hepatobiliary GB <3

Question 1

Liver blood supply

Answer 1

75% portal vein, 25% hepatic arteries (although 50-50 for oxygen due to different O2 sats). Celiac trunk -> common hepatic -> proper hepatic -> L and R hepatic arteries

Question 2

Liver venous drainage

Answer 2

R, M, L hepatic veins -> IVC

Question 3

Falciform ligament

Answer 3

Connects ab wall to liver, contains ligamentum teres (obliterated umbilical vein)

Question 4

Coronary ligament

Answer 4

Peritoneal reflection on cranial aspect of liver that attaches it to diaphragm

Question 5

Glisson’s capsule

Answer 5

peritoneal membrane covering the liver

Question 6

Hepatodudoenal ligament

Answer 6

Contains portal triad (CBD, portal vein, hepatic artery). Forms anterior boundary of epiploic foramen of Winslow, connects the greater and lesser peritoneal cavities.

Question 7

What are the components of bile?

Answer 7

Cholesterol, lecithin, bile acids, bilirubin

Question 8

Enterohepatic ciculation

Answer 8

Bile acids released from liver into duodenum -> reabsorbed in terminal ileum -> back to liver via portal vein

Question 9

Dark urine, clay-colored stools indicates what type of jaundice?

Answer 9

Obstructive (high levels of unconjugated bilirubin, which can enter urine)

Question 10

Treatment of liver abscess/cyst

Answer 10

Pyogenic: percutaneous drainage + IV abx. Amebic abscess (E. histolytica): IV metronidazole. Parasitic (hydatid cysts): albendazole (never aspirate!) followed by resection.

Question 11

Most common benign tumor of the liver?

Answer 11

Cavernous hemangioma (results from abnl differentiation of angioblastic tissue during fetal life). Usu just found incidentally; do NOT biopsy, resect only if symptomatic or going to rupture

Question 12

Hepatic adenoma

Answer 12

Seen in child-bearing females, risk factors include OCPs,, anabolic steroids, glycogen storage disease. Even if someone had adenoma that resolved after stopping OCPs, risk of rupture/hemorrhage during pregnancy.

Question 13

Focal nodular hyperplasia

Answer 13

Benign hepatic tumors with ‘central scar’ on pathology. Resect only if symptomatic

Question 14

Hepatocellular carcinoma (aka hepatoma) risk factors

Answer 14

Cirrhosis, Hep B and C, hemochromatosis, A1AT deficiency, liver flukes, anabolic steroid use

Question 15

What markers are elevated in HCC?

Answer 15

ALP, AST, ALT, GGT, AFP, DCP

Question 16

Treatment of HCC

Answer 16

Resection (or transplant) only cure

Question 17

Most common hepatic malignancy?

Answer 17

Metastasis; from colon, breast, lung most often

Question 18

What is Child-Pugh score based on?

Answer 18

Bilirubin, albumin, ascites, neuro disorder, PT

Question 19

Most common causes of portal HTN

Answer 19

US: alcoholic cirrhosis. World: schistosomiasis

Question 20

Esophageal varices

Answer 20

Left gastric vein -> esophageal veins

Question 21

Caput medusa

Answer 21

Umbilical vein (via falciform ligament) to epigastric veins

Question 22

Hemorrhoids

Answer 22

Superior rectal vein -> middle and inferior rectal veins

Question 23

Drawbacks of shunting for portal HTN

Answer 23

Increased incidence of hepatic encephalopathy (more toxins diverted to systemic circulation) and decreased blood to liver = increased death from hepatic failure

Question 24

What is the EEG like in hepatic encephalopathy?

Answer 24

Normal

Question 25

Esophageal varices

Answer 25

Use beta-blockers to prevent rupture, but not once actively bleeding / hemodynamically unstable

Question 26

Emphysematous cholecystitis

Answer 26

Rare, severe variant caused by gas-forming bacteria, most often seen in elderly diabetic men. Can result in perforation

Question 27

Acalculous cholecystitis

Answer 27

10% of all cases of acute cholecystitis. Acute inflammation in absence of gallstones, thought to be 2/2 stasis. Most often seen in ICU pt with multisystem organ failure, trauma (incl major surgery), burns, sepsis, TPN. Tx: urgent CCY

Question 28

Charcot’s triad

Answer 28

Acute cholangitis: fever, jaundice, RUQ pain

Question 29

Reynold’s pentad

Answer 29

Acute cholangitis: fever, jaundice, RUQ pain plus CNS symptoms and septic shock

Question 30

Gallstone ileus

Answer 30

SBO caused by gallstone in pt with long standing stones, most commonly a large one that erodes through GB directly into duodenum via fistula. Most common place for obstruction is ileocecal valve.

Question 31

Carcinoma of the gallbladder is usually what type

Answer 31

Adenocarcinoma. Rare. Peak age 75 yo, F>M

Question 32

Benign tumors of the bile ducts

Answer 32

Most common type is adenoma, commonly found at ampulla of Vater. Causes intermittent jaundice, RUQ pain. Tx: resection (surgical or endoscopic)

Question 33

Cholangiocarcinoma location

Answer 33

Nearly all are adenocarcinomas. Can arise anywhere along intrahepatic or extrahepatic biliary system, but most common spot is bifurcation into R and L hepatic ducts (Klatskin tumor)

Question 34

Tx of cholangiocarcinoma

Answer 34

Proximal: resect with RenY hepaticojejunostomy. Distal: Whipple procedure. Some are not resectable.