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Flashcards in Liver Deck (105):
1

what is the largest single gland of the body?

liver

2

what are the three hepatic veins

right middle and left

3

where does the caudate lobe drain?

directly into the IVC

4

what is 75% of the blood supply of the liver?

portal vein

5

Origin of the portal vein formed by confluence of the

SMV and splenic vein

6

what is the order of biliary drainage

Bile canaliculi → segmental bile ducts (drain the segments) → right and left hepatic ducts → common hepatic duct → common bile duct at point of insertion of the cystic duct

7

why would you resect a benign liver lesion?

Hemorrhage or risk of hemorrhage
Risk of malignant transformation
Inability to exclude malignancy

8

what is the most common benign hepatic tumor?

cavernous hemangioma

9

who typically gets cavernosu hemangiomas

women 30-50 years old

10

when are cavernous hemangiomas usually found?

incidental on x-ray

11

if symptomatic present with RUQ pain or fullness. (pain uncommon <8-10 cm)

hemangioma

12

PE findings w/ hemangioma

rare but may see hepatomegaly or arterial bruit in the RUQ

13

very rare presentations of hemangioma

CHF
Jaundice
Spontaneous or traumatic rupture – hemorrhagic shock
Early satiety, nausea and vomiting
Thrombocytopenia may be present from sequestration and destruction of platelets in large lesions

14

dx of hemangioma

CT/MRI
FNA (risk of hemorrhage)
U/S

15

what will a hemangioma look like on US

well-circumscribed
uniformly hyperechoic lesions

16

what type CT do you want for a hemangioma

contrast enhanced, triple phase w/ delayed imaging

17

in arterial phase filled in periphery then there is more central filling with delayed phase.

hemangioma

18

how will a hemangioma look like on MRI

T1- low signal intensity
T2- high signal intensity

19

what will a hemangioma look like on RBC scan (useful if MRI is non-diagnostic)

delayed centripetal filling

20

Follow-up for hemangioma

US at 6 months and at 12 months after initial diagnosis
if no change in size- probs don't need long term follow up

21

indications for resection of hemangioma

Severe symptoms
Inability to obtain a firm diagnosis
Rapid growth
Rupture

22

what can you do to decrease risk of bleeding w/ hemangioma

May embolize if hemorrhage or pre-resection to shrink tumor to decrease risk of bleeding

23

how is embolization done

catheter in femoral artery
go to hepatic artery and inject things into artery to get it to stop bleeding

24

what can be used for embolization

Coils, ethanol, sodium tetradecyl sulfate cyanoacrylate, polyvinyl alcohol (PVA), microspheres, gelatin sponge (Gelfoam)

25

2nd most common benign liver lesion
Usually well circumscribed lesion with central scar

focal nodular hyperplasia

26

who do focal nodular hyperlasia often occur in?

females of reproductive age
associated w/ OCP (possibly)

27

are focal nodular hyperplasias symptomatic

no, and usually have normal LFTS

28

is there risk w/ focal nodular hyperplasia?

Nope- Rarely ruptures and no risk of malignant transformation (unlike adenoma)

29

ways to diagnose a FNH

dynamic CT w/ delayed imaging (look for central scar)
US- characteristics spoke-whell vascular

30

what will FNH look like on a technetium scan?

Technetium sulphur colloid scan helpful b/c FNH contains Kupffer cells – increased uptake

31

what needs to be done if pain is present with FNH

look for other causes of pain

32

has a strong associated w/ estrogen use- mostly OCP found in women 30-50 y/o more common in women who have been on OCP longer.

hepatic adenoma

33

are hepatic adenomas at a higher risk of hemorrhaging

yes

34

where are there higher risks of hepatic adenomas bleedng

long term OCP
pergnancy
tumor >4 cm

35

what does US show w/ hepatic adenoma

hypoechoic lesion, subcapsular (7% pedunculated), well circumscribed lesion
Nonspecific

36

what study is the best for hepatic adenoma to detect fat and hemorrhage

MRI

37

what have more kupffer cells hepatic adenoma or FNH?

