Hepatobiliary Absite Flashcards

Front 1

Pt c/ thickened GB wall (also sludge, pericholecystic fluid), RUQ pain, high WBCs, (+) HIDA
Hx severe burns, prolonged TPN, trauma, or major surgery
Primary pathology = _ -> _ -> _
May also have _ 2/2 dehydration, ileus, transfusions
Tx; _

Back 1

ACALCULOUS CHOLECYSTITIS:
Burns, TPN, trauma, or major surgery ->
BILE STASIS 2/2 narcotics, fasting -> distension, ischemia
Also HIGH VISCOSITY 2/2 dehydration, ileus, transfusions
US: thickened GB wall, sludge, pericholecystic fluid. (+) HIDA
Tx: Cholecystectomy. Percutaneous drain if unstable

Front 2

_ = thickened nodule of mucosa + muscle ass'd c/ Rokitansky-Aschoff sinus
-Sx
-Prognosis
-Tx

Back 2

ADENOMYOSIS = thickened nodule of mucosa + muscle ass'd c/ Rokitansky-Aschoff sinus
-may cause pain
-NOT premalignant, doesn't cause stones
-Tx: cholecystectomy

Front 3

What tumor marker is considered most strongly associated with hepatocellular CA?

Back 3

80% of patients with HCC has elevated AFP

Front 4

Alpha 1 anti-trypsin deficiency: RF for what hepatobiliary cancer?

Back 4

Alpha 1 anti-trypsin deficiency:
YES RF for hepatocellular ca

Front 5

Liver lesion treatable c/ metronidazole; no surgery needed

Back 5

Amebic liver abscess:
-Anchovy paste appearance. Aspirate often sterile b/c protozoa only in peripheral rim
-Pt c/ hx of EtOH, travel to Mexico, fecal-oral transmission. Fevers, chills, RUQ pain, jaundice, hepatomegaly.
-(+) ENTAMOEBA HISTOLYTICA serology in 90%
-primary infection = AMEBIC COLITIS -> reaches liver via portal vein
-Tx: metronidazole. Aspiration if refractory or super-infection
-Surgery only for FREE RUPTURE, antibiotic failure

Front 6

Amebic liver abscess:
Primary infection is in _
Reaches liver via _

Back 6

Amebic liver abscess:
-Anchovy paste appearance. Aspirate often sterile b/c protozoa only in peripheral rim
-Pt c/ hx of EtOH, travel to Mexico, fecal-oral transmission. Fevers, chills, RUQ pain, jaundice, hepatomegaly.
-(+) ENTAMOEBA HISTOLYTICA serology in 90%
-primary infection = AMEBIC COLITIS -> reaches liver via portal vein
-Tx: metronidazole. Aspiration if refractory or super-infection
-Surgery only for FREE RUPTURE, antibiotic failure

Front 7

Pt presents c/ fever,. RUQ pain, tenderness after travel. Found to have amebic liver abscess.
-Tx is _

Back 7

Amebic liver abscess:
-Anchovy paste appearance. Aspirate often sterile b/c protozoa only in peripheral rim
-Pt c/ hx of EtOH, travel to Mexico, fecal-oral transmission. Fevers, chills, RUQ pain, jaundice, hepatomegaly.
-(+) ENTAMOEBA HISTOLYTICA serology in 90%
-primary infection = AMEBIC COLITIS -> reaches liver via portal vein
-Tx: metronidazole. Aspiration if refractory or super-infection
-Surgery only for FREE RUPTURE, antibiotic failure

Front 8

Amebic liver abscess:
(+) serology for organism _ in _%

Back 8

Amebic liver abscess:
-Anchovy paste appearance. Aspirate often sterile b/c protozoa only in peripheral rim
-Pt c/ hx of EtOH, travel to Mexico, fecal-oral transmission. Fevers, chills, RUQ pain, jaundice, hepatomegaly.
-(+) ENTAMOEBA HISTOLYTICA serology in 90%
-primary infection = AMEBIC COLITIS -> reaches liver via portal vein
-Tx: metronidazole. Aspiration if refractory or super-infection
-Surgery only for FREE RUPTURE, antibiotic failure

Front 9

Liver abscess in pt c/ hx of EtOH, travel to Mexico, fecal-oral transmission

Back 9

Amebic liver abscess:
-Anchovy paste appearance. Aspirate often sterile b/c protozoa only in peripheral rim
-Pt c/ hx of EtOH, travel to Mexico, fecal-oral transmission. Fevers, chills, RUQ pain, jaundice, hepatomegaly.
-(+) ENTAMOEBA HISTOLYTICA serology in 90%
-primary infection = AMEBIC COLITIS -> reaches liver via portal vein
-Tx: metronidazole. Aspiration if refractory or super-infection
-Surgery only for FREE RUPTURE, antibiotic failure

Front 10

Amebic liver abscess:
What do you expect to find on culture of cyst?

Back 10

Amebic liver abscess:
-Anchovy paste appearance. Aspirate often sterile b/c protozoa only in peripheral rim
-Pt c/ hx of EtOH, travel to Mexico, fecal-oral transmission. Fevers, chills, RUQ pain, jaundice, hepatomegaly.
-(+) ENTAMOEBA HISTOLYTICA serology in 90%
-primary infection = AMEBIC COLITIS -> reaches liver via portal vein
-Tx: metronidazole. Aspiration if refractory or super-infection
-Surgery only for FREE RUPTURE, antibiotic failure

Front 11

Liver abscess c/ "anchovy paste" contents

Back 11

Amebic liver abscess:
-Anchovy paste appearance. Aspirate often sterile b/c protozoa only in peripheral rim
-Pt c/ hx of EtOH, travel to Mexico, fecal-oral transmission. Fevers, chills, RUQ pain, jaundice, hepatomegaly.
-(+) ENTAMOEBA HISTOLYTICA serology in 90%
-primary infection = AMEBIC COLITIS -> reaches liver via portal vein
-Tx: metronidazole. Aspiration if refractory or super-infection
-Surgery only for FREE RUPTURE, antibiotic failure

Front 12

_ = #1 cancer of biliary tract
Main RF is _
Spreads 1st to liver segments _, _
Spreads to nodes _
90% present c/ stage _ disease
_% 5-yr survival

Back 12

GALLBLADDER ADENOCA = #1 cancer of biliary tract
PORCELIN GB => 10-20% risk (do open cholecystectomy 2/2 tumor implants @ trocar sites)
-Spreads to segments IV, V; cystic duct nodes (R)
-Stage 1 (mucosa, usually incidental finding) => cholecystectomy
-Stage 2 (muscle) => chole + 2-3 cm margins @ segments 3,4 + regional LNs inc.along portal triad
(may need Whipple, lobectomy, or resection of CBD)
-90% present c/ stage 4
-5% 5-yr survival

Front 13

adnocarcinma of GB:
-if grossly visible tumor, should do..

Back 13

GALLBLADDER ADENOCA = #1 cancer of biliary tract
-PORCELIN GB => 10-20% risk (do open cholecystectomy to avoid tumor implants @ trocar sites)
-Spreads to segments IV, V; cystic duct nodes (R)
-90% present c/ stage 4
5% 5-yr survival
-If grossly visible tumor, should do regional lymphadenectomy, wedge segment V, skeletonize portal triad

Front 14

Young F undergoes lap chole + GB adenoca found extending into muscular layer
-Next step = _

Back 14

GALLBLADDER ADENOCA = #1 cancer of biliary tract
-PORCELIN GB => 10-20% risk (do open cholecystectomy to avoid tumor implants @ trocar sites)
-Spreads to segments IV, V; cystic duct nodes (R)
-90% present c/ stage 4
5% 5-yr survival
-

Front 15

Why do people with cirrhosis get ascites?

Back 15

Cirrhosis ascites:
hepatocyte destruction -> scarring -> increased hepatic pressure -> portal congestion ->
LYMPHATIC OVERLOAD ->
LEAKAGE OF SPLANCHNIC/ HEPATIC LYMPH into peritoneum

Front 16

After paracentesis for ascites,
replace albumin _g/ 100cc removed

Back 16

After paracentesis for ascites,
replace albumin 1g/ 100cc removed

Front 17

Ascites 2/2 cirrhosis:
best diuretic is _

Back 17

Ascites 2/2 cirrhosis:
SPIRONOLACTONE = best diuretic
counteracts hyperaldosteronism often seen c/ liver failure

Front 18

Ascites 2/2 cirrhosis:
complication of peritoneovenous shunt (Denver, LeVeen) is _

Back 18

Ascites 2/2 cirrhosis:
complication of peritoneovenous shunt (Denver, LeVeen) =
DIC

Front 19

Ascites 2/2 cirrhosis:
Antibiotic prophylaxis against SBP is _

Back 19

Ascites 2/2 cirrhosis:
Antibiotic prophylaxis against SBP =
Cipro 750mg/WEEK

Front 20

Ascites 2/2 cirrhosis:
Pts have hyperaldosteronism b/c _

Back 20

Ascites 2/2 cirrhosis:
impaired hepatic metabolism, GFR ->
hyperaldosteronism
(for this reason, spironolactone is best diuretic)

Front 21

#1 cause of benign biliary stricture = _

Back 21

Iatrogenic (lap chole) = #1 cause of benign biliary stricture

Front 22

Biliary colic = _
Resolves in _-_ hrs

Back 22

Biliary colic = transient cystic duct obstruction 2/2 stone passage
Resolves in 4-6 hrs

Front 23

Bile: _% bile salts, _% lecithin, _% cholesterol
- Stones form if increased cholesterol or decreased salts or lecithin
-GB concentrates bile active by mechanism __.
-Bile pool _g, recirculated q_h, lose _g daily (_%)

Back 23

Bile: 80% bile salts, 15% lecithin, 5% cholesterol
- Stones form if increased cholesterol or decreased salts or lecithin
-GB concentrates bile by active resorption of NaCl, H20 then follows.
-Bile pool 5G, recirculated q4h, lose 0.5g daily (10%)

Front 24

3 things that increase bile excretion

Back 24

Increase bile excretion:
CCK
Secretin
Vagal input

Front 25

3 things that decrease bile
(2 hormones, 1 neuro mechanism)

Back 25

Decrease bile excretion:
VIP (from gut + pancreas cells)
Somatostatin (from antral D cells)
Sympathetic stimulation

Front 26

Endocrine stimulation by _ -> constant, steady tonic contraction of GB

Back 26

CCK -> constant, steady tonic contraction of GB

Front 27

3 essential functions of bile

Back 27

Essential functions of bile:
Fat-soluble vitamin absorbtion
Bilirubin excretion
Cholesterol excretion

Front 28

Active resorption of conjugated bile acids occurs in the _
(passive resorption of bile acids occurs 45% in sm intestine, 5% in colon)

Back 28

Active resorption of conjugated bile acids occurs in the TERMINAL ILEUM
(passive resorption of bile acids occurs 45% in sm intestine, 5% in colon)

Front 29

What makes poo brown?

Back 29

Stercobilin = breakdown product of conjugated bili in gut
Makes poo brown

Front 30

Delta bilirubin:
defined as _
-1/2 life is _

Back 30

Delta bilirubin:
-Bound to albumin
-1/2 life = 18 days
-Takes a while to clear after longstanding jaundice

Front 31

Primary bile acids = cholic acid, chenodeoxycholic acid
Secondary bile acids are formed by __: deoxycholic acid, lithocholic acid

Back 31

Primary bile acids = cholic acid, chenodeoxycholic acid
Secondary bile acids are formed by __: deoxycholic acid, lithocholic acid

Front 32

A 20-year-old woman with jaundice has a fusiform dilatation of her extrahepatic bile duct. Therapy for this condition is aimed at prevention of

Back 32

bile duct carcinoma

Front 33

Gallbladder: lies b/w liver segments _ and _

Back 33

Gallbladder: b/w segments 3 and 4

Front 34

Triangle of calot:
_ = lateral
_ = medial
_ = superior

Back 34

Triangle of calot:
cystic duct = lateral
CBD = medial
liver = superior

Front 35

Cystic artery branches off the _

Back 35

Cystic artery branches off the R hepatic artery

Front 36

Cystic veins drain into _ and _

Back 36

Cystic veins drain into:
R branch of portal vein
Liver

Front 37

Lymphatics are to the L or R of common bile duct?

Back 37

Lymphatics are to the R of common bile duct

Front 38

Parasympatetic fibers to biliary system course from L (anterior) or R (posterior) trunk of vagus?

Back 38

Parasympatetic fibers to biliary system course from L (anterior) trunk of vagus

Front 39

Sympathetic fibers to biliary system course from T_-T_, though _ and _ ganglia

Back 39

Sympathetic fibers to biliary system course from T7-T10, though splanchnic and celiac ganglia

Front 40

Sphincter of oddi:
Drug _ contracts it
Drug _ relaxes it

Back 40

Sphincter of oddi:
MORPHINE contracts it
GLUCAGON relaxes it

Front 41

Common bile duct:
Normal size is <_mm
<_ mm after cholecystectomy

Back 41

Common bile duct:
Normal size = <8mm
<10 mm after cholecystectomy

Front 42

Gallbladder wall:
Normal thickness is <_ mm

Back 42

Gallbladder wall:
Normal thickness is <4 mm

Front 43

Pancreatic duct:
Normal size is <_mm

Back 43

Pancreatic duct:
Normal size is <4 mm

Front 44

Highest concentration of CCk and secretin is in _

Back 44

Highest concentration of CCk and secretin is in DUODENUM

Front 45

Rokitansky-Aschoff sinuses = invagination of_
2/2_

Back 45

Rokitansky-Aschoff sinuses = invagination of GB wall epithelium
2/2 increased gallbladder pressure

Front 46

_ = biliary ducts that go directly from liver -> GB
Involved in post-cholecystectomy complication…

Back 46

Ducts of Luschka: direct from liver -> GB
Can leak after cholecystectomy

Front 47

Bile is secreted by _ cells (80%) and _ cells (_%)

Back 47

Bile is secreted by hepatocystes (80%) and bile cancalicualr cells (20%)

Front 48

A 68 year old man presents with painless jaundice. He states he has been yellow for two weeks and it keeps getting worse. Workup reveals pancreatic cancer with multiple liver metastasis and high grade obstruction of the distal common bile duct. He is scheduled for a percutaneous transhepatic biliary drainage procedure. Pre-procedure laboratory studies reveal Hgb 10.6 gm/dl; platelets 80,000/mm3; INR 1.63, PT 23; PTT 44. The most likely source of the patients elevated INR is :

Back 48

"Biliary obstruction -> lack of enteric bile salts -> decreased absorption of fat and fat solutes, inc. Vit K

Front 49

young woman develops jaudice + ascites 2 wks postpartum.
-Consistent c/ ...

