Hepatobiliary and Pancreas Flashcards
(153 cards)
1
Q
What are the boundaries of the triangle of Calot?
A
Lateral - Cystic Duct
Medial - CBD
Superior - Liver
2
Q
What supplies blood to the hepatic and CBD?
A
Right Hepatic and branches of the GDA
3
Q
What side of the CBD are lymphatic on?
A
The right
4
Q
Where do sympathetic and parasympathetic fibers come to the liver from?
A
Parasympathetic -> Left trunk of vagus
Sympathetic -> T7-T10
5
Q
What is unique about the histology of the GB?
A
It lacks any submucosa
6
Q
What is a normal size for the CBD, GB wall and pancreatic duct?
A
CBD < 8 mm (10 after cholecystectomy)
GB wall < 4 mm
Pancreatic duct < 4 mm
7
Q
What are RokitanskypAschoff sinuses?
A
Invaginations in the GB wall from increased GB pressure
8
Q
What are the Ducts of Luschka?
A
Biliary ducts lying in the GB fossa that can leak after cholecystectomy
9
Q
What signals increase bile secretion and decrease it?
A
Increase: CCK, secretin, vagal
Decrease: somatostatin, sympathetic
10
Q
What is the most common type of GB stone in the US?
A
Cholesterol stones
2/2: stasis, calcium nucleation, increased water resorption
11
Q
What are causes brown GB stones?
A
Primary CBD stones, formed in ducts, asians
Infection causes deconjugation
E. Coli most common
12
Q
What causes black GB stones?
A
Hemolytic disorders, cirrhosis, ill resection, chronic TPN
Calcium bilirubinate
13
Q
What is the sensitivity of ultrasound for GB stones?
A
95%
14
Q
What are indications for cholecystectomy after a CCK-S test?
A
GB not seen
> 60 min for GB to empty (chronic cholecystitis)
EF < 40% (biliary dyskinesia)
15
Q
What are indications for pre-op ERCP?
A
If any of the following high for > 24 hours:
AST or ALT > 200
Bilirubin > 4
Amylase or Lipase > 1000
16
Q
What is the most common route of infection of the bile?
A
Via seeding from the portal system
17
Q
What condition has the highest incidence of positive bile cultures?
A
Post-op strictures
18
Q
What bacteria usually causes emphysematous GB disease in diabetics?
A
C. Perfringens
19
Q
What is the threshold for primary repair of a CBD injury?
A
< 50% of circumference
Otherwise need hepatico-J
20
Q
What do suspect if N/V or jaundice after lap whole and no fluid collection?
A
If dilated hepatic ducts -> complet ductal transection
21
Q
What is the treatment for a complete bile duct transection?
A
< 7 days symptoms - Hepatico J
> 7 days symptoms - Delayed hepatico J (6-8 weeks)
22
Q
How do you treat anastomotic leaks following transplantation or hepatico-J?
A
Drainage and ERCP with temporary stent
23
Q
What is the most common cause of late post-op biliary strictures?
A
Ischemia after lap chole
Ddx: chronic pancreatitis, GB CA, bile duct CA
24
Q
What is workup of a biliary stricture?
A
MRCP
If CA not ruled out -> ERCP with brush biopsies
25
What is treatment for biliary strictures from ischemia or chronic pancreatitis?
Choledochojejunostomy
26
Where does gallbladder AC spread first?
Segments IV and V
| Cystic duct nodes
27
What is the treatment of GB carcinoma based on depth of invasion?
Not in muscle -> cholecystectomy
In muscle but not beyond -> wedge of segments IVb and V
If beyond muscle and resectable -> formal segments IVb and V resection
28
Why is laparoscopic approach contraindicated for GB cancer?
Tumor implants in port sites
29
What is treatment of cholangiocarcinoma of the upper 1/3 (Klatskin Tumor)?
Lobectomy if localized
| Worst prognosis
30
What is treatment of cholangiocarcinoma of middle 1/3 of duct?
Hepaticojejunosotmy
31
What is treatment of cholangiocarcinoma of lower 1/3 of duct?
Whipple
32
What is the most common type of choledochol cyst?
Type I - fusiform dilation of the extra hepatic pancreatic ducts
33
What causes choledochol cysts?
Reflux of pancreatic enzymes during uterine development
34
What antibody is present with primary biliary cirrhosis?
Antimitochondrial Antibodies
35
Is there a cancer risk with PBC?
No
36
What causes systemic bacteremia in cholangitis?
