Hepatobiliary Flashcards
Portal Triad
CBC Proper hepatic artery Portal vein - These run in hepatoduodenal ligament - Artery medial to Bile duct - Portal vein posterior to those
What separates R and L lobes of liver
Cantlie’s line - Btw gallbladder fossa and IVC
Hepatic veins
3 veins
R directly into IVC
L and Medial join together and drain into IVC
Replaced R hepatic
Off SMA, behind panc and CBD
Replaced L hepatic
Off L gastric, in gastrohepatic ligament
Asymptomatic cholelithiasis Tx
Observation
Uncomplicated symptomatic cholelithiasis Tx
Elective cholecystitis
Pregnant symptomatic cholelithiasis Tx
(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
Acute cholecystitis Tx
Lap chole within the day or so
Acute cholecystitis Tx in very sick pt
Perc chole tube
When recovers -> elective cholecystectomy
Choledocolithiasis Tx
Lap chole with IOC
Potential Pre-op EUS/ERCP
May consider MRCP if moderate suspicion of stone in duct
CBD stone during cholangiogram Tx
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
Gallstone panc Tx
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
Gallstone Ileus Tx
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
Rigler’s Triad for gallstone ileus
1) Bowel obstruction
2) Gallstone seen in intestine on plain field xray
3) Pneumobilia
Gallbladder polyps Tx
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
Portal HTN Definition
Hepatic Vein Pressure Gradient > 6 mmHg
HVPG -> Gradient from wedge hepatic vein pressure to free hepatic vein pressure
Portal HTN - presinusoidal
Schistosomiasis
Portal HTN - sinusoidal
Alcoholic cirrhosis; viral hepatitis
Portal HTN - postsinusoidal
Budd Chiari Syndrome
Collaterals from portal HTN
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
Medical tx for portal HTN
Acute -> splanchnic vasoconstrictors -> vasopressin; octreotide
When to do TIPS
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)
Acute esophageal variceal bleed
Transfuse Broad spectrum abx Intubate Octreotide EGD -> may temporize with blakemore balloon TIPS
If rebleed varices
2nd endoscopy then TIPS
