Liver Flashcards
(144 cards)
1
Q
What divides the right lobe of the liver?
A
The right hepatic vein divides the right lobe into anterior and posterior segments.
2
Q
What divides the liver into right and left lobes?
A
The middle hepatic vein divides the liver into right and left lobes. This plane runs from the inferior vena cava to the gallbladder fossa.
-Cantlie’s Line (imaginary): separates R & L lobes of the liver; line between gallbladder fossa and IVC
3
Q
How does the Falciform ligament divide the left lobe of the liver?
A
The Falciform ligament divides the left lobe into a medial segment (IV) and a lateral part (segments II and III).
4
Q
What supplies primary and secondary tumors of the liver?
A
Primary and secondary tumors of the liver are supplied by the hepatic artery.
5
Q
Where is the replaced right hepatic artery (RHA) most commonly located?
A
The replaced RHA from SMA is most commonly located behind the neck of the pancreas, posterior to the portal vein, and located posterior to the cystic duct.
6
Q
Where is the replaced left hepatic artery (LHA) typically found?
A
The replaced LHA from left gastric is typically found in the gastro-hepatic ligament (lesser omentum) medially.
-During foregut surgery, take care not to ligate a replaced left traveling in the gastrohepatic ligament.
7
Q
What segments do the hepatic veins correspond to?
A
Left: II, III and superior IV
Middle: V and inferior IV- represents an anatomical landmark and creates a resection plan for left and right hepatic resection
Right: VI, VII, VIII
3 hepatic veins -> drain into IVC
-Medial & left hepatic vein usually merge before draining into IVC
8
Q
What does the ligamentum teres carry?
A
The ligamentum teres carries the umbilical vein remnant.
9
Q
What is the rate limiting step for cholesterol synthesis?
A
HMGCoA reductase is the rate limiting step for cholesterol synthesis.
HMGCoA -> (HMGCoA reductase) -> cholesterol -> (7alpha-hydroxylase) -> bile salts
10
Q
What does bile contain?
A
Bile contains 80% bile acids, phospholipids (mainly lecithin), cholesterol, bilirubin, and proteins.
11
Q
How are primary bile acids conjugated?
A
Primary bile acids (cholic and chenodeoxycholic) are conjugated with taurine and glycine in hepatocytes -> improves water solubility -> secreted into bile -> goes into intestines
12
Q
Where are the majority of conjugated bile salts absorbed?
A
The majority of conjugated bile salts (80%) are absorbed using active transport in the terminal ileum.
Conjugated bile salts only absorbed in terminal ileum); the remainder are deconjugated by bacteria in the colon
Only 5 percent of bile acids escape enterohepatic circulation and end up in the stool
13
Q
What happens to deconjugated bile acids in the colon?
A
Deconjugated bile acids form secondary bile acids (deoxycholic and lithocholic) and are absorbed in the colon, returning to the liver.
14
Q
What is the serum to ascites albumin gradient (SAAG)?
A
SAAG is calculated as serum albumin minus ascites albumin; > 1.1 indicates portal hypertension.
15
Q
What is Budd-Chiari syndrome characterized by?
A
Budd-Chiari syndrome is characterized by a triad of ascites, RUQ pain, and hepatosplenomegaly. Also have Jaundice.
- Post sinusoidal portal HTN
- Classic CT in venous phase show hypertrophy of caudate lobe (that is brighter than the rest of segments) and inhomogeneous enhancement of whole liver
- Dx: Duplex-> No flow in hepatic veins
16
Q
What is the treatment for Budd-Chiari syndrome?
A
Acute treatment begins with heparin and percutaneous angioplasty +/- stent.
- There are rare reports of successful thrombolysis, however if used, it is only used in the ACUTE setting
- Subsequent treatment depends on the primary indication for intervention. If portal HTN then TIPS. If liver failure then liver transplant
- Patients will need lifelong anticoagulation
17
Q
What is the most common cause of cirrhosis worldwide?
A
The most common cause of cirrhosis worldwide is hepatitis B.
MCC of cirrhosis in US hepatitis C (likely) vs alcohol
18
Q
What is the most common indication for liver transplantation?
A
The most common indication for liver transplantation is hepatitis C but shifting to NASH
19
Q
What are the Milan criteria for liver transplantation for HCC?
A
Milan Criteria: Single lesion ≤ 5 cm or ≤ 3 lesions with largest < 3 cm with no metastasis.
20
Q
What is the treatment for simple liver cysts?
A
Simple liver cyst
- Homogenous, anechoic.
- No septations!
- If any thickening of cyst wall or nodularity, septations, loculations, papillary projections think CA not simple liver cyst
- Will not enhance on CT
Treatment is unroofing fenestration; only perform if symptomatic. Don’t do aspiration, recurs
21
Q
What is the most common symptom of hepatic cystadenoma?
A
The most common symptoms are anorexia and abdominal fullness.
Hepatic Cystadenoma
- They are CYSTS!!
