Hepatobiliary

Question 1

What 3 structures make up the portal triad?

Answer 1

CBD, portal vein, common hepatic artery - in the hepatoduodenal ligament

Question 2

Cantle’s Line

Answer 2

Separates the R and L lobe of the liver

Question 3

Segments of the liver

Answer 3

Question 4

What is the venous drainage of the liver?

Answer 4

3 hepatic veins drain into the IVC

Question 5

Most common replaced right hepatic artery comes off of?

Answer 5

The SMA

Question 6

Most common replaced left hepatic artery comes off of?

Answer 6

Left gastric (gastrohepatic ligament)

Question 7

In what trimester should cholecystectomy be done in pregnancy?

Answer 7

2nd trimester

Question 8

Stones identified during IOC?

Answer 8

Glucagon, flush

Question 9

Benign hyperplastic gallbladder polyps. What size to remove?

Answer 9

1.0cm

Question 10

Gallbladder polyps of ___ need serial imaging with yearly US

Answer 10

0.6-0.9cm

Question 11

Gallbladder polys >18mm treat as _____

Answer 11

Cancer

Question 12

Portal Hypertension is defined as a hepatic vein pressure gradient > than ______

Answer 12

6mmHg - difference between wedged hepatic vein pressure and free hepatic vein pressure

Question 13

Polyps between ____ and ____ size have an increased risk of malignancy and should undergo cholecystectomy

Answer 13

1.0 and 1.9cm

Question 14

Polyps of this size need repeat imaging in 1 year, and if stable, no further follow up required

Answer 14

<0.5cm

Question 15

Gallbladder cancer will first metastasize to which nodes?

Answer 15

Cystic duct nodes

Question 16

`What to do if CBD stones are identified on IOC?

Answer 16

Flush, glucagon x2

Question 17

In patients with severe pancreatitis, how long to wait for cholecystectomy?

Answer 17

At 6-8 weeks, ERCP + sphincterotomy

Question 18

Rigler’s Triad

Answer 18

Bowel obstruction, gallstone in intestine, pneumobilia

Question 19

What type of portal hypertension is schistosomiasis ?

Answer 19

Pre-sinusoidal

Question 20

What type of portal hypertension is alcoholic cirrhosis and viral hepatitis?

Answer 20

Sinusoidal

Question 21

What type of portal hypertension is Budd Chiari syndrome?

Answer 21

Post-sinudoisal

Question 22

TIPS (transjugular intrahepatic portosystemic shunt)

Answer 22

Stent between hepatic vein and portal vein. Used for acute variceal bleeding, Budd chiari or hepatic hydrothorax

Question 23

The use of ________ is associated with increased rates of primary fascial closure in patients with open abdomen

Answer 23

3% hypertonic saline (removes intestinal edema)

Question 24

Mattox Maneuver

Answer 24

Exposure of the left retroperitoneum
1. Mobilize the inferior portion of the descending colon
2. Divide the white line of toldt bluntly
3. Rotate kidney, pancreas and spleen medially

Question 25

Cattell-Braasch Maneuver

Answer 25

Right medial visceral rotation -Mobilize the right colon superiorly

Question 26

Selective portosystemic shunt

Answer 26

Decompresses only part of the portal venous system- good for variceal bleeding, does not help with ascites

Question 27

Non-selective portosystemic shunt

Answer 27

Decompresses the entire portal venous system, side to side portocaval shunt. Higher rate of encephalopathy

Question 28

What type of shunt to use with variceal bleeding?

Answer 28

Selective shunt

Question 29

What type of shunt to use with ascites?

Answer 29

Non-selective shunt

Question 30

Treatment of pyogenic abscess

Answer 30

Percutaneous drainage + ABX

Question 31

How to treat aeombic abscess?

Answer 31

Flagyl

Question 32

Double walled cyst on CT

Answer 32

Echinococcal cyst - Albendazole + Surgical excisin

Question 33

Hepatic vein pressure gradient required for variceal rupture?

Answer 33

12mmHg

Question 34

Child-Pugh Score

Answer 34

Pooh BEAAr- Prothrombin time, Bilirubin, encephalophy, ascites, albumin

Question 35

Components of MELD Score

Answer 35

Bilirubin, INR, Creatinine

Question 36

At which MELD score do patients have a survival benefit for transplant?

Answer 36

15

Question 37

What is the most common cause of a benign biliary stricture?

Answer 37

Previous cholecystectomy

Question 38

Most common risk factors for cholangiocarcinoma?

