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QUESTION NOTES > HEPATOBILIARY > Flashcards

HEPATOBILIARY Flashcards

1
Q

Bouveret syndrome

A

gastric outlet obstruction 2/2 gallstone in duodenum

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2
Q

Mirizzi syndorme

A

2/2 extrinsic compression of common hepatic duct due to impacted stone in cystic duct

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3
Q

Mgmt Mirizzi syndrome

A

subtotal cholecystectomy

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4
Q

If have pyogenic liver abscess after liver transplant… suspect?

A

hepatic artery thrombosis

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5
Q

Klatskin tumor

A

hilar cholangiocarcinoma

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6
Q

Most important prognostic indicator for HCC

A

vascular invasion

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7
Q

Hepatic tumors supplied by? Vs. normal liver supplied by?

A 
tumors = hepatic artery
normal = portal vein
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8
Q

Steps of lap choledochotomy

A
  • longitudinal incision in CBD
  • T-tube
  • closure with 4-0 absorbable
  • completion cholangio through T-tube to confirm stone removal
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9
Q

Where incision for lap choledochotomy? And why longitudinal?

A
  • incision below insertion of CD at CBD (not CHD) to avoid postsurgical proximal bile duct stenosis
  • longitudinal bc blood supply to extrahepatic bile duct runs along duct @ 3’ and 9’oclock positions
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10
Q

Steps transcystic approach for CBD exploration

A
  • cholangio
  • wire from CD to CBD
  • balloon cath to gently dilate to allow passage of flexible choledochoscope
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11
Q

Why delay fistula repair after enterotomy for gallstone ileus?

A

at risk for developing acute cholangitis

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12
Q

Dx HCC can be made with…? (2)

A

imaging + elevated AFP alone

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13
Q

MCC Budd-Chiari syndrome in U.S.

A

heme d/o (i.e. PV, PNH, myeloproliferative d/o, conditions associated w/ high estrogen levels ie. pregnancy, OCP) -> hypercoag -> acute/chronic thrombosis

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14
Q

MC presenting sign of Budd-Chiari

A

ascites

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15
Q

Rapid vs. Subtle hepatorenal syndrome (re: Cr levels)

A

Rapid: doubling Cr >221 in <2 weeks; GFR usually <20 cc/min
Subtle: initial Cr <221; diuretic-resistant ascites

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16
Q

Hepatic mets resection indicated for…? (2)

A
  • isolated hepatic mets AND

- locoregional control of primary d/o

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17
Q

Mgmt asymptomatic hepatic simple cysts

A

nothing

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18
Q

Mgmt symptomatic hepatic simple cysts or cannot r/o premalignant processes (ie. biliary cystadenoma)

A

lap fenestration w/ cyst wall and fluid pathology and cytology, respectively

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19
Q

C/I perQ drain of pyogenic liver abscess

A
  • coagulopathy (uncontrolled intrahepatic bleeding)
  • ascites (relative)
  • multiple abscesses (relative)
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20
Q

Steps of dx Budd-Chiari syndrome

A
  • conditional dx via duplex US
  • confirmed via angio of IVC and hepatic veins
    (will also need heme evaluation, coag studies, liver biopsy to eval etiology and extent of disease)
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21
Q

Biliary anatomy variations occurs in ? % of pts

A

30%

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22
Q

Why not do early ERCP for all pts with gallstone pancreatitis?

A

high Cx rates with no benefits

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23
Q

When would you do early ERCP (w/ stone extraction and sphincterotomy) in pts with gallstone pancreatitis?

A

if have obstructive jaundice and/or cholangitis

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24
Q

Dx steps for operative injury after lap choly

A
  1. US - fluid collection vs. intra/extrahepatic biliary duct dilation
  2. If fluid collection -> DISIDA scan to determine if leak is continuing
  3. If continued leak -> ERCP (stent) vs. perQ transhepatic cholangio
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25
Q

Tx metastatic GB cancer

A

gemcitabine + cisplatin

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26
Q

Can result in obstruction -> pancreatitis if not divided during transduodenal sphincteroplasty?

