Hepatobiliary Flashcards
R hepatic artery off of what artery in 17%?
SMA
L hepatic off of what artery in 10%?
L gastric artery
Kupffer cells
Clear portal blood
Immunosurveillance
Portal triad
Portal vein posterior to CBD (on right) and hepatic artery (on left)
Urine finding in hepatorenal syndrome?
Low urine Na
Cholangitis
Jaundice RUQ tenderness Fever Hypotension AMS
Tx: emergent ERCP, IV abx
Retained CBD stone identified on T-tube cholangiogram, tx?
Radiology stone retrieval
Porcelain gallbladder
30-65% risk of cancer
Cholecystectomy indicated
Hematobilia triad
GI bleed
Jaundice
RUQ pain
Tx: arteriogram
How is bile concentrated by gall bladder?
Active absorption of Na, Cl (H2O follows)
Hepatic adenoma tx?
10% rupture/bleed
Have malignant potential
Indication for resection
Hepatic hemangioma
Resect only if giant or symptomatic
Kasaback-Merritt syndrome?
Consumptive coagulopathy or CHF due to hemangioma
Amebic abscess tx
Tx: metronidazole
Hydatid cyst
Tx: resect
Cantilie line
imaginary line that divides right and left lobe of the liver, runs from IVC to middle of the GB (not the falciform ligament)
Segments within each lobe of liver
Caudate lobe-segment 1, left lobe-segment 2,3,4a,4b. right lobe-segment 5-8
Symptomatic cholelithiasis in pregnant patient
try to do elective chole in 2nd trimester
+IOC tx?
try to flush the stone through with glucagon (up to 2x)
- Large duct, small stone -> trancystic exploration
- Large stone, small duct -> lap CBD, post-op ERCP
No filling of hepatic ducts with IOC
high suspicion of hepatic duct injury, convert to open procedure
Gallstone ileus
SBO caused by gallstone lodged in ileocecal valve
- Fistula connecting GB to duodenum usually
- Riggler’s triad: pneumobilia, SBO, visible gallstone in small bowel
- Tx: enterotomy proximal to obstruction and milk out stone to relieve obstruction
o Wait to take down fistula and cholecystectomy later
Gallbladder polyp tx
- Asymptomatic -> nothing to do
- > 10 mm -> cholecystectomy (increased risk of cancer)
- > 18 mm treat as cancer until proven otherwise
- > 6 mm -> requires surveillance
Hepatic vein pressure gradient in portal HTN
> 6 mm Hg
o Gradient between wedged hepatic vein pressure and the free hepatic vein pressure
o Hepatic vein pressure >12 -> a/w variceal rupture
Pyogenic abscess
o MC abscess
o 2/2 to biliary tract or GI infxn -> E coli (MC)
o Tx: perc drain, abx
Amebic abscess
o South America, Mexico
o Dx: imaging, serology
o Tx: flagyl, rarely need drainage
Echinococcal abscess
o Hydatid cyst, double walled cystic appearance on CT
o Check serology
o Tx: albendazole, surgical excision, do not aspirate or spill (causes anaphylaxis)
Components of Child-Pugh
bili, albumin, PT, encephalopathy, ascites
Components of MELD
bili, INR, Cr
Todani classification of choledochal cysts
o Type 1: fusiform dilation of extrahepatic biliary tree
“ Tx: resection, hepaticojejunostomy
o Type 2: saccular diverticulum of CBD
“ Tx: excise, possibly need to do roux-en-y
o Type 3: choledococele, dilation of intramural duct
“ Tx: transduodenal excision or sphincteroplasty
o Type 4A: multiple dilation of intra and extrahepatic ducts
“ Tx: Hepatic resection of affected areas, hepatico-j
o Type 4B: multiple dilation of extrahepatic ducts alone
“ Tx: excision, hepatico-j
o Type 5: dilation of intrahepatic ducts
“ Tx: transplant
Hepatic cyst
- Symptomatic:
o Cyst fenestration
o R/o other pathology
Hemangioma
- Peripheral and central enhancement on arterial phase of CT
- Symptomatic
o Only reason to resect
FNH
- Benign
- Well demarcated, rapid arterial enhancement, central stellate scar
Adenoma
- 10% malignant potential
- Arterial enhancement with washout in porto-venous phase, smooth surface
- Tx
o Stop OCP, see if regresses
o >4 cm or no regression: resect
o Ruptured: IR embolization and then resect in elective setting
Hepatocellular carcinoma
- Hypervascular, hyperdense in arterial phase
- Can be diagnosed on imaging alone, with elevated AFP
- No PET scan
- MC site of metastasis: lung
Resection criteria in HCC
o Future liver remnant: can resect up to 75% in healthy liver
- 30-40% FLN required in Child-Pugh A
Milan criteria for transplant
” 1 lesion <5 cm
“ 3 or fewer lesions <3 cm
“ No gross vascular or extra-hepatic spread
GB cancer tx
- T1a: invades only lamina propria
o Tx: cholecystectomy - T1b and beyond: muscle layer and beyond
o Tx: cholecystectomy and limited hepatic resection (segment 4b and 5), portal LN resection
Highest negative predictive value for choledocholithiasis
GGT
Assessing biliary tree after roux-en-y
trans-gastric ERCP or double balloon endoscopy
Fibrolamellar variant of HCC
young patient without cirrhosis, better prognosis, neurotensin tumor marker
Hemobilia dx.tx
-> tx angioembolization, EGD first
Left lateral segmentectomy
segment 2 & 3
Extended right hepatectomy
5, 6, 7, 8 ,4