- Have ovarian like stroma
- Pre-malignant can progress to cystadenocarcinoma
- Can be serous or mucinous
- If bloody worry about CA
- Dx: Imaging septations, papillary projections, thickened cyst wall = KEY.
- Tx: non-anatomic Surgical hepatectomy OR enucleation
o If it is cystadenocarcinoma hepatectomy!
22
Q
What is the treatment for cystic intrapapillary mucinous neoplasm of the bile duct?
A
Cystic intrapapillary mucinous neoplasm of the bile duct (Intrahepatic) - similar to ipmn of pancreas
- No ovarian like stroma
- High risk of CA
- Dx: Imaging same as above but have bile duct nodules
- Tx: Surgical hepatectomy. all need IOC.
23
Q
What is the classic CT finding for Entamoeba histolytica liver abscess?
A
Entamoeba hystolytica - Contaminated food
Mexico! Southeast Asia, Africa, India
Fecal oral route
Associated with alcoholics
amebic colitis 1st (diarrhea). Reaches liver via portal vein.
Anchovy paste appearance
More likely to only have a SINGLE abscess
Classic CT finding: fluid collection in right lobe with a THICK rim (enhancing) and peripheral edema
Cultures of the collection or stool usually DO NOT grow anything
Dx: CT, but BEST is ELISA combined with indirect hemagglutination
Tx: Flagyl. Aspiration if that fails. Surgery only for free rupture
24
Q
How does a pyogenic liver abscess differ from an amebic liver abscess?
A
Pyogenic liver abscess is more likely to have multiple abscesses, while amebic is more likely to have a single abscess.
- Rim enhancing on CT
- Will enhance on CT
- MCC is E. Coli and Klebsiella pneumoniae
Pyogenic abscess (most common, > 80%)
-2/2 biliary tract infection (E. coli MC), GI source (diverticulitis, appendicitis)
-Tx: percutaneous drain and antibiotics
25
What is the most common cause of pyogenic liver abscess?
E. Coli and Klebsiella pneumoniae.
26
What is the definitive host for Echinococcus (Hydatid disease)?
The dog is the definitive (primary) host, while sheep are the intermediate host.
27
What are the main causes of cystic disease in humans infected with Echinococcus?
Humans infected: fecal-oral
E. Granulosus and Vogeli.
Alveolar disease Multilocularis does not cause cyst See pseudotumor on CT all need formal hepatic resection
Dx: ELISA + CT. Casoni’s skin test is old gold standard
- Will see mural calcifications or daughter cysts
Pre-op ERCP if jaundiced can cause cholangitis
28
What is the diagnosis method for Echinococcus?
ELISA and CT. Casoni's skin test is an old gold standard.
29
What is the treatment for Echinococcus?
Preoperative albendazole, followed by aspiration, injection of a sclerosing agent, and surgical removal.
Now for large simple cyst: PAIR treatment with transhepatic drain, aspiration, then injection of hypertonic saline/alcohol recommended before surgery
30
What is the diagnosis for Schistosoma infection?
ELISA and eosinophilia.
Schistosoma – Presinusoidal normal liver, and LFT
Travel to africa
Can cause portal HTN and esophageal varices bleed without cirrhosis
See a maculopapular rash
31
What is the treatment for Schistosoma infection?
Praziquantel.
32
What imaging is best for benign liver lesions?
MRI is the best for all benign liver lesions.
33
What are the characteristics of a hepatic adenoma?
Hypervascular, homogeneous, no Kupfer cells, and no uptake on sulfur colloid.
Risk of rupture/bleeding and malignancy
34
What is the first step in managing a hepatic adenoma in women?
Stop OCP and weight loss, then get an MRI after 6 months.
- If persistently > 5 cm or if increase in size resection
- If < 5 cm and stable, or decrease in size to < 5 cm yearly MRI
- If found in a male ALL NEED to be resected regardless of size or symptoms. They have a high rate of malignant transformation
If not on OCP or steroids: resect
NEED FORMAL RESECTION with NEGATIVE MARGINS
-Rare; OCP & androgen steroid us; 10% malignant
-Rupture risk inc with size; > 5 cm= 30% risk spontaneous bleeding
-Pain, abdominal fullness, abnormal LFTs, bleeding from rupture
-Imaging:
-CT: arterial enhancement w washout on portal phase; smooth surface w tumor capsule; no central scar
-MRI: mildly hyperintense on T1 & T2
-Tx
-Small lesions= d/c OCPs, may regress
-Larger lesions (> 4 cm) or no regression after d/c OCPs= resect
-Ruptured -> IR embolization, recover, then resect in elective setting
-Negative sulfur colloid uptake = absent Kupffer cells, from hepatocytes -> adenoma
35
What is the treatment for a bleeding hepatic adenoma?
Angioembolization.
36
What is the treatment for a ruptured hepatic adenoma?
Definitive management is exploratory laparotomy with resection.
37
What are the imaging characteristics of a hepatic hemangioma?
