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HPB Flashcards

1
Q

What proportion of PNETs are functioning?

A

10%

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2
Q

How quickly does the liver regenerate following resection of sections 2/3

A

4-6months

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3
Q

Which patients should have surveillance for pancreatic cancer?

A
  • 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

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4
Q

What are some characteristic findings of PSC?

A

Reveresed portal venous flow and early portal hypertension

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5
Q

What tests should be sent at EUS FNA for PCN?

A

CEA + Cytology/KRAS/GNAS and Lipase levels

Cannot differentiate between MCN/IPMN

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6
Q

What is a contraindication to TACE for HCC?

A

Portal vein thrombosis.

Sorafenib is useful in cases of irresectable disease.

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7
Q

When is a Kasai procedure used?

A

Congenital biliary atresia

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8
Q

What is the incidence of CBD stones with normal duct size and LFTs and age <55

A

5%

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9
Q

In which pancreatic cystic neoplasm is Ca19-9 useful?

A

IPMN where there is suspicion of malignant transformation

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10
Q

What is the most common site of metastasis with HCC?

A

Lung (direct to IVC) > LN

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11
Q

What are the risk factors for post ERCP Pancreatitis?

A 
Normal bilirubin
Young age
Pancreatic duct injection
Precut sphincterotomy
Balloon dilatation of spinchter
SOD
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12
Q

What proportion of cases of PSC are associated with IBD?

A

70%

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13
Q

What is the incidence of cancer in a porcelain gallbladder?

A

6-10%

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14
Q

How should <1cm GB polyps be followed up?

A

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

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15
Q

What factors make IPMN at high risk of progression to malignancy?

A
  • Jaundice
  • Enhancing mural nodule ≥5mm
  • MPD ≥10mm

High risk

MPD5-9.9, Cyst ≥40mm or enlarging ≥5mm per year increased risk

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16
Q

What adjunctive treaments should be given to patients undergoing surgery for CRLM?

A

Combination chemotherapy –> higher DFS and prob OS

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17
Q

What defines a locally advanced/irresectable pancreatic tumour?

A

Arterial

1) Head - SMA/CA >180
2) Body - SMA/CA >180 or aortic involvement

Venous
Unreconstructable SMV/PV

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18
Q

What nutritional support is required for patients with pancreatic cancer?

A

Pancreatin (creon)

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19
Q

How does a Hydatid cyst classically present?

A

Triad of jaundice, pain and urticarial rash

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20
Q

What is the optimal treatment of T2-3 GB cancer?

A

Formal resection of sections IVb and V

For T1 - open cholecystectomy and regional LN sampling

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21
Q

Which type of gallstone is most frequently found in the CBD?

A

a Brown pigment stone

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22
Q

In which patients with CRLM should ablative therapies be offered?

A

Only in those not suitable for liver resection.

-Selective internal radiation therapy (SIRT) is not recommended at present outside of research programmes

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23
Q

What is the Strasberg classification for BDI?

A

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

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24
Q

What factors are most prognostic of severe pancreatitis at presentation?

A

APACHE II>8

Obesity

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25
Q

What are the principle risks of ERCP?

A

Bleeding 1%
Duodenal perforation 0.4%
Cholangitis 1.1%
Pancreatitis 3.5%

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26
Q

What is the Barcelona Clinic Liver Classification for HCC?

A

Stage 0, A,B,C,D

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27
Q

What neoadjuvant treatment is given for CLRM?

A

Consideration of excision of primary tumour if symptomatic

FOLFOX +/- Cetuximab/Bevacizumab

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28
Q

After sphincterotomy and balloon trawl, how frequent is recurrent cholecystitis (elderly)?

A

80% no further episodes

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29
Q

What threshold of main duct dilatation should be take as an indication for surgery?

A

Absolute indication at >10mm, probably >5mm in either MD-IPMN or MT-IPMN if fit or other risk factor

Malignancy rate of 30-90%

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30
Q

How does the Bismuth classification integrate with the Strasberg system?

A 
Subdivides Strasberg E
E1 - CHD >2cm
E2 - CHD<2cm
E3 - hilum at confliuence
E4 - above hilum
E5 - Hilar injury + Strasberg C
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31
Q

What is the primary means of improving pain control in patients with chronic pancreatitis?

A

Alcohol abstinence

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32
Q

What is the incidence of R1/2 resection in Cholangiocarcinoma?

A

25%

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33
Q

How should patients with IPMN be followed up?

