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ABSITE > Hepatobiliary and Pancreas > Flashcards

Hepatobiliary and Pancreas Flashcards

1
Q

What are the boundaries of the triangle of Calot?

A

Lateral - Cystic Duct
Medial - CBD
Superior - Liver

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2
Q

What supplies blood to the hepatic and CBD?

A

Right Hepatic and branches of the GDA

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3
Q

What side of the CBD are lymphatic on?

A

The right

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4
Q

Where do sympathetic and parasympathetic fibers come to the liver from?

A

Parasympathetic -> Left trunk of vagus

Sympathetic -> T7-T10

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5
Q

What is unique about the histology of the GB?

A

It lacks any submucosa

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6
Q

What is a normal size for the CBD, GB wall and pancreatic duct?

A

CBD < 8 mm (10 after cholecystectomy)
GB wall < 4 mm
Pancreatic duct < 4 mm

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7
Q

What are RokitanskypAschoff sinuses?

A

Invaginations in the GB wall from increased GB pressure

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8
Q

What are the Ducts of Luschka?

A

Biliary ducts lying in the GB fossa that can leak after cholecystectomy

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9
Q

What signals increase bile secretion and decrease it?

A

Increase: CCK, secretin, vagal
Decrease: somatostatin, sympathetic

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10
Q

What is the most common type of GB stone in the US?

A

Cholesterol stones

2/2: stasis, calcium nucleation, increased water resorption

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11
Q

What are causes brown GB stones?

A

Primary CBD stones, formed in ducts, asians
Infection causes deconjugation
E. Coli most common

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12
Q

What causes black GB stones?

A

Hemolytic disorders, cirrhosis, ill resection, chronic TPN

Calcium bilirubinate

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13
Q

What is the sensitivity of ultrasound for GB stones?

A

95%

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14
Q

What are indications for cholecystectomy after a CCK-S test?

A

GB not seen
> 60 min for GB to empty (chronic cholecystitis)
EF < 40% (biliary dyskinesia)

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15
Q

What are indications for pre-op ERCP?

A

If any of the following high for > 24 hours:
AST or ALT > 200
Bilirubin > 4
Amylase or Lipase > 1000

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16
Q

What is the most common route of infection of the bile?

A

Via seeding from the portal system

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17
Q

What condition has the highest incidence of positive bile cultures?

A

Post-op strictures

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18
Q

What bacteria usually causes emphysematous GB disease in diabetics?

A

C. Perfringens

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19
Q

What is the threshold for primary repair of a CBD injury?

A

< 50% of circumference

Otherwise need hepatico-J

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20
Q

What do suspect if N/V or jaundice after lap whole and no fluid collection?

A

If dilated hepatic ducts -> complet ductal transection

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21
Q

What is the treatment for a complete bile duct transection?

A

< 7 days symptoms - Hepatico J

> 7 days symptoms - Delayed hepatico J (6-8 weeks)

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22
Q

How do you treat anastomotic leaks following transplantation or hepatico-J?

A

Drainage and ERCP with temporary stent

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23
Q

What is the most common cause of late post-op biliary strictures?

A

Ischemia after lap chole

Ddx: chronic pancreatitis, GB CA, bile duct CA

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24
Q

What is workup of a biliary stricture?

A

MRCP

If CA not ruled out -> ERCP with brush biopsies

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25
Q

What is treatment for biliary strictures from ischemia or chronic pancreatitis?

A

Choledochojejunostomy

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26
Q

Where does gallbladder AC spread first?

A

Segments IV and V

Cystic duct nodes

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27
Q

What is the treatment of GB carcinoma based on depth of invasion?

A

Not in muscle -> cholecystectomy
In muscle but not beyond -> wedge of segments IVb and V
If beyond muscle and resectable -> formal segments IVb and V resection

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28
Q

Why is laparoscopic approach contraindicated for GB cancer?