CT arterial phase shows peripheral enhancement, centripetal filling in portal venous phase, with retention of contrast in delayed phase.
-Contrast MRI in T1 is hypointense, while T2 is strong hyperintense
-Can use tagged RBC scan to dx
-NOT associated with OCP, don’t need to stop OCP if asymptomatic
-Imaging follow up is not required because its benign
38
What is the treatment for symptomatic hepatic hemangioma?
Resection or enucleation.
Leave alone if asymptomatic
-If bleeding or ruptured: 1st line is angioembolization
- If kassabach merit syndrome: angioembolization or steroids and vincristine
Hemangioendothelioma (infants, liver hemangomia) can lead to Kasabach-Merritt syndrome
- Arteriovenous shunting causing CHF and consumptive thrombocytopenia. Can cause DIC
- Treatment Embolization and steroids
- Congenital papillary malformation (port of wine stain) pulsed dye laser
39
What is focal nodular hyperplasia characterized by?
- Hyperintense in arterial phase, hypodense central scar
-CT shows well demarcated lesion with rapid arterial enhancement and central scar.
- Venous phase, central scar is hyperintense
- T1 shows no attenuation of central scar, T2 shows hyperintense central scar
- Usually in periphery of liver
- Has Kupfer cells. Hot on sulfur colloid scan
- Caused by embryologic disturbance in liver blood flow
- Associated with OCP use
-The second most common liver tumor, benign, usually asymptomatic.
-2nd MC liver tumor, women 30-50 years old * Completely benign, usually asymptomatic
-Imaging
-CT: well demarcated; rapid arterial enhancement with central stellate scar
-MRI: hypointense with central scar on T1; isointense with hyperintense scar on T2
-Tx: none; no malignant potential, no bleeding risk
-Sulfur colloid uptake = functioning Kupffer cells -> FNH
40
What is the treatment for symptomatic focal nodular hyperplasia?
Resect only if symptomatic; no need for follow-up imaging. No need to stop OCP.
41
What is required for resection of colon cancer metastasis to the liver?
Needs a 1 cm margin with resection. Non-anatomical resection
- No evidence to suggest simultaneous liver and colon resection, colon resection 1st, or liver resection 1st superiority
- Simultaneous resection is best for young, favorable operative risk, who do not need major hepatic resection (lobectomy)
- If doing colon resection first, do liver resection after 8 weeks with repeat imaging 1st
- Prognostic indicator for survival after resection of hepatic-colorectal mets:
- Disease free survival > 12 months, negative margin, tumor number < 3, CEA < 200, size < 5 cm, negative nodes
Primary liver tumor – hypervascular. Metastatic hypovascular
Incidental colorectal CA mets to liver during colectomy for CA if amenable and curable with just wedge resection do it
- If needs formal resection just Bx it
42
What is the most common primary liver tumor?
Hepatocellular carcinoma (HCC)
43
What correlates with tumor size in hepatocellular carcinoma?
AFP (Alpha-fetoprotein) correlates with tumor size; higher levels indicate worse prognosis.
MC 2/2 to Chronic liver disease from hepatitis C, alcoholic liver disease and NASH
RFs: alcoholism, smoking, aflatoxin (from aspergillus, grains), nitrites, hydrocarbons, vinyl chloride, thorotrast, hemochromatosis
All patients with cirrhosis need surveillance US +/- AFP every 6 months to screen for HCC
- If there is a lesion >1 cm or AFP > 20 then this is a positive screen MRI or CT
MRI IS BEST, better than CT- rapid enhancement of homogenous poorly circumscribed mass with rapid wash out in portal venous phase and a psuedocapsule. Has necrotic areas
Diagnosis of HCC CAN be made with only CT/MRI in a patient WITH cirrhosis if the lesion is > 1 cm and consistent with HCC (don’t need biopsy). If doesn’t have cirrhosis, imaging CANNOT diagnose it need biopsy here
Need CT chest to rule out lung mets MC location of mets
44
What is the first-line treatment for Child A cirrhotic patients with HCC?
Hepatic resection.
-Anatomic resection is treatment of choice with 1 cm margin
-Resection only attempted if negative margin possible, no mets and no vascular invasion
45
What are the Milan criteria for liver transplantation in HCC?
Single lesion ≤ 5 cm or ≤ 3 lesions with the largest < 3 cm, with no nodes or metastasis.
-If NOT a TXP candidate, child A/B or no cirrhosis then: 1-2 tumors, all < 5 cm, no vascular invasion: Ablation
-If > 3 tumors or any > 5 cm, no vascular invasion: TACE, embolization. Embolization can also be used as bridge to transplant
-If NOT a TXP candidate, Child C: Supportive care
-Metastasis, extrahepatic spread or vascular invasion with preserved liver: sorafenib + transarterial chemo-embolization (TACE); improves survival in patients with non-curable HCC
External beam radiation therapy indicated: unresectable disease not amenable to ablation or TACE due to tumor location.
