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Surgery > Liver, Biliary System And Spleen > Flashcards

Liver, Biliary System And Spleen Flashcards

1
Q

Liver primordium and bile duct arise from ventral endodermal outgrowth of foregut at

A

3rd and 4th week

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2
Q

Liver promordium penetrates septum transversum to become bud early in

A

5th week

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3
Q

Kupffer, hepatic stroma and hepatic vessels arise from

A

septum transversum mesoderm

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4
Q

Prolif of mesenchymal cells in dorsal mesogastrium at 5th week

A

Spleen promordium

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5
Q

Divided into eight segments corresponding to venous drainage but related to arterial blood supply and biliary drain

A

Segmental

French Couinaud

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6
Q

Two lobes divided by interlobar fissure Cantlie’s line)

A

Lobat (American)

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7
Q

Runs from left side of GB fossa to IVC

A

Cantlie’s line

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8
Q

Caudal lobe

A

Segment I

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9
Q

Segment II,III,IV

A

Left lobe

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10
Q

Segment V,VI,VII,VIII

A

Right lobe

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11
Q

Caudate lobe drains

A

directly to IVC

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12
Q

Functional unit of liver

Made up of biliary ductule, hepatic arteriole, portal venule (afferent)

A

Acinar unit

Portal triad

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13
Q

Liver zone are defined according to

A

Oxygen and solute concentration gradient

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14
Q

Closest to triad

Least susceptible to ischemic insult but most susceptible to toxic or chemical injury

A

Zone 1

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15
Q

Adjacent to terminal hepatic vein

Most susceptible to ishcemic injury

A

Zone 3

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16
Q

Bile from caudate lobe drains into

A

Left hepatic ductal system

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17
Q

GB is located under segment

A

4 and 5

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18
Q

Normal GB wall thickness

A

<4 mm

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19
Q

Source of postoperative bile leaks when correct operative technique is followed
Postulated to run from liver bed directly to GB or whether drainage ducts running from subsegments of liver along GB join cystic duct or CBD

A

Ducts of Luschka

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20
Q

Normal CBD size

A

<5 mm if <50 y/o

Inc by 1mm/decade after 50

Normally enlarged up to 12 mm following cholecystectomy

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21
Q

Relation of hepatic bile duct to right branch of porta vein

A

Anterior

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22
Q

Right hepatic artery runs

the common hepatic duct

A

behind

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23
Q

Layers of GB

A

Mucosa
Muscularis
Subserosa
Serosa

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24
Q

GB contains no

A

Submucosa

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25
Q

Mucosa lining of GB

A

columnar epithelium specialized for water absorption

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26
Q

Sinuses from invagination of epithelium through fibromuscular layer from inflammation and inc luminal pressure in GB (cholangitis, acute cholecystitis)

A

Rokitansky-Aschoff sinus

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27
Q

Hepatic artery relation to Portal Vein

A

Anterior

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28
Q

Hepatic artery relation to CBD

A

Medial

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29
Q

Exists in 17% of patients

Comes off as SMA to run lateral to CBD

A

Replaced right HA

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30
Q

Occurs in 10% of patients and usually comes off of splenic or left gastric artery

A

Replaced left HA

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31
Q

Liver tumors are supplied primarily by

A

Hepatic artery

True for both primary and metastatic tumor

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32
Q

Converges with hepatic vein before entering IVC in 80% of cases
Remaining 20% drain directly into IVC

A

Middle HV

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33
Q

Carries 75% of total blood flow to liver

A

Portal vein

But PV and HA give 50% of O2 supply to liver

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34
Q

Liver drainage

A 
3 HVs 
Left HV (II, III, IV) 
Middle HV (V, inferior IV)
Right HV (VI, VII, VIII)
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35
Q

There is sparing of caudate lobe in Budd Chiari because

A

There is a separate HV draining it directly to IVC

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36
Q

85% of spleen
Mononuclear phagocyte
Clearing of nucleated remnant from immature RBC, clearing of damaged or dead RBC

