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BTK Review 2024 > Hepatobiliary > Flashcards

Hepatobiliary Flashcards

1
Q

What separates the right and left lobes of the liver?

A

Cantlie’s line (between the gallbladder fossa and IVC)

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2
Q

Describe the classic venous drainage of the liver?

A
  • right hepatic vein directly into the IVC
  • middle and left hepatic veins merge before draining into the IVC
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3
Q

What is the most common variant for hepatic arterial anatomy? Where does it course?

A

a replaced right off the SMA, traveling behind the pancreas and CBD

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4
Q

What is the most common variant for the left hepatic artery?

A

a replaced left off the left gastric, coursing in the gastrohepatic ligament

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5
Q

How should you manage symptomatic cholelithiasis in pregnancy?

A
  • lap cholecystectomy in the second trimester
  • enter via Hassan technique
  • keep pneumoperitoneum low
  • bump the right side to offload the vena cava
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6
Q

Which patients may benefit from a prophylactic cholecystectomy?

A
  • sickle cell anemia
  • porcelain gallbladder
  • polyp > 1cm
  • stone > 2.5cm
  • known gallstones undergoing bariatric surgery
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7
Q

What is the next step if a CBD stone is noted on IOC?

A

administer 1mg of glucagon and attempt to flush out the stone, can attempt this twice

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8
Q

What are indications for trans cystic rather than direct CBD exploration?

A
  • cystic duct > 4mm
  • CBD < 8mm
  • stone < 10mm
  • fewer than 5 stones
  • stone distal to cystic duct/CBD confluence
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9
Q

What are the next steps if hepatic ducts are not visualized on IOC?

A
  • pull back the catheter and try flushing again
  • put the patient in Trendelenburg
  • convert to open to investigate possible injury
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10
Q

What is the role for ERCP in those with gallstone pancreatitis?

A
  • indicated for patients with signs of cholangitis
  • but there is no improvement in outcomes with early ERCP as the stone will likely pass on its own
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11
Q

When should cholecystectomy be performed for pancreatitis?

A
  • usually during index admission
  • can wait 6 weeks if there are significant peripancreatic fluid collections but should have ERCP/sphincterotomy in meantime
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12
Q

What is Rigler’s triad?

A

suggestive of gallstone ileus:
- pneumobilia
- bowel obstruction
- gallstone seen in intestine

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13
Q

How should you treat gallstone ileus?

A
  • enterotomy proximal to obstruction to remove stone
  • do not perform cholecystectomy concurrently
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14
Q

What is Mirizzi syndrome?

A

when a cystic duct stone causes external compression and obstruction of the common hepatic duct

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15
Q

How is Mirizzi syndrome managed?

A
  • cholecystectomy
  • consider repair of common hepatic duct or even HJ if there is a large fistula
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16
Q

What is the most common etiology of gallbladder polyps?

A

most are benign hyper plastic polyps

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17
Q

How should gallbladder polyps be treated?

A
  • symptomatic: cholecystectomy
  • 6-9mm: serial imaging
  • concurrent stones: cholecystectomy regardless of size
  • 10-18mm: cholecystectomy
  • > 18mm: treat as cancer until proven otherwise
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18
Q

What is the gold standard for diagnosing portal hypertension?

A

a wedged-to-free gradient of > 6mmHg

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19
Q

What does the site of increased portal resistance say about the etiology of portal hypertension?

A
  • pre-sinusoidal: schistosomiasis
  • sinusoidal: EtOH or viral hepatitis
  • post-sinusoidal: Budd-Chiari syndrome
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20
Q

What are the indications for TIPS?

A
  • acute or recurrent vatical bleeding
  • refractory ascites
  • Budd-Chiari syndrome
  • hepatic hydrothorax
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21
Q

What is the feared complication of TIPS?

A

worsening encephalopathy

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22
Q

Name two splanchnic vasoconstrictors to help with the treatment of portal hypertension.

A

octreotide and vasopressin

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23
Q

What are the three types of portosystemic shunts?

A
  • selective (e.g. splenorenal), which are good for variceal bleeding and have lower risk of encephalopathy
  • partial non-selective (e.g. interposition graft between PV and IVC), where flow is calibrated by size of the graft
  • non-selective (e.g. PV-IVC anastomosis), which has a high rate of encephalopathy and would complicate a potential transplant
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24
Q

What is the most common type of liver abscess?