5-year surival is 65-90% after transplantation
46
What is the treatment for Child B or C cirrhosis or portal HTN with HCC?
First-line treatment is liver transplantation if the patient is a candidate. No alcohol, other cancers, etc and Milan criteria
47
What is the treatment for ruptured HCC?
Ligation of the hepatic artery and embolization; do not perform hepatectomy.
48
What is fibrolamellar carcinoma characterized by?
Occurs in younger patients (median age 25), usually without cirrhosis/hepatitis B/elevated AFP.
Associated with neurotensin levels
-Tumor has central scar area: hard to distinguish from FNH. But central scar does not enhance like FNH does in venous phase
-Prognosis better than HCC
49
What is the main cause of death in fulminant hepatic failure?
Cerebral edema and high intracranial pressure (ICP).
50
Correction of cirrhotic hyponatremia
Use tolvaptan (ADH antagonist) (improves mental health scores) OR spironolactone
51
Coronary veins in portal HTN
Coronary veins – act as collaterals between portal vein and systemic venous system (Azygmous/hemiazygous) of lower esophagus in portal HTN
52
Cirrhotics and branched chain amino acid
Give Cirrhotics branched chain amino acid: metabolized by skeletal muscle-> Decreases hepatic encephalopathy
53
Hepatorenal syndrome
Hepatorenal syndrome – vasodilation of splanchnic vessels, release Nitric oxide CO increases, SVR and MAP decreases renal vaso-constriction and activation of RAS decreases sodium secretion
Treatment
- Critically ill (ICU) levophed (or vasopressin) and albumin
- Not critically ill Terlipressin (vasopressin analog decreases splanchnic vasodilation) and albumin
o If terlipressin not available midodrine, octreotide, albumin
- If medical management fails the next step is: TIPS!!!!!!!! Not liver TXP
Hepatorenal syndrome type I – 2 fold increase in Cr > 2.5 in < 2 weeks with oliguria – very severe, leads to death
54
Umbilical hernia in cirrhotic
Umbilical hernia in cirrhotic with ascites should be repaired – Do not wait, these should be repaired electively
- Do not use mesh if patient has ascites
For elective cases with no overlying skin issues:
- Child Pugh A proceed with elective surgery
- Child B medically optimize first then surgery
- Child C contraindicated
If overlying skin is perforated, infected, or necrotic emergent repair regardless of Child Pugh score primary repair without mesh if patient has ascites
Surgery for both emergent and non-emergent:
- First thing to do preop is remove ascites Give albumin 1 gram for every 100 cc removed, use 25% (low salt) only
- If medical management of ascites fails pre-operatively the patient needs TIPS FIRST before surgery
- Alternative, if the patient is a liver transplant candidate, can repair at time of liver transplant
- Then fix coagulopathy
- Primary closure if infected or perforated
55
Vasopressin for esophageal varices, in a patient with angina
Also give nitroglycerin
56
Complication from esophageal varices banding/sclerotherapy
-Stricture
-Tx: dilation
57
Hepatic venous pressure gradient (HVPG)
Hepatic venous pressure gradient (HVPG) = difference in pressure in portal (wedge pressure) and systemic.
- > 5 = portal HTN. > 10 = clinically significant, > 12 = variceal bleeding may occur
- Normal HVPG – 3-4 mmHg
58
Predictors of variceal bleeding from portal HTN
- Liver stiffness measured by US < 20 kPa = low risk of variceal bleed
- Platelets > 150k = low risk of variceal bleed
- DO not need endoscopic screening for EV if you have above values
Every cirrhotic needs a baseline EGD to evaluate for EV
59
Post partum liver failure with ascites
Post partum liver failure with ascites from hepatic vein thrombosis from ovarian vein thrombophlebitis (pelvic thrombophlebitis)
- Has infectious and hypercoagulability component.
- RUQ pain, jaundice, ascites
- Ovarian vein thrombosis -> IVC thrombus formation
- Dx: CT angio with venous phase
- Tx: heparin AND abx
60
PV thrombosis
PV thrombosis can cause portal HTN and esophageal varices or ascites WITHOUT liver failure
- Presinusoidal portal HTN LFT are normal here
- Can occur after umbilical vein catheterization in children
- Can be caused by: pancreatitis, post splenectomy, trauma, cirrhosis
- MCC of massive Hematemesis in children
- Dx: duplex
- Tx: heparin (avoid if UGIB)
- Consider shunt after 1st bleed (spleno-renal, meso-caval or REX (SMV to left portal)
- DON’T DO TIPS, does not work here
61
Pyelophlebitis
Pyelophlebitis = infectious inflammation of portal system
- MC occurs after diverticulitis or appendicitis. In children occurs with omphalitis (umbilical cord)
- Sx: Fever and abdominal pain, can have liver abscesses
- Dx: CT shows air AND thrombus portal system.
