HEPATOBILIARY Flashcards
(217 cards)
1
Q
Bouveret syndrome
A
gastric outlet obstruction 2/2 gallstone in duodenum
2
Q
Mirizzi syndorme
A
2/2 extrinsic compression of common hepatic duct due to impacted stone in cystic duct
3
Q
Mgmt Mirizzi syndrome
A
subtotal cholecystectomy
4
Q
If have pyogenic liver abscess after liver transplant… suspect?
A
hepatic artery thrombosis
5
Q
Klatskin tumor
A
hilar cholangiocarcinoma
6
Q
Most important prognostic indicator for HCC
A
vascular invasion
7
Q
Hepatic tumors supplied by? Vs. normal liver supplied by?
A
tumors = hepatic artery normal = portal vein
8
Q
Steps of lap choledochotomy
A
- longitudinal incision in CBD
- T-tube
- closure with 4-0 absorbable
- completion cholangio through T-tube to confirm stone removal
9
Q
Where incision for lap choledochotomy? And why longitudinal?
A
- incision below insertion of CD at CBD (not CHD) to avoid postsurgical proximal bile duct stenosis
- longitudinal bc blood supply to extrahepatic bile duct runs along duct @ 3’ and 9’oclock positions
10
Q
Steps transcystic approach for CBD exploration
A
- cholangio
- wire from CD to CBD
- balloon cath to gently dilate to allow passage of flexible choledochoscope
11
Q
Why delay fistula repair after enterotomy for gallstone ileus?
A
at risk for developing acute cholangitis
12
Q
Dx HCC can be made with…? (2)
A
imaging + elevated AFP alone
13
Q
MCC Budd-Chiari syndrome in U.S.
A
heme d/o (i.e. PV, PNH, myeloproliferative d/o, conditions associated w/ high estrogen levels ie. pregnancy, OCP) -> hypercoag -> acute/chronic thrombosis
14
Q
MC presenting sign of Budd-Chiari
A
ascites
15
Q
Rapid vs. Subtle hepatorenal syndrome (re: Cr levels)
A
Rapid: doubling Cr >221 in <2 weeks; GFR usually <20 cc/min
Subtle: initial Cr <221; diuretic-resistant ascites
16
Q
Hepatic mets resection indicated for…? (2)
A
- isolated hepatic mets AND
- locoregional control of primary d/o
17
Q
Mgmt asymptomatic hepatic simple cysts
A
nothing
18
Q
Mgmt symptomatic hepatic simple cysts or cannot r/o premalignant processes (ie. biliary cystadenoma)
A
lap fenestration w/ cyst wall and fluid pathology and cytology, respectively
19
Q
C/I perQ drain of pyogenic liver abscess
A
- coagulopathy (uncontrolled intrahepatic bleeding)
- ascites (relative)
- multiple abscesses (relative)
20
Q
Steps of dx Budd-Chiari syndrome
A
- conditional dx via duplex US
- confirmed via angio of IVC and hepatic veins
(will also need heme evaluation, coag studies, liver biopsy to eval etiology and extent of disease)
21
Q
Biliary anatomy variations occurs in ? % of pts
A
30%
22
Q
Why not do early ERCP for all pts with gallstone pancreatitis?
A
high Cx rates with no benefits
23
Q
When would you do early ERCP (w/ stone extraction and sphincterotomy) in pts with gallstone pancreatitis?
A
if have obstructive jaundice and/or cholangitis
24
Q
Dx steps for operative injury after lap choly
A
- US - fluid collection vs. intra/extrahepatic biliary duct dilation
- If fluid collection -> DISIDA scan to determine if leak is continuing
- If continued leak -> ERCP (stent) vs. perQ transhepatic cholangio
25
Tx metastatic GB cancer
gemcitabine + cisplatin
26
Can result in obstruction -> pancreatitis if not divided during transduodenal sphincteroplasty?
