PBS/HPB Flashcards
Which patients with panc ca should get dx laparoscopy?
Tumors >3 cm, ca 19-9 >100, and panc body or tail cancers (no consensus re: panc head cancers)
Division between left and right lobes of liver?
Cantlies line, ie a line from the middle of the GB fossa to the IVC
Where does the portal triad enter
sections IV and V
Give anatomic relationship of structures within hepatoduodenal ligament
Lateral is CBD, proper hepatic artery is medial, portal vein is posterior
What are Kuppfer cells?
Liver macrophages
Name of covering of liver
Glisson’s capsule
What sections do right and left portal vein supply
Portal vein is 2/3 of blood flow.
Right: sections V–VIII
Left: Sections II–IV
Where does middle hepatic artery most commonly branch from?
left hepatic artery
Venous drainage of liver?
3 Hepatic veins
Left: II, III, superior IV
Middle: inferior IV, and V
Right: VI-VIII
Where does nutrient uptake occur?
sinusoidal membrane
What is the energy source for the liver?
Ketones
Where is alk phos located
canalicular membrane
How much normal liver can be resected?
75%
What does the liver store?
Fat soluble vitamins and B12 (only water soluble vitamin stored in liver)
What clotting factors are NOT made in the liver?
vWF and Factor VIII (endothelium)
What is indirect bilirubin?
Unconjugated bili found in the colon after conjugated bili is broken down by bacteria in TI. Then free bili is absorbed and converted to urobilinogen
How high does bili have to be for jaundice and where is it first seen?
Tbili >2.5, seen under tongue first
What is conjugated to bilirubin?
glucoronic acid by glucoronyl transferase
What is Gilberts dz?
Abnormal conjugation due to mild defect in glucuronyl transferase
What is Crigler-Najjar dz?
severe defect in glucuronyl transferase leads to inability to conjugate–life threatenng
Causes of high unconjugated (indirect) bili
hemolysis, defect in conjugation, deficiency in hepatic uptake
What is Rotors dz?
deficiency in bili storage ability–high direct bili
What is Dubin-Johnson syndrome?
Defect in bili secretion leading to high direct bili
Which types of hepatitis can lead to fulminant/acute hepatic failure?
B, D, E
Which type of hepatitis is a DNA virus?
Hep B
How to tell difference between infection and immunization with hep B?
Hep B core antibody (IgM) is high in first 6 mos after infection, then IgG takes over. Infected people have high anti-core and anti-surface antibodies as well as HBs antigen present. People who were infected and recovered have no antigen. People who were immunized have anti-surface only.
What is Hep D?
Cofactor for hep B that worsens prognosis
What is Hep E?
leads to fulminant hepatic failure in pregnant women, usually during third trimester
Mortality of acute liver failure/
80%
most common cause of liver failure?
cirrhosis
best indicator of synthetic fxn in patient with cirrhosis?
prothrombin time (PT)
What are Kings college criteria for?
Poor prognostic indicators for ALF. Should consider urgent txp listing if they are met.
List Kings criteria for acetaminophen induced liver failure?
pH <7.3 or all of the following: INR>6.5, Cr >3.4, grade III/IV encephalopathy
List King’s criteria for non-acetaminophen induced ALF/
INR >6.5 or any 3 of the following: age <10 or >40, drug tox or unknown etiology, jaundice >7 days before encephalopathy, INR >3.5, bili >17
Tx for encephalopathy?
Lactulose–is a cathartic that acidifies the gut and therefore prevents uptake of NH3 by turning it into NH4–titrate to 2-3 stools per day.
Limit protein intake <70 g/day
Neomycin eradicates ammonium producing bacteria from gut
Ligate previous therapeutic shunts or large collaterals
What happens to aldosterone levels with liver failure?
elevated
What causes postpartum liver failure?
Hepatic vein thrombosis, has an infectious component. Tx with abx and heparin.
Most common organism causing SBP?
E coli
Risk fx for SBP?
Prior SBP, upper GI bleed, low protein ascites
Dx and tx of SBP?
Positive cx with PMNs>250 in fluid, tx with third gen cephalosporin
What is normal portal vein pressure
<12
What is the milan criteria?
Criteria that must be met for patient with HCC to be eligible for liver txp. Must have single tumor < 5cm or 3 or fewer tumors all less than 3 cm with no vascular or extrahepatic invasion.
