The Surgical Review- Hepatobiliary and Pancreas Flashcards
1
Q
What are the five different types of choledochal cysts?
A
I: Fusiform: dilation of CBD
II: isolated diverticulum protruding from the CBD
III: dilation of duodenal portion of CBD
IV: multiple dilations of intra and extra hepatic biliary tree
V (Caroli disease): intrahepatic without extra hepatic
2
Q
What is the treatment of type I, II and V?
A
I and II: Roux en y
V: liver txp
3
Q
patients with Primary sclerosing cholangitis have an increased risk for development of what type of cancer?
A
cholangiocarcinoma (follow them with serial CA19-9)
PSC assoc w UC
4
Q
what test is the most sensitive and specific for the diagnosis of pyogenic liver abscess?
A
CT
5
Q
Which bugs usually cause pyogenic liver abscess?
A
polymicrobial consisting of:
- klebsiella
- e coli
- streptococci
- bacteroides fragilis
6
Q
Treatment of pyogenic liver abscess?
A
IR percutaneous drainage _ broad spectrum antibiotics
open surgical drainage is reserved for septic patients who fail percutaneous drainage
7
Q
Which AMEBA causes liver abscesses and which populations do they affect?
A
- Entamoeba histolytica
- infects alcoholic and homosexual pts
- ingested then migrate from intestine to liver
8
Q
Treatment entamoeba histolytic abscess?
A
14 days metronidazole
9
Q
what bug cases hydatid liver disease (cysts)?
A
Echinococcus granulosum (tapeworm)
10
Q
treatment of hydatid cyst?
A
surgical resection is definitive, only 50% respond to albendazole
- cysts are highly antigenic and rupture may result in anaphylactic shock
11
Q
who are the definitive hosts for echinococcus granulosum?
A
dogs!
but humans get it after ingesting the eggs from sheep or cattle
- eggs penetrate the small bowel and migrate via the portal blood system
12
Q
2 causes of bleeding gastric varices?
A
- Portal HTN 2/2 cirrhosis (TIPS)
2. Splenic vein thrombosis (perform splenectomy)
13
Q
why do gastric varies provide a greater therapeutic challenge than esophageal varices?
A
their deeper submucosal position may preclude effective endoscopic therapy
14
Q
What are the contraindications to TIPS?
A
- Right sided heart failure with increased CVP
- Severe hepatic failure
- Portal vein thrombosis
- Severe hepatic encephalopathy
- Active local or systemic infection
15
Q
treatment of bleeding gastroesophageal varices?
A
endoscopic band ligation + serial endoscopy with banding
tips is second tier option
16
Q
What are the different types of portosystemic shunts?
A
- Nonselective shunts: portocaval or mesocaval, decompress the entire portal system
- Selective: distal splenorenal (warren), decompress the gastroesophageal bed only thus decreased risk of hepatic failure
17
Q
what is the Child’s Pugh score and what factors does it take into account? 5 factors
A
- score that classifies liver failure
1. Serum bilirubin
2. Serum albumin
3. Ascites
4. Encephalopathy
5. Nutrition
18
Q
What is the MELD score and what factors does it use?
A
Model for End Stage Liver Disease: pre and post surgical mortality associated with cirrhosis
- Creatinine
- Bilirubin
- INR
19
Q
Formula for MELD? teehee
A
= 0.957xlog(Cr)
+ 0.378xlog(Bilirubin)
+ 1.120xlog(INR)
20
Q
What are the most common benign solid tumors of the liver?
A
Hemangiomas: rarely bleed or cause symptoms, only when >10cm
21
Q
treatment of hemangiomas?
A
observe!
unless huge and symptomatic and surgical tx is warranted: enucleation
22
Q
what is Kasabach-Merritt syndrome?
A
Hemangioma + thrombocytopenia and consumptive coagulopathy
- thus surgical enucleation of hemangioma
- mostly seen in kids, assoc w high mortality
23
Q
management of benign hepatic cysts?
A
observe
24
Q
how do you distinguish between Focal Nodular Hyperplasia and hepatic adenoma?
