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Flashcards in Liver Deck (78):
1

LIVER

What is true about the falciform ligament?

A) Embryologically important
B) Divides R and L lobes of liver
C) Bifurcation of CHD lies at the base
D) Middle hepatic vein lies at the base
E) First thing divided when performing a left lateral segmentectomy

A

Base or free edge contains round ligament = ligamentum teres. Contains obliterated unpaired umbilical veins. Brings blood from placenta to liver

2

LIVER

Worldwide, what is the most common cause of hepatocellular carcinoma

A) Clonorchis sinensis
B) Hepatitis B
C) OCP
D) Immunosuppression

B

3

LIVER

Patient presents with hepatic metastasis from colon cancer. Which is most favorable?

A) 6 month interval from colon cancer to liver metastasis
B) Satellite lesions around hepatic tumor
C) Extra hepatic tumor
D) Favorable stage of primary lesion
E) 2 mm margin around liver lesion

D

Fong Criteria
-Seven factors found to be significant and independent predictors of poor long term outcome by multivariate analysis: Postivie margin, Extrahepatic diseases, Node positive primary, Disease free interval from primary to mets < 12 months, # of hepatic tumors, Largest hepatic tumor > 5 cm, CEA >200

4

LIVER

After liver trauma, at the time of pack remove, which should you not do:

A) Debride necrotic tissue
B) Ligate injured bile ducts
C) Remove GB with a 2 cm stone
D) Drain
E) Remove and replace packs

C

5

LIVER--Rush

Which of the following statements about the anatomy of the liver is true?

A. R lobe extends to the umbilical fissure and falciform ligament
B. L lobe ends at the falciform ligament
C. Quadrate lobe is a portion of the medial segment of the R lobe
D. L lobe contains the anterior and lateral segments
E. The lateral segment of L lobe in the American system consists of segments II and III

E

Surgical anatomy is based on distribution of hepatic veins and portal structures
American and French system

Cantilies line = longitudinal plane that extends from gallbladder fossa to IVC
AKA Portal fissure, which contains middle hepatic veins and bifurcation of portal vein

American = liver broken down into 4 segments, each lobe containing 2 segments
R lobe = anterior and posterior
L lobe = medial (quadrate) and lateral divided by falciform
Caudate independent of R and L lobes b/c it receives portal and arterial supply from both sides and drains directly into IVC

French = two lobes are broken down into eight segments
Formed by three vertical planes (scissurae) created by R, middle and L hepatic veins
4 sectors are divided by a plane created by branching portal system
L lobe --> medial and lateral segments by L hepatic vein
-Lateral segment: Segment II and III
-Medial segment: Segment IV
R Lobe--> Anteromedial and posterolateral sectors divided by vertical plane containing R hepatic vein
-Anteromedial: Segment V and VIII
-Posterolateral: Segment VI and VII

6

LIVER-- Rush

Which of the following statements is true about the hepatic arterial supply?

A. Aberrant hepatic arterial anatomy is present in <5% of all patients
B. Cystic artery is usually a branch off the proper hepatic artery
C. A "replaced" R hepatic artery arises from the SMA
D. The hepatic artery provides 75% of blood flow to the liver
E. The hepatic artery lies dorsal to the portal vein within the hepatic hilum

C

Hepatic artery supply normally derived from celiac axis by common hepatic artery, which becomes hepatic artery proper after giving off GDA branch and subsequently bifurcates into R and L hepatic branches

Hepatic artery lies ventral to the portal vein. Bile duct is lateral to hepatic artery.

Middle hepatic artery is usually a branch off the L hepatic artery and the cystic artery is a branch off the R hepatic artery. Variability in hepatic artery anatomy in up to 50% of patients. 15% R hepatic artery arises from SMA (replaced R hepatic artery) and found in R dorsal border of hepatoduodenal ligament. 10% L hepatic artery originates from L gastric and located in gastrohepatic ligament.

Arterial blood supply accounts for 25% of hepatic blood flow but 50% of oxygenated blood. Portal vein accounts for 75% of hepatic blood flow but 50% of oxygenated blood.

7

LIVER--Rush

Which of the following statements about the anatomy of the hepatic veins is true?

A. The left hepatic vein drains the entire L lobe
B. Veins from the caudate lobe enter the IVC directly
C. Middle hepatic vein usually drains into R hepatic vein
D. There are valves in the hepatic venous system
E. Hepatic veins have prominent hyperechoic walls on U/S

B

Hepatic veins begin in liver lobules as central veins that coalesce to form R, L and middle hepatic veins, which drain to IVC. Defined by three vertical scissurae

R vein--> largest, drains most of R lobe
L vein--> drains left lateral segment and a portion of the medial segment
Middle vein--> drains inferoanterior portion of right lobe and inferomedial segment of L lobe. Joins L hepatic vein in 80% and enters IVC in 20%

Human hepatic venous system has no valves.

Portal veins have prominent hyperechoic walls

8

LIVER--Rush

Which of the following statement is true about the portal vein?

A. It is formed by the junction of the IMV and splenic vein
B. It is the most dorsal structure in the hepatoduodenal ligament
C. Contains the valves of Mirizzi
D. R portal vein typically branches later than the L portal vein
E. Carries deoxygenated blood and provides only 10% of the liver's oxygenation

B

Portal vein formed dorsal to pancreatic neck by junction of SMV and splenic vein. Ascends posterior to CBD and hepatic artery in hepatoduodenal ligament. Make up the portal triad.

No valves in the portal system.

Portal vein bifurcates just outside the liver. R portal vein has anterior and posterior branches that diverge only a short distance from bifurcation and quickly dive into liver parenchyma. L portal vein has a longer transverse portion (pars transversus) and then angulates anteriorly in the umbilical fissure (pars umbilicus), where it gives off medial branches to segment IV and lateral branches to segments II and III

Portal vein provides 75% hepatic blood flow and 50-70% of liver's oxygenation

9

LIVER--Rush

Which of the following hepatic resections involves dissection in the plane of the falciform ligament or umbilical fissure?

