LIVER

Question 1

Amebic liver abscess - bilirubin?

Answer 1

Usually normal

Question 2

Pyogenic liver abscess - bilirubin?

Answer 2

Usually elevated

Question 3

Pyogenic liver abscess vs amebic liver abscess - which causes left shift?

Answer 3

Pyogenic liver abscess

Question 4

Indications for prophylactic abx against SBP

Answer 4

1. Presence of GIB
2. Hx SBP
3. Ascitic protein <1.5 g/dL
4. Cr >1.2 (impaired renal function)
5. BUN >25
6. Serum Na <130
7. Bilirubin >3
8. Child Pugh Score > 9

Question 5

Pathophysiology of SBP

Answer 5

Usually disturbance in gut flora –> overgrowth and extraintestinal dissemination of a specific organism (E. coli). Hepatic cirrhosis - predisposes patients to bacterial overgrowth due to altered small intestinal motility or hypochlorhydria (due to PPIs). In addition, pts with hepatic cirrhosis have increased intestinal permeability –> translocation of bacteria into mesenteric lymph nodes.

Question 6

Liver lesion on CT: well circumscribed, isoattenuated noncontrast. Mural and nodular enhancement with contrast

Answer 6

Biliary cystadenoma

Question 7

Liver lesion on CT: well circumscribed, homogenous. Centripetal enhancement and washout delayed phase

Answer 7

Hemangioma

Question 8

Liver lesion on MRI: well circumscribed, homogenous. T1 hypointense. T2: VERY hyperintense

Answer 8

Hemangioma

Question 9

Liver lesion on CT: hyperattenuated arterial phase (early enhancement), loss of contrast enhancement in delayed phase

Answer 9

Adenoma

Question 10

Liver lesion on MRI: Eovist (gadoxetic acid) NOT retained in delayed hepatobiliary phase

Answer 10

Adenoma

Question 11

MRI lesion (liver): eovist (gadoxetic acid) retention on delayed hepatobiliary phase

Answer 11

FNH

Question 12

Pre-hepatic portal HTN

Answer 12

portal vein thrombosis, splenic vein thrombosis, AVF

Question 13

Intra hepatic portal HTN

Answer 13

infiltrative liver diseases, cirrhosis, other fibrosing conditions, polycystic liver disease

Question 14

Post-hepatic portal HTN

Answer 14

Budd-Chiari, IVC webs and thrombosis, right heart failure

Question 15

Initial mgmt esophageal variceal hemorrhage

Answer 15

2 large bore IVs and rapoid transfusion, intubation
Transfusion target Hct 25-30% (over transfusion may worsen portal HTN)
Coagulopathy correction
Infusion with vasopressin in conjunction with nitroglycerin (to prevent ischemia)
Additional infusion with octreotide with PPIs

Question 16

After resuscitation initiated, next steps for esophageal varices

Answer 16

EGD - sclerotherapy, banding
If bleeding not controlled, balloon tamponade with Sengstaken-Blakemore tube or Minneosta tube (traction to compress GEJ). 50% rebleed rate

Question 17

Risk of esophageal varices bleeding (annual)

Answer 17

5-15%

Question 18

Tx for unresectable hepatocellular carcinoma

Answer 18

Atezolizumab + bevacizumab (better overall and progression free survival outcomes compared to sorafenib)

Question 19

How to dx amebic liver abscess

Answer 19

CT scan. Serum Abs will show it but it takes 7-10 days

Question 20

MELD score components

Answer 20

Bilirubin, creatinine, and INR (more recently, sodium)

Question 21

MELD exceptions

Answer 21

HCC, hepatopulmonary syndrome, portopulmonary HTN, familial amyloid polyneuropathy, primary hyperoxaluria, CF, hilar cholangioCA, hepatic a thrombosis (w/i 14 days of liver transplant)

Question 22

Stage I HCC

Answer 22

One nodule <2 cm; may be listed for liver txp but not receive exception points

Question 23

Stage II HCC

Answer 23

One nodule between 2-5 cm OR 2-3 nodules, none > 3 cm. At 6 months after dx/listing, MELD exception score of 28.

Question 24

Stage III HCC

Answer 24

One nodule >5 cm or 2-3 nodules with at least one >3 cm. Do NOT receive standard MELD exception.

Question 25

Stage IV HCC

Answer 25

4+ nodules, gross involvement of portal vein or hepatic vein, involvement of porta hepatis LN or metastatic disease. Do NOT receive MELD exception.

Question 26

Duration of anticoagulation in Budd Chiari

Answer 26

Lifelong

Question 27

What is the hepatic vein pressure gradient?

Answer 27

Gradient between wedged hepatic vein pressure and free hepatic vein pressure. If >6 mmHg, portal HTN diagnosed.

Question 28

MC primary malignant liver tumor in children

Answer 28

Hepatoblastoma

Question 29

Future liver remnant in cirrhotics

Answer 29

FLR > 40%

Question 30

Risk of transformation to malignancy in hepatic adenomas

Answer 30

5% (probably less)

Question 31

MCC SBP (bacteria)

Answer 31

E coli

Question 32

Order of vessel ligation in R hepatectomy

Answer 32

hepatic a --> portal v --> hepatic v

Question 33

5 steps of R hepatectomy

Answer 33

1. mobilization of liver 2. chole + cannulation of cystic duct 3. isolating and control of vascular structures with vessel loops 4. Ligation of hepatic a, portal v then hepatic v 5. division of hepatic parenchyma

Question 34

Treatment of advanced (unresectable) HCC with improved survival and progression free survival

Answer 34

Atezolizumab + bevacizumab

Question 35

Locations for varices

Answer 35

GE collaterals (intercostal, diaphragmatic, esophageal) Hemorrhoids (middle and inf hemorrhoidal) Caput medusa (umbilical and abdominal wall) RP collaterals (L renal v)

Question 36

Preferred technique for live donor liver resection in pediatric transplan

Answer 36

Left lateral hepatectomy (segments II and III, with or without segment I)

Question 37

MRI findings hepatic hemangioma

Answer 37

HYPOintense on T1 HYPERintense on T2

Question 38

Which liver lesion contains Kupffer cells (sulfur colloid WILL show uptake)

Answer 38

FNH

Question 39

hepatic adenoma - Kupffer cells? (sulfur colloid WILL show uptake)?

Answer 39

No

Question 40

Which liver lesion is Eovist NOT retained in delayed HPB phase

Answer 40

ADENOMA

Question 41

Which liver lesion is Eovist RETAINED in delayed HPB phase

Answer 41

FNH