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Hepatobiliary Flashcards

1
Q

cholangio dx

A

can be clinical; no tissuee needed

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2
Q

replace RHA

A

SMA > celiac or aorta.

posterior and lateral to the CBD and pancreas
palpation of a distinct pulse at this location should raise suspicion for this anatomical variant.

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3
Q

Milan criteria for HCC

A

1 tumor < 5 cm or 3 tumors < 3 cm each

txp = survival benefit has been demonstrated for these patients

also eligible:
hilar cholangiocarcinomas a
epithelioid hemangioendothelioma
large hepatic adenomas

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4
Q

UCSF criteria for liver txp in HCC

A

1 lesion < 6.5 cm or up to 3 lesions < 4.5 cm each and total < 8 cm

less restrictive

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5
Q

contraindication to liver txp

A

INTRAhepatic cholangiocarcinoma

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6
Q

arterial enhancement and delayed washouthepatic

A

HCC

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7
Q

strong arterial enhancement with central scar persistent in delayed phase

A

FNHrim

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8
Q

peripheral enhancing lesion in arterial phase

A

intrahpeatic cholangio

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9
Q

peripehral nodular enhancement in arterial phase with central fillin centripetal in delayed

A

heamngioma

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10
Q

adenoma resection lsize?

A

5cm

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11
Q

early washout on portal phase; no stellate scar; peripheral enhancement centripetla

A

adenoma

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12
Q

hyper T1

A

adenoma, FNH

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13
Q

hypo T1

A

hemangioma

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14
Q

dx bile leak after hepatectomy?

A

3x serum bili after POD 3
manage with drainage first

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15
Q

normal liver functional remnant?

A

20-25%c

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16
Q

childs a cirrhotic functional remnant?

A

40%

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17
Q

for HCC presumed off CT scan, what additional imaging recommended?

A

MRI with contrast if 1-2 cm (smal)… to determine FLR
otherwise, <5cm (milan), wack it out.

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18
Q

RCC met to liver tx

A

resection or perc radiofrequency or microwave ablation

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19
Q

FNH mgmt

A

NTD

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20
Q

left trisectionectomy = extended left

A

2, 3, 4, 5, 8

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21
Q

rigth trisectionectomy = extended right

A

4, 5, 6, 7, 8

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22
Q

falci

A

umbo vein remnant (extends to ligamentum teres) separates med/lat LEFT LOBE

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23
Q

Cantlies

A

middle of fossa to IVC separates R and L lobes

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24
Q

portal triad oritentation

A

CBD lateral
portal posterior
hepatic medial

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25
Q

composition of perfusion to liver

A

66% portal
33% hepatic aa

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26
Q

middle hepatic aa origin

A

from LHA
LHV and MHV also join before cava

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27
Q

what does middle vein drain

A

V and IVb

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28
Q

veins draining into IVC near top of liver

A

M/L, R, inferior phrenic, poss accessory RHV (medial R lobe), caudate vein (received R/L portal and arterial flow – drains directly into IVC)

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29
Q

vits stored in liver

A

ADEK B12

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30
Q

bile salts

A

cholic and chenodeoxycholic
deoxycholic and lithocholic

conjugated to turine and glycine for water solubility

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31
Q

bilirubin clinically evident

A

> 2.5 (under tongue first)

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32
Q

Gilbert disease

A

abnormal conjugation
glucuronyl transferase defect
indBil

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33
Q

Crigler Najjar disease

A

can’t conjugte. severe gluruonyl transferase def; life tthreatning
indBil

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34
Q

newborn. jaundice normal

A

immautre glucuronyl transferase (high iBili)

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35
Q

Rotors syndrome

A

def in storange abililty; high Dbil

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36
Q

Dubin Johnson

A

def in secretion abiliyt; high DBil

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37
Q

fulminant hepatic failure 2/2 to what hepatitis viruses

A

B D E

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38
Q

chronic hepatitis/hepatoma 2/2 to what hepatitis viruses

A

B C D.

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39
Q

MC hepatitis worldwide

A

HBV

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40
Q

MC hepatitis causing cirrhosis in Western world

A

HCV

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41
Q

best marker of synthetic function in cirrhosis

A

prothrombin TIME

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42
Q

Kings College Criteria for poor prognosis ACUTE LIVER FAILURE

A

pH < 7.3 or
INR 6.5, Cr 3.4, grade III+ encephalopathy
with tylenol toxicity

or if not tylenol, then INR 6.5 or
<10 YO, > 40 YO, 7 days jaundice, INR .3.5, bili 17

