Hepatobiliary

Question 1

R hepatic artery off of what artery in 17%?

Answer 1

SMA

Question 2

L hepatic off of what artery in 10%?

Answer 2

L gastric artery

Question 3

Kupffer cells

Answer 3

Clear portal blood

Immunosurveillance

Question 4

Portal triad

Answer 4

Portal vein posterior to CBD (on right) and hepatic artery (on left)

Question 5

Urine finding in hepatorenal syndrome?

Answer 5

Low urine Na

Question 6

Cholangitis

Answer 6

Jaundice
RUQ tenderness
Fever
Hypotension
AMS

Tx: emergent ERCP, IV abx

Question 7

Retained CBD stone identified on T-tube cholangiogram, tx?

Answer 7

Radiology stone retrieval

Question 8

Porcelain gallbladder

Answer 8

30-65% risk of cancer

Cholecystectomy indicated

Question 9

Hematobilia triad

Answer 9

GI bleed
Jaundice
RUQ pain

Tx: arteriogram

Question 10

How is bile concentrated by gall bladder?

Answer 10

Active absorption of Na, Cl (H2O follows)

Question 11

Hepatic adenoma tx?

Answer 11

10% rupture/bleed
Have malignant potential
Indication for resection

Question 12

Hepatic hemangioma

Answer 12

Resect only if giant or symptomatic

Question 13

Kasaback-Merritt syndrome?

Answer 13

Consumptive coagulopathy or CHF due to hemangioma

Question 14

Amebic abscess tx

Answer 14

Tx: metronidazole

Question 15

Hydatid cyst

Answer 15

Tx: resect

Question 16

Cantilie line

Answer 16

imaginary line that divides right and left lobe of the liver, runs from IVC to middle of the GB (not the falciform ligament)

Question 17

Segments within each lobe of liver

Answer 17

Caudate lobe-segment 1, left lobe-segment 2,3,4a,4b. right lobe-segment 5-8

Question 18

Symptomatic cholelithiasis in pregnant patient

Answer 18

try to do elective chole in 2nd trimester

Question 19

+IOC tx?

Answer 19

try to flush the stone through with glucagon (up to 2x)

• Large duct, small stone -> trancystic exploration
• Large stone, small duct -> lap CBD, post-op ERCP

Question 20

No filling of hepatic ducts with IOC

Answer 20

high suspicion of hepatic duct injury, convert to open procedure

Question 21

Gallstone ileus

Answer 21

SBO caused by gallstone lodged in ileocecal valve
- Fistula connecting GB to duodenum usually
- Riggler’s triad: pneumobilia, SBO, visible gallstone in small bowel
- Tx: enterotomy proximal to obstruction and milk out stone to relieve obstruction
o Wait to take down fistula and cholecystectomy later

Question 22

Gallbladder polyp tx

Answer 22

• Asymptomatic -> nothing to do
• > 10 mm -> cholecystectomy (increased risk of cancer)
• > 18 mm treat as cancer until proven otherwise
• > 6 mm -> requires surveillance

Question 23

Hepatic vein pressure gradient in portal HTN

Answer 23

> 6 mm Hg

o Gradient between wedged hepatic vein pressure and the free hepatic vein pressure
o Hepatic vein pressure >12 -> a/w variceal rupture

Question 24

Pyogenic abscess

Answer 24

o MC abscess
o 2/2 to biliary tract or GI infxn -> E coli (MC)
o Tx: perc drain, abx

Question 25

Amebic abscess

Answer 25

o South America, Mexico o Dx: imaging, serology o Tx: flagyl, rarely need drainage

Question 26

Echinococcal abscess

Answer 26

o Hydatid cyst, double walled cystic appearance on CT o Check serology o Tx: albendazole, surgical excision, do not aspirate or spill (causes anaphylaxis)

Question 27

Components of Child-Pugh

Answer 27

bili, albumin, PT, encephalopathy, ascites

Question 28

Components of MELD

Answer 28

bili, INR, Cr

Question 29

Todani classification of choledochal cysts

Answer 29

o Type 1: fusiform dilation of extrahepatic biliary tree " Tx: resection, hepaticojejunostomy o Type 2: saccular diverticulum of CBD " Tx: excise, possibly need to do roux-en-y o Type 3: choledococele, dilation of intramural duct " Tx: transduodenal excision or sphincteroplasty o Type 4A: multiple dilation of intra and extrahepatic ducts " Tx: Hepatic resection of affected areas, hepatico-j o Type 4B: multiple dilation of extrahepatic ducts alone " Tx: excision, hepatico-j o Type 5: dilation of intrahepatic ducts " Tx: transplant

Question 30

Hepatic cyst

Answer 30

- Symptomatic: o Cyst fenestration o R/o other pathology

Question 31

Hemangioma

Answer 31

- Peripheral and central enhancement on arterial phase of CT - Symptomatic o Only reason to resect

Question 32

FNH

Answer 32

- Benign | - Well demarcated, rapid arterial enhancement, central stellate scar

Question 33

Adenoma

Answer 33

- 10% malignant potential - Arterial enhancement with washout in porto-venous phase, smooth surface - Tx o Stop OCP, see if regresses o >4 cm or no regression: resect o Ruptured: IR embolization and then resect in elective setting

Question 34

Hepatocellular carcinoma

Answer 34

- Hypervascular, hyperdense in arterial phase - Can be diagnosed on imaging alone, with elevated AFP - No PET scan - MC site of metastasis: lung

Question 35

Resection criteria in HCC

Answer 35

o Future liver remnant: can resect up to 75% in healthy liver - 30-40% FLN required in Child-Pugh A

Question 36

Milan criteria for transplant

Answer 36

" 1 lesion <5 cm " 3 or fewer lesions <3 cm " No gross vascular or extra-hepatic spread

Question 37

GB cancer tx

Answer 37

- T1a: invades only lamina propria o Tx: cholecystectomy - T1b and beyond: muscle layer and beyond o Tx: cholecystectomy and limited hepatic resection (segment 4b and 5), portal LN resection

Question 38

Highest negative predictive value for choledocholithiasis

Answer 38

GGT

Question 39

Assessing biliary tree after roux-en-y

Answer 39

trans-gastric ERCP or double balloon endoscopy

Question 40

Fibrolamellar variant of HCC

Answer 40

young patient without cirrhosis, better prognosis, neurotensin tumor marker

Question 41

Hemobilia dx.tx

Answer 41

-> tx angioembolization, EGD first

Question 42

Left lateral segmentectomy

Answer 42

segment 2 & 3

Question 43

Extended right hepatectomy

Answer 43

5, 6, 7, 8 ,4