A
MRI can distinguish lesions
- confirmatory study: technetium-99m sulfur colloid scan, the Kupffer cells of FNH will take up radionuclide
25
what is Focal nodular Hyperplasia?
- hyperplastic nodule formed by normal hepatocytes and Kupffer cells that congregate around a solid central artery
- do not hemorrhage, are not hormonally responsive, not associated with malignant change
26
what is a hepatic adenoma?
- can have malignant degeneration to HCC
- may enlarge upon exposure to higher levels of circulating hormones
- can contain intraparenchymal hemorrhage
27
treatment of hepatic adenoma?
resection if possible
28
What are the most common malignant hepatic neoplasms?
Metastatic tumors from the GI tract, breast and lung
29
when CAN you resect a metastatic lesion in the liver?
metastases from colorectal cancer
30
What are the criteria for hepatic respectability for metastatic colorectal cancer confined to the liver? (3)
1) unilobar or bilobar disease
2) single or multiple mets
3) remnant liver = 20-30% of original volume (equivalent of 2 segments)
31
What are the criteria for hepatic respectability for metastatic colorectal cancer w Concomitant extra hepatic disease? (3)
1. Liver mets in the presence of resectable or abatable pull disease
2. Liver mets in the presence of resectable isolated extra hepatic disease (spleen, adrenal)
3. Liver mets in the presence of resectable invasion of adjacent structures: diaphragm and adrenal
32
What is the primary risk factor for the development of HCC?
cirrhosis of the liver of any etiology, most commonly men older than 40 with HCV cirrhosis
33
how can hepatocellular carcinoma (HCC) be diagnosed without a tissue sample?
if pt has a liver mass and an elevated AFP
34
What are the Milan Criteria?
- criteria for transplantation of pets w HCC
1. 1 tumor = 5cm
2. 3 or fewer tumors, each = 3cm in size
35
What are 3 risk factors for cholangiocarcinoma?
1. Congenital choledochal cysts
2. Primary Sclerosing cholangitis
3. Infection with liver fluke clonorchis sinensis
36
what is cholangiocarcinoma? 2 different subdivisions?
adenocarcinoma that arises from biliary ductal epithelium
1. Intrahepatic CC- pts present later, no jaundice
2. Extrahepatic CC- aka hilar or Klatskin tumor, presents earlier with obstructive jaundice
37
most important prognostic indicator of overall survival in extra hepatic cholangiocarcinoma?
radical resection ith negative surgical margins (NOT regional lymph node involvement)
38
most common cancer of the biliary tree?
gallbladder adenocarcinoma
39
Risk factors for gallbladder adenocarcinoma?
1. Female gender
2. Gallstones
3. Infections: salmonella, Helicobacter in the bile
4. Adenomatous polyps (puts with polyps >1cm should undergo chole)
40
Surgical management of gallbladder adenocarcinoma?
- extensive hepatic en bloc resection in addition to regional lymphadenectomy in pts with T2 or resectable T3 disease
41
Risk factors and management of hepatic angiosarcoma ?
Exposure to:
1. Vinyl chloride
2. Thorotrast contrast material
3. Arsenic
- Resection is only curative treatment
42
what are the most common primary malignant liver tumors occurring in children?
hepatoblastomas
| peak incidence 2 years old
43
management of hepatblastoma?
- resection or transplantation remains the primary modalities even in children w pulmonary mets that are responsive to chemo
- follow AFP
44
What is the embryological origin of the pancreas?
during 4th week of gestation: a dorsal and ventral bud
- the dorsal bud gives rise to the majority of the pancreas
- ventral bud gives rise to the uncinate process and a portion of the head of the pancreas
45
What are the two pancreatic ducts that form during development?