A. R lobectomy
B. R trisegmentectomy
C. L lobectomy
D. L lateral segmentectomy
E. None of the above

E

Anatomic resection, non anatomic resection, enucleation procedures

Anatomic--> American or French
R lobectomy: Seg V, VI, VII, VIII
R trisegmentectomy: Seg IV, V, VI, VII, VIII
L lobectomy: Seg II, III, IV
L lateral segmentectomy: Seg II, III

Umbilical fissure is a segmental plane between the medial and lateral segments of L lobe of liver. Portion of L branch of portal vein known as pars umbilicus, runs in the inferior portion of the umbilical fissure

Dissection never carried out directly in segmental fissure. L lateral segmentectomy is L of fissure. R trisegmentectomy is to the R of the fissure

10

Liver--Rush

Which of the following characteristics is typically seen on U/S imaging of the hepatic portal vein branches?

A. Hyperechoic vessel walls
B. Hepatofugal blood flow
C. Diastolic reversal of blood flow
D. Location between hepatic segments
E. Vertical orientation

A

Portal vein and its branches have prominent hyperechoic walls. Attributed to accompanying intrahepatic branches of hepatic artery and bile duct, which are not seen individually on U/S. Transversely oriented and larger caliber centrally. Located within anatomic liver segments. Portal flow is toward the liver (hepatopedal). Flow is low velocity with minor undulations and continued forward flow during diastole. Horizontally oriented.

Hepatic veins appear "wall-less". Anechoic or hypoechoic tubular structures. Vertically oriented and increase in caliber as they course to IVC. Found between segments. Flow is hepatofugal and varies according to cardiorespiratory cycle. Vertically oriented.

11

LIVER--Rush

40F arrives in ER complaining of RUQ pain. Vitals and labs are normal. U/S demonstrates a hyperechoic liver with a geographic hypoechoic area adjacent to gallbladder. What does this finding probably represent?

A. Duplication of the gallbladder
B. Reverberation artifact
C. Focal fatty sparing
D. Hepatic abscess
E. Bowel gas

C

Fatty infiltration of liver produces hyperechoic parenchymal pattern on U/S. Not unusual to have focal areas of fatty sparing within steatotic liver. Typically appear as zonal hypoechoic regions and are generally found adjacent to the gallbladder or anterior to the porta hepatis

Duplication of gallbladder is rare

Reverberation artifact are echoes within cystic structures.

Sonographic appearance of hepatic abscesses is variable, depending on cause and duration. Pyogenic abscesses are usually complex, with cystic characteristics and internal echoes caused by debris and septations.

Bowel gas is highly reflective and impedes U/S.

12

LIVER--Rush

Which of the following is true regarding the hepatic functional unit?

A. The center of the hepatic lobule is the portal triad
B. Blood flows from the hepatic vein to the portal triad
C. Zone III is the most susceptible to hypoxic injury
D. Hepatocytes in zone I have the lowest oxygen tension
E. Bile flows toward the centrilobular hepatic venule

C

Functional histologic unit of the liver is the acinus. At the center is the portal triad, which consists of a terminal branc of the portal vein (portal venule) along with a hepatic arterial and bile ductule. Blood from the terminal portal venule goes into the hepatic sinusoids, around which hepatocytes are located. Eventually, blood returns to central vein leading to the terminal hepatic venule at the periphery of the acinar unit

Hepatocytes of the acinus are divided into three zones. Zone I closest to afferent portal venule and zone III closest to efferent central hepatic venule. Zone II is between two points

Within the acinus, there is a gradient of solute concentration and oxygen tension that is greatest near the portal venule at the center of the acinus. Hepatocytes in Zone I are more exposed to oxygen and less subject to hypoxia than are hepatocytes in zone III. Explains histologic pattern of centrilobular necrosis following ischemia

Hepatic venule is at the center of the histologic hepatic lobule. Each hepatic lobule is surrounded by several peripheral acini. Bile is formed within the hepatocytes and empties into terminal canaliculi, which coalesce into bile ducts. Bile them flows toward portal triad

13

LIVER

Most common organisms for splenic and liver abscesses in immunocompromised?

A. Candida
B. Staph aureus
C. Klebsiella
D. Pseudomonas

A in answer key but maybe c?

Candida is most common in immunocompromised but not sure if it is the most common organism. Most common organisms are E. coli and Klesiella. Pseudomonas is most common in biliary malignancies

14

LIVER

How should a patient who had Dukes C cancer two years previously be followed for recurrence of liver mets?

A. Liver enzymes
B. CEA
C. US
D. CT
E. Radionuclide imaging

D

Dukes classification
A Invades mucosa
B Invades muscularis propria
C Lymph node involvement
D Metastatic disease

Follow up
-History and physical
Every 3-6 mo for 2 y, then every 6 mo for a total of 5 y
-CEA
Every 3-6 mo for 2 y, then every 6 mo for a total of 5 y
-Chest/abdominal/pelvic CT
Annually for up to 5 y for patients at high risk for recurrence
-Colonoscopy
In 1 y except if no preoperative colonoscopy due to obstructing lesion, colonoscopy in 3-6 mo
If advanced adenoma, repeat in 1 y
If no advanced adenoma, repeat in 3 y, then every 5 yv
-PET-CT scan is not routinely recommended

15

LIVER

During sigmoid resection, you find a lone 2.5 cm on the free edge of left lobe of the liver. What do you do?

A. Sigmoid resection and wedge of liver
B. Sigmoid resection and post op chemo
C. Sigmoid resection and delayed L lobectomy
D. Sigmoid resection and liver resection at 3 months

A

Resect liver prechemo if solitary and easy to do
Best option: sigmoid resection, post op chemo then liver resection

16

LIVER

Most common reason for liver transplant in children

A. Benign and malignant tumours
B. Biliary sclerosis
C. Billiary atresia
D. Inborn errors of metabolism
E. Post necrotic cirrhosis

C

Kasai hepatoportoenterostomy does not cure biliary atresia, which will progress in > 70% of infants who undergo procedure. Rate with which disease progresses, as evidenced by cirrhosis and portal HTN, is variable but may be expedited by recurrent cholangitis. 80% who have a Kasai procedure can live up to 10 years before transplant is needed. In infants who undergo transplant, outcomes are good with 10 year graft survival and overall survival at 73% and 86%

17

LIVER

Most common early complication of liver trauma

A. Sepsis
B. Bleeding
C. Liver failure
D. Resp failure

B

18

LIVER

Young female collapses at home while watching TV. In ER, US shows abdominal fluid and a liver lesion. Most likely dx

A. Adenoma
B. Hemorrhagic cyst
C. Hemangioma
D. FNH

A

Uncommon benign lesions associated with OCP. Associated with glycogen storage disease, diabetes, steroids, and pregnancy. Usually solitary but may be multifocal. Low potential for malignancy.
Adenomas are at higher risk of rupture and malignant transformation when > 5 cm

19

LIVER--Rush

Alkaline phosphatase is primarily located in which portion of the hepatocyte plasma membrane?

