Ch 31 Liver Flashcards
(164 cards)
1
Q
____ separates medial and lateral segments of left lobe and carries remnants of _____
A
falciform ligament; umbilical vein
2
Q
2 hepatic artery variants
A
- RHA off SMA (20%) behind pancreas, posterolateral to CBD
2. LHA off left gastric (20%) found in gastrohepatic ligament medially
3
Q
_____ carries the obliterated umbilical vein to the undersurface of the liver
A
ligamentum teres//extends from falciform
4
Q
________ line separates right and left lobes and extends from ____ to ____
A
Cantlie’s line or portal fissurel drawn from middle of gallbadder fossa to IVC
5
Q
L liver segments
A
I, II, III, IV
6
Q
R liver segments
A
V, VI, VII, VIII
7
Q
Describe location of L segments
A
4 medial (in center of liver)
2 and 3 lateral with 2 above 3
1 behind 4
8
Q
Describe location of R segments
A
5, 6, 7, 8 clockwise with 5 inferomedial/anterior to 6
*think of the liver as a mitered corner
9
Q
___ segment is the caudate lobe
A
I
10
Q
___ segment is the quadrate lobe
A
IV/Left medial
11
Q
____ covers the liver
A
glisson’s capsule/peritoneum
12
Q
_____ is a bare area not covered’ by glisson’s capsule
A
area on the posterior superior surface of liver
13
Q
_____ are the extensions of the coronary ligament that connect the liver to the ____ and are made of
A
right and left triangular; diaphragm; peritoneum
14
Q
the portal triad enters which segments?
A
IV and V
15
Q
the gallbladder lies under which segments?
A
IV and V
16
Q
_____are liver macrophages
A
Kupffer cells
17
Q
the portal triad includes ____ (3) and runs in the _______
A
cbd (lateral)
portal vein (posterior)
PHA (medial)
hepatoduodenal ligament/porta hepatis
18
Q
the _____ maneuver involves clamping the portal triad //caveat?
A
pringle maneuver
does not stop hepatic vein bleeding or IVC bleeding
19
Q
You do the pringle maneuver and then mobilize the R lobe. You see a rush of blood.
A
Injury to a hepatic vein likely
20
Q
You do the pringle maneuver and then mobilize the R lobe. You see a hematoma.
A
Injury to IVC likely –> pack the liver, sternotomy, Rummel tourniquet on IVC, repair vessel
21
Q
Structures in foramen of winslow
A
anterior - portal triad
posterior - ivc
inferior - duodenum
superior - liver
22
Q
what structures form the portal vein
A
smv and splenic vein (no valves) come together
imv enters the splenic vein
23
Q
portal veins/volume of flow/which segments
A
2 in liver; 2/3 of hepatic blood flow
L - segments II, III, IV
R - V, VI, VII, VIII
24
Q
What is the blood supply of the caudate?
A
separate right and left portal and arterial blood flow; drains directly into IVC with separate veins
25
Arterial and venous blood supply of the liver
R/L/MHA (mha branch of LHA)
R/L/MHV (mhv join LHV 80% before going to IVC/20% directly to IVC)
L - II,II, superior IV
M - inferior IV, V
R - VI, VII, VIII
26
Which vessel supplies most primary and secondary liver tumors
hepatic artery
27
_____ drains medial aspect of R lobe directly to IVC
accessory right hepatic veins (inferior phrenic veins also dump into IVC)
28
AlkPhos is normally released from the _____ membrane
canalicular
29
Nutrient uptake in the liver takes place in the ____ membrane
sinusoidal
30
___ is the usual source of energy for liver
ketones; glucose stored as glycogen/excess glucose converted to fat
31
where are vwf and factor VIII made?
vascular epithelium (not liver)
32
what is the only water soluble vitamin stored in liver
b12
33
most common problems with hepatic resection (2)
bile leak, bleeding
34
which hepatocytes are most susceptible to ischemia
central lobular (acinar zone III//by central veins)
35
maximum amt liver that can be safely resected
75%
36
Hgb downstream breakdown (3)
hgb, heme, biliverdin, bilirubin)
37
what improves water solubility of bilirubin and what molecule is implicated?
liver conjugation to glucoronic acid with glucoronyl transferase
38
Where does conjugated bilirubin go?