A

transampullary septectomy (thin layer connective tissue found within papilla)

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27
Q

Tokyo Guidelines acute cholangitis

A 
severity criteria
Grade 1 (mild): does not meet criteria of mod or severe -> Abx

Grade 2 (mod); 2+ of below -> Abx + fluid resus

  • abnormal WBC (<4, >12)
  • high fever (>39)
  • age (>75)
  • hyperbili (tbili >5)
  • hypoalbum (<0.7x lower limit)

Grade 3 (severe): end organ dysfunction -> urgent biliary drainage

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28
Q

Incidence bile duct injury during lap chole

A

0.3-0.7%

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29
Q

Bismuth-Corlette classification

A

classification for cholangiocarcinomas
Type 1 = common hepatic duct
Type 2 = hepatic bifurcation
Type 3 = secondary hepatic duct on one side
Type 4 = secondary hepatic duct on both sides (Klatskin)

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30
Q

Mgmt post-op cystic stump leak

A

endoscopic stent (diver bile flow away from leaky stump) + perQ fluid drainage

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31
Q

What is a HIDA?

A

hepatic iminodiacetic acid scan = biliary scintigraphy

  • shows biliary flow at either CD or bile duct
  • not good to do during cholangitis/infection (bc reduces biliary secretion of IMD acid into biliary tree)
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32
Q

MC organisms cholecystitis

A

E.coli > Enterococcus > Klebsiella

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33
Q

Best imaging to characterize GB polyps

A

transabdominal US (bc majority polyps are cholesterol)

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34
Q

How does cholesterolosis appear on RUQ US?

A

peduculated, hyperechoic, non-mobile, NO posterior shadowing

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35
Q

In which pts would you do prophylactic cholecystectomy in asymptomatic pt?

A
  • hemolytic anemia (sickle cell): high rate stone formation -> cholecystitis -> crisis
  • large >2.5cm stone
  • long common channel of bile and pank ducts
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36
Q

Mgmt neoplasm of ampulla of Vatar

A

ampullectomy vs. pancreaticodudoenectomy

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37
Q

ICU pt w/ GB gangrene at risk for…? Mgmt?

A

perforation - need fluids, IV Abx, and early cholecystectomy

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38
Q

Pt with distal CBD tumor present with high or low PT?

A

long-standing obstructive jaundice -> no bile to duodenum -> decreased fat absorption -> low VitK -> high PT

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39
Q

Where does replaced right hepatic artery commonly run?

A

off SMA -> posterior to pancreas and CBD (careful not to ligate when taking cystic duct and artery during lap chole!!)

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40
Q

Where does replaced left hepatic commonly travel?

A

gastrohepatic ligament

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41
Q

Ligamentum teres is remnant of…?

A

umbilical vein (can recannualize)

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42
Q

Where anatomically does SMV + splenic vein join?

A

behind neck of pancreas, runs behind D1 -> splits to R/L portal vein

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43
Q

Triangle of Calot (boundaries + significance)

A

CHD (medial), CD (lateral), liver (superior)

- contains cystic artery

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44
Q

Lab abnormality for: primary biliary cirrhosis

A

Antimitochondrial Abs

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45
Q

Lab abnormality for: primary sclerosing cholangitis

A

Anti-neutrophil

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46
Q

Lab abnormality for: Wilson’s disease

A

Ceruloplasmin

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47
Q

Lab abnormality for: HCC

A

AFP + CEA

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48
Q

choledocholithiasis: dilated CBD? bili?

A

dilated CBD >6mm, bili >3

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49
Q

If severe gallstone pancreatitis, mgmt?