Back 49

Post-partum hepatic vein thrombosis/Budd-Chiari ;
-rare, related to hypercoag state.
-Dx: mesenteric angiogram c/ venous phase contrast. MRI less sensitive

Front 50

Budd Chiari: tx is _

Back 50

Budd Chiari: occlusion of hepatic veins, IVC
-RUQ pain, hepatosplenomegaly, ascites, hepatic failure, muscle wasting, variceal bleeding
-Dx: CT angio c/ venous sphase contrast Liver bx: sinusoidal dilation, centrilobular congestion
Tx: portacaval sunt
(needs to connect to IVC above obstruction)

Front 51

Pt c/ portal HTN gets a bx that shows:
sinusoidal dilation, congestion, centrilobular congestion
What is wrong c/ pt?

Back 51

Budd Chiari:
Portal HTN 2/2 pre-sinusoidal obstruction
Bx:sinusoidal dilation, congestion, centrilobular congestion
What is wrong c/ pt?

Front 52

the caudate lobe is fed by what arterial supply?

Back 52

the caudate lobe:
- receives separate right and left portal and arterial blood flow
-has its own venous drainage to the IVC, so Budd Chiari has caudate lobe hypertrophy

Front 53

4 roles of CCK in digestion...

Back 53

CCK:
-GB contraction
-pancreatic enzyme release
-relaxation of sphincter of Oddi
-increased intestinal motility

Front 54

what are the elements of Child-Pugh score (hint: ProBAAN)

Back 54

Child-Pugh score: ProBAAN
Prothrombin tume
Bili
Albumin
Ascites
Neuro disorder

Front 55

what are the factors in Child's classification for liver failure?
(hint: 3 lab, 2 clinical)

Back 55

Child's classification of liver failure :
Lab: bilirubin, albumin, PT
Clinical: ascites, neurologic disorder.

Front 56

most common location for cholangiocarcinoma is _
-Tx is _

Back 56

Cholangiocarcinoma -RFs: elderly, male, C. sinensis, UC, choledochal cysts (15% risk) PSC, congen hepatic fibrosis, chronic bile duct ingecion, typhpid
-Suspect in pt c/ focal bile duct stenosis, no hx bile duct surgery or pancreatitis
-60-80% of cholangiocarcinomas occur in perihilar region (around hepatic duct bifurcation).
-Distal cholangiocarcinoma resection is more likely to be curative.
-Pancreatoduodenectomy (Whipple procedure) c/ pylorus preservation = treatment for distal resectable cholangiocarcinomas.
-CA 19-9 may be elevated in cholangiocarcinoma, similar to pancreatic cancer.
-Upper 1/3 (Klatskin) #1: if resectable, lobectomy + stent contralateral bile duct
-Middle 1/3 => EHBDR (extra-hep bile duct resection), hepatico-jej
-Lower 1/3: Whipple

Front 57

tx for cholangiocarcinoma in middle 1/3 of duct

Back 57

Cholangiocarcinoma -RFs: elderly, male, C. sinensis, UC, choledochal cysts (15% risk) PSC, congen hepatic fibrosis, chronic bile duct ingecion, typhpid
-Suspect in pt c/ focal bile duct stenosis, no hx bile duct surgery or pancreatitis
-60-80% of cholangiocarcinomas occur in perihilar region (around hepatic duct bifurcation).
-Distal cholangiocarcinoma resection is more likely to be curative.
-Pancreatoduodenectomy (Whipple procedure) c/ pylorus preservation = treatment for distal resectable cholangiocarcinomas.
-CA 19-9 may be elevated in cholangiocarcinoma, similar to pancreatic cancer.
-Upper 1/3 (Klatskin) #1: if resectable, lobectomy + stent contralateral bile duct
-Middle 1/3 => EHBDR (extra-hep bile duct resection), hepatico-jej
-Lower 1/3: Whipple

Front 58

tx for cholangiocarcinoma in lower 1/3 of duct

Back 58

Cholangiocarcinoma -RFs: elderly, male, C. sinensis, UC, choledochal cysts (15% risk) PSC, congen hepatic fibrosis, chronic bile duct ingecion, typhpid
-Suspect in pt c/ focal bile duct stenosis, no hx bile duct surgery or pancreatitis
-60-80% of cholangiocarcinomas occur in perihilar region (around hepatic duct bifurcation).
-Distal cholangiocarcinoma resection is more likely to be curative.
-Pancreatoduodenectomy (Whipple procedure) c/ pylorus preservation = treatment for distal resectable cholangiocarcinomas.
-CA 19-9 may be elevated in cholangiocarcinoma, similar to pancreatic cancer.
-Upper 1/3 (Klatskin) #1: if resectable, lobectomy + stent contralateral bile duct
-Middle 1/3 => EHBDR (extra-hep bile duct resection), hepatico-jej
-Lower 1/3: Whipple

Front 59

A 52 yo male with history of hepatolithiasis presents with painless jaundice. ERCP and brush biopsy reveals cholangiocarcinoma.
Where do most cholangiocarcinomas occur?
What location of cholangiocarcinoma is most amenable to resection and what would that surgery be?
What tumor marker may be elevated?

Back 59

Cholangiocarcinoma -RFs: elderly, male, C. sinensis, UC, choledochal cysts (15% risk) PSC, congen hepatic fibrosis, chronic bile duct ingecion, typhpid
-Suspect in pt c/ focal bile duct stenosis, no hx bile duct surgery or pancreatitis
-60-80% of cholangiocarcinomas occur in perihilar region (around hepatic duct bifurcation).
-Distal cholangiocarcinoma resection is more likely to be curative.
-Pancreatoduodenectomy (Whipple procedure) c/ pylorus preservation = treatment for distal resectable cholangiocarcinomas.
-CA 19-9 may be elevated in cholangiocarcinoma, similar to pancreatic cancer.
-Upper 1/3 (Klatskin) #1: if resectable, lobectomy + stent contralateral bile duct
-Middle 1/3 => EHBDR (extra-hep bile duct resection), hepatico-jej
-Lower 1/3: Whipple

Front 60

A 62-year-old woman had an uneventful cholecystectomy at age 30. She now has jaundice and pruritus. Endoscopic retrograde cholangiopancreatography shows a tight stricture at the junction of the right and left hepatic ducts. The most likely diagnosis is

Back 60

Cholangiocarcinoma -RFs: elderly, male, C. sinensis, UC, choledochal cysts (15% risk) PSC, congen hepatic fibrosis, chronic bile duct ingecion, typhpid
-Suspect in pt c/ focal bile duct stenosis, no hx bile duct surgery or pancreatitis
-60-80% of cholangiocarcinomas occur in perihilar region (around hepatic duct bifurcation).
-Distal cholangiocarcinoma resection is more likely to be curative.
-Pancreatoduodenectomy (Whipple procedure) c/ pylorus preservation = treatment for distal resectable cholangiocarcinomas.
-CA 19-9 may be elevated in cholangiocarcinoma, similar to pancreatic cancer.
-Upper 1/3 (Klatskin) #1: if resectable, lobectomy + stent contralateral bile duct
-Middle 1/3 => EHBDR (extra-hep bile duct resection), hepatico-jej
-Lower 1/3: Whipple

Front 61

Cholangiosarcoma:
2 things that correlate c/ outcome

Back 61

Cholangiosarcoma: these correlate c/ outcome
1.) TUMOR SIZE
2.) SATELLITE NODULES

Front 62

Cholangiosarcoma:
worse survival c/ intra- or extra-hepatic

Back 62

Cholangiosarcoma:
INTRA-hepatic => WORSE survival

Front 63

Clonorchiasis infection = RF for cancer _

Back 63

Clonorchiasis infection = RF for
CHOLANGIOSARCOMA

Front 64

Ulcerative colitis = RF for cancer _

Back 64

Cholangiocarcinoma:
-RFs elderly, male, C. sinensis, thphoid, UC, choledochal cyst, clerosing cholangitis, congen hepatic fibrosis, chronic bile duct obstruction
-Sx painless jaundice -> cholangitis, anemia, pruritus
-Dx ERCP then MRI. FOCAL BILE DUCT STENOSIS in pt s/ hx of biliary surgery or pancreatitis
-Upper 1/3 of tract = Klathskin tumor => most common but usually unresectable. Can do lobectomy + stent contralateral duct if localized to 1 lobe
-Middle 1/3 of tract => HEPATICOJEJUNOSTOMY
-Lower 1/3 of tract => WHIPPLE
-Unresectable => palliative stent
-20% 5-yr survival

Front 65

Choledochal cyst = RF for cancer _

Back 65

Cholangiocarcinoma:
-RFs elderly, male, C. sinensis, thphoid, UC, choledochal cyst, clerosing cholangitis, congen hepatic fibrosis, chronic bile duct obstruction
-Sx painless jaundice -> cholangitis, anemia, pruritus
-Dx ERCP then MRI. FOCAL BILE DUCT STENOSIS in pt s/ hx of biliary surgery or pancreatitis
-Upper 1/3 of tract = Klathskin tumor => most common but usually unresectable. Can do lobectomy + stent contralateral duct if localized to 1 lobe
-Middle 1/3 of tract => HEPATICOJEJUNOSTOMY
-Lower 1/3 of tract => WHIPPLE
-Unresectable => palliative stent
-20% 5-yr survival

Front 66

RFs for Cholangiocarinoma:
elderly men, typhoid, and "6 C's" which are…

Back 66

Cholangiocarcinoma:
-RFs elderly, male, C. sinensis, thphoid, UC, choledochal cyst, clerosing cholangitis, congen hepatic fibrosis, chronic bile duct obstruction
-Sx painless jaundice -> cholangitis, anemia, pruritus
-Dx ERCP then MRI. FOCAL BILE DUCT STENOSIS in pt s/ hx of biliary surgery or pancreatitis
-Upper 1/3 of tract = Klathskin tumor => most common but usually unresectable. Can do lobectomy + stent contralateral duct if localized to 1 lobe
-Middle 1/3 of tract => HEPATICOJEJUNOSTOMY
-Lower 1/3 of tract => WHIPPLE
-Unresectable => palliative stent
-20% 5-yr survival

Front 67

Suspect cholangiocarcinoma,
need to get 2 kinds of imaging _

Back 67

Cholangiocarcinoma:
-RFs elderly, male, C. sinensis, thphoid, UC, choledochal cyst, clerosing cholangitis, congen hepatic fibrosis, chronic bile duct obstruction
-Sx painless jaundice -> cholangitis, anemia, pruritus
-Dx ERCP then MRI. FOCAL BILE DUCT STENOSIS in pt s/ hx of biliary surgery or pancreatitis
-Upper 1/3 of tract = Klathskin tumor => most common but usually unresectable. Can do lobectomy + stent contralateral duct if localized to 1 lobe
-Middle 1/3 of tract => HEPATICOJEJUNOSTOMY
-Lower 1/3 of tract => WHIPPLE
-Unresectable => palliative stent
-20% 5-yr survival

Front 68

Cholangiocarcinoma: natural history of spread

Back 68

Cholangiocarcinoma:
-RFs elderly, male, C. sinensis, thphoid, UC, choledochal cyst, clerosing cholangitis, congen hepatic fibrosis, chronic bile duct obstruction
-Sx painless jaundice -> cholangitis, anemia, pruritus
-Dx ERCP then MRI. FOCAL BILE DUCT STENOSIS in pt s/ hx of biliary surgery or pancreatitis
-Upper 1/3 of tract = Klathskin tumor => most common but usually unresectable. Can do lobectomy + stent contralateral duct if localized to 1 lobe
-Middle 1/3 of tract => HEPATICOJEJUNOSTOMY
-Lower 1/3 of tract => WHIPPLE
-Unresectable => palliative stent
-20% 5-yr survival

Front 69

Elderly man c/ early painless jaundice, high bili, high alk phos -> +/- cholangitis, wt loss, anemia, pruritus -> focal bile duct stenosis
No hx of biliary surgery or pancreatits
Suggestive of _
_% 5-yr survival

Back 69

Cholangiocarcinoma:
-RFs elderly, male, C. sinensis, thphoid, UC, choledochal cyst, clerosing cholangitis, congen hepatic fibrosis, chronic bile duct obstruction
-Sx painless jaundice -> cholangitis, anemia, pruritus
-Dx ERCP then MRI. FOCAL BILE DUCT STENOSIS in pt s/ hx of biliary surgery or pancreatitis
-Upper 1/3 of tract = Klathskin tumor => most common but usually unresectable. Can do lobectomy + stent contralateral duct if localized to 1 lobe
-Middle 1/3 of tract => HEPATICOJEJUNOSTOMY
-Lower 1/3 of tract => WHIPPLE
-Unresectable => palliative stent
-20% 5-yr survival

Front 70

Cholangiocarcinoma type that is most common, worst prognosis
Tx

Back 70

Cholangiocarcinoma:
-RFs elderly, male, C. sinensis, thphoid, UC, choledochal cyst, clerosing cholangitis, congen hepatic fibrosis, chronic bile duct obstruction
-Sx painless jaundice -> cholangitis, anemia, pruritus
-Dx ERCP then MRI. FOCAL BILE DUCT STENOSIS in pt s/ hx of biliary surgery or pancreatitis
-Upper 1/3 of tract = Klathskin tumor => most common but usually unresectable. Can do lobectomy + stent contralateral duct if localized to 1 lobe
-Middle 1/3 of tract => HEPATICOJEJUNOSTOMY
-Lower 1/3 of tract => WHIPPLE
-Unresectable => palliative stent
-20% 5-yr survival

