the elective setting
  • would repair at the time of transplant if eligible
  • close in layers without mesh and aggressively control ascites (with intermittent paracentesis) post-op if done urgently
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32
Q

If you urgently repair an umbilical hernia in a cirrhotic with poorly controlled ascites, how should you control ascites post-operatively?

A
  • avoid leaving a drain as this can lead to large, uncontrolled fluid shifts and hypotension
  • instead, opt for intermittent paracenteses
33
Q

How is symptomatic cholelithiasis managed in cirrhotics?

A

medical optimization until cirrhosis is compensated, then lap chole

34
Q

Choledochal Cysts

  • etiology?
  • complications?
A
  • etiology is unclear but likely secondary to an anomalous biliary-pancreatic duct junction with reflux of pancreatic enzymes
  • complicated by pain, biliary obstruction, cirrhosis, and malignant transformation
35
Q

How are choledochal cysts classified and managed?

A
  • type I: fusiform dilation of extra hepatic biliary tree, treat with resection and hepaticojejunostomy
  • type II: saccular diverticulum of CBD, treat with excision but will likely require RNY reconstruction
  • type III: dilation of intramural duct (aka choledochocele), treat with transduodenal excision or sphincteroplasty
  • type IVa: multiple intra- and extra-hepatic ductal dilations, treat with hepatic resection and biliary reconstruction
  • type IVb: multiple extra-hepatic ductal dilations: treat with excision and hepaticojejunostomy
  • type V: multiple intrahepatic ductal dilations, treat with partial liver resection versus transplantation depending on distribution of disease
36
Q

How are simple hepatic cysts managed?

A

laparoscopic fenestration or enucleation as aspiration alone has a 100% recurrence rate

37
Q

What is the most common liver tumor?

A

hemangiomas

38
Q

What are hepatic hemangiomas? How are they diagnosed and treated?

A
  • they are the most common liver tumor and are congenital vascular malformations
  • can present with pain, compressive symptoms, or (rarely) hemorrhage
  • are hypointense with central enhancement on the arterial phase and persistent enhancement on delayed series
  • are hypointense on T1 and hyper intense on T2
  • observed regardless of size when asymptomatic since they don’t have a risk of rupture; resection for symptomatic disease
39
Q

What is Kasabach-Merritt syndrome?

A

consumptive coagulopathy secondary to a hepatic hemangioma

40
Q

What is the most likely diagnosis for a hypointense liver lesion on CT with central enhancement on arterial phase and persistent enhancement on delayed series?

A

hepatic hemangioma (no risk of rupture regardless of size, resect for symptoms)

41
Q

What is the treatment for hepatic hemangiomas?

A

resection for symptoms but since they have no risk of rupture, they can be observed if asymptomatic

42
Q

What are the two most common hepatic tumors?

A
  • hemangiomas

- focal nodular hyperplasia

43
Q

What is the most likely diagnosis for a liver lesion on CT that is well demarcated with rapid arterial enhancement and central stellate scar?

A

focal nodular hyperplasia

44
Q

Which population is most likely to have focal nodular hyperplasia of the liver? How are these diagnosed and treated?

A
  • second most common liver tumor
  • most often in women aged 30-50
  • seen on CT as well demarcated with rapid arterial enhancement and a central stellate scar
  • require no treatment since they have no malignant potential and no bleeding risk
45
Q

What is a sulfur colloid uptake test?

A
  • a nuclear medicine scan
  • positive uptake reflects the presence of Kupffer cells
  • thus positive uptake is suggestive of FNH rather than hepatic adenoma
46
Q

Describe the risk factors, complications, diagnosis and treatment of hepatic adenomas.

A
  • associated with OCP and androgen steroid use
  • 10% risk of malignant transformation
  • 30% risk of spontaneous bleed when > 5cm and higher risk of rupture with greater size in general
  • also complicated by pain, abdominal fullness, and abnormal LFTs
  • have arterial enhancement with washout on portal phase and a smooth surface on CT
  • for smaller lesions, can discontinue OCPs and they may regress
  • for those > 4cm or that fail to regress, should resect
  • if ruptured, send to IR and then resect electively
47
Q

How are hepatic adenomas treated?