transampullary septectomy (thin layer connective tissue found within papilla)
27
Tokyo Guidelines acute cholangitis
```
severity criteria
Grade 1 (mild): does not meet criteria of mod or severe -> Abx
```
Grade 2 (mod); 2+ of below -> Abx + fluid resus
- abnormal WBC (<4, >12)
- high fever (>39)
- age (>75)
- hyperbili (tbili >5)
- hypoalbum (<0.7x lower limit)
Grade 3 (severe): end organ dysfunction -> urgent biliary drainage
28
Incidence bile duct injury during lap chole
0.3-0.7%
29
Bismuth-Corlette classification
classification for cholangiocarcinomas
Type 1 = common hepatic duct
Type 2 = hepatic bifurcation
Type 3 = secondary hepatic duct on one side
Type 4 = secondary hepatic duct on both sides (Klatskin)
30
Mgmt post-op cystic stump leak
endoscopic stent (diver bile flow away from leaky stump) + perQ fluid drainage
31
What is a HIDA?
hepatic iminodiacetic acid scan = biliary scintigraphy
- shows biliary flow at either CD or bile duct
- not good to do during cholangitis/infection (bc reduces biliary secretion of IMD acid into biliary tree)
32
MC organisms cholecystitis
E.coli > Enterococcus > Klebsiella
33
Best imaging to characterize GB polyps
transabdominal US (bc majority polyps are cholesterol)
34
How does cholesterolosis appear on RUQ US?
peduculated, hyperechoic, non-mobile, NO posterior shadowing
35
In which pts would you do prophylactic cholecystectomy in asymptomatic pt?
- hemolytic anemia (sickle cell): high rate stone formation -> cholecystitis -> crisis
- large >2.5cm stone
- long common channel of bile and pank ducts
36
Mgmt neoplasm of ampulla of Vatar
ampullectomy vs. pancreaticodudoenectomy
37
ICU pt w/ GB gangrene at risk for...? Mgmt?
perforation - need fluids, IV Abx, and early cholecystectomy
38
Pt with distal CBD tumor present with high or low PT?
long-standing obstructive jaundice -> no bile to duodenum -> decreased fat absorption -> low VitK -> high PT
39
Where does replaced right hepatic artery commonly run?
off SMA -> posterior to pancreas and CBD (careful not to ligate when taking cystic duct and artery during lap chole!!)
40
Where does replaced left hepatic commonly travel?
gastrohepatic ligament
41
Ligamentum teres is remnant of...?
umbilical vein (can recannualize)
42
Where anatomically does SMV + splenic vein join?
behind neck of pancreas, runs behind D1 -> splits to R/L portal vein
43
Triangle of Calot (boundaries + significance)
CHD (medial), CD (lateral), liver (superior)
| - contains cystic artery
44
Lab abnormality for: primary biliary cirrhosis
Antimitochondrial Abs
45
Lab abnormality for: primary sclerosing cholangitis
Anti-neutrophil
46
Lab abnormality for: Wilson's disease
Ceruloplasmin
47
Lab abnormality for: HCC
AFP + CEA
48
choledocholithiasis: dilated CBD? bili?
dilated CBD >6mm, bili >3
49
If severe gallstone pancreatitis, mgmt?
ERCP spincterotomy (to reduce Cx during waiting period) + interval chole 6-8wks
50
Rigler's triad
bowel obstruction + gallstone seen on imaging + pneumobilia = gallstone ileus
51
Mgmt GB polyps
symptomatic = lap chole
= 5mm -> fu US 6-12m, if no change in size, then NTD
>5mm = serial imaging q6m for 1yr, then annually
>10 = suspect adenoma; lap chole
>18 = treat as GB cancer + CT for invasive cancer eval
52
Portal HTN defined as...?
hepatic vein pressure gradient >6mmHg
53
Portal venous pressure best approx by...?
hepatic venous wedge pressure
54
child + hematemesis + splenomegaly... suspect?
portal vein thrombosis
55
Rectal varices 2/2 what splanchnic - systemic connection?
inferior mesenteric vein + pudendal vein
56
Umbilicus varices 2/2 what splanchnic - systemic connection?
umbilical vein (recannulizes) + left portal vein
57
RP varices 2/2 what splanchnic - systemic connection?