- Tx: treat infection (appendectomy), abx, and heparin
62
Portal triad:
Portal triad:
-Common bile duct
-Proper hepatic artery (medial)
-Portal vein (posterior)
-Runs in hepatoduodenal ligament
63
-Anatomic liver segments
-Segments in liver resection:
-Anatomic liver segments:
-I = caudate lobe
-II-III = left lateral segments
-IV = left inferior anteromedial
-V = right inferior anteromedial
-VI-VII = right posterior lateral
-VIII = right superior anteromedial
-Segments in liver resection:
-Right= 5-8
-Left= 2-4 +/- caudate (1)
-Left lateral segmentectomy: 2-3
-Extended right: 5-8 + 4
-Extended left: 2-4 + 5 and 8
64
Liver Tumor Flow Chart
65
Systemic, portal, and collateral circulation
66
Comparison of image findings of benign liver lesions
67
What is the best method to prevent first bleed in large or medium size varices?
Endoscopic ligation is superior to beta-blockers for prevention. Best when combined.
68
What are the indications for TIPS?
Refractory bleeding, ascites, visceral hypoperfusion, hepato-renal syndrome, hepato-pulmonary syndrome, selective cases of Budd Chiari.
- Really good to use as a bridge for candidates of liver TXP who have refractory varices bleeding awaiting TXP
- Non-selective shunt
- Not meant for long term portal decompression
69
When is TIPS contraindicated?
Encephalopathy, PCOS, Caroli's disease, right heart failure, severe pulmonary hypertension, polycystic liver disease.
70
What is the risk of TIPS in patients with MELD >19 and Child C?
Significant risk of hepatic failure due to shunting blood away from the liver; these patients need liver transplantation.
71
In which Child classes is TIPS indicated?
TIPS is indicated for Child A or B.
72
What does prehepatic portal hypertension not relieved by TIPS indicate?
Portal vein thrombosis.
73
When are surgical shunts indicated?
For chronic and current bleeding when medical management and TIPS have failed or TIPS has thrombosed.
74
In which Child classes should surgical shunts be performed?
Only in Child A or B; never for Child C.
75
What is a selective shunt?
Decompresses the portal-azygous system while preserving portal inflow to the liver.
Decompress only part of the portal venous system; good for variceal bleeding but does not help ascites.
76
What is a distal splenorenal shunt and its contraindication?
Do not perform in patients with ascites as it worsens ascites.
o Has lower hepatic encephalopathy
o Used only for Child’s A cirrhotic with JUST BLEEDING
o Technically demanding, long operation, that is not well suited for emergent indications
o Best indicated for patients who need long term decompression, in a semi-elective manner, who are NOT candidates for TXP who have recurrent variceal bleeding (once bleeding has been medically controlled!!!!)
77
What is the Rex Recessus (Rex shunt) used for?
For children with portal vein thrombosis and refractory upper gastrointestinal bleeding.
SMV to left portal vein – reduces portal HTN and improves blood flow to liver
78
What are non-selective shunts?
Divert all portal flow away from the liver.
Most common type of nonselective portosystemic shunt: Side to side portocaval shunt.
-Divert flow from liver to caval system
- end-to-side portacaval shunts – rarely performed and only done in emergent settings
o Has unacceptably high hepatic encephalopathy, never done anymore
o Discouraged if patient is liver transplant candidate
- side to side portacaval shunts - rarely performed and only done in emergent settings
o Increases risk of liver failure and hepatic encephalopathy
o Discouraged if patient is liver transplant candidate
- Mesocaval shunt – SMV to IVC- rarely performed and only done in emergent settings
o Avoids dissection in porta hepatis can still do liver transplant after this
o Use H type shunt if wanting to bridge to liver TXP
All portosys¬temic shunts decrease gastroesophageal varices and reduce the risk of hemorrhage
79
What is the risk associated with end-to-side portacaval shunts?
Has unacceptably high hepatic encephalopathy; rarely performed.
80
What is the indication for mesocaval shunt?
To avoid dissection in porta hepatis; can still do liver transplant after this.
81
What is the purpose of LeVeen or Denver shunt?
Used for ascites.
LeVeen or Denver shunt = peritoneovenous shunt used for ascites
- Complications - DIC
82
What are the contraindications for LeVeen or Denver shunt?
Severe liver failure, previous spontaneous bacterial peritonitis, previous variceal bleed, coagulopathy.
83
What condition is splenic vein thrombosis associated with?
Sinistral portal hypertension.
84
What is the MELD score threshold for elective surgery?
Most elective surgery is OK for Child A and B only.
85
What is the MELD score threshold for liver resection?
MELD > 9 indicates no liver resection due to 20% mortality risk.
Liver resection only for child A only
86
What is the MELD score threshold for elective general surgery?
MELD > 15 indicates no elective general surgery.
87
What is the MELD score threshold for TIPS?
MELD > 19 indicates no TIPS.
Portal vein embolization only for Child A
TIPS for Child A or B only
Surgical shunt ok for Child A and B
88
What is the significance of indocyanine green retention in plasma at 15 minutes?
Major resection of HCC should not be performed if it exceeds 15% in cirrhotic patients.
