HPB Flashcards
What proportion of PNETs are functioning?
10%
How quickly does the liver regenerate following resection of sections 2/3
4-6months
Which patients should have surveillance for pancreatic cancer?
- Hereditary pancreatitis and a PRSS1 mutation
- BRCA1/2, PALB2/CDKN2a mutations with 1+ FDR
- Peutz Jaegers syndrome
- Consider with 2 FDR or Lynch syndrome
Screen with MRI/MRCP/EUS
In hereditary pancreatitis offer pancreatic CT
What are some characteristic findings of PSC?
Reveresed portal venous flow and early portal hypertension
What tests should be sent at EUS FNA for PCN?
CEA + Cytology/KRAS/GNAS and Lipase levels
Cannot differentiate between MCN/IPMN
What is a contraindication to TACE for HCC?
Portal vein thrombosis.
Sorafenib is useful in cases of irresectable disease.
When is a Kasai procedure used?
Congenital biliary atresia
What is the incidence of CBD stones with normal duct size and LFTs and age <55
5%
In which pancreatic cystic neoplasm is Ca19-9 useful?
IPMN where there is suspicion of malignant transformation
What is the most common site of metastasis with HCC?
Lung (direct to IVC) > LN
What are the risk factors for post ERCP Pancreatitis?
Normal bilirubin Young age Pancreatic duct injection Precut sphincterotomy Balloon dilatation of spinchter SOD
What proportion of cases of PSC are associated with IBD?
70%
What is the incidence of cancer in a porcelain gallbladder?
6-10%
How should <1cm GB polyps be followed up?
If ‘high risk’ (Age >50, PSC, Indian, Sessile)
<6mm - US at 6months then annually
6-9mm - Cholecystectomy
Otherwise
<6mm US at 1,3,5 years
6-9mm - US 6 months then annually
If increases by 2mm or more –> cholecystectomy
EAES guidelines
What factors make IPMN at high risk of progression to malignancy?
- Jaundice
- Enhancing mural nodule ≥5mm
- MPD ≥10mm
High risk
MPD5-9.9, Cyst ≥40mm or enlarging ≥5mm per year increased risk
What adjunctive treaments should be given to patients undergoing surgery for CRLM?
Combination chemotherapy –> higher DFS and prob OS
What defines a locally advanced/irresectable pancreatic tumour?
Arterial
1) Head - SMA/CA >180
2) Body - SMA/CA >180 or aortic involvement
Venous
Unreconstructable SMV/PV
What nutritional support is required for patients with pancreatic cancer?
Pancreatin (creon)
How does a Hydatid cyst classically present?
Triad of jaundice, pain and urticarial rash
What is the optimal treatment of T2-3 GB cancer?
Formal resection of sections IVb and V
For T1 - open cholecystectomy and regional LN sampling
Which type of gallstone is most frequently found in the CBD?
a Brown pigment stone
In which patients with CRLM should ablative therapies be offered?
Only in those not suitable for liver resection.
-Selective internal radiation therapy (SIRT) is not recommended at present outside of research programmes
What is the Strasberg classification for BDI?
A - cystic duct/liver bed leak
B - partial ligation of biliary tree (mostly aberrant right hepatic)
C - partial transection of biliary tree not communicating with CBD
D - lateral injury of biliary system without loss of continuity
E - Ligation/division of biliary tree
What factors are most prognostic of severe pancreatitis at presentation?
APACHE II>8
Obesity
What are the principle risks of ERCP?
Bleeding 1%
Duodenal perforation 0.4%
Cholangitis 1.1%
Pancreatitis 3.5%
What is the Barcelona Clinic Liver Classification for HCC?
Stage 0, A,B,C,D
What neoadjuvant treatment is given for CLRM?
Consideration of excision of primary tumour if symptomatic
FOLFOX +/- Cetuximab/Bevacizumab
After sphincterotomy and balloon trawl, how frequent is recurrent cholecystitis (elderly)?
80% no further episodes
What threshold of main duct dilatation should be take as an indication for surgery?
Absolute indication at >10mm, probably >5mm in either MD-IPMN or MT-IPMN if fit or other risk factor
Malignancy rate of 30-90%
How does the Bismuth classification integrate with the Strasberg system?