1. Duct of Wirsung: main duct that connects with the CBD and drains via the major papilla
2. Accessory duct of Santorini: empties via the minor papilla
46
Blood supply of the head and uncinate process of the pancreas?
anterior and posterior superior and inferior pancreaticoduodenal arteries
47
blood supply of the body and tail of the pancreas?
branches of the splenic and Left gastroepiploic aa
48
all venous drainage of the pancreas enters the?
portal vein
49
parasympathetic innvervation of the pancreas?
originate in vagal nuclei and travel through the posterior vagal trunk
50
what is annular pancreas?
normal pancreatic tissue completely surrounds the second portion of the duo
- assoc with downs syndrome, intracardiac defects and intestinal malro
51
treatment of annular pancreas?
duodenojejunostomy to bypass the annulus
52
what are the exocrine units of the pancreas?
acinar cells: 80% of the pancreas, responsible for production of enzymes
53
What are the endocrine units of the pancreas?
islet cells: consist of a core (beta cells) and a peripheral mantle (composed of alpha, delta and pancreatic polypeptide cells)
54
distribution of islet cells in the pancreas
Head = PP cells
Body/tail = alpha cells
Beta and delta cells are evenly distributed
55
what is the most potent endogenous stimulant of pancreatic bicarbonate secretion? where is it synthesized?
secretin: synthesized in mucosal S cells of the crypts of Lieberkuhn of the proximal small bowel
- released in the presence of luminal acid and bile
56
Function of Secretin
to neutralize stomach acid that enters the duodenum
57
Trypsinogen: What form is it secreted in and what is function?
- trypsin(activated by enterokinase in the duo)
- fxn: protease that activates other pancreatic proenzymes for protein digestion (chymotrypsin, elastase, carboxypeptidase A and B)
58
Lipase: What form is it secreted in and what is function?
- excreted in active form
| - cleaves fatty acids in preparation for gut absorption
59
Colipase: What form is it secreted in and what is function?
- excreted in active form
| - prevents lipase inactivation by bile acids in the duo
60
Cholesterol esterase: What form is it secreted in and what is function?
- excreted in active form
| - cleaves cholesterol ester bonds in preparation for fatty acid and cholesterol absorption
61
Amylase: What form is it secreted in and what is function?
- excreted in active form
| - Cleaves complex carbohydrates in preparation for sugar absorption
62
Three phases of digestion
1. Cephalic phase: smell/taste leads to secretion of enzyme rich bicarb poor fluid
2. Gastric phase: antral distention and protein delivery stimulate release of gastrin, acidification of the duo leads to secretin release
3. Intestinal phase: secretin and CCK release, CCK stimulates the secretion of pancreatic enzymes from acinar cells
63
Glucagon:
| cell type? Function?
- alpha cells
| - acts primarily on hepatocytes, raises blood sugar via gluconeogenesis, lipolysis, glycogenolysis
64
Insulin: cell type? function?
- beta cells
| - decrease blood sugar levels, glucose uptake at cellular level
65
Somatostatin: cell type? function?
- delta cells
| - inhibitor of acid production, regulates pancreatic endocrine function
66
Pancreatic Polypeptide: cell type? function?
- PP cells
| - decreases gallbladder and pancreatic secretion
67
Vasoactive Inhibitory Peptide (VIP): cell type? function?
- Delta 2 cells
| - Increases gut motility and secretion
68
Describe the following signs:
Turner's
Cullens
Fox's
Turners: flank ecchymosis
Cullens: periumbilical ecchymosis
Fox's: ecchymosis below the inguinal ligament and/or involving the scrotum
69
Causes of Pancreatitis Mnemonic
```
I: idiopathic
G: gallstones
E: ethanol (alcohol)
T: trauma
S: steroids
M: mumps (and other infections) / malignancy
A: autoimmune
S: scorpion stings/spider bites
H: HLD/hypercalcaemia (metabolic disorders)
E: ERCP
D: drugs
```
70
Two different types of amylase and where theyre secreted from
1. P type: 40%, pancreas
| 2. S type: 60%, salivary glands, fallopian tubes, ovaries, endometrium, prostate, breast, lungs and liver
71
Describe the following signs:
- Sentinel loop sign
- Colon Cutoff sign
Sentinel: a focal jejunal ileus
Colon cutoff: transverse colonic ileus
- signs seen in acute pancreatitis
72
What is the significant of ranson's criteria and what scores are assoc w which mortality?
- 11 signs that are predictive of morbidity and mortality from pancreatitis
7 = nearly 100%
73
Which antibiotics have good penetration of pancreatic tissue in the case of pancreatic necrosis?
