Hepatobiliary

• R hepatic artery off SMA in 17%. Left hepatic off left gastric artery in 10%
• Kupffer cells: clear portal blood, immunosurveillance
• Portal Triad: portal vein posterior to CBD (on right) and hepatic artery (on left)
• Portal Vein = SMV + splenic vein (IMV joins splenic first). Portal system has no valves
• Hepatorenal syndrome: see low urinary Na
• Cholangitis: jaundice, RUQ tenderness, fever, hypotension, change mental status; Need immediate IV abx, fluid resuscitation and emergent drainage of CBD
• Retained CBD stone indentified on T-Tube cholangiogram 6 weeks post op best managed by radiologic stone retrieval
• Benign biliary stricture: #1 cause is iatrogenic (lap chole)
• Gallbladder adenocarcinoma: 90% have stones. Cholecystectomy adequate if confined to mucosa. If grossly visible tumor, do regional lymphadenectomy, wedge segment V, skeletonize portal triad
• Porcelain gallbladder = 30-65% risk of cancer. Cholecystectomy indicated
• Hematobilia triad = gi bleed, jaundice, RUQ pain. Workup (and RX) with arteriogram
• Gallbladder concentrates bile by active absorption of Na, Cl (H2O then follows)
• Normal gallbladder ejection fraction is >35%. Less is biliary dyskinesia, indication for lap chole
• Hepatic adenoma: 10% rupture/bleed; have malignant potential; 'cold' on liver scan. Hepatic adenoma is an indication for resection
• Hepatic hemangioma: do nothing unless giant or symptomatic/consumptive. Kasabach Merritt syndrome: consumptive coagulopathy or CHF due to hemangioma
• Amebic Abscess (anchovy paste) Rx metronidazole, not surgical
• Hydatid = Echinococcal cyst: + Casoni skin test, + indirect hemaglutination; resect (pericystectomy)
• Hepatocelluar CA #1 worldwide. May have high alpha-fetalprotein. Chronic Hep B and C is #1 cause; also associated with any cirrhosis (EtOH, hemochromatosis, primary biliary cirrhosis, alpha-1 antitrypsin deficiency), clonorchis sinensis (flukes), aflatoxins. Fibrolamellar variant has better prognosis

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