Liver 3 Flashcards
This liver lesion enhances on arterial phase and washes out on portal-venous phase;
HCC
Both hepatic adenomas and HCC enhance on arterial phase, how do we distinguish the two?
adenomas do not demonstrate delayed washout on portal-venous phase
HCC has delayed washout on portal-venous phase
Appropriate steps to therapy for acute suppurative cholangitis include what?
resuscitate
biliary decompression
systemic antibiotics
This mass appears as a heterogenous, poorly circumscribed mass with bright arterial enhancement and quick washout;
HCC
Peripheral to central enhancement on a CT, we think of what liver lesion?
hemangioma
Enhancement of a central scar is typical of what liver lesion?
FNH
When would you not do a laparoscopic trans-cystic common bile duct exploration?
if you have stones in common hepatic duct
if cystic duct friable or small (<3 mm)
gallstones greater than 6-8 mm
>8 CBD stones
When doing a cholecystectomy, and you get spillage of bile and stones, how do we classify the wound?
contaminated wound–> high risk for post-op intra-abdominal abscess
dirty wound–> gangrenous cholecystitis
clean-contaminated–> elective chole with little or no bile spillage
How do we position pts for percutaneous liver biopsies?
supine
hand over head
lidocaine injection over upper border of rib to avoid subcostal vessels
inject needle
have pt hold breath while removing biopsy specimen
What is future liver remnant?
amount of liver remaining after a surgical resection needed to maintain normal liver function
20-25% FLR is adequate in healthy pts
in pts w/underlying liver dx, or prior chemo, higher % needed to prevent post-hepatectomy liver failure
Bile leak occurs in what % of pts after hepatectomy?
10%
How do we confirm a bile leak after hepatectomy?
when bilirubin concentration in drainage fluid is >3x greater than that of serum bilirubin usually on day 3
Procedure of choice for suspected bile leak after hepatectomy?
percutaneous drainage
Performing a laparoscopic cholecystectomy and intraop cholangiogram shows CBD stone, what do you do next?
attempt to flush CBD w/NS
give 1-2 mg of glucagon IV (relaxes Sphincter of Oddi)
perform a laparoscopic exploration next
How do we treat proximal biliary tree injuries such as transection of the proximal hepatic duct slightly distal to hepatic bifurcation?
distal bile duct should be oversewn
proximal duct should be resected back to healthy tissues
and anastomosed to jejunum in a s-s fashion
Incidence of cholangiocarcinoma seen in what age groups?
50-70 yrs old
exception are pts with PSC, and those w/choledochal cysts
In terms of cholangiocarcinoma, peri-hilar tumors involving the bifurcation of the hepatic ducts are commonly referred to as?
Klatskin tumors
What classification system do we use to classify choledochal cysts?
Todani classification
What are the Todani classifications of choledochal cysts?
I–> fusiform dilation of CBD without intra-hepatic involvement
II–> a diverticulum off of the CBD
IV A–> single fusiform dilation of the extrahepatic bile duct as well as dilation of intrahepatic bile ducts
IV B–> multiple extra-hepatic bile duct dilations
V (Caroli’s dx)–> an intrahepatic bile duct cyst only
Adenomyomatosis of GB commonly found where in the GB and is it cancerous?
commonly in fundus
not considered a premalignant lesion
seen in 1-9% of GB specimens
Cholecystitis can precipitate symptoms and crises in which pts?
sickle cell pts
(these pts need tube decompression for cholecystitis, 3-8 weeks later once tract has formed, they need an interval cholecystectomy, risk of recurrence is 20-30%)
What test do we use to test for sphincter of oddi dysfunction that could benefit from transduodenal sphincteroplasty?
morphine-neostigmine test
morphine–> causes sphincter contraction
neostigmine–> causes biliary contraction
On US if we see a defined compressible mass with hyperechoic features we think of?
hemangioma
If we see late arterial homogenous enhancement with a hypodense central scar that enhances on delayed contrast imaging we think of what liver lesion?