Colovenous reflux (>200 mmHg)
37
What are early and late causes of shock after lap chole?
Early - clip fell off cystic after
| Late - sepsis from clip on CBD with subsequent cholangitis
38
What are worrisome features of GB polyps?
> 1 cm
| > 60 years old
39
What is delta bilirubin and what is its implication?
Covalently bound to albumin, half life of 18 days
40
What is Mirizzi syndrome?
Compression of common hepatic duct from:
1) Stone in GB infundibulum
2) inflammation from GB or cystic duct causing CHD stricture
41
What antibiotic is associated with sludge and cholestatic jaundice?
Ceftriaxone
42
Which lies lateral and anterior, SMV or SMA ?
SMV
43
What are the effects of GI hormones on pancreatic secretions?
Secretin - Increase HCO3
CCK - Increase pancreatic enzymes
Ach - Increase both
Somatostatin Glucagon - Decrease exocrine
44
What duct connects the inferior pancreatic bud to the duodenum?
Duct or Wirsung - Becomes the major pancreatic duct
45
What is the small accessory duct that drains directly into duodenum from pancreas?
Duct of Santorini
46
What causes annular pancreas?
Failure of clockwise rotation of ventral pancreatic bud
47
What is treatment of annular pancreas?
Duodenojejunostomy or duodenoduodenostomy
48
What is the main consequence of pancreas divisor?
Pancreatitis from stenotic duct of Santorini
49
What is the treatment of pancreas divisor?
ERCP with sphincteroplasty
50
What is a sentinel loop?
In pancreatitis, dilated loop of bowel near pancreas as a result of inflammation
51
What does a necrotic pancreas look like on CT?
Will not take up contrast
52
What is Grey Turner sign?
Flank ecchymosis from pancreatic bleeding
53
What is Cullen's sign?
Periumbilical ecchymosis from pancreatic bleeding
54
What is Fox's sign?
Inguinal ecchymosis from pancreatic bleeding
55
What is the most important risk factor for necrotizing pancreatitis?
Obesity
56
What must be ruled out in cysts not associated with pancreatitis?
Cancer
57
What is tx for pancreatic pseudocyst?
3 months to stabilize and see if resolve
If continued sx, surgery/procedure
If growing, surgery to r/o cancer
58
Which cysts do you not need to worry about for cancer?
If cyst is serous and not complex, can follow these
59
What is Tx for pancreatic fistula?
Drainage, stent, allow to close on own
| Octrotide
60
What is the most common symptoms of chronic pancreatitis?
PAIN
| anorexia, weight loss, malabsorption
61
What does imaging show for chronic pancreatitis?
CT: shrunken pancreas with calcifications
U/S: Panc ducts > 4 mm, cysts, atrophy
Chain of Lakes: alternating dilations and stenosis in pancreatic duct
62
What is a Puestow procedure?
pancreaticojejunostomy, for duct > 8 mm
63
What are surgical options for chronic pancreatitis?
```
Puestow Procedure
Distal pancreatic resection
Whipple
Berger-Frey
Pain ctrl with thoracoscopic splanchnicectomy or celiac ganglionectomy
```
64
What is the most common cause of splenic vein thrombosis?
Chronic pancreatitis
65
What is the most common symptom of pancreatic cancer?
Weight loss
66
What is the serum marker for pancreatic cancer?
CA19-9
67
What is the most common mutation in pancreatic cancer?
p16
68
What are indications of unresectable disease for pancreatic cancer?
PV, SMV, RP invasion
Mets to peritoneum, momentum, liver
Mets to celiac or SMA nodal system
69
What are the histologies of pancreatic cancer?
```
Ductal adenocarcinoma (90%)
Papillary or mutinous cyst-adenocarcinoma
```
70
Do all patients need a biopsy with suspected pancreatic cancer?
No, if resectable and in the pancreas, you are taking it out regardless
71
What are signs of cancer on an MRCP?
Duct with irregular narrowing, displacement, destruction
| Vessel involvement
72
What are the most common complications from a whipple?
Delayed gastric emptying
Fistula
Leak
Marginal ulceration
73
What is treatment for post-op bleeding after whipple?
Angio for embolization
74
What is prognosis of pancreatic cancer related to?
Nodal invasion and ability to get a clear margin
75
What are the characteristics of non-functional endocrine neoplasms of the pancreas?
90% malignant
Indolent and protracted course
Resect
76
What chemotherapy is used for non-functional endocrine tumors of the pancreas?
