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Senior - Surgery 1 > 6 - Hepato-Biliary Surgery > Flashcards

6 - Hepato-Biliary Surgery Flashcards

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1
Q

Cholecyst means

A

Gallbladder

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2
Q

Cholecystitis means

A

Inflammation of the gallbladder (infection)

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3
Q

Cholecystectomy means:

A

Gallbladder removal

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4
Q

Cholelithiasis means

A

Stones in the gall bladder

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5
Q

Choledocho means

A

Bile duct

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6
Q

Choledocholithiasis means

A

Stones in bile duct

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7
Q

Common patient type for gallstones

A

Fat
Fair
Female
Forty

Obsese pt’s who rapidly lose weight

Unusual in children

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8
Q

Most gallstones are made of:

A

Cholesterol

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9
Q

How does estrogen cause gallstones?

A

Its causes increased cholesterol secretion, liver can’t keep up with bile salts to emulsify the cholesterol

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10
Q

How does progesterone lead to gallstones?

A

Decreases bile acid secretion, leading to decreased emulsification of cholesterol

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11
Q

Why are pregnant patients more likely to get gallstones?

A

Increased estrogen and progesterone

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12
Q

Pt presentation for cholelithiasis

A

Many are asymptomatic

Classic: crampy RUQ pain, possible correlated with meals, N/V, anorexia

Severe - jaundice, fever, chills, increased t. bili, LFT’s, WBC’s

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13
Q

Valuable and easy diagnostic tool to look for gallstones and cholecystitis?

A

Ultrasound

Add’l workup tests include the usual shit - CBC, CMP, amlyase/lipase, PT/INR, UA c HCG

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14
Q

What is biliary colic?

A

Stones obstruct the neck of the gallbladder and it cannot expel bile -> transient, post-prandial RUQ pain

(Food intake -> CCK secretion -> gall bladder contraction)

Usually treated with pain management and anti-emetics

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15
Q

How does cholecystitis present?

A

Persistent, colicky, RUQ pain, fever, chills, N/V

Murphy’s Sign (RUQ pain rebound tenderness)

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16
Q

Labs - tests for cholecystitis?

A

Leukocytosis c left-shift
Normal t. bili
Normal amy/lip

US - thickened gallbladder wall (>4mm)

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17
Q

Plan for cholecystitis

A

Admit

NPO
IV ABX (GNR coverage)

Surgery (usually within 24 hours but can wait up to 72)

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18
Q

What is acalculous cholecystitis?

A

Gall bladder infection not caused by stones (normally 2/2 stasis in gallbladder)

Long-term hospitalized patients
NPO
Starvation

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19
Q

What is the imaging study of choice for cholecystitis?

A

Ultrasound

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20
Q

What is the normal thickness for a gallbladder?

A

Less than 4mm

Add 1mm for every decade after 60yrs

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21
Q

What is a sonographic Murphy’s sign?

A

RUQ rebound tenderness / pain elicited by using transducer

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22
Q

What is Mickey Mouse sign?

A

Portal vein (head)

Common bile duct and hepatic artery (ears)

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23
Q

Common bile duct (CBD) obstruction - describe

A

Stone blocks duct shared by pancreas, gallbladder, and liver (YIKES!)

Obstructive jaundice quickly develops

Acholic stools (white)

Pancreatitis possible

Bacteria form duodenum ascends to the liver (ascending cholangitis)

So much badness!!!

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24
Q

Labs for CBD obstruction?

A

Leukocytosis c left-shift
Elevated LFTs and t. bili
Amy/lip elevated if pancreas involved
Prolonged PT/INR