Front 71

Cholangiocarcinoma in middle 1/3 of tract =>
Tx: _

Back 71

Cholangiocarcinoma:
-RFs elderly, male, C. sinensis, thphoid, UC, choledochal cyst, clerosing cholangitis, congen hepatic fibrosis, chronic bile duct obstruction
-Sx painless jaundice -> cholangitis, anemia, pruritus
-Dx ERCP then MRI. FOCAL BILE DUCT STENOSIS in pt s/ hx of biliary surgery or pancreatitis
-Upper 1/3 of tract = Klathskin tumor => most common but usually unresectable. Can do lobectomy + stent contralateral duct if localized to 1 lobe
-Middle 1/3 of tract => HEPATICOJEJUNOSTOMY
-Lower 1/3 of tract => WHIPPLE
-Unresectable => palliative stent
-20% 5-yr survival

Front 72

Cholangiocarcinoma in lower 1/3 of tract =>
Tx: _

Back 72

Cholangiocarcinoma:
-RFs elderly, male, C. sinensis, thphoid, UC, choledochal cyst, clerosing cholangitis, congen hepatic fibrosis, chronic bile duct obstruction
-Sx painless jaundice -> cholangitis, anemia, pruritus
-Dx ERCP then MRI. FOCAL BILE DUCT STENOSIS in pt s/ hx of biliary surgery or pancreatitis
-Upper 1/3 of tract = Klathskin tumor => most common but usually unresectable. Can do lobectomy + stent contralateral duct if localized to 1 lobe
-Middle 1/3 of tract => HEPATICOJEJUNOSTOMY
-Lower 1/3 of tract => WHIPPLE
-20% 5-yr survival

Front 73

Cholangiocarcinoma that is unresectable =>
Tx: _

Back 73

Cholangiocarcinoma that is unresectable => PALLIATIVE STENT

Front 74

Cholangitis:
#1 cause = _
-2 most common organisms are _

Back 74

Cholangitis:
-Gallstones = #1 cause
-E. coli > Klebsiella

Front 75

Cholangitis:
#1 serious complication is _ , which is 2/2 _

Back 75

Cholangitis:
-Renal failure = #1 serious complication, 2/2 SEPSIS

Front 76

Cholangitis:
Tx is _

Back 76

Cholangitis:
-E coli = #1 organism
Tx: resuscition, abx, ERCP + sphincterotomy + stone extraction
2nd line (e.g. ,if unable to cannulate the CBD) percutaneous transhepatic cholangiography (PTC) 3rd line (e.g. radiologist unable to place PTC tube) place T-tube in OR

Front 77

Cholangitis:
Tx if PTC tube present = _

Back 77

Cholangitis:
Change PTC tube if already present

Front 78

Cholangitis:
2 late complications

Back 78

Cholangitis:
2 late complications = stricture, hepatic abscess

Front 79

Cholangitis 2/2 biliary obstruction:
-US findings_

Back 79

Cholangitis 2/2 biliary obstruction:
-CBD >8mm (>10mm after cholecytectomy)

Front 80

Pt presents c/ jaundice, RUQ tenderness, fever, hypotension, mental status change
-This patient has __
-Tx is __

Back 80

Cholangitis:
-jaundice, RUQ tenderness, fever, hypotension, mental status change
-Tx: immediate IV abx, fluid resuscitation, emergent drainage of CBD

Front 81

Recurrent cholangitis 2/2 primary CBD stones is called _
2/2 _
Tx: surgical, medical

Back 81

ORIENTAL CHOLANGIOHEPATITIS = recurrent cholangitis 2/2 primary CBD stones
2/2 C. sinensis, A. lumbricoides, T trichura, E. coli
Tx: HEPATICOJEJUNOSTOMY + ANTI-PARASITICS

Front 82

#1 RF for positive bile culture = _
#1 bacteria = _

Back 82

#1 RF for positive bile culture = POST-OP STRICTURE
#1 bacteria = E. coli (often polymicrobial)

Front 83

Common bile duct injury:
Anatomic abnormality in 10% of people that increases risk
If > _mm => must open + perform _ (or _)
If <_% of circumference, can perform _

Back 83

Common bile duct injury:
10% have R posterior duct (from segment 6 or 7) entering CBD separately (confused for cystic duct)
<50% of circumference => primary repair > 2mm => open hepatojejunostomy (or choledochojejunostomy)

Front 84

After cholecystectomy, intra-op cholangiogram shows good CBD filling but no filling of proximal hepatic duct
-Suspect _
-Next step = _

Back 84

After cholecystectomy, intra-op cholangiogram shows good CBD filling but no filling of proximal hepatic duct
-Suspect that hepatic duct was mistaken for cystic duct + clipped
-Open to evaluate

Front 85

After cholecystectomy, intra-op cholangiogram shows good CBD filling but no filling of proximal hepatic duct
-Pt re-opened and hepatic duct found to be ligated
-Next step = _

Back 85

After cholecystectomy, intra-op cholangiogram shows good CBD filling but no filling of proximal hepatic duct
-Suspect that hepatic duct was mistaken for cystic duct + clipped
-Open to evaluate -> hepaticojejunostomy
(end-to-end hepatic duct anastomosis leads to stricture)

Front 86

After cholecystectomy, intra-op cholangiogram shows poor CBD filling
(there had never been any sign CBD stone)
-Suspect _
-Next step = _

Back 86

After cholecystectomy, intra-op cholangiogram shows poor CBD filling, bur there is no CBD stone
-Likely CBD ligated
-Open + do choledocho-jejunostomy

Front 87

Pt has persistant N/V after cholecystectomy:
Order a _ to look for _

Back 87

Pt has persistant N/V after cholecystectomy:
Order RUQ US to r/o bile leak, cystic duct remnant leak, injuries to hepatic or CBD, leak from duct of Luschka

Front 88

Pt has persistant N/V after cholecystectomy, US shows fluid collection
Next step is _

Back 88

Pt has persistant N/V after cholecystectomy, US shows fluid collection=>
Percutaneous drain to determine whether it is a bile leak
-If bilious, send pt for ERCP

Front 89

Pt has persistant N/V after cholecystectomy -> US shows fluid collection -> percutaneous drain shows bilious fluid
Next step is _

Back 89

Pt has persistant N/V after cholecystectomy -> US shows fluid collection -> percutaneous drain shows bilious fluid =>
ERCP
-Cystic duct remnant leak, hepatic duct injury, Duct of Luscka leak, CBD injury => sphincterotomy + temporary stent (cystic duct remnant will eventually scar down)
-Hepatic duct or CBD transection => hepaticojujunosotmy or choledochojejunostomy
-More serious injuries might require drain x 6-8 wks, then reoperation

Front 90

Pt has persistant N/V after cholecystectomy -> US shows fluid collection -> percutaneous drain shows bilious fluid -> ERCP shows CYSTIC DUCT REMNANT LEAK.
Tx = _

Back 90

Pt has persistant N/V after cholecystectomy -> US shows fluid collection -> percutaneous drain shows bilious fluid -> ERCP shows cystic duct remnant leak.
Tx = SPHINCTEROTOMY + STENT

Front 91

Pt has persistant N/V after cholecystectomy -> US shows fluid collection -> percutaneous drain shows bilious fluid -> ERCP shows SMALL INJURY TO HEPATIC or CB DUCT.
Tx = _

Back 91

Pt has persistant N/V after cholecystectomy -> US shows fluid collection -> percutaneous drain shows bilious fluid -> ERCP shows small injury to hepatic or common bile duct
Tx = SPHINCTEROTOMY + STENT

Front 92

Pt has persistant N/V after cholecystectomy -> US shows fluid collection -> percutaneous drain shows bilious fluid -> ERCP shows LEAK FROM DUCT OF LUSCKA.
Tx = _

Back 92

Pt has persistant N/V after cholecystectomy -> US shows fluid collection -> percutaneous drain shows bilious fluid -> ERCP shows leak from Duct of Luscka
Tx = SPHINCTEROTOMY + STENT

Front 93

Pt has persistant N/V after cholecystectomy -> US shows fluid collection -> found to have COMPLETE CBD TRANSECTION.
Tx = _

Back 93

Pt has persistant N/V after cholecystectomy -> US shows fluid collection -> found to have complete CBD transection.
Tx = CHOLEDOCHOJEJUNOSTOMY

Front 94

Pt has persistant N/V after cholecystectomy -> US shows NO fluid collection, but DILATED HEPATIC DUCTS -> probably 2/2 _.
Tx = _

Back 94

Pt has persistant N/V after cholecystectomy -> US shows NO fluid collection, but DILATED HEPATIC DUCTS -> likely TRANSECTED CBD, needs choledochojejunostomy

Front 95

Pt has ANASTOMOTIC LEAK after hepaticojejunostomy or transplant
Tx is _

Back 95

Pt has ANASTOMOTIC LEAK after hepaticojejunostomy or transplant
Tx = ERCP + STENT

Front 96

Pt is septic s/p cholecystectomy -> fluid resuscitate, stabilize -> RUQ US shows fluid collection or dilated intrahepatic ducts.
2 possible culprits

Back 96

Sepsis s/p cholecystectomy, RUQ US shows fluid collection or dilated intrahepatic ducts:
COMPLETE CBD TRANSECTION, CHOLANGITIS

Front 97

Pt is septic s/p cholecystectomy -> fluid resuscitate, stabilize -> RUQ US shows fluid collection, NO dilated intrahepatic ducts => Tx is _

Back 97

Pt is septic s/p cholecystectomy -> fluid resuscitate, stabilize -> RUQ US shows fluid collection, NO dilated intrahepatic ducts =>
do ERCP + STENT STRICTURED AREA

Front 98

#1 cause of late post-op biliary strictures
2 other causes
Dx (2 options)
Tx

Back 98

ISCHEMIA = #1 cause of late post-op biliary strictures
Also 2/2 chronic pancreatitis, stricture of biliary-enteric anastomosis
Dx:ERCP shows stricture, US shows dilated intrahepatic ducts
Tx: ERCP + SPHINCTEROTOMY +/- STENT to decompress -> PTC tube if that fails

Front 99

Bilie duct injury c/ symptoms within 7 days of surgery:
Tx is _

Back 99

Bile duct injury within 7 days of surgery=>
HEPATICOJEJUNOSTOMY
(unlikely to be sufficiently treated c/ ERCP, balloon, stent)

Front 100

Bile duct injury c/ symptoms >7days after surgery:
Tx is _

Back 100

Bile duct injury c/ symptoms >7days after surgeryy =>
HEPATICOJEJUNOSTOMY 6-8 wks after surgery
Late injuries: ERCP, sphincterotomy, stent. Get brushings to r/o malignancy

Front 101

Bile duct injury/Biliary stricture years after surgery =>
Tx is _.
Make sure to r/o _

Back 101

Bile duct injury/Biliary stricture years after surgery =>
ERCP, sphincterotomy, stent.
Get brushings to r/o malignancy

Front 102

Arterial injury during cholecystectomy is usually to the _

Back 102

R HEPATIC ARTERY = arterial injury during cholecystectomy

Front 103

Pt s/p lap cholecystectomy found to have GB adenoca limited to mucosa (stage _)
Mgmt is _
Worry about complication of surgery _

Back 103

Pt s/p lap cholecystectomy found to have GB adenoca limited to mucosa (stage 1)
No more surgery
Worry about tumor implants @ trocar site

Front 104

Pt s/p lap cholecystectomy found to have GB adenoca into muscle (stage _)
Mgmt is _
Worry about complication of lap chole _

Back 104

Pt s/p lap cholecystectomy found to have GB adenoca into muscle (stage 2)
Wide resection (2-3 cm margins) around liver bed @ segments IV, V (most common site of spread), regional lymphadenectomy including portal triad (most commonly spreads to cystic duct nodes on R)
May need Whipple, lobectomy, or CBD resection
Worry about tumor implants @ trocar site

Front 105

Pt s/p cholecystectomy <24 hrs ago, now in shock
Likely _

Back 105

Pt s/p cholecystectomy <24 hrs ago, now in shock
Likely HEMORRHAGIC 2/2 CLIP FALLING OFF CYSTIC ARTERY

Front 106

Pt s/p cholecystectomy >24 hrs ago, now in shock
Likely _

Back 106

Pt s/p cholecystectomy >24 hrs ago, now in shock
Likely SEPTIC 2/2 ACCIDENTAL CLIP ON CBD -> CHOLANGITIS

Front 107

2 indications for asymptomatic cholecystectomy

Back 107

3 indications for asymptomatic cholecystectomy =
-Liver transplant
-Gastric bypass

Front 108

Pt undergoing routine lap chole suddenly develops drop in end-tidal CO2, (-) breath sounds, but stable BP and HR
-Suspect _
-Tx is _

Back 108

Disconnection from vent:
-End-tidal CO2 reflects CO2 exchange from blood to alveolus ->
sudden decrease suggests disconnection from vent, air embolus

Front 109

Pt undergoing routine lap chole suddenly develops rise in end-tidal CO2, decreased BS @ bases, but stable BP and HR
-Suspect _
-Tx is _

Back 109

Atelectasis intra-op:
-Rise in ET CO2 reflects impaired exchange @ alveolar level 2/2 lung collapse, atelectasis ->
probably needs larger tidal volumes

Front 110

Cholecystitis: 3 most common organisms

Back 110

Cholecystitis: 3 most common organisms =
E. coli
Klebsiella
Enterococcus

Front 111

Gallstone type that has most risk of cholecystitis?
pigmented/non-pigmented

Back 111

PIGMENTED gallstones => most risk of cholecystitis
Black: hemolysis, cirrhosis, chronic TPN, ileal resection
Brown (form in CBD): Asians, 2/2 E. coli producing beta-glucuronidase -> deconjugates bili -> Ca bilirubinate

Front 112

US:
_% sensitive for gallstones
3 US findings of cholecystitis
_ suggests a CBD stone/obstruction

Back 112

US:
95% sensitive for gallstones
Cholecystitis; stones, BG wall >4mm thick, pericholecystic fluid
CBD>8mm suggests a CBD stone/obstruction

Front 113

Bacterial infection of bile
Most common cause
Other possible cause

Back 113

Bacterial infection of bile
Dissemination from PORTAL SYSTEM = most common cause
Also 2/2 retrograde infection from bacteria in duodenum

Front 114

Diabetic pt c/ sudden severe ab pain, N/V, sepsis
Gas in GB wall on ab x-ray
Diagnosis is _
#1 organism = _
Complication to be worried about _
Tx: _

Back 114

EMPHYSEMATOUS GALLBLADDER DZ:
Sudden severe ab pain, N/V, sepsis
RF: Diabetics 2/2 CLOSTRIDIUM PERFRINGENS
Ab x-ray: gas in GB wall
PERFORATION risk
EMERGENT CHOLECYSTECOMY or percutaneous drain if unstable

