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Absite 2019 > PBS/HPB > Flashcards

PBS/HPB Flashcards

1
Q

Which patients with panc ca should get dx laparoscopy?

A

Tumors >3 cm, ca 19-9 >100, and panc body or tail cancers (no consensus re: panc head cancers)

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2
Q

Division between left and right lobes of liver?

A

Cantlies line, ie a line from the middle of the GB fossa to the IVC

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3
Q

Where does the portal triad enter

A

sections IV and V

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4
Q

Give anatomic relationship of structures within hepatoduodenal ligament

A

Lateral is CBD, proper hepatic artery is medial, portal vein is posterior

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5
Q

What are Kuppfer cells?

A

Liver macrophages

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6
Q

Name of covering of liver

A

Glisson’s capsule

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7
Q

What sections do right and left portal vein supply

A

Portal vein is 2/3 of blood flow.
Right: sections V–VIII
Left: Sections II–IV

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8
Q

Where does middle hepatic artery most commonly branch from?

A

left hepatic artery

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9
Q

Venous drainage of liver?

A

3 Hepatic veins
Left: II, III, superior IV
Middle: inferior IV, and V
Right: VI-VIII

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10
Q

Where does nutrient uptake occur?

A

sinusoidal membrane

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11
Q

What is the energy source for the liver?

A

Ketones

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12
Q

Where is alk phos located

A

canalicular membrane

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13
Q

How much normal liver can be resected?

A

75%

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14
Q

What does the liver store?

A

Fat soluble vitamins and B12 (only water soluble vitamin stored in liver)

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15
Q

What clotting factors are NOT made in the liver?

A

vWF and Factor VIII (endothelium)

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16
Q

What is indirect bilirubin?

A

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

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17
Q

How high does bili have to be for jaundice and where is it first seen?

A

Tbili >2.5, seen under tongue first

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18
Q

What is conjugated to bilirubin?

A

glucoronic acid by glucoronyl transferase

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19
Q

What is Gilberts dz?

A

Abnormal conjugation due to mild defect in glucuronyl transferase

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20
Q

What is Crigler-Najjar dz?

A

severe defect in glucuronyl transferase leads to inability to conjugate–life threatenng

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21
Q

Causes of high unconjugated (indirect) bili

A

hemolysis, defect in conjugation, deficiency in hepatic uptake

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22
Q

What is Rotors dz?

A

deficiency in bili storage ability–high direct bili

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23
Q

What is Dubin-Johnson syndrome?

A

Defect in bili secretion leading to high direct bili

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24
Q

Which types of hepatitis can lead to fulminant/acute hepatic failure?

A

B, D, E

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25
Q

Which type of hepatitis is a DNA virus?

A

Hep B

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26
Q

How to tell difference between infection and immunization with hep B?

A

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.

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27
Q

What is Hep D?

A

Cofactor for hep B that worsens prognosis

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28
Q

What is Hep E?

A

leads to fulminant hepatic failure in pregnant women, usually during third trimester

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29
Q

Mortality of acute liver failure/

A

80%

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30
Q

most common cause of liver failure?

A

cirrhosis

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31
Q

best indicator of synthetic fxn in patient with cirrhosis?

A

prothrombin time (PT)

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32
Q

What are Kings college criteria for?

A

Poor prognostic indicators for ALF. Should consider urgent txp listing if they are met.

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33
Q

List Kings criteria for acetaminophen induced liver failure?

A

pH <7.3 or all of the following: INR>6.5, Cr >3.4, grade III/IV encephalopathy

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34
Q

List King’s criteria for non-acetaminophen induced ALF/

A

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

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35
Q

Tx for encephalopathy?

A

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

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36
Q

What happens to aldosterone levels with liver failure?

A

elevated

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37
Q

What causes postpartum liver failure?

A

Hepatic vein thrombosis, has an infectious component. Tx with abx and heparin.

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38
Q

Most common organism causing SBP?

A

E coli

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39
Q

Risk fx for SBP?

A

Prior SBP, upper GI bleed, low protein ascites

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40
Q

Dx and tx of SBP?