A

Red pulp

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37
Q

15% of spleen
Lymphoid cell, mostly B
Clearing of bloodborne antigen:
bacteria without preexistinf antibody, poorly opsonized bacteria, foreign particle, cellular debris

A

White pulp

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38
Q

BS of biliary system

A

Cystic artery from R HA and vein

Cystic vein absent and drainage through surface vein into liver bed

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39
Q

BS of spleen

A

Splenic artery
L gastroepiploic artery
Short gastric artery

Splenic vein posterior inferior to splenic artery and drains to PV

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40
Q

Innveration of liver

A

Sympa: T7-T10
Parasympathetic: right and left vagus

synapse with peripheral nerve fibers that run anterior and posterior to HA

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41
Q

Lymph drainage of liver

A

Perisinusoidal space of Disse and clefts of Mall
Porta hepatis
Cysterna chili
Thoracic duct

Opposite of PV blood and does not follow HV flow

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42
Q

Oxidation (CYP450), reduction, hydroxylation, hydrolysis to expose functional groups

A

Phase I

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43
Q

Reactions involve conjugation to alter solubility

A

Phase II

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44
Q

Dec permeability of sinusoidal epithelial cells alters lymphatic drainage leading to ascites

A

ascites

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45
Q

Rate limiting enzyme in bile acid production

A

cholesterol 7alpha-hydroxylase

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46
Q

Made primarily by endothelial cells and the liver to some degree

Restoration of normal levels in some successful liver transplants in patients with Hemophilia A

A

Factor 8

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47
Q

Nutrient stores in liver

A 
Glycogen
Triglyceride
Vitamin B12
Iron
Copper
Fat soluble vitamin
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48
Q 
35, F
Takes OCP
RUQ pain
Work up: 3cm hepatic adenoma
Tx?
A

Stop OCP and observe

If >4cm or symptoms persist, resection

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49
Q

Consumption thrombocytopenia
related to hepatic hemangiomata
Leads to DIC

A

Kasabach-Meritt Syndrome

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50
Q 
Infection with Echinicoccus granulosum
Sheep 
Primary host: dogs stool infecting
Intermediate: humans 
RUQ pain, hepatomegaly, obstructive sx
Leak lead to allergic symptoms
Eosinophilia
\+indirect agglutination 85% 
\+complement fixation test
A

Hydatid cyst

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51
Q

Hydatid cyst have predilection for

A

Right lobe of liver

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52
Q

Hydatid cyst abdominal CT:

A

cacified ectocyst, endocyst

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53
Q

Hydatid cyst tx

A

Preoperative Albendazole or Mebendazole with complete surgical removal including wall

Intraoperative aspiration with injection of saline

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54
Q

Hydatic cyst course

A

Expansion -> rupture -> spread -> anaphylaxis -> death

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55
Q

Most common benign liver tumor

Not related to OCP use

A

Hemangioma

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56
Q

Asymptomatic
Dx: CT contrast or MRI T2 bright
Mx: observe (asymptomatic)
Enucleation or lobectomy if with symptom or uncertain dx
Radioablation or embolization of hepatic artery for poor candidate
Complication: rupture (rare) hemorrhagic shock, acts like AV fistula, cardiac hypertrophy, CHF

A

Hemangioma

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57
Q

Common in women
Ave age: 35 years old not related to OCP

Asymptomatic

Dx: CT shows hypervascular mass with HYPODRNSE STELLATE SCAR; hot on Tc macroaggregated albumin scan
Biopsy shows hepatocyte and bile duct

Mx: observe with serial CT, if symp resect

Complication: no potential for malignant degeneration, low chance of rupture

A

Focal nodular hyperplasia

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58
Q 
Reproductive age women
Related to OCP use
75%- abdominal pain
MRI, CT (lacks central scar)
Cold on Tc macroaggregated albumin scan
Biopsy: hepatocyte