A

ERCP spincterotomy (to reduce Cx during waiting period) + interval chole 6-8wks

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50
Q

Rigler’s triad

A

bowel obstruction + gallstone seen on imaging + pneumobilia = gallstone ileus

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51
Q

Mgmt GB polyps

A

symptomatic = lap chole
= 5mm -> fu US 6-12m, if no change in size, then NTD
>5mm = serial imaging q6m for 1yr, then annually
>10 = suspect adenoma; lap chole
>18 = treat as GB cancer + CT for invasive cancer eval

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52
Q

Portal HTN defined as…?

A

hepatic vein pressure gradient >6mmHg

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53
Q

Portal venous pressure best approx by…?

A

hepatic venous wedge pressure

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54
Q

child + hematemesis + splenomegaly… suspect?

A

portal vein thrombosis

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55
Q

Rectal varices 2/2 what splanchnic - systemic connection?

A

inferior mesenteric vein + pudendal vein

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56
Q

Umbilicus varices 2/2 what splanchnic - systemic connection?

A

umbilical vein (recannulizes) + left portal vein

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57
Q

RP varices 2/2 what splanchnic - systemic connection?

A

mesenteric + ovarian veins

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58
Q

Esophageal varices 2/2 what splanchnic - systemic connection?

A

coronary/short gastric veins + azygous vein

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59
Q

How to check if TIPS is still patent?

A

ultrasound

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60
Q

When to consider gastroesophageal devascularization?

A

if extensive portovenous thrombosis + no shunt options

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61
Q

What is gastroesophageal devascularization?

A

devascularization of entire greater curvature (+ splenectomy) + first 2/3 lesser curve + lower circumferential 7.5cm esophagus

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62
Q

Warren (splenorenal) shunt

A

selective: good for variceal bleeding; C/I if have ascites (will worsen)

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63
Q

Dx ameabic liver abscess

A

imaging (US/CT - no rim enhancement) + serology (serum E. histolytica Ab)

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64
Q

HVPG required for variceal rupture

A

> 12mmHg

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65
Q

Factors of Childs-Pugh score

A
  • bili
  • albumin
  • PT/INR
  • encephalopathy
  • ascites
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66
Q

Factors of MELD

A
  • bli
  • INR
  • Cr
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67
Q

What MELD score until have survival benefit w/ liver tx?

A

> 15

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68
Q

Mgmt cirrhotic pt with symptomatic umbilical hernia?

A

intermittent paracentesis for ascites + elective repair with MESH (high % recurrance)

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69
Q

Mgmt cirrhotic pt with complicated/infected umbilical hernia?

A

reduce and close in MULTIPLE LAYERS (no mesh) + aggressive ascites control

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70
Q

Todani classification, mgmt?

A 
type 1: fusiform dilation of extrahepatobiliary (mgmt: resection + hepatoJ)
type 2: saccular dilation of CBD (mgmt: excise, often have to do RNY enteric reconstruction)
type 3: dilation intramural duct (mgmt: transduodenal approach, excise or sphincteroplasty)
type 4A: intra + extrahepatic dilations (mgmt: involved hepatic resection + hepatoJ)
type 4B: extrahepatic (mgmt: excision + hepatoJ)
type 5 (Caroli): intrahepatic (mgmt: transplant)
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71
Q

Caroli disease; associated with…? mgmt?

A

Type 5 choledococyst: 50% associated with congenital hepatic fibrosis (mgmt: tx)

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72
Q

Why have to resect choledococysts?

A

malignant potential + recurrent cholangitis

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73
Q

Sxs choledococysts

A

pain, biliary obstruction, cirrhosis

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74
Q

Mgmt large, symptomatic simple hepatic cysts

A

lap-cyst fenestration; send capsule for pathology

*100% recurrence rate if only aspirate

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75
Q

Kasabach-Merritt syndomre

A

consumptive coagulopathy (thrombocytopenia) 2/2 large hemangioma

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76
Q

Mgmt asymptomatic hemangioma

A

obs, no matter how large bc no risk rupture

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77
Q

If hemangioma in peds pt, can cause…?