A

pyogenic, usually secondary to biliary tract infection or GI source

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25
Q

Describe the etiology and management of pyogenic hepatic abscess.

A
  • usually secondary to biliary or GI source
  • most common pathogen is E. coli
  • treat with perm drainage and antibiotics
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26
Q

How are amoebic liver abscesses diagnosed and treated?

A
  • usually seen in patients who recently traveled to Mexico
  • diagnosed with circulating anti-amoebic antibodies
  • treated with flagyl and rarely need drainage
27
Q

Describe an echinococcal or “hydatid” cyst on imaging.

A

characteristic double walled cyst

28
Q

How is an echinococcal/hydatid cyst diagnosed and treated?

A
  • characteristic double walled cyst on imaging
  • positive ELISA
  • treat with albendazole and drainage versus resection
29
Q

Why are choledochal cysts problematic?

A

they can cause pain, obstruction, cirrhosis, and malignancy

30
Q

What are the types of choledochal cysts?

A
  • I: fusiform extra hepatic dilatation
  • II: saccular diverticulum of CBD
  • III: dilatation fo intramural duct
  • IVa: multiple dilatations of intra-and extra-hepatic ducts
  • IVb: multiple extrahepatic ducts
  • V: multiple dilatations of intrahepatic ducts
31
Q

How are the various types of choledochal cysts treated?

A
  • I: resection with HJ
  • II: excision
  • III: transduodenal excision or sphincteroplasty versus endoscopic drainage
  • IVa: hepatic resection and biliary reconstruction
  • IVb: excision and HJ
  • V: transplantation
32
Q

How should simple hepatic cysts be treated?

A
  • observation if asymptomatic
  • lap cyst fenestration if symptomatic
  • 100% recurrence with aspiration so only utilized if etiology is unclear
33
Q

What is the most common liver tumor?

A

hepatic hemangioma

34
Q

Describe the presentation, imaging, and treatment of hepatic hemangiomas.

A
  • the most common liver tumor
  • have a female predominance
  • usually asymptomatic but can present with pain, compressive symptoms, or consumptive coagulopathy
  • CT findings: hypodense pre-contrast, peripheral to central enhancement in arterial phase, persistent enhancement on delayed series
  • MRI findings: hypointense on T1, hyperintense on T2
  • most can be observed but can resect for symptoms or rupture
35
Q

What is Kasabach-Merritt syndrome?

A
  • associated with hepatic hemangioma
  • it is a consumptive coagulopathy and thrombocytopenia
36
Q

Describe the presentation, imaging, and management of focal nodular hyperplasia.

A
  • 2nd most common liver tumor
  • usually asymptomatic
  • CT: well demarcated, rapid arterial enhancement with central stellate scar
  • MRI: hypo intense with central scar on T1, isointense with hyper intense scar on T2
  • requires no intervention
37
Q

Describe the presentation, imaging, and management of hepatic adenomas.

A
  • associated with OCP and androgen steroid use
  • carries a 10% risk of malignancy and a 30% risk of spontaneous hemorrhage if > 5cm
  • CT: arterial enhancement with washout on PV phase
  • MRI: mildly hyper intense on T1 and T2
  • for smaller lesions, discontinue OCPs
  • for larger lesions > 5cm, in males, and with no regression after stopping OCPs, you should resect
  • if ruptured, send to IR with interval resection in the elective setting
38
Q

Describe the CT findings for:
- hepatic hemangioma
- FNH
- adenoma
- HCC

A
  • hemangioma: hypodense pre-contrast, peripheral to central arterial enhancement, delayed washout
  • FNH: rapid arterial enhancement with central stellate scar
  • adenoma: arterial enhancement with rapid washout
  • HCC: hypervascular, hyperintense during arterial phase, hypodense during the delayed phase
39
Q

Describe the MRI findings for:
- hepatic hemangioma
- FNH
- adenoma

A
  • hemangioma: hypointense on T1, hyperintense on T2
  • FNH: hypointense on T1, isodense on T2 with hyper dense scar
  • adenoma: hyperintense on T1 and T2
40
Q

Describe the management of hepatic adenomas.