FNH

38

what is diagnostics for a hepatic adenoma?

resection

39

indicatiosn for hepatic adenoma resection

unable to differentiate b/w HCC and hepatic adenoma
symptomatic
evidence of bleeding
poor follow up
lives in remote area
>5cm
elevated alpha-fetoprotein
patients wanting to become pregnant
pregnancy in second trimester

40

if you are going to observe a patient w/ hepatic adenoma what should be done

tell them to d/c OCPs
immediate imaging w/ signs of hemorrhage

41

if there is a free rupture of a hepatic adenoma what needs to be done

hepatic artery embolization

42

Congenital or aquired
Lined by biliary-type epithelium
The fluid in the cyst has an electrolyte composition that mimics plasma – not bile
Usually asymptomatic
dull RUQ pain if large or bloating, early satiety

simple cysts

43

diagnosis for simple cels

CT_ thin wall w/ homogenous low density interior

44

Tx for simple cysts

only if large and cause symptoms
will recur w/ aspiration so needs surgical tx (must unroof cyst wall)

45

Congenital and usually associated with autosomal dominant polycystic kidney disease
Cysts are numerous and enlarge
Rarely arises in childhood
Observed at the time of puberty and increase in adulthood

polycystic liver disease

46

how do patients w/ polycystic liver disease present

abdominal pain as cysts enlarge

47

will hepatic function decline with polycystic liver disease

it is rare
ocasionally can lead to hepatic fibrosis, portal HTN, liver failure

48

how to confirm polycystic liver disease

Ultrasound or CT scan
will see multiple liver cysts

49

when should people w/ polycystic liver dz be considered for surgery

clearly disabling pain

50

is a premalignant lesion with transformation to cystadenocarcinoma (malignant) 10% risk
often misdiagnosed as liver cysts

cystadenoma

51

who are cystadenocarcinomas more common in

females >40

52

how sill a cysatenoma prsent on CT and US

usually appear multiloculated with internal septations, heterogeneous density, and irregularities in the cyst wall

53

what must you rule out with cystadenoma?

hydatid cyst

54

diagnosis for cystadenoma

FNA (could be missed)
surgical excision

55

treatment for cystadenoma

resection

56

cyst caused by parasites of the genus Echinococcus - E. granulosus or E. multilocularis
Rare in the US

parastic (hydatid) liver cyst

57

where is the parasite causing hydatid liver cysts often found?

areas of sheep farming and exposure to canines

58

3 ways hydatid liver cysts can rupture

biliary tree (jaundice or cholangitis)
diaphragm (chest)
peritoneal cavity (anaphylactic shock)

59

should hydatid liver cysts be biopsied?

Can cause peritoneal seeding and possibly anaphylaxis

60

what is also noted in people w/ hydatid liver cysts

eosiniphilia
echinococcal antibody titers

61

do hydatid cysts affect only the liver

no, can affect other organs

62

tx for hydatid liver cysts

chemo if disseminated (albendazol)
PAIR

63

what is PAIR for unilocular hydatid cysts

Puncture
Aspiration
Injection (scolicidal agent)
Reaspiration

64

surgical treatment for hydatid liver cysts

Total cystectomy or hepatic resection
Partial cystectomy with omentoplasty
Surgical PAIR with omentoplasty

65

cause of pyogenic liver abscess

instrumentation
ascending colangitis
via portal vein b/c GI infection (diverticulitis)

66

causes of fungal liver abscess

In pts with long term biliary stents, associated with recurrent cholangitis

67

how will a patient w/ a liver abscess present

RUQ pain, fever, and leukocytosis
Alk phos likely elevated
peritonitis if ruptures