Front 115

Charcot's triad

Back 115

Charcot's triad =
RUQ pain
Fever
Jaundice

Front 116

Reynold's pentad is _, suggests _

Back 116

Reynold's pentad suggests SEPSIS 2/2 cholangitis
RUQ pain
Fever
Jaundice
Mental status changes
Shock

Chylovenous reflux @ 20 mmHg -> systemic bacteremia

Front 117

Choledochal cysts:
Gender
Geography
_% extrahepatic
_% cancer risk (cancer _)

Back 117

Choledochal cysts:
-Females in Asia, Japan
-occurs during uterine development. poss 2/2 reflux of pancreatic enzymes 2/2 bad angle of insertion
9-0% extrahepatic
-15% cancer risk (cholangiocarcinoma)

Front 118

Type 1 _ = fusiform or saccular dilation of extrahepatic ducts
Tx: _

Back 118

Type 1 CHOLEDOCHAL CYST (85%) = fusiform or saccular dilation of extrahepatic ducts
Tx: CYST EXCISION + HEPATOCOJEJUNOSTOMY or CHOLECYSTECTOMY

Type 2: isolated diverticulum protruding from CBD => same surgery
Type 3/choledochocele: dilatation of duodenal portion of CBD or where pancreatic duct meets => NO surgery
Type 4 (10%): dilation of intra- and extra-hepatic CBD=> same surgery +/- hepatectomy
Type 5/Caroli's dz: cystic dilation of intrahepatic ducts => poss hepatectomy. liver TRANSPLANT if diffuse

Front 119

Type _ choledochal cyst = partially intrahepatic
Tx: _

Back 119

Type 1 CHOLEDOCHAL CYST (85%) = fusiform or saccular dilation of extrahepatic ducts
Tx: CYST EXCISION + HEPATOCOJEJUNOSTOMY or CHOLECYSTECTOMY

Type 2: isolated diverticulum protruding from CBD => same surgery
Type 3/choledochocele: dilatation of duodenal portion of CBD or where pancreatic duct meets => NO surgery
Type 4 (10%): dilation of intra- and extra-hepatic CBD=> same surgery +/- hepatectomy
Type 5/Caroli's dz: cystic dilation of intrahepatic ducts => poss hepatectomy. liver TRANSPLANT if diffuse

Front 120

Type _ choledochal cyst = totally intrahepatic
(AKA _)
Tx: _

Back 120

Type 1 CHOLEDOCHAL CYST (85%) = fusiform or saccular dilation of extrahepatic ducts
Tx: CYST EXCISION + HEPATOCOJEJUNOSTOMY or CHOLECYSTECTOMY

Type 2: isolated diverticulum protruding from CBD => same surgery
Type 3/choledochocele: dilatation of duodenal portion of CBD or where pancreatic duct meets => NO surgery
Type 4 (10%): dilation of intra- and extra-hepatic CBD=> same surgery +/- hepatectomy
Type 5/Caroli's dz: cystic dilation of intrahepatic ducts => poss hepatectomy. liver TRANSPLANT if diffuse

Front 121

In utero bad angle of insertion -> abnl reflux of pancreatic enzymes during development ->
Infant c/ _

Symptoms

Back 121

Type 1 CHOLEDOCHAL CYST (85%) = fusiform or saccular dilation of extrahepatic ducts
Tx: CYST EXCISION + HEPATOCOJEJUNOSTOMY or CHOLECYSTECTOMY

Type 2: isolated diverticulum protruding from CBD => same surgery
Type 3/choledochocele: dilatation of duodenal portion of CBD or where pancreatic duct meets => NO surgery
Type 4 (10%): dilation of intra- and extra-hepatic CBD=> same surgery +/- hepatectomy
Type 5/Caroli's dz: cystic dilation of intrahepatic ducts => poss hepatectomy. liver TRANSPLANT if diffuse

Front 122

Antibiotic _ can -> gallbladder sludging, cholestatic jandice

Back 122

CEFTRIAXONE can -> gallbladder sludging, cholestatic jandice

Front 123

_ = speckled cholesterol deposits on gallbladder wall

Back 123

Cholesterolosis = speckled cholesterol deposits on gallbladder wall

Front 124

Up to _% of pts c/ cirrhosis develop hernia of anterior ab wall
-4 complications
Main RF for peritonitis (and therefore op indication) = _
-_% recurrence if ascites not medically controlled afterward
-Can use _ pre-op to reduce production of ascites

Back 124

Up to 20% of pts c/ cirrhosis develop hernia of anterior ab wall
Complications :hemorrhage 2/2 variceal disruption, peritnitis, post-op asictes leak, heaptic decompensation
Ascites leak = main RF for peritonitis (and therefore op indication)
-73% recurrence if ascites not medically controlled afterward
-can use TIPS pre-op to reduce ascites production

Front 125

Pt undergoing routine lap chole suddenly develops hypotension, tachycardia, drop in end-tidal CO2, but (+) breath sounds
-Suspect _
-Tx is _

Back 125

CO2 embolus
-End-tidal CO2 reflects CO2 exchange from blood to alveolus -> sudden decrease suggests disconnection from vent, air embolus
-Trendelenburg, L side down, increase minute ventilation (absorb CO2 faster), 100% O2
(O2 absorbed faster than CO2 -> O2 comes into equilibrium with CO2 within embolus, can get absorbed)
-If CPR needed, should go on a long time to allow reabsorbtion of embolus

Front 126

2 coagulation factors not made in liver….

Back 126

vWF + Factor 8 are not made in liver
(made in endothelium)

Front 127

what bile duct anatomic variant present in 10% of patients is a big contributor to CBD injuries?

Back 127

10% of patients a RIGHT POSTERIOR duct (from segment 6 or &) than enters the CBD separately =>
confused for cystic duct during cholecystectomy
-if injured and >2 mm, need to open + do hepaticojejunostomy

Front 128

42 y/o female for lap chole, found to have a segment of common bile duct in when you look as the specimen. What is the most appropriate treatment?

Back 128

Immediate reconstruction with biliary enteric anastamosis.
-Simple CBD injury found intraop => primary repair +/- stent
-Major CBD injury found intraop =>roux-en-y HEPATICO-JEJUNOSTOMY (or sometimes choledocho-jejunostomy)
-CBD injury found late => place a PTC, then hepatico-jejunostomy 6 weeks later.

Front 129

most common variant of common hepatic artery (2%) = _

Back 129

most common variant of common hepatic artery = off SMA (2%)

Front 130

aberrant __ artery can be mistaken for cystic artery during lap chole

Back 130

CYSTIC ARTERY.
Up to 75% of blood flow comes from portal vein, the rest from hepatic artery. Most of blood supply to metastasis comes from hepatic artery. Gastroduodenal artery is a landmark for dividing common form proper hepatic artery. Hepatic artery provides more blood to bile ducts than the portal veins. Ligation of right hepatic artery, mistake for cystic artery, is an important cause of lap chole complication.

Front 131

"

Back 131

endoscopic stenting and percutaneous fluid drainage

Front 132

Crohns patient presents c/ duodenal obstruction, failed medical mgmt.
-what is the treatment

Back 132

Crohn's + duodenal obstruction, failed medical mgmt =>
GASTROJEJUNOSOMY in most cases
(if distal, could do side-to-side duodeno-jejunostomy)

unlike rest of sm bowel, stricturoplasty very difficult unless very short segment and resection not possible short of a Whipple

Front 133

Liver abscess that has:
(+) Casoni skin test
(+) indirect hemagglutination

Tx is _

Back 133

Echinococcus liver abscess (hydatid cyst):
(+) Casoni skin test
(+) indirect hemagglutination
-Sheep are carriers. Humans exposed by dogs.
-RIGHT > left liver lobe.
-CT: ectocyst (calcified) + endocyst
-Do not aspirate (risk for anaphyaxis)

Tx: Pre-op albendazole (+ ERCP if jaundice, LFTs, or cholangitis to r/o biliary communcation) -> surgical removal of cyst
-may inject alcohol before excision. make sure entire wall is excised.

Front 134

Echinococcus liver cyst:
Do pre-op _ to check for _ if jaundice, high LFTs, or cholangitis

Back 134

Echinococcus liver abscess (hydatid cyst):
(+) Casoni skin test
(+) indirect hemagglutination
-Sheep are carriers. Humans exposed by dogs.
-RIGHT > left liver lobe.
-CT: ectocyst (calcified) + endocyst
-Do not aspirate (risk for anaphyaxis)

Tx: Pre-op albendazole (+ ERCP if jaundice, LFTs, or cholangitis to r/o biliary communcation) -> surgical removal of cyst
-may inject alcohol before excision. make sure entire wall is excised.

Front 135

Liver abscess c/ CT showing ectocyst (calcified) and endocyst

Back 135

Echinococcus liver abscess (hydatid cyst):
(+) Casoni skin test
(+) indirect hemagglutination
-Sheep are carriers. Humans exposed by dogs.
-RIGHT > left liver lobe.
-CT: ectocyst (calcified) + endocyst
-Do not aspirate (risk for anaphyaxis)

Tx: Pre-op albendazole (+ ERCP if jaundice, LFTs, or cholangitis to r/o biliary communcation) -> surgical removal of cyst
-may inject alcohol before excision. make sure entire wall is excised.

Front 136

Echinococcus:
_ = animal carrier
_ = animal transmission to human

Back 136

Echinococcus liver abscess (hydatid cyst):
(+) Casoni skin test
(+) indirect hemagglutination
-Sheep are carriers. Humans exposed by dogs.
-RIGHT > left liver lobe.
-CT: ectocyst (calcified) + endocyst
-Do not aspirate (risk for anaphyaxis)

Tx: Pre-op albendazole (+ ERCP if jaundice, LFTs, or cholangitis to r/o biliary communcation) -> surgical removal of cyst
-may inject alcohol before excision. make sure entire wall is excised.

Front 137

Echinococcus liver cyst:
_ lobe = most common

Back 137

Echinococcus liver abscess (hydatid cyst):
(+) Casoni skin test
(+) indirect hemagglutination
-Sheep are carriers. Humans exposed by dogs.
-RIGHT > left liver lobe.
-CT: ectocyst (calcified) + endocyst
-Do not aspirate (risk for anaphyaxis)

Tx: Pre-op albendazole (+ ERCP if jaundice, LFTs, or cholangitis to r/o biliary communcation) -> surgical removal of cyst
-may inject alcohol before excision. make sure entire wall is excised.

Front 138

If pt undergoing cholecystectomy has jaundice, cholangitis, pancreatitis, high bili, high AST/ALT, stone in CBD on US

Back 138

Pre-op ERCP if: jaundice, cholangitis, gallstone pancreatitis, high bili, high AST/ALT, stone in CBD on US
<5% of pts undergoing cholecystectomy have retained CBD stone, 95% of these cleared c/ ERCP

Front 139

Air in biliary tree
Most common culprit is _
2 other possible causes

Back 139

Air in biliary tree
Usually after ERCP + sphincterotomy
Also 2/2 cholangitis, gallstone ileus (gallstone erosion into duodenum)

Front 140

Esophageal varices:
1st line tx for bleed
2 drugs

Back 140

Esophageal varices:
Sclerotherapy 90% effective @ stopping bleed = 1st line tx
Octreotide, Vasopressin

Front 141

Pt c/ bleeding esophageal varix + hx CAD is on vasopressin
Need to also give_

Back 141

Pt c/ bleeding esophageal varix + hx CAD is on vasopressin
Need to also give NTG

Front 142

Esophageal varices:
_% mortality c/ 1st bleed

Back 142

Esophageal varices: from short gastrics to azygos
30% mortality c/ 1st bleed

Front 143

Esophageal varices:
Drug _ may help prevent rebleed

Back 143

Esophageal varices: from short gastrics to azygos
PROPRANOLOL may help prevent rebleed

Front 144

Esophageal varices:
Complication of sclerotx is _
Treat c/ _

Back 144

Esophageal varices: from short gastrics to azygos
Complication of sclerotx = stricture
Treat c/ dilation

Front 145

Esophageal varices:
Tx for refractory bleeding (despite sclerotx)

Back 145

Esophageal varices: from short gastrics to azygos
Refractory bleeding (despite sclerotx) ->
TIPS

Front 146

Esophageal varices:
_% mortality c/ 1st bleed
_% will rebleed
_% mortality c/ each subsequent episode

Back 146

Esophageal varices:
30% mortality c/ 1st bleed
50% will rebleed
50% mortality c/ each subsequent episode

Front 147

where is the falciform ligament located?

Back 147

FALCIFORM LIGAMENT
Separates medial (1+4) + lateral (2+3) segments of L lobe
Attaches liver to anterior ab wall
extends to umbilicus + carries remnant of umbical vein from the underside of liver AKA LIGAMENTUM TERES

Front 148

Benign liver tumor c/ (+) uptake on sulfer colloid scan = _

Back 148

Focal nodular hyperplasia:
NO malignant potential. Very unlikely to rupture.
-Dx ab CT (or MRI) => hypervascular tumor c/ CENTRAL STELLATE SCAR that can look like cancer
-Often have an overt feeding artery
-KUPFFER cells => increased uptake on SULFUR COLLOID SCAN
-Tx: no surgery unless symptomatic

Front 149

Focal nodular hyperplasia:
Risk of malignancy?