89
What are hepatic stellate cells (Ito cells) responsible for?
They are the principal mediators of fibrosis leading to cirrhosis.
90
What defines acute liver failure?
Encephalopathy, jaundice, coagulopathy (INR > 1.5), elevated liver function tests.
Note does not have portal hypertensive bleeding
91
What defines fulminant liver failure?
Encephalopathy (cerebral edema) and liver injury with an inciting event < 8 weeks.
Note does not have portal hypertensive bleeding
Chronic liver failure = no cerebral edema
92
What are the indications for liver transplantation?
Acute failure, end-stage liver disease, hepatocellular carcinoma, cholangiocarcinoma, metastatic neuroendocrine tumor.
Indications in chronic liver disease:
- Hepatic encephalopathy
- High bili with intractable pruritus
- Portal HTN (bleeding, ascites, varices, hypersplenism)
- Coagulopathy
- Poor quality of life, failure to thrive
93
What are the criteria for liver transplantation in acute liver failure?
King's College criteria.
94
What are the contraindications to liver transplantation?
Active substance abuse, sepsis, extra-hepatic cancer.
95
What is polycystic liver disease associated with?
Autosomal dominant inheritance; seen with polycystic kidney disease 95% of the time.
- Most asymptomatic.
- Tx: leave alone unless symptomatic then laparoscopic fenestration is BEST
- Definitive tx is liver transplant. Combined liver/kidney required in 40%
- Avoid OCP (estrogen) will cause it to grow - Stop OCP if using it
96
What should be avoided in polycystic liver disease?
Oral contraceptive pills (estrogen) as they can cause it to grow.
97
What are the contraindications to liver resection in HCC?
Child B/C, portal hypertension, esophageal varices, ascites, metastasis, insufficient liver remnant.
98
What is the purpose of pre-operative portal vein embolization prior to hepatic resection?
Used to increase the size of the remnant liver after resection.
- Portal vein embolization OK in Child A, contraindicated in B/C
- MC used for right hepatectomy and extended right (trisegmentectomy). So embolize right.
- Left and extended left does not require this because it leaves enough behind
75% of normal liver (Right trisegmentectomy) can be safely resected without liver failure.
Diagnostic laparoscopy 1st
99
What is the peak hypertrophy time after portal vein embolization?
Hypertrophy peaks at 2 weeks but is reassessed in 4 weeks.
100
What is the minimum liver remnant required in healthy liver and cirrhosis?
At least 20% in healthy liver; at least 40% in cirrhosis.
101
What is the risk factor for mortality after liver resection?
MELD > 9 is the number one risk factor.
Also: portal HTN
102
What defines portal hypertension?
Portosystemic venous collaterals, ascites, hepatic encephalopathy, splenomegaly.
103
What is portal hypertension indicated by?
Hepatic vein pressure gradient (HVPG) > 6 mmHg.
104
What HVPG is required for variceal rupture?
HVPG of 12 mmHg.
105
What is the Child-Turcotte-Pugh score based on?
Bilirubin, albumin, prothrombin time, encephalopathy, ascites.
106
What is the MELD score based on?
Bilirubin, INR, creatinine.
107
What is the MELD score at which patients have a survival benefit for transplantation?
MELD score of 15.
108
What are the sites of increased portal resistance in portal hypertension?
Presinusoidal (schistosomiasis), sinusoidal (alcoholic cirrhosis, viral hepatitis), postsinusoidal (Budd-Chiari syndrome).
-Both presinusoidal and sinusoidal elements: primary biliary cirrhosis
109
What are the sites of collateral circulation in portal hypertension?
-Sites of collateral circulation: where splanchnic venous system meets systemic drainage
-Distal esophagus/proximal stomach: esophageal submucosal veins to proximal gastric veins
-Rectum: IMV to pudendal vein
-Umbilicus: vestigial umbilical vein to left portal vein
-Retroperitoneum: mesenteric and ovarian veins
110
What is the management for acute portal hypertension?
-Splanchnic vasoconstrictors in acute setting = vasopressin, octreotide
-Non-selective beta-blockers for prophylaxis = nadolol, propranolol
-Endoscopic variceal banding
-Transjugular intrahepatic portosystemic shunt (TIPS): acute or recurrent variceal bleeding, refractory ascites, Budd-Chiari syndrome, hepatic hydrothorax
111
What is the management of acute esophageal variceal bleeding?
Resuscitate, transfuse, antibiotics, intubation for airway protection, octreotide, endoscopic treatment, TIPS if uncontrolled uncontrolled (balloon tamponade temporizing measure)
-If rebleed after initial endoscopic control: 2nd endoscopy -> consider TIPS
112
What are the surgical options for portal hypertension?
