Liver and Gallbladder Flashcards
(99 cards)
1
Q
___ refers t the plane separating the true left and right lobes
A
Cantlie’s line
from GB fossa to IVC
2
Q
What separates the left lobe into lateral and medial segments?
A
falciform ligament
Small left lobe, large right lobe
3
Q
What divides the quadrate and caudate lobe?
A
- GB
- Fissure for ligamentum teres
- IVC
- Fissure of ligamentum venosum
4
Q
What lobe lies between the IVC and fissure for ligamentum venosum?
A
Caudate lobe
5
Q
What lobe is located between the fissure for ligamentum teres and GB?
A
Quadrate Lobe
Remember, Quad = Teres
6
Q
What are the contents of your porta hepatis?
A
- Hepatic Duct
- Hepatic artery
- Portal vein
7
Q
[Name the corresponding segment]
caudate
A
segment 1
Drained by IVC
8
Q
[Name the corresponding segment]
Left lateral
A
Segment 2 and 3
Drained by Left hepatic
9
Q
[Name the corresponding segment]
left medial
A
Segment 4
4A and 4B
10
Q
[Name the corresponding segment]
Right anterior
A
Segment 5 and 8
11
Q
[Name the corresponding segment]
right posterior
A
Segment 6 and 7
12
Q
What liver segments are drained by middle hepatic?
A
Segment 4, 5, 8
13
Q
What structures are compressed in pringle maneuver?
A
- Portal vein
- Hepatic artery
- CBD
14
Q
What clotting factor is not measured by your PT and INR?
A
Factor VIII
15
Q
What is the level of serum bilirubin to cause a jaundice?
A
> 2.5 to 3 mg/dL
16
Q
What are the most common causes of haemobilia?
A
- Iatrogenic
- Traumatogenic
- Neoplastic
17
Q
What do you call the triad of haemobilia?
A
Quicke Triad
- Jaundice
- RUQ abdominal pain
- Upper GI hemorrhage
18
Q
What is the hormone implicated with spider angiomata?
A
Estradiol
19
Q
Caput medusa is due to re-opening of what veins?
A
umbilical vein
shunting blood from the portal vein
20
Q
Ascites is clinically detected when greater than ____ L
A
1.5L
21
Q
____ syndrome refers to an epigastric murmur seen in cirrhotic patients wherein blood from the portal vein is shunted to the umbilical vein
A
Cruveilhier-Baumgarten Syndrome
22
Q
____ (horizontal/vertical) nail bands are seen in cirrhotic patients due to hypoalbuminemia.
A
horizontal
23
Q
Dupuytren contracture in cirrhosis is due to?
A
enhanced oxidative stress, increased hypoxanthine
24
Q
Hypogonadism in cirrhotic patients wis mainly due to?
A
direct toxic effect of iron or alcohol
25
The presence of asterixis in hepatic enceph is due to ___
disinhibition of motor neurons
26
What compound is implicated in fetor hepaticus seen in cirrhotic patients?
Volatile dimethyl sulfide
27
What is the first line drug for SBP?
Cefotaxime
28
What are the components of your Child Pugh Score B
```
Jaundice - Bilirubin 2-3
Ascites - minimal, controlled
PTT - 40 to 70%
Albumin 2.8 to 3.5
Nutritional status - good
```
29
What is the normal portal pressure?
5-10 mmHg
30
What is the cut off value of portal hypertension based on splenic vein pressure?
>15mmHg
31
What is the most accurate method of determining portal hypertension?
Hepatic venography
32
What is the most significant manifestation of portal HPN?
esophageal varices
33
What is the surgical management for refractory BEV child pugh A
Surgical Shunt
34
What is the surgical management for refractory BEV child pugh B
TIPS
35
[Classification of portosystemic surgical shunts for BEV]
Eck fistula
End-to-side portocaval shunt
36
[Classification of portosystemic surgical shunts for BEV]
Linton shunt
Proximal splenorenal shunt
37
[Classification of portosystemic surgical shunts for BEV]
Warren shunt
Distal splenorenal (selective)
38
[Classification of portosystemic surgical shunts for BEV]
Inokuchi shunt
Left gastric vena caval shunt (selective)
39
[Classification of portosystemic surgical non-shunts for BEV]
used for recurrent BEV despite endoscopic and medical treatment who are not candidates for TIPS
Sugiura-Fukugawa procedure
Ligate venous branches entering distal esophagus and the proximal stomach from the level of inferior pulmonary vein,
40
[Classification of portosystemic surgical non-shunts for BEV]
consist of splenectomy, perihiatal devascularization of the lower esophagus, ligation of the left gastric vessels, devascularization of the proximal half of the stomach, separation of stomach from its bed
Hassab
41
What is the most definitive surgical procedure of portal hypertension?