- Imipenem
- Third generation cephalosporins
- Piperacillin
- Fluoroquinolones
- Metronidazole
74
What are three life-threatening complications of acute pancreatitis that may require surgical intervention?
1. Pancreatic abscess
2. Infected pancreatic pseudocyst
3. Infected pancreatic necrosis
75
What is the soap bubble sign in relation to pancreatitis?
- extraluminal retroperitoneal air seen on plain films of the abdomen indicative of pancreatic infection
76
Treatment of pancreatic infectious complications with pancreatitis?
antibiotics and judicious surgical debridement, abscess and necrotic tissue requires debridement and wide drainage
77
Causes of idiopathic chronic pancreatitis (5)
1. Social drinking
2. Analgesic abuse
3. Autoimmune diseases: PSC, sjogren syndrome, PBC
4. Genetic abnormalities: cystic fibrosis and hereditary pancreatitis
5. Pancreatic divisum
78
what gene is mutated in hereditary pancreatitis?
cationic trypsinogen gene
79
what can you see on pancreatogram in chronic pancreatitis?
- most commonly: uniform ductal dilation
| - chain of lakes characteristic
80
what is a simple test to evaluate exocrine pancreatic function?
- fecal fat secretion: look for elevated fecal elastase levels (sensitive and specific for diagnosis of dysfunction)
81
endogenous enzyme secretion must be decreased by ___ to produce malabsorption?
90%
82
How do you manage a pt w a dilated pancreatic duct in need of operative therapy for chronic pancreatitis?
Puestow procedure
| side-to-side pancreaticojejunostomy
83
when do you consider a pancreatic fluid collection a pseudocyst?
if they persist beyond 4 weeks after the onset of acute pancreatitis
84
Management of pancreatic pseudocysts
- trial of 6weeks of observation attempted
| - surgical resection (cyst jejunostomy or cyst gastrostomy) if persistent on fu CT or persistent pain/complications
85
Pancreatic Trauma Classification: Description and Treatment- Class I
- Minor pancreatic contusion or superficial laceration without main ductal injury
- observation and/or external drainage depending on whether laparotomy is warranted from other injuries
86
Pancreatic Trauma Classification: Description and Treatment- Class II
- Major contusion or major laceration without main ductal injury
- Observation and/or external drainage depending on whether laparotomy is indicated for other injuries
87
Pancreatic Trauma Classification: Description and Treatment- Class III
- Severe parenchymal injury or main distal ductal disruption/distal pancreatic transection
- body and tail injuries are treated with distal pancreatectomy
- inferior head/uncinate process injuries are treated with external drainage or pancreaticojejunostomy
- central head injuries adjacent to duo are treated like class IV injuries
88
Pancreatic Trauma Classification: Description and Treatment- Class IV
- severe parenchymal injury with proximal pancreatic ductal injury involving the ampulla
- debridement and external drainage, consider pyloric exclusion and gastrojejunostomy
89
Pancreatic Trauma Classification: Description and Treatment- Class V
- massive disruption of the pancreatic head
| - consider whipple like class IV
90
which tumor suppressor genes have been implicated in the pathogenesis of pancreatic cancer? (4)
1. p53
2. DPC4
3. k-ras
4. BRCA2
91
what is couvoisier sign?
the presence of an enlarged gallbladder (palpable) which is nontender + obstructive jaundice 2/2 tumors of the biliary tree
92
What are the following nodes:
1. Virchow's
2. Sister Mary Joseph node
3. Blumer shelf
1. Virchow: left supraclavicular adenopathy
2. Sister mary: periumbilical lymphadenopathy
3. Blumer: drop medastases in the pelvis palpable on rectal exam
93
most common type of pancreatic cancer?