A

6 monthly for 1 year then annually

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34
Q

What proportion of cases of pancreatitis are classified as idiopathic?

A

<20%

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35
Q

Who should receive screening for HCC?

A

Cirrhotic patients (any cause) Should have 6 monthly USS +/- AFP (unless Hep B then def AFP)

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36
Q

What is the risk of a pancreatic fistula after Whipple?

A

15% (lower for distal panc)

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37
Q

What complications can occur after RFA for CRLM?

A

Bleeding, biliary tree injury, sepsis in 9%

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38
Q

What future liver volume is required for resection in healthy patients?

A

> 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

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39
Q

What is the most common cause of benign biliary stricture?

A

Cholecystectomy, up to 75% unrecognised and 30% >5 years post surgery

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40
Q

What defines a borderline resectable pancreatic tumour?

A 
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
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41
Q

What proportion of cases of pancreatitis are related to gallstones and alcohol?

A

35% and 25% respectively

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42
Q

What are the typical features of HCC on CT (3)?

A

1) Arterial enhancement
2) Rapid washout on porto-venous/delayed phase
3) Heterogenous appearance of tumour

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43
Q

What is the minimum number of liver segments that must be preserved in liver resection?

A

2 contiguous

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44
Q

What is the most common composition of gallstones?

A

Mixed
20% Cholesterol

TPN can result in pigment stones

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45
Q

What are the classification systems for CBD Injury?

A

Strasberg (A:E)

Bismuth (1:5)

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46
Q

What are the primary bile salts?

A

Cholate and chenodoyxcholate

Secondary formed by bacterial action –> deoxycholate (absorbed) and lithocholate (excreted)

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47
Q

How quickly does the liver regenerate following resection of sections 2/3

A

4-6months

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48
Q

How can a cholangiocarcinoma be differentiated from a HoP tumour on USS?

A

in Hilar cholangio (Klatskin) there is only intrahepatic biliary dilatation (not extra hepatic)

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49
Q

What are the common causes of liver abscess?

A

Appendicitis, biliary, diverticulitis,

rarely tumours (consider colonoscopy)

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50
Q

When should patients receive neoadjuvant therapy for pancreatic cancer?

A

For borderline resectable, as part of a trial.

However the recent PREOPANC trial suggests that NACRT is beneficial regardless

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51
Q

What is the most common type of Choledochal cyst?

A

Type 1 - fusiform dilatation of CBD

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52
Q

Is HCC more common in Men or Women?

A

Men.

Less risk with PBC
Screen with USS and AFP

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53
Q

What factors are most prognostic of severe pancreatitis at 48hrs?

A

Glasgow score ≥3
CRP >150
Persistent organ failure

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54
Q

What is the effect of beta blockade on bleeding prophylaxis for varices?

A

Reduction from 25-15% over 24 months, with no difference in overall mortality.

Following bleeding reduction of 7% mortality

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55
Q

What is the normal thickness of the GB wall?

A

<3mm

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56
Q

How are Hydatid cysts best treated?

A

Usually with surgery after instillation of mebendazole.

Care must be taken to avoid rupture which can cause a Type 1 hypersensitivity/ anaphylaxis

Echinococcus granulises

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57
Q

What is the recommended treatment for Hepatocellular Adenomas?

A

If >5cm or symptomatic or male –> resection

Rupture risk >5cm –> 10% mortality

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58
Q

What is the rate of malignancy transformation of serous cystic neoplasm?

A

0% this is benign - follow up for 1 year only and discharge

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59
Q

What is the Todani classification?

A

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)

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60
Q

Which size of mucinous cystic neoplasm should undergo surgical resection?

A

≥40mm or symptomatic or risk factors (mural nodule) or jaundice

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61
Q

How is pancreatic drainage affected by pancreatictic divisum?

A

The Duct of Santorini drains via the minor papilla and the duct of Wirsung drains via the major papilla

7% prevalence

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62
Q

What is Mirrizzi Syndrome?

A

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

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63
Q

In which patients with gallbladder polyps should Lap Chole be performed?

A

≥10mm or symptomatic

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64
Q

What medications can reduce the risk of post ERCP pancreatitis?

A

Indomethacin and possibly diclofenac

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65
Q

What is the risk of tumour seeding with HCC?

A

2.7%

66
Q

How much bile is produced daily?

A

500-1500ml/day

67
Q

What are risk factors for pancreatic adenocarcinoma?