FNH
What do we do first in a delayed >72 hrs, suspected bile duct injury?
infection control w/;
broad spectrum abx
decompress biliary tree
drainage of the fluid collection
(this can be accomplished with a percutaneous cholangiogram)
need time for inflammation to resolve before starting biliary reconstruction–> increases chances of anastomosis success
These liver lesions are typically benign and asymptomatic, with their growth often accelerated by pregnancy and OCP (high estrogen states);
hepatic adenomas
When do we remove hepatic adenomas?
when > 5 cm
**concern for malignant transformation vs spontaneous rupture
What is a type I choledochal cyst?
fusiform dilation of CBD, minimal involvement of common hepatic ducts, normal intrahepatic ducts
85% of choledochola cysts
Absolute contraindications to performing percutaneous liver biopsy?
pts inability to cooperate with procedure
can’t identify an adequate biopsy site
(relative contraindications; cirrhosis, morbid obesity, intra-abdominal infection)
Antibiotics commonly used for pyogenic liver abscesses?
flouoroquinolones + metronidazole
Pt’s with CBD strictures post-cholecystectomy, how do we treat initially?
serial dilations first and stenting
if this fails or recurrent–> surgery
When do we perform cholecystectomies in pts with gallstone pancreatitis?
once abdominal pain has resolved–> remove GB on same admission
What do we do for an incidentally found T2 gallbladder cancer after routine cholecystectomy?
staging laparoscopy needed
remove segments IVB/V from liver
portal LN dissection needed
MCC of bud-chiari syndrome in US (obstruction of hepatic veins)?
hematologic disorders (myeloproliferative disorders and polycythemia vera)
After a choledochotomy for stone extraction that was unable to occur via ERCP, we are unable to remove some stones from CBD, what do we do?
surgical biliary-enteric anastomosis; choledochoduodenostomy or hepaticojejunostomy, T-tube drainage, transduodenal exploration and sphincterotomy
When performing a choledochotomy for a laparoscopic or open bile duct exploration how should the incision be made?
longitudinally below the cystic duct (you want to explore the CBD not the common hepatic duct which can lead to post-surgical stenosis proximally which is more difficult to repair than CBD)
What are some risk factors for the development of acalculous cholecystitis?
trauma critical illness surgery IV nutrition sepsis/hypotension
In an acute ill patient with gallstone ileus, what is the best test to clarify what’s going on?
CT w/IV and PO
will help define the cholecystoenteric fistula
**an upper GI series w/SB follow thru will likely not reach the distal ileum
When you have a CBD stone and you are trying to go trans-cystically via cystic duct, what needs to happen?
the cystic duct almost always needs to be dilated up to 12Fr to allow scope to be inserted
Order of ways to explore the CBD for stones:
transcystic approach first
choledochotomy next
transduodenal sphincteroplasty
(** going straight for choledochotomy risks stricture of CBD)
How do we handle pts with PSC that have simultaneous gallbladder polyps?
14% of pts w/PSC who have cholecystectomy has mass lesions of which 50% are adenocarcinomas
thus asymptomatic GB polyps that are less than 10 mm, in pts w/PSC need a cholecystectomy
Why do we wait 4-6 weeks for T-tubes before we do anything?
helps tract mature
This scoring system helps grade severity of acute cholangitis and dictates management;
tokyo guidelines
Grade I mild–> abx, fluids
Grade II moderate–> fluid resuscitation, abx
Grade III severe–> evidence of end-organ dysfunction, need urgent decompression, abx
Pt has gallstone ileus, air in biliary tree, stone seen on CT in terminal ileum, decompressed colon, how do we proceed?
fluids, NG tube, ex-lap, enterolithotomy
these pts are sick at presentation, takedown of the cholecysto-enteric fistula should happen at a later time
Second most common benign liver tumor after hemangiomas?
FNH
Peripheral arterial enhancement with central stellate scar on CT is typical of?
FNH
Anatomy variations in biliary anatomy are common, what %?