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43
Q

SBP dx

A

PMN > 250 in fluid

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44
Q

SBP ppx indication

A

Ascites total protein < 1 g/dL

or previous hx of SBP

ppx = cipro (vs tx of SBP is CTX), or cipro x 7 days only if active GI bleed

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45
Q

portal hypertension dx

A

portal vein pressure > 10-12 mm Hg
portal - wedge >6

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46
Q

indication for splenorenal shunt

A

Chids A with bleeding (can worsen asictes)

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47
Q

chids C mortaility after shunt

A

50%

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48
Q

budd chiari tx

A

porta caval shunt
If acute, consider catheter directed TPA

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49
Q

splenic VT presentation an dmgmt

A

gastric varices bleed
splenectomy

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50
Q

PVT treatment

A

heparin
but if bleeding, maybe just shunt

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51
Q

amebic liver abscess location

A

RIGHT mostly usually single (from colon)

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52
Q

risk factor amebic (entamoeba histolytica)

53
Q

dx amebic

A

E. histlytica serology; aspiration is negative (protozoa on rim)

54
Q

mgmt amebic

A

flagyl only

surgery if free rupture only

55
Q

echinococcal cyst dx

A

positive serology ELISA, Casoni skin test, indirect hemagglutinin, latex agglutination, indirect immunofluorescence ab teset

E. granulosus, multilocularis, vulgari

don’t aspirate (anaphylaxis)
DOG (definitive) > sheep hx
CT double walled cyst

56
Q

echinococcal cyst location

A

RIGHT, multiple

57
Q

mgmt echinococcal

A

preop albendazole 2 wks
intraop injection of alcohol PAI
resect ALL of the cyst wall

58
Q

schistosomiasis suspicion

A

presinusoidal portal hypertension (variceal bleeding without LFT issues) + maculopapular rash + Eosinophils
hx water contact

59
Q

schisto mgmt

A

praziquantel and UGIB tx

60
Q

pyogenic abscess

A

MC
MC from E.coli

61
Q

pyogenic abscess location

62
Q

hepatic adenoma risk of…

A

80% pain, 50% RUPTURE, 5% malignancy

63
Q

hepatic adenoma location

64
Q

hepatic adenoma Kupffer/sulfur colloid scan…

A

won’t show up (no Kupffer cells in adenoma)

65
Q

hepatic adenoma CTA findings

A

CTA arterial enhancement with washout portal z

66
Q

mgmt hepatic adenoma

A

< 4cm: stop OCP
> 4cm or sx: resect (preop angioembolization considered)
ruptured? angioembolize. recover. then resect.

67
Q

focal nodular hyperplasia imaging findings

A

CTA hyperintense arterial, washout with stellate scar
will light up on sulfur colloid

68
Q

mgmt FNH

A

no resection

69
Q

hemangioma MC what

A

MC benign tumor in liver

70
Q

dx heamngioma

A

CT peripheral to central enhancement**; hypervascular; nodular enhancement peripherally

71
Q

complication of hemangioma (not rupture)

A

consumptive coagulopathy = Kasabach - Merritt syndrome and CHF

72
Q

MC cause HCC worldwide

73
Q

best and worse prognosis HCC

A

best: fibrolamellar (young peopel)

worst: diffuse nodular

74
Q

fibrolamellar variant HCC

A

best px but recurs often…. NEUROTENSIN biomarker

75
Q

AFP correlates with what

76
Q

5 yr survival with resectoin HCC

77
Q

margin required for HCC

78
Q

intrahepatic cholangio dx

A

CT scan: peripheral arterial and venous enhancement involving DUCTS

don’t need to Bx

79
Q

dx lap role in intrahepatic cholangio

A

for staging

80
Q

mgmt of cholangio

A

resectable if no LN past porta hepatis and no multifocal disease

just resect for negative margin

81
Q

mgmt of hilar cholangiocarcinom

A

contralateral hemi liver must have intact arterial/portal flow and biliary drainage uninvolved
then, RNY HJ

82
Q

varices

A

distal esophagus = esophageal submucosa - proximal gastric (pyloric (right gastric) and coronary (left gastric)
rectum = IMV - pudendal
umbilicus = vestigial umbilical V - epigastric veins to L portal V
RP = mesenteric - ovarian

83
Q

portal HTN bleeding Rx acute vs ppx

A

acute = octreotide/vasopressin, EGD, TIPS

ppx = B blockers

84
Q

what may TIPS WORSEN*

A

encephalopathy

85
Q

mgmt of esophgeal variceal bleeding

A
  1. resuscitate
  2. transfuse
  3. Abx
  4. intubate for airway and EGD
  5. EGD
  6. octreotide, vasopressin
    7.* TIPS if EGD fails
  7. Senstaken Blakemore if EGD fails
86
Q

surgical options for portal HTN decompression

A

(not TIPS)
1. gastroesophageal devascularization
2. esopahgeal transection and re-anastomosis
3. portosystemic shunts

87
Q

types of portosystemic shunts done surgically

A

selective (I.e.: distal splenorenal WARREN shunt) - will not help ascites

partial nonselective: side to side via interposition graft between portal vein and cava

nonselective portocaval side to side without interposition … high rate encepholaphty and complicated liver txp in the future

88
Q

PET scan for HCC?