mesenteric + ovarian veins
58
Esophageal varices 2/2 what splanchnic - systemic connection?
coronary/short gastric veins + azygous vein
59
How to check if TIPS is still patent?
ultrasound
60
When to consider gastroesophageal devascularization?
if extensive portovenous thrombosis + no shunt options
61
What is gastroesophageal devascularization?
devascularization of entire greater curvature (+ splenectomy) + first 2/3 lesser curve + lower circumferential 7.5cm esophagus
62
Warren (splenorenal) shunt
selective: good for variceal bleeding; C/I if have ascites (will worsen)
63
Dx ameabic liver abscess
imaging (US/CT - no rim enhancement) + serology (serum E. histolytica Ab)
64
HVPG required for variceal rupture
>12mmHg
65
Factors of Childs-Pugh score
- bili
- albumin
- PT/INR
- encephalopathy
- ascites
66
Factors of MELD
- bli
- INR
- Cr
67
What MELD score until have survival benefit w/ liver tx?
>15
68
Mgmt cirrhotic pt with symptomatic umbilical hernia?
intermittent paracentesis for ascites + elective repair with MESH (high % recurrance)
69
Mgmt cirrhotic pt with complicated/infected umbilical hernia?
reduce and close in MULTIPLE LAYERS (no mesh) + aggressive ascites control
70
Todani classification, mgmt?
```
type 1: fusiform dilation of extrahepatobiliary (mgmt: resection + hepatoJ)
type 2: saccular dilation of CBD (mgmt: excise, often have to do RNY enteric reconstruction)
type 3: dilation intramural duct (mgmt: transduodenal approach, excise or sphincteroplasty)
type 4A: intra + extrahepatic dilations (mgmt: involved hepatic resection + hepatoJ)
type 4B: extrahepatic (mgmt: excision + hepatoJ)
type 5 (Caroli): intrahepatic (mgmt: transplant)
```
71
Caroli disease; associated with...? mgmt?
Type 5 choledococyst: 50% associated with congenital hepatic fibrosis (mgmt: tx)
72
Why have to resect choledococysts?
malignant potential + recurrent cholangitis
73
Sxs choledococysts
pain, biliary obstruction, cirrhosis
74
Mgmt large, symptomatic simple hepatic cysts
lap-cyst fenestration; send capsule for pathology
*100% recurrence rate if only aspirate
75
Kasabach-Merritt syndomre
consumptive coagulopathy (thrombocytopenia) 2/2 large hemangioma
76
Mgmt asymptomatic hemangioma
obs, no matter how large bc no risk rupture
77
If hemangioma in peds pt, can cause...?
CHF 2/2 AV shunting
78
central stellate scar on CT
focal nodular hyperplasia
79
Mgmt hepatic adenoma
<4cm: stop causing Rx (ie. OCP)
>4cm or no regression: resect
Rupture: IR hep artery embolization, then elective resection
80
Cx hepatic adenoma
10% malignant transformation + risk of rupture (30% risk bleed if >5cm)
81
Type hepatic adenoma w/ highest risk malignant transformation
beta-catenin mutated adenoma
82
Most common benign hepatic tumor
Hemangioma
83
Most common malignant hepatic tumor
HCC
84
Most common site of mets for HCC
lungs
85
High indicator of post-operative morbidity/mortality following HCC resection
portal HTN
86
Dx staging used to predict prognosis in HCC?
TNM is NOT used - does not predict survival and needs tissue. Evaluate extent of CA and cirrhosis.
87
How much future liver remnant needed in Child A?
30-40%
88
Milan-UNOS criteria
- 1 lesion <5cm
- 3 or less lesions all <3cm
- no gross vascular or extrahepatic spread
89
If surgery not option, what other options for mgmt HCC?
- ablation by IR (small lesion)
- TACE (unresectable >5cm)
- EBRT (if not amendable to above 2/2 tumor location)
90
Most common primary hepatobiliary tumor in peds? Associated with...?
hepatoblastoma. associated with FAP syndrome.