US - dilated CBD/intrahepatic ducts

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25
Plan for CBD obstruction
NPO IV ABX Urgent GI consult for ERCP OR Surgery for percutaneous drainage
26
What is ERCP?
Endoscopic Retrograde Cholangio-Pancreatogram An upper endoscopy performed by GI Locate and cannulate the Ampulla of Vater Inject contrast and obtain imaging to evaluate CBD
27
Describe sphincterotomy
Performed with ECRP Allows for passage of large stone to be delivered May cause injury to pancreas, duodenum, or bleeding
28
Applicability of Magnetic Resonance Cholangio-Pancreatogram (MRCP)
Diagnostic only Non-invasive Performed by radiologist in MRI suite Good test for CBD obstruction or CBD injury after cholecystectomy
29
What is Hepatobiliary IminoDiacetic Acid (HIDA) Scan?
Nuclear med study Series of images taken at timed intervals Radioactive tracer Gamma camera Evaluates for obstruction
30
What is cholangitis?
CBD obstruction with infection
31
What is the most serious complication of cholelithiasis?
Cholangitis (CBD obstruction with infection) Lethal if not treated ASAP
32
Cholangitis presentation?
Charcot’s Triad (fever, jaundice, RUQ pain) Reynolds Pentad (fever, jaundice, RUQ pain, confusion, shock)
33
Labs for cholangitis?
Leukocytosis c left shift Increased LFT’s, t. bili, PT/INR, possibly amy/lip
34
Txt for cholangitis
ICU ADMISSION IV ABX ERCP Percutaneous trans-hepatic drainage Cholecystectomy with inraoperative choplangiogram
35
Indications for cholecystectomy
Symptomatic cholelithiasis (biliary colic) Cholecystitis (infection) Cholangitis (CBD obstruction with infection - worst complication of stones) Cholangiocarcinoma (gallbladder CA is rare)
36
What is Intra-Operative Cholangiogram (IOC) used for?
To make sure your cholecystectomy went well before you close up Contrast injected to look for extravasation, obstruction, etc
37
Complications of cholecystectomy
``` Bleeding Injury to surrounding structures Infection Retained CBD stones Bile leak Incisional hernia ```
38
Follow-up for cholecystectomy
``` NPO initially Track WBC’s, electrolytes IV ABX until afebrile LMWH (DVT prophylaxis) and ambulate as soon as possible Pulm toilet Control pain Discharge when criteria met Normal activity in 6-8 weeks ```
39
What is percutaneous gallbladder drainage?
Reserved for patients with CBD obstruction refractory to ERCP/IOC Tube comes out the abd through the skin, drains into bag Temporary measure
40
What does the liver synthesize?
Factors V and VII Prothrombin Acute phase proteins Bile
41
Imaging for the liver:
US - evaluates the biliary tree CT/MRI - good detail of small soft tissue masses Nuclear med Angiography Biopsies
42
Non-operative management of liver trauma
Frequent abd exams Ensure hemodynamically stable R/o other visceral injuries
43
If hepatic hematoma becomes infected s/p trauma:
Requires drainage
44
What is hemobilia?
Blood in the biliary tree Think bad infection, gas-producing bacteria
45
What pneuomobilia?
Air in the biliary tree Rare with trauma May occur if infected with gas-producing bacteria
46
How does liver abscess typically present?
RUQ pain with radiation to right shoulder Fever, chills, leukocytosis Hepatomegaly with TTP
47
Causes of liver abscess?
Pyogenic abscess (90%) - intra-abdominal infection (IBD flare, Crohn’s, appendicitis) - liver trauma Fungal Hydatid cyst Entameboae histolytica
48
Txt for liver abscess
Abx if solitary, small, or scattered If large and amendable - percutaneous drainage Surgery (last resort)
49
MC primary liver malignancy?
Hepatocellular Carcinoma (HCC)
50
MC CA of the liver?
Malignant CA (usually from colon)
51
Describe congenital liver cysts:
Smooth-walled, well-circumscribed and homogeneous fluid on US Normally small and found incidentally on US or CT Can be symptomatic if larger
52
Describe neoplastic liver cysts
Irregular cysts Aspiration of fluid necessary but not always diagnostic (inconclusive)(need follow-up with surgery to confirm or rule out malignancy)
53
What is polycystic liver dz?
Congenital (AD) Large, multiple cysts invade / replace normal hepatocytes - results in liver failure - need liver transplant *should also check for polycystic kidneys
54
What is the MC solid hepatic tumor?
Hepatic hemangioma Normally asymptomatic and no intervention req’d
55
Hepatic adenoma - what is it?
Benign proliferation of non-functioning hepatocytes (cold nodules) Associated with estrogen therapy Mostly asymptomatic unless encroaching on surrounding organ Loses signal in T2 image Bleeding risk > benefit of percutaneous Bx and FNA Not dysplastic Don’t rupture
56
When would you do surgery on hepatic adenoma?
If its a large, invasive lesion which is not responding to estrogen cessation
57
What is focal nodular hyperplasia? (FNH)
Hyperplasia of FUNCTIONING hepatocytes “Hot” on nuclear med scan Most asymptomatic Surgery indicated only on large, invasive lesions
58
What is MC cause of new liver dysfunction in the US?
Non-Alcoholic Steato Hepatitis (NASH)
59
Describe NASH
Fatty liver -> fibrosis -> cirrhosis and can progress to HCC
60
Risk factors for NASH
``` Older age DM Serum transferases > 2 times normal Hepatocellular ballooning + Mallory hyaline/fibrosis on Bx BMI > 28 Visceral adipose deposits ```
61
Management of NASH
Weight loss Control underlying co-morbidities Limited role of Vit E, Olristat, statins
62
HCC is associated with:
Hep B/C Cirrhosis Aflatoxins
63
Workup of HCC
Screen high-risk patients Alpha-fetoproteins elevated MRI/CT Bleeding risk outweighs benefit of percutaneous Bx
64
Study of choice for HCC workup?
MRI/CT
65
Txt for HCC
Resection - smaller lesions and patients with adequate functional reserve Liver transplant RFA for small tumors, non-mets
66
Acute liver failure presentation
Jaundice Encephalopathy Coagulopathy
67
Chronic liver dz presentation
``` Ascites Esophageal varices Hemorrhoids Caput medusae Ascites Jaundice (2/2 elevated unconjugated t. bili Encephalopathy Coagulopathy ```
68
Txt for chronic liver dz
Admission, resuscitation, nutritional support TIPA procedure for portal HTN (transjugular intrahepatic portosystemic shunt) BB’s Lactulose (to bind free NH3)
69
There was a sign on the lawn at a drug rehab center that said
“Keep off the Grass”

Senior - Surgery 1 (8 decks)

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