ductal adenocarcinoma: 65% arise in head, neck or uncinate process
15% in body or tail
20% diffusely
94
acing cell carcinoma of the pancreas: describe
thought to results from malignant degeneration of acing cells of pancreas
- can present w subcutaneous fat necrosis, an erythema nodosum like rash, eosinophilia or polyarthralgia
95
Intraductal papillary mucinous neoplasm: IPMN, describe, genetic mutation
- considered a precursor lesion to adenocarcinoma
- genetic mutations of k-ras and p53
- mucin producing and cellular atypia
96
solid pseudopapillary tumor: describe, pt population
- low malignant potential
- can grow as large as 30cm
- females (10:1 males), pts in their mid twenties
97
mucinous cystic neoplasm (MCN): describe, pt population
- cystic mucin-secreting tumor
- will likely degenerate to cystuadenocarcinoma if not resected early
- female predominance, age 40-50
98
intraductal oncocytic and papillary neoplasm (IOPN): describe
intraductal neoplasm similar to IPMN with slightly more malignant potential
99
most common primary tumor that metastasizes to the pancreas
renal cell carcinoma
100
pancraeticoduodenectomy is used for which pancreatic tumors?
tumors at the head of the pancreas
101
when initially entering the abdomen for a whipple for pancreatic cancer, what factors preclude continuing on with resection? (2)
1. Distant metastases to the peritoneum or liver
| 2. local extension to the mesenteric vessels
102
what are the three anastamoses created in a whipple?
1. Pancreaticojejunostomy
2. Choledochojejunostomy
3. Duodenojejunostomy or gastrojejunostomy (depending on whether the pylorus is preserved)
103
management of biliary obstruction 2/2 unresectable pancreatic cancer?
hepaticojejunostomy and roux-en-y reconstruction
104
what is the prevalence of pancreatic neuroendocrine tumors?
1% of all pancreatic tumors, 5 cases per 1 million people
105
which neuroendocrine pancreatic tumor rarely has malignant potential?
Insulinoma (10%)
106
what are the five pancreatic neuroendocrine tumors?
1. Insulinoma
2. Gastrinoma
3. Glucagonoma
4. VIPoma
5. Somatostatinoma
107
Whipple's triad for insulinoma
1. Hypoglycemia while exercising or fasting
2. Plasma glucose level lower than 50mg/dL
3. Resolution of symptoms with administration of IV glucose
108
what is the most sensitive study for the localization of insulinomas?
endoscopic US
109
What is nesidioblastosis? treatment?
- nestlike increase in islet cells in children leading to hypoglycemia
- tx: near total pancreatectomy
110
what percentage of gastrinomas are associated with MEN-1?
25%
111
diagnosis of gastrinoma? how do you localize the tumor?
- serum gastrin level! if higher than 1000 then virtually diagnostic
- confirm with secretin stimulation test, an increase in gastrin levels following a secretin bolus is a positive result
- localize with somatostatin receptor scintigraphy, if fails then intro US and direct visualization
112
symptoms of a gastrinoma?
1. diarrhea
2. peptic ulcers
3. epigastric pain/reflux esophagitis
113
what is Passaro's triangle?
where the majority of gastrinomas are found, aka the gastrinoma triangle
114
Treatment of gastrinoma?
initially: H2 blockers and PPIs
| resection indicated in cases of localized disease
115
What is Verner-Morrison syndrome?
1. Profound watery diarrhea
2. Hypokalemia
3. Achlorhydria
- caused by VIPoma, resection is considered if localized
116
Glucagonoma symptoms (4)
1. Erythematous skin eruptions (can become necrotic- i.e. necrolytic migrating erythema)
2. Mild diabetes mellitus
3. Weight loss
4. Anemia
117
treatment of glucagonoma?
surgical resection
| skin rash can be tx with high protein diet, zinc, control of diabetes
118
Symptoms of somatostatinoma?
1. Steatorrhea
2. N/v
3. Gallstones
- surgical resection
119
hemobilia is most frequently accompanied by what other finding?
arterial pseudoaneurysm
120
what is the triad of hemobilia?
1. Hematemesis (upper GI bleeding)
2. RUQ pain
3. Jaundice
121
what is the underlying pathology in hemobilia? treatment?
typically due to trauma, a pseudoaneurysm (arterial) that has a connection with the biliary tree (hence jaundice), treatment: angiographic embolization of the artery
122
how do you diagnose choledochal cysts?