91
Sxs hepatoblastoma
asymptomatic mass; mild anemia + thrombocytopenia
92
Mgmt hepatoblastoma
chemo -> resection
93
HCC in young pt without cirrhosis, suspect...? Neuromarker?
fibrolamellar variant; neurotensin neuromarker
94
Isolated gastric varices, suspect...? Mgmt?
splenic vein thrombosis commonly 2/2 pancreatitis; mgmt: splenectomy
95
4-wk post liver lac managed non-op, now presenting w/ hematemesis, suspect...? Dx?
suspect hemobilia 2/2 hepatic artery to biliary duct fistula
Dx: EGD to confirm, if see blood from duodenal papilla, then confirm -> angioembolization
96
Dx sphincter of Oddi dysfunction
biliary colic w/ morphine (sphincter contraction) and neostigmine (biliary contraction) [[Nardi test]]
97
Surgical mgmt sphincter of Oddi dysfxn
transduodenal sphincterectomy
98
MCC Budd-Chiari in Asia
membranous webs
99
How dilated must cystic duct be for choledochoscopy (for CBD stone extraction)?
8mm
100
What does transcystic choledochotomy entail?
Transverse incision halfway up diameter of CD and insert endoscope to explore for CBD stone
101
MC variant HCC
fibrolamellar HCC
102
Characteristics of fibrolamellar HCC (imaging, histo, lab)
Imaging: well-circumscribed mass w/ central scar
Histo: clusters of large polygonal cells interspersed w/ sheets of collagen
Lab: normal AFP; elevated neurotensin level
103
Liver mass, normal AFP, elevated neurotensin... think?
Fibrolamellar variant of HCC
104
Components of bile
water, bile salts, cholesterol, lecithin (phospholipid)
105
Ratio of bile components least likely to form cholesteral stones
high bile salt, high lecithin, low cholesterol ratio
106
What is an abnormal CCK-HIDA scan?
EF<35% after 20 minutes of injection (but note that other etiologies for abnormal EF i.e. diabetes, IBD)
107
What hormone is most potent stimulator of bile secretion?
secretin
108
Secretion of bile is dependent on what ion channel?
Chloride (that is stimulated mostly be secretin)
109
Primary source of bilirubin in body?
from breakdown of RBC
110
Primary bile acids are...? Conjugated with...?
cholic acid and chenodeoxycholic acid; conj w/ either taurine or glycine
111
Incidental hepatic mass, asymptomatic, peripheral enhancement on CT... think?
Hemangioma
112
Conjugated bile salts (if not absorbed at terminal ileum) are deconjugated by colonic bacteria to...?
deoxycholate and lithocholate
113
How and where are deconjugated bile salts absorbed?
by passive transport in colon and returned to liver
114
MC etiology for cystic duct stump leak s/p lap chole
inflammation around duct in setting of acute cholecystitis -> dislodges clips
115
Only known effective systemic medical therapy for pts with HCC?
sorafenib (multikinase inhibitor w/ activity against VEGF-R, c-kit receptor, PDGF-R, and kinases of MAPKK pathway)
116
Mgmt GB cancers at infundibulum
CBD resection, extended liver resection, then RNY hepaticoJ + complete lymphadenectomy
117
Mgmt GB cancers at fundus
limited hepatic resection wo excision of CBD + complete lymphadenectomy (CBD, hepatic artery, portal vein)
118
If concern for cholangiocarcinoma, next step for dx...?
MRI with cholangiography protocol (MR cholangiopancreatography) to evaluate extent of disease
119
GB cancer will first metastasize where...?
cystic duct lymph nodes
120
MC morphology cholangiocarcinoma...? Most favorable histology...?
nodular; papillary
121
Fxn glucuronyl transferase
conjugates bilirubin
122
MC organisms of pyogenic liver abscess
E.coli and Klebsiella (latter particularly in gas-forming abscesses)
123
Best test for liver function
PT
124
Dx modality of choice to reassess GB polyp (surveillance)
ultrasound (doppler assessment of blood flow through mucosal abnormalities can differentiate early malignancy vs. benign)
125
Wilson disease is 2/2 deficiency of...?
