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Liver and Gallbladder Flashcards

1
Q

___ refers t the plane separating the true left and right lobes

A

Cantlie’s line

from GB fossa to IVC

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2
Q

What separates the left lobe into lateral and medial segments?

A

falciform ligament

Small left lobe, large right lobe

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3
Q

What divides the quadrate and caudate lobe?

A
  1. GB
  2. Fissure for ligamentum teres
  3. IVC
  4. Fissure of ligamentum venosum
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4
Q

What lobe lies between the IVC and fissure for ligamentum venosum?

A

Caudate lobe

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5
Q

What lobe is located between the fissure for ligamentum teres and GB?

A

Quadrate Lobe

Remember, Quad = Teres

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6
Q

What are the contents of your porta hepatis?

A
  1. Hepatic Duct
  2. Hepatic artery
  3. Portal vein
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7
Q

[Name the corresponding segment]

caudate

A

segment 1

Drained by IVC

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8
Q

[Name the corresponding segment]

Left lateral

A

Segment 2 and 3

Drained by Left hepatic

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9
Q

[Name the corresponding segment]

left medial

A

Segment 4

4A and 4B

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10
Q

[Name the corresponding segment]

Right anterior

A

Segment 5 and 8

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11
Q

[Name the corresponding segment]

right posterior

A

Segment 6 and 7

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12
Q

What liver segments are drained by middle hepatic?

A

Segment 4, 5, 8

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13
Q

What structures are compressed in pringle maneuver?

A
  1. Portal vein
  2. Hepatic artery
  3. CBD
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14
Q

What clotting factor is not measured by your PT and INR?

A

Factor VIII

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15
Q

What is the level of serum bilirubin to cause a jaundice?

A

> 2.5 to 3 mg/dL

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16
Q

What are the most common causes of haemobilia?

A
  1. Iatrogenic
  2. Traumatogenic
  3. Neoplastic
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17
Q

What do you call the triad of haemobilia?

A

Quicke Triad

  1. Jaundice
  2. RUQ abdominal pain
  3. Upper GI hemorrhage
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18
Q

What is the hormone implicated with spider angiomata?

A

Estradiol

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19
Q

Caput medusa is due to re-opening of what veins?

A

umbilical vein

shunting blood from the portal vein

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20
Q

Ascites is clinically detected when greater than ____ L

A

1.5L

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21
Q

____ syndrome refers to an epigastric murmur seen in cirrhotic patients wherein blood from the portal vein is shunted to the umbilical vein

A

Cruveilhier-Baumgarten Syndrome

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22
Q

____ (horizontal/vertical) nail bands are seen in cirrhotic patients due to hypoalbuminemia.

A

horizontal

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23
Q

Dupuytren contracture in cirrhosis is due to?

A

enhanced oxidative stress, increased hypoxanthine

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24
Q

Hypogonadism in cirrhotic patients wis mainly due to?

A

direct toxic effect of iron or alcohol

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25
Q

The presence of asterixis in hepatic enceph is due to ___

A

disinhibition of motor neurons

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26
Q

What compound is implicated in fetor hepaticus seen in cirrhotic patients?

A

Volatile dimethyl sulfide

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27
Q

What is the first line drug for SBP?

A

Cefotaxime

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28
Q

What are the components of your Child Pugh Score B

A 
Jaundice - Bilirubin 2-3
Ascites - minimal, controlled
PTT - 40 to 70%
Albumin 2.8 to 3.5
Nutritional status - good
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29
Q

What is the normal portal pressure?

A

5-10 mmHg

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30
Q

What is the cut off value of portal hypertension based on splenic vein pressure?

A

> 15mmHg

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31
Q

What is the most accurate method of determining portal hypertension?

A

Hepatic venography

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32
Q

What is the most significant manifestation of portal HPN?

A

esophageal varices

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33
Q

What is the surgical management for refractory BEV child pugh A

A

Surgical Shunt

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34
Q

What is the surgical management for refractory BEV child pugh B

A

TIPS

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35
Q

[Classification of portosystemic surgical shunts for BEV]

Eck fistula

A

End-to-side portocaval shunt

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36
Q

[Classification of portosystemic surgical shunts for BEV]

Linton shunt

A

Proximal splenorenal shunt

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37
Q

[Classification of portosystemic surgical shunts for BEV]

Warren shunt

A

Distal splenorenal (selective)

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38
Q

[Classification of portosystemic surgical shunts for BEV]

Inokuchi shunt

A

Left gastric vena caval shunt (selective)

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39
Q

[Classification of portosystemic surgical non-shunts for BEV]

used for recurrent BEV despite endoscopic and medical treatment who are not candidates for TIPS

A

Sugiura-Fukugawa procedure

Ligate venous branches entering distal esophagus and the proximal stomach from the level of inferior pulmonary vein,

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40
Q

[Classification of portosystemic surgical non-shunts for BEV]

consist of splenectomy, perihiatal devascularization of the lower esophagus, ligation of the left gastric vessels, devascularization of the proximal half of the stomach, separation of stomach from its bed

41
Q

What is the most definitive surgical procedure of portal hypertension?