Acute variceal bleed management?
Vasopressin and octreotide for splanchnic vasoconstriction. Then EGD for banding and sclerotherapy. If pt is unstable then use Blakemore balloon. Propanolol can help prevent rebleeding. Refractory bleeding is an indication for TIPS.
What are the elements of the Child Pugh score?
Albumin, bilirubin, encephalopathy, ascites, INR
How much liver does a Childs A pt need after liver resection?
30-40%
When to use a splenorenal shunt?
In Childs A pt who presents with bleeding only. Also has lower incidence of encephalopathy. Don’t use if patient has ascites
What is Budd Chiari syndrome?
Hepatic vein occlusive dz (cause of post sinusoidal portal HTN)
Most common cause of splenic vein thrombosis?
pancreatitis
Characteristics of amebic cyst?
*Primary infxn is in the colon and travels to liver via portal vein. Recent travel to Mexico, RUQ pain, elevated WBC. Imaging: liver abscess without rim enhancement. Dx; serology positive for Entamoeba histolytica. Tx: flagyl. Don’t aspirate unless refractory, don’t operate except for free rupture.
Characteristics and tx of echinococcal cyst?
AKA hytatid cyst. See double walled cyst on CT. Tx with preop albendazole and then resection. DO NOT aspirate 2/2 anaphylaxis if contents are spilled.
Characteristics and tx of schistosomiasis.
Primary infxn in colon. Can get variceal bleeding (pre sinusoidal cause of portal HTN), maculopapular rash, and elevated eosinophils. Tx with praziquantal.
Tx of pyogenic liver abscess?
Abx and perc drainage.
Most common organism for pyogenic liver abscess?
E coli, #2 is Klebsiella. Usually from concominant biliary infxn–can occur after bacteremia, diverticulitis, appendicitis
Describe hepatic adenoma
Usually seen in women, assoc with OCP and steroid use. On CT is hypervascular and rapidly enhancing during arterial phase with rapid washout during portal phase, and has no uptake on sulfur colloid scan (no kuppfer cells). Need tx 2/2 risk of malignant conversion or rupture with hemorrhage. If < 4cm then stop OCP and see if regresses. If no regression then needs resection.
Describe focal nodular hyperplasia
Appears similar to hepatic adenoma but has central stellate scar. DOES have uptake on sulfur colloid scan . Does not need any tx.
What is the most common benign liver tumor?
Hemangiomas
Describe hemangioma
Hypervascular on CT with peripheral to cental enhancement/peripheral nodular enhancement on delayed imaging. Does not need tx unless symptomatic. Do not bx 2/2 risk of hemorrhage. Kasabach Meritt syndrome is a consumptive coagulopathy that is a rare complication
What is the most common cancer worldwide?
HCC
How to dx HCC?
CT appearance and elevated AFP
How to differentiate between primary liver tumors and mets?
Primary are hypervascular and mets are hypovascular.
Most common cause of portal venous thrombosis in children?
Umbilical vein infection
How to dx hemobilia?
Start with EGD to look for blood at the ampulla of vater, then progress to angiography as this can be diagnostic and therapeutic
What are the vit K dependent clotting factors?
Factors II, VII, IX, X and protein C and S
CT appearance of benign hepatic cyst?
well defined mass with internal septae, papillary projections, intramural hemorrhage, fine calcifications
What is Rigler’s triad?
Pneumobilia, SBO, ectopic gallstone. (All 3 present in only 15% of cases of gallstone ileus)
Steps to take when CBD stone won’t flush out with saline?
Give 1-2 mg of glucagon IV, then transcystic stone retrieval (basket under fluoro or choledochoscope–cystic duct must be 8mm, laparoscopic choledochotomy with balloon sweep and T tube placement)
Which nerve stimulates GB contraction and what inhibits it?
Vagus stimulates contraction and splanchnic sympathetics inhibit contraction
What percent of bile acids are excreted in stool?
5%
Where are bile salts conjugated and with what?
Conjugated in hepatocytes with glycine and taurine to form cholic acid and chenodeoxycholic acid (primary bile acids)
What happens to bile after being excreted into intestine?
80% of conjugated bile acids are absorbed by active transport in the TI. The remainder get deconjugated in the colon by bacteria and are absorbed by passive transport in the colon.
What is the most common cause of Budd Chiari syndrome in the West? In the East?
