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Surgery Review 6

SR 6: Hepatopancreaticobiliary, spleen, hernia, transplant, wound healing

What is a replaced right or left hepatic artery? Replaced right - originating off SMA (occurs in 17%) Replaced left - originating off left gastric (occurs in 10%)
Which segment of the liver drains directly into IVC? Segment I - caudate lobe
What is Cantlie’s line? Line drawn from gallbladder fossa to IVC separating right and left hepatic lobes
What are Kupffer cells? Specialized macrophages in the liver responsible for clearing portal blood and immunosurveillance. Also responsible for early alcohol-induced liver injury
Describe the anatomical relationship of the portal triad Portal vein posterior to CBD (on R) and hepatic artery (on L)
What are the boundaries of the Foramen of Winslow? Anterior – portal triad, posterior – IVC, inferior – duodenum, superior – liver
Where is alkaline phosphatase located? canalicular membrane
What is the only water soluble vitamin stored in the liver? B12
Which hepatocytes are most sensitive to ischemia? Central lobular (acinar zone III)
What are the primary bile acids? cholic and chenodeoxycholic
What are the secondary bile acids? deoxycholic and lithocholic (dehydroxylated primary bile acids by bacteria in gut)
What is the main biliary phospholipid which solubilizes cholesterol and emulsifies fat in the intestine? Lecithin
Where is jaundice first evident? Under the tongue
Which hereditary hyperbilirubinemia is characterized by abnormal uptake and mildly high unconjugated bilirubin? Gilbert’s disease
Which hereditary hyperbilirubinemia is characterized by inability to conjugate and deficiency of glucuronyl transferase causing high unconjugated bilirubin and life-threatening disease? Crigler-Najjar disease
Which hereditary hyperbilirubinemia is characterized by immature glucuronyl transferase and unconjugated bilirubin? Physiologic jaundice of newborn
Which hereditary hyperbilirubinemia is characterized by deficiency in storage ability and high conjugated bilirubin? Rotor syndrome
Which hereditary hyperbilirubinemia is characterized by deficiency in secreation ability and high conjugated bilirubin levels? Dubin-Johnson syndrome
Which viral hepatitis cannot cause chronic hepatitis and hepatoma? Hepatitis A (but all viral agents can cause acute hepatitis and fulminant hepatic failure)
What is the most common viral hepatitis leading to liver transplant? Hepatitis C
What is the only DNA hepatitis virus? Hepatitis B
What is the treatment of hepatic encephalopathy? lactulose, limit protein <70g/day, branched chain AA, dopamine receptor agonists. Rule out SBP and GI bleed
What is the treatment for esophageal varices? sclerotherapy (90% effective), vasopressin, octreotide acutely, TIPS if refractory; nitro if CAD; propanolol may prevent rebleeding
What act as collaterals between the portal vein and the systemic venous system of the lower esophagus? Coronary veins
What are the indications for TIPS? protracted bleeding, progression of coagulopathy, refractory ascites, and visceral hypoperfusion
What is the cause of portal hypertension in children? extrahepatic thrombosis of portal vein
What is Budd-Chiari syndrome? Treatment? Occlusion of hepatic veins and IVC. Tx: portacaval shunt (needs to connect IVC above obstruction)
What is the treatment for hepatic adenoma? Hepatic adenoma is an indication for resection – 10% rupture/bleed + malignant potential (some texts say may trial stopping OCPs first for regression)
What is the difference between a hepatic adenoma and focal nodular hyperplasia on colloid scan? Hepatic adenomas do not have Kupffer cells, so have no uptake on sulfur colloid scan (cold), FNH will take up sulfur colloid
What is the treatment for hepatic hemangioma? Do nothing unless giant or symptomatic/consumptive
What is the treatment of focal nodular hyperplasia? Conservative treatment only, no malignancy risk, very unlikely to rupture
What is Kasabach-Merritt syndrome? Consumptive coagulopathy or CHF due to hemangioma - usually in infants
What is the treatment of liver amebic abscess? metronidazole, surgical only if free rupture
What is the treatment of hydatid cysts? Surgical resection with albendazole or mebendazole before and after
What is the work-up of hydatid cysts? Casoni skin test + Indirect hemagglutination. Do not aspirate (risk of anaphylactic shock)
What causes a maculopapular rash and increased eosinophils? Schistosomiasis
What is the treatment of schistosomiasis? praziquantal and control of variceal bleeding