A. Sinusoidal membrane
B. Basolateral membrane
C. Canalicular membrane
D. Basement membrane
E. None of the above

C

Plasma membrane of hepatocyte has different regions with structures designed for different functions
Sinusoidal membrane--> borders perisinusoidal space of Disse, covered with microvilli which increase absorptive area and allow proteins, solutes and other substances to be transported across the hepatocyte
Basolateral membrane--> flat, connect adjacent hepatocytes and is important for attachment and cellular interactions
Canalicular membrane--> specialize in bile formation and transport of substances into bile, separated from pericellular space by tight junctions. Contains ALP and 5' nucleotidase. Therefore high levels of ALP with extrahepatic duct obstruction

20

LIVER--Rush

During fasting, the liver provides energy substrates by all bunt which of the follow mechanisms?

A. Glycogenolysis
B. Glycolysis
C. Gluconeogenesis from alanine
D. Gluconeogenesis from lactate
E. Formation of ketone bodies from fatty acids

B

In fed state, glucose converted to glycogen for storage.
Liver obtains energy from keto acids rather than glucose, can use glycolysis during periods of glucose excess

During fasting, liver provides glucose by breakdown of stored glycogen (glycogenolysis). Glucose is critical to RBCs, CNS and kidneys. Glycogen stores depleted after 48 hrs, liver generates glucose from other sources like alanine, other amino acids, lactate and glycerol by gluconeogenesis. Lipolysis occurs during prolonged fasting and fatty acids releases from adipose stores are oxidized in hepatocytes to form ketone bodies, an important alternative fuel for brain and muscle

21

LIVER--Rush

The reticuloendothelial function of the liver is primarily dependent on which of the following cells?

A. Hepatocytes
B. Kupffer cells
C. Histiocytes
D. Ito cells
E. All of the above

RES functions to clear circulation of particulate matter and microbes. Consists of fixed phagocytize cells located primarily in liver, lung and spleen
Located along the lining of the hepatic sinusoids (along with sinusoidal epithelial cells), positioned to phagocytize and process gut antigens from sphlachnic and systemic circulation. Play a role in production and control of cytokines and inflammatory regulators.

Histiocytes are macrophages in connective tissue
Ito cells aka hepatic stellate cells are perisinusoidal cells involved in collagen and vitamin A metabolism

22

LIVER--Rush

Which of the following proteins is not primarily synthesized in the liver?

A. Albumin
B. Fibrinogen
C. von Willebrand factor
D. Transferrin
E. Factor VII

C

Liver is primary or sole source for numerous plasma proteins including, albumin, alpha globulins, and other transport proteins such as transferrin, hepatoglobulin, ferritin, ceruloplasmin

Eleven proteins involved in hemostasis are synthesized in the liver. Includes factor I (fibrinogen), the vitamin k dependent factors (II, VII, IX, X) and all of the procoagulation factors except von Willebrand factor (which is synthesized in vascular endothelial cells)

Because factor VII has the shorted half life (5-7 hrs), measurements of factor VII are useful for determining liver failure

23

Liver--Rush

The cytochrome p450 system transforms compounds by all of the following mechanisms except:

A. Oxidation
B. Hydrolysis
C. Conjugation
D. Reduction
E. Both A and C

C

Liver is responsible for biotransformation of many endogenous and exogenous substances. Detoxifies potentially injurious substances and facilitates elimination.

In some instances, hepatic biotransformation produces more toxic metabolites.

Two mechanics the liver accomplishes biotransformation: oxidation, reduction, and hydrolysis (phase I reactions) and conjugation (phase II).

Cytochrome p450 catalyzes phase I reactions.

Second mechanism involves an array of enzymes that conjugate substances with other endogenous molecules. Known as phase II. Converts hydrophobic substances into hydrophilic ones that are water soluble and can be eliminated in bile or urine

Liver is also principal site of conversion of ammonia to urea via the urea cycvia the, which is a separate process.

24

LIVER--Rush

The liver is integral in which of the following steps in vitamin D metabolism?

A. Intestinal absorption
B. 1 Hydroxylation
C. 25 Hydroxylation
D. Formation of cholecalciferol
E. Both A and C

Vitamin D is either produced in the skin when 7 dehydrocholesterol reacts with UV B light to form cholecalciferol or is ingested.

Liver is integral to metabolism of fat soluble vitamins (A, D, E, K). Requires fatty acid micellization for adequate intestinal absorption, which requires bile salts made in the liver

Liver also plays role in activation steps, 25 hydroxylation. It then undergoes 1 hydroxylation in the kidneys to arrive at its metabolically active form, which is important in the homeostasis of calcium and phosphate

25

Liver--Rush

In a patient with obstructive jaundice, which of the following enzymes is usually elevated?

A. ALP
B. Leucine aminopeptidase
C. GGT
D. 5' Nucleotidase
E. All of the above

E.

AST, ALT and LDH are indicators of integrity of the cell membrane and elevated levels reflect hepatocyte injury with leakage. Levels are usually mildly or moderately elevated in pure obstructive jaundice

ALP, 5' nucleotidase, leucine aminopeptidase, and GGT reflect the excretory capacity of the liver. Levels are typically elevated in presence of extrahepatic biliary obstruction or intrahepatic cholestasis. Elevations also seen in patients with hepatic parenchymal disease or liver tumors

Transferrin and albumin levels decrease with liver disease b/c they reflect changes in liver function and nutritional status.

26

LIVER--Rush

Which of the following operative techniques limits blood loss during major hepatic resection?