Subdivides Strasberg E E1 - CHD >2cm E2 - CHD<2cm E3 - hilum at confliuence E4 - above hilum E5 - Hilar injury + Strasberg C
What is the primary means of improving pain control in patients with chronic pancreatitis?
Alcohol abstinence
What is the incidence of R1/2 resection in Cholangiocarcinoma?
25%
How should patients with IPMN be followed up?
6 monthly for 1 year then annually
What proportion of cases of pancreatitis are classified as idiopathic?
<20%
Who should receive screening for HCC?
Cirrhotic patients (any cause) Should have 6 monthly USS +/- AFP (unless Hep B then def AFP)
What is the risk of a pancreatic fistula after Whipple?
15% (lower for distal panc)
What complications can occur after RFA for CRLM?
Bleeding, biliary tree injury, sepsis in 9%
What future liver volume is required for resection in healthy patients?
> 20%.
For patients with significant liver disease this is 40%
If less than this, can conduct portal vein embolisation to induce enlargement of normal liver
What is the most common cause of benign biliary stricture?
Cholecystectomy, up to 75% unrecognised and 30% >5 years post surgery
What defines a borderline resectable pancreatic tumour?
Arterial 1)Head - Contact with CHA - Contact with SMA≤180d 2)Body Contact with CA≤180 or ≥180 without aorta or GDA
Venous
- Contact with SMV/PV >180d SMV/PV but reconstructable
- Contact with IVC
What proportion of cases of pancreatitis are related to gallstones and alcohol?
35% and 25% respectively
What are the typical features of HCC on CT (3)?
1) Arterial enhancement
2) Rapid washout on porto-venous/delayed phase
3) Heterogenous appearance of tumour
What is the minimum number of liver segments that must be preserved in liver resection?
2 contiguous
What is the most common composition of gallstones?
Mixed
20% Cholesterol
TPN can result in pigment stones
What are the classification systems for CBD Injury?
Strasberg (A:E)
Bismuth (1:5)
What are the primary bile salts?
Cholate and chenodoyxcholate
Secondary formed by bacterial action –> deoxycholate (absorbed) and lithocholate (excreted)
How quickly does the liver regenerate following resection of sections 2/3
4-6months
How can a cholangiocarcinoma be differentiated from a HoP tumour on USS?
in Hilar cholangio (Klatskin) there is only intrahepatic biliary dilatation (not extra hepatic)
What are the common causes of liver abscess?
Appendicitis, biliary, diverticulitis,
rarely tumours (consider colonoscopy)
When should patients receive neoadjuvant therapy for pancreatic cancer?
For borderline resectable, as part of a trial.
However the recent PREOPANC trial suggests that NACRT is beneficial regardless
What is the most common type of Choledochal cyst?
Type 1 - fusiform dilatation of CBD
Is HCC more common in Men or Women?
Men.
Less risk with PBC
Screen with USS and AFP
What factors are most prognostic of severe pancreatitis at 48hrs?
Glasgow score ≥3
CRP >150
Persistent organ failure
What is the effect of beta blockade on bleeding prophylaxis for varices?
Reduction from 25-15% over 24 months, with no difference in overall mortality.
Following bleeding reduction of 7% mortality
What is the normal thickness of the GB wall?
<3mm
How are Hydatid cysts best treated?
Usually with surgery after instillation of mebendazole.
Care must be taken to avoid rupture which can cause a Type 1 hypersensitivity/ anaphylaxis
Echinococcus granulises
What is the recommended treatment for Hepatocellular Adenomas?
If >5cm or symptomatic or male –> resection
Rupture risk >5cm –> 10% mortality
What is the rate of malignancy transformation of serous cystic neoplasm?
0% this is benign - follow up for 1 year only and discharge
What is the Todani classification?
Choledochal cysts
Type 1 - fusiform CBD (most common)
Type 2 - CBD diverticulum
Type 3 - Choledochocele (at ampulla)
Type 4 - type 1 extending to IHDs (second most common)
Type 5 - intrahepatic cystic disease (Carolis disease)
Which size of mucinous cystic neoplasm should undergo surgical resection?
≥40mm or symptomatic or risk factors (mural nodule) or jaundice
How is pancreatic drainage affected by pancreatictic divisum?
The Duct of Santorini drains via the minor papilla and the duct of Wirsung drains via the major papilla
7% prevalence
What is Mirrizzi Syndrome?
