Hepatobiliary Flashcards
What 3 structures make up the portal triad?
CBD, portal vein, common hepatic artery - in the hepatoduodenal ligament
Cantle’s Line
Separates the R and L lobe of the liver
Segments of the liver
What is the venous drainage of the liver?
3 hepatic veins drain into the IVC
Most common replaced right hepatic artery comes off of?
The SMA
Most common replaced left hepatic artery comes off of?
Left gastric (gastrohepatic ligament)
In what trimester should cholecystectomy be done in pregnancy?
2nd trimester
Stones identified during IOC?
Glucagon, flush
Benign hyperplastic gallbladder polyps. What size to remove?
1.0cm
Gallbladder polyps of ___ need serial imaging with yearly US
0.6-0.9cm
Gallbladder polys >18mm treat as _____
Cancer
Portal Hypertension is defined as a hepatic vein pressure gradient > than ______
6mmHg - difference between wedged hepatic vein pressure and free hepatic vein pressure
Polyps between ____ and ____ size have an increased risk of malignancy and should undergo cholecystectomy
1.0 and 1.9cm
Polyps of this size need repeat imaging in 1 year, and if stable, no further follow up required
<0.5cm
Gallbladder cancer will first metastasize to which nodes?
Cystic duct nodes
`What to do if CBD stones are identified on IOC?
Flush, glucagon x2
In patients with severe pancreatitis, how long to wait for cholecystectomy?
At 6-8 weeks, ERCP + sphincterotomy
Rigler’s Triad
Bowel obstruction, gallstone in intestine, pneumobilia
What type of portal hypertension is schistosomiasis ?
Pre-sinusoidal
What type of portal hypertension is alcoholic cirrhosis and viral hepatitis?
Sinusoidal
What type of portal hypertension is Budd Chiari syndrome?
Post-sinudoisal
TIPS (transjugular intrahepatic portosystemic shunt)
Stent between hepatic vein and portal vein. Used for acute variceal bleeding, Budd chiari or hepatic hydrothorax
The use of ________ is associated with increased rates of primary fascial closure in patients with open abdomen
3% hypertonic saline (removes intestinal edema)
Mattox Maneuver
Exposure of the left retroperitoneum
1. Mobilize the inferior portion of the descending colon
2. Divide the white line of toldt bluntly
3. Rotate kidney, pancreas and spleen medially
Cattell-Braasch Maneuver
Right medial visceral rotation
-Mobilize the right colon superiorly
Selective portosystemic shunt
Decompresses only part of the portal venous system- good for variceal bleeding, does not help with ascites
Non-selective portosystemic shunt
Decompresses the entire portal venous system, side to side portocaval shunt. Higher rate of encephalopathy
What type of shunt to use with variceal bleeding?
Selective shunt
What type of shunt to use with ascites?
Non-selective shunt
Treatment of pyogenic abscess
Percutaneous drainage + ABX
How to treat aeombic abscess?
Flagyl
Double walled cyst on CT
Echinococcal cyst - Albendazole + Surgical excisin
Hepatic vein pressure gradient required for variceal rupture?
12mmHg
Child-Pugh Score
Pooh BEAAr- Prothrombin time, Bilirubin, encephalophy, ascites, albumin
Components of MELD Score
Bilirubin, INR, Creatinine
At which MELD score do patients have a survival benefit for transplant?
15
What is the most common cause of a benign biliary stricture?
Previous cholecystectomy
Most common risk factors for cholangiocarcinoma?
UC and PSC
Bismuth A injury
Injury to cystic duct or ducts of Luschka
Bismuth B injury
Injury to aberrant R hepatic duct
Bismuth C injury
Leak from aberrant R hepatic duct
Bismuth D injury
Lateral CBD injury
Bismuth E1 injury
Hepatic duct injury >2cm from R and L hepatic duct confluence
Bismuth E2 injury
Hepatic duct injury <2cm from R and L hepatic duct confluence
Bismuth E3 injury
CBD injury at confluence or R and L hepatic duct
Bismuth E4 injury
CBD injury above the confluence or R and L hepatic duct
Bismuth E5 injury
Main hepatic duct and accessory R hepatic duct injury
Ductal injures <3cm treatment?
Simple ligation and drain placement
Ductal injuries >4mm treatment?
Repair or reconstruction
Type I choledocal cyst
Extrahepatic ductal dilation - Tx = Resection with hepaticojejnostomy
Type II choledocal cyst
Diverticulum of CBD - Tx = Roux en Y
Type III choledocal cyst
Choledococele or dilation of ampulla of vader - Tx = ERCP - transduodenal excision or spinchterplasty
Type IVa choledocal cyst
Dilation of intra AND extrahepatic ducts- Tx = Excision with biliary reconstruction.
Type V choledocal cyst
Caroli’s disease- dilation of intrahepatic ducts ONLY - Tx = Transplant
Soap Bubble or Paintbrush sign on IOC
Villous small bowel adenoma
Which is preferred CBD exploration transcystic or transductal?
Transcystic
Most potent stimulator of bile secretion
Secretin
Future Liver Remnant in patients without underlying liver disease?
20-30%
Future Liver Remnant in patients with underlying liver disease?
40%
Type of shunt used for variceal bleeding?
Selective shunt
Type of shunt used for ascites?
Non-selective shunt
Type IVb choledocal cyst
Extrahepatic ductal dilation ONLY
Most common liver tumor?
Hemangima
Kasabach-Meritt Syndrome
Consumptive coagulopathy associated with hemangioma
Name that tumor:
On CT Hypodense on pre-contrast
Peripheral to central enhancement in arterial phase
Persistent contrast on delayed series
Hemangioma
Hemangioma MRI findings
Hypointense on T1, hyperintense on T2
2nd most common liver tumor?
FNH
Name that tumor:
On CT well demarcated
Rapid enhancement in arterial phase with central stellate scar
FNH
FNH MRI findings
Hypointense with central scar on T1, isointense with hyperintense scar on T2
Name that tumor:
On CT: arterial enhancement with washout on portal phase
Smooth surface with tumor capsule
Associated with OCP’s and seroids
Adenoma
Adenoma MRI findings
Hyperintense on T1 and T2
FNH is (negative/positive) for suulfer colloid uptake)
Positive
Adenoma is (negatiive/positive) for sulfer colloids uptake
Negative
Name that tumor:
On CT: hyperintense on arterial phase, hypodense during delayed phase
Hepatocellular carcinoma
Milan criteria for transplant in early to severe cirrhosis in patients with HCC?
One less than 5 or 3 less than 3, no gross vascular or extrahepatic spread
Afferent limb syndrome is caused by?
Too long afferent limb, should be less than 12-15cm
Epigastric pain, postprandial fullness, and sudden explosive vomiting of bilious contents
Roux syndrome
Early vs Late dumping syndrome
Early- 30-60 minutes after eating- tachycardia, diaphoresis, caused by fluid shifts
Late 2-3 hrs after eating- weakness, hunger, autonomic symptoms due to hyperinsulinemic response
Surgical management T1a gallbladder cancer
Lamina propria- Cholecystectomy alone
Surgical management T1b gallbladder cancer and greater
Invades muscle layer - cholecystectomy with segment IVb V hepatic resection and portal lymphadenectomy
Highest negative predictive value for choledocolithiasis?
GGT - Normal GGT has 97% NPV
Tumor marker for fibrolamellar variant of HCC?
Neurotensin
Whats the first treatment for hemobilia coming from trauma?
Angioembolization
Right liver resection
Segments 5-8
Left liver resection
2-4 +/- caudate