A

CHF 2/2 AV shunting

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78
Q

central stellate scar on CT

A

focal nodular hyperplasia

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79
Q

Mgmt hepatic adenoma

A

<4cm: stop causing Rx (ie. OCP)
>4cm or no regression: resect
Rupture: IR hep artery embolization, then elective resection

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80
Q

Cx hepatic adenoma

A

10% malignant transformation + risk of rupture (30% risk bleed if >5cm)

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81
Q

Type hepatic adenoma w/ highest risk malignant transformation

A

beta-catenin mutated adenoma

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82
Q

Most common benign hepatic tumor

A

Hemangioma

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83
Q

Most common malignant hepatic tumor

A

HCC

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84
Q

Most common site of mets for HCC

A

lungs

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85
Q

High indicator of post-operative morbidity/mortality following HCC resection

A

portal HTN

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86
Q

Dx staging used to predict prognosis in HCC?

A

TNM is NOT used - does not predict survival and needs tissue. Evaluate extent of CA and cirrhosis.

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87
Q

How much future liver remnant needed in Child A?

88
Q

Milan-UNOS criteria

A
  • 1 lesion <5cm
  • 3 or less lesions all <3cm
  • no gross vascular or extrahepatic spread
89
Q

If surgery not option, what other options for mgmt HCC?

A
  • ablation by IR (small lesion)
  • TACE (unresectable >5cm)
  • EBRT (if not amendable to above 2/2 tumor location)
90
Q

Most common primary hepatobiliary tumor in peds? Associated with…?

A

hepatoblastoma. associated with FAP syndrome.

91
Q

Sxs hepatoblastoma

A

asymptomatic mass; mild anemia + thrombocytopenia

92
Q

Mgmt hepatoblastoma

A

chemo -> resection

93
Q

HCC in young pt without cirrhosis, suspect…? Neuromarker?

A

fibrolamellar variant; neurotensin neuromarker

94
Q

Isolated gastric varices, suspect…? Mgmt?

A

splenic vein thrombosis commonly 2/2 pancreatitis; mgmt: splenectomy

95
Q

4-wk post liver lac managed non-op, now presenting w/ hematemesis, suspect…? Dx?

A

suspect hemobilia 2/2 hepatic artery to biliary duct fistula

Dx: EGD to confirm, if see blood from duodenal papilla, then confirm -> angioembolization

96
Q

Dx sphincter of Oddi dysfunction

A

biliary colic w/ morphine (sphincter contraction) and neostigmine (biliary contraction) [[Nardi test]]

97
Q

Surgical mgmt sphincter of Oddi dysfxn

A

transduodenal sphincterectomy

98
Q

MCC Budd-Chiari in Asia

A

membranous webs

99
Q

How dilated must cystic duct be for choledochoscopy (for CBD stone extraction)?

100
Q

What does transcystic choledochotomy entail?

A

Transverse incision halfway up diameter of CD and insert endoscope to explore for CBD stone

101
Q

MC variant HCC

A

fibrolamellar HCC

102
Q

Characteristics of fibrolamellar HCC (imaging, histo, lab)

A

Imaging: well-circumscribed mass w/ central scar

Histo: clusters of large polygonal cells interspersed w/ sheets of collagen

Lab: normal AFP; elevated neurotensin level

103
Q

Liver mass, normal AFP, elevated neurotensin… think?

A

Fibrolamellar variant of HCC

104
Q

Components of bile

A

water, bile salts, cholesterol, lecithin (phospholipid)

105
Q

Ratio of bile components least likely to form cholesteral stones

A

high bile salt, high lecithin, low cholesterol ratio

106
Q

What is an abnormal CCK-HIDA scan?

A

EF<35% after 20 minutes of injection (but note that other etiologies for abnormal EF i.e. diabetes, IBD)

107
Q

What hormone is most potent stimulator of bile secretion?

