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TOBIAS Whole book 2 > LIVER, PANCREAS: 95, 96, 97 > Flashcards

LIVER, PANCREAS: 95, 96, 97 Flashcards

1
Q

Liver anatomy

A

442

4 lobes (right, left, quadrate, caudate)
4 sublobes (right, left lateral and medial)
2 processes (caudate, papillary)
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2
Q

is it more difficult to access surgically the left or right lobe? why?

A

easier the LEFT (sustantial cleft separating the medial and lateral portions

the right medial lobe has a substantial attachment to the quadrate lobe
the right lateral lobe is fused at it’s base with the caudate lobe

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3
Q

blood supply and O2 supply to the liver

A

HEPATIC ARTERY: 20% volume, 50% O2

PORTAL VEIN: 80% volume, 50% O2

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4
Q

possible conformation of the Heparic artery

A

1- common trunk
2- right lateral + left
3- right lateral + right medial + left

left always the larger

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5
Q

where the cystic artery of the gallbladder originates from?

A

from the left branch of the hepatic artery

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6
Q

DOG vs CAT: difference in anatomy beetween intrahepatic portal vein

A

CANINE: usually divide in right and left main branch
FELINE: usually divide in 3 branches ( right, central, left)

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7
Q

how it is called the manouvre to stop the the blood inflow to the liver?

A

pringle manouvre

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8
Q

number of hepatic ducts in dog

A

2-8

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9
Q

DOG vs CAT: major and minor papilla differences

A

DOG:
major papilla: CBD. Adjacent to CBD enters the pancreatic duct
minor papilla: accessory pancreatic duct (larger)

CAT:
major papilla: CBD + pancreatic duct (conjoined with the CBD)
minor papilla: 20% cats have accessory pancreatic duct (smaller)

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10
Q

compensatory hypertrophy and hyperplasia of liver after 70% resection

A

usually reached after 6 days. may take up to 6-10 weeks

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11
Q

factors that impede liver regeneration

A

diabetes mellitus: insulin is one of the most potent hepatotrophic factors in protal blood

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12
Q

most common cause of extrahepatic biliary tract injury

A

blunt abdominal trauma

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13
Q

most common causes of extrahepatic biliary obstruction

A

pancreatitis, neoplasia, mucoceles, cholangitis, cholelitiasis

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14
Q

possible consequences of extrahepatic biliary tract obstruction

A 
hypotension
decreased myocardial contractility 
AKI
coagulopaties
gastrointestinal hemorrage
delayed wound healing

absence of bile salts lead to bacterial overgrowth?

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15
Q

mortality rates beetween sterile-septic bile peritonitis

A

higher mortality rates with septic bile peritonitis

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16
Q

RX visualization of coleliths

A

50% radiopaque in dogs

80% radiopaque in cats

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17
Q

first US sign of extrahepatic biliary tract obstruction

A 
CBD dilation (normal: 3-4 mm) 
begins to dilate as soon as 48 h after obstruction
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18
Q

prevalence of coagulation abnormality in dogs with liver desease

A

up to 57% of dog with at least one abnormality

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19
Q

is there a concrete risk of hemorrage with liver desease?

A

in human no increased bleeding tendencies have been seen in patients with coagulation abnormalities due to liver desease

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20
Q

degree of liver resection at wich we can observe hypoglicemia

A

when up to 70% of liver is resected

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21
Q

most common bacteria isolated in liver culture

A

clostridium perfringens

staphylococcus spp

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22
Q

oxidized regenerated cellulose VS gelatin sponge

A

ORC seem to have antibacterial properties

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23
Q

name the 3 technique to control extensive hemorrage from hepatic surgery

A

1- control of central venous pressure
2- occlusion of liver inflow
3- occlusion of liver inflow and outflow

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24
Q

time of liver inflow occlusion tolerated

A

20 min: dogs are less tolerant than humans because they have reduced intrinsic portosystemic collateral circulation

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25
Q

difference beetween stapling technique and dissection and ligation technique

A

both safe and effective

dissection and ligation tough associated with more microscopic hemorrage, necrosis and inflammation

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26
Q

serum bilirubin concentration to see icterus

A

> 1.5- 2 mg/dl

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27
Q

is there aboundant fluid associated with bile peritonitis? how it is diagnosed?