A

Orthotopic Liver Transplantation

42
Q

Which is the most frequent site (left or right lobe) of pyogenic liver abscess?

A

right lobe

40% monomicrobial

43
Q

What is the CT scan finding diagnostic of pyogenic liver abscess?

A

Hypodense lesions with or without air-fluid levels and peripheral enhancement

44
Q

Which part of the liver is the most frequent location of amebic liver absccess?

A

Anterior aspect of right lobe

45
Q

Which part of the liver is commonly affected by hydatid disease?

A

Antero-inferior or posteroinferior portions of the right lobe

46
Q

What is the most frequently encountered liver lesion overall?

A

Hepatic cyst

47
Q

What is the most common benign solid mass seen in the liver?

A

hemangioma

48
Q

What is the most common symptom in liver hemangiona and indication for resection?

49
Q

What is the clearest risk factor for liver adenoma?

A

Prior or current use of oral contraceptives

50
Q

What is the most common malignant liver tumor?

A

Metastatic

usually from colonic CA

51
Q

What are the criteria for hepatoma that is viable for resection only?

A
  1. Non-cirrhotic
  2. Child A
  3. Single lesion
  4. No metastasis
52
Q

What is the criteria for liver transplant in patients with Hepatoma?

A
  1. One nodule <5cm
  2. 2 or 3 nodules < 3cm
  3. No vascular invasion
  4. No extrahepatic spread
  5. Child A, B, C
53
Q

Where is the location of a Klatskin Tumor?

A

Occurs in the hepatic duct confluence

54
Q

What is the gold standard in the surgical management of cholangiocarcinoma?

55
Q

The cystic artery is a branch of?

A

Right hepatic artery

56
Q

The budd triangle or the hepatocystic triangle is formed by the:

A
  1. Cystic duct to the right
  2. Common hepatic duct to the left
  3. Margin of the right lobe of the liver superiorly

Basta border ang right lobe of the liver

57
Q

What are the borders of triangle of Calot?

A
  1. cystic duct
  2. Common Hepatic Duct
  3. Cystic artery
58
Q

__ are in which you can see 85% of the hepatic pedicle

A

Moosman area

59
Q

The ampulla of vater is ___ cm distal to the pylorus

A

10cm

surrounded by sphincter of oddi

60
Q

What nerve plays a role in GB contraction

61
Q

What hormone inhibits GB contraction?

A
  1. VIP

2. Somatostatin

62
Q

What is the basal pressure of the sphinter of oddi?

A

13mmHg above duodenal pressure

63
Q

What is the most common presentation of gallstone disease?

A

Recurrent biliary colic

64
Q

What are the TRADITIONAL indications for cholecystectomy in asymptomatic patients?

A
  1. Elderly with DM
  2. Isolation from medical care for extended periods
  3. Increased risk of GB cancer
65
Q

What are the indications for prophylactic cholecystectomy?

A
  1. Sickle Cell Disease
  2. Hereditary spherocytosis and thalassemia at the time of splenectomy
  3. Cardiac and lung transplant patients
66
Q

What are the contraindications for prophylactic cholecystectomy?

A
  1. DM patients
  2. Cirrhotic patients
  3. Transpant recipeints
  4. Porcelain gallbladder
  5. Patients receiving prolonged TPN
  6. Spinal cord injury
67
Q

What are the critical view of safety in laparoscopic cholecystectomy?

A
  1. Triangle of calot must be dissected free of fat (without exposing the common bile duct)
  2. The base of the GB must be dissected off the lover bed or cystic plate
  3. Two structures (cystic duct and artery) enter the GB and can be seen circumferentially
68
Q

What are the absolute contraindications for cholecystectomy?

A
  1. Inability to tolerate GA or laparotomy
  2. Refractory coagulopathy
  3. Diffuse peritonitis with hemodynamic compromise
  4. Cholangitis
  5. Potentially curable GB cancer
69
Q

[Eponym]

examiner hooks finger under right costal margin and ask patient to deeply inhale. Positive test if the patient stops inhaling suddenly due to pain

A

Acute cholecystitis

70
Q

[Eponym]

Hyperesthesia in the RUQ or right infrascapular region

71
Q

[Eponym]

Present when the patient points to the right scapular tip with a fist and thumb pointing upwards to describe the pain

A

Collins Sign

72
Q

What is the most typical sign of acute cholecystitis?