108
Q

Secretion of bile is dependent on what ion channel?

A

Chloride (that is stimulated mostly be secretin)

109
Q

Primary source of bilirubin in body?

A

from breakdown of RBC

110
Q

Primary bile acids are…? Conjugated with…?

A

cholic acid and chenodeoxycholic acid; conj w/ either taurine or glycine

111
Q

Incidental hepatic mass, asymptomatic, peripheral enhancement on CT… think?

A

Hemangioma

112
Q

Conjugated bile salts (if not absorbed at terminal ileum) are deconjugated by colonic bacteria to…?

A

deoxycholate and lithocholate

113
Q

How and where are deconjugated bile salts absorbed?

A

by passive transport in colon and returned to liver

114
Q

MC etiology for cystic duct stump leak s/p lap chole

A

inflammation around duct in setting of acute cholecystitis -> dislodges clips

115
Q

Only known effective systemic medical therapy for pts with HCC?

A

sorafenib (multikinase inhibitor w/ activity against VEGF-R, c-kit receptor, PDGF-R, and kinases of MAPKK pathway)

116
Q

Mgmt GB cancers at infundibulum

A

CBD resection, extended liver resection, then RNY hepaticoJ + complete lymphadenectomy

117
Q

Mgmt GB cancers at fundus

A

limited hepatic resection wo excision of CBD + complete lymphadenectomy (CBD, hepatic artery, portal vein)

118
Q

If concern for cholangiocarcinoma, next step for dx…?

A

MRI with cholangiography protocol (MR cholangiopancreatography) to evaluate extent of disease

119
Q

GB cancer will first metastasize where…?

A

cystic duct lymph nodes

120
Q

MC morphology cholangiocarcinoma…? Most favorable histology…?

A

nodular; papillary

121
Q

Fxn glucuronyl transferase

A

conjugates bilirubin

122
Q

MC organisms of pyogenic liver abscess

A

E.coli and Klebsiella (latter particularly in gas-forming abscesses)

123
Q

Best test for liver function

124
Q

Dx modality of choice to reassess GB polyp (surveillance)

A

ultrasound (doppler assessment of blood flow through mucosal abnormalities can differentiate early malignancy vs. benign)

125
Q

Wilson disease is 2/2 deficiency of…?

126
Q

Most sensitive dx test to identify other areas of liver mets intra-op

A

ultrasound (2-5mm sensitivity)

127
Q

How long does it take for VitK to reverse effects of warfarin?

128
Q

% of pts who die of fulminant liver failure shown to have cerebral edema

129
Q

MCC portal vein thrombosis in children

A

umbilical vein infection

130
Q

Lipoprotein that carries the highest concentration of cholesterol is…?

131
Q

MC organism of spontaneous bacterial peritonitis

132
Q

Pt w/ hx UC presenting w/ c/o nausea, itching, fatigue + hx multiple biliary strictures s/p stents… think?

A

primary sclerosing cholangitis -> fibrosis and strictures in biliary tree (mgmt: liver tx)

133
Q

Where does cystic artery pass in relation to common hepatic duct?

134
Q

Double cystic arteries found in ?% of pts?

135
Q

Most important indicator of prognosis for GB adenocarcinoma

A

lymph node status

136
Q

What GB polyp characteristics should consider cholecystectomy?

A
  • polyps >10mm
  • in pts with cholelithiasis
  • in pts with primary sclerosis cholangitis
137
Q

Monitoring of GB polyp

A

if <1cm + asymptomatic, should have serial US q6-12m for 2 years

138
Q

Typical dose of glucagon to relax sphincter of Oddi

139
Q

Rate of post-TIPS encephalopathy?

140
Q

Major limitation of TIPS that may occur within first year?

A

high incidence (up to 50%) of stent stenosis (MC) or thrombosis

141
Q

Mgmt for TIPS shunt stenosis

A

balloon dilation of TIPS, or by placement of second shunt

142
Q

Well-defined hepatic mass with contrast enhancement during arterial phase, followed by rapid washout during portal phase… consistent with?