Compression of common hepatic duct by gallstone/gallbladder
Csendes classfication
1) Extrinsic compression
2) Involvement of <1/3 CBD circumference
3) Involvement of 1/3-2/3 CBD circumference
4) Complete destruction of CBD wall
5) Any + fistula
In which patients with gallbladder polyps should Lap Chole be performed?
≥10mm or symptomatic
What medications can reduce the risk of post ERCP pancreatitis?
Indomethacin and possibly diclofenac
What is the risk of tumour seeding with HCC?
2.7%
How much bile is produced daily?
500-1500ml/day
What are risk factors for pancreatic adenocarcinoma?
Smoking + ETOH ++
DM
Gallstones and cholecystectomy
Chronic pancreatitis (5% over 20 years)
What is the survival for patients undergoing potentially curative resection for cholangiocarcinoma?
25-40% at 5 years.
Chemoradio resistant
What is Budd-Chiari syndrome?
Occlusion of hepatic veins, presenting with pain, hepatomegaly and ascites
May be associated with OCP use or thrombophilic tendencies
Treat with TIPPS
What vessels influence resectability of a pancreatic adenocarcinoma?
Arteries - CHA, SMA, CA
Veins - SMV, PV
Which patients with pancreatic cysts should be referred for resection?
1) Obstructive jaundice with cystic lesions in head
2) Enhancing solid component in cyst
3) Main pancreatic duct ≥10mm
Consider FNAC if more information needed + CEA assay
What adjuvant treatment is recommended for pancreatic cancer?
Gemcitabine and capecitabine
What is the second most common manifestation of MEN-1
Gastrinoma (after Parathyroid)
What factors increase the risk of a pancreatic fistula following Whipples?
Soft remnant (22%)
Age >70
Jaundice for long period (not severity)
CAD or EBL>1000ml
Preoperative CRT decreases the risk!
There may be a lower rate with pancreaticogastrostomy, but this is controversial. Stents and octreotide conflicting data
What is the characteristic imaging finding for Focal nodular hyperplasia?
Stellate scar (70%) Usually distinguished from Liver cell adenoma on MRI - iso or hypointense on T1 and iso or hyperintense on T2
How frequently are bile salts recycled?
Up to 6 times per day in TI
What is the recommended treatment for hepatic cyst adenomas?
Resection (10% malignant, cannot distinguish)
Most common R>L lobe 85% Female, 95% mucinous
What is the most common cause of Haemobilia?
Trauma
Triad of pain, UGI bleed and jaundice
What volume of pancreatic secretions are released in 24 hours?
About 1000ml, ph of 8
From where are enzymatic pancreatic secretions released?
Acinar cells
Trypsinogen, procarboxylase, amylase, elastase
Which hormone is the most potent in increasing pancreatic secretions?
CCK
How is trypsinogen activated?
By enterokinase in duodenum
How is the change in urine and bowel colour with obstructive jaundice mediated?
Bilirubin is conjugated normally but not excreted into bowel and degraded in stercobilinogen so stools pale and urine dark
What is the characteristic finding on imaging for FNH?
Central scar
What is the most common benign liver tumour?
Haemangioma (about 5%)»_space;FNH>HCA
What are the typical findings of a liver haemangioma?
Hyperechoic lesion , sharp lesion, posterior enhancement, absence of halo sign (US)
T2 strongly hyperintense
T1 Hypointesnse
What syndrome is associated with hepatic giant haemangioma?
Kasabach-Merritt syndrome
- consumptive coagulopathy and inflammatory reaction syndrome associated with giant haemangioma
How often does FNH have multiple lesions?
20-30%
Most solitary and <5cm
Hyperplastic hepatocellular lesion associated with arterial malformation
Associated with ECM genes, TGF-B, Wnt/B-catenin
How is FNH best diagnosed?
For lesions >3cm, MRI –> biopsy
For lesions <3cm, add CEUS if uncertain –> biopsy
How should OCPs be managed with FNH?
No indication for stopping, no follow up during pregnancy
How should patients with FNH be followed up?
Not at all
What is the risk of HCAs?
Bleeding, rupture, malignant transformation
Especially where lesions ≥5cm
What factors are associated with the development of HCA?
COCP (30-40x)
Obesity nad metabolic syndrome
Female gender
HNF1-A mutation most common
Beta-HCAs and men highest risk of malignancy
What imaging is best for HCA?