ATP7B
126
Most sensitive dx test to identify other areas of liver mets intra-op
ultrasound (2-5mm sensitivity)
127
How long does it take for VitK to reverse effects of warfarin?
~6 hours
128
% of pts who die of fulminant liver failure shown to have cerebral edema
80%
129
MCC portal vein thrombosis in children
umbilical vein infection
130
Lipoprotein that carries the highest concentration of cholesterol is...?
LDL
131
MC organism of spontaneous bacterial peritonitis
E.coli
132
Pt w/ hx UC presenting w/ c/o nausea, itching, fatigue + hx multiple biliary strictures s/p stents... think?
primary sclerosing cholangitis -> fibrosis and strictures in biliary tree (mgmt: liver tx)
133
Where does cystic artery pass in relation to common hepatic duct?
posterior
134
Double cystic arteries found in ?% of pts?
10%
135
Most important indicator of prognosis for GB adenocarcinoma
lymph node status
136
What GB polyp characteristics should consider cholecystectomy?
- polyps >10mm
- in pts with cholelithiasis
- in pts with primary sclerosis cholangitis
137
Monitoring of GB polyp
if <1cm + asymptomatic, should have serial US q6-12m for 2 years
138
Typical dose of glucagon to relax sphincter of Oddi
1mg
139
Rate of post-TIPS encephalopathy?
~30%
140
Major limitation of TIPS that may occur within first year?
high incidence (up to 50%) of stent stenosis (MC) or thrombosis
141
Mgmt for TIPS shunt stenosis
balloon dilation of TIPS, or by placement of second shunt
142
Well-defined hepatic mass with contrast enhancement during arterial phase, followed by rapid washout during portal phase... consistent with?
hepatic adenoma
143
Well-defined hepatic mass with peripheral + central enhancement on delayed imaging... consistent with?
hepatic hemangioma
144
Poorly defined mass @ peripheral w/ low attenuation, central necrosis, cystic degeneration... think?
metastatic hepatic lesion
145
Well-defined hepatic mass with internal septae, papillary projections, intratumoral hemorrhage, fine calcifications... think?
hepatic cyst
146
When should antibiotics start for variceal bleeding?
prophylactic Abx started as part of resuscitation and continued for 7-days -> decrease risk bacterial infxn and increase survival
147
Dominant artery to biliary tree is...?
right hepatic artery (loss of this inflow -> biliary stricture; also supplies cystic artery)
148
Primary prophylaxis for pts with high risk variceal bleeding
Non-selective BB - lowers portal pressure and reduces risk first bleeding in pts with esophageal varices
149
Patho for "defect in GB wall"... think?
GB wall ischemia -> necrosis -> perf bc gangrenous
150
Pt s/p enterotomy for gallstone ileus, presenting with AMS, RUQ tenderness... think?
cholangitis - can get from reflux via fistula
151
Mgmt bleeding hepatic hemangioma
embolization
152
Mgmt symptomatic or >10cm hepatic hemangioma
resection vs. enucleation
153
Second MC benign hepatic tumor
focal nodular hyperplasia
154
Mgmt asymptomatic focal nodular hyperplasia
observation; may do q1y US for 2-3 years for women who wish to continue OCP
155
Surgical indication for hepatic adenoma
1. size of >5cm
2. male patient
3. inability to r/o malignancy
156
What % future liver remnant is predictive of post-op liver failure?
<40%
157
What clearance can be used to assess functional capacity of liver? What is the threshold to predict post-op liver failure?
indocyanine green clearance - checked after 15min injection (nl = <10% detectable)
>40% retention predictive of post-op liver failure regardless of resection size
158
Medications that reduce GB contractility (and should be withheld before CCK cholescintigraphy)
- atropine
- CCB
- octreotide
- progesterone
- indomethacin
- theophylline
- benzos, all opioids
- H2-blockers
159
Most appropriate time to semi-electively operate on pregnant female w/ cholecystitis...? Why?
second trimester (13-26wks) - bc lower incidence of premature labor
160
When in pregnant female w/ cholecystitis should conservative mgmt be attempted initially?