A. Portal triad clamping
B. Normothermic total hepatic vascular isolation
C. Total hepatic vascular isolation with venovenous bypass
D. Anesthesia with low CVP
E. All of the above

E

Hemorrhage is a major hazard during division of hepatic parenchyma and life threatening hemorrhage is most commonly from hepatic veins.

Intraoperative technique to avoid this problem. Disadvantage of any vascular occlusion is potential for ischemic injury to the liver, particular in patients with underlying hepatocellular disease.

Occlusion of portal triad (Pringle) can be useful for limiting bleeding from hepatic artery and portal vein. Periods of occlusion should not exceed 20 mins.

Total hepatic vascular isolation requires occlusion of IVC above and below the liver, in addition to the Pringle maneuver. Can be complex and not well tolerated.

Venovenous bypass, which has been commonly used during liver transplant, a has also been applied to major hepatic resections at some centres.

Attempts to protect liver during vascular occlusion via local hepatic hypothermia or systemic steroids have not been successful.

Anesthesia with low CVP minimizes hepatic venous bleeding by fluid restriction, head down positioning, and vasodilator effects of anaesthetics. Low CVP during hepatic resection decreases need for perioperative blood transfusion. Has low rates of mortality and post operative renal compromise.

27

LIVER--Rush

Resection of hepatic metastasis has most clearly benefited patients with which of the following cancers?

A. Colon
B. Breast
C. Stomach
D. Pancreas
E. Lung

A

Resection of hepatic mets from CRC provides clear survival advantage over any other tx and should be performed when possible. 5 yr survival is 25% and as high as 40% in favourable subgroups.

Resection of metastatic neuroendocrine tumor (e.g. Carcinoid, insulinoma, gastrinoma) can be valuable fro controlling symptoms of excessive endocrine secretion

Hepatic resection for mets from portal sites (e.g. Stomach, pancreas and biliary) or nonportal sites (e.g. Lung, breast, melanoma, gyne,. H&N, and renal) has been more limited and results have not been as encouraging. Occasionally resection of isolated hepatic met is curative. However natural hx of noncolorectal primary is such that isolated mets to liver rarely develop.

Hepatic resection for direct, contiguous growth of the primary tumor (stomach and biliary) into liver sometimes produces long term survivors

28

LIVER--Rush

50F incidentally found to have a 4 cm hepatic cyst with no internal echoes on U/S. Which of the following would be the most appropriate management?

A. Observation of the cyst
B. Tamoxifen to prevent enlargement
C. Resection b/c of risk for hemorrhage
D. Percutaneous aspiration for cytologic study
E. MRI for further characterization of cyst

A

Simple, non parasitic hepatic cysts are presumed to be congenital. Single or multiple. More common in women. Usually asymptomatic. Absence of internal echoes is diagnostic of simple rather than complex cyst, a cystic neoplasm or solid lesion. No further intervention is indicated for asymptomatic liver cysts when diagnosis is certain on U/S, CT or MRI. If dx of simple cyst is made on U/S, no need for MRI. Complications such as hemorrhage or infection are rare. Not premalignant. Exogenous hormones are not recognized to be harmful, nor antihormonal therapy indicated.

Occasionally large cysts are symptomatic from local pressure, which may cause biliary obstruction. Tx is operative resection or unroofing. Open or laparoscopic. Percutaneous drainage or injection of alcohol or other sclerosing agents does not suffice and is not recommended. If cyst is found to communicate with bile ducts, either excision or Roux-en-y cystgastrostomy

29

LIVER--Rush

30M Hispanic man visiting from Mexico come to ER with a hx of 2 was of RUQ pain and tenderness, F/C, and diarrhea. He is febrile to 102.9. His HR and bp are 120 beats/min and 100/75 mm Hg. Lab results including a WBC of 16, AST 50 and ALT 93. U/S of abdo shows a 4x7 round, hypoechoic, non homogenous lesion with a smaller adjacent lesion measuring 2x2 cm. Which of the following is the most appropriate course of action?

A. Observation
B. Open surgical drainage
C. Broad spectrum abx and percutaneous drain
D. Serologic testing for Entameoba histolytica and oral flatly
E. Therapeutic FNA

Pyogenic and amebic liver abscess may present similarly with fever and pain

Pyogenic--> E. coli or other gram neg bacteria. Strep, anaerobes and Bacteroides. Most frequent source is contiguous infection in biliary tract (i.e. Cholangitis). Other sources include infectious foci within PV drainage system, direct extension from perihepatic sites, and hematogenous spread. R lobe most commonly affected (streaming effect from PV). ~20% are cryptogenic. Dx on clinical findings and hepatic imaging and may be confirmed by FNA. Tx usually requires operative drain or percutaneous approaches. Abx alone may suffice for multiple, small abscesses.

Amebic are cause by protozoan entamoeba histolytica which is spread feco-orally. Ingested cysts pass into intestines, where trophozoite is released and transmitted to colon. Invade colonic mucosa and reach liver via PV. In liver, results in liquefaction necrosis (anchovy paste). Usually Protozoa not isolated from abscess b/c they are located in peripheral rim of tissue. Dx requires hepatic imaging (U/s or CT) and serologic testing for E. histolytica antibodies, as well as Hx & Px. This patient is from an endemic region who has signs and symptoms of liver abscess. Lack of rim enhancement on imaging suggests dx of amebic abscess rather than pyogenic abscess. Hepatic amebiasis is rx with amebicidal drugs, which flagyl being the choice. Percutaneous aspiration may be indicated if does not respond to tx or dx is in question. Percutaneous or operative drainage is also indicated in the presence of secondary bacterial infection, which occurs in 10%

30

LIVER--Rush

50F complains of 4 month hx of RUQ pain and nausea. Her VS are stable and she is afebrile. Her physical exam is unremarkable except for hepatomegaly. U/S of the abdomen shows an 8 cm well circumscribed cyst with a rosette appearance. What is the preferred tx of this patient?