A
  • for small lesions, stop OCPs and monitor for regression
  • if there is no regression or if tumors are found in men or are larger than 5cm, resection
  • if they rupture, embolize and then perform interval, elective resection
41
Q

What tumor marker is associated with HCC?

A

AFP

42
Q

How does HCC appear on CT?

A
  • hyper vascular
  • hyper-intense during arterial phase
  • hypodense during delayed phase
43
Q

Which HCC lesions should be resected?

A

those without major vascular invasion in patients with adequate liver function (child class A without portal hypertension)

44
Q

How much functional liver remnant is required to allow for resection of a liver mass?

A
  • no cirrhosis: 20-25%
  • child A: 30-40%
45
Q

What is the preferred management for HCC in a patient with mdoerate-to-severe cirrhosis?

A

neoadjuvant chemotherapy and transplantation if they meet Milan criteria

46
Q

What are the Milan criteria?

A
  • criteria for transplantation in those with HCC
  • one lesion < 5cm or three sessions < 3cm, all without vascular or extra hepatic spread
  • give neoadjuvant chemotherapy
47
Q

What is the role for loco regional HCC therapy?

A
  • usually for patients who are not candidates for surgical, curative therapy
  • ablation is best for lesions < 5cm
  • transarterial chemoembolization is best for lesions > 5cm
  • external beam radiation is best for lesions that are not amenable to either due to location
48
Q

What is the surgical treatment for the following types of cholangiocarcinoma:
- intra-hepatic
- extra-hepatic
- hilar
- distal

A
  • intra-hepatic: resection with negative margin
  • extra-hepatic: resection with negative margin and lymphadenectomy
  • hilar: resection with HJ
  • distal: whipple
49
Q

What is the pathologic difference between a T1a and T1b gallbladder carcinoma?

A
  • T1a invades lamina propria
  • T1b invades the muscular layer
50
Q

What is the surgical treatment of gallbladder carcinoma?

A
  • T1a: cholecystectomy
  • T1b: cholecystectomy with resection of IVb and V and portal lymphadenectomy
51
Q

What hepatic vein pressure gradient is typically required for variceal rupture?

A

> 12mmHg

52
Q

What are the components of the Child’s score?

A
  • bilirubin
  • albumin
  • prothrombin time
  • encephalopathy
  • ascites
53
Q

What are the components of the MELD score?

A
  • INR
  • bilirubin
  • Cr
  • Na
54
Q

A patient with CRC and isolated liver mets receives neoadjuvant FOLFOX therapy and restating shows complete radiologic response, what is the next step?

A

to perform a hepatic resection since complete pathologic response is rare

55
Q

How should you manage a patient with an asymptomatic 5mm polyp and cholelithiasis?

A

cholecystectomy because the risk of transformation for polyps is higher with concurrent gallstones

56
Q

Which test has the highest negative predictive value test for choledocholithiasis?

A

normal GGT has a 97% negative predictive value

57
Q

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

A
  • these are usually of the fibrolamellar variant and carry a better prognosis with lower risk of recurrnce
  • the pertinent biomarker is then neurotensin
58
Q

What is neurotensin?

A

a biomarker for the fibrolamellar variant of HCC, which carries a better prognosis and is seen in younger patients without cirrhosis

59
Q

What should the next steps be for an incidental diagnosis of stage Ib gallbladder adenocarcinoma?

A
  • staging CT C/A/P
  • tumor markers with CA 19-9 and CEA
  • RTOR for resection of IVb and V and portal lymphadenectomy
  • do not need to resect port sites
60
Q

True or false, you should resect port sites if returning to the OR for gallbladder adenocarcinoma.

A

false, there is no oncologic benefit

61
Q

What is the significance of isolated gastric varices and how should this be managed?

A
  • typically results from splenic vein thrombosis secondary to pancreatitis
  • treat with splenectomy
62
Q

Patient is four weeks after hospitalization from a car accident resulting in a liver laceration that was managed non-operatively. They now return with UGIB. What is the next step?

A
  • start with EGD
  • if blood is coming from ampulla, consider artery-biliary duct fistula and refer to IR for embolization
63
Q
A

BTK Review 2024 (19 decks)

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