A

Tumor implants in port sites

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29
Q

What is treatment of cholangiocarcinoma of the upper 1/3 (Klatskin Tumor)?

A

Lobectomy if localized

Worst prognosis

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30
Q

What is treatment of cholangiocarcinoma of middle 1/3 of duct?

A

Hepaticojejunosotmy

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31
Q

What is treatment of cholangiocarcinoma of lower 1/3 of duct?

A

Whipple

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32
Q

What is the most common type of choledochol cyst?

A

Type I - fusiform dilation of the extra hepatic pancreatic ducts

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33
Q

What causes choledochol cysts?

A

Reflux of pancreatic enzymes during uterine development

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34
Q

What antibody is present with primary biliary cirrhosis?

A

Antimitochondrial Antibodies

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35
Q

Is there a cancer risk with PBC?

A

No

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36
Q

What causes systemic bacteremia in cholangitis?

A

Colovenous reflux (>200 mmHg)

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37
Q

What are early and late causes of shock after lap chole?

A

Early - clip fell off cystic after

Late - sepsis from clip on CBD with subsequent cholangitis

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38
Q

What are worrisome features of GB polyps?

A

> 1 cm

> 60 years old

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39
Q

What is delta bilirubin and what is its implication?

A

Covalently bound to albumin, half life of 18 days

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40
Q

What is Mirizzi syndrome?

A

Compression of common hepatic duct from:

1) Stone in GB infundibulum
2) inflammation from GB or cystic duct causing CHD stricture

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41
Q

What antibiotic is associated with sludge and cholestatic jaundice?

A

Ceftriaxone

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42
Q

Which lies lateral and anterior, SMV or SMA ?

A

SMV

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43
Q

What are the effects of GI hormones on pancreatic secretions?

A

Secretin - Increase HCO3
CCK - Increase pancreatic enzymes
Ach - Increase both
Somatostatin Glucagon - Decrease exocrine

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44
Q

What duct connects the inferior pancreatic bud to the duodenum?

A

Duct or Wirsung - Becomes the major pancreatic duct

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45
Q

What is the small accessory duct that drains directly into duodenum from pancreas?

A

Duct of Santorini

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46
Q

What causes annular pancreas?

A

Failure of clockwise rotation of ventral pancreatic bud

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47
Q

What is treatment of annular pancreas?

A

Duodenojejunostomy or duodenoduodenostomy

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48
Q

What is the main consequence of pancreas divisor?

A

Pancreatitis from stenotic duct of Santorini

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49
Q

What is the treatment of pancreas divisor?

A

ERCP with sphincteroplasty

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50
Q

What is a sentinel loop?

A

In pancreatitis, dilated loop of bowel near pancreas as a result of inflammation

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51
Q

What does a necrotic pancreas look like on CT?

A

Will not take up contrast

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52
Q

What is Grey Turner sign?

A

Flank ecchymosis from pancreatic bleeding

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53
Q

What is Cullen’s sign?

A

Periumbilical ecchymosis from pancreatic bleeding

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54
Q

What is Fox’s sign?

A

Inguinal ecchymosis from pancreatic bleeding

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55
Q

What is the most important risk factor for necrotizing pancreatitis?

A

Obesity

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56
Q

What must be ruled out in cysts not associated with pancreatitis?

A

Cancer

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57
Q

What is tx for pancreatic pseudocyst?

A

3 months to stabilize and see if resolve
If continued sx, surgery/procedure
If growing, surgery to r/o cancer

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58
Q

Which cysts do you not need to worry about for cancer?

A

If cyst is serous and not complex, can follow these

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59
Q

What is Tx for pancreatic fistula?

A

Drainage, stent, allow to close on own

Octrotide

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60
Q

What is the most common symptoms of chronic pancreatitis?

A

PAIN

anorexia, weight loss, malabsorption

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61
Q

What does imaging show for chronic pancreatitis?