A

Positive cx with PMNs>250 in fluid, tx with third gen cephalosporin

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41
Q

What is normal portal vein pressure

A

<12

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42
Q

What is the milan criteria?

A

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.

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43
Q

Acute variceal bleed management?

A

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.

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44
Q

What are the elements of the Child Pugh score?

A

Albumin, bilirubin, encephalopathy, ascites, INR

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45
Q

How much liver does a Childs A pt need after liver resection?

A

30-40%

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46
Q

When to use a splenorenal shunt?

A

In Childs A pt who presents with bleeding only. Also has lower incidence of encephalopathy. Don’t use if patient has ascites

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47
Q

What is Budd Chiari syndrome?

A

Hepatic vein occlusive dz (cause of post sinusoidal portal HTN)

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48
Q

Most common cause of splenic vein thrombosis?

A

pancreatitis

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49
Q

Characteristics of amebic cyst?

A

*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.

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50
Q

Characteristics and tx of echinococcal cyst?

A

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.

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51
Q

Characteristics and tx of schistosomiasis.

A

Primary infxn in colon. Can get variceal bleeding (pre sinusoidal cause of portal HTN), maculopapular rash, and elevated eosinophils. Tx with praziquantal.

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52
Q

Tx of pyogenic liver abscess?

A

Abx and perc drainage.

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53
Q

Most common organism for pyogenic liver abscess?

A

E coli, #2 is Klebsiella. Usually from concominant biliary infxn–can occur after bacteremia, diverticulitis, appendicitis

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54
Q

Describe hepatic adenoma

A

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.

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55
Q

Describe focal nodular hyperplasia

A

Appears similar to hepatic adenoma but has central stellate scar. DOES have uptake on sulfur colloid scan . Does not need any tx.

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56
Q

What is the most common benign liver tumor?

A

Hemangiomas

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57
Q

Describe hemangioma

A

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

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58
Q

What is the most common cancer worldwide?

A

HCC

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59
Q

How to dx HCC?

A

CT appearance and elevated AFP

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60
Q

How to differentiate between primary liver tumors and mets?

A

Primary are hypervascular and mets are hypovascular.

61
Q

Most common cause of portal venous thrombosis in children?

A

Umbilical vein infection

62
Q

How to dx hemobilia?

A

Start with EGD to look for blood at the ampulla of vater, then progress to angiography as this can be diagnostic and therapeutic

63
Q

What are the vit K dependent clotting factors?

A

Factors II, VII, IX, X and protein C and S

64
Q

CT appearance of benign hepatic cyst?

A

well defined mass with internal septae, papillary projections, intramural hemorrhage, fine calcifications

65
Q

What is Rigler’s triad?

A

Pneumobilia, SBO, ectopic gallstone. (All 3 present in only 15% of cases of gallstone ileus)

66
Q

Steps to take when CBD stone won’t flush out with saline?

A

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)

67
Q

Which nerve stimulates GB contraction and what inhibits it?

A

Vagus stimulates contraction and splanchnic sympathetics inhibit contraction

68
Q

What percent of bile acids are excreted in stool?

A

5%

69
Q

Where are bile salts conjugated and with what?

A

Conjugated in hepatocytes with glycine and taurine to form cholic acid and chenodeoxycholic acid (primary bile acids)

70
Q

What happens to bile after being excreted into intestine?

A

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.

71
Q

What is the most common cause of Budd Chiari syndrome in the West? In the East?

A

West: Acute or chonic thrombosis and malignancy. East: membranous webs

72
Q

What hormone is the secretion of bile dependent on?

A

Secretin (stimulates chloride channel) is the most potent stimulator of bile secretion

73
Q

How to manage abscess from spilled gallstone?

A

Lap drainage and removal of stone

74
Q

What is goal of resection of cholangiocarcinoma?

A

R0 (microscopically negative margin) resection

75
Q

Normal diameter of CBD?

A

4 to 10 mm

76
Q

What % of esophageal bleeding can be controlled with Blakemore tube and what % rebleed?

A

90% can be controlled and 50% rebleed.

77
Q

What is the Warren shunt?