Tx: discontinue OCP
<4cm observe
>4cm resect due to rupture and malignant degen

25% chance of rupture or hemorrhage
Rare malignant degeneration

A

Hepatic adenoma

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59
Q

Cholestasis, fibrotic intrahepatic and extrahepatic biliary tree
Men in 3rd-4th decade
Autoimmune associated with ulcerative colitis, retroperitoneal fibrosis, insulin dep DM, Grave’s, Sjogren’s, Riedel’s, AI pancreatitis, MG

A

Primary sclerosing cholangitis

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60
Q

PSC is associated with HLA

A

HLA B8

HLA DR3

61
Q

PSC may progress to

A

Cirrhosis

Cholangiocarcinoma (20%)

62
Q

PSC Dx:

A

Inc ALP and bilirubin
ERCP: multiple dilatation and stricture of both intra and extrahepatic biliary tree
Biopsy determine degree of fibrosis and cirrhosis

63
Q

PSC Tx

A

None

Endo or percutaneous dilation and stent are symptomatic relief

If without significant hepatic fibrosis or cirrhosis, surgical resection of extrahepatic biliary tree with hepaticojejunostomy

Advanced: liver transplant
10-20% will have recurrence

Colectomy if with UC

64
Q

Confirms diagnosis of PSC

Rule out

A

ERCP and liver biopsy

Cholangiocarcinoma

65
Q

Most common in US (80%)
Hematogenous spread from intraabdominal infection (diverticulutis, appendicitis) or ascending infection (cholangitis)
Direct extension from intraperitoneal infection
Stent placement, manipulation, trauma

organism: Staph, Gram - (E coli, Kleb), Anaerobe (Bacteriodes fragilis)

Fever, chills, liver tenderness/enlargement, jaundice

Leukocytosis, + blood culture 40%,
Confirm with CT/UTZ
CT: HYPODENSE abscess wall enhances with IV contrast

Mx: IV antibiotics 2 weeks followed by oral (1 month)
CT UTZ guided aspiration/drain or surgical drain
Prolong antibiotics if multiple abscess

A

Bacterial hepatic Abscesses

66
Q

Most common worldwide
Primary infection from colon spreading to liver via PV
By entamoeba hystolitica
Most commonly as single abscess on:

Fever, RUQ, chills, sweating, hepatomegaly
Antecedent diarrhea 25%
Jaundice rare
Anchovy paste abscess

Leukocytosis, abdominal liver function
Entamoeba hystolitica serology 90%
+ stool culture 15%
Radiographically similar to bacterial

Tx: metronidazole
sx reserved to failed antibiotic therapy or complication (bacterial infection)

A

Amoebic abscesses

67
Q

Chronic inflammation
Hepatocyte destruction and regeneration
Fibrosis
Portal HTN

By alcohol, Hepa B, C, prolonged cholestasis, metabolic (Wilson, alpha 1 antitrypsin)

A

Cirrhosis

68
Q

Most common cause of cirrhosis in US

worldwide

A

Alcohol

HCV

69
Q

AST and ALT in CLD

A

> 3 times normal

70
Q

AST/ALT in Alcoholic cirrhosis

A

> 2

71
Q

Synthetic function of liver is best assessed by

A

PT

72
Q

Anemia
Thrombocytopenia
Inc PT and INR
Inc AST and ALT >3

A

Cirrhosis

73
Q

Confirms presence of cirrhosis and established cause

A

Liver biopsy

74
Q

Helps determine extent of cirrhosis and predict operative mortality

A

Child Pugh classification

75
Q 
No ascites
No neurologic disorder
Bilirubin: <2 mgdl
Albumin >3.5 mgdl
PT 1-3
INR <1.7
Operative mortality: 10%
A

Child Pugh A

76
Q 
Minimal or controlled ascites
Mininal or controlled neurologic disorder
Bilirubin: 2-3 mgdl
Albumin: 2.8-3.5 mgdl
PT: 4-6
INR: 1.7-2.2
Operative mortality: 30%
A

Child Pugh B

77
Q 
Moderate-severe ascites
Moderate severe COMA
Bilirubin >3mgdl
Albumin <2.8 mgdl
PT >6
INR >2.2
Operative mortality: 70%
A

