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Flashcards in Liver Deck (111):
1

What is the name of the liver capsule?

Glisson's capsule

2

What is the "bare" area of the liver?

Posterior section of the liver against the diaphragm that is "bare" without peritoneal covering

3

What is Cantle's line?

Line drawn from the gallbladder to a point just to the left of the IVC, which transects the liver into the right and left lobes

4

Which ligament goes from the anterior abdominal wall to the liver?

Falciform ligament

5

What does the falciform ligament contain?

Ligamentum teres (obliterated umbilical vein)

6

What is the coronary ligament?

Peritoneal reflection on top of the liver that "crowns" the liver and attaches it to the diaphragm

7

What are the triangular ligaments of the liver?

Right and left lateral extents of the coronary ligament, which form triangles

8

What is the origin of the hepatic arterial supply?

From the proper hepatic artery off of the celiac trunk

9

What is the venous supply to the liver?

Portal vein, formed from the splenic vein and the SMV

10

What is the hepatic venous drainage?

Via the hepatic veins, which drain into the IVC

11

What sources supply O2 to the liver?

Portal vein: 50%
Hepatic artery: 50%

12

From what sources does the liver receive blood?

Portal vein: 75%
Hepatic artery: 25%

13

What is the maximum amount of liver that can be resected while retaining adequate liver function?

>80%; if given adequate recovery time, the original mass can be regenerated

14

What are the signs and symptoms of liver disease?

Hepatomegaly, splenomegaly, icterus, pruritus (bile salts in skin), blanching spider telangiectasia, gynecomastia, testicular atrophy, caput medusa, dark urine, clay-colored stools, bradycardia, edema, ascites, fever, fetor hepaticus, hemorrhoids, variceal bleeding, anemia, alopecia, liver tenderness, palmar erythema

15

Which liver enzymes are made by hepatocytes?

AST and ALT

16

What is the source of alkaline phosphatase?

Ductal epithelium

17

What is Child's class?

Classification system that estimates hepatic reserve in patients with hepatic failure and mortality

18

What comprises the Child's classification?

A BEAP:
Labs: Albumin, Bilirubin
Clinical: Encephalopathy, Ascites, PT

19

What does the MELD score stand for?

Model for End-stage Liver Disease

20

What is measured in the MELD score?

INR, T.Bili, serum creatinine

21

What is the most common liver cancer?

Metastatic disease 20:1 (usually GI source)

22

What is the most common primary malignant liver tumor?

Hepatocellular carcinoma (hepatoma)

23

What is the most common primary benign liver tumor?

Hemangioma

24

What lab tests comprise the workup for liver metastasis?

LFTs (AST and alkaline phosphatase most useful), CEA for suspected primary colon cancer

25

What are the associated imaging studies for liver cancer?

CT, U/S, A-gram

26

What is a right hepatic lobectomy?

Removal of the right lobe of the liver (all tissue to the right of Cantle's line)

27

What is a left hepatic lobectomy?

Removal of the left lobe of the liver (all tissue to the left of Cantle's line)

28

What is a right trisegmentectomy?

Removal of all the liver tissue to the right of the falciform ligament

29

What are the 3 common types of primary benign liver tumors?

1. Hemangioma
2. Hepatocellular adenoma
3. Focal nodular hyperplasia

30

What are the 4 common types of primary malignant liver tumors?

1. Hepatocellular carcinoma
2. Cholangiocarcinoma
3. Angiosarcoma
4. Hepatoblastoma

31

What chemical exposures are risk factors for angiosarcoma?

Vinyl chloride, arsenic, thorotrast contrast

32

What is a hepatoma?

Hepatocellular carcinoma

33

What are the other benign liver masses?

Benign liver cyst, bile duct hamartoma, bile duct adenoma

34

What is a liver hamartoma?

White hard nodule made up of normal liver cells

35

What is hepatocellular adenoma?

A benign liver tumor

36

Describe the histology of hepatocellular adenoma.

Normal hepatocytes without bile ducts

37

What are the associated risk factors for hepatocellular adenoma?

Women (M:F=1:9), OCPs, anabolic steroids, GSD

38

What are the signs and symptoms of hepatocellular adenoma?