A. Pericystectomy
B. Percutaneous catheter drainage
C. Transperitoneal surgical drainage
D. Metronidazole
E. Albendazole

A

Echinococcus granulosus is responsible for most hydatid disease of the liver. Usually a unilocular process involving the R lobe, although may manifest as multiple cysts. Complications include intrabiliary, intraperitoneal, or intrapleural rupture, secondary infection, anaphylaxis and mass replacement of liver.
Calcified wall and can be dx serologically by indirect hemagglutination tests, complement fixation tests, serum immunoelectrophoresis and formerly the Casoni skin test
CT and U/S may demonstrate daughter cysts (hydatid sand) or granddaughter cysts (rosette appearance) within the cyst
Tx is primarily surgical. Percutaneous aspiration is contraindicated b.c of risk of intraperitoneal dissemination
Principles of surgical therapy are to avoid spillage and remove the entire germinal layer (pericyst). Resection is usually accomplished with pericystectomy. Anatomic hepatic resection is not generally required but may be used. Surgery in addition to preop and postop benzimadole has been shown to be effective
20% of echinococcal cysts exhibit biliary communication, assessment by pre-op ERCP or intraop cholangiography is important in any patient with jaundice, cholangitis, elevated liver enzymes or bile noted during resection. Scolicidal agents should be used with caution b/c of risk of sclerosing the bile ducts in the event the agent finds its way into the biliary system.

31

LIVER--Rush

28 y.o. asymptomatic, white woman is incidentally found to have a 3.5 cm hypervascular lesion with a central scar in the right lobe of her liver On delayed images, there is increased uptake of contrast in the scar in comparison with surrounding liver parenchyma. She is healthy and takes no meds. Liver enzyme and AFP are within normal limits. Which of the following is the most appropriate management of this patient?

A. Open Liver Resection
B. Open Surgical Therapy
C. Observation
D. Chemoradiation
E. Hepatic Artery Embolization

C

Patient has focal nodular hyperplasia which is often found incidentally on imaging or during laparotomy. Benign liver tumor that predominantly occurs in women in 30-50s.

Similar to hepatic adenoma with important differentiating clinical and histologic features as well as therapeutic indications. Both occur most commonly in women of childbearing age, however HA is assoc with OCP, anabolic steroids and glycogen storage diseases. HA is usually symptomatic (80%) and is assoc w/rupture and bleeding in a substantial portion of patients whereas FNH is asymptomatic and found incidentally. HA has potential for malignant transformation, whereas the risk of malignancy in FNH is unlikely but uncertain. Histologically, HA consists of hepatocytes without bile ducts or Kupffer cells. FNH contains Kupffer cells along with a central stellate scar surrounded by fibrous tissue. Scanning for Kupffer cell activity with technetium 99m labeled soulful colloid is useful in differentiating the lesions.

B/c of asymptomatic nature of this patient, small size and negligible risk for malignant transformation, observation is appropriate. Surgical resection is reserved for symptomatic patients or when dx is uncertain

32

RUQ abdominal pain develops in a 25F taking OCPs. CT demonstrates a hypodense, 6 cm mass in the R lobe of the liver. A Tc99m labeled scan reveals a defect in the area of the mass. Angiography reveals a hypervascular tumor with a peripheral blood supply. Which of the following is the appropriate management?

A. Discontinuation of OCPS and observation with serial CT
B. Percutaneous needle bx
C. Hepatic Resection
D. Arterial Embolization
E. Radiation Therapy

C

Imaging characteristics are typical of hepatic adenoma. B/c HA does not contain Kupffer cells, it does not take up radioisotope. Useful for differentiating HA from FNH but not necessarily from other masses.

Percutaneous bx of HA is not advisable b/c of risk of hemorrhage. HA assoc with OCPs tend to be larger and have a higher risk of bleeding. Regression does not reliably occur with cessation of OCPs. However, for lesions < 4 cm, a trial of cessation of OCPs or steroids with observation may be attempted. Resection is indicated for most suspected HAs, particularly for symptomatic lesions, for patients not taking OCPs, and if the dx is uncertain. Embolization may be useful for treating hemorrhage in a patient whose HA is inoperable or hemodynamically unstable from rupture. Radiation has no role in management of HAs.

33

LIVER--Rush

Asymptomatic 45F found to have a 4 cm liver mass. CT demonstrates an initial hypodense lesion with peripheral to central enhancement by contrast. MRI shows a dense T2-weighted phase. Which of the following is the appropriate management?

A. Arteriography
B. Observation
C. Percutaneous needle biopsy
D. Resection
E. Radiation Therapy

Hemangiomas are most common benign liver tumor and occur in 7% of the population.
Characterized by collection of dilated blood vessels that can be dx by their appearance on noninvasive imaging. Contrast enhanced CT reveals a typical pattern of enhancement (peripheral to central). Dense T2 weighted image on MRI is sensitive (although not specific). Radiolabeled RBC scan can also dx hemagiomas. Angiography would likewise be diagnostic but is not necessary.
Usually asymptomatic and can be observed. Do not have a high risk for spontaneous bleeding. Resection by enucleation is appropriate for symptomatic lesions, enlarging lesions, or if the dx is uncertain. No established role for arterial ligation, embolization or radiation.

34

LIVER--Rush

Hepatocellular carcinoma is epidemiologically associated with all of the following except:

A. Hepatitis A infection (HAV)
B. Hepatitis B infection (HBV)
C. Hepatitis C infection (HCV)
D. Wilson disease
E. Alcoholic cirrhosis

Primary HCC is the most common malignant neoplasm worldwide. Endemic areas include sub-Saharan Africa, SE Asia, and Japan.
Primary RF are chronic liver disease with cirrhosis from any cause, chronic infection with HBV or HCV, and various hepatotoxins. Can also develop in patients with liver disease related to alcohol abuse, hemochromatosis, alpha 1 antitrypsin deficiency, Wilson's disease, HA, and other conditions. Exogenous RFs include dietary aflatoxins (found in grains, dairy products and peanuts), OCPs, anabolic steroids, vinyl chloride and certain pesticides. HAV is not assoc with HCC

35

Which of the following statement is true regarding intrahepatic cholangiocarcinoma?