30% of pts will have biliary variations
Pt has a distal CBD tumor, obstructive jaundice, what metabolic derangements do we see?
pt is not releasing bile into duodenum
can’t form micelles
can’t absorb ADEK vitamins
no K–> no II, VII, IX, X–> increased PT
In relation to liver Couinad segmental anatomy, which liver lesions are amenable to biopsy?
lesion near dome of segment 7—> is high on the liver, can cause pneumothorax
segment 1, or posterior segment of 5–> risks injuring the IVC
tip of segment 3–> risks injury to the stomach
parenchyma of segment 6–> usually avascular, safe
For a T1A adenocarcinoma of the GB, once we remove the GB, what else needs to be done?
nothing
cure rate is approx. 100%
During IOC, what medication can we give to help flush the bile tract and push CBD stones into duodenum ?
glucagon helps relax sphincter of oddi
What does glucagon do to the sphincter of oDDI?
relaxes it
This medication know to induce spasms and contractions of Sphincter of Oddi:
morphine
Tx for a rupture pyogenic abscess in a pt with signs of septic shock secondary to intraperitoneal spillage?
Surgery for washout
How do you perform a choledochotomy for CBD exploration?
perform a Kocher maneuver to palpate retroduodenum and intrapancreatic bile duct for stones
dissection of CBD performed on anterior section of CBD to avoid devascularization
opening should be 1.5 cm
What anomaly is assc. w/majority of choledochal cysts and is thought to contribute to their pathogenesis?
anomalous pancreatobiliary junction–> fused long pancreatic and biliary channel
pancreatic enzymes reflux back into biliary tree–> inflammation and cystic degeneration
Lower rates of restenosis are assc with endoscopic sphincterotomy or transduodenal sphincteroplasty?
transduodenal sphincteroplasty
Pts with gallstone ileus that have a patent cholecysto-enteric fistula are at risk for what?
developing ascending cholangitis
Why do we perform cholecystectomy within the same hospitalization for a pt with gallstone pancreatitis?
25% incidence of recurrent pancreatitis and gallstone related complications in pts when cholecystectomy delayed even 2 weeks after discharge
Why do pts with acute acalculous cholecystitis require prompt and rapid treatment?
high risk for gallbladder gangrene and perforation
Do incidental FNH lesions have any malignant or rupture potential?
NO
You are performing a laparoscopic cholecystectomy, and you notice a bile leak, but not sure where it’s coming from, what do you do?
stop all dissection
perform an IOC
Most common bacteria encountered from gallbladder?
e.coli
enterococcus
klebsiella
tx–> abx that cover gram negatives and anaerobes like piperacillin-tazobactum (zosyn)
For a T2 gallbladder cancer do we resect the bile duct or the port-site along with segments IVB and V and portal LN dissection?
bile duct resection not necessary unless cystic duct margin is positive
port site resection not indicated
What are the TOKYO guidelines for grading severity of acute cholecystitis?
Grade 1–> mild, acute cholecystitis, with no organ dysfunction and dx limited to GB, cholecystectomy is a low-risk procedure
Grade 2–> no organ dysfunction, but there is extensive disease in GB, making dissection difficult ( pts usually have elevated WBC, sxs of > 72hrs, imaging shows significant inflammation)
Grade 3–> severe, GB dx with end organ damage
In which pt population would you consider a prophylactic cholecystectomy?
sickle cell pts
these pts have high rate of pigment stone formatio, cholecystitis can precipitate a crisis
What are the criteria for liver transplant in pts with HCC?
single lesion 2-5 cm in diameter
2-3 lesions less than 3 cm each without evidence of macrovascular invasion or extrahepatic disease
First line treatment for a partial distal CBD injury identified 48 hrs later?
endoscopic placement of a covered bile duct stent is reasonable
Incidence of bile duct injuries during laparoscopic cholecystectomy?