bile --> ileum --> bacterial breakdown in terminal ileum --> conversion to urobilinogen (colorless)-->
1/2 --> converted to stercobilin --> feces
1/2 --> absorped through PV --> circulation --> kidney releases in urine as (oxidized in circulation) urobilin (yellow) --> excess conjugated bilirubin turns urine cola dark (i.e. in biliary obstruction, cbili enters circulation and peed out)
39
Composition of bile
```
85% bile salts
proteins
lecithin (phospholipids)
cholesterol
bilirubin
```
40
_____ determines final bile composition/density
Na/K ATPase mediates reabsorption of water in gallbladder
41
Primary bile acids
cholic and chenodeoxycholic
42
Secondary bile acids
deoxycholic and lithocholic (dehydroxylated primary bile acids by bacteria in gut)
43
What improves the water solubility of bile salts?
conjugation to taurine and glycine
44
___ is the main biliary phospholipid
lecithin
45
Jaundice occurs at bilirubin > ___ and is first evident ___
2.5; under the tongue
46
Maximum bilirubin is ___ unless (3 conditions)
30; renal disease, hemolysis, bile duct-hepatic vein fistula
47
Causes of elevated unconjugated bilirubin
deficient/reduced hepatic uptake, deficiency in glucoronyl transferase, hemolysis/prehepatic
48
Causes of increased conjugated bilirubin
posthepatic biliary obstruction (stones, strictures, tumor), absence of gut bacteria (e.g. from abx)
49
What disease? abnormal conjugation; mild defect in glucoronyl transferase
Gilbert
50
What disease? inability to conjugate; severe deficiency of glucoronyl transferase, high unconjugated bilirubin, life threatening
Crigler-Najjar
51
What disease? immature glucoronyl transferase; high unconjugated bilirubin
physiologic jaundice of newborns
52
What disease? deficiency in storage; high conjugated bilirubin
Rotor's
53
What disease? deficiency in secretion; high conjugated bilirubin
Dubin-Johnson (black liver)
54
bilirubin encephalopathy is also known as
kernicterus --> common in crigler najjar prior to bililamps
55
Which hepatitis can cause acute hepatitis
All of them
56
Which hepatitis can cause fulminant hepatic failure
B,D,E (rare with A and C)
57
which hepatitis can cause chronic hepatitis
B,C,D
58
which hepatitis can cause chronic hepatoma
B,C,D
59
Hepatitis - RNA or DNA?
RNA except for B (DNA)
60
most common hepatitis leading to transplant
C
61
____ leads to fulminant hepatic failure in ___ trimester of pregnancy
hepatitis E in 3rd trimester
62
Hep B ab progression
infected: anti-HBc-IgM elevated in first six months and then IgG; HBsAg present
vaccination: elevated anti-HBs; no HBsAg
recovery: elevated anti-HBc and anti-HBs; no HBsAg
63
Most common cause of liver failure
cirrhosis
64
Best indicator of synthetic function in patient with cirrhosis
prothrombin time (PT)
65
mortality rate in acute liver failure and main determinant
80%; course of encephalopathy
66
King's College Criteria for acetominophen induced ALF
ph6.5, creat >3.4, grade III/IV encephalopathy
67
King's College Criteria for non acetominophen induced ALF
INR>6.5
OR ANY 3 of:
age40, drug tox/undetermined etiology, jaundice >7days before encephalopathy, INR>3.5, bili >17
68
pathophys of hepatic encephalopathy
liver failure --> inability to metabolize --> buildup of ammonia, mercatanes and false nt's
69
Differential for encephalopathy
liver, gi bleed, infection (SBP), electrolyte, drugs
70
Tx and functions of hepatic encephalopathy
1. lactulose (titrate to 2-3 stools/day) - removes gut bacteria, acidifies colon (prevents NH3 uptake by converting to ammonium)
2. limit protein intake (
71
Mechanism of cirrhosis
hepatocyte destruction --> fibrosis and scarring of liver --> increased hepatic pressure --> portal venous congestion --> lymphatic overload --> leakage of splanchnic and hepatic lymph into peritoneum --> ascites
72
Albumin replacement for paracentesis
1 g for every 100 cc removed
73
Tx of ascites
water restriction (1-1.5 L/day)
salt restriction (1-2g/day)
diuretics (spironolactone counterats hyperaldo seen in liver failure)
paracentesis
TIPS
prophylactic abx for sbp (norfloxacin if previous SBP or current UGI bleed)
74
heptorenal syndrome findings and tx
progressive renal failure (sign of end stage liver disease); same lab findings as prerenal azotemia
Tx: stop diuretics, give volume, no good therapy other than liver txp
75
Likely cause of postpartum liver failure with ascites -DX and Tx
hepatic vein thrombosis (has an infectious component)
Dx: SMA arteriogram with venous phase contrast
Tx: heparin and abx
76
Findings in SBP
fever, abdominal pain
| PMN>250 in fluid, positive cultures
77
Causes of SBP
ecoli > pneumococci >streptococci
78
Concern for SBP but with multiple species
--> probably bowel perforation (SBP typically monoorganism)
79
Tx of SBP and response time
3rd gen cephalosporin --> response within 48 hours
80
How do esophageal varices bleed?
