Flashcards in The Surgical Review- Hepatobiliary and Pancreas Deck (207)
What are the five different types of choledochal cysts?
I: Fusiform: dilation of CBD
II: isolated diverticulum protruding from the CBD
III: dilation of duodenal portion of CBD
IV: multiple dilations of intra and extra hepatic biliary tree
V (Caroli disease): intrahepatic without extra hepatic
What is the treatment of type I, II and V?
I and II: Roux en y
V: liver txp
patients with Primary sclerosing cholangitis have an increased risk for development of what type of cancer?
cholangiocarcinoma (follow them with serial CA19-9)
(PSC assoc w UC)
what test is the most sensitive and specific for the diagnosis of pyogenic liver abscess?
Which bugs usually cause pyogenic liver abscess?
polymicrobial consisting of:
- e coli
- bacteroides fragilis
Treatment of pyogenic liver abscess?
IR percutaneous drainage _ broad spectrum antibiotics
(open surgical drainage is reserved for septic patients who fail percutaneous drainage)
Which AMEBA causes liver abscesses and which populations do they affect?
- Entamoeba histolytica
- infects alcoholic and homosexual pts
- ingested then migrate from intestine to liver
Treatment entamoeba histolytic abscess?
14 days metronidazole
what bug cases hydatid liver disease (cysts)?
Echinococcus granulosum (tapeworm)
treatment of hydatid cyst?
surgical resection is definitive, only 50% respond to albendazole
- cysts are highly antigenic and rupture may result in anaphylactic shock
who are the definitive hosts for echinococcus granulosum?
but humans get it after ingesting the eggs from sheep or cattle
- eggs penetrate the small bowel and migrate via the portal blood system
2 causes of bleeding gastric varices?
1. Portal HTN 2/2 cirrhosis (TIPS)
2. Splenic vein thrombosis (perform splenectomy)
why do gastric varies provide a greater therapeutic challenge than esophageal varices?
their deeper submucosal position may preclude effective endoscopic therapy
What are the contraindications to TIPS?
1. Right sided heart failure with increased CVP
2. Severe hepatic failure
3. Portal vein thrombosis
4. Severe hepatic encephalopathy
5. Active local or systemic infection
treatment of bleeding gastroesophageal varices?
endoscopic band ligation + serial endoscopy with banding
tips is second tier option
What are the different types of portosystemic shunts?
1. Nonselective shunts: portocaval or mesocaval, decompress the entire portal system
2. Selective: distal splenorenal (warren), decompress the gastroesophageal bed only thus decreased risk of hepatic failure
what is the Child's Pugh score and what factors does it take into account? 5 factors
- score that classifies liver failure
1. Serum bilirubin
2. Serum albumin
What is the MELD score and what factors does it use?
Model for End Stage Liver Disease: pre and post surgical mortality associated with cirrhosis
Formula for MELD? teehee
What are the most common benign solid tumors of the liver?
Hemangiomas: rarely bleed or cause symptoms, only when >10cm
treatment of hemangiomas?
unless huge and symptomatic and surgical tx is warranted: enucleation
what is Kasabach-Merritt syndrome?
Hemangioma + thrombocytopenia and consumptive coagulopathy
- thus surgical enucleation of hemangioma
- mostly seen in kids, assoc w high mortality
management of benign hepatic cysts?
how do you distinguish between Focal Nodular Hyperplasia and hepatic adenoma?
MRI can distinguish lesions
- confirmatory study: technetium-99m sulfur colloid scan, the Kupffer cells of FNH will take up radionuclide
what is Focal nodular Hyperplasia?
- hyperplastic nodule formed by normal hepatocytes and Kupffer cells that congregate around a solid central artery
- do not hemorrhage, are not hormonally responsive, not associated with malignant change
what is a hepatic adenoma?
- can have malignant degeneration to HCC
- may enlarge upon exposure to higher levels of circulating hormones
- can contain intraparenchymal hemorrhage
treatment of hepatic adenoma?
resection if possible
What are the most common malignant hepatic neoplasms?
Metastatic tumors from the GI tract, breast and lung
when CAN you resect a metastatic lesion in the liver?
metastases from colorectal cancer