Answer 38

UC and PSC

Question 39

Bismuth A injury

Answer 39

Injury to cystic duct or ducts of Luschka

Question 40

Bismuth B injury

Answer 40

Injury to aberrant R hepatic duct

Question 41

Bismuth C injury

Answer 41

Leak from aberrant R hepatic duct

Question 42

Bismuth D injury

Answer 42

Lateral CBD injury

Question 43

Bismuth E1 injury

Answer 43

Hepatic duct injury >2cm from R and L hepatic duct confluence

Question 44

Bismuth E2 injury

Answer 44

Hepatic duct injury <2cm from R and L hepatic duct confluence

Question 45

Bismuth E3 injury

Answer 45

CBD injury at confluence or R and L hepatic duct

Question 46

Bismuth E4 injury

Answer 46

CBD injury above the confluence or R and L hepatic duct

Question 47

Bismuth E5 injury

Answer 47

Main hepatic duct and accessory R hepatic duct injury

Question 48

Ductal injures <3cm treatment?

Answer 48

Simple ligation and drain placement

Question 49

Ductal injuries >4mm treatment?

Answer 49

Repair or reconstruction

Question 50

Type I choledocal cyst

Answer 50

Extrahepatic ductal dilation - Tx = Resection with hepaticojejnostomy

Question 51

Type II choledocal cyst

Answer 51

Diverticulum of CBD - Tx = Roux en Y

Question 52

Type III choledocal cyst

Answer 52

Choledococele or dilation of ampulla of vader - Tx = ERCP - transduodenal excision or spinchterplasty

Question 53

Type IVa choledocal cyst

Answer 53

Dilation of intra AND extrahepatic ducts- Tx = Excision with biliary reconstruction.

Question 54

Type V choledocal cyst

Answer 54

Caroli's disease- dilation of intrahepatic ducts ONLY - Tx = Transplant

Question 55

Soap Bubble or Paintbrush sign on IOC

Answer 55

Villous small bowel adenoma

Question 56

Which is preferred CBD exploration transcystic or transductal?

Answer 56

Transcystic

Question 57

Most potent stimulator of bile secretion

Answer 57

Secretin

Question 58

Future Liver Remnant in patients without underlying liver disease?

Answer 58

20-30%

Question 59

Future Liver Remnant in patients with underlying liver disease?

Answer 59

40%

Question 60

Type of shunt used for variceal bleeding?

Answer 60

Selective shunt

Question 61

Type of shunt used for ascites?

Answer 61

Non-selective shunt

Question 62

Type IVb choledocal cyst

Answer 62

Extrahepatic ductal dilation ONLY

Question 63

Most common liver tumor?

Answer 63

Hemangima

Question 64

Kasabach-Meritt Syndrome

Answer 64

Consumptive coagulopathy associated with hemangioma

Question 65

Name that tumor: On CT Hypodense on pre-contrast Peripheral to central enhancement in arterial phase Persistent contrast on delayed series

Answer 65

Hemangioma

Question 66

Hemangioma MRI findings

Answer 66

Hypointense on T1, hyperintense on T2

Question 67

2nd most common liver tumor?

Answer 67

FNH

Question 68

Name that tumor: On CT well demarcated Rapid enhancement in arterial phase with central stellate scar

Answer 68

FNH

Question 69

FNH MRI findings

Answer 69

Hypointense with central scar on T1, isointense with hyperintense scar on T2

Question 70

Name that tumor: On CT: arterial enhancement with washout on portal phase Smooth surface with tumor capsule Associated with OCP's and seroids

Answer 70

Adenoma

Question 71

Adenoma MRI findings

Answer 71

Hyperintense on T1 and T2

Question 72

FNH is (negative/positive) for suulfer colloid uptake)

Answer 72

Positive

Question 73

Adenoma is (negatiive/positive) for sulfer colloids uptake

Answer 73

Negative

Question 74

Name that tumor: On CT: hyperintense on arterial phase, hypodense during delayed phase

Answer 74

Hepatocellular carcinoma

Question 75

Milan criteria for transplant in early to severe cirrhosis in patients with HCC?

Answer 75

One less than 5 or 3 less than 3, no gross vascular or extrahepatic spread

Question 76

Afferent limb syndrome is caused by?

Answer 76

Too long afferent limb, should be less than 12-15cm

Question 77

Epigastric pain, postprandial fullness, and sudden explosive vomiting of bilious contents

Answer 77

Roux syndrome

Question 78

Early vs Late dumping syndrome

Answer 78

Early- 30-60 minutes after eating- tachycardia, diaphoresis, caused by fluid shifts Late 2-3 hrs after eating- weakness, hunger, autonomic symptoms due to hyperinsulinemic response

Question 79

Surgical management T1a gallbladder cancer

Answer 79

Lamina propria- Cholecystectomy alone

Question 80

Surgical management T1b gallbladder cancer and greater

Answer 80

Invades muscle layer - cholecystectomy with segment IVb V hepatic resection and portal lymphadenectomy

Question 81

Highest negative predictive value for choledocolithiasis?

Answer 81

GGT - Normal GGT has 97% NPV

Question 82

Tumor marker for fibrolamellar variant of HCC?

Answer 82

Neurotensin

Question 83

Whats the first treatment for hemobilia coming from trauma?

Answer 83

Angioembolization

Question 84

Right liver resection

Answer 84

Segments 5-8

Question 85

Left liver resection

Answer 85

2-4 +/- caudate