HPB Flashcards
mother pancreatic lesion
mucinous cystic neoplasm (middle aged F)
elevated marker in mucinous cystic neoplasm
CEA (ovarian stroma)
most common location mucinous cystic neoplasm
tail
grandmother pancreatic lesion
serous cystadenoma
NCCN resectability of panc adenoca
- no arterial contact
- SMV/PV <180 without vein deformity
NCCN borderline resectability of panc adenoca
- SMA <180
- HA <180 or variant anatomy
- tail tumor <180 contact with celiac axis + intact GDA
NCCN unresectable panc adenoca
- SMA >180
- celiac axis >180
- unreconstructable SMV/PV
- distant mets
most common pancreatic adenoca mets
liver
peritoneum
5 yr risk cancer in main duct IPMN
50-70%
1 primary hepatic malignancy
HCC
2 most common benign hepatic tumor
FNH
1 most common benign hepatic tumor
cavernous hemangioma
subtypes of hepatocellular adenomas
- hepatocyte nuclear factor 1a inactivated (30-40%)
- inflammatory (40-50%)
- beta-catenin activated (10-15%)
- unclassified (10-25%)
subtype hepatic adenoma with highest malignant transformation
beta catenin activated
difference between FNH & adenoma on hepatobiliary phase
FNH iso or hyper
adenoma hypo
genetic association with hepatic angiomyolipoma
tuberous sclerosis
most common functioning pNET
insulinoma (whipples triad)
Todani classification of bile duct cysts
I: fusiform dilation of EHD
II: true diverticulum of supraduodenal EHD
III: choledochocele (focally dilated intraduodenal segment of EHD within duodenal wall)
IV: intra and extrahepatic cystic dilations
V: Caroli dz, intrahepatic cystic dilation 2/2 AR in-utero malformation of ductal plate, central dot sign
Mirizzi syndrome
CHD and IHD dilation 2/2 extrinsic compression from stone in GB neck or cystic duct
predisposed by:
- long cystic duct running parallel to CHD
- low insertion of cystic duct into CBD
Bouveret syndrome
gastric outlet obstruction 2/2 to impaction of a gallstone in the pylorus or proximal duodenum
biliary-enteric fistulas causes & results in
causes:
- chronic cholecystitis
- duodenal ulcer
- tumor
- trauma
results in: Bouveret syndrome, gallstone ileus
Rigler triad
- pneumobilia
- SBO
- ectopic calcified gallstone (usu in the right iliac fossa)
seen in gallstone ileus
adenomyomatosis pathology
- idiopathic, nonneoplastic, noninflammatory GB wall thickening
- epithelial hyperplasia with mucosal invagination into smooth muscle layer
- bile or cholesterol crystals deposit in Rokitansky-Aschoff sinuses
- thickening = focal, segmental, diffuse
adenomyomatosis imaging
thickening = focal, segmental, diffuse
- segmental form: annular thickening -> strictures (“hourglass” appearance in GB mid body)
US: echogenic foci with comet tail (reverberation of US pulse within cholesterol crystals)
MRI: cystic spaces (=R-A sinuses) with curvilinear arrangement; string of beads
GB polyps - types
- cholesterol (>50%)
- adenoma (30%): premalignant
- inflammatory (10%)
- malignant (5%): adenoca (90%), other (mets, SCC, angiosarcoma)
GB polyps - management
≤6 mm: no f/u
7-9 mm: yearly f/u w US to ensure no growth
≥10 mm: surgical consultation for cholecystectomy (greater chance of premalignant adenoma)
- if no cholecystectomy, annual f/u
ACR 2013
primary sclerosing cholangitis - imaging
multifocal regions of segmental intra- & extrahepatic biliary ductal dilation and stricturing
- active inflammation: abN thickening, hyperenhancement of bile duct walls
- clue on MRCP: greater than expected number of peripheral ducts
- string of beads, withered tree
primary sclerosing cholangitis - complications
cholangiocarcinoma (NOT HCC)
biliary cirrhosis: “central regenerative hypertrophy”
colorectal carcinoma (if assoc w IBD)
recurrent pyogenic cholangitis
formation of pigment stones throughout biliary tree
- resultant biliary strictures, repeated bouts of cholangitis
- 2/2 Clonorchiasis (liver fluke), Ascaris infxn
dilated IHD/EHD full of T1 bright pigmented stones
localized IHD dilation MC affects left hepatic lobe
Von Meyenberg complexes
benign biliary hamartomas
failure of involution of embryonic bile ducts
1-5mm cystic masses, no communic w biliary tree
US: echogenic +/- comet tail artifact
likely dx if innumerable small, slightly complex “cysts” in healthy pt
HIV cholangiopathy
biliary inflam’n caused by AIDS-related opportunistic infxns
- CMV, cryptosporidium
presumptive diagnosis in advanced AIDS (CD4 <100)
HIV cholangiopathy - imaging
multiple intrahepatic strictures (identical to PSC)
papillary stenosis
GB wall thickening
biliary ischemia
complication of hepatic artery stenosis/thrombosis
- sole vascular supply to biliary system
- assoc w biliary necrosis & abscess formation
high mortality rates if retransplantation or thrombectomy/thrombolysis not immediately performed
critical to recognize
peribiliary cyst
thin walled cysts of serous glands adj to IHD
- no communication with biliary tree
benign; do not mistaken for dilated bile ducts
assoc w chronic liver dz, cirrhosis, ADPCKD
hepatic mucinous cystic neoplasm
formerly biliary cystadenoma/carcinoma
- now non-invasive or invasive hepatic MCN
well-defined uni or multiloculated cystic mass in liver with septations, papillary projections, mural calcifications
no communication with biliary tree
cholangiocarcinoma - risk factors
primary sclerosing cholangitis
recurrent pyogenic cholangitis
Clonorchiasis (liver fluke)
choledochal cyst
cholangiocarcinoma - locations
hilar (Klatskin) - confluence of hepatic ducts
intrahepatic/peripheral (least common)
- capsular retraction
distal (extrahepatic; distal CBD)
- “sclerosing”: stricture, ill-defined, desmoplastic
- “papillary”: intraductal, polypoid mass
emphysematous cholecystitis - demographics
50-70 yo diabetics
emphysematous cholecystitis - bugs
Clostridium welchii / perfringens
E. coli
Bacteroides fragilis
Milan criteria liver transplant HCC
One HCC <5 cm or 3 HCC all <3 cm without tumor in vein or evidence of mets elsewhere
criteria to use LiRADS
- prior bx proven HCC
- cirrhosis
- chronic hep B
which cystic pancreatic lesions need surgical mgmt
- mucinous cystic neoplasm
- main duct IPMN
hemochromatosis patterns
Primary: liver, Pancreas, Myocardium, thyroid
Secondary: liver, Spleen, bone marrow
cholangiocarcinoma risk in choledochal cyst/caroli disease
< 10%
types of castleman’s disease
- unicentric (hyaline vascular –> plasmacytic)
- HHV8 associated (hypervascular –> plasmacytic)
- HHV8 -ve/idiopathic (“ “)
medication given during ERCP to see pancreatic ducts
secretin
syndromes associated w/ PNET
MEN1
VHL
TS
NFI
enhancement pattern peliosis hepatis
central to peripheral
infectious causes of peliosis
bartonella
most common cause graft failure post liver transplant
rejection
most common vascular complication liver transplant
hepatic artery stenosis or thrombosis