rupture
81
Tx of varices
tx: banding and sclerotherapy (95% effective)
temporize:
1. vasopressin (splanchnic artery constriction)
2. octreotide (reduce portal pressure)
prevent rebleed: propanolol
82
Concern with vasopressin for treating varices
hx of CAD should not receive NTG while on vasopressin
83
Tx of refractory variceal bleeding
TIPS
84
Framework and differential for portal hypertension
pre-sinusoidal: schisto, congenital hepatic fibrosis, portal vein thrombosis (50% of phtn in kids)
sinusoidal: cirrhosis
post sinusoidal obstruction: budd chiari, constrictive pericarditis, CHF
85
Normal portal vein pressure
86
_____ act like collaterals between portal vein and systemic azygous vein
coronary veins
87
major cause of portal htn in children
extrahepatic portal vein thrombosis; most common cause of massive hematemesis in children
88
Consequences of portal hypertension
esophageal varices, ascites, splenomegaly, hepatic encephalopathy
89
indications for TIPS
protracted bleeding, progression of coagulopathy, visceral hypoperfusion, refractory ascites
90
Complication of TIPS
development of encephalopathy
91
Describe TIPS
transjugular intrahepatic portosystemic shunt
catheter in hepatic vein via jugular vein.
needle passed through to a major portal vein branch, dilated with angioplasty and then stent
92
_____ shunts can worsen ascites but reduce _____.
Splenorenal; encephalopathy
93
Indication for splenorenal shunt
Child's A with bleeding as only symptom --> this shunt is more durable; otherwise tips
94
Indication for TIPS
Child's B or C with shunt indication
95
How does Child's score correlate with mortality
only after open shunt placement
A: 2% mortality with shunt
B: 10% mortality with shunt
C: 50% mortality with shunt
96
Child's A score
5-6
97
Child's B score
7-9
98
Child's C score
>9
99
Child's components
PT/INR, albumin, bilirubin, ascites, encephalopathy
"pour another beer at eleven"
100
Dx and Tx of budd chiari syndrome
occlusion of hepatic veins or ivc
dx: angiogram with venous phase, CT angio
tx: portocaval shunt (need to connect to IVC above obstruction)
101
Symptoms of budd-chiari
ruq pain, hsm, ascites, fulminant hepatic failure, muscle wasting, variceal bleeding
102
____ can lead to isolated gastric varices without elevation of pressure in rest of the portal system
splenic vein thrombosis
*these varices can bleed
103
Most common cause of splenic vein thrombosis
pancreatitis
104
Tx of splenic vein thrombosis
splenectomy if symptomatic
105
Amoebic abscess: labs, location, primary infection
increased WBC, LFTs with + serology for entamoeba histolyica usually single in right lobe; primary infection = amebic colitis
106
risk factors for amoebic abscess
travel to mexico (fecal/oral), etoh
107
____% of those with + entamoeba serology have infection
90
108
Amebic abscess: clinical features
jaundice, hepatomegaly, fever, chills, RUQ pain
109
Amoebas reach the liver via ____
portal veinydatid cyst
110
Culture finding in amoebic abscess
culture negative --.> protozoa only exist in peripheral rim
111
Dx of amoebic abscess
ct
112
Tx amoebic abscess
flagyl, aspiration only if refractory, surgery only if free rupture
113
Hydatid cyst caused by ___ and tends to be in ___ lobe
echinococcus; R
114
Dx of hydatid cyst
+ casoni skin test, + serology, CT
115
CT findings in hydatid cyst
ectocyst (calcified) and endocyst (double walled cyst)
116
Echnococcus carrier is ____ and transmitted to humans via _____
sheep; dogs
117
Tx of hydatid cyst
preop albendazole (2 weeks) then intra op alcohol injection to kill organisms, aspirate, then need to get cyst wall
118
Why not aspirate hydatid cyst percutaneously?
spillage of cyst contents will cause anaphylactic shock
119
What preop mgmt for hydatid cyst?