Child Pugh C

78
Q

Child Pugh Classification

A 
Prothrombin
Bilirubin
Albumin
Ascites
Neurologic

ProBAAN

79
Q

Collaterals between short gastric veins to azygos result in

A

esophageal varices

80
Q

Cirrhosis tx

A

Ascites: diuresis (spironolactone, furo), paracentesis and peritoneal jugular shunt

81
Q

Acute infection of peritoneal fluid presenting with fever and abdominal pain
Most commonly by:
Suspect other etiology if polymicrobial flora and found on culture
Confirm diagnosis by >250 PMN/ul in ascitic fluid that is + culture

Treat with:

A

Spontaneous bacterial peritonitis

E coli

Third gen cephalosporin (cefotaxime)

82
Q

Complications of cirrhosis

A

Variceal bleeding 33% mortaity in first episode
With rebleed 50%?
Portal HTN
Liver failure: transplant

83
Q

Variceal bleed tx

A 
Endoscopy
Rubber band ligation 
Sclerotherapy
Vasopressin
Ocreotide
Transjugular intrahepatic portasystemic shunt TIPS
84
Q

Abnormal inc in PV pressure (>12mmHg)
Obstruction blocks flow
Inc PV pressure
Vasoconstriction
Vasodilation and inc splanchnic flow
Collaterals between portal and systemic circulation
Hepatofugal PV flow (inc blood flow in PV reversed and blood flows out of liver)

A

Portal HTN

85
Q

Collatera between portal and systemic circulation

A 
coronary
umbilical
retroperitoneal
hemorrhoidal
short gastric vein
86
Q

occlusion of major hepatic vein results into postsinusoidal portal HTN

A

Budd-chiari syndrome

87
Q

Extrahepatic causes of portal HTN

A 
Portal vein thrombosis
Congenital
Sepsis
Trauma
Malignant occlusion
88
Q

Intrahepatic causes of portal vein HTN

A

Schistosomiasis

Congenital hepatic fibrosis

89
Q

Sinusoidal cause of portal HTN

A

Cirrhosis

90
Q

Postsinusoidal cause of portal htn

A

Budd Chiari

Veno-occlusive disease

91
Q

Budd Chiari is common in

RUQ pain
Jaundice
Ascites
Hepatosplenomegaly

A

Women in hypercoagulable state

92
Q

Budd Chiari tx

A

Anticoagulant
Porta caval shunt
Porta atrial shunt

93
Q

Portal HTN complication

A

ascites
esophageal varicea
liver failure

94
Q

Portal HTN Dx

A

Transcutaneous liver doppler uts: parenchyma and blood flow pattern

Lab test confirms source of cirrhosis: HBV,HCV titers

95
Q

Portal HTN tx

A

Surgical shunt: for well preserved liver function Child Pugh A and B requiring liver transplant in future >1 yr
(Portocaval and mesocaval shunt)

Liver transplant: Model for End stage Liver Disease (MELD) score
For transplant

96
Q

Caused by splenic vein thrombosis
Resultant from pancreatitis
Results in esophageal varices without main PV HTN
Preserved liver function but bleeding occurs
Tx: splenectomy

A

Sinistral portal HTN

97
Q

Occlusion of PV
Preserved liver function but my require portocaval shunt
No role for TIPS
Splenomegaly, hemorrhage

A

PV thrombosis

98
Q

Portal vein thrombosis in childhood is caused by

A

umbilical vein catheterization

99
Q

Portal vein thrombosis causes in adult

A 
Malignancy HCC
Cirrhosis (low heptopetal flow)
Hyercoagulable state
Dehydration
Infection (schistosomiasis)
100
Q

Dx of portal vein thrombosis confirmed by

A

Duplex Doppet UTZ
CTA
MRA

101
Q

Portal vein thrombosis tx

A

Long term anticoagulation and clot lysis via transhepatic infusion through PV

102
Q

50, M
Hx of HBV found to have hepatic mass
AFP elevated
Lesion is HCC

Apart from staging, what will determine resectability?