32 weeks (risk premature labor)
161
If conservative mgmt fails in >32wk pregnant female w/ cholecystitis, then mgmt?
operation - pretreat w/ betamethasone 24hrs and 12hrs pre-op; at 32wks, okay to conduct necessary radiographs (ie. intra-op cholangiogram, ERCP)
162
Acute portal vein thrombosis in adult... think?
prothrombotic state vs. myeloproliferative disorder
163
Intent when using external beam radiation or transarterial chemoembolization for liver mets is...?
palliation - not curative
164
Gallbladder polyps are classified into...?
- pseudotumors (cholesterol polyps, adenomyomas, inflammatory polyps)
- epithelial (adenomas)
- mesenchymal (leiomyomas)
- malignancy (adenocarcinomas)
165
When do cholecystectomy for GB polyp?
- polyp >5mm + age >50
- polyp >10mm
- single poly any size + gallstones
166
When need CT eval for invasive cancer for GB polyp?
- polyp >18mm (treat as if malignant)
| - polyp >10mm + age <60
167
MRCP findings of primary sclerosing cholangitis
"bead-on-a-string"
168
What autoimmune disease could also mimic MRCP findings of primary sclerosing cholangitis?
IgG4-associated autoimmune pancreatitis (if suspect, then can give trial of steroid immunosuppression)
169
Abx of choice for spontaneous bacterial peritonitis
3rd-gen cephalosporin
170
Hx ulcerative colitis, now presenting with fatigue, weight loss, pruritus... think?
concern for primary sclerosing cholangitis - need MRCP for dx
171
Primary lab abnormality in primary sclerosing cholangitis pts
elevated ALP, most have normal bilirubin levels - if elevated, then suggestive of advanced disease or malignancy
172
Post-ERCP scan showing RP air...think? Mgmt?
benign - (Type 4 ERCP perf) microperf 2/2 compressed air used to maintain patency of duodenal lumen
Mgmt: IV Abx
173
After placement of perQ chole for acute cholecystitis in poor surgical candidate... next step during follow-up for tube?
cholangiogram via chole tube - confirm correct placement and assess CD is patent
174
Alternative to cholecystectomy for patients who remain poor surgical candidates?
endoscopic transpapillary GB stent (ETGS)
175
What is Child A/B/C score by points?
Child A = 5-6 pts
Child B = 7-9 pts
Child C = 10-15 pts
176
Primary bile salts
- colic acid
| - chenodeoxycholic acid
177
Process: cholesterol -> primary bile salts -> ?
Cholesterol in liver -> conjugated by glycine or taurine -> primary bile salts -> secreted into bile to duodenum (enterohepatic circulation)
178
Anatomy: relative location of 3 parts of CBD (superior, middle, inferior third)
Supraduodenal: in hepatoduo ligament and along edge of lesser momentum, anterior to portal vein, lateral to proper hepatic
Retroduo: behind 1st-duo, lateral to portal vein, anterior to IVC
Intrapancreatic: posterior pancreas in tunnel to enter 2nd-duo (joined by panc duct) @ papilla of Vater
179
Foramen of Winslow contains what structures?
Portal triad: vein, proper hepatic, CBD
180
Triad for ascending cholangitis
Charcot triad (fever, jaundice, RUQ pain)
181
MC Cx if gallstone is not retrieves s/p lap chole (and spill)
Abscess formation
182
Mgmt abscess with “radiopaque” object s/p lap chole (cx: spill)
Lap drainage of abscess + retrieval of foreign body (gallstone)
183
Secondary bile acids
- deoxycholic
| - lithocholic acids
184
CCK is produced by what cells? And where?
I-cells of the duodenum
185
Pt w/ jaundice and cholelethiasis + “paint brush” or “soap bubble” sign on upper GI series
Small bowel villous adenoma
186
MC location for small bowel adenoma
2nd-duodenum @ periampullary region
187
When post-op can chole T-tube be manipulated?