A

CT: shrunken pancreas with calcifications
U/S: Panc ducts > 4 mm, cysts, atrophy

Chain of Lakes: alternating dilations and stenosis in pancreatic duct

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62
Q

What is a Puestow procedure?

A

pancreaticojejunostomy, for duct > 8 mm

63
Q

What are surgical options for chronic pancreatitis?

A 
Puestow Procedure
Distal pancreatic resection
Whipple
Berger-Frey
Pain ctrl with thoracoscopic splanchnicectomy or celiac ganglionectomy
64
Q

What is the most common cause of splenic vein thrombosis?

A

Chronic pancreatitis

65
Q

What is the most common symptom of pancreatic cancer?

A

Weight loss

66
Q

What is the serum marker for pancreatic cancer?

67
Q

What is the most common mutation in pancreatic cancer?

68
Q

What are indications of unresectable disease for pancreatic cancer?

A

PV, SMV, RP invasion
Mets to peritoneum, momentum, liver
Mets to celiac or SMA nodal system

69
Q

What are the histologies of pancreatic cancer?

A 
Ductal adenocarcinoma (90%)
Papillary or mutinous cyst-adenocarcinoma
70
Q

Do all patients need a biopsy with suspected pancreatic cancer?

A

No, if resectable and in the pancreas, you are taking it out regardless

71
Q

What are signs of cancer on an MRCP?

A

Duct with irregular narrowing, displacement, destruction

Vessel involvement

72
Q

What are the most common complications from a whipple?

A

Delayed gastric emptying
Fistula
Leak
Marginal ulceration

73
Q

What is treatment for post-op bleeding after whipple?

A

Angio for embolization

74
Q

What is prognosis of pancreatic cancer related to?

A

Nodal invasion and ability to get a clear margin

75
Q

What are the characteristics of non-functional endocrine neoplasms of the pancreas?

A

90% malignant
Indolent and protracted course
Resect

76
Q

What chemotherapy is used for non-functional endocrine tumors of the pancreas?

A

5FU and streptozosin

77
Q

What are the most common endocrine pancreatic tumors in the head?

A

Gastrinoma

Somatostatinoma

78
Q

What is Whipple’s Triad of insulinomas?

A

Fasting hypoglycemia
Symptoms of hypoglycemia (palpitations, tachy)
Relief of symptoms with glucose

79
Q

What should you suspect if c-peptide and proinsulin are not also elevated with insulin:glucose > 0.4?

A

Muchausen’s syndrome

80
Q

What is the treatment for insulinoma or gastronome?

A

< 2 cm - enucleate

> 2 cm formal resection

81
Q

What is the most common pancreatic islet cell tumor in MEN-1 patients?

A

Gastrinoma

82
Q

What is the 50% rule for gastrionma?

A

50% malignant

50% multiple

83
Q

What is the gastrinoma triangle?

A

CBD
Neck of pancreas
third portion of duodenum

84
Q

What are the laboratory and imaging studies for gastrinoma?

A

Gastrin > 200, 1000s is diagnostic
Secretin stimulation test: ZES gastrin > 200
Imaging: Octrotide scan

85
Q

What is treatment for duodenal gastrinoma?

A

Resection and primary closure

Whipple if extensive

86
Q

What is the characteristics of glucagonoma?

A

Most are malignant and in distal pancreas

87
Q

What are the characteristics of VIPoma?

A

Most malignant

Most in distal pancreas, 10% extrapancreatic

88
Q

What are the characteristics of somatostatinoma?

A

Malignant (most)
Most in head of pancreas
Do a cholecystectomy with resection

89
Q

What is the relation of the splenic vein to the splenic artery?

A

Splenic vein posterior and inferior to splenic artery

90
Q

Where is an accessory spleen most commonly found?

A

Splenic hilum

91
Q

What are indications for splenectomy (non-trauma)?

A

ITP and TTP (ITP&raquo_space;>TTP)

92
Q

What is the defect in ITP?

