Hepatobiliary Sx - Karnik

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What are the common hepatobiliary tumors of dogs & cats?

Hepatocellular
Cholangiocelluar
Mesnechymal
Neuroendrocrine
Metastatic (most common)

What is the #1 hepatobiliary tumor in the dog?

Hepatocellular

What is the #1 hepatobiliary tumor in the cat?

Cholangiocellular adenoma (hepatoma)

What is the #2 hepatobiliary tumor in the dog?

Cholangiocellular

What vessels are compressed in the pringle maneuver?

portal V. & hepatic A.A.

What is the #2 hepatobiliary tumor in the cat?

adenoma (hepatoma)

T/F primary hepatic neoplasms are common in the cat & dog

F

What is the prognosis for a hepatocellular adenocarinomas in the dog

Massive - good (mst 1460d)
Nodular - not so good
Diffuse - bad

What are the common sites of met. for a diffuse hepatocellular adenocarcinoma in the dog?

lungs, ln.n. & peritoneum

T/F Most diffuse hepatocellular adenocarcinomas are metastatic.

T (93-100%)

What is another name for cholangiocellular carcinomas?

bile duct carcinomas

What is the m.c. location for a hepatocellular tumor?

lt. lat & med. lobes

What are cholangiocellular tumors?

bile duct tumors

What is #2 primary malignant tumor in the dog?

cholangiocellular

What is the incidence of mets. of of a cholangiocellular tumor in the dog?

up to 88%

Where do cholangiocellular tumors m.c. met. to in the dog?

l.n.n. & lungs

From where do cholangiocellular tumors arise in the cat?

intrahepatic bile duct epithelium

What is the m.c. hepatobiliary tumor in the cat?

cholangiocellular

What type of tumor comprises >50% of the hepatobiliary tumors in the cat?

Adenoma

What are the 2 different types of hepatobiliary adenomas in the cat?

cystadenoma
choecystadenoma

What is the #1 malignant cholangiocellular tumor in the cat?

carcinoma

What is the incidence of met. for a cholangiocellular carcinoma in the cat?

67-80%

What is carcinomatosis?

Seeding of neoplastic cells to other surrounding viscera.
Can cause all of the other organs to fibrose together into a "ball of guts."

What type of tumor does carcinomatosis occur with?

Cholangiocellular carcinoma in the cat.

What structures are involved w/regard to extra hepatic biliary dz?

hepatic, cystic & bile ducts, as well as the gb

What lobes in the liver is the gb located between?

quadrate medially & rt. medial lobe laterally

What are 6 forms/types of extra hepatic biliary dz?

Cholecystitis
Biliary mucocele
Obstruction
Trauma
Neoplasia
Choledocholiths

Where does the dog's bile duct terminate?

@ the duodenum near the opening of the minor pancreatic duct.

What comprises the major duodenal papilla?

combined opening of the minor pancreatic duct & the bile duct.

What does the feline bile duct join prior to entering the duodenum? What does this make them susceptible to?

major pancreatic duct
makes them susceptible to ascending infection

Rupture of cholecystitis/cholangiohepatitis may result in _________ _________.

septic peritonitis

What is the medical txt for cholecystitis/cholangiohepatitis if there is no rupture?

treat for enteric organisms

What are the 4 m.c. enteric organisms?

E. coli
Klebsiella
Enterobacter
Anaerobes

What is the sx txt for cholecysitis/cholangiohepatitis?

assess extrahepatic biliary tree
cholecystectomy

What is the etiopathogenesis of a biliary mucocele?

unclear but could be d/t:
hyperplasia of mucus-secreting cells & excessive mucus secretion OR
alterations in gb motility OR
accumulation of inspissated bile OR
overdistension of gb can result in rupture
may/may not have cholecystitis

Is overdistension of the gb grossly or histologically evident?

grossly ~50% of clinical cases
histologically present in >70%

How do you manage a biliary mucocele?

can try med. mgt w/fluids & cholorectics.