West: Acute or chonic thrombosis and malignancy. East: membranous webs
What hormone is the secretion of bile dependent on?
Secretin (stimulates chloride channel) is the most potent stimulator of bile secretion
How to manage abscess from spilled gallstone?
Lap drainage and removal of stone
What is goal of resection of cholangiocarcinoma?
R0 (microscopically negative margin) resection
Normal diameter of CBD?
4 to 10 mm
What % of esophageal bleeding can be controlled with Blakemore tube and what % rebleed?
90% can be controlled and 50% rebleed.
What is the Warren shunt?
splenorenal shunt–good for bleeding only, not good for ascites
Normal size of panc duct?
<4 mm
Normal thickness of GB wall?
<4 mm
What are ducts of Luschka?
biliary ducts in the GB fossa that can leak after chole
What are Rokitansky-Aschoff sinuses?
Epithelial invaginations of GB wall from elevated GB pressure
What is the rate limiting step in cholesterol synthesis?
HmG CoA reductase
What percentage of the population have gallstones?
10%
What 3 things increase bile excretion?
secretin (#1), CCK, and vagal stimulation
What 2 things decrease bile excretion?
somatostatin, sympathetic input from splanchnic
What is the highest negative predictive value for choledocholithiasis?
GGT (97% neg predictive value)
Young patient without cirhosis develops HCC…
fibrolamellar variant,better prognosis but recurrence is common, normal AFP but elevated neurotensin
GB adenocarcinoma important stages:
T1a: lamina propria, cholecystectomy alone
T1b: muscularis propria invasion, need chole + IVb+ V resection + portal LND
Isolated gastric varices are most commonly caused by
splenic vein thrombosis most commonly caused by pancreatitis
Describe different types of liver resection:
Right liver resection: V-VIII Left: II-IV Left lateral: II, III Extended right: V-VIII + IV Ext left: II-IV + V +VIII
Describe management of GB polyps:
Majority are benign hyperplastic symptomatic: need cholecystectomy asymptomatic but concurrent stones: need chole > 6 mm: 6 mos US > 10 mm: need chole > 18 mm: tx as GB cancer
Definition of portal HTN?
Hepatic vein pressure gradient >6
Pressure needed to rupture a varix?
12
Risk factors for cholangiocarcinoma?
PSC, UC, choledochal cyst, C sinensis infection, CBD infection
Most common morphology of cholangiocarcinoma? What histology has best prognosis?
Nodular morphology and papillary histology
What is the chemo for HCC?
sorafenib
What are the most common GB stones in the US? Worldwide?
US: cholesterol
World: pigmented
what are primary CBD stones?
Primary = formed within the duct. Brown stones caused by E coli deconjugating bilirubin to calcium bilirubinate. Need sphincteroplasty for tx.
What are the 3 most common cholecystitis organisms?
E coli (#1), klebsiella, enterococcus
Definition of biliary dyskinesia?
EF <40%
HIDA finding for chronic cholecystitis?
> 60 minutes for GB emptying
What is the mechanism of acalculous cholecystitis
Bile stasis (narcotics, fasting) leading to distention of GB and ischemia
What are risk fx for emphysematous GB? Most common organism?
DM is a risk factor. Clostridium perfringens
How to manage early vs late presentation of total CBD transection?
< 7 days postop– hepaticoJ
>7 days postop do hepaticoJ in 6-8 wks bc tissue is too friable at 7 days
Risk fx for GB adenoCa?
Porcelain GB (15% cancer)
What is the cause of a choledochal cyst?
Aberrant pancreatic duct anatomy causing reflux of panc enzymes
Best dx test for cholangiocarcinoma?
MRCP
Surgical approach to GB cancer?
Should do staging laparoscopy first bc 50% of patients will have unresectable dz. If dz is resectable, procedure should be performed open. Cancers in the GB infundibulum require CBD resection and RNY hepaticoJ. Frozen section has only 70% accuracy for depth of invasion. Patients with unresectable disease have only 6 mos median survival.
What is the most common cause of benign biliary stricture?
Injury from prior operation such as lap chole
What is the Bismuth-Corlette classification and name the types
Classified cholangiocarcinoma based on location of disease.
Type I: tumor involving common hepatic duct
II: involving hepatic bifurcation
III: involving secondary hepatic ducts on one side
IV: involving secondary hepatic ducts on both sides
What are the first nodes of metastasis for GB adenocarcinoma?