A

Child Pugh Classification since resection is limited to A or B

103
Q

Most common cancer of liver worldwide
Men, HBV, HCV, alcohol, hemochromatosis, alpha 1 anti, PSC, hepatic adenoma, steroid use, aflatoxin exposure and pesticide

A

HCC

104
Q

Most common cause of HCC worldwide

A

HBV

105
Q

Majority of liver cases are

1 out of 20 malignant cases are

A

Metastatic lesions

HCC

Lesions in liver require cancer workup to localize primary lesion

106
Q

HCC is associated with

A

AFP >500 ng/dl

107
Q

Dx for HCC

A

UTZ
CT
MRI

108
Q

If AFP nondiagnostic and not surgical candidate, perform in HCC

If candidate for surgery,

CXR and Chest CT to

A

fine needle aspiration with cytology as confirmatory

Perform exlap with or without biopsy

Rule out malignancy

109
Q

For Child Pugh A and B tx

A

Partial hepatectomy

Neoadjuvant chemo and adjuvant for some

110
Q

Transplantation for

A

tumor <5cm
<3 tumors
No PV or IVC involvement

111
Q

Only 15-20% amenable to surgery because

A

tumor multicentricity
Extensive involvement of both lobes
PV invasion
Lymphatic disease

112
Q

If not for surgery, perform

A

HA embolization or tumor cryotherapy
Radioablation
Ethanol injection

113
Q

Staging of HCC

A

Number of tumors
Size
Vascular invasion

Overall prognosis poor 5yr survival for all comes <30%

114
Q 
Cancer of intra or extrahepatic bile duct
Associated with PSC 
Ulcerative colitis
Choledochal cyst
Chronic bile duct infection
A

Cholangiocarcinoma

115
Q

Parasite associated with cholangiocarcinoma

A

Chlonorchid sinensis

116
Q

Inc ALP
Inc bilirubin
Inc GGT
NORMAL Transaminase

A

Cholangiocarcinoma

117
Q

Cholangiocarcinoma confirmed by

A

ERCP

MRI

118
Q

Most common location of cholangiocarcinoma

Unresectable but if amenable, attempt resection of affected liver lobe and bile duct

A

Upper 1/3 of cholangiocarcinoma

119
Q

Middle 1/3 cholangiocarcinoma sx:

A

Hepaticojejunostomy

120
Q

Lower 1/3 cholangiocarcinoma sx:

A

Whipple procedure

121
Q

Cholangiocarcinoma at junction of right and left hepatic ducts

A

Klatskin tumor

122
Q

Median survival of cholangiocarcinoma

A

12-59 months after resection with overall 5 yr survival 20-42%

123
Q

Most common type of gallstone in US

Failure of cholesterol and Ca salts to remain in solution as result imbalance of chole, lecithin and bile acid

A

Cholesterol

124
Q

Black stone caused by precipitation of unconjugated bilirubin with Ca -> Ca bilirubin
Found in association with hemolysis, cirrhosis, chronic TPN, ileal resection

Brown related to chronic biliary infection (E coli)

A

Pigmented black stones

125
Q

Obstruction of pancreatic duct by stone

1/3 of acute pancreatitis cases

A

Gallstone pancreatitis

126
Q

Less than 1%
25% of SBO in elderly who do not have adhesions
Gallstone enters intestine via cholecystoduodenal fistula

A

Gallstone ileus

127
Q

Imaging study of choice for gallstone related diseases

A

RUQ ultrasound

128
Q

Pain by transient obstruction of cystic duct by gallstone

Abrupt or transient RUQ epigastric pain, postprandial (fatty food)

UTZ: Gallstone on RUQ

Mx: avoidance of inciting factors
elective cholecystectomy for symptomatic patients without serious comorbidities

A

Biliary colic

129
Q

Gallbladder inflammation by gallstone obstruction of cystic duct

RUQ pain + Murphy’s sign + fever

Normal LFT
WBC: 12-15 k/UL
RUQ UTZ: Gallstones, Gallbladder wall thickening >4mm, pericholecystic fluid, + sonographic Murphy’s sign