A

abdominal pain

73
Q

What are the components of your 2013 Tokyo Guidelines?

A

A

  1. Murphy sign
  2. RUQ mass or pain or tenderness

B

  1. fever
  2. Elevated CRP
  3. Elevated WBC

C. Imaging characteristic of acute cholecystitis

74
Q

According to tokyo guidelines, cholecystitis is suspected if

A

1 item in A + 1 item in B

A

  1. Murphy sign
  2. RUQ mass or pain or tenderness

B

  1. fever
  2. Elevated CRP
  3. Elevated WBC
75
Q

According to tokyo guidelines, definite cholecystitis is when

A

One item A + One Item B + C

A

  1. Murphy sign
  2. RUQ mass or pain or tenderness

B

  1. fever
  2. Elevated CRP
  3. Elevated WBC

C. Imaging characteristic of acute cholecystitis

76
Q

What are the UTZ finding suggestive of cholecystitis?

A
  1. Enlarged GB
  2. Thickening of GB wall >5mm
  3. Debris echo
  4. UTZ Murphy sign
77
Q

Immediate cholecystectomy and biliary drainage should be carried out in what severity grade for acute cholecystitis?

78
Q

How many months can you perform cholecystectomy in patients with severe cholecystitis

A

2-3 months after

79
Q

In grade I cholecystitis, cholecystectomy should be done within _____ hours

80
Q

What is the cut off year to say that a GB stone is either residual or recurrent post cholecystectomy

A

2 years

Residual - <2 years
Recurrent - >2 years

81
Q

What is the gold standard in diagnosing GB stone?

82
Q

A dilated CBD in abdominal UTZ has a diameter of?

83
Q

___ syndrome wherein the common hepatic duct obstruction is due to an extrinsic compression from an impacted stone in the cystic duct or hartmann’s pouch pf the GB

A

Mirrizi Syndrome

84
Q

___ syndrome refers to gallstone ileus of the duodenum

A

Bouveret Syndrome

85
Q

[Tokyo guideline for acute cholangitis]

What are the clinical context criteria?

A
  1. History of biliary disease
  2. Fever or chills
  3. Jaundice
  4. Abdominal pain (RUQ or upper abdomen)
86
Q

What are the procedures that can be done in patients with Grade II Acute Cholangitis to drain the bile?

A
  1. ERCP + Papillotomy
  2. PTC with catheter drainage
  3. Laparotomy with decompression of the bile duct with a T-tube
87
Q

Most common form of choledochal cyst?

A

Type 1 - Fusiform

88
Q

___ disease wherein choledochal cysts are found in the intrahepatic ducts

A

Caroli Disease

89
Q

What is the triad of choledochal cyst?

A
  1. Abdominal pain
  2. Jaundice
  3. Mass
90
Q

What is the surgical management for Type 3 choledochal cyst?

A

Sphincterotomy

Type 3 - choledochocoele, multiple cyst

91
Q

What is the surgical management for Type 2 choledochal cyst?

A

Excision; defect in the CBD is closed over a T-tube

Type 2 - saccular

92
Q

What is the management for Type 4A choledochal cyst?

A

Segmental liver resection, excision of and roux en y hepaticojejunostomy

Type 4 - intra and extra

93
Q

What are the factors associated with malignancy in GB polyp?

A
  1. Presence of single polyp
  2. Size of polyp >1cm
  3. Age >50 years
  4. Rapid growth
  5. Sessile in morphology
  6. Adenomatous in histology
94
Q

[GB CA surgical management]

tumor invading the lamina propria

A

This is T1a - simple cholecystectomy

95
Q

[GB CA surgical management]

Tumor invades the muscle layer

A

This is T1b

do an extended cholecystectomy include segment IVB and V + lyphadenectomy

96
Q

[GB CA surgical management]

Tumor invades the perimuscular connective tissue

A

This is T2

Extended cholecystectomy

97
Q

[GB CA surgical management]

tumor perforates the serosa and invades liver or adjacent organs

A

Extended right hepatectomy + en bloc resection of the CBD

98
Q

Most common type of bile duct CA?

A

> 95% are adenocarcinoma

99
Q

What is the most common presentation of bile duct CA?

A

painless jaundice

Surgery (19 decks)

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