Cystic duct nodes
What is the most sensitive modality for detecting liver mets?
intraoperative US
Tx for Budd Chiari?
Anticoagulation followed by tips if AC doesn’t resolve it
What is adequate tumor resection margin for CRC liver mets?
> 1cm
What percentage of patients who die of fulminant hepatic failure have cerebral edema on autopsy?
80%
How to measure portal pressure in cirrhotics (ie sinusoidal dz)?
Hepatic venous wedge pressure (>6 = portal HTN)
How to measure portal pressure in patients with presinusoidal dz?
Need direct cannulation of transhepatic veins because hepatic wedge will be normal and give falsely low measurements
Risk fx for GB cancer?
Choledochal cysts, cholelithiasis, large stones (>3 cm), polyps > 1 cm, porcelain GB
Describe Wilsons Dz
autosomal recessive, defeciency in ATP7B which leads to copper buildup in tissues and eventually leads to cirrhosis
What is the normal course of the right hepatic artery? What about replaced right?
Normal R hepatic artery travels posterior to the common hepatic duct in 85% of people and anterior to it in 15% of people. Replaced right comes off SMA and passes through the medial aspect of Calot’s triangle, posterior to cystic duct.
Where does replaced left hepatic artery travel?
Comes off the left gastric and travels in the gastrohepatic ligament
What is the histologic appearance of fibrolamellar HCC?
large polyglonal cells interspersed with sheets of collagen
What are the primary and secondary bile acids?
Primary: cholic acid and chenodeoxycholic acid (conjugated in hepatocytes by glycine and taurine)
Secondary: deoxycholic and lithocholic acid (further conjugated by bacteria in intestine)
What are the bounds of Calot’s triangle?
Cystic duct, common hepatic duct, inferior border of the liver
What is Caroli’s dz?
AKA Type V choledochal cyst = multiple completely intrahepatic cysts–these pts need liver txp
What is most common type of choledochal cyst?
Type I, which is fusiform or saccular dilation of extrahepatic ducts
antimitochondrial Ab assoc with?
Primary biliary cirrhosis
What can be used to decrease sxs of elevated bili in pts with PBC?
cholestyramine and ursodeoxycholic acid (UDCA)
Medical tx for chronic pancreatitis?
pain control, cessation of ETOH, enzyme replacement with PPI (to prevent inactivation of enzymes from acid), +- antisecretory therapy (SST or octreotide), medium chain TG (long chain TG can’t be digested)
Difference between pseudocyst and true cyst?
true cyst has epithelial lining
Where is the panc duct opened in the Peustow procedure? How big should the duct be?
main duct is incised anteriorly, all the way to the GDA medially and laterally into the tail beyond any appreciable strictures. >7 mm
Tx for refractory pain in panc Ca or chronic pancreatitis?
Celiac plexus neurolysis
Signs of infected panc necrosis on CT?
air within necrotic tissue or evidence of abscess with air fluid level
What happens with injection of secretin normally? What about if pt has gastrinoma (ZE syndrome)?
Normally, gastrin level drops. In ZE syndrome, gastrin level increases.
Characteristics of unresectable pancreatic cancer?
any mets, extension into hepatoduodenal ligament, involvement of SMA or celiac artery, involvement of celiac or SMA nodes
What is the most common pancreatic neuroendocrine tumor?
Nonfunctional neuroendocrine tumor
What is the most common type of pancreatic tumor in pts with MEN1?
gastrinoma
What is the most common type of functional pancreatic neuroendocrine tumor?
insulinoma
How much exocrine fxn must be lost before pt has steatorrhea?
90%
What activates trypsingoen?
enterokinase in the duodenum
Ovarian stroma in panc tumor is ?
mucinous cystic neoplasm
Most common site of met for panc adenocarcinoma?
liver
Sister Mary Joseph nodules are
periumbilical adenopathy
Blumer shelf sign is
pelvic drop metastases from pancreatic cancer
Only substance that inhibits both endocrine and exocrine pancreatic secretions?
Somatostatin
Treatment for ampullary cancer?
Whipple
Treatment for benign ampullary adenoma <2cm?
endoscopic or transduodenal local excision with 2-3 mm margins
Fishmouth papilla on EUS
IPMN
