Hemangioma Liver

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Q) True about management of hemangioma liver

a) All hemangioma more than 10 cm should be resected

b) OCPs and pregnancy should be avoided in young females as there is risk of rupture

c) Arterial embolization should be routinely done in large hemangiomas

d) If surgery is decided  hemangioma located at the periphery should be enucleated

Ans)d

Whatever the size there is no role of resection for asymptomatic hemangioma. Risk of rupture is very small and therefore there is no rationale for stopping OCPS, pregnancy or physical activities.

 Arterial embolization, which may be considered for temporary control of hemorrhage has limited success and is occasionally associated with morbidity

In symptomatic hemangioma liver resection is the treatment of choice, in peripheral tumors enucleation and in centrally placed tumors, formal resection should be done

REf Blumgart Surgery of liver 6th edition

 

Complications of Billroth 2 surgery

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Q) What is true regarding complications of billroth 2 surgery?

a) It has less complications than billroth 1 surgery

b) Recurrent ulceration is more common in the afferent limb as compared to efferent limb.

c) Afferent loop obstruction is more common after billroth 2 surgery

d) Billroth I operation is preferred in scarred duodenum

 

Answer c -

In billroth 2 surgery, afferent limb obstruction is more common

In surgery for benign gastric ulcers, billroth I reconstruction is the preferred choice. Billroth II surgery has problems of

  1. Retained antrum syndrome
  2. Afferent loop obstruction
  3. Duodenal stump leak (1-3%)

Billroth 2 surgery is done when there is

1. Inadequate mobility of the duodenum

2. Scarring of duodenum

Complications of gastric surgery
Complications of gastrectomy

  1. Nutritional and weight loss - Iron deficiency, Copper deficiency, Vit B12 , Anemia
  2. Delayed gastric emptying
  3. Roux statsis- Seen in roux en y loops-  Pain, nausea, vomiting, abdominal bloating
  4. Cholelithiasis-  Higher incidence in roux en y reconstruction as compared to B1 and B 2 gastrectomy
  5. Recurrent ulceration

Complications of Billroth 2 surgery

  1. Dumping syndrome
  2. Afferent loop obstruction - It can be minimized by keeping the length of afferent loop less than 20 cm and using a retrocloic approach.
  3. Bile reflux gastritis - More common with billroth I and billroth 2 surgery, incidence is decreasing after the use roux en y anastomosis

 

HCC Cancer

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Q) Which of the following is true about screening in hepatocellular carcinoma (HCC Cancer) 

a) Alpha feto protein should be done 6 monthly

b) Ultrasound abdomen should be done 6 monthly

c) Candidates for liver transplant should be screened every 3 months

d) Nodules more than 2 cm should be followed up  more regularly

Answer b

Cirrhosis is prone for development of HCC. Screeing has to be stringrnt.  Earlier ultrasound of liver and alpha feto protein were both used for screening

In 2009 Marrero et al demonstrated the suboptimal accuracy of AFP and after that it has been removed from the screening protocol and now only ultrasound is being done.

The screening recommendation is not for those patients with severe associated conditions and with advanced liver disease who are already considered for  transplant. So there is no screening for those who are already listed. Nodules more than 1 cm are highly suspicious where as in nodules less than 1 cm only 40% will be malignant.

Ref: blumgart 6th edition

 

 

Gall Bladder Cancer in setting of APBDJ

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Q) Gall bladder cancer arising in the setting of APBDJ , all are true except

a) It occurs in younger age

b) Prevalent in Asian countries

c) More common in males

d) Less often associated with Gall stones

Answer (free)
c)  It is more common in females

In APBDJ, pancreatic and biliary duct meet more than 15 mm away from the duodenal wall. APBDJ is seen more in asian countries and is associated as a cause of gall bladder cancer.

It is seen in younger age group

Most of the patients are females

Ref article- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658122/

Recurrent Pyogenic Cholangitis

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Q) Not true about  recurrent pyogenic cholangitis :

a) Mostly there are intrahepatic strictures with involvement of the left side duct

b) It can present as choledochoduodenal fistula

c) In it there is complete biliary obstruction which  leads to marked jaundice and pruritis

d) MRCP and other other cholangiography can be diagnostic

Answer c

In recurrent pyogenic cholangitis (RPC)  complete obstruction does not occur and jaundice and pruritis is not marked.  RPC is a disease commonly seen in young Asians (also known as oriental cholangiohepatitis) which leads to multiple strictures in extra or intrahepatic ducts.

Association with Ascaris lumbricoides and Clonorchis sinensis has been noted.

It can present as choledocholithiasis  with stricture, choledochoduodenal fistula, acute pancreatitis, secondary biliary cirrhosis and can lead to cholangiocarcinoma.

MRCP can be diagnostic and is preferred because of its non invasive nature.