A

Anti-platelet IgG bind it and result in decreased platelets

Spleen is normal

93
Q

Which group with ITP should you avoid splenectomy in?

A

Children > 10 years (often self resolves)

94
Q

What is the primary therapy for ITP?

A

Steroids and then gammaglobulin

95
Q

What is the common cause of death in TTP?

A

Intracerebral hemorrhage

96
Q

What is the incidence of post-splenectomy sepsis?

A

0.1% (increased in kids)

Highest with hemolytic disorders or malignancy

97
Q

What age should you try to wait until for splenectomy?

A

Age 5 as you get all immunizations

98
Q

What is the most common congenital hemolytic anemia requiring splenectomy?

A

Spherocytosis

99
Q

What is the pathophysiology of spherocytosis?

A

Defect in spectrum leads to splenic sequestration

100
Q

What is Tx for spherocytosis?

A

Splenectomy AND Cholecystectomy

101
Q

What is the most common hemolytic anemia not involving membrane protein needing splenectomy?

A

Pyruivate kinase deficiency

Others: Warm-antibody hemolytic anemia, occasionally beta-thalasemia

102
Q

What is the staging for Hodgkin’s disease?

A

A - asymptomatic
B - symptomatic
I - 1 area or 2 contiguous areas on same side of diaphragm
II - 2 non-continguious on same side of diaphragm
III - both sides of diaphragm
IV - Non-lymphoid tissue other than spleen

103
Q

What is the most common cause of chylous ascites?

104
Q

What is the most common cause of splenic artery/vein thrombosis?

A

Pancreatitis

105
Q

What changes do you see post-splenectomy?

A

Increased RBC, WBC (persistent increase in lymphs and monos), Platelets
Platelets > 1 000 000, give ASA

106
Q

What is the most common splenic tumor?

A

Hemangioma

107
Q

What is the treatment for splenic cysts?

A

Surgery if symptomatic or > 10 cm

108
Q

What is the treatment of a splenic abscess?

A

Splenectomy (perc drainage has bleeding risk)

109
Q

What is the most common variant of the hepatic arteries?

A

Right hepatic off of SMA coursing behind pancreas and posterolateral to the CBD

110
Q

What is the common variant of the left hepatic artery?

A

Off of left gastric (20%) found in gastrohepatic ligament medially

111
Q

What gives blood supply to most tumors of the liver?

A

Hepatic artery

112
Q

Where does the middle hepatic vein come from?

A

80% of people it is a branch of the left hepatic vein

20% go directly from IVC

113
Q

What is the only water-soluble vitamin stored in the liver?

114
Q

What are primary and secondary bile salts?

A

Primary: chalice and chenodeoxycholic
Secondary: deoxycholic and lithocholic (formed by bacteria)

115
Q

At what TBilli does jaundice occur?

116
Q

What enzyme is implicated in Gilbert’s, Crigler-Najjar and physiologic jaundice?

A

Glucuronyl Transferase

Mild, severe, and temporary defects respectively

117
Q

What is Rotor’s syndrome?

A

Deficiency in bile storage ability

118
Q

What is dubin-johnson syndrome?

A

Deficiency in secretion of bile

119
Q

What are the criteria for urgent liver Txp listing in fulminant liver failure?

A

Non-APAP induced:
INR > 6.5 OR 3 of the following:
Age < 10 or > 40, drug toxicity or undetermined etiology, jaundice > 7 days prior to encephalopathy, INR > 3.5, bilirubin > 17

120
Q

What kidney hormone is elevated in liver failure?

A

Aldosterone

121
Q

What is the etiology of postpartum liver failure with ascites?

A

Hepatic vein thrombosis + infection

Tx: Heparin + ABX

122
Q

What is the diagnostic criteria for SBP?

A

PMNs > 250 in fluid

123
Q

What ist he treatment for ruptured esophageal varies?