0.3—0.7%
What artery passes thru the triangle of calot?
right hepatic artery
which gives off cystic artery
A cystic duct stump leak after a lap. chole is classified as what type of bile duct injury?
type A on the Bismuth-Strasburg classification
typically seen during 1st post-op week
For biliary reconstruction following bile duct injuries, why do we not perform side-to-side choledochoduodenostomies?
can cause recurrent episodes of cholangitis due to food, debris, sludge, stones obstructing distal CBD–> sump syndrome
When performing a cholecystectomy, and stones are spilled in the abdomen, what’s a common complication that can occur from spilled stones?
stones tend to form abscesses intra-abdominally
0.1–6%
Most common complication of cholecystostomy tube placement?
bile leak when tube is placed or removed
** seen in 3% of pts
Tx for amebic liver abscess?
metronidazole 500 -750 mg 3x/day for 7-10 days
90% cure rate
has high concentration in liver and intestines
response should be seen in 3-4 days
After cholangiography, what material is best for closing the cystic duct stump?
ENDOLOOPS better than clips
Most common symptoms seen in Budd CHiari syndrome is?
abdominal distention/ascites
Gold standard to establish a diagnosis of a hepatic abscess is?
CT
A 6 cm right lobe of liver cyst seen, with calcified rim, with 3, 1 cm smaller cysts next to larger cyst, what is this?
hydatid cyst
Tx for hydatid cysts?
rupture causes anaphylaxis, so goal is to remove cyst in tact
tx with albendazole pre and post-op are recommended
In a pt with acute cholecystits, initially, what king of inflammatory response do we see?
initially it’s sterile
we see inflammation of GB, distention, then ischemia
if untreated, this leads to a secondary infection, perforation etc
Antibiotics in acute cholecystitis cover what organisms?
E.coli
klebsiella
enterobacter
Bacteroides
**seen in 50% of cultures
For acute cholecystectomy, surgery is easiest when performed within?
first 72 hrs
Laparoscopic liver resections are ideal for what type of tumors?
tumors < 5 cm in segments 2, 3, 4, 5, 6
This type of cholecystitis, its commonly assc with gallstones and mechanical irritation due to recurrent attacks causing fibrosis and GBW thickening;
chronic chole
What is the Strasberg classification?
system used to classify bile duct injuries A–>E
A; leak from cystic duct stump or ducts of Lushcka
B: ligation of aberrant right hepatic duct
C; transection with leakage of an aberrant right hepatic duct
D: lateral injury to a major duct
E: complex injury, complete transection of hepatic duct
How do we classify leaks from cystic duct stump?
type A on Strasberg classification system
What is the most sensitive test to identify small, 2-5 mm liver mets during segmental liver resections?
intra-op US
Pt has ascending cholangitis due to gallstone pancreatitis, what do we do?
Fluid resuscitate
ICU admit
Antibiotics
Decompression of biliary tree w/ERCP and stent
***in abscence of cholangitis, early ERCP not done, MRCP is done to check for duct clearance
Most common symptoms of extrahepatic lower duct cholangiocarcinoma is?
painless jaundice
Treatment for an extrahepatic lower duct cholangiocarcinoma?
pancreaticoduodenectomy
Which bacteria commonly cultured from pyogenic liver abscesses?
klebsiella
Pyogenic liver abscesses are usually poly-microbial, with high rate of gram negative and anaerobic bacteria such as:
klebsiella
e.coli
With bile duct strictures after cholecystectomy, are they commonly caused by open or laparoscopic approaches?
laparoscopic
Most CBD strictures are caused by?
iatrogenic injury during chole
mostly from laparoscopic approaches vs open
One of the main stimuli for GB contraction is release of CCK from where?
duodenum in response to a meal
How does GB empty after a meal?
GB emptying takes 1-2 hrs after meal is ingested
releases 50-75% of its contents within 30 mins
*** refills gradually over next 60-90 mins
How does the vagus nerve influence the GB?
vagus stimulates GB contraction
splanchnic sympathetic system inhibits contraction
Cholangiocarcinomas commonly occur in men in what age range?
50-70 y/o
Risk factors for cholangiocarcinomas?
PSC
UC
biliary tract infection
choledochal cysts
Most common type of cholangiocarcinoma?
sclerosing (periductal infiltratin)
- **papillary assc with better prognosis
- **nodular assc w/ worse prognosis
Majority of small bowel adenomas are found where?
duodenum
mostly in peri-ampullary region
Why do we care about small bowel adenomas?