US
123
treatment of choledochal cysts?
excising the cyst with a biliary enteric bypass (risk of malignancy increases with the more advanced age at which the cyst is detected)
124
how do you repair a small lateral injury to the CBD?
closing the ductotomy over a T tube
125
how do you repair a complete transection of the CBD?
biliary enteric bypass, ie hepaticojejunostomy, however if no experienced surgeon is available then drain the area, place transhepatic catheters and refer the patient
126
what effect does the vagus nerve have on the gallbladder?
causes gallbladder contraction
127
what is the management of T1 gallbladder adenocarcinoma?
those that are discovered incidentally and are superficial ie carcinoma in situ or T1 lesions (do not extend into perimuscular connective tissue) and have negative margins, tx = cholecystectomy alone
128
management of more advanced gallbladder adenocarcinoma (T2-T4)
radical cholecystectomy including subsegmental resection of segments IVb and V + hepatoduodenal ligament lymphadenectomy, followed by radiation therapy postoperatively
129
what 4 diseases are associated with sclerosing cholangitis?
1. ulcerative colitis
2. diabetes
3. riedel thyroiditis
4. retroperitoneal fibrosis
130
what is the hallmark feature of emphysematous cholecystitis?
gas within the gallbladder wall or lumen
131
what are the 4 most common pathogens associated with emphysematous cholecystitis?
1. Clostridia welchii
2. E coli
3. Enterococcus
4. Klebsiella
132
management of emphysematous cholecystitis?
broad spectrum antibiotics and emergent surgery (still has a 25% mortality and 50% morbidity)
133
what makes up bile?
80% bile salts, 15% phospholipids, 5% cholesterol
134
what is the management of gallstone ileus?
transverse enterotomy proximal to the obstructed stone and strong removal (cholecystectomy should be reserved for you, low-risk, stable patients)
135
why do u get air in the biliary tree in gallstone ileus?
the large gallstone erodes through the gallbladder and into the adjacent duodenum creating a cholecystoenteric fistula
136
what are aschoff-rokitansky sinuses?
seen in chronic cholecystitis, these sinuses develop as a result of atrophy of the mucosa , the epithelium protrudes into the muscle coat leading to sinus formation
137
US findings were considered positive for acalculous cholecystitis if what 3 criteria were present?
1. Wall thickness >4mm
2. hydrops
3. sludge
138
what is the most sensitive finding on HIDA scan to diagnose acalculous colecystitis?
failure to visualize the gallbladder
139
management of acalculous cholecystitis?
urgent cholecystectomy unless patient is super ill then perform percutaneous US/ CT guided cholecystostomy
140
whats the difference between black and brown cholesterol stones
black: seen in hemolytic disorders i.e. hereditary spherocytosis
brown: formed within the ducts themselves, are friable, and are assoc with parasitic infections and bacteria
141
which population do you see more brown stones than black?
asian populations
142
what is the most common cause of benign bile duct stricture?
ischemic from operative injury
143
why do you excise a choledochal cyst?
because of the risk of malignancy
144
what is cholesterolosis?
aka strawberry gallbladder caused by accumulation of cholesterol in macrophages in the gallbladder mucosa, gives the mucosa a characteristic strawberry gallbladder, benign condition
145
what is a klatskin tumor?
perihilar cholangiocarcinomas
146
what are the four types of klatskin tumors?
1. Limited to the common hepatic duct
2. involve the bifurcation of the right and left hepatic duct (type II)
3/4. Enter into the secondary right (IIIa) or left (IIIb) intrahepatic ducts
147
how do you manage type I and II klatskin tumors?
resection of the entire extrahepatic biliary tree with portal lymphadenectomy and bilateral roux-en-y hepaticojejunostomies, + hemihepatectomy
148
how do you manage type III klatskin tumors?
lobectomy of liver
149
what is the postulated cause of FNH?
an early embryologic disturbance in liver blood flow
150
what are the hallmark features of FNH?
presence of a central scar on CT or MRI that enhances with contrast
151
what is an effective screening tool for pts at high risk of developing HCC?
US and AFP
152
what is budd chiari syndrome?
thrombosis of the hepatic IVC or hepatic veins themselves that leads to hepatic venous outflow obstruction, postsinusoidal liver failure and cirrhosis
153
what is the classic triad of budd chiari syndrome?
1. Abdominal pain
2. Ascites
3. Hepatomegaly
154
What are the four forms of budd chiari syndrome?