If a biliary mucocele isn't septic, how is it managed?

cholecystectomy &/or Abx.

During a cholecystectomy for a biliary mucocele, what do you need to confirm?

patentcy of bile duct.

How do you treat a biliary mucocele if the gb wall is viable?

cholecystoenterostomy

What is a laboratory result that may indicate rupture of a biliary mucocele?

increased venous lactate.

What are some biochemical abn. seen w/a biliary mucocele?

inreased: alk. phos.
ALT
GGT
total bilirubin

What are the diagnostic procedures to determine presence of a biliary mucocele?

survey rads & U/S

What would you expect to see on U/S of a biliary mucocele?

enlarged gb w/immobile echogenic bile
striated or stellate pattern ("Kiwi" sign)

What are the 5 possible causes of intraluminal biliary obstruction?

inflammatory dz
choleliths/choledocholiths
neoplasia
inspissated bile
parasites

What are the 2 possible causes of extraluminal biliary obstruction?

pancreatic dz
duodenal dz

What are 3 possible causes of bile peritonitis?

trauma
spontaneous rupture
iatrogenic

What is the more common cause of bile peritonitis?

bile duct trauma

Spontaneous rupture of the _________ can cause bile peritonitis

gallbladder

What are the tools used to diagnose bile peritonitis

abd. effusion --> pos. if abd. fl >/=2X serum
abdominocentesis: 4 quad tap
U/S guided aspirate
DPL

What is the most important prognostic factor in the mgmt of bile peritonitis?

Sterile bile vs. infected bile

What is sterile bile & what is the prog. for the pt. in this case?

sterile bile = chemical peritonitis
usu. well tolerated
prog. good if underlying cause eliminated

What is infected bile & what is the prog. for the pt. in this case?

infected bile = septic peritonitis
porg. fuarded/poor
morbidity & mortality are high

What are the 3 type of hepatic sx?

bx
partial lobectomy
complete lobectomy

What are the 3 biliary surgical methods?

cholecystotomy/cholecystectomy
bile duct exploration/reconstruction
biliary diversion

What are the 3 types of biliary diversion?

Cholecystoduodenostomy
Cholecystojejunostomy
Choledochoenterotomy

Which liver lobe should you bx if you suspect diffuse liver dz & why?

lt. lobe to avoid the main biliary structures

What are the 5 methods for harvesting a liver bx?

FNA
Tru-cut needles
Laparoscopic
Skin bx punch
Guillotine

What are the 3 surgical methods used when harvesting a liver bx w/a tru-cut needle?

U/S guided
Laparoscopy
Exploratory celiotomy

When would you use the FNA approach for harvesting a liver bx?

feline hepatic lipidosis

______ is an insensitive/unreliable method for harvesting a liver bx for diffuse dz & for those pts. th/may have congenital vascular shunts.

FNA

In what type of liver dz(s) is an FNA a useful diagnostic method?

diffuse hepatic neoplasia (lymphoscarcoma) & feline hepatic lipidosis

T/F There are substantial limitations of dx'ing hepatic dz in dogs & cats by percutaneous techniques

T

What must be determined before clinical illness d/t hepatic lipidosis can be dx'd?

th/there is sufficient fat in the hepatocytes to be causing hepatic dysfunction

Animals w/what c/s & clin. path. results shouldn't have a percutaneous bx d/t increased risk of uncontrollable hemorrhage?

clinical bleeding
severe thrombocytopenia
cavitary lesions
prolonged bleeding time
highly vascular lesions

What are the advantages to performing a laparoscopic bx?

can find lesions missed by U/S
better tissue samples taken
bx multiple liver lobes
can inspect entire abd.
quick (pt. dischgd within hours)

T/F If an animal has a coagulopathy, a laparoscopic bx is absolutely cx?