A

splenorenal shunt–good for bleeding only, not good for ascites

78
Q

Normal size of panc duct?

A

<4 mm

79
Q

Normal thickness of GB wall?

A

<4 mm

80
Q

What are ducts of Luschka?

A

biliary ducts in the GB fossa that can leak after chole

81
Q

What are Rokitansky-Aschoff sinuses?

A

Epithelial invaginations of GB wall from elevated GB pressure

82
Q

What is the rate limiting step in cholesterol synthesis?

A

HmG CoA reductase

83
Q

What percentage of the population have gallstones?

A

10%

84
Q

What 3 things increase bile excretion?

A

secretin (#1), CCK, and vagal stimulation

85
Q

What 2 things decrease bile excretion?

A

somatostatin, sympathetic input from splanchnic

86
Q

What is the highest negative predictive value for choledocholithiasis?

A

GGT (97% neg predictive value)

87
Q

Young patient without cirhosis develops HCC…

A

fibrolamellar variant,better prognosis but recurrence is common, normal AFP but elevated neurotensin

88
Q

GB adenocarcinoma important stages:

A

T1a: lamina propria, cholecystectomy alone
T1b: muscularis propria invasion, need chole + IVb+ V resection + portal LND

89
Q

Isolated gastric varices are most commonly caused by

A

splenic vein thrombosis most commonly caused by pancreatitis

90
Q

Describe different types of liver resection:

A 
Right liver resection: V-VIII
Left: II-IV
Left lateral: II, III
Extended right: V-VIII + IV
Ext left: II-IV + V +VIII
91
Q

Describe management of GB polyps:

A 
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
92
Q

Definition of portal HTN?

A

Hepatic vein pressure gradient >6

93
Q

Pressure needed to rupture a varix?

A

12

94
Q

Risk factors for cholangiocarcinoma?

A

PSC, UC, choledochal cyst, C sinensis infection, CBD infection

95
Q

Most common morphology of cholangiocarcinoma? What histology has best prognosis?

A

Nodular morphology and papillary histology

96
Q

What is the chemo for HCC?

A

sorafenib

97
Q

What are the most common GB stones in the US? Worldwide?

A

US: cholesterol
World: pigmented

98
Q

what are primary CBD stones?

A

Primary = formed within the duct. Brown stones caused by E coli deconjugating bilirubin to calcium bilirubinate. Need sphincteroplasty for tx.

99
Q

What are the 3 most common cholecystitis organisms?

A

E coli (#1), klebsiella, enterococcus

100
Q

Definition of biliary dyskinesia?

A

EF <40%

101
Q

HIDA finding for chronic cholecystitis?

A

> 60 minutes for GB emptying

102
Q

What is the mechanism of acalculous cholecystitis

A

Bile stasis (narcotics, fasting) leading to distention of GB and ischemia

103
Q

What are risk fx for emphysematous GB? Most common organism?

A

DM is a risk factor. Clostridium perfringens

104
Q

How to manage early vs late presentation of total CBD transection?

A

< 7 days postop– hepaticoJ

>7 days postop do hepaticoJ in 6-8 wks bc tissue is too friable at 7 days

105
Q

Risk fx for GB adenoCa?

A

Porcelain GB (15% cancer)

106
Q

What is the cause of a choledochal cyst?

A

Aberrant pancreatic duct anatomy causing reflux of panc enzymes

107
Q

Best dx test for cholangiocarcinoma?

A

MRCP

108
Q

Surgical approach to GB cancer?

A

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.

109
Q

What is the most common cause of benign biliary stricture?

A

Injury from prior operation such as lap chole

110
Q

What is the Bismuth-Corlette classification and name the types

A

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

111
Q

What are the first nodes of metastasis for GB adenocarcinoma?

A

Cystic duct nodes

112
Q

What is the most sensitive modality for detecting liver mets?

A

intraoperative US

113
Q

Tx for Budd Chiari?

A

Anticoagulation followed by tips if AC doesn’t resolve it

114
Q

What is adequate tumor resection margin for CRC liver mets?

A

> 1cm

115
Q

What percentage of patients who die of fulminant hepatic failure have cerebral edema on autopsy?

