Flashcards in Liver Deck (111):
What is the name of the liver capsule?
What is the "bare" area of the liver?
Posterior section of the liver against the diaphragm that is "bare" without peritoneal covering
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
Which ligament goes from the anterior abdominal wall to the liver?
What does the falciform ligament contain?
Ligamentum teres (obliterated umbilical vein)
What is the coronary ligament?
Peritoneal reflection on top of the liver that "crowns" the liver and attaches it to the diaphragm
What are the triangular ligaments of the liver?
Right and left lateral extents of the coronary ligament, which form triangles
What is the origin of the hepatic arterial supply?
From the proper hepatic artery off of the celiac trunk
What is the venous supply to the liver?
Portal vein, formed from the splenic vein and the SMV
What is the hepatic venous drainage?
Via the hepatic veins, which drain into the IVC
What sources supply O2 to the liver?
Portal vein: 50%
Hepatic artery: 50%
From what sources does the liver receive blood?
Portal vein: 75%
Hepatic artery: 25%
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
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
Which liver enzymes are made by hepatocytes?
AST and ALT
What is the source of alkaline phosphatase?
What is Child's class?
Classification system that estimates hepatic reserve in patients with hepatic failure and mortality
What comprises the Child's classification?
Labs: Albumin, Bilirubin
Clinical: Encephalopathy, Ascites, PT
What does the MELD score stand for?
Model for End-stage Liver Disease
What is measured in the MELD score?
INR, T.Bili, serum creatinine
What is the most common liver cancer?
Metastatic disease 20:1 (usually GI source)
What is the most common primary malignant liver tumor?
Hepatocellular carcinoma (hepatoma)
What is the most common primary benign liver tumor?
What lab tests comprise the workup for liver metastasis?
LFTs (AST and alkaline phosphatase most useful), CEA for suspected primary colon cancer
What are the associated imaging studies for liver cancer?
CT, U/S, A-gram
What is a right hepatic lobectomy?
Removal of the right lobe of the liver (all tissue to the right of Cantle's line)
What is a left hepatic lobectomy?
Removal of the left lobe of the liver (all tissue to the left of Cantle's line)
What is a right trisegmentectomy?
Removal of all the liver tissue to the right of the falciform ligament
What are the 3 common types of primary benign liver tumors?
2. Hepatocellular adenoma
3. Focal nodular hyperplasia
What are the 4 common types of primary malignant liver tumors?
1. Hepatocellular carcinoma
What chemical exposures are risk factors for angiosarcoma?
Vinyl chloride, arsenic, thorotrast contrast
What is a hepatoma?
What are the other benign liver masses?
Benign liver cyst, bile duct hamartoma, bile duct adenoma
What is a liver hamartoma?
White hard nodule made up of normal liver cells
What is hepatocellular adenoma?
A benign liver tumor
Describe the histology of hepatocellular adenoma.
Normal hepatocytes without bile ducts
What are the associated risk factors for hepatocellular adenoma?
Women (M:F=1:9), OCPs, anabolic steroids, GSD
What are the signs and symptoms of hepatocellular adenoma?
RUQ pain/mass, RUQ fullness, bleeding (rare)
What are the possible complications of hepatocellular adenoma?
Rupture with bleeding, necrosis, pain, risk of hepatocellular carcinoma
How is hepatocellular adenoma diagnosed?
CT, U/S, +/- biopsy
What is the treatment for a small hepatocellular adenoma (< 5cm)?
Stop OCPs; if no regression, surgical resection
What is the treatment for a large hepatocellular adenoma (> 5cm)?
What is focal nodular hyperplasia?
Benign liver tumor
Describe the histology of FNH.
Normal hepatocytes and bile ducts
What are the associated risk factors for FNH?
Is FNH associated with OCPs?
Yes, but not as clearly as hepatocellular adenoma
How is the diagnosis of FNH made?
Nuclear technetium-99 study, U/S, CT, A-gram, biopsy
What is the classic CT finding in FNH?
Liver mass with central scar
What are the possible complications of FNH?
Pain (no risk of cancer, hemorrhage rare)
Is there a cancer risk with FNH?
What is the treatment for FNH?
If symptomatic, resection or embolization; Otherwise, stop OCPs and follow
Why does embolization work with FNH?
FNH tumors are usually fed by only one major artery
What is hepatic hemangioma?
Benign vascular tumor of the liver
What are the signs and symptoms of hepatic hemangioma?
RUQ pain/mass, bruits
What are the possible complications of hepatic hemangioma?
Pain, CHF, coagulopathy, obstructive jaundice, gastric outlet obstruction, Kasabach-Merritt syndrome, hemorrhage (rare)
What is Kasabach-Merritt syndrome?