-Gastroesophageal devascularization: patients with extensive portal venous thrombosis and no portosystemic shunt options
-Esophageal transection with division and anastomosis: rarely used since TIPS
-Devascularization procedures: total devascularization of the greater curvature and upper 2/3rd of the lesser curvature and circumferential devascularization of the lower 7.5 cm of the esophagus
-Portosystemic shunts
-Selective shunts (e.g. distal splenorenal or “Warren” shunt)
-Decompress only part of portal venous system
-Good for variceal bleeding but does not help ascites
-Partial portosystemic shunts
-Type of side to side shunt where flow is calibrated by the size of the synthetic interposition graft placed between the portal vein and vena cava
-Nonselective portosystemic shunts= ascites
-Decompress the entire portal venous system
-Side to side portocaval shunt is most common
-High rate of encephalopathy and complicate later liver transplant
113
What is the difference between selective and non-selective portosystemic shunts?
Selective shunts decompress part of the portal venous system; non-selective decompress the entire system.
114
What is the management for umbilical hernias in a cirrhotic with ascites?
Ideally elective repair after medically controlling ascites; urgent repair for complicated cases.
-Ideally elective (use mesh); medically control ascites first -> reduce recurrence wound infection, evisceration, ascites drainage, peritonitis
-If refrac to meds: intermittent paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt
-If transplant eligible-> repair hernia at time of transplant
-Complicated= incarcerated, strangulated, ruptured= repair urgently- no mesh, close in layers (close peritoneum), sterile dressing, aggressive ascites control postop
-Avoid intraperitoneal drain on the exam – can get hypotensive. Intermittent paracentesis standard
115
What is the treatment for echinococcal cysts?
-Hydatid cyst; characteristic double walled cyst on CT
* Check serology
* Tx= albendazole followed by surgical excision; do not aspirate or spill -> anaphylaxis
116
What are choledochal cysts associated with?
Anomalous biliary-pancreatic duct junction with reflux of pancreatic enzymes (long common BP duct)
-Most identified/ treated early childhood; pain, biliary obstruction, cirrhosis; malignant potential
117
What is the imaging characteristic of hepatic hemangioma?
-MC liver tumor, M > W, = distribution in liver
-Congenital vascular malformations, generally asx
-Pain, compressive sxs; rarely hemorrhage, inflammation, or coagulopathy
-Kasabach-Merritt Syndrome = hemangioma + consumptive coagulopathy
-Imaging
-CT: hypodense pre-contrast; peripheral -> central enhancement in the arterial phase; persistent contrast on delayed series
-MRI: hypointense on T1; hyperintense on T2
-Tx
-Asx: observation (regardless of size, no risk of rupture)
-Sx: resection
118
What are the imaging characteristics of hepatocellular carcinoma?
CT shows hypervascular lesions; hyperintense during arterial phase, hypodense during delayed phase.
-Risk factors (causes of liver inflammation): HBV, HCV, cirrhosis of any cause, inherited errors of metabolism (hemochromatosis, alpha 1 antitrypsin deficiency), aflatoxin
-CT scan: hypervascular lesions; hyperintense during arterial phase; hypodense during delayed phase
-Characteristic lesion on imaging + elevated AFP = no biopsy needed
-No PET/CT
-Lung= most common site of metastasis
-Management=
-Resection indicated for cure if solitary mass without major vascular invasion and adequate liver function (low grade with normal function or Childs A without portal hypertension)
-FLR (future liver remnant) needed?
-No cirrhosis= 25%
-Childs= 30-40%
-Portal vein embolization= strategy to hypertrophy the anticipated FLR in advance of major hepatectomy.
-No cirrhosis or Childs A and early stage= resection
-Moderate to severe cirrhosis and early stage= transplant
-Must meet Milan criteria:
-One lesion < 5 cm
-3 or fewer lesions all less than 3 cm and no gross vascular or extrahepatic spread
-Neoadjuvant chemotherapy prior to transplant
-Locoregional therapies if not candidates for surgical curative treatments
-Ablation (radiofrequency, cryoablation, microwave)= best for small lesions < 5 cm
-Arterially directed therapies – transarterial chemoembolization (TACE)
-Consider for unresectable tumors > 5 cm
-External beam radiation therapy
-Unresectable disease; not amenable to ablation or TACE due to tumor location
119
What is the management for solitary hepatocellular carcinoma without major vascular invasion?
Resection is indicated if there is adequate liver function.
120
What are the common risk factors (RF) for cholangiocarcinoma?
Primary sclerosing cholangitis, ulcerative colitis, bile duct stones, choledochal cysts, liver fluke infections, HBV, HCV.
121
What types of cholangiocarcinoma exist?
-Intrahepatic or extrahepatic disease
Sclerosing or periductal infiltrating (most common), nodular, papillary, diffusely infiltrating.
122
What is the prognosis for papillary cholangiocarcinoma?
Better prognosis with improved outcomes.
