Ms3 Surgery: Liver, Gb, Pancreas

Front 1

liver capsule

Back 1

Glisson's capsule

Front 2

Liver anatomy

Back 2

Cantle's Line separates R and L liver. 8 segments, numbered clockwise from caudate lobe.

Front 3

falciform ligament

Back 3

connects anterior abd wall to liver and contains the ligamentum teres (remnant of umbilical vein)

Front 4

liver's blood supply

Back 4

hepatic artery (25%) and portal vein (75%)

Front 5

common hepatic artery

Back 5

comes off celiac artery

Front 6

portal vein

Back 6

from splenic vein and SMV

Front 7

liver is drained by

Back 7

hepatic veins drain to IVC

Front 8

most common liver malignancy

Back 8

mets, not primary liver tumor

Front 9

most common primary liver malignancy

Back 9

hepatocellular carcinoma

Front 10

HCC risk factors, presentation

Back 10

Risk factors: HBV, HCV, cirrhosis, aspergillous aflatoxins

Often presents as painful hepatomegaly with high AFP

Commonly invades locally and mets to the lung

-gold standard for dx is biopsy

Front 11

most common benign liver tumors

Back 11

hemangioma > hepatocellular adenoma > focal nodular hyperplasia

Front 12

hemangioma

Back 12

Usually asx, incidental finding, manage w/ observation

Front 13

hepatocellular adenoma

Back 13

Remember ABC: adenoma birth control

Related to estrogen exposure and seen most often in young women taking OCP's. May regress if OCPs are stopped.

-Biggest risk is bleeding (not malignancy), so need to differentiate from focal nodular hyperplasia - can do so w/ an MRI

Front 14

focal nodular hyperplasia

Back 14

Liver mass w/ central scar. Can observe if asx.

Front 15

hepatoblastoma

Back 15

most common primary liver tumor in kids; seen age 1-3; high AFP

Front 16

Liver abscess

Back 16

often from biliary tree.

-bacterial: usual gram-neg, tx is AB and percutaneous drainage

Front 17

entamoeba histolitica

Back 17

**pt. has recently been near US/Mexico border

dx is indirect hemoagglutination

Front 18

when do varices develop

Back 18

when portal pressure >20mm Hg. Normal is <10

Front 19

Things that cause portal HTN

Back 19

cirrhosis, schistomiasis, Wilson's, hemachromatosis, Budd-Chiari

Front 20

how to treat bleeding varices

Back 20

banding, sclerotherapy, balloon, TIPS shunt btw portal vein and hepatic vein

Front 21

clinical signs of portal HTN

Back 21

esophageal varices, splenomegaly, caput medusae, hemorrhoids

Front 22

biliary tree

Back 22

R + L hepatic ducts >> common hepatic duct + cystic duct >> common bile duct + pancreatic duct >> empty into sphincter of oddi at duodenal ampulla

Front 23

what is the triangle of calot

Back 23

bordered by the 3 C's: cystic duct, common hepatic duct, cystic artery

Front 24

where does alkaline phosphatase come from

Back 24

bile duct epithelium

Front 25

what's in bile

Back 25

cholesterol, lecithin, bile acids, bilirubin

Front 26

GB blood supply

Back 26

cystic artery/veins

Front 27

GB functions

Back 27

storage, concentration, release of bile

Front 28

pigmented stones

Back 28

black, associated w/ hemolytic disorders

Front 29

unconjugated vs conjugated bilirubin

Back 29

Unconjugated (indirect) is produced from RBC breakdown and is not water-sol. It is conjugated to glucuronic acid in the liver and is excreted in stool, urine.

Front 30

Diff Dx for jaundice

Back 30

prehepatic: hemolysis

intrahepatic: genetic liver dz, hepatitis

post-hepatic: malignant/stone obstruction

Front 31

Jaundice H&P

Back 31

meds, alcohol, hep or HIV risk, hereditary diseases, fever, RUQ pain, anorexia, Murphy, Courvoisier, acholic stool

Front 32

jaundice lab workup

Back 32

ALT, AST, AP, albumin, total and unconjugated bili,

Front 33

cholelithiasis

Back 33

gallstones in GB. Cholecystectomy NOT indicated if asx.

Front 34

biliary colic

Back 34

colicky RUQ pain after eating due to GB conracting against stone.

-normal PE, labs

-Dx w/ US

Front 35

cholecystitis

Back 35

Cystic duct obstruction and GB inflammation

-ill-appearing, constant RUQ pain, fever, leukocytosis, Murphy's sign

-RUQ US and HIDA to see if duct is blocked

Front 36

choledocholithiasis

Back 36

stone in CBD

-fever, RUQ pain, high ALT, AST, bili, AP, GGT

-RUQ US and ERCP

-liver and pancreas can potentially be affected

Front 37

management of cholecystitis, choledocholithiasis

Back 37

fluids, NPO, NG tube, AB, then do surgery

Front 38

common complication of cholecystectomy

Back 38

injury to common bile duct

Front 39

ascending cholangitis

Back 39

constant RUQ pain, jaundice, high LFT's, pancreatitis sx, high fever and leukocytosis

Front 40

common presentations of post-hepatic obstruction

Back 40

1. Choledocholithiasis: RUQ pain, fever, leukocytosis, Murphy's, jaundice. Do RUQ US and ERCP

2. Malignancy: painless jaundice, Courvoisier's sign, dilated, thin-walled GB

Front 41

malignancies that can cause post-heptic obstruction

Back 41

pancreatic cancer, cholangiocarcinoma, ampullary cancer

Front 42

pancreatic cancer

Back 42

other key sx is migratory thrombophlebitis. Do US, biopsy. Tx is whipple

Front 43

cholangiocarcinoma

Back 43

bile duct epithelial malignancy; dx w/ ERCP and tx is resection

Front 44

Charcot's Triad

Back 44

Fever, RUQ pain, jaundice

assoc w/ cholangitis

Front 45

Reynolds Pentad

Back 45

Charcot's Triad + shock + altered mental status

assoc w/ ascending cholangitis

Front 46

pancreatitis

Back 46

epigastric pain that bores to back, is positional

-high amylase and lipase (lipase best indicator)

Front 47

management of pancreatitis

Back 47

Pain ctl + fluids + NPO; CT if sx fail to resolve or pt dev ascites, early satiety. could be abscess, pseudocyst or necrotizing pancreatitis

Front 48

pseudocyst management

Back 48

If <6cm and <6wks >> wait/watch

If >6cm and >6wks >> drainage needed

Front 49

symptomatic cholelithiasis in pregnant woman

Back 49

try to manage non-op w/ fluids and pain meds. Remove GB after pregnancy. If surgery is needed, do in 2nd trimester.