Back 149

Focal nodular hyperplasia:
NO malignant potential. Very unlikely to rupture.
-Dx ab CT (or MRI) => hypervascular tumor c/ CENTRAL STELLATE SCAR that can look like cancer
-Often have an overt feeding artery
-KUPFFER cells => increased uptake on SULFUR COLLOID SCAN
-Tx: no surgery unless symptomatic

Front 150

Focal nodular hyperplasia:
Tx_

Back 150

Focal nodular hyperplasia:
NO malignant potential. Very unlikely to rupture.
-Dx ab CT (or MRI) => hypervascular tumor c/ CENTRAL STELLATE SCAR that can look like cancer
-Often have an overt feeding artery
-KUPFFER cells => increased uptake on SULFUR COLLOID SCAN
-Tx: no surgery unless symptomatic

Front 151

Benign liver tumor c/ central stellate scar that can look like cancer

Back 151

Focal nodular hyperplasia:
NO malignant potential. Very unlikely to rupture.
-Dx ab CT (or MRI) => hypervascular tumor c/ CENTRAL STELLATE SCAR that can look like cancer
-Often have an overt feeding artery
-KUPFFER cells => increased uptake on SULFUR COLLOID SCAN
-Tx: no surgery unless symptomatic

Front 152

liver mass with increased uptake on sulfur colloid scan
-Suspect _

Back 152

Focal nodular hyperplasia:
NO malignant potential. Very unlikely to rupture.
-Dx ab CT (or MRI) => hypervascular tumor c/ CENTRAL STELLATE SCAR that can look like cancer
-Often have an overt feeding artery
-KUPFFER cells => increased uptake on SULFUR COLLOID SCAN
-Tx: no surgery unless symptomatic

Front 153

liver mass with central stellate scar on imaging
-Suspect _

Back 153

Focal nodular hyperplasia:
NO malignant potential. Very unlikely to rupture.
-Dx ab CT (or MRI) => hypervascular tumor c/ CENTRAL STELLATE SCAR that can look like cancer
-Often have an overt feeding artery
-KUPFFER cells => increased uptake on SULFUR COLLOID SCAN
-Tx: no surgery unless symptomatic

Front 154

A 42yo female with no history of cirrhosis presents for referral concerning a 1.5cm liver lesion. Contrast enhanced CT showed a mass with a “central scar.” Follow-up nuclear medicine scan demonstrated increased uptake. The most likely diagnosis is:

Back 154

Hemangiomas have characteristic findings on CT that are diagnostic. Contrast enhanced CT will demonstrate peripheral nodular enhancement and progressive centripetal fill-in. Hepatocellular carcinoma (HCC) is most commonly diagnosed in the setting of cirrhosis. HCC is most easily seen during the arterial phase of contrast enhanced CT. This lesion is characterized as a hyper-vascular lesion with early filling. Simple cysts are demonstrated on CT as fluid-filled structures with thin, non-enhancing walls and absent internal septations. Liver Cell Adenomas and Focal Nodular Hyperplasia (FNH) can appear similar on CT imaging, however, the presence of Kupffer cells in FNH (which are usually absent in adenoma) allow uptake of sulfa-colloid and therefore have an enhanced appearance on Technetium scan

Front 155

in the foramen of Winslow.

Back 155

Foramen of Winslow = omental foramen:
-B/w lesser + greater omentum
Portal triad is anterior
IVC is posterior
Duodenum is inferior
Liver is superior

Front 156

laparoscopic cholecystectomy is contraindicated in a patient with_

Back 156

GB adenocarcinoma:
-Rare but #1 cancer of biliary tract (4x more common than cholangiocarcinoma)
-Liver = #1 site for mets
-Porcelain GB => 10-20% risk of cancer. need cholecystectomy.
-1st spreads to segments 4, 5,. 1st nodes = cystic duct nodes. (R)
-Sx jaundice -> RUQ pain
-Stage 1a (mucosa only) => cholecystectomy
-Into muscle (stage 2) => wedge segments 4,5 + LN stripping along portal triad
-Stage 3=> wide resection around liver bed @ segments 4, 5 c/ 2-3 cm margins. regional LNs inc. portal triad. +/- Whipple, lobectomy, or CBD resection
-90% PRESENT C/ STAGE 4
-LAP CHOLE CONTRAINDICATED 2/2 risk of tumor implants @ trocar sites
-5% 5-yr survival

Front 157

After laparoscopic cholecystectomy, frozen section reveals cancer that has invaded the muscular layer. What additional treatment would be appropriate

Back 157

Wedge resection of segments 4, 5 + stripping of LNs along portal triad (not formal anatomic lobe resection)
Gallbladder cancer invaded into the muscular layer = T1b = more likely to have extended into the adjacent hepatic parenchyma.
(Simple cholecystectomy appropriate for Tis and T1a lesions)
Consider adjuvant chemo or XRT AFTER surgical resection.

Front 158

gallbladder anatomy:
GB concentrates bile by active resorption of __, __; __ then follows

Back 158

gallbladder anatomy:
GB concentrates bile by active resorption of Na, Cl; H20 then follows

Front 159

Gallbladder polyps:
-Worrisome if > _cm or pt >_ years old
Tx: _

Back 159

Gallbladder polyps:
-Worrisome for malignancy if > 1cm or pt >60 years old
Tx: cholecystectomy

Front 160

<_% of pts undergoing cholecystectomy have retained CBD stone
_% of CBD stones are cleared c/ ERCP

Back 160

<5% of pts undergoing cholecystectomy have retained CBD stone, 95% of these cleared c/ ERCP

Front 161

If pt being considered for cholecystectomy is very ill, may want to do _ instead

Back 161

If pt undergoing cholecystectomy is very ill, may want to do place CHOLECYSTOSTOMY tube => do surgery when pt healthy

Front 162

Gallstone ileus:
_ = #1 site of obstruction
2/2 fistual b/w _ Dx by _
Tx

Back 162

Gallstone ileus:
-Fistula b/w GB + 2nd portion of duodenum releases stone -> SB obstruction, most commonly in TERMINAL ILEUM
-Ab x-ray: pneumobilia
-Tx: ex lap + enterotomy prox to obstruction to remove stone -> cholecystectomy + fistula resection/closure if pt can tolerate
(if pt too sick, leave GB and fistula)

Front 163

Pt presents c/ crampy ab pain
-Plain film shows air-fluid levels, pneumobilia, colon decompressed
-No hx biliary surgery
-Suspect _
-Tx is _

Back 163

Gallstone ileus:
-Fistula b/w GB + 2nd portion of duodenum releases stone -> SB obstruction, most commonly in TERMINAL ILEUM
-Ab x-ray: pneumobilia
-Tx: ex lap + enterotomy prox to obstruction to remove stone -> cholecystectomy + fistula resection/closure if pt can tolerate
(if pt too sick, leave GB and fistula)

Front 164

What is the recommended standard of care in the treatment of gallstone pancreatitis?

Back 164

Gallstone Pancreatitis: 3-8% of symptomatic cholelithiasis.
-Tx: fluids, early nutritional support, +/- hemodynamic and ventilatory support. NG drainage if ileus.
-ERCP and sphincterotomy may be necessary to relieve the biliary obstruction.
-Intraoperative cholangiography if there is suspected or documented choledocholithiasis.
-Recurrent biliary pancreatitis in 34-56% within 6 weeks.
-Cholecystectomy after the resolution of acute pancreatitis but before hospital discharge

Front 165

Gallstone in fat person is likely 2/2 _

Back 165

Gallstone in fat person is likely 2/2
overactive HMG CoA reductase
(HMG CoA + HMG CoA reductase -> cholesterol
Cholesterol + 7-alpha-hydroxylase -> bile acids)

Front 166

Gallstone in a thin person is likely 2/2:
over/underactive?
7-alpha-hydroxylase/HMG Co-A reductase?

Back 166

Gallstone in a thin person is likely 2/2 underactive 7-alpha-hydroxylase
(HMG CoA + HMG CoA reductase -> cholesterol
Cholesterol + 7-alpha-hydroxylase -> bile acids)

Front 167

_% of gallstones are radiopaque

Back 167

10% of gallstones are radiopaque

Front 168

Gallstones occur in _% of population
Most asymptomatic

Back 168

Gallstones occur in 10% of population
Most asymptomatic

Front 169

Patient with a primary common bile duct stone (formed in the CBD) likely has a _-type stone
The stone type is usually 2/2 _, causing _, which creates the stone
Tx = _

Back 169

Patient with a primary common bile duct stone (formed in the CBD) likely has a BROWN stone
Infection-> deconjugation of bili
E. coli most common, makes beta-glucuronidase, which deconjugates bili, forms Ca bilirubinate
Most common in Asians
Most need a biliary drainage procedure - sphincteroplasty

Front 170

_ type gallstones are 2/2 hemolytic disorders, cirrhosis, TPN, ileal resection
(increased bili, low liver fx, bile stasis)
Form in _
Tx is _

Back 170

BLACK stones
2/2 hemolytic disorders, cirrhosis, TPN, ileal resection
(increased bili, low liver fx, bile stasis)
Form in gallbladder
Tx = cholecystectomy

Front 171

75% of gallstones in US are type _
Mechanism by which they form _
Due to low levels of _, _
Form in _

Back 171

Non-pigmented stones = 75% in US
Low lecithin, bile acids -> cholesterol insolubilization
(stasis, Ca nucleation by mucin glycoproteins, increased water resorption by GB)
Form in gallbladder

Front 172

Pigmented stones = _% of gallstones in US
Formed by solubilization of _ c/ precipitation of _, _
Are dissolution agents a good therapy?

Back 172

Pigmented stones = 25% of gallstones in US
(majority of gallstones worldwide)
Solubilization of UNconjugated bili c/ precipitation of Ca bilirubinate, insoluble salts
Dissolution agents don't work (mono-octanoin)

Front 173

Most pt's c/ _-type gallstones need a bilary drainage procedure - sphincteroplasty (90% successful)
This stone type typically forms in CBD
Need to check for ampullary stenosis, duodenal diverticula, abnl sphincter of Oddi

Back 173

Most pt's c/ BROWN stones need a bilary drainage procedure - sphincteroplasty (90% successful)
This stone type typically forms in CBD
Need to check for ampullary stenosis, duodenal diverticula, abnl sphincter of Oddi

Front 174

Best tx for late CBD stone is _
_ procedure allows for removal of stone
3 main risks of procedure are _

Back 174

ERCP = best tx for late CBD stone is
Sphincterotomy allows stone removal c/ graspers
3 main risks = bleeding, pancreatitis, perforation

Front 175

C. sinensis, A. lumbricoides, T trichura, E. coli cause liver dz _

Back 175

C. sinensis, A. lumbricoides, T trichura, E. coli ->
CBD stones ->
recurrent cholangitis ->
oriental cholangiohepatitis

Front 176

Which GI hormone?
-GB contraction
-Pancreatic enzyme release
-Relaxation of sphincter of Oddi
-Some increase in intestinal motility

Back 176

Cholecystokinin:
-AA's, fatty acids in SB > CCK released from I cells of duodenum, jejunum
-GB contraction
-Pancreatic enzyme release
-Relaxation of sphincter of Oddi
-Some increase in intestinal motility

Front 177

Which GI hormone?:
-Inhibits HCl and gastrin release in stomach
-Increases bile flow
-Increases pancreatic HCO3- release

Back 177

Secretin:
-Fat, bile, pH <4 -> released from S cells of duodenum
-Inhibits HCl and gastrin release in stomach
-Increases bile flow
-Increases pancreatic HCO3- release
-Gastrinoma => secretin injection increases gastrin release

Front 178

_ = benign neuroectoderm tumor that can occur in biliary tract
-Sx
-Tx

Back 178

GRANULAR CELL MYOBLASTOMA = benign neuroectoderm tumor that can occur in biliary tract
-Sx like cholecystitis
-Tx: cholecystectomy

Front 179

#1 benign hepatic tumor = _

Back 179

#1 benign hepatic tumor = HEMANGIOMA
-Most asymptomatic. Rupture rare. F > M
-Do not bx (risk of hemorrhage)
-MRI (better), CT: hypervascular c/ peripheral to central enhancement.
-Tx if symptomatic => surgery +/- embolization. Steroids + XRT if unresectable.
-Kasabach--Merritt syndome = rare complication, more common in kids = consumptive coagulopathy, thrombocytopenia
-CHF 2/2 AV shunting
-Large hemangioma in child should be resected

Front 180

Benign liver tumor c/ peripheral to central enhancement on MRI, CT

Back 180

#1 benign hepatic tumor = HEMANGIOMA
-Most asymptomatic. Rupture rare. F > M
-Do not bx (risk of hemorrhage)
-MRI (better - hot on T2), CT: hypervascular c/ peripheral to central enhancement.
-Tx if symptomatic => surgery +/- embolization. Steroids + XRT if unresectable.
-Kasabach--Merritt syndome = rare complication, more common in kids = consumptive coagulopathy, thrombocytopenia
-CHF 2/2 AV shunting
-Large hemangioma in child should be resected

Front 181

Hemangioma:
Tx is _

Back 181

#1 benign hepatic tumor = HEMANGIOMA
-Most asymptomatic. Rupture rare. F > M
-Do not bx (risk of hemorrhage)
-MRI (better), CT: hypervascular c/ peripheral to central enhancement.
-Tx if symptomatic => surgery +/- embolization. Steroids + XRT if unresectable.
-Kasabach--Merritt syndome = rare complication, more common in kids = consumptive coagulopathy, thrombocytopenia
-CHF 2/2 AV shunting
-Large hemangioma in child should be resected

Front 182

Hemangioma:
Tx for symptomatic, unresectable cases

Back 182

#1 benign hepatic tumor = HEMANGIOMA
-Most asymptomatic. Rupture rare. F > M
-Do not bx (risk of hemorrhage)
-MRI (better), CT: hypervascular c/ peripheral to central enhancement.
-Tx if symptomatic => surgery +/- embolization. Steroids + XRT if unresectable.
-Kasabach--Merritt syndome = rare complication, more common in kids = consumptive coagulopathy, thrombocytopenia
-CHF 2/2 AV shunting
-Large hemangioma in child should be resected

Front 183

Hemangioma:
2 rare complications
Population most commonly seen in _

Back 183

#1 benign hepatic tumor = HEMANGIOMA
-Most asymptomatic. Rupture rare. F > M
-Do not bx (risk of hemorrhage)
-MRI (better), CT: hypervascular c/ peripheral to central enhancement.
-Tx if symptomatic => surgery +/- embolization. Steroids + XRT if unresectable.
-Kasabach--Merritt syndome = rare complication, more common in kids = consumptive coagulopathy, thrombocytopenia
-CHF 2/2 AV shunting
-Large hemangioma in child should be resected

Front 184

Hemangioma:
most common population

Back 184

#1 benign hepatic tumor = HEMANGIOMA
-Most asymptomatic. Rupture rare. F > M
-Do not bx (risk of hemorrhage)
-MRI (better), CT: hypervascular c/ peripheral to central enhancement.
-Tx if symptomatic => surgery +/- embolization. Steroids + XRT if unresectable.
-Kasabach--Merritt syndome = rare complication, more common in kids = consumptive coagulopathy, thrombocytopenia
-CHF 2/2 AV shunting
-Large hemangioma in child should be resected

Front 185

liver mass with peripheral to central enhancement on imaging
-Suspect _

Back 185

#1 benign hepatic tumor = HEMANGIOMA
-Most asymptomatic. Rupture rare. F > M
-Do not bx (risk of hemorrhage)
-MRI (better), CT: hypervascular c/ peripheral to central enhancement.
-Tx if symptomatic => surgery +/- embolization. Steroids + XRT if unresectable.
-Kasabach--Merritt syndome = rare complication, more common in kids = consumptive coagulopathy, thrombocytopenia
-CHF 2/2 AV shunting
-Large hemangioma in child should be resected

Front 186

#1 liver tumor = _

Back 186

Hemangioma is the most common benign tumor affecting the liver, followed by focal nodular hyperplasia (FNH). Hepatic hemangiomas are mesenchymal in origin and usually are solitary. They should be resected if symptomatic e.g. bleeding

Front 187

The most common benign neoplasm of the liver is _

Back 187

Hemangioma = #1 benign tumor of the liver.
-3:1 F:M, mean age 45.
-Majority require no surgery.
-Indications for resection: rupture, change in size, and development of the Kasabach-Merritt syndrome (thrombocytopenia and consumptive coagulopathy)

Front 188

Pt presents c/ UGI bleed, jaundice, RUQ pain
50% of cases are after trauma
Also 2/2 4 other things
Dx by _
Tx is _

Back 188

HEMOBILIA (bile duct - hepatic arterial fistula)
UGI bleed, jaundice, RUQ pain
50% after trauma
Also 2/2 infection, gallstones, aneurysm, tumors
Dx: ANGIOGRAM
Tx: ANGIOGRAM + EMBOLIZATION -> SURGERY = 2nd line

Front 189

Hemobilia triad is ...