A

hepatic adenoma

143
Q

Well-defined hepatic mass with peripheral + central enhancement on delayed imaging… consistent with?

A

hepatic hemangioma

144
Q

Poorly defined mass @ peripheral w/ low attenuation, central necrosis, cystic degeneration… think?

A

metastatic hepatic lesion

145
Q

Well-defined hepatic mass with internal septae, papillary projections, intratumoral hemorrhage, fine calcifications… think?

A

hepatic cyst

146
Q

When should antibiotics start for variceal bleeding?

A

prophylactic Abx started as part of resuscitation and continued for 7-days -> decrease risk bacterial infxn and increase survival

147
Q

Dominant artery to biliary tree is…?

A

right hepatic artery (loss of this inflow -> biliary stricture; also supplies cystic artery)

148
Q

Primary prophylaxis for pts with high risk variceal bleeding

A

Non-selective BB - lowers portal pressure and reduces risk first bleeding in pts with esophageal varices

149
Q

Patho for “defect in GB wall”… think?

A

GB wall ischemia -> necrosis -> perf bc gangrenous

150
Q

Pt s/p enterotomy for gallstone ileus, presenting with AMS, RUQ tenderness… think?

A

cholangitis - can get from reflux via fistula

151
Q

Mgmt bleeding hepatic hemangioma

A

embolization

152
Q

Mgmt symptomatic or >10cm hepatic hemangioma

A

resection vs. enucleation

153
Q

Second MC benign hepatic tumor

A

focal nodular hyperplasia

154
Q

Mgmt asymptomatic focal nodular hyperplasia

A

observation; may do q1y US for 2-3 years for women who wish to continue OCP

155
Q

Surgical indication for hepatic adenoma

A
  1. size of >5cm
  2. male patient
  3. inability to r/o malignancy
156
Q

What % future liver remnant is predictive of post-op liver failure?

157
Q

What clearance can be used to assess functional capacity of liver? What is the threshold to predict post-op liver failure?

A

indocyanine green clearance - checked after 15min injection (nl = <10% detectable)
>40% retention predictive of post-op liver failure regardless of resection size

158
Q

Medications that reduce GB contractility (and should be withheld before CCK cholescintigraphy)

A
  • atropine
  • CCB
  • octreotide
  • progesterone
  • indomethacin
  • theophylline
  • benzos, all opioids
  • H2-blockers
159
Q

Most appropriate time to semi-electively operate on pregnant female w/ cholecystitis…? Why?

A

second trimester (13-26wks) - bc lower incidence of premature labor

160
Q

When in pregnant female w/ cholecystitis should conservative mgmt be attempted initially?

A

32 weeks (risk premature labor)

161
Q

If conservative mgmt fails in >32wk pregnant female w/ cholecystitis, then mgmt?

A

operation - pretreat w/ betamethasone 24hrs and 12hrs pre-op; at 32wks, okay to conduct necessary radiographs (ie. intra-op cholangiogram, ERCP)

162
Q

Acute portal vein thrombosis in adult… think?

A

prothrombotic state vs. myeloproliferative disorder

163
Q

Intent when using external beam radiation or transarterial chemoembolization for liver mets is…?

A

palliation - not curative

164
Q

Gallbladder polyps are classified into…?

A
  • pseudotumors (cholesterol polyps, adenomyomas, inflammatory polyps)
  • epithelial (adenomas)
  • mesenchymal (leiomyomas)
  • malignancy (adenocarcinomas)
165
Q

When do cholecystectomy for GB polyp?

A
  • polyp >5mm + age >50
  • polyp >10mm
  • single poly any size + gallstones
166
Q

When need CT eval for invasive cancer for GB polyp?

