ABSITE 25 > HPB > Flashcards

HPB Flashcards

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1
Q

MC Location: Replaced RIGHT hepatic artery

A

Off SMA
20%
Behind pancreas, posterolateral to CBD (careful in lap chole!)

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2
Q

MC Location: Replaced LEFT hepatic artery

A

Off L Gastric
20%
Found in gastrohepatic ligament medially (careful in foregut sugery!)

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3
Q

Ligamentum teres carries the obliterated __ to __

A

Ligamentum teres carries the obliterated UMBILICAL VEIN to undersurface of the liver, extends from falciform

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4
Q

Line from GB fossa to IVC

A

Cantlie’s line (or portal fissure)
- bisects liver (unlike falciform)

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5
Q

Name of peritoneum that covers the liver?

What’s not covered by this peritoneum?

A

Glisson’s capsule

Bare area- posterior-superior surface

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6
Q

Lateral to coronary ligaments of liver

A

Triangular ligaments

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7
Q

Name: Liver macrophages

A

Kupffer cells

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8
Q

Name: Entrance to lesser sac

A

Foramen of winslow

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9
Q

2 veins that join to form PV

A

SMV + splenic
- after IMV joined splenic

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10
Q

What % of blood supply comes from PV?

A

75%

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11
Q

What 2 hepatic veins join before going into IVC
*similarly also arteries join

A

MIDDLE HV joins LEFT HV (80%)
MIDDLE HA is a branch OFF LEFT HA

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12
Q

Does a LEFT or RIGHT hepatectomy (also extended) include the caudate?

A

LEFT and LEFT extended

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13
Q

Where is urea synthesized vs eliminated?

A

Liver - synthesized
Kidneys - eliminated

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14
Q

What coagulation factors are NOT made in the liver, and where are they made?

A

vWF and VIII (8)
Endothelium

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15
Q

Where are hepatocytes most at risk of ischemia?

A

Central lobular, acinar zone III

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16
Q

Hgb is converted to bilirubin, which is then conjugated in the liver to __

A

Glucuronic acid; this is actively secreted into bile

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17
Q

Where is conjugated bili broken down?

A

TI by bacteria -> to urobilinogen (what gives urine dark color if excess)

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18
Q

At what level of bilirubin does jaundice appear? Where do you see first?

A

> 2.5
Under tongue

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19
Q

Maximum bilirubin level

A

30

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20
Q

Gilbert’s vs. Crigler-Najjar: which is more severe? are these pre or post-conjugation

A

PRE conjugation (glucuronyl transferase)
CN»_space; worse than G

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21
Q

Rotor vs. Dubin-Johnson: which is more severe? are these pre or post-conjugation

A

High conjugated bili’s (issues w/ storage and secretion abilities)
DJ»_space; worse than R

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22
Q

MC hepatitis worldwide

A

HBV

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23
Q

How does lactulose treat hepatic encephalopathy?

A

gets rid of bacteria in gut and acidifies colon (NH3->NH4). NH3 is bad and can be taken up in blood by other organs

titrate to 2-3 stools/day

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24
Q

After paracentesis, how much albumin should be repleted?