What are the main risk factors for hepatocellular carcinoma? Alcoholism, Hep B+C, hemochromatosis, PSC, aflatoxin, alpha-1-antitrypsin deficiency - PBC and Wilson's are not risk factors
What type of HCC has best prognosis? Fibrolamellar (followed by clear cell and lymphocyte infiltrative)
What is the most potent risk factor for the development of HCC? hepatitis B surface antigen positivity
What are risk factors for hepatic sarcoma? PVC, thorotrast, arsenic
How does the gallbladder concentrate bile? Active absorption of Na, Cl (H20 then follows)
What is bile conjugated to? taurine and glycine
What are the boundaries of the triangle of Calot? cystic duct, hepatic duct, and cystic artery (some texts say liver edge)
What is the blood supply to the common bile duct? Right hepatic (lateral) and retroduodenal branches of GDA (medial)
What is the rate-limiting step in cholesterol formation? HMG CoA Reductase
What causes gallstones in obese people? In thin people? Obese – overactive HMG CoA reductase; thin – underactive 7-alpha-hydroxylase
What are the common causes of black gallstones? Cirrhosis, hemolytic disorders, chronic TPN, ileal resection
What type of stones are generally primary CBD stones, formed in ducts? Brown stones, caused by infection and subsequent deconjugation of bilirubin (E. coli most common)
What are the symptoms and treatment of cholangitis? Fever, RUQ pain, jaundice, +/- hypotension, MS changes. Needs immediate IV Abx, IVF, emergent decompressions/drainage of CBD
What is the 1 cause of benign biliary stricture?
What is the treatment of common bile duct strictures? Hepaticojejunostomy. If early symptoms (<7 days), perform immediately; if late symptoms, perform 6-8 weeks after injury
What is the triad of hemobilia? UGIB, RUQ pain, and jaundice - caused by fistula between biliary duct and hepatic arterial system
What is the treatment of hemobilia? workup and treatment with arteriogram
What is the treatment of gallbladder adenocarcinoma? Cholecystectomy adequate if confined to mucosa. If grossly visible tumor - regional lymphadenectomy, wedge segment V, skeletonize portal triad
What is the treatment of cholangiocarcinoma? Upper 1/3 (Klatskin) – lobectomy and stenting of contralateral duct if localized, but usually unresectable; middle 1/3 – hepaticojejunostomy; lower 1/3 – whipple
What is the medical treatment of primary sclerosing cholangitis? cholecystryramine, UDCA (urodeoxycholic acid)
What is the treatment of primary biliary cirrhosis? Liver transplant
What is Mirizzi syndrome? Compression and/or inflammation of common hepatic duct by a stone in the infundibulum of the gallbladder causing stricture and hepatic duct obstruction
What is the only pancreatic enzyme secreted in active form? amylase
Which pancreatic cells receive a majority of the blood supply related to size? Islet cells
What are the two types of pancreatic cells? Acinar cells (98% of mass) – exocrine function and islet cells – endocrine function
What makes up the majority of the islet cells in the pancreas? Insulin-producing B cells, located centrally make up 50-70% of the islet population
What do the delta cells of the pancreas produce? somatostatin
What are the signs of annular pancreas? Treatment? Double bubble on x-ray, prone to pancreatitis, possible obstruction. Treat obstruction with duodenojejunostomy, or duodenoduodenostomy and sphincteroplasty (do not resect pancreas)
What is the treatment of pancreas divisum? sphincteroplasty and stent placement if symptomatic (if long-standing, may need longitudinal pancreaticojejunostomy)
What is the pathophysiology of acute pancreatitis? impaired extrusion of zymogen granules and activation of degradation enzymes leading to autodigestion
What is ranson’s criteria? Admit – GA LAW – Glucose >200, AST >250, LDH >350, age >55, WBC >16k; 48 hours – C HOBBS – Calcium <8, Hct drop >10%, oxygen < 60 mm, BUN > 5, base deficit > 4, sequestration of fluid > 6L
When do you operate on pancreatitis? Only for infected pancreatitis, need to remove infected material, but generally leave sterile necrosis alone
What is the most important risk factor for necrotizing pancreatitis? Obesity
What complications of pancreatitis are caused by the release of phospholipases and proteases? phospholipases – ARDS and pancreatic/fat necrosis, proteases - coagulopathy
What is treatment of pancreatic pseudocyst? Expectant management initally - 85% resolve on their own; If persistent and symptomatic or growing - internal drainage by cyst-gastrostomy, -duodenostomy, or –jejunostomy
Which pancreatic cells are usually preserved in chronic pancreatitis? islet cells, whereas exocrine tissue gets calcified and fibrotic