A
  • polyp >18mm (treat as if malignant)

- polyp >10mm + age <60

167
Q

MRCP findings of primary sclerosing cholangitis

A

“bead-on-a-string”

168
Q

What autoimmune disease could also mimic MRCP findings of primary sclerosing cholangitis?

A

IgG4-associated autoimmune pancreatitis (if suspect, then can give trial of steroid immunosuppression)

169
Q

Abx of choice for spontaneous bacterial peritonitis

A

3rd-gen cephalosporin

170
Q

Hx ulcerative colitis, now presenting with fatigue, weight loss, pruritus… think?

A

concern for primary sclerosing cholangitis - need MRCP for dx

171
Q

Primary lab abnormality in primary sclerosing cholangitis pts

A

elevated ALP, most have normal bilirubin levels - if elevated, then suggestive of advanced disease or malignancy

172
Q

Post-ERCP scan showing RP air…think? Mgmt?

A

benign - (Type 4 ERCP perf) microperf 2/2 compressed air used to maintain patency of duodenal lumen
Mgmt: IV Abx

173
Q

After placement of perQ chole for acute cholecystitis in poor surgical candidate… next step during follow-up for tube?

A

cholangiogram via chole tube - confirm correct placement and assess CD is patent

174
Q

Alternative to cholecystectomy for patients who remain poor surgical candidates?

A

endoscopic transpapillary GB stent (ETGS)

175
Q

What is Child A/B/C score by points?

A

Child A = 5-6 pts
Child B = 7-9 pts
Child C = 10-15 pts

176
Q

Primary bile salts

A
  • colic acid

- chenodeoxycholic acid

177
Q

Process: cholesterol -> primary bile salts -> ?

A

Cholesterol in liver -> conjugated by glycine or taurine -> primary bile salts -> secreted into bile to duodenum (enterohepatic circulation)

178
Q

Anatomy: relative location of 3 parts of CBD (superior, middle, inferior third)

A

Supraduodenal: in hepatoduo ligament and along edge of lesser momentum, anterior to portal vein, lateral to proper hepatic
Retroduo: behind 1st-duo, lateral to portal vein, anterior to IVC
Intrapancreatic: posterior pancreas in tunnel to enter 2nd-duo (joined by panc duct) @ papilla of Vater

179
Q

Foramen of Winslow contains what structures?

A

Portal triad: vein, proper hepatic, CBD

180
Q

Triad for ascending cholangitis

A

Charcot triad (fever, jaundice, RUQ pain)

181
Q

MC Cx if gallstone is not retrieves s/p lap chole (and spill)

A

Abscess formation

182
Q

Mgmt abscess with “radiopaque” object s/p lap chole (cx: spill)

A

Lap drainage of abscess + retrieval of foreign body (gallstone)

183
Q

Secondary bile acids

A
  • deoxycholic

- lithocholic acids

184
Q

CCK is produced by what cells? And where?

A

I-cells of the duodenum

185
Q

Pt w/ jaundice and cholelethiasis + “paint brush” or “soap bubble” sign on upper GI series

A

Small bowel villous adenoma

186
Q

MC location for small bowel adenoma

A

2nd-duodenum @ periampullary region

187
Q

When post-op can chole T-tube be manipulated?

188
Q

Next step: US finding of intrahepatic ductal dilation and mass @ hilum

A

Define proximal extent of hilar cholangiocarcinoma w/ MRI (cholangiography)

189
Q

Stage 5-yr survival of gallbladder adenoCA

A

TIS = 80%
Stage 1 = 50%
Stage 2 = 29%
Stage 3, 4 = <10%

190
Q

RF cholangiocarcinoma (cancer of bile ducts)

A
  • male; age 50-70
  • PSC
  • UC
  • biliary tract infection
  • choledochal cyst
191
Q

RF gallbladder adenoCA

A
  • females; age 70’s
  • cholelithiasis
  • larger gallstones >3cm (10x risk, likely due to chronic inflammation)
  • large, single GB polyp >1cm
  • choledochal cyst
192
Q

Cystic artery divides into…? To supply gallbladder.