-Sclerosing & nodular: lower resectability and cure rates
-Intrahepatic
-Preop bx not necessary if radiographically and clinically suggested malignancy
-Diagnostic laparoscopy to rule out disseminated disease
-Lymph node metastasis past porta hepatis and distant metastases contraindicate resection
-Multifocal liver disease generally not amenable to resection
-Extrahepatic:
-Complete resection with negative margins and regional lymphadenectomy
-Location hilar: in order to be resectable, contralateral hemi-liver must have intact arterial/portal flow and biliary drainage uninvolved with tumor; reconstruction generally with Roux-en-Y hepaticojejunostomy
-Location distal: pancreaticoduodenectomy (Whipple)
123
What is the next step for a patient with colorectal cancer and isolated liver metastasis after neoadjuvant FOLFOX therapy shows complete radiologic response?
Still perform hepatic resection as complete pathologic response is rare.
124
What is the highest negative predictive value test for choledocholithiasis?
GGT (beta-glutamyl transpeptidase) -> normal GGT has 97% NPV.
125
How do you manage choledocholithiasis in a patient with prior Roux-en-Y gastric bypass?
Transgastric ERCP or advanced double-balloon endoscopy.
126
What is the significance of HCC found in a young patient without cirrhosis?
Fibrolamellar variant with better prognosis; recurrence is common. Marker = Neurotensin.
127
Do you need to excise port sites after surgery?
No benefit
128
What is the significance of isolated gastric varices?
Most commonly caused by splenic vein thrombosis secondary to pancreatitis. Treatment = splenectomy.
129
What is the treatment for hemobilia from hepatic artery-biliary duct fistula?
Angioembolization.
130
What is the management for injury to the extrahepatic biliary system?
For any injury to the CBD with ductal tissue loss, if unstable, perform percutaneous drainage or ligation of CBD.
131
What is the treatment for distal CBD injury?
Roux-en-Y choledochojejunostomy.
-For any injury to the CBD with ductal tissue loss or when > 50% of the duct is involved
-If unstable patient: percutaneous drainage or ligation of CBD
-Roux-en-Y choledochojejunostomy (distal CBD injury)
-Roux-on-Y hepaticojejunostomy (proximal CBD injury): small bowel is divided & distal small bowel (Roux limb) is brought up and sutured to bile duct (end-to-side hepaticjejunostomy). End-to-side bowel-bowel anastomosis. Enterotomy is only made through the seromuscular layers.
132
What is the treatment for proximal CBD injury?
Roux-en-Y hepaticojejunostomy.
133
What is the most common cause of peritoneal dialysis catheter infection?
MCC by Staph aureus.
134
What is the contraindication for placement of a PD catheter?
Active infection.
- VP shunt and G tube are not contraindications to placement of PD catheter
- Hernia is not a contraindication to placement, but they must be repaired during PD placement
135
What is the treatment for exit site and tunneled infection of PD catheter?
Cephalexin and cipro (oral); get US to look for abscess. If + abscess, drain it.
136
What is the treatment for peritonitis in PD catheter infection?
Need MRSA and pseudomonas coverage; intraperitoneal route is better than IV.
- If fungal infxn: immediately remove catheter
137
What is needed for SBP prophylaxis?
Previous SBP, ascitic protein < 1.0, bili > 2.5, GI bleed.
138
What is the albumin treatment for a patient diagnosed with SBP?
1.5 g/kg at the time of diagnosis and another dose of 1 g/kg on day 3 of antibiotic treatment.
139
Todani classification system and treatment by type?
Type III: intraduodenal or intrapancreatic dilations of the common bile duct; associated with cholangitis and pancreatitis; small- ERCP and sphincterotomy or excision; larger- transduodenal excision with reimplantation of pancreatic duct if involved
140
Primary Sclerosing Cholangitis
-Hx of ulcerative colitis, pruritis, fatigue, abnormal liver enzymes
-Autoimmune disease that causes fibrosis and strictures in the biliary tree -> progressive cholestatic liver disease -> biliary sepsis, cirrhosis
-Cholangiography: "chain-of-lakes" or beaded appearance of bile ducts
-Bx dominant stricture because risk of cholangiocarcinoma
Tx: start with ursodeoxycholic acid= improves liver enzymes; ERCP with balloon dilation of dominant strictures= symptomatic treatment
-Definitive treatment= liver transplant; can occur in transplanted liver but less aggressive
141
Lesion characteristics of CT scan
-Focal nodular hyperplasia: homogenous/ isodense enhancement of a hypodense lesion with an associated central scar
-Hepatic adenoma: heterogenous mass with rapid enhancement during arterial phase
-Hemangioma: low density and peripheral nodular enhancement
142
Most accurate way to identify all pulmonary metastatic lesions
Intraoperative indocyanine green fluoroscopy
-Seen in lung at 24 hours; HB tissues retain ICG for up to two weeks
143
Best test of liver function
Prothrombin time
Albumin indication of synthetic function
144
Pneumobilia vs portal venous gas
Portal vein gas: patient's usually ill- pneumatosis intestinalis, ischemic bowel; P for peripheral; flow of portal veins away from hilum
Pneumobilia: biliary tract infections, liver abscess, recent biliary instrumentation; C for CBD and Central gas patern