Mx: IV antibiotic cholecystectomy, percutaneous cholecystectomy tube in seriously ill

A

Acute cholecystitis

130
Q

Gallstone in CBD

RUQ epigastric pain, fever, chill, jaundice, acute pancreatitis

Inc ALP/GGT
RUQ UTZ: Dilated CBD >8mm
Stone not well visualized if in distal duct

ERCP with sphincterotomy for patients with previous cholecystectomy or preoperative CBD clearance
Lap chole with intraoperative cholangiogram if preoperative clearance was not achieved

A

Choledocholithiasis

131
Q

Bacterial infection of biliary tract

Charcot triad

Reynaud’s pentacld

RUQ UTZ: Normal biliary tree, dilated CBD >8mm without clear CBD stone does not rule out cholangitis

Supportive therapy with aggressive fluid resuscitation, electrolyte correction, broad spec IV, pain control

Timely ductal drainage: ERCP, sphincterotomy and stone extrac

A

Acute cholangitis

132
Q

Fever
RUQ pain
Jaundice

A

Charcot’s triad

133
Q

Reynold’s pentad

A 
Fever
RUQ pain
Jaundice
Hypotension
Altered mental status
134
Q

gallstone lodges in the ileum at distance

A

1-2 ft proximal to ileocecal valve

135
Q

Rare 1%
Women
Associated with chronic gallbladder inflammation
Associated with porcelain gallbladder (diffuse Ca in gallbladder wall)
Asymptomatic or similar to biliary colic for extended time

A

Gallbladder adenocarcinoma

136
Q

Gallbladder adenocarcinoma is confirmed with

A

UTZ
CT
MRI
MRCP

137
Q

for cases incidentally found after cholecystectomy and with margins no extension through GB wall

A

no further treatment necessary

138
Q

Gallbladder resection needs

A

en bloc till underlying liver depth of 2cm and regional lymphadenectomy

Survival: 5 year 5%

139
Q

35 y, M
Shattered spleen after MVC
Hemodynamically unstable taken emergently to OR for splenectomy

Postop vaccine?

A

Pneumococcus
Meningococcus
H influenzae

140
Q

Indication for splenectomy

A

Traumatic injury: >2 units pRBC transfusion, persistent decline in Hgb, peritonitis, significant intra-abdominal blood

Hodgkin’s: for staging if without evidence of nodal or hepatic disease
Rarely done unless staging will influence treatment

Hematologic disorder: myeloproliferative disorder, refractory idioathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, hereditary spherocytosis and thalassemia major

141
Q

In children, threshold to perform splenectomy is

A

40ml/kg transfused blood or instability

142
Q

Benign implantation of splenic tissue following splenic rupture
Retain function and clear particulate matter from RBCs with resultant norma blood smear

A

Splenosis

143
Q

Post splenectomy complication

A 
Pancreatic leak
Abscess
Left pleural effusion
Infection (encapsulated)
Thrombocytosis
Splenic vein and PV thromboses
144
Q

Clearing of damaged blood cells in the spleen occur in

A

red pulp

145
Q

What segment in the liver will you find the GB

A

IV and V

146
Q

72, F
Biliary obstruction
Medical factors necessitating preoperative percutaneous drainage

A

Cholangitis
Immunosupression
Renal insufficiency
Coagulopathy

147
Q

40 y, M
UGIB from esophagea varices
Medication?

A

Vasopressin

Ocreotide

148
Q

25, F
Protein C deficiency
Acute RUQ pain and jaundice
Occlusion of hepatic vein at IVC

SYNDROME?
Tx

A

Budd Chiari

Anticoagulation

149
Q

75, F
RUQ pain, jaundic, fever
WBC= 16 k/uL with left shift

Next step in management?

A

Reynold’s pentad

Treat with aggressive fluid resuscitation
Broad spec IV antibiotics
Timely ERCP and sphincterotomy with stone extraction

Surgery (17 decks)

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