A

Smoking + ETOH ++
DM
Gallstones and cholecystectomy
Chronic pancreatitis (5% over 20 years)

68
Q

What is the survival for patients undergoing potentially curative resection for cholangiocarcinoma?

A

25-40% at 5 years.

Chemoradio resistant

69
Q

What is Budd-Chiari syndrome?

A

Occlusion of hepatic veins, presenting with pain, hepatomegaly and ascites

May be associated with OCP use or thrombophilic tendencies

Treat with TIPPS

70
Q

What vessels influence resectability of a pancreatic adenocarcinoma?

A

Arteries - CHA, SMA, CA

Veins - SMV, PV

71
Q

Which patients with pancreatic cysts should be referred for resection?

A

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

72
Q

What adjuvant treatment is recommended for pancreatic cancer?

A

Gemcitabine and capecitabine

73
Q

What is the second most common manifestation of MEN-1

A

Gastrinoma (after Parathyroid)

74
Q

What factors increase the risk of a pancreatic fistula following Whipples?

A

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

75
Q

What is the characteristic imaging finding for Focal nodular hyperplasia?

A 
Stellate scar (70%)
Usually distinguished from Liver cell adenoma on MRI - iso or hypointense on T1 and iso or hyperintense on T2
76
Q

How frequently are bile salts recycled?

A

Up to 6 times per day in TI

77
Q

What is the recommended treatment for hepatic cyst adenomas?

A

Resection (10% malignant, cannot distinguish)

Most common R>L lobe 85% Female, 95% mucinous

78
Q

What is the most common cause of Haemobilia?

A

Trauma

Triad of pain, UGI bleed and jaundice

79
Q

What volume of pancreatic secretions are released in 24 hours?

A

About 1000ml, ph of 8

80
Q

From where are enzymatic pancreatic secretions released?

A

Acinar cells

Trypsinogen, procarboxylase, amylase, elastase

81
Q

Which hormone is the most potent in increasing pancreatic secretions?

A

CCK

82
Q

How is trypsinogen activated?

A

By enterokinase in duodenum

83
Q

How is the change in urine and bowel colour with obstructive jaundice mediated?

A

Bilirubin is conjugated normally but not excreted into bowel and degraded in stercobilinogen so stools pale and urine dark

84
Q

What is the characteristic finding on imaging for FNH?

A

Central scar

85
Q

What is the most common benign liver tumour?

A

Haemangioma (about 5%)&raquo_space;FNH>HCA

86
Q

What are the typical findings of a liver haemangioma?

A

Hyperechoic lesion , sharp lesion, posterior enhancement, absence of halo sign (US)

T2 strongly hyperintense
T1 Hypointesnse

87
Q

What syndrome is associated with hepatic giant haemangioma?

A

Kasabach-Merritt syndrome

- consumptive coagulopathy and inflammatory reaction syndrome associated with giant haemangioma

88
Q

How often does FNH have multiple lesions?

A

20-30%

Most solitary and <5cm
Hyperplastic hepatocellular lesion associated with arterial malformation

Associated with ECM genes, TGF-B, Wnt/B-catenin

89
Q

How is FNH best diagnosed?

A

For lesions >3cm, MRI –> biopsy

For lesions <3cm, add CEUS if uncertain –> biopsy

90
Q

How should OCPs be managed with FNH?

A

No indication for stopping, no follow up during pregnancy

91
Q

How should patients with FNH be followed up?

A

Not at all

92
Q

What is the risk of HCAs?

A

Bleeding, rupture, malignant transformation

Especially where lesions ≥5cm

93
Q

What factors are associated with the development of HCA?

A

COCP (30-40x)
Obesity nad metabolic syndrome
Female gender

HNF1-A mutation most common

Beta-HCAs and men highest risk of malignancy

94
Q

What imaging is best for HCA?

A

MRI - up to 80% can be subtyped, especially HNF1-a and inflammatory

95
Q

In which patients should HCAs be excised?

A

Men
Beta catenin mutations
Women after 6 months of lifestyle if ≥5cm.

If <5cm then annual surveillance (MRI)

96
Q

What is the epithelial lining of the gallbladder?

A

Columnar

97
Q

From where is the arterial supply of the gallbladder derived?

A

Cystic artery via right hepatic artery

98
Q

What is the orientation of the structures within the hepatoduodenal ligament?

A

Posteriorly - portal vein
Anteromedially - proper hepatic artery
Anterolaterally - CBD

99
Q

From where is the arterial supply of the CBD derived?