Back 189

"Haemobilia:
-2/2 fistula b/w a vessel of the splanchnic circulation and the intra- or extrahepatic biliary system.
-TRIAD present in 22% of cases = GI BLEED, JAUNDICE, RUQ PAIN
-next step = ARTERIOGRAM + EMBOLIZATION
-Endoscopic trans-arterial embolisation (TAE) = catheterization of a hepatic artery, then embolic occlusion. Surgery is indicated when TAE has failed or sepsis present in biliary tree or drainage has failed.

Front 190

Hemochromatosis:
RF for 2 liver cancers…

Back 190

Hemochromatosis = RF for:
Hepatocellular ca
Cholangiosarcoma

Front 191

Which liver lesion:
-"cold" on liver scan
-Malignant potential
-10% risk of rupture/bleed
-Tx is _

Back 191

Hepatic adenoma:
Pop women, steroid use, OCPs, type 1 collagen storage dz
-80% symptomatic (pain, increased LFTs, palpable mass), 10-20% risk of rupture/bleed
-Malignant potential
-RIGHT >left lobe
-Dx: hypervascular tumor on MRI, peripheral blood supply. Cold on sulfur colloid scan.
-If asymptomatic, stop OCPs, monitor. Resect if no regression
-If symptomatic, resect b/c of malignancy and bleeding risk. Embolize if multiple/unresectable

Front 192

Type 1 collagen storage dz = RF for benign liver tumor_

Back 192

Hepatic adenoma:
Pop women, steroid use, OCPs, type 1 collagen storage dz
-80% symptomatic (pain, increased LFTs, palpable mass), 10-20% risk of rupture/bleed
-Malignant potential
-RIGHT >left lobe
-Dx: hypervascular tumor on MRI, peripheral blood supply. Cold on sulfur colloid scan.
-If asymptomatic, stop OCPs, monitor. Resect if no regression
-If symptomatic, >4 cm, unable to stop OCPs, or planning to become pregnant, resect b/c of malignancy and bleeding risk. Embolize if multiple/unresectable

Front 193

Hepatic adenoma:
_% asymptomatic

Back 193

Hepatic adenoma:
Pop women, steroid use, OCPs, type 1 collagen storage dz
-80% symptomatic (pain, increased LFTs, palpable mass), 10-20% risk of rupture/bleed
-Malignant potential
-RIGHT >left lobe
-Dx: hypervascular tumor on MRI, peripheral blood supply. Cold on sulfur colloid scan.
-If asymptomatic, stop OCPs, monitor. Resect if no regression
-If symptomatic, >4 cm, unable to stop OCPs, or planning to become pregnant, resect b/c of malignancy and bleeding risk. Embolize if multiple/unresectable

Front 194

Hepatic adenoma:
_-_% risk of rupture/bleed

Back 194

Hepatic adenoma:
Pop women, steroid use, OCPs, type 1 collagen storage dz
-80% symptomatic (pain, increased LFTs, palpable mass), 10-20% risk of rupture/bleed
-Malignant potential
-RIGHT >left lobe
-Dx: hypervascular tumor on MRI, peripheral blood supply. Cold on sulfur colloid scan.
-If asymptomatic, stop OCPs, monitor. Resect if no regression
-If symptomatic, >4 cm, unable to stop OCPs, or planning to become pregnant, resect b/c of malignancy and bleeding risk. Embolize if multiple/unresectable

Front 195

Hepatic adenoma:
Most common in _ lobe

Back 195

Hepatic adenoma:
Pop women, steroid use, OCPs, type 1 collagen storage dz
-80% symptomatic (pain, increased LFTs, palpable mass), 10-20% risk of rupture/bleed
-Malignant potential
-RIGHT >left lobe
-Dx: hypervascular tumor on MRI, peripheral blood supply. Cold on sulfur colloid scan.
-If asymptomatic, stop OCPs, monitor. Resect if no regression
-If symptomatic, >4 cm, unable to stop OCPs, or planning to become pregnant, resect b/c of malignancy and bleeding risk. Embolize if multiple/unresectable

Front 196

Hepatic adenoma:
Malignant potential?

Back 196

Hepatic adenoma:
Pop women, steroid use, OCPs, type 1 collagen storage dz
-80% symptomatic (pain, increased LFTs, palpable mass), 10-20% risk of rupture/bleed
-Malignant potential
-RIGHT >left lobe
-Dx: hypervascular tumor on MRI, peripheral blood supply. Cold on sulfur colloid scan.
-If asymptomatic, stop OCPs, monitor. Resect if no regression
-If symptomatic, >4 cm, unable to stop OCPs, or planning to become pregnant, resect b/c of malignancy and bleeding risk. Embolize if multiple/unresectable

Front 197

Hepatic adenoma:
Tx if asymptomatic

Back 197

Hepatic adenoma:
Pop women, steroid use, OCPs, type 1 collagen storage dz
-80% symptomatic (pain, increased LFTs, palpable mass), 10-20% risk of rupture/bleed
-Malignant potential
-RIGHT >left lobe
-Dx: hypervascular tumor on MRI, peripheral blood supply. Cold on sulfur colloid scan.
-If asymptomatic, stop OCPs, monitor. Resect if no regression
-If symptomatic, >4 cm, unable to stop OCPs, or planning to become pregnant, resect b/c of malignancy and bleeding risk. Embolize if multiple/unresectable

Front 198

Hepatic adenoma:
Tx if symptomatic (pain, elevated LFTs, palpable mass

Back 198

Hepatic adenoma:
Pop women, steroid use, OCPs, type 1 collagen storage dz
-80% symptomatic (pain, increased LFTs, palpable mass), 10-20% risk of rupture/bleed
-Malignant potential
-RIGHT >left lobe
-Dx: hypervascular tumor on MRI, peripheral blood supply. Cold on sulfur colloid scan.
-If asymptomatic, stop OCPs, monitor. Resect if no regression
-If symptomatic, >4 cm, unable to stop OCPs, or planning to become pregnant, resect b/c of malignancy and bleeding risk. Embolize if multiple/unresectable

Front 199

Benign liver tumor c/ (-) uptake on sulfer colloid scan = _

Back 199

Hepatic adenoma:
Pop women, steroid use, OCPs, type 1 collagen storage dz
-80% symptomatic (pain, increased LFTs, palpable mass), 10-20% risk of rupture/bleed
-Malignant potential
-RIGHT >left lobe
-Dx: hypervascular tumor on MRI, peripheral blood supply. Cold on sulfur colloid scan.
-If asymptomatic, stop OCPs, monitor. Resect if no regression
-If symptomatic, resect b/c of malignancy and bleeding risk. Embolize if multiple/unresectable

Front 200

How does lactulose work?
2 mechanisms

Back 200

Lactulose:
1. cathartic that removes bacteria from gut
2. acidifies colon -> converts NH3 to ammonium -> prevents uptake

Front 201

3 drug classes that can treat hepatic encephalopathy

Back 201

Tx of hepatic encephalopathy:
-Lactulose: reduce gut bacteria, acidify gut to convert NH3-> NH4
-Neostigmine
-Dopamine R agonists: L-dopa, bromocriptine

Front 202

Hepatic encephalopathy tx:
May need to embolize (2 areas)

Back 202

Hepatic encephalopathy tx:
May need to embolize previous therapeutic shunts, other major collaterals

Front 203

liver lesion which may present c/ Kasaback-Merritt syndrome

Back 203

Hepatic hemangioma:
-Tx: do nothing unless giant/symptomatic/consumptive
-Kasaback-Merritt syndrome = hemangioma thrombocytopenia syndrome. presents c/ consumptive coagulopathy. most common in babies
-Pts can also have CHF

Front 204

Hepatic sarcoma:
RFs
Prognosis

Back 204

Hepatic sarcoma:
RFs: PVC, thorotrast (x-ray contrast medium), arsenic
RAPIDLY FATAL

Front 205

PVC = RF for cancer _

Back 205

PVC = RF for HEPATIC SARCOMA
(rapidly fatal)

Front 206

Thorotrast (x-ray contrast medium) = RF for cancer _

Back 206

Thorotrast = RF for HEPATIC SARCOMA
(rapidly fatal)

Front 207

Arsenic = RF for cancer _

Back 207

HEPATIC SARCOMA
RF's: Thorotrast (former contrast medium), arsenic, PVC
(rapidly fatal)

Front 208

Post-partum liver failure c/ ascites is 2/2 _
Dx by _

Back 208

Relative hypercoagulable state after pregnancy (higher risk if pre-exisiting hypercoalulability) ->
HEPATIC VEIN THROMBOSIS ->
post-partum liver failure c/ ascites
Dx: SMA arteriogram c/ venous phase contrast (more sensitive than MRI)

Front 209

3 types of viral hepatitis can cause chronic hepatitis, hepatoma

Back 209

hepatitis B, C, D can cause chronic hepatitis, hepatoma

Front 210

Hep A is a DNA or RNA virus?

Back 210

Hep A is an RNA virus
PICORNAvirus

Front 211

Hep B:
Antibody type _ dominates for 1st 6 mo

Back 211

Hep B:
IgM dominates for 1st 6 mo
(check for Anti-HBc-IgM = anti-core Ab)
IgG then takes over

Front 212

Hep B: IgM dominates for 1st 6 mo
Anti-_ rises 10-12 wks after infection
Anti-_ rises 12-14 wks after infection
Anti-_ rises 14-16 wks after infection

Back 212

Hep B: IgM dominates for 1st 6 mo
Anti-HBc rises 10-12 wks after infection
Anti-HBe rises 12-14 wks after infection
Anti-HBs rises 14-16 wks after infection

Front 213

HepB vaccination -> elevated Anti-_ Ab

Back 213

HepB vaccination -> elevated anti-HBs (surface) only

Front 214

HepC = RNA or DNA virus?

Back 214

HepC = RNA virus
FLAVIvirus

Front 215

Hep_ -> fulminant hepatic failure in pregnancy
most often 3rd trimester
DNA or RNA virus?

Back 215

HepE -> fulminant hepatic failure in pregnancy
most often 3rd trimester
RNA virus = probably CALCIvirus

Front 216

What type of virus is HepD?

Back 216

HepD = VIROID (RNA virus)

Front 217

Only DNA viral hepatitis is …

Back 217

HepB = only DNA viral hepatitis
HEPADNAvirus

Front 218

#1 cancer worldwide is _

Back 218

#1 cancer worldwide = hepatocellular ca

Front 219

#1 cause of hepatocellular ca worldwide = _

Back 219

HepB = #1 cause of hepatocellular ca worldwide

Front 220

Hemochromatosis: a RF for hepatocellular ca?

Back 220

Hemochromatosis:
YES a RF for hepatocellular ca

Front 221

Aflatoxins: RF for hepatocellular ca?

Back 221

Aflatoxins:
YES a RF for hepatocellular ca

Front 222

Steroids: a RF for hepatocellular ca?

Back 222

Steroids:
YES a RF for hepatocellular ca

Front 223

Hepatocellular ca:
lab: _ level correlates c/ tumor size

Back 223

Hepatocellular ca:
AFP level correlates c/ tumor size
(AFP >500 has very high likelihood of cancer)

Front 224

Hepatocellular ca:
_% 5-yr survival after resection

Back 224

Hepatocellular ca:
30% 5-yr survival after resection

Front 225

Hepatocellular ca:
Resection: need _cm margins
Typically resectable?