What is the optimal treatment for bleeding gastric varices in chronic pancreatitis? Splenectomy (chronic pancreatitis is the most common cause of splenic vein thrombosis)
What is the number 1 risk factor for pancreatic adenocarcinoma? tobacco
What is effective pain relief for non-resectable pancreatic CA? Celiac plexus block (50% EtOH on both sides of aorta near celiac)
What % of nonfunctioning pancreatic tumors are malignant? 90%
What is the most common islet cell tumor in the pancreas? In MEN I? Insulinoma overall, gastrinoma in MEN I patients
What can help alleviate symptoms in a functional endocrine pancreatic tumor? Octreotide, debulking surgery. Chemotherapy – 5FU and streptozocin
What are the signs of an insulinoma? Treatment? Whipple's triad (symptoms of hypoglycemia, fasting glucose <45, improvement with glucose) Insulin to glucose ratio >0.4 Increased C-peptide and proinsulin; Tx = enucleation if <2cm, formally resect if >2cm (though 90% are benign)
What are the boundaries of the gastrinoma triangle? (1) cystic/CBD junction (2) 3rd part of the duodenum (3) neck of the pancreas
What are the signs of gastrinoma? Severe ulcer disease, diarrhea (lipase destruction by acid, malabsorption, increased secretion)
What test evaluates gastrinoma? Secretin stimulation test - normal patients will decrease gastrin after secretin, though a baseline serum gastrin level >1000 is virtually diagnostic
What is the best test for localizing a gastrinoma? Somatostatin receptor scintigraphy
What are the symptoms of a somatostatinoma? gallstones steatorrhea pancreatitis diabetes
What are the symptoms of a glucagonoma? Treatment? diabetes glossitis, DVT, stomatitis necrolytic migratory erythema (presenting problem in 70%) Rx = streptozocin/doxorubican (selectively destroy alpha cells) and octreotide (inhibits release), consider prophylactic anticoagulation
What are the symptoms of VIP-oma? WDHA syndrome = watery diarrhea hypokalemia achlorydia
Describe the basic anatomy and physiology of the spleen 85% red pulp – filter for RBCs, 15% white pulp – immunologic function (major site of bacterial clearance that lacks preexisting antibodies)
What are the effects of splenectomy on the immune system? decreased tuftsin, properidin, and fibronectin (non-specific opsonins), decreased IgM production - susceptible to encapsulated organisms
What % of patients does splenectomy improve: hereditary spherocytosis? ITP? 100% spherocytosis, 80% ITP
What is the treatment for TTP? plasmapheresis (primary), steroids, ASA; not splenectomy
What is the pathophysiology of ITP? Antiplatelet IgG originating in the spleen
For what condition is the risk of overwhelming postsplenectomy sepsis highest? Thalassemia (also high with malignancies)
What hematologic disease has the highest morbidity after splenectomy? Myeloid dysplasia
What vaccines are needed prior to splenectomy? Pneumococcus, meningococcus, H. influenzae
What are the operative indications for splenic cysts? Symptomatic or >10 cm
What is Felty’s syndrome? rheumatoid arthritis, hepatomegaly, splenomegaly; splenectomy if symptomatic splenomegaly
What is the most common type of Hodgkin’s disease? Best prognosis? Worst prognosis? Most common – nodular sclerosing, best – lymphocyte predominant, worst – lymphocyte depleted
What type of transplant is ABO blood compatibility not required for? Liver
What type of cell mediates graft vs host disease? T cells
What is the treatment for mild rejection? What about severe or secondary rejection? Mild – pulse steroids, severe = OKT3 or other drugs
What is the number 1 and 2 malignancies following any transplant? 1 = Skin cancer (squamous cell), 2 = Posttransplant lymphoproliferative disorder (PTLD) – EBV related – need to withdraw immunosuppresion
What is the mechanism of azathioprine (Imuran)? 6MP derivative, purine analog that acts as an antimetabolite, decreases DNA synthesis which inhibits T cells
What is the mechanism of mycophenolate (cellcept)? blocks purine synthesis to decrease T and B cell proliferation
How do steroids promote immunosuppresion? inhibit genes for cytokine synthesis (IL-1, IL-6) and from macrophages
What is the mechanism of cyclosporine? Calcineurin inhibitor – binds cyclophilin protein and inhibits mRNA encoding of IL-2, IL-3, IL-4
What is the mechanism of FK506 (Prograf / Tacrolimus)? Calcineurin inhibitor - binds FK binding protein, blocks IL-2 expressions/production from T cells, actions similar to cyclosporine but 10-100 times more potent
What is the mechanism of OKT3? Monoclonal antibodies that block antigen recognition function of T cells by binding CD3; interferes with both class I and II MHC
What is the mechanism of sirolimus (Rapamune)? mTOR inhibitor - inhibits the response of IL-2 thereby blocking the activation of T and B cells