1. 2 weeks preop albendazole
| 2. preop ERCP for jaudnice, increased lft, cholangitis to check for biliary communication
120
Primary infection in schisto and findings at primary site
sigmoid colon --> fine granulation tissue, petechaie, ulcers
121
Tx of schisto
praziquantel and control of variceal bleeding
122
Clinical findings in schisto
maculopapular rash, increased eosinophils
123
80% of liver abscesses
pyogenic
124
symptoms of pyogenic abscess
fever, chills, weight loss, ruq pain, increased lfts, increased wbc, sepsis
125
pyogenic abscess mortality
15% with sepsis
126
pyogenic abscess location
increased in r lobe
127
most common organism in pyogenic abscess
gnr - ecoli
128
etiology of pyogenic abscess
typically secondary to contiguous infection from biliary tract
also from bacteremia from other infections (appendicitis, diverticulitis)
129
Dx of pyogenic abscess
aspiration
130
Tx of pyogenic abscess
ct guided drainage and antibiotics; surgical drainage for unstable condition and continued signs of sepsis
131
4 benign liver tumors
adenomas, focal nodular hyperplasia, hemangiomas, solitary cysts
132
Risk factors for hepatic adenoma
women, steroid use, ocps
133
Symptoms of hepatic adenoma
80% symptomatic
20% risk of significant bleeding/rupture
symptoms: pain, hemodynamic instability (from rupture) palpable mass
134
Malignant potential of hepatic adenoma
possible transformation
135
Dx of hepatic adenoma
no kupffer cells in adenomas thus no uptake on sulfur colloid scan (cold); MRI shows hypervascular tumor
136
Tx of hepatic adenoma
asymptomatic: stop ocps, if regression no more therapy; if no regression, resection
symptomatic: tumor resection for bleeding and malignancy risk; embolization for multiple and unresectable
137
location of hepatic adenoma
R lobe preference
138
lab findings in hepatic adenoma
elevated lfts
139
focal nodular hyperplasia has a _____ sign that may look like cancer
central stellate star
140
malignancy risk of focal nodular hyperplasia
none and unlikely to rupture
141
Dx focal nodular hyperplasia
ct scan; has kupffer cells so will take up sulfur colloid on scan; mri/ct shows hypervascular tumor
142
Tx focal nodular hyperplasia
conservative therapy
143
Most common benign hepatic tumor
hemangioma
144
hemangioma rupture risk
low; more in women
145
Dx hemangioma
don't biopsy --> rupture
| MRI/CT show peripheral to central enhancement of hypervascular lesion
146
Tx hemangioma
conservative unless symptomatic, then surgery +/- preop embolization; steroids (possible XRT) for unresectable disease
147
Rare complications of hemangioma (2)
consumptive coagulopathy (kasabach merritt), CHF --> both typically in children
148
Solitary cysts are msot common in ____ location in ____ population and are unique because ____
R lobe; women; blue hue
149
Tx of solitary hepatic cysts
leave alone
150
Metastasis:primary ratio in liver tumor
20:1
151
Most common cancer worldwide
hcc
152
risk factors for hcc
hep B (#1), hepC, etoh, hemochromatosis, alpha1antitrypsin deficiency, psc, aflatoxin, hepatic adenoma, steroid, pesticide
153
primary hepatic diseases that are not risk factors for hcc
wilsons and pbc
154
3 types of hcc with best prognosis
clear cell, lymphocyte infiltrative, fibrolamellar (adolescents and young adults)
155
____ correlates with tumor size in hcc
afp level
156
hcc survival rate with resection
30% at 5 years
157
why can we not resect many hepatic tumors
cirrhosis; portohepatic involvement; metastases
158
margin for hcc
1 cm
159
tumor recurrence of hcc is most likely in ____ after resection
liver
160
risk factors hepatic sarcoma
pvc, thorotrast, arsenic --> rapidly fatal
161
management of colon CA mets to liver
resect if can leave sufficient liver
162
survival of colon CA met resection in liver
35% @ 5 years after resection
163
Vascularity of malignant liver tumors
```
primary = hyper
met = hypo
```
164
Recess of liver from which accessory bile ducts (e.g. luschka) communicate with gallbladder
Rouviere's Sulcus aka incisura hepatis dextra, Gans incisura