5FU and streptozosin
77
What are the most common endocrine pancreatic tumors in the head?
Gastrinoma
| Somatostatinoma
78
What is Whipple's Triad of insulinomas?
Fasting hypoglycemia
Symptoms of hypoglycemia (palpitations, tachy)
Relief of symptoms with glucose
79
What should you suspect if c-peptide and proinsulin are not also elevated with insulin:glucose > 0.4?
Muchausen's syndrome
80
What is the treatment for insulinoma or gastronome?
< 2 cm - enucleate
| > 2 cm formal resection
81
What is the most common pancreatic islet cell tumor in MEN-1 patients?
Gastrinoma
82
What is the 50% rule for gastrionma?
50% malignant
| 50% multiple
83
What is the gastrinoma triangle?
CBD
Neck of pancreas
third portion of duodenum
84
What are the laboratory and imaging studies for gastrinoma?
Gastrin > 200, 1000s is diagnostic
Secretin stimulation test: ZES gastrin > 200
Imaging: Octrotide scan
85
What is treatment for duodenal gastrinoma?
Resection and primary closure
| Whipple if extensive
86
What is the characteristics of glucagonoma?
Most are malignant and in distal pancreas
87
What are the characteristics of VIPoma?
Most malignant
| Most in distal pancreas, 10% extrapancreatic
88
What are the characteristics of somatostatinoma?
Malignant (most)
Most in head of pancreas
Do a cholecystectomy with resection
89
What is the relation of the splenic vein to the splenic artery?
Splenic vein posterior and inferior to splenic artery
90
Where is an accessory spleen most commonly found?
Splenic hilum
91
What are indications for splenectomy (non-trauma)?
ITP and TTP (ITP >>>TTP)
92
What is the defect in ITP?
Anti-platelet IgG bind it and result in decreased platelets
| Spleen is normal
93
Which group with ITP should you avoid splenectomy in?
Children > 10 years (often self resolves)
94
What is the primary therapy for ITP?
Steroids and then gammaglobulin
95
What is the common cause of death in TTP?
Intracerebral hemorrhage
96
What is the incidence of post-splenectomy sepsis?
0.1% (increased in kids)
| Highest with hemolytic disorders or malignancy
97
What age should you try to wait until for splenectomy?
Age 5 as you get all immunizations
98
What is the most common congenital hemolytic anemia requiring splenectomy?
Spherocytosis
99
What is the pathophysiology of spherocytosis?
Defect in spectrum leads to splenic sequestration
100
What is Tx for spherocytosis?
Splenectomy AND Cholecystectomy
101
What is the most common hemolytic anemia not involving membrane protein needing splenectomy?
Pyruivate kinase deficiency
| Others: Warm-antibody hemolytic anemia, occasionally beta-thalasemia
102
What is the staging for Hodgkin's disease?
A - asymptomatic
B - symptomatic
I - 1 area or 2 contiguous areas on same side of diaphragm
II - 2 non-continguious on same side of diaphragm
III - both sides of diaphragm
IV - Non-lymphoid tissue other than spleen
103
What is the most common cause of chylous ascites?
Lymphoma
104
What is the most common cause of splenic artery/vein thrombosis?
Pancreatitis
105
What changes do you see post-splenectomy?
Increased RBC, WBC (persistent increase in lymphs and monos), Platelets
Platelets > 1 000 000, give ASA
106
What is the most common splenic tumor?
Hemangioma
107
What is the treatment for splenic cysts?
Surgery if symptomatic or > 10 cm
108
What is the treatment of a splenic abscess?
Splenectomy (perc drainage has bleeding risk)
109
What is the most common variant of the hepatic arteries?
Right hepatic off of SMA coursing behind pancreas and posterolateral to the CBD
110
What is the common variant of the left hepatic artery?
Off of left gastric (20%) found in gastrohepatic ligament medially
111
What gives blood supply to most tumors of the liver?
Hepatic artery
112
Where does the middle hepatic vein come from?
80% of people it is a branch of the left hepatic vein
| 20% go directly from IVC
113
What is the only water-soluble vitamin stored in the liver?
B12
114
What are primary and secondary bile salts?
Primary: chalice and chenodeoxycholic
Secondary: deoxycholic and lithocholic (formed by bacteria)
115
At what TBilli does jaundice occur?
2.5
116
What enzyme is implicated in Gilbert's, Crigler-Najjar and physiologic jaundice?