Back 225

Hepatocellular ca:
1 cm margins
NOT typically resectable
2/2 cirrhosis, portohepatic involvement, mets

Front 226

Hepatocellular ca:
average Met:Primary ratio is _

Back 226

Hepatocellular ca:
average Met:Primary ratio is 1:20

Front 227

Hepatocellular ca:
After resection, tumor recurrence is most likely in _

Back 227

Hepatocellular ca:
After resection, tumor recurrence is most likely in LIVER

Front 228

liver lesion c/ elevated AFP and hx cirrhosis

Back 228

hepatocellular ca:
-#1 cancer worldwide
-may have high AFP
-#1 cause = chronic HepB/C
-Also ass'd c/ any cirrhosis: EtOH, hemochromatosis, primary biliary cirrhosis, alpha-1-antitrypsin defic, clonorchis sinensis (flukes), aflatoxin
-Fibrolamellar variant => better prognosis

Front 229

Clear cell, lymphocyte infiltrative, fibrolamellar types of hepatocellar carcinoma:
Population
Prognosis

Back 229

Clear cell, lymphocyte infiltrative, fibrolamellar types of hepatocellar carcinoma:
YOUNG ADULTS
BEST Prognosis

Front 230

criteria for liver transplant for HCC

Back 230

Liver tx candidate for HCC if :
-no PV or IVC involvement
-tumor<5 cm
-3 tumors <3 cm

Front 231

liver mass with elevated AFP
-Suspect _

Back 231

liver mass with elevated AFP => hepatocellular ca

Front 232

Patient c/ liver disease + pre-prenal appearance...
-Suspect _
-Tx would be _

Back 232

Hepatorenal syndrome:
-see low urinary Na - same appearance as prerenal azotemia
Tx: stop diuretics, give volume

Front 233

HIDA scan:
_ taken up by _, excreted into _
If GB not seen on HIDA => suggests _, requires tx of _
<_% of GB volume excreted over 2 hrs => suggests _ => _% benefit from cholecystectomy

Back 233

HIDA scan:
TECHNICIUM taken up by liver, excreted into GB
GB not seen on HIDA => CYSTIC DUCT STONE => CHOLECYSTECTOMY
<25% of GB volume excreted/2 hrs => BILIARY DYSKINESIA => 50% benefit from cholecystectomy

Front 234

Liver lesion c/ (+) Casoni skin test, (+) indirect hemaggutinin
-Tx is _

Back 234

Hydatid cyst:
-Echinococcus
-(+) casoni skin test = wheal after intradermal injection of sterilised fluid from hydatid cysts
-(+) indirect hemagglutinin
-CT ectocyst (calcified) and endocyst
-Albendazole then resect (pericystectomy), get all of cyst wall. - do not aspirate (risk of anaphylaxis)
-Preop ERCP if jaundice, increased LFTs, or cholangitis to r/o communication c/ biliary system
-Can inject alcohol prior to cyst removal

Front 235

Hgb is broken down to _ -> _ -> _

Back 235

Hgb is broken down to heme -> biliverdin -> bilirubin

Front 236

In liver, enzyme _ conjugates bilirubin to _, which improves water solubility

Back 236

In liver, glucuronyl transferase conjugates bilirubin + glucuronic acid -> improves water solubility

Front 237

Bacteria in _ region of small bowel break down bilirubin to form _ -> reabsorbed in blood + secreted in urine
Urine changes to _ if excess bilirubin present

Back 237

Bacteria in terminal ileum break down bilirubin urobilinogen -> reabsorbed in blood + secreted in urine
Urine becomes dark (like cola) if excess bilirubin present

Front 238

_ = many biliary phospholipid

-solubilizes cholesterol, emulsifies fat in intestine

Back 238

lecithin = many biliary phospholipid

-solubilizes cholesterol, emulsifies fat in intestine

Front 239

Bacteria in gut dehydroxylate primary bile acids (cholic, chenodeoxycholic) to secondary bile acids _, _

Back 239

Bacteria in gut dehydroxylate primary bile acids (cholic, chenodeoxycholic) ->
secondary bile acids: deoxycholic, lithocholic

Front 240

Bile acids are conjugated to _, _ to improve water solubility

Back 240

Bile acids are conjugated to TAURINE, GLYCINE to improve water solubility

Front 241

Jaundice:
tends to occur when bilirubin > _
Appears first @ _

Back 241

Jaundice:
tends to occur when bilirubin > 2.5
Appears first under tongue

Front 242

Maximim bilirubin is _
unless pt has renal dz, hemolysis, or bile duct-hepatic vein fistula

Back 242

Maximim bilirubin is 30
unless pt has renal dz, hemolysis, or bile duct-hepatic vein fistula

Front 243

Jaundice syndrome:
abnormal uptake to bili
high unconjugated bilirubinemia

Back 243

GILBERT'S disease:
abnormal uptake to bili
high unconjugated bilirubinemia

Front 244

Jaundice syndrome:
inability to conjugate
deficinent glucuronyl transferase
high unconjugated bili
life treatening

Back 244

CRIGLER-NAJJAR disease:
inability to conjugate
deficinent glucuronyl transferase
high unconjugated bili
life treatening

Front 245

Jaundice syndrome:
immature glucouronyl transferase
high unconjugated bili

Back 245

Physiologic jaundice of newborn:
immature glucouronyl transferase
high unconjugated bili

Front 246

Jaundice syndrome:
deficiency in bili storage
high conjugated bili

Back 246

ROTOR'S syndrome:
deficiency in bili storage
high conjugated bili

(Gilbert's => high unconj bili)

Front 247

Jaundice syndrome:
deficiency in secretion ability
high conjugated bili

Back 247

DUBIN-JOHNSON syndrome:
deficiency in secretion ability
high conjugated bili

Front 248

What do Kuppfer cells do?

Back 248

Kupffer cells = liver macrophages.
Clear portal blood. Immunosurveilance

Front 249

most common variant of L hepatic artery = off _
(travels in _)

Back 249

most common R hepatic artery variant = off L gastric
-travels in gastro-hepatic ligament

Front 250

What is the best way to differentiate amoebic vs. pyogenic liver abscess?

Back 250

Serology is the gold standard to diagnosing amoebic vs. pyogenic liver abscesses. A positive fluorescent antibody test for E. histolytica is diagnostic for patient’s with suspected amebiasis.

Front 251

Liver abscesses: #1 type (_%)

Back 251

Liver abscesses: 80% are pyogenic
-Pyogenic cysts usually 2/2 GNRs, following intra-abdominal infection like diverticuliis, appendictis
-Tx = percutaneous drainage + broad-spec abx to cover GNRs + anaerobes

Front 252

Pyogenic liver abscess:
Usually 2/2 _
(most common organism = _)
Can also be 2/2 _

Back 252

Pyogenic liver abscess: 80% of liver abscesses
RIGHT>left lobe
Usually 2/2 contiguous spread from biliary tract, e.g. weeks after diverticulitis or appendicitis
(E. coli = #1)
Can also be 2/2 bacteremia (from diverticulitis, appendicitis)

Tx: CT-guided drainage + abx. Surgical drainage if pt unstable, continued sepsis.
May need surgery for biliary obstruction or multiple abscesses

Front 253

Pyogenic liver abscess:
Tx is _

Back 253

Pyogenic liver abscess:
Tx: CT-guided drainage PLUS broad-spectrum abx (GNRs most common)
Surgery if pt unstable, continued sepsis, bilary obstruction, multiple abscesses

Front 254

Pyogenic liver abscess:
more likely in _ lobe

Back 254

Pyogenic liver abscess:
more likely in R lobe

Front 255

Pyogenic liver abscess:
_ % mortality c/ sepsis

Back 255

Pyogenic liver abscess:
15% mortality c/ sepsis

Front 256

#1 common hepatic variant

Back 256

#1 common hepatic variant = off SMA (2%)

Front 257

#1 hepatic artery variant

Back 257

#1 R hepatic artery variant =
off SMA (20%)
coursees behind pancreas, posterp;lateral to CBD

Front 258

#1 R hepatic artery variant

Back 258

#1 R hepatic artery variant =
off SMA in 17%
-usually travels in the hepatoduodenal ligament laterally

Front 259

#1 L hepatic artery variant

Back 259

#1 L hepatic artery variant =
off L gastric artery (10-20%)
-travels in gastrohepatic ligament medially

Front 260

Liver gets symp signaling frm T_-_, parasymp signaling from _

Back 260

Liver:
-Sympathetic from T7-10
Parasymp from R + L vagus

Front 261

_ separates medial + lateral segments of left lobe
Attaches liver to anterior ab wall
extends to umbilicus + carries remnant of umbical vein

Back 261

FALCIFORM LIGAMENT
Separates medial + lateral segments of left lobe
Attaches liver to anterior ab wall
extends to umbilicus + carries remnant of umbical vein

Front 262

_ carries obliterated umbilical vein to undersurface of liver

Back 262

LIGAMENTUM TERES carries obliterated umbilical vein to undersurface of liver
Extends from falciform ligament

Front 263

Portal fissure or Cantle's line:
Line from _ to _
Separates _ and _ lobes

Back 263

Portal fissure or Cantle's line:
Line from middle of gallbladder fossa to IVC
Separates R and L lobes

Front 264

_ = name for peritoneum that covers the liver

Back 264

Glisson's capsule = peritoneum that covers the liver

Front 265

Liver segment _ = caudate lobe

Back 265

Liver segment 1 = caudate lobe (just anterior to IVC)

Front 266

Liver segment _ = quadrate lobe

Back 266

Liver segment 4 = quadrate lobe

Front 267

what is the tx for colon ca mets to liver segments 1+2?

Back 267

Seg 1 = caudate (posterior to IVC), Seg 2 = top part of L lobe
-Tx = L hepatic lobectomy

Front 268

Left lobe of liver is segments ...
Right lobe of liver is segments ...

Back 268

Caudate lobe = segment 1 (posterior to IVC)
Left lobe = segments 2 (left, superior) + 3 (left, inferior), 4 (anteriuor to IVC
Right lobe = segments

Front 269

From the front of liver, you see 5 sections …

Back 269

From the front of liver, you see (clockwise):
segments 2, 3, 4, 5, 8

Front 270

Glisson's capsule does not cover _

Back 270

Glisson's capsule does not cover:
Bare area = area on posterior-superior surface

Front 271

_ = peritoneum on posterior surface of liver
= lateral + medial extensions of _ ligament

Back 271

Triangular ligaments = peritoneum on posterior surface of liver
= lateral + medial extensions of coronary ligament

Front 272

Portal triad enters liver segments (2)..

Back 272

Portal triad enters liver segments 4, 5

Front 273

Gallbladder lies under liver segments (2) …

Back 273

Gallbladder lies under liver segments 4, 5

Front 274

Inferior border of liver segment _ overlies the hepatic duct confluence

Back 274

Inferior border of liver segment 4 overlies the hepatic duct confluence
Divide connective tissue -> elevate segment 4 -> "lowers" hilar plate to expose hepatic duct confluence

Front 275

_ cells = liver macrophages

Back 275

Kupffer cells = liver macrophages

Front 276

Bile duct, portal vein, + hepatic artery (portal triad) meet @ the _ ligament

Back 276

Bile duct, portal vein, + hepatic artery (portal triad) meet @ the HEPATODUODENAL ligament

Front 277

In portal triad,
_ is posterior, _ is lateral, _is medial

Back 277

In portal triad,
portal vein is posterior,
CBD is lateral,
hepatic artery is medial

Front 278

Pringle maneuver = clamping of _
Will not stop bleeding from _

Back 278

Pringle maneuver = clamping of porta hepatis
Will not stop bleeding from hepatic vein

Front 279

Foramen of Winslow:
_ is anterior
_ is posterior
_ is inferior
_ is superior

Back 279

Foramen of Winslow:
Portal triad is anterior
IVC is posterior
Duodenum is inferior
Liver is superior

Front 280

Portal vein arises from _ vein and _ vein

Back 280

Portal vein arises from superior mesenteric vein and splenic vein (inferior mesenteric vein empties into splenic vein)

Front 281

L hepatic drains segments (3)

Back 281

L hepatic drains segments:
2, 3, superior 4

Front 282

Middle hepatic vein drains segments (2)

Back 282

Middle hepatic vein drains segments:
5, inferior 4

Front 283

R hepatic vein drains segments (3)

Back 283

R hepatic vein drains segments:
6, 7, 8

Front 284

In 80% of people, middle hepatic vein joins _ before draining into IVC
(other 20% go directly to IVC)

Back 284

In 80% of people, middle hepatic vein joins LEFT hepatic vein before draining into IVC
(other 20% go directly to IVC)

Front 285

Accessory R hepatic veins drain _ aspect of _ lobe directly into IVC

Back 285

Accessory R hepatic veins drain MEDIAL aspect of R lobe directly into IVC

Front 286

Inferior phrenic veins drain into _

Back 286

Inferior phrenic veins drain directly into IVC

Front 287

The _ lobe of liver gets separate R and L portal and arterial flow.
L hepatic vein drains _ aspect
Middle hepatic vein drains _ aspect

Back 287

The CAUDATE (4) lobe of liver gets separate R and L portal and arterial flow.
L hepatic vein drains SUPERIOR aspect
Middle hepatic vein drains INFERIOR aspect

Front 288

Enzyme _ is normally located in the canalicular membrane of liver

Back 288

ALK PHOS is normally located in the canalicular membrane of liver

Front 289

Usual energy source for liver is _.

Back 289

Usual energy source for liver is keotnes.
Glucose converted to glyogen + stored
Excess glucose converted to fat

Front 290

_ = only water-soluble vitamin stored in liver

Back 290

B12 = only water-soluble vitamin stored in liver
(liver stores large amount of fat-soluble vitamins)

Front 291

2 most common post-op probs after hepatic resection are …

Back 291

3 most common post-op probs after hepatic resection are:
Bile leak
Bleeding

Front 292

What area of liver is most susceptible to ischemia?

Back 292

Central lobular region of liver (Acinar zone 3) is most susceptible to ischemia

Front 293

_% of normal liver can be safely resected

Back 293

75% of normal liver can be safely resected

Front 294

Solitary liver cysts
Most common population, location

Back 294

Solitary liver cysts
WOMEN
RIGHT>left lobe
-Resect if bleeding or infected (and can't be treated percutaneously)
-Complications rare - most can be left alone
-Walls have characteristic BLUE hue

Front 295

Solitary liver cysts
Characteristic appearance

Back 295

Solitary liver cysts
WOMEN
RIGHT>left lobe
-Resect if bleeding or infected (and can't be treated percutaneously)
-Complications rare - most can be left alone
-Walls have characteristic BLUE hue

Front 296

#1 cause of liver failure is _

Back 296

#1 cause of liver failure = CIRRHOSIS

Front 297

Acute fulminant hepatic failure => _% mortality
Outcome determined by course of _

Back 297

Acute fulminant hepatic failure => 80% mortality
Couse of ENCEPHALOPATHY determines outcome

Front 298

A week after sustaining blunt abdominal trauma in an MVC, a 35 year old otherwise healthy man returns to the ER with hematemesis. Emergent EGD reveals no source of bleeding in the esophagus or stomach, but the duodenum is full of bright red blood. No ulcer is seen. What is the appropriate management of this patient?

Back 298

Arteriography + embolization
This scenario is a classic description of a liver hematoma caused by blunt trauma which eventually bleeds into the biliary system. The patient in this scenario has an upper GI bleed due to hemobilia, not varices, gastritis, or ulcer disease. Sometimes blood is visualized as coming from the ampulla in the duodenum. There is no endoscopic therapy for this condition; the next best step in angiography with embolization to control the bleeding.