A

Branches of hepatic artery (40%) and retroduodenal gastroduodenal artery (60$)

100
Q

How are the left and right hemilivers separated?

A

Cantlie’s line - from GB fossa and IVC (right and left branches of hepatic artery)

101
Q

What are the 4 sections of the liver?

A

Right anterior/posterior

Left medial/lateral

102
Q

What is the blood supply to the caudate lobe?

A

From both right and left hepatic arteries/veins

103
Q

From where do replaced right and left hepatic arteries arise?

A 
right SMA (up to 25% of cases)
left LGA
104
Q

What is the embryological origin of the left portal vein?

A

Does not follow the artery and ducts. Connected to umbilical vein and ductus venosus

105
Q

What is the normal dimensions of an adult spleen?

A

12.5cm long x 7.5cm wide

106
Q

In which ligament does the splenic vessels lie?

A

Lienorenal (also has tail of pancreas!)

107
Q

What are the classical cause of massive splenomegaly? (5)

A 
Myelofibrosis
CML
Malaria
Gaucher's syndrome
Visceral leishmaniasis (kala-azar)
108
Q

From where is the arterial supply to the pancreas derived?

A

Head - pancreaticoduodenal artery (SMV)

Rest - splenic artery (Splenic vein)

109
Q

Where do most pancreatic secretions drain in pancreas divisum?

A

The minor papilla (duct of Santorini)

[Major duct drains duct Wirsung]

110
Q

Which duct has the longest extra hepatic duct?

A

Left hepatic

111
Q

How many hepatic veins enter the IVC?

A

2 - left and middle tend to fuse prior to joining IVC

112
Q

What are risk factors for the development of pancreatic fistula after Whipples (5)?

A 
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

113
Q

What size main duct IPMN is indicated for resection?

A

> 5mm relative

>10mm absolute

114
Q

What size main duct IPMN is indicated for resection?

A

> 5mm relative

>10mm absolute

115
Q

What liver segments should be resected in T2-T3 GB cancer?

A

IVb and V

116
Q

What patient characteristics make GB polyps high risk?

A

Age > 50
History of PSC
Indian ethnicity.

If >6mm ->LC

117
Q

Which marker is elevated in autoimmune pancreatitis?

A

IgG4

Also gives Riedel’s thyroiditis, scleroing sialadenitis, pseudo-tumours and retroperitoneal/mediastinal fibrosis

118
Q

What criteria are required for resectability of CRLM?

A

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

119
Q

When is the incidence of OPSI highest post splenectomy?

A

First 2 years

120
Q

How frequently will patients with gallstone develop pancreatitis?

A

5%

121
Q

In whom with a cholangiocarcinoma might a transplant be indicated?

A
  • Not locally resectable perhilar tumour
  • ≤3cm radial diamater
  • no evidence of intra/extra hepatic metastases
122
Q

How can cholangiocarcinomas be classified?

A

Bismuth Corlette classification

123
Q

What is the most common mutation seen with Pancreatic adenocarcinoma?

A

KRAS (50%)

124
Q

What are the contrast appearances of a liver haemangioma?

A

Early peripheral enhancement followed by very delayed central enhancemen

125
Q

What are the characteristics of mucinous cystic neoplasm of the pancreas?

A

Much more common in women
Mostly in Tail of pancreas
Septated with fibrous wall

High risk of malignant transformation –> resection
Ddx pseudocyst

126
Q

In which pancreatic lesion is a central stellate scar seen?

A

Serous cystadenoma

Benign
VHL association

127
Q

In which pancreatic tumour are calcification, solid and cystic components seen?

A

Solid pseudo papillary neoplasm

128
Q

In which pancreatic tumour are calcification, solid and cystic components seen?

A

Solid pseudo papillary neoplasm

129
Q

Anatomically what is the distal pancreas?

A

To the left of the SMV

130
Q

What is the AAST classification of pancreatic injuries?

A

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

131
Q

How do somatostatinomas present?

A 
DM
Cholelithiasis
Steatorrhoea and diarrhoea
Weight loss/malabsorption
Hypochlorhydria/achlorhydria
132
Q

In which conditions are Rokitansky-Achoff sinuses seen?

A

Adenomyomatosis or chronic cholecystitis

133
Q

what drugs have been shown to reduce the rate of post ERCP pancreatitis?