A

usually yes, because of hyperosmolar nature of bile

diagnosed when bilirubin concentration of peritoneal fluid is 2- > then bil in the serum

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28
Q

DOG vs CAT: prevalence of positive culture of bile

A

17-39% of dogs

30-50% cats

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29
Q

best antibiotic choice for septic bile peritonitis

A

2 gen cephalosporin, it lack efficacy against enterococci

-> add ampicillin for enterococcus spp.

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30
Q

critical point to decide when medical treatement alone or when perform surgery?

A

if patency of the CBD can not be demostrated via normograde or retrograde catheterization of the duct, consider a sirgical approach with cholecistoenterostomy.

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31
Q

choledochal catheterization approach in order:

A

1- small antimesenteric duodenotomy to cateterize major papilla
2- establish patency
3- colecistectomy
4- thorough flushing of the duct

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32
Q

cholecistectomy tip

A

always flushing the CBD to ensure that all gelatinous bile is removed from the common bile duct

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33
Q

port placement for laparoscopic cholecystectomy

A

4 PORT:

subumbilical camera
LEFT: 5-8 lateral, 3-5 cranial umbilicus
RIGHT: 3-5 lateral umbilicus
RIGHT: 5-8 lateral umbilicus

1 PORT: umbilicus

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34
Q

tip to remove the gallbladder laparoscopically from the abdomen

A

when in the retrival bag, puncture and aspirate it’s content to facilitate exteriorization

35
Q

when to perform a cholecystoenterostomy

A
  • when the CBD is too small or fragile to permit choledochoduodenostomy
  • can’t reestablish patency of CBD

-not do when suspect pf necrotic gallbladder

36
Q

how to reduce stroma narrowing with cholecystoenterostomy

A

appose mucosa on mucosa

37
Q

size of stenting fot choledocal stenting

A

CAT: 3.5-5 Fr
DOG: 8-12 Fr

38
Q

choledocal stenting outcome in cats

A

probably due to reduced diameter it can lead to reobstruction after a few days-weeks from the stenting

39
Q

surgical options for a colecystostomy tube

A

traditional “open” technique

laparoscopic assisted

40
Q

percoutaneous drainage ad alcoholization of hepatic abscesses (Zatelli et al.)

A 
ultrasound guidance
place 20 G needle
aspirate
95% ethanol 1/2 volume removed 
left in situ for 3 minutes
41
Q

signalment of dogs with liver lobe torsion

A

middle-old large breed dogs

no gender or underlying desease predisposition

42
Q

endocrinopaties associated with gallbladder mucocele

A

hypotiroidism, hyperadrenocorticism

43
Q

can you perform a cholecistoduodenostomy in a dog with gallbladder mucocele?

A

usually no, because gallbladder wall is not healthy enough

44
Q

choleliths composition ad difference with humans

A

in dogs less saturated with colesterol

usually composed of calcium carbonate or calcium bilirubinate, cholesterol in varying quantities

45
Q

what are the 4 possible general type hepatic tumors

A

hepatocellular
cholangiocellular
neuroendocrine
mesenchymal

metastatic

46
Q

what’s the most common liver neoplasm? DOG VS CAT

A

DOG: hepatocellular carcinoma (50-70%) of non hematopoietic
CAT: bile duct tumors most common primary hepatic tumor (biliary duct adenomas 2 more common than biliary duct carcinomas). hepatocellular adenomas more common than carcinomas

47
Q

possible forms of diffusion of liver tumors

A

massive (61%)
nodular (29%)
diffuse (10%)

left lobe in 67% cases

48
Q

tributaries of the portal vein from caudal to cranial

A

CRANIAL MESENTERIC : jejunal+caudal pancreaticoduodenal
CAUDAL MESENTERIC: ileocolic+left colic+right colic+middle colic
SPLENIC: splenic+left gastroepiploic+left gastric+branch from pancreas
GASTRODUODENAL: pancreas+duodenum +stomach (right gastric and right gastroepiploic)

49
Q

portal vein anatomy

A

RIGHT BRANCH
caudate process+right lateral lobe

LEFT BRANCH
RIGHT VENTROLATERAL BRANCH right medial lobe
PAPILLARY BRANCH to papillary process
DIVIDE IN quadrate, left medial, left lateral

50
Q

how many hepatic veins usually a dog have?