Orthotopic Liver Transplantation
42
Which is the most frequent site (left or right lobe) of pyogenic liver abscess?
right lobe
40% monomicrobial
43
What is the CT scan finding diagnostic of pyogenic liver abscess?
Hypodense lesions with or without air-fluid levels and peripheral enhancement
44
Which part of the liver is the most frequent location of amebic liver absccess?
Anterior aspect of right lobe
45
Which part of the liver is commonly affected by hydatid disease?
Antero-inferior or posteroinferior portions of the right lobe
46
What is the most frequently encountered liver lesion overall?
Hepatic cyst
47
What is the most common benign solid mass seen in the liver?
hemangioma
48
What is the most common symptom in liver hemangiona and indication for resection?
pain
49
What is the clearest risk factor for liver adenoma?
Prior or current use of oral contraceptives
50
What is the most common malignant liver tumor?
Metastatic
usually from colonic CA
51
What are the criteria for hepatoma that is viable for resection only?
1. Non-cirrhotic
2. Child A
3. Single lesion
4. No metastasis
52
What is the criteria for liver transplant in patients with Hepatoma?
1. One nodule <5cm
2. 2 or 3 nodules < 3cm
3. No vascular invasion
4. No extrahepatic spread
5. Child A, B, C
53
Where is the location of a Klatskin Tumor?
Occurs in the hepatic duct confluence
54
What is the gold standard in the surgical management of cholangiocarcinoma?
Resection
55
The cystic artery is a branch of?
Right hepatic artery
56
The budd triangle or the hepatocystic triangle is formed by the:
1. Cystic duct to the right
2. Common hepatic duct to the left
3. Margin of the right lobe of the liver superiorly
Basta border ang right lobe of the liver
57
What are the borders of triangle of Calot?
1. cystic duct
2. Common Hepatic Duct
3. Cystic artery
58
__ are in which you can see 85% of the hepatic pedicle
Moosman area
59
The ampulla of vater is ___ cm distal to the pylorus
10cm
surrounded by sphincter of oddi
60
What nerve plays a role in GB contraction
Vagus
61
What hormone inhibits GB contraction?
1. VIP
| 2. Somatostatin
62
What is the basal pressure of the sphinter of oddi?
13mmHg above duodenal pressure
63
What is the most common presentation of gallstone disease?
Recurrent biliary colic
64
What are the TRADITIONAL indications for cholecystectomy in asymptomatic patients?
1. Elderly with DM
2. Isolation from medical care for extended periods
3. Increased risk of GB cancer
65
What are the indications for prophylactic cholecystectomy?
1. Sickle Cell Disease
2. Hereditary spherocytosis and thalassemia at the time of splenectomy
3. Cardiac and lung transplant patients
66
What are the contraindications for prophylactic cholecystectomy?
1. DM patients
2. Cirrhotic patients
3. Transpant recipeints
4. Porcelain gallbladder
5. Patients receiving prolonged TPN
6. Spinal cord injury
67
What are the critical view of safety in laparoscopic cholecystectomy?
1. Triangle of calot must be dissected free of fat (without exposing the common bile duct)
2. The base of the GB must be dissected off the lover bed or cystic plate
3. Two structures (cystic duct and artery) enter the GB and can be seen circumferentially
68
What are the absolute contraindications for cholecystectomy?