MRI - up to 80% can be subtyped, especially HNF1-a and inflammatory
In which patients should HCAs be excised?
Men
Beta catenin mutations
Women after 6 months of lifestyle if ≥5cm.
If <5cm then annual surveillance (MRI)
What is the epithelial lining of the gallbladder?
Columnar
From where is the arterial supply of the gallbladder derived?
Cystic artery via right hepatic artery
What is the orientation of the structures within the hepatoduodenal ligament?
Posteriorly - portal vein
Anteromedially - proper hepatic artery
Anterolaterally - CBD
From where is the arterial supply of the CBD derived?
Branches of hepatic artery (40%) and retroduodenal gastroduodenal artery (60$)
How are the left and right hemilivers separated?
Cantlie’s line - from GB fossa and IVC (right and left branches of hepatic artery)
What are the 4 sections of the liver?
Right anterior/posterior
Left medial/lateral
What is the blood supply to the caudate lobe?
From both right and left hepatic arteries/veins
From where do replaced right and left hepatic arteries arise?
right SMA (up to 25% of cases) left LGA
What is the embryological origin of the left portal vein?
Does not follow the artery and ducts. Connected to umbilical vein and ductus venosus
What is the normal dimensions of an adult spleen?
12.5cm long x 7.5cm wide
In which ligament does the splenic vessels lie?
Lienorenal (also has tail of pancreas!)
What are the classical cause of massive splenomegaly? (5)
Myelofibrosis CML Malaria Gaucher's syndrome Visceral leishmaniasis (kala-azar)
From where is the arterial supply to the pancreas derived?
Head - pancreaticoduodenal artery (SMV)
Rest - splenic artery (Splenic vein)
Where do most pancreatic secretions drain in pancreas divisum?
The minor papilla (duct of Santorini)
[Major duct drains duct Wirsung]
Which duct has the longest extra hepatic duct?
Left hepatic
How many hepatic veins enter the IVC?
2 - left and middle tend to fuse prior to joining IVC
What are risk factors for the development of pancreatic fistula after Whipples (5)?
Soft pancreas Age >70 Long period of jaundice (not severity) IHD Blood loss >1000ml
May be higher with pancreatic-jej. May be reduced by octreotide
What size main duct IPMN is indicated for resection?
> 5mm relative
>10mm absolute
What size main duct IPMN is indicated for resection?
> 5mm relative
>10mm absolute
What liver segments should be resected in T2-T3 GB cancer?
IVb and V
What patient characteristics make GB polyps high risk?
Age > 50
History of PSC
Indian ethnicity.
If >6mm ->LC
Which marker is elevated in autoimmune pancreatitis?
IgG4
Also gives Riedel’s thyroiditis, scleroing sialadenitis, pseudo-tumours and retroperitoneal/mediastinal fibrosis
What criteria are required for resectability of CRLM?
1) Complete resection possible
2) At least 2 adjacent liver segments can be spared
3) Remaining liver is at least 20% of original volume of liver
When is the incidence of OPSI highest post splenectomy?
First 2 years
How frequently will patients with gallstone develop pancreatitis?
5%
In whom with a cholangiocarcinoma might a transplant be indicated?
- Not locally resectable perhilar tumour
- ≤3cm radial diamater
- no evidence of intra/extra hepatic metastases
How can cholangiocarcinomas be classified?
Bismuth Corlette classification
What is the most common mutation seen with Pancreatic adenocarcinoma?
KRAS (50%)
What are the contrast appearances of a liver haemangioma?
Early peripheral enhancement followed by very delayed central enhancemen
What are the characteristics of mucinous cystic neoplasm of the pancreas?
Much more common in women
Mostly in Tail of pancreas
Septated with fibrous wall
High risk of malignant transformation –> resection
Ddx pseudocyst
In which pancreatic lesion is a central stellate scar seen?
Serous cystadenoma
Benign
VHL association
In which pancreatic tumour are calcification, solid and cystic components seen?
Solid pseudo papillary neoplasm
In which pancreatic tumour are calcification, solid and cystic components seen?
Solid pseudo papillary neoplasm
Anatomically what is the distal pancreas?
To the left of the SMV
What is the AAST classification of pancreatic injuries?
1 : minor contusion/lac
2: major, no ductal disruption
3: Major, distal ductal disruption/transection
4: Major, proximal ductal disruption/transection or involvement of ampulla
5: Massive disruption of pancreatic head
How do somatostatinomas present?