25% harbor malignancy
On upper GI series if we a see a soap bubble or paint brush sign what do we think?
duodenal villous adenoma
What’s the Kocher maneuver?
mobilizing the lateral peritoneal attachments of 2nd part of duodenum
used for exposing pancreatic head and duodenum
What’s the Mattox maneuver?
mobilizing the parietal peritoneum at the white line of Toldt from sigmoid colon to splenic flexure
spleen, tail of pancreas, left kidney, stomach are mobilized and reflected medially to expose the aorta
helps w/zone 1 and 2 retroperitoneal injuries
Does the Pringle maneuver help control bleeding from hepatic veins?
NO
it controls blood inflow into the liver only
Major hepatectomy is defined as what?
resection of three or more liver segments
b/l subcostal incisions commonly made
First step in performing a major left hepatectomy?
cholecystectomy
cannulate the cystic duct for IOC to check for bile leak
ligate left hepatic artery (inflow vessels are ligated first to prevent engorgement of liver)
In someone with acute gallstone pancreatitis, if we don’t perform cholecystectomy on same admission, what happens?
risk of recurrence is 25-30% within 6-18 weeks
What do we see on ERCP of suspected PSC?
diffuse dilations and strictures of intra and extra hepatic biliary tree (beading or chain of lakes)
What’s beading or chain of lakes seen in PSC?
diffuse dilations and strictures of intra and extra hepatic biliary tree
What is the treatment of choice for PSC?
liver transplant
should be referred once MELD > 15
How do you claculate a MELD score?
bilirubin
Cr
INR
The initiating event in the formation of ascites in pts with portal htn/liver cirrhosis is?
sinusodial portal htn
Reynauds penatad seen in ascending cholangitis, what is it?
fever RUQ pain hypotension AMS jaundice
Most common bacteria isolated in cholangitis?
e.coli
Causes of cholangitis?
biliary stones
malignancy
benign strictures
1st step in managing ascending cholangitis?
fluids
abx
What abx would you start a pt with ascending cholangitis?
pip-tazo–> zosyn
Indications for IOC?
delineate biliary anatomy
suspicion of CBD stones
ductal injury
What maintenance med would you put someone with asymptomatic esophageal varices?
non-selective bblocker like propranolol
(timolol, nadolol can also be used)
they decrease CO via B1 blockade
decrease splanchnic bloodflow via B2 blockade
***non-selective bblockers however do not prevent variceal formation
What type of incisions do we perform for a right hepatectomy vs a left hepatectomy?
right–> subcostal incision
left–> midline incision
Steps of a hepatectomy;
mobilize liver by dividing ligaments cholecystectomy and cannulate cystic duct for IOC ligate hepatic Artery ligate portal vein ligate hepatic vein divide liver parenchyma
Fungal hepatic abscesses usually diagnosed in people following chemo, immunocompromised pts, how do we tx?
drainage + antifungals (micafungin)
An emphysematous gallbladder with air in the gallbladder wall is commonly see in what pts?
pts with uncontrolled DM
Emphysematous cholecystitis is caused by?
clostridium perfringens
** these pts need an emergent operation due to high risk of perforation
During a cholecystectomy, converted to open, what do you do if you can’t define the cystic duct or cystic artery?
perform an cholangiogram
(if cholangiogram cannot be performed then we can do partial cholecystectomy or cholecystostomy tube placement as bailout move)
MCC of portal vein thrombosis in children?
umbilical vein infection
PVT is seen in pts with advanced cirrhosis, 10% can occur spontaneously, most cases in adults are idiopathic
Obstructive jaundice due to a peri-ampullary mass can lead to nutritional deficiencies of ADEK vitamins and what symptoms?
night blindness A
osteomalacia D
neuromuscular weakness E
coagulopathy K
In amebic liver abscess, we see typical anchovy paste on aspiration, why are aspirations and cultures usually negative?
organisms usually only present on the rim of abscess
Tx for amebic liver abscesses?
metronidazole
aspiration if recurrence or persist
surgery if perforates
How do we typically make diagnosis of hepatic mets of colon adenocarcinoma?
typically CT is enough without bx
HIDA scan has a high false positive rate in pts that are what?
fasting
on IV nutrition
MCC of ascites in US?
cirrhosis
Hepatic hemangiomas occur more frequent in women and are usually asymptomatic, when are they likely to be symptomatic?
in younger women
>4 cm
What do hepatic hemangiomas demonstrate on imaging?
demonstrate delayed or late phase filling
show peripheral to central enhancement
Aberrant or replaced right hepatic artery originating off the SMA occurs in what % of pts?
