Hepatobilliary

Question 1

Exploring CBD; cannot extract stone with a balloon sweep or basket; Give three additional options:

Answer 1

1. Choledochoduodenostomy
2. roux-en-y choledochojejunostomy
3. Duodenostomy and sphincterotomy

Question 2

1. Where on the ampulla do you make a sphincterotomy?

2. When should you do this?

Answer 2

1. 3:00 and 9:00
2. Probably never; unless Ebola virus wipes out all GI doctors worldwide. Also consider temporizing with a T tube or doing a choledochojejunostomy

Question 3

How long should a cystic duct stump leak take to heal after ERCP/IR drain?

Answer 3

1 week

Question 4

When can you consider a primary repair of a bile duct injury?
What should you typically add?

Answer 4

transaction <50% with no thermal injury

Add a t-tube at a different position.

Question 5

What is the only type of Choledochal cyst that gets asked on the board?

Answer 5

Type I - extrahepatic only.

Question 6

What is indication and operation for a Type I choledochal cyst?

Answer 6

All should be resected due to later malignancy risk.

Excise cyst and do a hepaticojejunostomy

Question 7

Type I choledochal cyst - what do you do if you cant get around the cyst due to inflammation?

Answer 7

Resect what you can; open the cyst and dissect out the remaining mucosa/inner layer. Complete the choledochojejunostomy.

Question 8

Palliative operation for a Klatskin tumor at the junction of the hepatic ducts?

Answer 8

Take down the hilar plate at the umbilical fissue.
Identify the extraanatomic portion of the left hepatic duct.
Perform a hepatico jejunostomy to this duct.

Question 9

When do you do a liver resection for hemangioma?

Answer 9

Bleeding, pain or thrombocytopenia.

Question 10

When do you do a liver resection for hemangioma?

Answer 10

Bleeding, pain or thrombocytopenia. (rare)

Question 11

When do you resect focal nodular hyperplasia?

Answer 11

If any enlargement on scan calls diagnosis into question.

Question 12

When do you resect hepatic adenoma?

Answer 12

if fails to regress with cessation of OCP.

Question 13

If god forbid you do ever operate on acute pancreatic necrosis what vascular procedure and intestinal procedure should you add?

Answer 13

Ligate the splenic artery to prevent a late pseudoaneurysm bleed.
Distal feeding tube.

Question 14

What is the incidence of OPSS in adults?

Answer 14

0.3%

Question 15

Classic presentation, what disease?
postadolescent female with the onset of easy bruising, bleeding from gums with trivial trauma, or menorrhagia. In children, follows an acute “viral” infection, often in the springtime, and is self-limited in over 85% of pediatric patients. Antecedent infections rarely noted in the adult setting

Answer 15

Immune thrombocytopenic purpura

Question 16

Diagnosis of ITP?

Answer 16

normal to elevated numbers of megakaryocytes seen on bone marrow aspirate.

Question 17

What is inital medical stabilization of ITP?

Answer 17

steroids alone (prednisone 1 mg/kg) if the patient is not having serious hemorrhage, steroids plus anti-IgG globulin if there is significant hemorrhage

Question 18

What is remission rate for ITP after splenectomy?

Answer 18

75-90% of ITP will remit withsplenectomy

Question 19

How do you work-up persistent thrombocytopenia after splenectomy for ITP?

Answer 19

> 2% of cells have Howell-Jolly bodies on peripheral blood smear
(nuclear debris in red cells that is usually cleared in the spleen), patient is asplenic and no sense looking for accessory spleens