A

1g/100cc drained

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25
Preferred agent in hepatorenal syndrome, why?
Vasopressin - splanchnic vasoconstriction
26
Dx and Txt: Postpartum liver failure with ascites
Hepatic vein thrombosis (from ovarian source) Infectious pelvic thrombophlebitis Txt: thus, heparin AND abx
27
Esophageal varices: propranolol, vasopressin, octreotide -- when give?
Propranolol - preventive Vasopressin, octreotide - when bleeding
28
MCC: Pre-sinusoidal liver obstruction
1) PVT (50% of portal HTN in children) 2) Schistosomiasis (chronic damage to vasculature)
29
MCC: Sinusoidal liver obstruction
cirrhosis (eg etoh, viral)
30
MCC: Post-sinusoidal liver obstruction
Budd-Chiari syndrome (hepatic vein thrombus), constrictive pericarditis, CHF Backup of blood into IVC
31
Veins that result in esophageal varices (Collaterals btw esophagus and PV)
Coronary vein (L gastric vein) Pyloric vein (R gastric vein) To remember- heart is on the left and pylorus is on the right
32
Who may get a splenorenal shunt?
Child A cirrhotic presenting with ONLY bleeding, can worsen ascites Selective shunt- ligate L adrenal, L gonadal, IMV, coronary, and pancreatic branches of splenic vein (NO splenectomy needed)
33
Components of Childs Pugh
Albumin Bilirubin Encephalopathy Ascites INR
34
MELD components
INR Creatinine Total bilirubin
35
MELD score minimum to get survival benefit from liver transplant
15+
36
Maximum MELD score
40
37
Txt: Budd Chiari
Heparin gtt Catheter-directed tPA Also, possible stent or retrohepatic TIPS
38
Txt: Splenic vein thrombosis
Splenectomy if symptomatic
39
Txt: Portal vein thrombosis
Heparin gtt
40
Test also needed if occult pyogenic abscess?
Colonoscopy to r/o CA
41
Treatment: Amebic liver abscess
Metronidazole Aspiration only if refractory (Rare) Surgery only if free rupture
42
Treatment: Echinococcal cyst
Pre-op albendazole x2 weeks THEN surgical removal after etoh killing of organisms then aspirate. Need to get ALL cyst wall Do NOT aspirate
43
Treatment: schistosomiasis
Praziquantel
44
Imaging: Hepatic adenoma
Arterial centripetal enhancement with rapid PV washout (like HCC) MRI: hyperintense T1/T2
45
Treatment: Hepatic adenoma
Asx and <4cm: stop OCPs. If no regression, need resection Sx or >4cm: tumor resection for bleeding and and malignancy risk Rupture: emergent embolization
46
Imaging: Focal nodular hyperplasia
Central stellate scar with radiating septa +sulfor colloid on liver scan (has Kupffer cells)
47
Treatment: Focal nodular hyperplasia
Conservative, no resection
48
Imaging: Hemangioma
CT: peripheral to central enhancement, persistent on delayed phases MRI: VERY hypervascular on T2
49
MC benign liver lesion
hemangioma
50
Treatment: Hemangioma
Asx: conservative Sx: resection +/- preop embolization; if unresectable, try steroids
51
Which liver lesion can have associated consumptive coagulopathy?
Kasabach-Merritt syndrome, can result in CHF. Esp seen in peds Hemangioma
52
Treatment: simple liver cysts
Sx: lap fenestration (don't just aspirate)
53
MCC: cancer worldwide
HCC
54
#1 cause of HCC worldwide
HBV
55
Which type of HCC has best prognosis?
Fibrolamellar (adolescent and young adults)
56
Which type of HCC has worst prognosis?
Diffuse nodular type
57
HCC: AFP level correlates with
Tumor size
58
MC site met: for HCC
Liver
59
Imaging: HCC
Early arterial enhancement with washout Mosaic pattern (nonhomogenous necrotic areas mixed with hypervascular sections) May also have central scar like FNH but does not have delayed enhancement of scar
60
No cirrhosis: % future liver remnant (FLR) after resection
25% of preop liver
61
Child A: % future liver remnant (FLR) after resection
40% of preop liver
62
Surgical margin for HCC
1cm
63
How do you decide parenchymal distribution of resection for HCC?
Ligate corresponding HA, PV, HV - then divide based on ischemic demarcation
64
Palliative txt: HCC
<5cm ablation (radiofreq or microwave) >5cm TACE Late stage tumors- sorafenib
65
Imaging: primary vs metastatic liver tumors
Primary: generally HYPERvascular Metastasis: generally HYPOvascular
66
MC complication after liver transplant
Bile leak (occurs in 10-30% of cases)
67
Key SUPERIOR landmark in axillary dissection (first step)
Axillary vein (first step after entering clavipectoral fascia)
68
Key LATERAL and MEDIAL nerves in axillary dissection
LATERAL - Thoracodorsal (arm/shoulder weakness; lats) MEDIAL - long thoracic (serratus anterior; winged scapula)
69
Treatment: methemoglobinemia
Methylene blue (chocolate covered blood)
70
Pembrolizumab: MOA and cancer
Antibody AGAINST PD-1 receptor Non-small lung CA (binds to programmed death ligand 1 receptor, prevents PDL1& 2 ligand binding)
71
Ipililumab
CTLA-4 melanoma
72
Selpercatinib
RET Medullary thyroid CA in MEN 2A/2B
ABSITE 25
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