A. Survival following resection is generally lower than that for distal bile duct cancer
B. Resection is contraindicated unless histologically negative margins can be obtained
C. The best survival is achieved with liver transplantation
D. Adjuvant chemotherapy improves survival following resection
E. None of the above

A

Cholangiocarcinoma arises from the bile duct epithelium and can occur anywhere along the biliary tract. 5-20% of primary liver cancers.

Tumors arising from extrahepatic ducts differ from intrahepatic in terms of their clinical findings. Extrahepatic tumors manifest as biliary obstruction. Intrahepatic tumors appear similar to HCC with absent or vague symptoms, such as, pain, wt loss, nausea and anorexia

Tx is surgical excision, which is assoc with 15-20% 5 year survival rate. Prognosis is best for tumors of distal bile ducts that can be resected by Whipple. Tumors involving bifurcation of bile duct (Klatskin) are less often resectable. Tumor size and presence of satellite nodules are correlated with outcome. Histologically neg margins are always desirable but prolonged survival can be attained even with microscopically involved margins. If the tumor cannot be resected, improved survival has been noted with bypass or stenting. Liver transplant for cholangiocarcinoma has been associated with freq recurrence and has not generally been encouraged. Adjuvant chemo has not been typically useful for bile duct cancer.

36

Liver--Rush

60 y.o. African American man w/ a hx of R hemi for colon ca comes to the office for a routine FU. His labs are significant for CEA of 80. CT of the chest/abdo/pelvis show an isolated hepatic lesion in the R lobe of the liver suspicious for a metastasis. Which of the following is the best management option?

A. Chemo alone
B. Chemo and radiation
C. Colonoscopy and hepatic resection
D. Hepatic Resection
E. Chemoembolization

C

Surgical resection remains gold standard for select patients with hepatic mets from CRC

Systemic chemo alone is ineffective w/1 yr survival rate of 20-30% whereas, surgical resection has a cure rate of 20% in appropriately selected patients.

Careful pre-op patient selection is paramount. Inadequate liver reserve, presence of of extrahepatic mets (except limited pulmonary mets or colonic anastomotic recurrence), total hepatic involvement, advanced cirrhosis and IVC or PV invasions are considered contraindications to curative resection.

Goal is to resect all hepatic disease. Survival is adversely affected by positive margins or margins <1 cm. As long as resection margin is adequate, specific type of liver resection (anatomic vs wedge) does not influence survival.

Synchronous lesions discovered at time of initial operation for CRC may be removed at the original operation if length of original procedure, general condition of the patient, extent of hepatic resection, and experience of surgeon allow such resection. Otherwise resection can be performed at a later date. The patient should undergo surveillance colonoscopy to evaluate for local recurrence, as well as resection of the isolated metastatic lesion.

Hepatic arterial infusion of chemo agents has higher response rate than systemic administration, although adjuvant chemo has not prolonged survival following hepatic resection in randomized studies. Radiation therapy is not useful for hepatic mets. Ablative therapies, such as RFA, may be useful for patients who cannot undergo resection

37

LIVER--Rush

Which of the following is the most accurate method for identifying hepatic metastases?

A. Transabdominal US
B. CT
C. Laparoscopy
D. Intraoperative palpating
E. Intraoperative US

E

Transabdominal US is as accurate as CT for detecting liver tumors that are 2 cm in size or larger. For smaller lesions, CT is more accurate, although it can miss the smallest lesions (<1 cm).

Laparoscopy is useful for identifying small metastases on the liver or peritoneal surfaces that escape discovery by noninvasive pre-op imaging. Has been incorporated into the staging work up. However one of its limitations is its ability to assess the interior surface of solid organs.

Well recognized that intraoperative us is the most accurate method for detecting and assessing hepatic tumors. Not only does it discover more lesions than any other modality (including palpating) but it also clearly demonstrated the anatomic relationship of tumors to important vascular structures, which is a critical determinant of respectability and extent of resection necessary. Affect surgical management of 1/3 to 1/2 of patients.

38

LIVER--Rush

56F with cirrhosis of the liver secondary to ETOH abuse has had worsening mental status that has now progressed to hepatic coma. Which of the following can be used for initial treatment of a patient in hepatic coma?

A. Reduction of dietary protein to 50g/day or less
B. Control of active bleeding
C. Lactulose
D. Neomycin
E. All of the above

E

Tx of hepatic encephalopathy is aimed at limiting the nitrogen that the liver must metabolize by eliminating nitrogenous material from the GI tract and by inhibiting its absorption. At the same time, precipitating causes are sought and treated.

Nutritional support is important and can be initiated with standard amino acids and restriction of dietary protein. Cessation of GI bleeding from varicose is important step in deducting the conversion of intraluminal blood to ammonia. Lactulose acts as a cathartic and also inhibits the absorption of ammonia by acidifying the colon. No absorbable ABX, such as neomycin and kanamycin, reduce colonic flora and production of ammonia. Systemic Abx may be useful for tx specific infections that precipitate encephalopathy but are not indicated empirically. B/C the colon is the major site of ammonia absorption, colon resection or exclusion has been suggested to improve encephalopathy but it is not a widely used therapeutic measure.

39

LIVER--Rush

43M with alcoholic cirrhosis has had increasing abdo distension over the last month. His vitals are stable and he is afebrile. Physical exam reveals a distended abdo w/a fluid wave. The initial management of the patient's ascites should include all of the following except:

A. Transjugular intrahepatic portocaval shunt (TIPS)
B. Sodium restriction
C. Diuretic administration
D. Fluid restriction
E. Diagnostic para centres is

A

Ascites is the most common major complication of hepatic cirrhosis. It is assoc w/ a 2 yr survival of 50% and its onset in a cirrhotic patient should prompt an evaluation for liver transplant

Tx of ascites depends on its cause and therefore diagnostic paracentesis is reqd after an H&P. Abdo U/S can confirm the presence of ascites if it snot certain by exam. The serum-ascites albumin gradient is useful diagnostically. High gradient (>1.1) indicated portal HTN and suggest the patient will be responsive to medical management.

Medical management consists of sodium restriction (2000mg/day) and oral diuretics. Usually both spironolactone and furosemide are administered to produce fluid loss and natriuresis. Spironolactone alone may cause hypoklalemia and furosemide alone is less effective. Medical therapy controls ascites in 90%

When ascites is refractory, serial therapeutic paracenteses (+/- albumin) is indicated. Liver transplant is the ultimate treatment.