DM Cholelithiasis Steatorrhoea and diarrhoea Weight loss/malabsorption Hypochlorhydria/achlorhydria
In which conditions are Rokitansky-Achoff sinuses seen?
Adenomyomatosis or chronic cholecystitis
what drugs have been shown to reduce the rate of post ERCP pancreatitis?
PR diclofenac, indomethacin
What is the drainage of the splenic vein?
IMV joins Splenic vein then merges with SMV –> Portal vein
What is the Water Lily sign?
Detachment of endocyst membrane floating within cyst content in hydatid cyst - CE3a transitional cyst
What is the difference between the left lateral sector and left lateral segment?
LL Segment = 2+3
LL sector = 2
LM Segment = 4
LM sector = 3+4
How is post hepatectomy bleeding graded?
ISGLS grading
A: PHH ≤2 units
B: PHH >2 units no invasivve
C: Requiring angioembolisation or laparotomy
In which patients with Cirrhosis should surveillance be less favoured?
PSC
Auto-immune hepatitis
Women with PBC/Alcohol
What is the next investigation for cirrhotic patients undergoing liver surveillance where a lesion is identified?
CT –> MRI
Which single factor gives the highest risk of pancreatitis when undergoing an ERCP?
SOD
How should a T1b gallbladder tumour be treated?
at least 6 lymph nodes, possibly sections 4b and 5
Which anti rejection drug is associated with nephrotoxicity
Calcineurin inhibitors
In which condition is a fish mouth papilla seen on imaging?
Main duct IPMN
What is the surgical aim of resection for cholangiocarcinoma?
Tumour free margin of >5mm
For Bismuth-Corlette 1/2 tumours what is the surgical treatment of choice?
- Below/at (Klatskin) hepatic duct confluence
- Resection of EHBD + GB + lymphadenetctomy + RnY
Consider segment 1 resection with II + disease
For Bismuth-Corlette 3 tumours what is the surgical treatment of choice?
Involving CHD, confluence and one main duct
- Resection of EHBD + GB + lymphadenetctomy + RnY + R (3a)/L (3b) hepatectomy
For Bismuth-Corlette 4 tumours what is the surgical treatment of choice?
Usually not resectable
What adjuvant treatment is given to resected Cholangiocarcinomas?
R0 - Bilcap trial - Capecitabine - improves OS
R1 - chemorads
How are tumours of the CBD treated?
Pancreaticoduodenectomy
If no varices are seen in patients with CLD at endoscopy when should OGD be repeated?
3 years
How is compensated advanced chronic liver disease screened?
Transient elastography repeated on 2 separate days (Fasted)
<10 no
10-15 maybe
>15 likely
How can compensated advanced chronic liver disease be definitively diagnosed?
- Liver biopsy showing cirrhosis or severe fibrosis
- Collage proportionate area
- OGD varices
- Hepatic venous pressure gradient >5mmHg
What is clinically significant portal hypertension?
Hepatic Venous Pressure Gradient ≥10mmHg
In patients with virus associated CLD can use transient elastography (≥20-25 on 2+ occasions)
Which patients with CLD can avoid screening endoscopy for varices?
TE <20kPa and Platelets >150
What MELD score suggests risk of cirrhosis complications?
≥12
In patients with cirrhosis and no varices on OGD, when should an OGD be repeated?
3 years
Which patients with Hepatitis B Cirrhosis should have screening USS/AFP for HCC?
- Significant Cirrhosis/Fibrosis (METAVIR ≥F2 or Ishak ≥3)
- Age >40 + FH + HBV DNA ≥20,000iU/ml
What is Puestow’s procedure?
Lateral (side-side) pancreaticojejunostomy
Advantages - no removal of tissue
Disadvantages - needs 6mm duct, does not drain head
What is Frey’s procedure?
Coring out of pancreatic head and lateral (side-side) pancreaticojejunostomy
Advantages - drains head
Disadvantages - removes tissue
What is Beger’s procedure?
Resection of pancreatic head (almost all), then reconstruction with a single loop of jejunum
What autoantibody May be raised in PBC
Antimitochondrial antibody
what is the optimum management of a Type 3 Todani Choledochal cyst?
Spincteroplasty +/- excision (low risk malignant transformation)