RUQ pain/mass, RUQ fullness, bleeding (rare)

39

What are the possible complications of hepatocellular adenoma?

Rupture with bleeding, necrosis, pain, risk of hepatocellular carcinoma

40

How is hepatocellular adenoma diagnosed?

CT, U/S, +/- biopsy

41

What is the treatment for a small hepatocellular adenoma (< 5cm)?

Stop OCPs; if no regression, surgical resection

42

What is the treatment for a large hepatocellular adenoma (> 5cm)?

Surgical resection

43

What is focal nodular hyperplasia?

Benign liver tumor

44

Describe the histology of FNH.

Normal hepatocytes and bile ducts

45

What are the associated risk factors for FNH?

Women

46

Is FNH associated with OCPs?

Yes, but not as clearly as hepatocellular adenoma

47

How is the diagnosis of FNH made?

Nuclear technetium-99 study, U/S, CT, A-gram, biopsy

48

What is the classic CT finding in FNH?

Liver mass with central scar

49

What are the possible complications of FNH?

Pain (no risk of cancer, hemorrhage rare)

50

Is there a cancer risk with FNH?

No

51

What is the treatment for FNH?

If symptomatic, resection or embolization; Otherwise, stop OCPs and follow

52

Why does embolization work with FNH?

FNH tumors are usually fed by only one major artery

53

What is hepatic hemangioma?

Benign vascular tumor of the liver

54

What are the signs and symptoms of hepatic hemangioma?

RUQ pain/mass, bruits

55

What are the possible complications of hepatic hemangioma?

Pain, CHF, coagulopathy, obstructive jaundice, gastric outlet obstruction, Kasabach-Merritt syndrome, hemorrhage (rare)

56

What is Kasabach-Merritt syndrome?

Hemangioma, thrombocytopenia and fibrinogenopenia

57

How is the diagnosis of hepatic hemangioma made?

CT w/ IV contrast, tagged RBC scan, MRI, U/S

58

Should a biopsy of hepatic hemangioma be performed?

No (risk of hemorrhage)

59

What is the treatment for hepatic hemangioma?

Observation

60

What are the indications for resection of hepatic hemangioma?

Symptoms, hemorrhage, unclear diagnosis

61

What is hepatocellular carcinoma?

Most common primary malignancy of the liver

62

What is the incidence of hepatocellular carcinoma?

80% of all primary malignant liver tumors

63

What are the geographic high-risk areas for hepatocellular carcinoma?

Africa and Asia

64

What are the associated risk factors for hepatocellular carcinoma?

Hepatitis B, cirrhosis, aflatoxin, alpha-1-antitrypsin deficiency, hemochromatosis, liver fluke, anabolic steroids, polyvinyl chloride, GSD type I

65

What percentage of patients with cirrhosis will develop hepatocellular carcinoma?

5%

66

What are the signs and symptoms of hepatocellular carcinoma?

Dull RUQ pain, hepatomegaly, abdominal mass, weight loss, paraneoplastic syndromes, signs of portal hypertension, ascites, jaundice, fever, anemia, splenomegaly

67

What tests should be ordered for workup of hepatocellular carcinoma?

U/S, CT, angiography, tumor marker elevation

68

What are the tumor markers for hepatocellular carcinoma?

Elevated AFP

69

What is the most common way to get a tissue diagnosis of hepatocellular carcinoma?

Needle biopsy with CT, U/S or lapascopic guidance

70

What is the most common site of hepatocellular carcinoma metastasis?

Lungs

71

What is the treatment for hepatocellular carcinoma?

Surgical resection; liver transplant

72

What are the treatment options for hepatocellular carcinoma if the patient is not a surgical candidate?

Percutaneous ethanol tumor injection; cryotherapy; intra-arterial chemotherapy

73

What are the indications for liver transplantation in hepatocellular carcinoma?

Cirrhosis, no resection candidacy, no distant or lymph node metastases, no vascular invasion

74

What is the prognosis for unresectable hepatocellular carcinoma?

Almost none survive a year

75

What is the prognosis for resectable hepatocellular carcinoma?