Front 299

Colon cancer mets to liver => _% 5-yr survival after resection

Back 299

Colon cancer mets to liver => 20% 5-yr survival after resection

Front 300

Metastatic, primary liver tumors get arterial supply via _

Back 300

Metastatic, primary liver tumors are supplied by HEPATIC ARTERIES

Front 301

Primary liver tumors;
hypo- or hyper-vascular?

Back 301

Primary liver tumors are HYPERvascular
(supplied by hepatic arteries)

Front 302

Metastatic liver tumors;
hypo- or hyper-vascular?

Back 302

Metastatic liver tumors are HYPOvascular
(supplied by hepatic arteries)

Front 303

Mirizzi syndrome = _

Back 303

Mirizzi syndrome = compression of hepatic duct
-Stone in GB infundibulum
-Inflammation from GB or cystic duct extending to hepatic duct

-Causes stricture and hepatic duct obstruction

Front 304

what is nephrotic syndrome?

Back 304

Nephrotic syndrome:
-renal damage -> leakage of protein, at least 3.5 g/day
-Small holes in podocytes allow protein to pass through -> hypoalbuminemia, hyperlipidemia
-4 main types:
1. Minimal change dz: drugs e.g. NSAIDS, malignancy esp. Hodgkin's dz
2. Focal segmental glomerulosclerosis: HTN, HIV, DM, obesity, kidney loss
3. Memranous nephropathy: HepB, Sjogren's, SLE, DM, sarcoid, syphilis, drugs, malignancy
4. Membranoproliferative

Front 305

An 80 year old woman without prior abdominal surgery presents with small bowel obstruction. A KUB shows air in the biliary tree. What is the most likely diagnosis?

Back 305

Pneumobilia (air in biliary tree) in the context of SBO is likely 2/2 fistula between gallbladder and duodenum. Gallstone ileus is rarely diagnoses pre-operatively.
-Tx: removal of the stone via proximal enterotomy. The gallbladder and fistula should be left in tact, unless patient can tolerate this procedure.

Front 306

Porcelin GB => __-__% risk of cancer
-Tx is __

Back 306

Porcelin GB => 30-65% risk of cancer (Fiser book says 10-20%)
-Cholecystectomy indicated

Front 307

Venous colaterals 2/2 portal HTN;
Veins of _ drain portal blood through bare areas of diaphragm -> paraumbilical vein collaterals -> umbilicus
Veins of _ form in retroperitoneum, shunt portal blood from bowel, other organs -> vena cava

Back 307

Venous colaterals 2/2 portal HTN;
Veins of SAPPEY drain portal blood through bare areas of diaphragm -> paraumbilical vein collaterals -> umbilicus
Veins of RETZIUS form in retroperitoneum, shunt portal blood from bowel, other organs -> vena cava

Front 308

Portal HTN 2/2 PREsinusoidal obstruction:
3 causes

Back 308

Portal HTN 2/2 presinusoidal obstruction: 2/2
1. Schistosomiasis
2. Congenital hepatic fibrosis
3. Portal vein thrombosis

Front 309

Portal HTN 2/2 POSTsinusoidal obstruction:
3 causes

Back 309

Portal HTN 2/2 POSTsinusoidal obstruction: 2/2
1. Budd-Chiari (hepatic vein occlusive dz
2. Constrictive pericarditis
3. CHF

Front 310

Normal portal vein pressure is < _ mmHg

Back 310

Normal portal vein pressure is <12 mmHg

Front 311

Portal HTN:
coronary veins act as collaterals b/w portal vein + systemic venous system of _

Back 311

Portal HTN:
coronary veins act as collaterals b/w portal vein + systemic venous system of LOWER ESOPHAGUS

Front 312

Portal HTN:
the 4 major complications

Back 312

Portal HTN: 4 major complications
1. esophageal variceal hemorrhage
2. ascites
3. splenomegaly
4. hepatic encephalopathy

Front 313

Portal HTN:
4 indications for TIPS

Back 313

Portal HTN: 4 indications for TIPS
1. Protracted bleeding
2. Progression of coagulopathy
3. Visceral hypoperfusion
4. Refractory ascites
(add risk of deveoping encephalopathy)

Front 314

Portal HTN:
the major risk of TIPS

Back 314

Portal HTN:
TIPS => increased risk of encephalopathy

Front 315

Portal HTN:
indication for splenorenal shunt

Back 315

Portal HTN:
Splenorenal shunt rarely used anymore
CHILDS A cirrhosis who present with BLEEDING ONLY
Low rate of encephalopathy
Can worsen ascites

Front 316

Portal HTN:
contraindication for splenorenal shunt

Back 316

Portal HTN:
Splenorenal shunt contraindicated in REFRACTORY ASITES
(can worsen ascites)

Front 317

Portal HTN:
Creation of a _ involves ligation of L adrenal vein, L gonadal vein, inferior mesenteric vein, coronary vein, pancreatic branches of splenic vein

Back 317

Portal HTN:
SPLENORENAL SHUNT: ligation of L adrenal vein, L gonadal vein, inferior mesenteric vein, coronary vein, pancreatic branches of splenic vein
(Only for Childs A cirrhotics who present c/ bleeding only; low risk of encephalopathy, but increased risk of ascites)

Front 318

Portal HTN:
Tx for pt c/ Childs B/C + indication for shunt

Back 318

Portal HTN:
Childs B/C + indication for shunt =>
TIPS

Front 319

Portal HTN:
Tx for pt c/ Childs A + just bleeding as symptom

Back 319

Portal HTN:
Childs A + just bleeding as symptom =>
Splenorenal shunt

Front 320

Portal HTN:
_ predicts mortality after shunt

Back 320

Pootal HTN:
CHILDS CLASS predicts mortality after shunt

Front 321

Portal HTN in child is usually 2/2 _ (50%)

Back 321

Portal HTN in child is usually 2/2
50% is 2/2 Extrahepatic thrombosis of portal vein

Front 322

What is the anatomy of the portal traid
(i.e. what is posterior, R/lateral, and L/medial)?

Back 322

Portal triad:
-Portal vein posterior.
CBD on R
Hepatic artery on L

Front 323

#1 cause of massive hematemesis of children is _

Back 323

#1 cause of massive hematemesis of children = extrahepatic thrombosis of portal vein
(portal vein thrombosis -> presinusoidal obstruction -> portal HTN)
50% of portal HTN in children

Front 324

Primary biliary cirrhosis: a RF for hepatocellular ca?

Back 324

Primary biliary cirrhosis:
NOT a RF for hepatocellular ca

Front 325

Woman c/ fatigue, prouritus, jaundice, xanthomas
-Medium-sized hepatic ducts
-Likely is _
- Lab test _
-Cancer risk
-Tx

Back 325

PRIMARY BILIARY SCLEROSIS
Woman c/ fatigue, prouritus, jaundice, xanthomas
-Medium-sized hepatic ducts
-anti-MITOCHONDRIAL Ab's
-NO cancer risk
-Tx: tranplant

Front 326

Primary sclerosing cholangitis: a RF for hepatocellular ca?

Back 326

Primary sclerosing cholangitis: YES a RF for hepatocellular ca

Front 327

Primary sclerosing cholangitis:
RF for 2 cancers…

Back 327

Primary sclerosing cholangitis = RF for:
Hepatocellular ca
Cholangiosarcoma

Front 328

RFs for _ =
men 30's-40's, retroperitoneal fibrosis, Reidel's thyroiditis, pancreatitis, UC, DM
Dx by lab test _, procedure _

Back 328

PRIMARY SCLEROSING CHOLANGITIS risk factors:
men 30's-40's, retroperitoneal fibrosis, Reidel's thyroiditis, pancreatitis, UC, DM
ERCP => beaded appearance 2/2 strictures + dilations
anti-MITOCHONDRIAL Ab's

Front 329

ERCP shows "beading" 2/2 strictures + dilations => likely _

Back 329

ERCP shows "beading" 2/2 strictures + dilations => likely PRIMARY SCLEROSING CHOLANGITIS

Front 330

Primary sclerosing cholangitis:
4 main Complications

Back 330

Primary sclerosing cholangitis ->
(scarring + patching c/ porgressive fibrosis of intra- + extrahepatic ducts) ->
Portal HTN, hepatic failure, cirrhosis, cholangiocarcinoma

Front 331

Primary sclerosing cholangitis: Tx
Most need _
2 surgeries can help
1 procedure
2 medicines

Back 331

Primary sclerosing cholangitis:
Transplant for most
May benefit from PTC tube drainage, choledochojejunostomy
Balloon dilation of stricture(s)
Cholestyramine to decrease pruritus
UDCA (urosodeoxycholic acid) to decrease bile acids, improve liver enzymes

Front 332

Pt comes in c/ signs of cholangitis, CBD obstruction
-GI can't cannulate the ampulla of vater for ERCP
-Next step = _

Back 332

Percutaneous transhepatic cholangiography (PTC) tube:
-To decompress biliary system if ERCP not possible

Front 333

Pt comes in c/ signs of cholangitis, CBD obstruction
-GI can't cannulate the ampulla of vater for ERCP, then radiologist can't place PTC tune
-Next step = _

Back 333

Pt c/ signs of cholangitis, CBD obstruction, but ERCP and PTC tube not possible ->
to OR for T-tube to decompress bilary system

Front 334

What is the most common cause of pyogenic liver abcesses?

Back 334

Pyogenic liver abscess = 80% of liver abscesses:
-2/2 Biliary (cholangitis) > diverticulitis > appendicitis. Can arise weeks later.
-RIGHT > left lobe. 15% mortality c/ sepsis
-E. coli most common. Also cover for anaerobes.
-Dx by aspiration
-Tx: CT-guided drainage + abx. Surgery if unstable, biliary obstruction, or multiple abscesses

Front 335

what is the effect of ligating a replaced R or L hepatic artery?

Back 335

either can be ligated without significant issue relative to hepatic ishemia

Front 336

retained CBD stone indentified on T-tube cholangiogram 6 wks post-op is best managed by ...

Back 336

retained CBD stone indentified on T-tube cholangiogram 6 wks post-op =>
radiology stone removal

Front 337

most common variant of R hepatic artery = off _
(travels in _)

Back 337

most common R hepatic artery variant = off SMA
-usually travels in hepato-duodenal ligament laterally
-courses behind pancreas, posterior to portal vein (not anterior c/ common hepatic artery), lateral to CBD (not medial c/ common hepatic artery)

Front 338

Liver abscess that presents c/:
Maculopapular rash
Increased eosinophils
Sigmoid colon: granulation tissue, petichiae, ulcers

Tx is 2 things…

Back 338

Schistosimiasis liver abscess:
-Presentation: Maculopapular rash, Increased eosinophils, +/- esophageal varices
-Sigmoid colon c/ fine granulation tissue, petichiae, ulcers
-Tx: praziquantel + control of variceal bleeding
-Percutaneously drain if superinfected
-Surgery only for complications, e.g. bleeding

Front 339

Fat, bile, pH <4 trigger release of __ from S cells in duodenum, which reduced HCL/gastrin release, increases bile flow, increases pancreatic HCO3- release

Back 339

Secretin:
-Fat, bile, pH <4 -> released from S cells of duodenum
-Inhibits HCl and gastrin release in stomach
-Increases bile flow
-Increases pancreatic HCO3- release
-Gastrinoma => secretin injection increases gastrin release

Front 340

_ in liver occurs in sinusiodal membrane

Back 340

Nutrient uptake in liver occurs in SINUSOIDAL membrane

Front 341

_ can lead to isolated gastric varices s/ elevation of P in rest of portal system

Back 341

Splenic vein thrombosis can ->
isolated gastric varices s/ elevation of P in rest of portal system

Front 342

Tx for splenic vein thombosis

Back 342

Splenic vein thrombosis:
Tx: splenectomy

Front 343

Spenic vein thrombosis:
#1 cause

Back 343

Spenic vein thrombosis:
#1 cause = PANCREATITIS
-Gastic varices s/ esophageal varices (very rare c/ cirrhosis)

Front 344

Spontaneous bacterial peritonitis:
PMNs > _ in fluid

Back 344

Spontaneous bacterial peritonitis:
-Fever, ab pain, PMNs >250 in fluid, (+) cx
-
-Usually mono-organism: E coli > pneumococcus, strep
-If poly-organismal, worry suspect bowel perf
-RFs; prior SBP, variceal hemorrhage, low-protein ascites, nephrotic syndrome, SLE in children
-Tx: 3rd gen cephalosporin, usually responds w/in 48 hrs

Front 345

Spontaneous bacterial peritonitis:
#1 organism
2 other organisms
If polymicrobial, need to r/o _

Back 345

Spontaneous bacterial peritonitis:
-Fever, ab pain, PMNs >250 in fluid, (+) cx
-
-Usually mono-organism: E coli > pneumococcus, strep
-If poly-organismal, worry suspect bowel perf
-RFs; prior SBP, variceal hemorrhage, low-protein ascites, nephrotic syndrome, SLE in children
-Tx: 3rd gen cephalosporin, usually responds w/in 48 hrs

Front 346

Spontaneous bacterial peritonitis:
Tx

Back 346

Spontaneous bacterial peritonitis:
-Fever, ab pain, PMNs >250 in fluid, (+) cx
-
-Usually mono-organism: E coli > pneumococcus, strep
-If poly-organismal, worry suspect bowel perf
-RFs; prior SBP, variceal hemorrhage, low-protein ascites, nephrotic syndrome, SLE in children
-Tx: 3rd gen cephalosporin, usually responds w/in 48 hrs

Front 347

The primary cell type responsible for hepatic fibrosis is:

Back 347

Stellate cells are responsible for fibrosis.

Front 348

Wilson's dz: a RF for hepatocellular ca?

Back 348

Wilson's dz:
NOT a RF for hepatocellular ca

Front 349

Crohns patient presents c/ duodenal obstruction, failed medical mgmt.
-what is the treatment

Back 349

Crohn's + duodenal obstruction, failed medical mgmt =>
GASTROJEJUNOSOMY in most cases
(if distal, could do side-to-side duodeno-jejunostomy)

unlike rest of sm bowel, stricturoplasty very difficult unless very short segment and resection not possible short of a Whipple