Glucuronyl Transferase
| Mild, severe, and temporary defects respectively
117
What is Rotor's syndrome?
Deficiency in bile storage ability
118
What is dubin-johnson syndrome?
Deficiency in secretion of bile
119
What are the criteria for urgent liver Txp listing in fulminant liver failure?
Non-APAP induced:
INR > 6.5 OR 3 of the following:
Age < 10 or > 40, drug toxicity or undetermined etiology, jaundice > 7 days prior to encephalopathy, INR > 3.5, bilirubin > 17
120
What kidney hormone is elevated in liver failure?
Aldosterone
121
What is the etiology of postpartum liver failure with ascites?
Hepatic vein thrombosis + infection
| Tx: Heparin + ABX
122
What is the diagnostic criteria for SBP?
PMNs > 250 in fluid
123
What ist he treatment for ruptured esophageal varies?
banding, sclerotherapy
Vasopressin, octreotide
Propranolol chronically
TIPS
124
What are causes of pre-sinusoidal obstruction?
Schistosomiasis
Congenital hepatic fibrosis
Portal vein thrombus
125
What is a normal portal vein pressure?
< 12 mmHg
126
What veins act as collaterals between portal and systemic venom system?
Coronary veins
127
What are the indications for TIPS?
Protracted bleeding
Progression of coagulopathy
Visceral hypoperfusion
Refractory ascites
128
How is a splenorenal shunt done?
Ligate left adrenal vein left gonadal vein, IMV, coronary vein, pancreatic branches of splenic vein
129
When is splenorenal shunt indicated?
Child's A cirrhotics with just bleeding (can worsen ascites)
130
What is the Child-Pugh score based on?
```
Albumin
Bilirubin
Encephalopathy
Ascites
INR
```
131
What is the most common cause of massive hematemesis in children?
extra-hepatic portal vein thrombosis
132
What causes isolated gastric varices?
Splenic vein thrombosis
133
What is the classic presentation of amebic liver abscess?
Increased LFTS, right lobe of liver, single abscess with sterile culture (organism lives in rim)
134
What tests diagnose echinococcus cyst?
Casoni skin test, serology
| CT: ectocyst (calcified) endocyst (double-walled)
135
What is treatment of echinococcus abscess?
Pre-op albendazole and then surgical removal
136
What is the symptoms of schistosomiasis?
Maculopapular rash, eosinophilia, vatical bleeding
137
What is most common organism in hepatic abscess?
GNRs/ E.Coli
138
What causes pyogenic liver abscess?
Infection from biliary tree or bacteremia
139
What are the imaging features of hepatic adenomas?
No uptake on sulfur colloid scan
| MRI with hyper vascular tumor
140
What is treatment of hepatic adenomas?
Asymptomatic - stop OCPs no Tx for regression, otherwise resect
Symptomatic - resect
141
What is the imaging features of FNH?
Central stellate scar
Hypervascular tumor on CT/MRI
Uptake on sulfur colloid liver scan
142
What are the features of FNH?
No malignancy risk
| Unlikely to rupture
143
What is the most common benign hepatic tumor?
Hemangioma
144
What are the imaging features of hepatic hemangioma?
Peripheral to central enhancement
| Hypervascular
145
What is the treatment for symptomatic hemangioma?
surgery +/- embolization pre-op
146
What is Kasabach-Merritt syndrome?
Consumptive coagulopathy from hepatic hemangioma
147
What liver diseases are not risk factors for HCC?
Primary biliary cirrhosis
| Wilson's disease
148
What types of HCC have the best prognosis?
Clear cell
Lymphocyte infiltrative
Fibrolamellar types
149
What tumor marker correlates with size in HCC?
AFP
150
What are the risk factors for hepatic sarcoma?
PVC
Thorotrast
Arsenic
151
What is the vascular pattern for primary vs metastatic liver tumors?
Primary - hypervascular
| Mets - hypo vascular
152
What are the "worrisome features" of an IPMN that mandate EUS?
cyst of at least 3 cm
an enhancing mural nodule
thickened or enhancing cyst walls
main duct size of 5 to 9 mm
any abrupt change in caliber of the duct with distal atrophy,
lymphadenopathy
elevated cancer antigen 19-9 (normal: 0-37 U/mL)
cyst growth rate of at least 5 mm over 2 years.
153
What are the high-risk features of an IPMN that would lead to resection?
obstructive jaundice
enhancing mural nodules of at least 5 mm
main duct dilation to at least 10 mm