68

how do liver abscesses appear on imaginings

cystic tend to have hypervascular walls

69

tx for small liver abscess

abx

70

tx for large liver abscess

abx plus percutaneous drainage or surgical if percutaneous drainage fails

71

Rare in the US caused by
Entamoeba histolytica

amedbic abscess

72

what will someone with amebic abscess present with

hx of diarrhea and weight loss

73

what will an amebic abscess look like on aspiration

sterile and anchovy paste

74

tx for amebic abscess

amebicidse (metroniadzole)
drainage not needed

75

most common liver malignancy

hepatocellular carcinoma (HCC)

76

what is the most common cause of a liver lesion

metastatic

77

cancer associated w/ cirrhosis secondary to hepatitis B and C or alcoholism or NASH

hepatocellular carcinoma (hepatoma)

78

cure for hepatocellular carcinoma

surgery (only possibl ein 5%)

79

where are metastatesse common w/ hepatomas

lung, portal vein, periportal nodes, bone, or brain

80

who do you suspect a hepatocellcular carcinoma in

Suspect in cirrhotic patients with sudden decompensation
Jaundice/worsening jaundice
Encephalopathy/worsening encephalopathy
Ascites/worsening ascites

81

if AFP is >500-1000 what is it almost always

hepatocellular carcinoma

82

what is lab work w/ HCC used for?

determine severity and etiology of underlying liver dz

83

first way of screening for HCC

US (can miss small tumors)

84

what will a triphasic CT show with HCC

Hypervascular pattern with arterial enhancement and rapid washout during the portal venous phase
extrahepatic dz can be seen

85

benefit of MRI to evaluate HCC

better for nodular cirrhotic livers

86

only chances for cure w/ HCC

surgical resection and liver transplantation

87

who can resection of HCC be done in

Childs A

88

who is a liver transplantation done in w/ HCC

cirrhotic B or C with tumors <3 cm

89

indications for tumor resection for HCC

adequate general health (ex- cardiopulmonary function)
extrahepatic dz is excluded (except pulmonary mets and may be amenable to resection)
anatomic location

90

treatment that may downstage tumor so patient is eligble for transplatation or resection

ablation

91

in children where are common sites for liver mets

common liver metastases are from a neuroblastoma, a Wilms tumor, or leukemia

92

how should resections be done?

Starting with laparoscopy and intraoperative U/S

93

Portal pressures ≥ 12 - 15 mm Hg (normal is 5-10)

portal HTN

94

complications w/ portal HTN

GI variceal bleeding
Hepatorenal syndrome
Ascites
Hepatic encephalopathy
Spontaneous (primary) peritonitis

95

what will portal HTN look like on PE

dilated veins on anterior abdominal wall
caput medusa
venous pattern on flanks
paraumbilical hernia

96

what will you on imaging for portal HTN

splenomegaly
collateral circulation
dilation of IVC

97

what has the highest rate of morality w/ all the complications of cirrhosis

variceal bleeding

98

tx for acute bleed from variceal bleeding

2 large bore IVs
blood products
tx coagulopathies
urinary cath
monitor in ICU

99

Drugs that can help tx of acute bleeding

IV somatostatin (splanchnic vasoconstriction)
IV vasopressin

100

procedures that can help w/ an acute bleed due to portal HTN

endoscopy w/ sclerotherapy
luminal tamponade
TIPS

101

what is TIPS

transjugular intrahepatic portosystemic shunt
relieves pressure from collaterals

102

how to prevent recurrent bleeding w/ varices

beta blockade (decrease portal venous flow)
ablation of varices
TIPS (patient on transplant list)
surgical shunts (patient not on transplant list)

103

indications for liver transplant

end stage liver disease, life-threatening complications of liver disease, correction of inborn errors of metabolism, and neoplasm

104

what is Child's class based on

albumin
bilirubin
ascites
encephalopathy
nutritional state

105

surgical problems w/ cirrhotics

hemorrhage (venous collaterals)
impaired coagulation, poor wound healing
different metabolism of meds
impaired immune functions
difficult fluid management (ascites)