1. Inability to tolerate GA or laparotomy
2. Refractory coagulopathy
3. Diffuse peritonitis with hemodynamic compromise
4. Cholangitis
5. Potentially curable GB cancer
69
[Eponym]
examiner hooks finger under right costal margin and ask patient to deeply inhale. Positive test if the patient stops inhaling suddenly due to pain
Acute cholecystitis
70
[Eponym]
Hyperesthesia in the RUQ or right infrascapular region
Boas sign
71
[Eponym]
Present when the patient points to the right scapular tip with a fist and thumb pointing upwards to describe the pain
Collins Sign
72
What is the most typical sign of acute cholecystitis?
abdominal pain
73
What are the components of your 2013 Tokyo Guidelines?
A
1. Murphy sign
2. RUQ mass or pain or tenderness
B
1. fever
2. Elevated CRP
3. Elevated WBC
C. Imaging characteristic of acute cholecystitis
74
According to tokyo guidelines, cholecystitis is suspected if
1 item in A + 1 item in B
A
1. Murphy sign
2. RUQ mass or pain or tenderness
B
1. fever
2. Elevated CRP
3. Elevated WBC
75
According to tokyo guidelines, definite cholecystitis is when
One item A + One Item B + C
A
1. Murphy sign
2. RUQ mass or pain or tenderness
B
1. fever
2. Elevated CRP
3. Elevated WBC
C. Imaging characteristic of acute cholecystitis
76
What are the UTZ finding suggestive of cholecystitis?
1. Enlarged GB
2. Thickening of GB wall >5mm
3. Debris echo
4. UTZ Murphy sign
77
Immediate cholecystectomy and biliary drainage should be carried out in what severity grade for acute cholecystitis?
Grade II
78
How many months can you perform cholecystectomy in patients with severe cholecystitis
2-3 months after
79
In grade I cholecystitis, cholecystectomy should be done within _____ hours
72 hours
80
What is the cut off year to say that a GB stone is either residual or recurrent post cholecystectomy
2 years
Residual - <2 years
Recurrent - >2 years
81
What is the gold standard in diagnosing GB stone?
ERCB
82
A dilated CBD in abdominal UTZ has a diameter of?
>8mm
83
___ syndrome wherein the common hepatic duct obstruction is due to an extrinsic compression from an impacted stone in the cystic duct or hartmann's pouch pf the GB
Mirrizi Syndrome
84
___ syndrome refers to gallstone ileus of the duodenum
Bouveret Syndrome
85
[Tokyo guideline for acute cholangitis]
What are the clinical context criteria?
1. History of biliary disease
2. Fever or chills
3. Jaundice
4. Abdominal pain (RUQ or upper abdomen)
86
What are the procedures that can be done in patients with Grade II Acute Cholangitis to drain the bile?
1. ERCP + Papillotomy
2. PTC with catheter drainage
3. Laparotomy with decompression of the bile duct with a T-tube
87
Most common form of choledochal cyst?
Type 1 - Fusiform
88
___ disease wherein choledochal cysts are found in the intrahepatic ducts
Caroli Disease
89
What is the triad of choledochal cyst?
1. Abdominal pain
2. Jaundice
3. Mass
90
What is the surgical management for Type 3 choledochal cyst?
Sphincterotomy
Type 3 - choledochocoele, multiple cyst
91
What is the surgical management for Type 2 choledochal cyst?
Excision; defect in the CBD is closed over a T-tube
Type 2 - saccular
92
What is the management for Type 4A choledochal cyst?
Segmental liver resection, excision of and roux en y hepaticojejunostomy
Type 4 - intra and extra
93
What are the factors associated with malignancy in GB polyp?
1. Presence of single polyp
2. Size of polyp >1cm
3. Age >50 years
4. Rapid growth
5. Sessile in morphology
6. Adenomatous in histology
94
[GB CA surgical management]
tumor invading the lamina propria
This is T1a - simple cholecystectomy
95
[GB CA surgical management]
Tumor invades the muscle layer
This is T1b
do an extended cholecystectomy include segment IVB and V + lyphadenectomy
96
[GB CA surgical management]
Tumor invades the perimuscular connective tissue
This is T2
Extended cholecystectomy
97
[GB CA surgical management]
tumor perforates the serosa and invades liver or adjacent organs
Extended right hepatectomy + en bloc resection of the CBD
98
Most common type of bile duct CA?
>95% are adenocarcinoma
99
What is the most common presentation of bile duct CA?
painless jaundice