A

PR diclofenac, indomethacin

134
Q

What is the drainage of the splenic vein?

A

IMV joins Splenic vein then merges with SMV –> Portal vein

135
Q

What is the Water Lily sign?

A

Detachment of endocyst membrane floating within cyst content in hydatid cyst - CE3a transitional cyst

136
Q

What is the difference between the left lateral sector and left lateral segment?

A

LL Segment = 2+3
LL sector = 2
LM Segment = 4
LM sector = 3+4

137
Q

How is post hepatectomy bleeding graded?

A

ISGLS grading
A: PHH ≤2 units
B: PHH >2 units no invasivve
C: Requiring angioembolisation or laparotomy

138
Q

In which patients with Cirrhosis should surveillance be less favoured?

A

PSC
Auto-immune hepatitis
Women with PBC/Alcohol

139
Q

What is the next investigation for cirrhotic patients undergoing liver surveillance where a lesion is identified?

A

CT –> MRI

140
Q

Which single factor gives the highest risk of pancreatitis when undergoing an ERCP?

A

SOD

141
Q

How should a T1b gallbladder tumour be treated?

A

at least 6 lymph nodes, possibly sections 4b and 5

142
Q

Which anti rejection drug is associated with nephrotoxicity

A

Calcineurin inhibitors

143
Q

In which condition is a fish mouth papilla seen on imaging?

A

Main duct IPMN

144
Q

What is the surgical aim of resection for cholangiocarcinoma?

A

Tumour free margin of >5mm

145
Q

For Bismuth-Corlette 1/2 tumours what is the surgical treatment of choice?

A
  • Below/at (Klatskin) hepatic duct confluence
  • Resection of EHBD + GB + lymphadenetctomy + RnY

Consider segment 1 resection with II + disease

146
Q

For Bismuth-Corlette 3 tumours what is the surgical treatment of choice?

A

Involving CHD, confluence and one main duct

- Resection of EHBD + GB + lymphadenetctomy + RnY + R (3a)/L (3b) hepatectomy

147
Q

For Bismuth-Corlette 4 tumours what is the surgical treatment of choice?

A

Usually not resectable

148
Q

What adjuvant treatment is given to resected Cholangiocarcinomas?

A

R0 - Bilcap trial - Capecitabine - improves OS

R1 - chemorads

149
Q

How are tumours of the CBD treated?

A

Pancreaticoduodenectomy

150
Q

If no varices are seen in patients with CLD at endoscopy when should OGD be repeated?

A

3 years

151
Q

How is compensated advanced chronic liver disease screened?

A

Transient elastography repeated on 2 separate days (Fasted)
<10 no
10-15 maybe
>15 likely

152
Q

How can compensated advanced chronic liver disease be definitively diagnosed?

A
  • Liver biopsy showing cirrhosis or severe fibrosis
  • Collage proportionate area
  • OGD varices
  • Hepatic venous pressure gradient >5mmHg
153
Q

What is clinically significant portal hypertension?

A

Hepatic Venous Pressure Gradient ≥10mmHg

In patients with virus associated CLD can use transient elastography (≥20-25 on 2+ occasions)

154
Q

Which patients with CLD can avoid screening endoscopy for varices?

A

TE <20kPa and Platelets >150

155
Q

What MELD score suggests risk of cirrhosis complications?

A

≥12

156
Q

In patients with cirrhosis and no varices on OGD, when should an OGD be repeated?

A

3 years

157
Q

Which patients with Hepatitis B Cirrhosis should have screening USS/AFP for HCC?

A
  • Significant Cirrhosis/Fibrosis (METAVIR ≥F2 or Ishak ≥3)

- Age >40 + FH + HBV DNA ≥20,000iU/ml

158
Q

What is Puestow’s procedure?

A

Lateral (side-side) pancreaticojejunostomy

Advantages - no removal of tissue
Disadvantages - needs 6mm duct, does not drain head

159
Q

What is Frey’s procedure?

A

Coring out of pancreatic head and lateral (side-side) pancreaticojejunostomy

Advantages - drains head
Disadvantages - removes tissue

160
Q

What is Beger’s procedure?

A

Resection of pancreatic head (almost all), then reconstruction with a single loop of jejunum

161
Q

What autoantibody May be raised in PBC

A

Antimitochondrial antibody

162
Q

what is the optimum management of a Type 3 Todani Choledochal cyst?

A

Spincteroplasty +/- excision (low risk malignant transformation)

FRCS (13 decks)

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