A
  • for smaller lesions, stop OCPs and watch for regression
  • for those > 4cm or that fail to regress, resect
  • for ruptured, send to IR then resect electively
48
Q

Which benign hepatic tumors should be resected?

A
  • symptomatic hemangiomas

- adenomas > 4cm, that fail to regress with cessation of OCPs, or that rupture

49
Q

What hepatic tumor is suggested by the following CT findings:

  • hypointense with central enhancement on the arterial phase and persistent enhancement on delayed series
  • well demarcated with rapid arterial enhancement and central stellate scar
  • smooth surface with arterial enhancement and portal phase washout
A
  • hepatic hemangiomas
  • focal nodular hyperplasia
  • adenoma
50
Q

What is the risk of rupture for hepatic adenomas?

A
  • increases with size

- greater than 30% when > 5cm

51
Q

What is the malignant risk for hepatic adenomas?

A

10%

52
Q

How are ruptured hepatic adenomas treated?

A

IR embolization followed by elective resection after recovery

53
Q

What is the most common site of metastasis for HCC?

A

the lungs

54
Q

What are the risk factors for HCC?

A
  • HBV/HCV
  • cirrhosis of any etiology
  • inherited errors of metabolism including a1AT deficiency and hemochromatosis
  • aflatoxin
55
Q

How does HCC appear on CT scan?

A
  • hypervascular and thus hyperintense during the arterial phase
  • hypodense during the delayed
56
Q

How is HCC diagnosed?

A
  • CT finding a hyperintense lesion during arterial phase with hypodense during delayed
  • that with an elevated AFP is sufficient without biopsy
  • no role for HCC
57
Q

How is HCC managed?

A
  • can perform resection for cure if it is a solitary mass without major vascular invasion and the patient has adequate liver function (need 25% remnant liver for those without cirrhosis and 30-40% for those with Childs class A disease)
  • if patient doesn’t have sufficient remnant liver, than consider pre-op portal vein embolization of the diseased side
  • transplant is indicated for those with severe cirrhosis if Milan criteria are met
  • for those that aren’t surgical candidates, can consider ablation, arterially directed therapies, and external beam radiation
58
Q

What are the milan criteria for HCC?

A

transplant indicated for cure if there is a single HCC lesion less than 5cm or 3 lesions fewer than 3cm with no gross vascular or extrahepatic spread

59
Q

How much liver remnant is required for resection of HCC? What if this isn’t available?

A
  • require 25% for those without cirrhosis and 30-40% for those with Childs Class A disease
  • alternatives are pre-op portal vein embolization of the diseased side or transplantation
60
Q

HCC

A
  • risk factors are HCV/HBV, cirrhosis, a1AT deficiency, hemochromatosis, aflatoxin exposure
  • diagnosed with characteristic imaging findings and elevated AFP
  • appears hyperintense during arterial phase of CT and hypodense during the delayed phase
  • most commonly metastasizes to the lungs
  • can resect if patient has sufficient liver remnant and there is no major vascular invasion or metastasis
  • those without cirrhosis need 25% remnant, those with Childs Class A disease need 30-40%
  • for those without sufficient remnant, consider pre-op embolization of the diseased side or transplantation
  • for transplant, must meet Milan criteria with a single lesion less than 5cm or three lesions less than 3cm and without gross vascular or extrahepatic spread
  • treat with neoadjuvant chemotherapy prior to transplantation
  • for those that aren’t surgical candidates, consider ablation for lesions <5cm, transarterial chemoembolization for tumors >5cm, and external beam radiation for those not in a good position for the other two
61
Q

When should you consider the following locoregional therapies for HCC?

  • ablation
  • transarterial chemoembolization
  • radiation
A
  • ablation for smaller lesions < 5cm
  • TACE for tumors > 5cm
  • radiation for those that are in a bad position for ablation or TACE`
62
Q

What are the risk factors for cholangiocarcinoma?

A

all related to inflammation of the bile ducts

  • primary sclerosing cholangitis
  • bile duct stones
  • choledochal cysts
  • liver fluke infections
  • HBV/HCV
63
Q

How are intra-hepatic cholangiocarcinomas managed?

A
  • no indication for pre-op biopsy
  • diagnostic lap to rule out metastatic disease (nodes beyond porta hepatis is a contraindication to resection)
  • hepatic resection with negative margin is the goal
64
Q

How are extra-hepatic cholangiocarcinomas managed?