A

Superficial and deep branches

193
Q

Anatomy: location cystic artery in relation to CHD

A

Lateral, posterior (high variability)

194
Q

What nerve stimulates contraction of the gallbladder? Which is inhibitory?

A

Stimulators: vagus
Inhibitory: splanchnic sympathetic stimulation

195
Q

When should you do T-tube cholangiography to evaluate for retained stones?

A

2 weeks ( to evaluate for possible removal)

196
Q

Mgmt cholangiocarcinoma resection based on location

A

Superior (hilar and duct involvement): partial hepatectomy +CBD resection
Middle (rare): CBD w/ regional lymphadenectomy
Intrapancreatic: Whipple

197
Q

Most potent stimulator of bile secretion

198
Q

Mgmt acute cholecystitis in a poor surgical candidate, what is definitive mgmt?

A

PerQ insertion of cholecystostomy tube -> decompression (at later date, can do cholecystography through tube to eval for obstructing stone)

199
Q

Contraindications for resection of cholangiocarcinoma

A
  • distant mets (inability to do R0 resection)
  • encasement of main portal vein
  • b/l hepatic lobar artery involvement
  • lobar atrophy w/ involvement of contralateral portal vein
200
Q

Highest NPV for cholelithiasis (aka. If normal, then likely negative)

A

GGP (beta-glutamotranspeptidase)

201
Q

CT: liver lesion of arterial phase w/ peripheral and central enhancement + delayed but persistent peripheral nodular enhancement

A

Hepatic hemangioma

202
Q

CT: liver lesion well-circumscribed + early enhancement in arterial phase with rapid washout on portal phase; heterogenous mass

A

Hepatic adenoma

203
Q

What is presentation of acute liver failure vs. cirrhotic?

A

Acute liver failure = cirrhotic (ascites, encephalopathy) + unstable, coagulopathic

204
Q

If isolated gastric varices, and suspect splenic vein thrombosis… should do what to confirm? And if not splenic vein thrombosis, mgmt?

A

Abdominal US. If gastric varices due to portal HTN, then NO splenectomy.

205
Q

How does splenic vein thrombosis cause isolated gastric varices?

A

Retrograde flow through short gastric and posterior gastric veins

206
Q

Portal pressure is calculated by difference in what two vein pressures?

A

IVC and portal vein pressures

207
Q

If multiple organs present in ascitic fluid… suspect?

A

Not spontaneous bacterial peritonitis (usually single) - suspect secondary peritonitis (ie. Diverticulitis)

208
Q

Which esophageal balloon tamponade has proximal port to allow drainage of salivary secretions?

A

Minnesota tube

209
Q

How does metastatic liver lesions appear on CT?

210
Q

What % of variceal bleeding rebleeds after balloon tamponade?

211
Q

Which hydatid liver cysts require surgery?

A

CE2 (multispetated) and CE3b (daughter cyst) - many compartments

212
Q

Main site of urea production? Of excretion? Immediate AA precursor of urea?

A 
Production = liver
Excretion = kidney
AA = arginine
213
Q

Ascites from liver dysfunction due to…?

A

High intravascular pressure 2/2 portal HTN -> capillary leakage (NOT due to low intravascular oncotic pressures due to poor protein stores)

214
Q

Patho biliary leak complications following OLT

A

Ischemia of donor biliary tree (must r/o hepatic artery stenosis or thrombosis) -> biliary leak

215
Q

Drainage of ? from biloma is not likely to resolve without further intervention?

A

If >300cc/day from perQ drain, will likely not resolve, will need ERCP.

216
Q

Gastric varices commonly seen with ?-side portal HTN?

A

left-sided portal HTN - seen with splenic vein thrombosis

217
Q

Expected overall surgical mortality risk: Child A/B/C

A

A: 10%
B: 30%
C: 75-80%

QUESTION NOTES (28 decks)

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