HPB

Question 1

Treatment for bleeding esophageal varices

Answer 1

Fluid and PCT resuscitation
Octreotide(somatostatin)
Prophylactic Abx

Question 2

What are some clinical signs of Necrotising pancreatitis

Answer 2

Grey turner and cullens signs

Question 3

What do grey turners sign suggest

Answer 3

Necoritising pancreatitis or retroperitoneal hemorrhage

Question 4

Signs of Decompensated Liver failure

Answer 4

Albumin: Pedal Edema
Coagulopathy:Ecchymoses
Bilirubin:Jaundice/hyperbilirubinemia
Distension: Ascites
Encephalopathy/asterixis
Portal HTN signs

Question 5

Signs of chronic liver disease

Answer 5

Palmar erythema
Spider naevi
Dilated abdominal veins
Gynaecomastia
Clubbing
Jaundice

Question 6

4 Fs of cholelithiasis

Answer 6

Female
Forty
Fertile(pregnant)
Fat

Question 7

Type of jaundice with most intense itch

Answer 7

Post hepatic obstructive jaundice

Question 8

boundaries of Calots/hepatocystic triangle

Answer 8

1. inferior edge of liver
2. Common hepatic duct
3. Cystic duct

Question 9

Contents of Calots triangle to avoid in surgery

Answer 9

1. Right hepatic artery
2. Cystic artery
3. Cystic lymph node of lund
4. Lymphatics
5. Connective tissue

Question 10

Score for pancreatitis

Answer 10

Glasgow Imrie score

Question 11

5 exceptions to Courvoisiers Law

Answer 11

1. Mirizzi syndrome
2. Bile duct structures
3. Parasites eg ascaris, liver flukes
4. Stone in both cystic duct and CHD
   5?

Medbear page 309

Question 12

Eponymous name of hilar cholangiocarcinoma

Answer 12

Klatskin tumor

Question 13

Causes of hepatic bruit

Answer 13

Arteriovenous malformations, alcoholic liver cirrhosis

Question 14

Dydx caput medusae vs dilated abdominal veins(IVC obstruction)

Answer 14

Below umbilicus
-caput medusae point inferiorly ?
-dilated abdominal veins point superiorly?

Question 15

Dydx hepatomegaly vs liver mass

Answer 15

Liver mass usually does not cross midline unless bilobar disease

Question 16

Cardinal Sx of Chronic Pancreatitis

Answer 16

1) Pain
2) Diabetes
3) Steatorrhea
4) malnutrition

Question 17

What to look for in a Endoscopic Retrograde Pancreatography

Answer 17

For any
1) Filling defects including gallbladder +- masses
2) shouldering(strictures)
3) Rat tailing(flow of contrast from CBD into ampulla)
4) CBD size >7mm(age and s/p dependent)
5) abnormal biliary tree
- LHD and RHD
- distal tapering of contrast

Question 18

Pathognomonic sign of gallstone ileus on XR

Answer 18

Rigler’s triad

Pneumobilia
SBIO
Gallstone often at RUQ( Ileocecal valve)

Question 19

Why ERCP perforation unlikely to cause pneumoperitoneum on erect CXR

Answer 19

D2 where ampulla of vater enters, is retroperitoneal

Question 20

Dy/dx Hepatocellular carcinoma, liver metastases, hepatic haemangioma in triphasic CT

Answer 20

HCC: portal venous washout
Mets: Portal venous enhancement
Haemangioma: delayed phase enhancement

Question 21

Contraindications to Trans Arterial Chemo Embolisation(TACE) for HCC

Answer 21

1. Decompensated Liver Cirrhosis
2. Portal Vein Thrombosis

Question 22

Contraindicated surgical approach in gallbladder cancer

Answer 22

Laparoscopic: tendency for tumor deposits on trocar(keyhole) sites

Question 23

Condition associated with Primary Sclerosing Cholangitis

Answer 23

IBD specifically Ulcerative COlitis

Question 24

Risk factors for cholangiocarcinoma

Answer 24

Non modifiable
Age
Female
Primary Sclerosing Cholangitis

Modifiable
Choledocholithiasis/ Hepatolithiasis
Biliary tree abnormalities
Choledochal cyst
Anomalous biliary-pancreatic malformations
Liver Cirrhosis
Viral Hepatitis:: B, C and HIV
Parasitic Infections
Carcinogen exposure, mainly occupational: Thorotrast
Diabetes Mellitus

Question 24

Bismuth Corlette Classification of Cholangiocarcinomas

Answer 24

I: Below confluence of hepatic ducts II: Tumor involving confluence IIIa: Tumor involving confluence and right hepatic duct IIIb: Tumor involving confluence and left hepatic duct IV: Tumor involving both hepatic ducts and confluence OR mulicentric

Question 24

Classification of non hilar cholangiocarcinomas

Answer 24

1. Mass forming 2. Intra ductal 3. Peri ductal/sclerosing

Question 25

Surgical options for cholangiocarcinoma

Answer 25

Intrahepatic tumor: Hepatic Lobectomy and excision of affected duct Hilar tumor(Klatskin’s): Bile duct resection + bilateral hepaticojejunostomy and caudate lobectomy Extrahepatic involving Common bile duct: Biliary tree and hilar lymphatics resection Distal tumor: Pancreaticoduodenectomy( Whipple’s)

Question 26

Aim and options for palliative treatment of cholangiocarcinoma

Answer 26

Relieve jaundice and pruritus, avoid cholangitis and liver failure, improve quality of life Endoscopic biliary drainage Endoscopic or percutaneous stents with SEMS( Self expanding metal stents) PTBD RT Chemo Photodynamic therapy

Question 27

Reason post ERCP perforation is most likely to be retroperitoneal

Answer 27

Occurs at D2, at the site of the sphincterotomy OR in the bile duct, which is retroperitoneal

Question 28

Invx for epigastric pain post ERCP

Answer 28

Pancreatitis: Amylase Inferior AMI: ECG and troponins Perforation: CT Scan( often retroperitoneal)

Question 29

What is OPSI and how to treat

Answer 29

Overwhelming Post Splenectomy Infection - blood c/s - empirical broad spectrum Abx

Question 30

Why patients have higher risk of VTE post splenectomy

Answer 30

Post splenectomy thrombocytosis