A 32 yo woman is being evaluated in the ED following a MVC. She was the driver and was wearing a seatbelt. She skidded off the road and hit a tree. She did not lose consciousness. She has mild abd pain but is hemodynamically stable. A contrast-enhanced CT scan of the abd shows a 12cm mass in the right lobe of the liver w/ progressive peripheral-to-central prominent enhancement and a central hypodense region. There is no extravasation of contrast. The most appropriate recommendation for her would be:
An 83 yo man is seen in clinic to discuss further cancer management. He has a hx of rectal carcinoma, tx w/ neoadjuvant chemo/ZRT and surgery 3yrs ago. He has been feeling well and is very active, but there has been a recent increase in his CEA to 21. The initial w/u for recurrent/met carcinoma and 4 hepatic lesions were found. On imaging, MRI and PET scan, these lesions are consistent w/ hepatic colorectal mets and no other lesions are found. What is the next step in this pt’s management?
Evaluation for surgical resection
A 56yo man w/ hx of Hep C infxn is seen in clinic to discuss tx for a 7cm mass seen on u/s of the liver. An MRI of the liver, performed w/ gadolinium, shows a mass in segment 3 w/ arterial enhancement and ring-type enhancement on delayed images. The liver is not cirrhotic in appearance, and a recent bx of the non-tumor portion of the liver showed only mild fibrosis. The best tx for this pt is:
A 72 yo man w/ known advanced cirrhosis is brought to the ED by ambulance after vomiting large quantity of blood. The pt has known portal HTN and has undergone endoscopic banding of esophageal varices in the past. He is admitted to the ICU and medical therapy is initiated. Endoscopy is performed and shows bleeding from the gastric varices which are not able to be treated with banding. Which of the following would be the most appropriate next step in the management of this pt?
Transjugular intrahepatic portacaval shunt
A 41 yo woman complains of recurrent nausea and bloating that does not seem to be related to eating. She has not traveled and has no pets. Her vital signs are stable and she is afebrile. There is mild tenderness in the RUQ. The rest of PE is normal. A RUQ u/s is done and reveals a 12x9x10cm right liver cystic lesion. The cystic lesion is found to have a thick wall and multiple septations within it. Select the correct combo of the most likely dx and most appropriate next step in management:
A 55 yo woman w/ known hep C cirrhosis and severe emphysema, requiring continuous O2, is admitted w/ abd pain and distention. W/u reveals ascites and pt is treated empirically for spontaneous bacteria peritonitis and her sxs do improve. Incidentally, on imaging, a 3x2x3cm lesion in the liver is found and is consistent with hepatocellular carcinoma. The patient is referred for eval for hepatic transplantation and was found to be not a candidate due to:
The severe pulmonary disease
A 24 yo man is in the surgical ICU for tx of injuries sustained in a MCV 2 days ago. At the time of admission he was stable w/normal vital signs and a GCS of 15. His main compliant was severe RUQ abd pain. A CT scan is obtained and reveals a grade III liver laceration, rib fxs, and right lower lung contusion. No free air or fluid is noted in the abd. Non-op management was elected. Now, the 2nd HD, he has 3 episodes of hematemesis. On exam his abd is b9 w/o any evidence of peritonitis. What is the most appropriate next step in management?
Interventional Radiology w/ selective hepatic artery embolization if a bleeding site is identified.
A 21 yo man is being evaluated in your trauma bay following a MVC 60min ago. He is stable w/ normal vital signs and a GCS of 15. His main compliant is of severe RUQ abd pain. A CT scan is obtained and reveals a grade III liver laceration, rib fractures, and a right lower lung contusion. No free air or fluid is noted in the abdomen. With respect to his liver injury, what is the most appropriate management?
Observation w/ close monitoring
A 33 yo woman is brought to the ED by her husband b/c of severe diffuse abd pain that began suddenly 2 hrs ago. She has otherwise been healthy. Her only med is oral contraceptive. Her initial vital signs were BP 90/60, P110, R20, and her abd was diffusely tender w/ rebound. Her vital signs improved to 110/70 and P90 after receiving rapid infusion of normal saline. A CT scan shows a 2cm solid hypodense lesion on the surface of the left liver w/ evidence of hemorrhage into the abd. Constast extravasation is thought to be seen. Select the correct combo of the most likely dx and most appropriate next step in management.
Hepatic adenoma, arterial embolization
10. A 60 yo woman w/chronic hep C is brought to an acute care clinic by her family b/c of increasing confusion.PE identifies jaundice, spider angiomata, and splenomegaly (VASE). Neurologic exam shows the pt to be lethargic; asterixis is present. Which of the following pharmacologic agents is most appropriate for tx of this condition?