Hemangioma, thrombocytopenia and fibrinogenopenia
How is the diagnosis of hepatic hemangioma made?
CT w/ IV contrast, tagged RBC scan, MRI, U/S
Should a biopsy of hepatic hemangioma be performed?
No (risk of hemorrhage)
What is the treatment for hepatic hemangioma?
What are the indications for resection of hepatic hemangioma?
Symptoms, hemorrhage, unclear diagnosis
What is hepatocellular carcinoma?
Most common primary malignancy of the liver
What is the incidence of hepatocellular carcinoma?
80% of all primary malignant liver tumors
What are the geographic high-risk areas for hepatocellular carcinoma?
Africa and Asia
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
What percentage of patients with cirrhosis will develop hepatocellular carcinoma?
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
What tests should be ordered for workup of hepatocellular carcinoma?
U/S, CT, angiography, tumor marker elevation
What are the tumor markers for hepatocellular carcinoma?
What is the most common way to get a tissue diagnosis of hepatocellular carcinoma?
Needle biopsy with CT, U/S or lapascopic guidance
What is the most common site of hepatocellular carcinoma metastasis?
What is the treatment for hepatocellular carcinoma?
Surgical resection; liver transplant
What are the treatment options for hepatocellular carcinoma if the patient is not a surgical candidate?
Percutaneous ethanol tumor injection; cryotherapy; intra-arterial chemotherapy
What are the indications for liver transplantation in hepatocellular carcinoma?
Cirrhosis, no resection candidacy, no distant or lymph node metastases, no vascular invasion
What is the prognosis for unresectable hepatocellular carcinoma?
Almost none survive a year
What is the prognosis for resectable hepatocellular carcinoma?
35% at 5 years
Which subtype of hepatocellular carcinoma has the best prognosis?
Fibrolamellar hepatoma (young adults)
What is a liver abscess?
Abscess in the liver parenchyma
What are the types of liver abscess?
Pyogenic (bacterial), parasitic (amebic), fungal
What is the most common location of abscess in the liver?
Right > left lobe
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
What are the 2 most common types of liver abscesses?
Bacterial and amebic
What are the 3 most common bacterial organisms affecting the liver?
1. E. coli
What are the most common sources/causes of bacterial liver abscess?
Cholangitis, diverticulitis, liver cancer, liver metastasis
What are the signs and symptoms of a bacterial liver abscess?
Fever, chills, RUQ pain, leukocytosis, increased LFTs, jaundice, sepsis, weight loss
What is the treat for bacterial liver abscesses?
IV antibiotics (triple with metronidazole), percutaneous drainage w/ CT or U/S guidance
What are the indications for operative drainage of a bacterial liver abscess?
Multiple/loculated abscesses or if multiple percutaneous attempts have failed
What is the etiology of amebic liver abscesses?
How does an amebic liver abscess spread?
What are the risk factors for amebic liver abscesses?
Patients from countries south of the US-Mexico border, institutionalized patients, homosexual men, alcoholics
What are the signs and symptoms of amebic liver abscesses?
RUQ pain, fever, lymphadenopathy, diarrhea
Which lobe is the most common site of amebic liver abscesses?
What is the classic description of the contents of amebic liver abscesses?
"Anchovy paste" pus
How is the diagnosis of amebic liver abscess made?
Lab tests, U/S, CT
What lab tests should be performed in the workup of amebic liver abscess?
Indirect hemagglutination titers for Entamoeba antibodies, LFTs
What is the treatment of amebic liver abscesses?
What are the indications for percutaneous surgical drainage of an amebic liver abscess?
Refractory to metronidazole, bacterial co-infection, or peritoneal rupture
What are the possible complications of large left lobe amebic liver abscesses?
Erosion into the pericardial sac
What is a hydatid liver cyst?
Usually a right lobe cyst filled with Echinoccus granulosus
What are the risk factors for hydatid liver cysts?
Travel; exposure to dogs, sheep, cattle
What are the signs and symptoms of hydatid liver cysts?
RUQ abdominal pain, jaundice, RUQ mass
How is the diagnosis of hydatid liver cyst made?
Indirect hemagglutination antibody test, Casoni skin test, U/S, CT, radiographic imaging
What are the findings on AXR with a hydatid liver cyst?
Possible calcified outline of cyst
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
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
When should percutaneous drainage of a hydatid liver cyst be performed?
What is the treatment for a hydatid liver cyst?
Mebendazole, then surgical resection
What is hemobilia?
Blood draining via the common bile duct into the duodenum
What is the diagnostic triad of hemobilia?
1. RUQ pain
2. Guaiac positive, upper GI bleeding
What are the causes of hemobilia?
Trauma with liver laceration, percutaneous transhepatic cholangiography, tumors
How is the diagnosis of hemobilia made?