A

5 to 8

51
Q

how many pairs of cardinal veins develop in the embryonic trunk?

A

3

caudal cardinal
subcardinal
sopracardinal

52
Q

a congenital portocaval or portoazygos shunt is an abnormal connection beetween the ……………….. and ……………………….system

A

cardinal vitelline

53
Q

left sided IHPSS usually result from patency of

A

the ductus venosus

54
Q

name the 3 categories of liver vascular desease

A

1- congenital PSS
2- primary hypoplasia of the portal vein (PVH)
PVH with portal hypertension (idiopatic noncirrhotic portal hypertension)
PVH without PH (microvascular dysplasia MVD)
3- disturbances in portal outflow

55
Q

prevalence of PSS in dogs with PVH-MVD

A

58% dogs and 87% cats with PVH-MVD have a congenital PSS

56
Q

what is a hepatic arteriovenous malformation?

A

multiple high pressure vessel connecting hepatic artery with portal vein through multiple (tens to hundreds) shunting vessels

57
Q

name some of the toxins implicated with hepatic encephalopathy

A

14:

ammonia
aromatic amino acids
bile acids
decrease alpha ketoglutarate

endogenous benzodiazepines
GABA
false neurotransmitters

tyrosine
phenylalanine
methionine
glutamine
tryptophan
phenol
SCFAs
58
Q

coagulopaties in patients with PSS

A

43% found coagulation abnormalities

40 times more lijely when hepatic encephalophaty present

59
Q

breed associated with increase in PSS prevalence

A

EHPSS

35.9% yorkshire terrier 
maltese
pugs
miniature schnauzer
norwegian terriers 
havanese

IHPSS

large breed dogs: irish wolfhounds, retrievers, australian cattle dog, australian sheperd. left divisional considered heritable in irish wolfhounds

60
Q

potential causes of PU-PD in dogs with PSS

A

poor medullary gradient due to low urea
increased GFR
increase in ACTH associated with hypercortisolism
psycogenic polididpsia

61
Q

hypoalbuminemia in dogs with PSS

A

most common in dogs with a concurrent

PLE
GI ulceration or IBD or lymphangectasia
heavy intestinal parasite loads

62
Q

liver function tests

A

bile acids: after 12 h fasting and 2 hour postprandial (up to 100% sensitive with both measurements or only post-prandial)

ammonia: abnormal in 62% to 88% of animals

ammonia tolerance test? (amonium cloride orally or rectally)

63
Q

common findings in histopatology of PSS liver

A 
bile duct proliferation
hypoplasia of intrahepatic portal tributaries 
hepatocellular atrophy
arteriolar proliferation or duplication
lipidosis
cytoplasmatic vacuolar changes 
smooth muscle hypertrophy
increased lymphatics around central veins
Ito and Kupffer cell hypertrophy
64
Q

is it possible to differentiate PSS from PVH-MVD (without hypertension) from PVH (with hypertension) based on hustopatologhic changes?

A

usally no

dogs with non cirrothic PH often have more significant fibrosis extending in the parenchima

65
Q

Portal vein to Aorta ratio to detect PSS

A

PV/Ao

1-2 normal

0,14-‘,6 suggestive of PSS

66
Q

medical management of PSS

A

lactulose: entrapment of luminal ammonia in form of ammonium (acidificate colon content) + osmothic effect

plasma for coagulopathies

antiacids for GI ulcerations

seizure control. benzo-amtagonist to reverse hepatic encephalopaty? seizures not caused by hypoglicemia or hyperammoniemia treated with benzodiazepines

mannitol to decrease cerebral edema

hepatoprotector

diuretics for ascites. spironolactome is a potassium sparing drugs, furosemide may potentiate hypokaliemia

67
Q

prognosis IHPSS vs EHPSS

A

IHPSS: on medical management persistent neuro and urinary signs, nut GI gets better

EHPSS: neuro, urinary, GI, same or better with medical therapy

68
Q

for how long should preoperative therapy be used?