1. Acute
2. Chronic
3. Asymptomatic
4. Fulminant
155
what is budd chiari syndrome associated with?
Hypercoagulable state either inherited (protein C, protein S, factor V leiden) or acquired (myeloproliferative disorders, polycythemia vera, pregnancy)
156
how do you diagnose budd chiari syndrome?
duplex ultrasound showing thrombosed hepatic veins or IVC
157
what is the most prominent feature on CT scan of budd chiari syndrome?
caudate lobe (segment I) hypertrophy and inhomogenous contrast enhancement
158
how do you distinguish FNH and hepatic adenomas?
sulfur colloid scan- adenomas will appear "cold" and FNHs "hot" because of presence of Kupffer cells
159
what are the four types of cystic hydatid disease? and what causes cystic hydatid disease?
caused by tapeworm Echinococcus granulosus
Type 1: simple cyst
Type 2: hydatid sand, a cyst w free floating hyperechogenic material
Type 3: a cyst with a rosette appearance suggesting daughter cyst
Type 4: a cyst with a diffuse hyperechoic solid pattern
160
what is the treatment of type I and type II hydatid cysts?
PAIR: percutaneous aspiration, injection of solicidal agent and reaspiration
161
steps in managing ascites in cirrhosis pts?
1. Low sodium diet with spironolactone and furosemide
2. large volume (4-6L) paracentesis
3. TIPS if good liver function
4. liver txp if bad liver function
162
what is the classic triad of pyogenic liver abscess?
1. RUQ pain
2. Fever
3. Jaundice
163
what is the most common etiology of pyogenic liver abscesses?
biliary tract
164
treatment of pyogenic liver abscsess?
IV abx with percutaneous aspiration with or without catheter drainage
165
the principal mediators of fibrosis leading to cirrhosis in the liver are:
ITO (liver stellate) cells
166
esophageal varices + splenomegaly in the absence of evidence of cirrhosis (normal hepatic function), is suggestive of what?
Portal Vein Thrombosis!
| thus perform duplex ultrasound of portal vein
167
when should you selectively use preoperative biliary drainage via endoscopic retrograde cholangiopancreatography and stunting before a whipple?
1. cholangitis
2. severe intractable pruritus
(otherwise it increases wound infections and pancreatic fistulas)
168
most common polyp of the gallbladder?
cholesterol polyps
169
what are the indications for cholecystectomy in a patient w a polyp? 4
1. A symptomatic polyp
2. A polyp in association with gallstones
3. A polyp larger than 10mm
4. Age older than 50
170
why do you use moprhine in a HIDA scan of a pt with suspected acalculous cholecystitis?
it decreases rate of false positive HIDA scans bc it leads to sphincter of oddi contraction and increases the likelihood of filling of the gallbladder
171
why does transecting the CBD interrupt its blood supply?
because the right hepatic aa and gastroduodenal aa run along the medial and lateral walls at the 3 and 9 o'clock positions
172
how do you treat injuries to the distal CBD?
choledochoduodenostomy
173
what is poland syndrome?
webbed fingers associated with hypoplasia of the ipsilateral pectorals mm and chest wall
174
etiology of portal vein thrombosis (PVT) in adults versus children?
Adults: malignancy and cirrhosis
Children: neonatal umbilical vein catheterization (portal venous injury), neonatal omphalitis (umbilical sepsis), intra-abdominal sepsis (infectious seeding to portal vein)
175
how does portal venous thrombosis present in children?
upper GI bleeding 2/2 esophageal varices, tx: octreotide and sclerotherapy
176
for children with portal vein thrombosis and recurrent refractory UGI bleeding, what do you do?