A

80%

116
Q

How to measure portal pressure in cirrhotics (ie sinusoidal dz)?

A

Hepatic venous wedge pressure (>6 = portal HTN)

117
Q

How to measure portal pressure in patients with presinusoidal dz?

A

Need direct cannulation of transhepatic veins because hepatic wedge will be normal and give falsely low measurements

118
Q

Risk fx for GB cancer?

A

Choledochal cysts, cholelithiasis, large stones (>3 cm), polyps > 1 cm, porcelain GB

119
Q

Describe Wilsons Dz

A

autosomal recessive, defeciency in ATP7B which leads to copper buildup in tissues and eventually leads to cirrhosis

120
Q

What is the normal course of the right hepatic artery? What about replaced right?

A

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.

121
Q

Where does replaced left hepatic artery travel?

A

Comes off the left gastric and travels in the gastrohepatic ligament

122
Q

What is the histologic appearance of fibrolamellar HCC?

A

large polyglonal cells interspersed with sheets of collagen

123
Q

What are the primary and secondary bile acids?

A

Primary: cholic acid and chenodeoxycholic acid (conjugated in hepatocytes by glycine and taurine)
Secondary: deoxycholic and lithocholic acid (further conjugated by bacteria in intestine)

124
Q

What are the bounds of Calot’s triangle?

A

Cystic duct, common hepatic duct, inferior border of the liver

125
Q

What is Caroli’s dz?

A

AKA Type V choledochal cyst = multiple completely intrahepatic cysts–these pts need liver txp

126
Q

What is most common type of choledochal cyst?

A

Type I, which is fusiform or saccular dilation of extrahepatic ducts

127
Q

antimitochondrial Ab assoc with?

A

Primary biliary cirrhosis

128
Q

What can be used to decrease sxs of elevated bili in pts with PBC?

A

cholestyramine and ursodeoxycholic acid (UDCA)

129
Q

Medical tx for chronic pancreatitis?

A

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)

130
Q

Difference between pseudocyst and true cyst?

A

true cyst has epithelial lining

131
Q

Where is the panc duct opened in the Peustow procedure? How big should the duct be?

A

main duct is incised anteriorly, all the way to the GDA medially and laterally into the tail beyond any appreciable strictures. >7 mm

132
Q

Tx for refractory pain in panc Ca or chronic pancreatitis?

A

Celiac plexus neurolysis

133
Q

Signs of infected panc necrosis on CT?

A

air within necrotic tissue or evidence of abscess with air fluid level

134
Q

What happens with injection of secretin normally? What about if pt has gastrinoma (ZE syndrome)?

A

Normally, gastrin level drops. In ZE syndrome, gastrin level increases.

135
Q

Characteristics of unresectable pancreatic cancer?

A

any mets, extension into hepatoduodenal ligament, involvement of SMA or celiac artery, involvement of celiac or SMA nodes

136
Q

What is the most common pancreatic neuroendocrine tumor?

A

Nonfunctional neuroendocrine tumor

137
Q

What is the most common type of pancreatic tumor in pts with MEN1?

A

gastrinoma

138
Q

What is the most common type of functional pancreatic neuroendocrine tumor?

A

insulinoma

139
Q

How much exocrine fxn must be lost before pt has steatorrhea?

A

90%

140
Q

What activates trypsingoen?

A

enterokinase in the duodenum

141
Q

Ovarian stroma in panc tumor is ?

A

mucinous cystic neoplasm

142
Q

Most common site of met for panc adenocarcinoma?

A

liver

143
Q

Sister Mary Joseph nodules are

A

periumbilical adenopathy

144
Q

Blumer shelf sign is

A

pelvic drop metastases from pancreatic cancer

145
Q

Only substance that inhibits both endocrine and exocrine pancreatic secretions?

A

Somatostatin

146
Q

Treatment for ampullary cancer?

A

Whipple

147
Q

Treatment for benign ampullary adenoma <2cm?

A

endoscopic or transduodenal local excision with 2-3 mm margins

148
Q

Fishmouth papilla on EUS

A

IPMN

Absite 2019 (18 decks)

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