6-weeks
188
Next step: US finding of intrahepatic ductal dilation and mass @ hilum
Define proximal extent of hilar cholangiocarcinoma w/ MRI (cholangiography)
189
Stage 5-yr survival of gallbladder adenoCA
TIS = 80%
Stage 1 = 50%
Stage 2 = 29%
Stage 3, 4 = <10%
190
RF cholangiocarcinoma (cancer of bile ducts)
- male; age 50-70
- PSC
- UC
- biliary tract infection
- choledochal cyst
191
RF gallbladder adenoCA
- females; age 70’s
- cholelithiasis
- larger gallstones >3cm (10x risk, likely due to chronic inflammation)
- large, single GB polyp >1cm
- choledochal cyst
192
Cystic artery divides into...? To supply gallbladder.
Superficial and deep branches
193
Anatomy: location cystic artery in relation to CHD
Lateral, posterior (high variability)
194
What nerve stimulates contraction of the gallbladder? Which is inhibitory?
Stimulators: vagus
Inhibitory: splanchnic sympathetic stimulation
195
When should you do T-tube cholangiography to evaluate for retained stones?
2 weeks ( to evaluate for possible removal)
196
Mgmt cholangiocarcinoma resection based on location
Superior (hilar and duct involvement): partial hepatectomy +CBD resection
Middle (rare): CBD w/ regional lymphadenectomy
Intrapancreatic: Whipple
197
Most potent stimulator of bile secretion
Secretin
198
Mgmt acute cholecystitis in a poor surgical candidate, what is definitive mgmt?
PerQ insertion of cholecystostomy tube -> decompression (at later date, can do cholecystography through tube to eval for obstructing stone)
199
Contraindications for resection of cholangiocarcinoma
- distant mets (inability to do R0 resection)
- encasement of main portal vein
- b/l hepatic lobar artery involvement
- lobar atrophy w/ involvement of contralateral portal vein
200
Highest NPV for cholelithiasis (aka. If normal, then likely negative)
GGP (beta-glutamotranspeptidase)
201
CT: liver lesion of arterial phase w/ peripheral and central enhancement + delayed but persistent peripheral nodular enhancement
Hepatic hemangioma
202
CT: liver lesion well-circumscribed + early enhancement in arterial phase with rapid washout on portal phase; heterogenous mass
Hepatic adenoma
203
What is presentation of acute liver failure vs. cirrhotic?
Acute liver failure = cirrhotic (ascites, encephalopathy) + unstable, coagulopathic
204
If isolated gastric varices, and suspect splenic vein thrombosis... should do what to confirm? And if not splenic vein thrombosis, mgmt?
Abdominal US. If gastric varices due to portal HTN, then NO splenectomy.
205
How does splenic vein thrombosis cause isolated gastric varices?
Retrograde flow through short gastric and posterior gastric veins
206
Portal pressure is calculated by difference in what two vein pressures?
IVC and portal vein pressures
207
If multiple organs present in ascitic fluid... suspect?
Not spontaneous bacterial peritonitis (usually single) - suspect secondary peritonitis (ie. Diverticulitis)
208
Which esophageal balloon tamponade has proximal port to allow drainage of salivary secretions?
Minnesota tube
209
How does metastatic liver lesions appear on CT?
Hypodense
210
What % of variceal bleeding rebleeds after balloon tamponade?
50%
211
Which hydatid liver cysts require surgery?
CE2 (multispetated) and CE3b (daughter cyst) - many compartments
212
Main site of urea production? Of excretion? Immediate AA precursor of urea?
```
Production = liver
Excretion = kidney
AA = arginine
```
213
Ascites from liver dysfunction due to...?
High intravascular pressure 2/2 portal HTN -> capillary leakage (NOT due to low intravascular oncotic pressures due to poor protein stores)
214
Patho biliary leak complications following OLT
Ischemia of donor biliary tree (must r/o hepatic artery stenosis or thrombosis) -> biliary leak
215
Drainage of ? from biloma is not likely to resolve without further intervention?
If >300cc/day from perQ drain, will likely not resolve, will need ERCP.
216
Gastric varices commonly seen with ?-side portal HTN?
left-sided portal HTN - seen with splenic vein thrombosis
217
Expected overall surgical mortality risk: Child A/B/C
A: 10%
B: 30%
C: 75-80%