Rex shunt: superior mesenteric vein-to-left portal vein bypass at the Rex recessus
177
finding of isolated gastric varices without esophageal varices is suggestive of what?
splenic vein thrombosis
178
most common cause of splenic vein thrombosis?
chronic pancreatitis (4-8% of pts)
179
splenic vein thrombosis with gastric variceal formation is referred to as what?
left sided or sinistral portal hypertension
180
anchovy paste appearance of fluid
amebic liver- entamoeba histolytica
181
CT showing single fluid collection in the right lobe with a rim of peripheral edema
entamoeba histolytica liver abscess
182
how do you diagnose amebic liver abscess w entamoeba histolytica? tx?
serologic testing using enzyme immunoassays, treat w oral metronidazole unless pt doesn't improve within 48-72hrs then US guided aspiration
183
most common benign liver tumor?
hemangiomas
184
whats one complication of giant hemangioma in children?
can lead to arteriovenous shunting with CHF and thrombocytopenia
185
which two methods are used to prevent first time bleeds in pts w esophageal varices?
1. endoscopic ligation (superior)
| 2. Beta blockade
186
what are the two different classifications of portovenous shunts?
1. Nonselective: much more effective at decompressing portal HTN and stopping variceal hemorrhage but high risk of encephalopathy
2. Selective: less encephalopathy
187
what are the different nonselective portovenous shunts? (4)
1. end to side portocaval shunt
2. side to side portocaval shunt
3. mesocaval shunt
4. large diameter interposition shunts
5. Central splenorenal shunt
188
what are the selective portovenous shunts? (2)
1. Distal splenorenal shunt
| 2. Small diameter portocaval H graft shunt
189
what do you see elevated in fibrolamellar carcinoma?
neurotensin (NOT AFP), it also does NOT enhance on arterial phase of CT (like FNH does) nor is it hyper intense on gadolinium MRI (like FNH is)
190
the hepatic veins drain which segments? right, middle, left
Right: V, VI, VII, VIII
Middle: IVA, IVB, V, VIII
Left: II, III
*middle and left veins join together before entering into the vena cava
191
what is the round ligament of the liver and whats its significance?
remnant of the umbilical vein, marks the location of the intrahepatic location of the left portal vein
192
what is the ligament venosum and whats its significance?
remnant of the ductus venosus and marks the border between the caudate lobe and the left lateral sector
193
what is a replaced right hepatic artery?
arises from the superior mesenteric artery and is posterior to the portal vein
194
what are 7 predictors of poor long-term outcome after resection of hepatic metastasis from colon cancer?
1. positive tumor margin
2. presence of extra hepatic disease
3. node positive primary tumor
4. disease-free interval from primary tumor to mets less than 12 months
5. multiple hepatic tumors
6. largest tumor >5cm
7. CEA >200ng/mL
195
most common primary liver tumor in children, what is it associated with?
hepatoblastoma, assoc with familial polyposis syndrome
196
presentation and treatment of hepatoblastoma in children?
abdominal mass, anemia, thrombocytosis, elevated AFP levels, tx: chemotherapy then resection
197
what are the components of CHild-Pugh?
```
Ascites (none, mild, tense)
Encephalopathy (none, stage I-II, III-IV)
Bilirubin (3)
INR (2.3)
Albumin (>3.5, 2.8-3.5,
```
198
what is budd chiari syndrome?
thrombosis of the hepatic veins or intrahepatic vena cava leading to portal hypertension, jaundice from hepatic congestion
199
management of budd chiari syndrome?
heparinization!! then portosystemic shunt
200
what is the proposed etiology of FNH?
early embryological vascular injury
201
when is portal vein embolization indicated?
when the remnant liver volume is expected to less than 40% with normal liver function and
202
what are the three types of portal hypertension and etiologies?
1. Presinusoidal: intrahepatic causes (schistosomiasis, congenital hepatic fibrosis), extrahepatic
2. Sinusoidal: alcoholism, cirrhosis, hemochromatosis, Wilson
3. Postsinusoidal: Budd chiari, congenital webs in intrahepatic inferior vena cava
203
absolute contraindications to TIPS placement? 2
1. Polycystic liver disease
| 2. right heart failure
204
what is the ligamentum teres?
also known as the round ligament of the liver, its the remnant of the fetal umbilical vein
205
when taking down the gastrohepatic ligament, what anomaly might you encounter?
a replaced left hepatic artery coming off of a left gastric
206
where are most bile acids reabsorbed?
terminal ileum
207
what is th imaging modality of choice for diagnosis and surveillance of gallbladder polyps?
US (MRI and CT are used to evaluate for invasion)