A

at least 2 weeks

69
Q

possible location of EHPSS

A

phrenic: esophageal hiatus
azygos: aortic hiatus
epiploic foramen: CVC dorsal, HA PV ventral, celiac artery caudally
caudal abdomen: colon caval shunts, falciform ligament, hilus liver to internal thoracic vein

70
Q

determining the degree of shunt attenuation

A

up to 86% of dogs undergoing acute occlusion require partial attenuation

MAX 17-24 mmHg post ligation, or 2x the previous measured pressure

closure limited to a degree where the flow become epatopetal

71
Q

how can you classify IHPSS

A

shunt of the left division
shunt of the central division
shunt of the right division

72
Q

name the 4 main concearn-complications associated with PSS surgical attenuation

A
  • significant postoperative hypoglicemia: reported in up to 44% of dogs within 4 hours of surgery
  • hemorrage anemia
  • portal hypertension: 2-14% with acute ligation, less common in partial. clinical signs can be hypovolemic shock, hypotermia, abdominal pain, abdominal distention, dhiarrea, vomiting.
73
Q

pancreas vascular suppy

A

CELIAC ARTERY:

       splenic artery (left limb)
       hepatic artery: terminates as cranial PD artery (body+proximal right limb)

CRANIAL MESENTERIC

   caudal PD artery
74
Q

name the 2 pancreatic ducts

A

accessory PD: duct of Santorini (dog bigger, exit at minor papilla)

second duct: duct of Wirsung (dog smaller, exit major papilla)

  80% cats have only one duct thet fuses with CBD and exit at major papilla
75
Q

what are the 3 mechanism to prevent autodigestion of pancreas

A

1: stored as inactive zymogens
2: storage of inactuve zymogen inside the rough endoplasmic reticulum of pancreas
3: pancreatic secretory trypsin inhibitor

76
Q

what are the 2 molecules that activate the exocrine pancreas secretion?

A

secretin (bicarbonates)
cholacystokinin (digestive enzymes)

released from duodenal cells whan ingesta passes or smell, or food in the stom

77
Q

what anesthetic shouldn’t be used in dogs with insulinoma or diabetes mellitus?

A

a2 agonist: in normal animals produce hypoinsulinemia and hyperglicemia. in diseased animals the impact is unknown

78
Q

based on hystopatologic result, wtah technique beetween blunt dissection and suture fracture technique is the best for pancreatic biopsy?

A

blunt dissection revealed less severe inflammatory reaction.

however, no differences detected on clinical signs beetween two groups

79
Q

bacterial culture in pancreatic abscesses in dog and cats

A

in humans majority of pancreatic abscesses have positive cultures.

dogs majority seems to be sterile.

80
Q

serum lipase correlation with pancreatic carcinoma

A

when 25 times upper normal limit highly suggestive of malignant carinoma rather tha simply pancreatitis

81
Q

insulinomas: benign or malign?

A

60% are carcinomas, 40% are adenomas.

50 % metastasis at time of diagnosis

MST: no met (18 months) met (7-9 months)

82
Q

insulinomas on TC

A

insulinomas appear uniformly hypervascular and can be differentiated from usually hypovascular exocrine carcinomas.

common false positive results for detection of metastases

83
Q

gastrinoma: what are the cells involved in malignant transformation?

A

somatostatin-secreting delta cells

84
Q

condition usually associated with glucagonoma

A

rather than the expected hyperglicemia, usually associated with hepatocoutaneous syndrome (superficial necrolytic dermatitis).

TOBIAS Whole book 2 (18 decks)

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