35% at 5 years

76

Which subtype of hepatocellular carcinoma has the best prognosis?

Fibrolamellar hepatoma (young adults)

77

What is a liver abscess?

Abscess in the liver parenchyma

78

What are the types of liver abscess?

Pyogenic (bacterial), parasitic (amebic), fungal

79

What is the most common location of abscess in the liver?

Right > left lobe

80

What are the sources for liver abscesses?

Direct spread from biliary tract infection, portal spread from GI infection (e.g. appendicitis, diverticulitis), systemic source (e.g bacteremia), liver trauma (e.g. gun shot), cryptogenic

81

What are the 2 most common types of liver abscesses?

Bacterial and amebic

82

What are the 3 most common bacterial organisms affecting the liver?

Gram negatives:
1. E. coli
2. Klebsiella
3. Proteus

83

What are the most common sources/causes of bacterial liver abscess?

Cholangitis, diverticulitis, liver cancer, liver metastasis

84

What are the signs and symptoms of a bacterial liver abscess?

Fever, chills, RUQ pain, leukocytosis, increased LFTs, jaundice, sepsis, weight loss

85

What is the treat for bacterial liver abscesses?

IV antibiotics (triple with metronidazole), percutaneous drainage w/ CT or U/S guidance

86

What are the indications for operative drainage of a bacterial liver abscess?

Multiple/loculated abscesses or if multiple percutaneous attempts have failed

87

What is the etiology of amebic liver abscesses?

Entamoeba histolytica

88

How does an amebic liver abscess spread?

Fecal-oral transmission

89

What are the risk factors for amebic liver abscesses?

Patients from countries south of the US-Mexico border, institutionalized patients, homosexual men, alcoholics

90

What are the signs and symptoms of amebic liver abscesses?

RUQ pain, fever, lymphadenopathy, diarrhea

91

Which lobe is the most common site of amebic liver abscesses?

Right lobe

92

What is the classic description of the contents of amebic liver abscesses?

"Anchovy paste" pus

93

How is the diagnosis of amebic liver abscess made?

Lab tests, U/S, CT

94

What lab tests should be performed in the workup of amebic liver abscess?

Indirect hemagglutination titers for Entamoeba antibodies, LFTs

95

What is the treatment of amebic liver abscesses?

Metronidazole IV

96

What are the indications for percutaneous surgical drainage of an amebic liver abscess?

Refractory to metronidazole, bacterial co-infection, or peritoneal rupture

97

What are the possible complications of large left lobe amebic liver abscesses?

Erosion into the pericardial sac

98

What is a hydatid liver cyst?

Usually a right lobe cyst filled with Echinoccus granulosus

99

What are the risk factors for hydatid liver cysts?

Travel; exposure to dogs, sheep, cattle

100

What are the signs and symptoms of hydatid liver cysts?

RUQ abdominal pain, jaundice, RUQ mass

101

How is the diagnosis of hydatid liver cyst made?

Indirect hemagglutination antibody test, Casoni skin test, U/S, CT, radiographic imaging

102

What are the findings on AXR with a hydatid liver cyst?

Possible calcified outline of cyst

103

What are the majors complications of a hydatid liver cyst?

Erosion into the pleural cavity, pericardial sac, biliary tree; rupture in the peritoneal cavity causing fatal anaphylaxis

104

What is the risk of surgical removal of hydatid liver cysts?

Rupture or leakage of cyst contents into the abdomen causing a fatal anaphylactic reaction

105

When should percutaneous drainage of a hydatid liver cyst be performed?

Never

106

What is the treatment for a hydatid liver cyst?

Mebendazole, then surgical resection

107

What is hemobilia?

Blood draining via the common bile duct into the duodenum

108

What is the diagnostic triad of hemobilia?

1. RUQ pain
2. Guaiac positive, upper GI bleeding
3. Jaundice

109

What are the causes of hemobilia?

Trauma with liver laceration, percutaneous transhepatic cholangiography, tumors

110

How is the diagnosis of hemobilia made?

EGD, A-gram

111

What is the treatment for hemobilia?

A-gram with embolization of the bleeding vessel