What is the mechanism of Zenapax? Human monoclonal antibody against IL-2 receptors; used with induction and to treat rejection
What causes hyperacute rejection? pre-formed antibodies activate complement cascade and thrombosis of vessels occur
What test can identify patients who will develop hyperacute rejection? Crossmatch
What causes acute rejection? Due to HLA mismatch, foreign MHC antigens of graft cells activate host T cells
During what timeframe is acute rejection at highest risk to occur? 1 week to 3 months
What is the mechanism of chronic rejection? Fibrosis of blood vessels of transplanted tissue - loss of blood supply, partially a type IV hypersensitivity reaction
What is the number 1 complication of a kidney transplant? Urine leak – treat with drainage and stenting
What is the cause of post-op oliguria in a kidney transplant recipient? ATN
What does new proteinuria in a kidney transplant recipient suggest? Renal vein thrombosis
What is the empiric treatment for an increase in Cr in a kidney transplant recipient? U/S with duplex (to rule out vascular problem or ureteral obstruction) and biopsy; decrease CSA or FK (nephrotoxicity); pulse steroids
What are contraindications to liver transplant? Current alcohol abuse or acute ulcerative colitis
What disease is most likely to recur in new liver allograft? Hepatitis C – reinfects essentially all grafts
What is the treatment for a patient with hepatitis B undergoing liver transplant? HBIG (hep B immunoglobulin) and lamivudine (protease inhibitor) postoperatively
What is the number 1 predictor of primary nonfunction in a transplanted liver? Macrosteatosis – if 50% of cross section is macrosteatatic, there’s a 50% chance of primary nonfunction
What is the number 1 post-op complication of a liver transplant? Bile leak – treat with PTC tube and stent
What is the most common cause of biliary complications post transplant? Ischemia – check hepatic arterial flow
How does chronic rejection manifest in a liver transplant? Vanishing bile ducts
What donor vessels are needed for pancreatic transplant? Donor celiac and SMA for arterial supply, donor portal vein for venous drainage
What does a biopsy showing perivascular infiltrate with increased grades of myocyte inflammation and necrosis on a heart transplant patient suggest? Acute rejection
What is the number 1 cause of early mortality in lung transplant? Reperfusion injury
How long can you store a donor heart? Lungs? Kidney? Liver? Kidney = 48 hrs, Liver = 24 hours, Heart/Lungs = 6 hours
What is the number 1 viral infection post-transplant? CMV
Which risk is higher in patients on immunosupression: viral or bacterial infection? Viral > bacterial because immunosuppression is largely cellular and not humoral
What is the order of cells to a healing wound? Platelets, PMNs, macrophages (essential), fibroblasts (dominant by day 5), lymphocytes
What is the function of fibronectin? Chemotactic for macrophages; anchors fibroblasts
What is the most important factor in healing closed incisions? tensile strength – depends on collagen deposition and cross-linking of collagen
What is the strength layer of the bowel? submucosa
What is the most important factor in healing open wounds (secondary intention)? epithelial integrity – depends on granulation tissue, migration from wound edges
What cells provide wound contraction and are responsible for healing by secondary intention? Myofibroblasts
What is the primary collagen in a scar? Type I
When does a healing wound reach its maximum tensile strength? 8 weeks (but this is only 80% of original strength)
What is the time frame of collagen production in a wound? Begins day 3, max at day 21, then constant amount but more crosslinking, strength
What counteracts the effects of steroids on wound healing? Vitamin A
What is the principal collagen in a healing wound? Type III (this is the collagen of granulation tissue)
What type of collagen is low in Ehlers-Danlos syndrome? Type III
What is the defect in Marfan’s syndrome? fibrillin
What is the most common cause of leg ulcers? 90% are caused by venous insufficiency
At what point does chemotherapy have no effect on wound healing? Fourteen days
What is the cause of keloid scar? failure of collagen breakdown and increased collagen production
Which type of scar extends beyond original margins: keloid or hypertrophic? Keloid
What is the treatment for a hypertrophic or keloid scar? Both can benefit from steroids, silicone, and pressure dressings; keloid can also be treated with XRT
What is fetal wound healing characterized by? increased hyaluronic acid synthesis
Created by: jclanton82