Hepatobiliary

Question 1

Portal Triad

Answer 1

CBC
Proper hepatic artery
Portal vein
- These run in hepatoduodenal ligament
- Artery medial to Bile duct
- Portal vein posterior to those

Question 2

What separates R and L lobes of liver

Answer 2

Cantlie’s line - Btw gallbladder fossa and IVC

Question 3

Hepatic veins

Answer 3

3 veins
R directly into IVC
L and Medial join together and drain into IVC

Question 4

Replaced R hepatic

Answer 4

Off SMA, behind panc and CBD

Question 5

Replaced L hepatic

Answer 5

Off L gastric, in gastrohepatic ligament

Question 6

Asymptomatic cholelithiasis Tx

Answer 6

Observation

Question 7

Uncomplicated symptomatic cholelithiasis Tx

Answer 7

Elective cholecystitis

Question 8

Pregnant symptomatic cholelithiasis Tx

Answer 8

(Higher rates of SAB with non op mgmt)
2nd trimester lap chole
Low pneumoperitoneum
Bump on R side to offload IVC
Place ports via open Hassan technique

Question 9

Acute cholecystitis Tx

Answer 9

Lap chole within the day or so

Question 10

Acute cholecystitis Tx in very sick pt

Answer 10

Perc chole tube

When recovers -> elective cholecystectomy

Question 11

Choledocolithiasis Tx

Answer 11

Lap chole with IOC
Potential Pre-op EUS/ERCP
May consider MRCP if moderate suspicion of stone in duct

Question 12

CBD stone during cholangiogram Tx

Answer 12

1) Flush with glucagon (1 gm up to twice) and normal saline
2) If small stone and large duct -> transcystic CBD exploration with fluoro, or choledoco scope
3) Large stone, small duct -> Lap CBD exploration or ERCP post op
4) If no back filling in hepatic duct -> pull catheter back then reshoot cholangio, place pt in trendelenberg to see; if still no filling -> open exploration to look for injury to hepatic duct

Question 13

Gallstone panc Tx

Answer 13

1) ERCP if has choledoco or cholangitis
2) Interval Lap Chole on same admission b/c of high recurrence rate
3) If severe panc with large peripancreatic fluid collection; Interval chole @ 6-8 wks; but also do ERCP with sphincterotomy to reduce risk of early recurrence

Question 14

Gallstone Ileus Tx

Answer 14

SBO from gallstone at TI valve via choloenteric fistula
1) Enterotomy -> remove stone
Interval -> low risk of recurrence so want cool down
2) Takedown of fistula
3) Lap chole

Question 15

Rigler’s Triad for gallstone ileus

Answer 15

1) Bowel obstruction
2) Gallstone seen in intestine on plain field xray
3) Pneumobilia

Question 16

Gallbladder polyps Tx

Answer 16

Benign hyperplastic and asymptomatic -> nothing
If > 6 mm -> serial US follow up; or chole to get rid of need for surveillance
If > 10 mm -> cholecystectomy
If > 18 mm -> tx as GB cancer

Question 17

Portal HTN Definition

Answer 17

Hepatic Vein Pressure Gradient > 6 mmHg

HVPG -> Gradient from wedge hepatic vein pressure to free hepatic vein pressure

Question 18

Portal HTN - presinusoidal

Answer 18

Schistosomiasis

Question 19

Portal HTN - sinusoidal

Answer 19

Alcoholic cirrhosis; viral hepatitis

Question 20

Portal HTN - postsinusoidal

Answer 20

Budd Chiari Syndrome

Question 21

Collaterals from portal HTN

Answer 21

Splanchnic overwhelmed so drains into low pressure systemtic drainage sites

1) Splanchnic to -> Esophageal varices/proximal gastric
2) Splanchnic to -> Rectal varices
3) Umbilicus to L portal vein
4) Mesesntery

Question 22

Medical tx for portal HTN

Answer 22

Acute -> splanchnic vasoconstrictors -> vasopressin; octreotide

Question 23

When to do TIPS

Answer 23

Acute or recurrent variceal bleeding
Refractory ascites
Budd chiari
Hepatic hydrothorax
(Decompresses portal system)
(Cannulate hepatic vein through Internal jugular -> US TIPS if pt with TIPS comes in later with variceal bleed to make sure it's still open)

Question 24

Acute esophageal variceal bleed

Answer 24

Transfuse
Broad spectrum abx
Intubate
Octreotide
EGD -> may temporize with blakemore balloon
TIPS

Question 25

If rebleed varices

Answer 25

2nd endoscopy then TIPS