A peritoneovenous shunt is an option for patients with refractory ascites who are not transplantation candidates or who cannot undergo repeated paracenteses. Many complications and do not prolong survival.

Transjugular intrahepatic portosystemic shunts or operative side to side type portosystemic shunts may control ascites in select patients.

40

LIVER--Rush

Which of the following is an indication for TIPS?

A. Recurrent varicella bleeding
B. Ascites
C. Spontaneous bacterial peritonitis (SBP)
D. Hepatorenal syndrome
E. Portal gastropathy

A

Portal HTN is responsible for the majority of the morbidity and mortality assoc with cirrhosis, such as variceal bleeding, refractory ascites, and hepatic hydrothorax.

1st line therapy with primary variceal bleeding is endoscopic therapy with variceal band ligation or sclerotherapy. There is a high risk for rebelling not amenable to endoscopic techniques (refractory bleeding) or continuation of bleeding (recurrent bleeding).

Transjugular intrahepatic portosystemic shunt procedure decompressed the portal system by creating a portosystemic Shuang and has been effective in up to 90%

Primary tx of ascites is medical management, although in patients with refractory ascites that is unresponsive to sodium restriction, high dose diuretics, and other medical therapies, TIPS does improve their ascites. However, there is no survival benefit in this population.

Hepatorenal syndrome, SBP, and portal gastropathy are not indications for TIPS

41

LIVER--Rush

Which of the following statement is true regarding SBP?

A. The diagnosis can be made clinically without paracentesis
B. Infection is most commonly polymicrobial
C. Antibiotic therapy is reserve for patients with positive findings on ascitic fluid culture
D. Gram-negative enteric bacteria are often present
E. None of the above

D

SBP is a potentially lethal complication of ascites that affects about 10% of patients with cirrhotic ascites. Fever and abdo pain are common manifestation but the S&S may be subtle. Dx requires paracentesis with demonstration of an elevated ascitic fluid PMN count (>250) or positive findings on culture.

Abx therapy should be initiated promptly based on an elevated ascitic fluid PMN count or on symptoms even if the PMN is lower. Infection usually from one organism, most commonly E.coli, Klebsiella, or pneumococcus. 3rd gen cephalosporin is typically preferred Abx.

Differentiation from SBP secondary to a surgical condition is critical. Patients with SBP typically respond to Abx within 48 hrs and ascitic PMN counts decreases. Failure to improve, presence of polymicrobial infection, or ascitic fluid with a total protein >1 g/dL, LDH > than serum, or glucose <50 mg/dL suggests secondary peritonitis.

RF for SBP include previous SBP, variceal hemorrhage, and low protein ascites (<1.0 g/dL). Short or long term Abx Ppx may be appropriate for high risk patients

42

LIVER--Rush

With regards to hernias in patients with ascites, which of the following statements is true?

A. Increased abdominal pressure is one cause of umbilical hernias in patients with ascites
B. Umbilical recurrence rates for patients with and without ascites are the same
C. Patients with asymptomatic groin hernias should be treated surgically
D. Pre-operative paracentesis is not a helpful strategy for electively repairing these hernias
E. All of the above

A

Umbilical and less frequently, inguinal hernias occur in ~20% of patients with ascites. Develop as a result of increased intra-abdominal pressure, muscle wasting, fascial thinning, and nutritional deficits.

Recurrence rate following repair of umbilical hernias in patients with ascites may be as high as 73%. B/c of high complication rate following hernia repair, it should not be entertained for asymptomatic hernias. Pre-op optimization with paracentesis helps decrease intra-abdominal pressure. Ascites leakage following a surgical procedure should be treated aggressively and early wound exploration with repair of fascial dehiscence is necessary. Diuretic therapy alone is ineffective in this situation.

43

LIVER--Rush

Which of the following is a contraindication to radiofrequency ablation (RFA) of liver tumors?

A. Proximity of the tumor to major vascular structures
B. Multiple lesions
C. In conjunction with liver resection
D. Metastatic colon cancer
E. None of the above

E in answer key. Not sure about A though--> heat sink effect

RFA is a technique in which a needle electrode is inserted into a malignant liver tumor. A radiofrequency generator is connected to the electrode, which produces localized tumor destruction with coagulation necrosis as the temp of the tissue exceed 50 degrees Celsius. Introduction of the electrode can be performed through a laparotomy incision, laparoscopically, or even percutaneously with the use of U/S guidance.

Used in HCC as well as liver mets from CRC. Some institutions combine the treatment with resection when multiple lesions are involved and resection alone would not leave enough viable hepatic parenchyma. RFA works well when the lesions are close to major vascular structures. The maximum size of lesion that can be a latex by RFA is unclear b/c multiple applications can be used but it does apprear to be more effective on smaller lesions (<5 cm to 6 cm)

From Uptodate: In addition to size, local efficacy is also affected by proximity of the lesion to large blood vessels (≥3 mm). In a histologic study of explanted livers from 24 patients with HCC undergoing RFA prior to liver transplantation, the rates of complete necrosis for tumors with nonperivascular and perivascular locations were 88 and 47 percent, respectively. It is speculated that blood flow in these large abutting vessels carries heat away from the lesions, known as the "heat sink" phenomenon

44

LIVER--Rush

8 weeks after open heart surgery with transfusion, a 56M notes dark urine, fatigue, and anorexia. Physical exam discloses only mild, tender hepatomegaly. Lab investigations reveal bilirubin of 2, AST 540, ALT 630, ALP 1120, and neg assay results for HepBsAg, Hep B core Ab, immunoglobulin M anti-HAV antibody (IgM), and anti-HCV antibody (anti-HCV). Which of the following is the most likely explanation for the patients clinical condition?

A. Acute viral hepatitis A
B. Acute viral hepatitis B
C. Acute viral hepatitis C
D. Acute viral hepatitis D
E. Acute viral hepatitis E

C.

Post transfusion non-A, non-B hepatitis is mostly the result of HCV infection. The incubation period is usually 5-10 wks and the mean peak aminotransferase levels are 500 to 1000 IU/L

Anti-HCV antibody is commonly not detectable until 18 wks after acute onset of illness. Approx 70% of patients with acute hep C progress to chronic hepatitis and potentially cirrhosis.