F

When would you use the guillotine technique to perform a liver bx?

when you are taking a bx of the hepatic margin

What add'l procedure should be routinely done during a laparoscopy in an animal known to have or suspected of having liver dz?

sx bx

Why should a sx bx be routinely done during a laparoscopy in an animal known to have or suspected of having liver dz?

it allows the entire liver to be thoroughly inspected & palpated & bx's taken of focal lesions
hemorrhage can be readily controlled

What are the 5 indications for a partial liver lobectomy?

bx
neoplasia
trauma
abscess
cysts

In what dz state could a partial liver lobectomy be indicated?

when the dz involves only a portion of a liver lobe such as a peripheral hepatic A-V fistulae, focal neoplasia, hepatic abscesses or trauma

What liver lobe bx technique generally results in the most blood loss?

parenchymal fx & ligation

What is an indication for a complete lobectomy?

some focal lesions involving 1 or 2 hepatic lobes

What 2 liver lobes maintain separation near the hilus more than other lobes?

Lt. lat & medial

What liver lobes can be removed using a single encircling ligature around the base of the lobe?

Lt. lat. & medial

What liver lobes require careful dissection around the hepatic caudal v.c.?

Rt. lat & caudate

How much of the liver can be removed & regeneration will still occur?

regen. possible even after 80% has been removed

T/F Liver lacerations must be sutured closed, even if the bleeding is minor

F (closed only when bleeding is profuse)

What artery in the liver can be ligated to control bleeding in an emergency.

proper hepatic A

How are complete fxs or sever contusions of the liver txtd?

hepatic lobectomy if ligation of hepatic A doesn't result in hemostatsis

What is the most common & serious complication regarding the stapling technique in the liver?

hemorrhage

What are the complications after major resection of the liver?

portal hyperT
ascites
fever
hemorrhage
persistent bile drainage

What is the m.c. indication for bile duct stenting?

most commonly done to relieve obstruction d/t extraluminal compression

What does bile duct stenting achieve?

obstruction d/t compression (most commonly)
temporarily diverts bile after suturing the bile duct

What are the 6 indications for a cholecystectomy?

necrotizing cholecystitis
chronic cholecystitis
biliary mucocele
cholelithiasis
neoplasia
trauma

What must be confirmed prior to performing a cholecystectomy?

patency of bile duct

How do you confirm patency of the bile duct?

squeeze the gb

What are the complications after a cholecystectomy?

bile peritonitis
bleeding

What are the causes of bile peritonitis following a cholecystectomy?

failure to adequately ligate the bile duct
failure to recognize & ligate small ducts entering cystic duct.

What is the cause of hemorrhage following a cholecystectomy

failure to ligate the cystic A

When is biliary diversion indicated?

Irreparable obstruction or trauma of the cbd w/o gb involvement

What are the options for biliary diversion?

Cholecystoduodenostomy
Cholecystojejunostomy
Choledochoenterotomy
Roux-en-Y (jejunal conduit betw. gb & duodenum or prox. jejunum)

What size does the stoma need to be for a cholecystoduodenostomy/cholecystojejunostomy? Why?

The initial size needs to be 2.5-3cm long to reduce the risk of the gb becoming impacted w/ingesta causing cholecystitis &/or cholangiohepatitis.

Due to the uncertainties regarding healing of the bile duct in the presence of infection, leakage or tension, what procedures are commonly performed rather than repair of the cbd?

draining procedures such as a cholecystojejunostomy

What are the common complications associated w/biliary diversion?

leakage
Cats: chronic vomiting
Dogs: ascending infections
bleeding @ stoma site

T/F Cats have a high mortality rate associated w/biliary diversion complications?

T (often assoc. w/underlying dz)

What are the potential complications associated w/a cholecystectomy?

generalized peritonitis
shock
sepsis
hypoglycemia
hypotproteinemic
hypokalemic

What are the potential complications associated w/sx of the cbd?

stricture
leakage
dehiscence

What are the potential complications associated w/biliary diversion?

ascending choangiohepatitis

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