89
Q

cholangio risk factors

A

PSC, choledocholithiasis, choledochal cysts, liver fluke infections, HBV, HCV

90
Q

duodenal adenoma

A

soap bubble sign

91
Q

hepatorenal syndrome types

A
  1. acute/severe = sharp decline
  2. chronic slow progression
92
Q

HRS pathophys

A

portal HTN > splanchnic vasodilation > arterial decrease to kidney> RAAS activated> decreased GFR

93
Q

HRS dx

A

is of exclusion

Lab findings can be: increased Cr and BUN
UNa < 10.
URBC < 50
Uprot < 500

94
Q

HRS tx

A
  1. octreotide - splanch vasoconstrictor
  2. systemic vasoconstriction - midodrine, terlipressin, etc.
  3. albumin
  4. abx if infxn
  5. HD
  6. liver txp or TIPS
95
Q

HBV vaccination efficacy

A

90% in immuncompetent; so don’t wait

96
Q

Wilsons disease

A

copper accumulation;
ATP7B AR

97
Q

hcv tx medical

A

sofosbuvir
ribavirin

98
Q

factors not made in the liver

A

vWF and Factor VIII

99
Q

acinar zone III

A

CENTRALLOBAR = most sensitive to ischemia (closest to hepatic VEIN) and artery

100
Q

bile salts conjugated to

A

taurine or glycine

101
Q

primary bile acids (salts)

A

cholic and chenodeoxycholic

102
Q

secondary bile acids (salts)

A

deoxycholic and lithocholic
(dehydroxylated primary bileacids by bacteria in gut)

103
Q

bile components

A

bile salts 85%
protein
lecithin
cholesterol
bilirubin

104
Q

lecithin

A

main biliary phospholipid (emulsifies fat, solubilizes chlesterol)

105
Q

jaundice first place

A

under tongue

106
Q

worst hepatitis prognosis overall

107
Q

hep e

A

MC fulminant hepatic failure in pregnancy…. most often in 3rd trimester

108
Q

BCAAs in cirrhosis

A

because metabolized in skeletal muscle

109
Q

propranolol role in UGI bled

A

not much… may prevent asx varices from bleeding

110
Q

splenorenal shunt

A

CHilds A with bleeding

CI: ascites

ligate: left adrenal, left gonadal, IMV, coronary vein, pancreatic branches of splenic
DON’T NEED SPLENECTOMY

111
Q

if refractory ascites, what kind of shunt?

A

TIPS&raquo_space;»> OR for partial portosystemic (interposition graft between portal and iVC)

112
Q

Childs score and shunt placement

A

correlates with mortality after shunt placement

113
Q

MC cause of pedatric portal hypertension

A

extrahepatic portal vein thrombosis

114
Q

size cut off for TACE first in HCC palliation or mets

A

5 cm (otherwise just ablate)

115
Q

hepatic sarcoma RF

A

PVC
thorotrast (contrast)
arsenic

rapidly fatal

116
Q

hmg coa to bile salts

A

hmg coa reductase to cholesterol.
cholesterol with 7-a-hydroxylase to bile salts

HGM COA REDUCTASE IS RATE LIMITING REACTION TO CHOLESTEROL SYNTHESIS

117
Q

brown stone

A

secondary to infection // primary bile duct stones Ca-bilirubinate (E coli makes B-glucuronidase which deconjugates BR)

118
Q

black and cholesterol stones in CBD are SECONDARY bile duct stones…. not like brown stones

119
Q

RNY cholecystitis

A

if GB there, chole + intraop CBD exploration
if GB no there, lap G and ERCP through that

120
Q

what is more common: GB adenoca or cholangio?

A

GB adenoca

121
Q

risk factor infection for cholangio

A

C. sinensiso

122
Q

other risk factors for cholangio

A

UC, choledochal cyst, PSC, chornic bile duct infection, HBV, HCV, inflammation

123
Q

need bx for cholangio?

A

no. can just have MRCP + sx

124
Q

diagnostic lap in cholangio

A

YES before resection!!!!!

125
Q

resectability of gallbaldder ca

A

intrahepatic: no LN involvement past porta
extra: not involve SMA or celiac nodes

126
Q

klatskin tumor

A

upper 1/3 extrahepatic cholangio; R0 may need lobectomy but hard to resect

127
Q

GB polyp etiology

A

cholesterol > hyperplastic > adenoma

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