15%
Serological testing in pts with hydatid dx shows what?
varying false positive/negative rats
CT shows hypoattenuation
How do liver mets from colon look like on CT?
hypoattenuating
multiple, diffuse
Primary bile salts are made in the liver and conjugated in the liver to what?
glycine
taurine
these conjugated bile salts then secreted in bile and intestines to aid in digestion
majority 80% are actively absorbed in terminal ileum
5% of bile acids escape absorption and passed in stool
1st line abx tx for pts with spontaneous bacterial peritonitis?
3rd gen cephalosporin–> cefotaxime
IV albumin can be used as adjunct, shown to decrease mortality
This is a tyrosine kinase inhibitor used to treat HCC:
sorafenib
What type of cells do we see in FNH?
kupffer cells
What type of cells distinguish hepatic adenomas from FNH?
FNH have kupffer cells, adenomas DO NOT
Does FNH transform to cancer or rupture?
NO
Homogenous enhancement with hypodense central scar on arterial phase, rapid washout on portal phase, and isodense on venous phase?
FNH
Resection place of right vs left hepatectomies is what?
Cantlie’s line –> from GB fossa to IVC
the middle hepatic vein represents anatomic landmark of this plane
HCC is what # cancer in the world?
5
Gold standard for hydatid cyst management?
several weeks of albendazole followed by surgical excision
Liver produces all of the coagulation factors except?
Factor 8 (made by endothelium)
Vit K can be used to reverse effects of Warfarin but it takes how long to take effect?
6 hrs
These lesions appear hypervascular with peripheral nodular enhancement and centripetal fill in:
hemangiomas
Although benign, hepatic adenomas pose 2 risks:
malignant transformation
rupture with intraperitneal hemorrhage
Up to 95% of pts with gallbladder cancer have?
cholelithiasis
**only 0.5-1.5% of pts with cholelithiasis will have GB cancer
What is the association between gallbladder cancer and cholelithiasis?
related to the chronic inflammation of stones
Risk factors for gallbladder cancer
cholelithiasis choledochal cysts PSC procelain GB polyps > 10 mm
What is the normal size of CBD?
3-6 mm in diameter for pts under 60
increases 1 mm every decade
Lab test with best positive predictive value for choledocholithiasis is?
ALK
Pure fungal liver abscesses are seen in pts with?
hematological malignancies
recovering from chemo-induced neutropenia
What causes pyogenic liver abscesses?
biliary tree instrumentation
hepatobiliary malignancies
Most common fungal pathogen causing liver abscesses?
candida
***capsofungin/micafungin
Major cause of pyogenic liver abscess?
cholangitis
How do we calculate future liver remnant volume?
use CT volumetry to calculate % future remnant
** in pts with normal liver function, a FLR of 20% is considered adequate
Pts with hx of cirrhosis need a future liver remnant of what %?
40%
These are the only gallbladder lesions that have malignant potential and harbor a significant risk of malignancy are?
adenomatous polyps
Most common benign and most common malignant lesions of GB?
bening–> adenomas
malignant–> adenocarcinoma
GB polyps that are >2 cm are almost always what?
Ca
Safest approach to obtaining a liver bx in a pt who is cirrhotic and has elevated INR (coagulopathic)?
transjugular approach (0.2% risk of hemoperitoneum)
What do we do with gallbladder polyps?
> 2 cm–> resection, 100% risk of Ca
>1 cm–> 43-77% risk of Ca
How do we perform an IOC via the cystic duct?
place clip between infundibulum and cystic duct (so contrast doesn’t backflow in GB)
linear incision made on cystic duct
cholangiocatheter introduced into cystic duct