A

banding, sclerotherapy
Vasopressin, octreotide
Propranolol chronically
TIPS

124
Q

What are causes of pre-sinusoidal obstruction?

A

Schistosomiasis
Congenital hepatic fibrosis
Portal vein thrombus

125
Q

What is a normal portal vein pressure?

126
Q

What veins act as collaterals between portal and systemic venom system?

A

Coronary veins

127
Q

What are the indications for TIPS?

A

Protracted bleeding
Progression of coagulopathy
Visceral hypoperfusion
Refractory ascites

128
Q

How is a splenorenal shunt done?

A

Ligate left adrenal vein left gonadal vein, IMV, coronary vein, pancreatic branches of splenic vein

129
Q

When is splenorenal shunt indicated?

A

Child’s A cirrhotics with just bleeding (can worsen ascites)

130
Q

What is the Child-Pugh score based on?

A 
Albumin
Bilirubin
Encephalopathy
Ascites
INR
131
Q

What is the most common cause of massive hematemesis in children?

A

extra-hepatic portal vein thrombosis

132
Q

What causes isolated gastric varices?

A

Splenic vein thrombosis

133
Q

What is the classic presentation of amebic liver abscess?

A

Increased LFTS, right lobe of liver, single abscess with sterile culture (organism lives in rim)

134
Q

What tests diagnose echinococcus cyst?

A

Casoni skin test, serology

CT: ectocyst (calcified) endocyst (double-walled)

135
Q

What is treatment of echinococcus abscess?

A

Pre-op albendazole and then surgical removal

136
Q

What is the symptoms of schistosomiasis?

A

Maculopapular rash, eosinophilia, vatical bleeding

137
Q

What is most common organism in hepatic abscess?

A

GNRs/ E.Coli

138
Q

What causes pyogenic liver abscess?

A

Infection from biliary tree or bacteremia

139
Q

What are the imaging features of hepatic adenomas?

A

No uptake on sulfur colloid scan

MRI with hyper vascular tumor

140
Q

What is treatment of hepatic adenomas?

A

Asymptomatic - stop OCPs no Tx for regression, otherwise resect
Symptomatic - resect

141
Q

What is the imaging features of FNH?

A

Central stellate scar
Hypervascular tumor on CT/MRI
Uptake on sulfur colloid liver scan

142
Q

What are the features of FNH?

A

No malignancy risk

Unlikely to rupture

143
Q

What is the most common benign hepatic tumor?

A

Hemangioma

144
Q

What are the imaging features of hepatic hemangioma?

A

Peripheral to central enhancement

Hypervascular

145
Q

What is the treatment for symptomatic hemangioma?

A

surgery +/- embolization pre-op

146
Q

What is Kasabach-Merritt syndrome?

A

Consumptive coagulopathy from hepatic hemangioma

147
Q

What liver diseases are not risk factors for HCC?

A

Primary biliary cirrhosis

Wilson’s disease

148
Q

What types of HCC have the best prognosis?

A

Clear cell
Lymphocyte infiltrative
Fibrolamellar types

149
Q

What tumor marker correlates with size in HCC?

150
Q

What are the risk factors for hepatic sarcoma?

A

PVC
Thorotrast
Arsenic

151
Q

What is the vascular pattern for primary vs metastatic liver tumors?

A

Primary - hypervascular

Mets - hypo vascular

152
Q

What are the “worrisome features” of an IPMN that mandate EUS?

A

cyst of at least 3 cm
an enhancing mural nodule
thickened or enhancing cyst walls
main duct size of 5 to 9 mm
any abrupt change in caliber of the duct with distal atrophy,
lymphadenopathy
elevated cancer antigen 19-9 (normal: 0-37 U/mL)
cyst growth rate of at least 5 mm over 2 years.

153
Q

What are the high-risk features of an IPMN that would lead to resection?

A

obstructive jaundice
enhancing mural nodules of at least 5 mm
main duct dilation to at least 10 mm

ABSITE (8 decks)

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