A
  • hilar masses is resection with roux-en-y hepaticojejunostomy (contralateral hemi-liver must have portal triad uninvolved by tumor)
  • distal masses require Whipple
  • both require lymphadenectomy
65
Q

How is cholangiocarcinoma resected?

A
  • basic principle is resection with negative margin
  • start with diagnostic laparoscopy as nodal involvement beyond porta hepatis is a contraindication
  • singular intra-hepatic masses should be treated with hepatic resection (e.g. wedge, segmentectomy, etc.)
  • hilar are resected with roux-en-y reconstruction and lymphadenectomy
  • more distal extra-hepatic are resected with Whipple and lymphadenectomy
66
Q

Describe the treatment for the following forms of cholangiocarcinoma:

  • singular intra-hepatic lesion
  • multiple intra-hepatic lesions
  • singular intra-hepatic lesion with lymph node mets beyond the porta hepatis
  • singular intra-hepatic lesion with distant nodal involvement
  • hilar lesion with uninvolved portal triad for contralateral liver
  • hilar lesion with involvement of contralateral portal triad
  • distal lesion
A
  • singular intra-hepatic lesion: liver resection
  • multiple intra-hepatic lesions: unresectable
  • singular intra-hepatic lesion with lymph node mets beyond the porta hepatis: unresectable
  • singular intra-hepatic lesion with distant nodal involvement: unresectable
  • hilar lesion with uninvolved portal triad for contralateral liver: resection with roux-en-y reconstruction and lymphadenectomy
  • hilar lesion with involvement of contralateral portal triad: unresectable
  • distal lesion: Whipple with lymphadenectomy
67
Q

What are the risk factors for gallbladder carcinoma?

A
  • chronic inflammation
  • porcelain gallbladder
  • polyps > 1cm
  • typhoid infection, primary sclerosing cholangitis
  • IBD
68
Q

How is gallbladder carcinoma managed?

A
  • T1a tumors involving the lamina propria only require cholecystectomy
  • T1b or greater involving the muscle layer require cholecystectomy with limited hepatic resection (IVb and V) and portal lymphadenectomy
69
Q

If a patient with CRC and isolated liver mets receives neoadjuvant FOLFOX and restaging shows a complete radiology response, what is the next step?

A

hepatic resection since complete pathologic response is rare

70
Q

For a patient with asymptomatic cholelithiasis and a 5mm gallbladder polyp, what is the best next step?

A

cholecystectomy since polyps associated with cholelithiasis have a higher rate of malignant transformation

71
Q

Which test has the highest NPV for choledocholithiasis?

A

normal GGT has a 97% NPV

72
Q

What is the significance of HCC found in a young patient without cirrhosis?

A
  • most likely this is a fibrolamellar variant, which has a better prognosis and is less likely to recur
  • neurotensin is a marker to confirm
73
Q

What is neurotensin?

A

a marker used to diagnose the fibrolamellar variant of HCC

74
Q

What is the next step for a patient with an incidentally discovered gallbladder adenocarcinoma that invades the muscularis?

A

RTOR for resection of segments IVb and V along with lymphadenectomy

75
Q

What is the most common cause of isolated gastric varices?

A

splenic vein thrombosis secondary to pancreatitis

76
Q

What is the treatment for isolated gastric varices?

A

most often due to splenic vein thrombosis, thus treatment is splenectomy

77
Q

For a patient that is four weeks out from a car accident with liver laceration managed non-operatively and now has upper GI bleed…

  • What is the diagnosis?
  • What is the next step?
  • What is the treatment?
A
  • diagnosis is hemobilia from hepatic artery-biliary duct fistula
  • first step is EGD and will likely find blood coming from the duodenal papilla
  • treat with angioembolization
78
Q

Which segments are resected in each of the following:

  • right liver resection
  • left liver resection
  • left lateral segmentectomy
  • extended right
  • extended left
A
  • right liver resection: 5-8
  • left liver resection: 2-4 +/- 1
  • left lateral segmentectomy: 2-3
  • extended right: 5-8 + 4
  • extended left: 2-4 + 5 and 8

btk book review (13 decks)

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