The negative serologic study results exclude acute infection with HAV and HBV. Hep D is capable of infecting only patients who also have Hep B bc HDV is a an incomplete RNA virus. Hep E (epidemic) virus is rare, except in association with water borne epidemics in India, the Middle East, and South America

45

LIVER--Rush

Which of the following clinical conditions is indicated by the presence of serum antibodies against hep B surface antigen (Anti-HBs) and anti HBc in the absence of HBSag

A. Active, acute infection with HBV
B. Normal response to vaccination with the hepatitis B vaccine
C. Chronic active hepatitis secondary to HBV
D. Recovery with subsequent immunity following acute hepatitis B
E. Asymptomatic chronic carrier to HBV

D

Pattern of neg HBsAg, pos anti-HBs and pos anti-HBc assays is seen during the recovery phase following acute hepatitis B and clearance of HBsAg from the liver. The antibody pattern may persist for years and is not assoc with liver disease or infectivity.

Vaccination with Hep B vaccine is assoc with development of anti-HBs antibody alone

Active, ongoing infection with HBV whether acute hepatitis, chronic active hepatitis or asymptomatic chronic carrier is manifested by presence of HBsAg and anti-HBc in serum

46

Liver

All except which of the following can be used to differentiating between FNH and adenoma?

A. Color
B. Surface vascularity
C. Texture
D. Size
E. Solitary vs multiple

D

Resect adenoma if symptomatic, > 5 cm, growing on interval imaging while off OCPs or planning pregnancy

47

Liver

In addition to endoscopic sclerotherapy, what is the best medical therapy in acute bleeding varices:

A. Vasopressin
B. Beta blocker
C. Nitrates
D. Somatostain

D

48

Liver

Portal vein thrombosis is associated with all except

A. Hypersplenism and thrombocytopenia
B. Elevated splenic pulp pressure
C. Esophagogastric varices
D. Hypersplenism and leukopenia
E. Elevated hepatic wedge pressure

E

Results in decreased hepatic wedge pressure

49

Liver

All except which of the following is true with respect to liver anatomy:

A. Bile duct run in between sectors
B. Hepatic veins run in between sectors
C. L and R lobes divided by plane going through the gallbladder fossa
D. Segment IV is also called the quadrate lobe
E. Segment IV is also called the medial segment of the L lobe

A

50

Liver

Which of the following is not part of the Milan criteria?

A. Single tumor < 5 cm
B. 3 tumors < 3 cm
C. No extrahepatic involvement
D. No major vessel involvement
E. Single tumor < 7 cm

E

Milan Criteria to assess suitability for transplant

51

LIVER

All except one of the following are main tributaries of the portal vein?

A. Splenic vein
B. SMV
C. IMV
D. L gastric vein
E. R gastric vein

C

Main tributaries of the portal vein in addition to the splenic and SMV include:
-R and L gastric veins
-Cystic veins
-Para umbilical veins

IMV is a tributary of splenic vein

52


LIVER

Definition of an isograft

A. Mother to daughter
B. Same species but different individuals
C. Identical twins
D. Within the same individuals
E. Between difference species

C

Isograft is a graft of tissue between two individuals who are genetically identical (monozygotic twins). Transplant rejection virtually never occurs

Allograft is a graft of tissue between different individuals but same species (e.g. Strangers, mother to daughter)

Autograft is a graft of tissue from the same individuals

Xenografts is a graft of tissue from different species

53

LIVER

Worldwide main risk factor for HCC

A. Hep C
B. Alcoholic cirrhosis
C. Hep B
D. NASH

C

Hep B does not require cirrhosis before HCC forms
In Hep C and EtOH, cirrhosis occurs before HCC

54

LIVER

Branch of the common hepatic artery
A. R gastric artery
B. Splenic artery
C. L gastric artery
D. Gastroduodenal artery
E. R gastroepiploic artery

D

Common hepatic branches to GDA, and hepatic artery proper.R gastric comes off hepatic artery proper
GDA branches into R gastroepiploic and superior pancreaticoduodenal

55

LIVER

6 week old infant presents with direct hyperbilirubinemia. All of the following are possible causes except:

A. Biliary atresia
B. Alpha 1 anti-trypsin deficiency
C. Hepatic Teratoma
D. Congenital infection with CMV
E. Choledochal cyst

C

Direct hyperbilirubinemia = conjugated = post hepatic

Biliary atresia or choledochal cyst result in duct obstruction and elevated bilis
Alpha 1 anti-trypsin deficiency results in accumulation within hepatocytes--> hepatocyte damage and cholestasis
CMV results in cholestasis and elevated bilis

Other causes include Sepsis, Hep B or C, TORCH infections, Metabolic conditions, Drugs, TPN, or idiopathic

56

LIVER

Which route is Hep A transmitted?

A. Blood transfusion
B. IV drug use
C. Feco-oral
D. Sexually transmitted
E. Tattoo

C

57

LIVER

Which of the following is characteristic of bile duct hamartoma?

A. Associated with malignant transformation
B. Can be a large intrahepatic mass
C. Congenital lesion which increases in size over time
D. Needs to be promptly resected
E. Small white raised nodule on surface often found incidentally at laparotomy

E

Biliary hamartomas or biliary hyperplasia are common and are often seen as small white surface lesions that can mimic small metastatic tumors at abdominal exploration

58

LIVER

Complications of sclerotherapy for esophageal varices include:

A. Retrosternal chest pain
B. Stricture formation
C. Recurrent bleeding
D. Necrosis and perforation of the esophagus
E. Bacteremia secondary to sclerosant

E

Sclerotherapy is associated with perforation, mediastinitis, and stricture. Retrosternal chest pain can occur from ulcer formation post sclerotherapy. Banding is the therapy of choice and associated with lower complication rate

59

LIVER

38M alcoholic with proven first time esophageal variceal bleeding. What is the treatment?

A. Vasopressin
B. Blakemore tube
C. Emergency shunt
D. Banding or sclerotherapy

D

Vasopression or ocretotide is used as a temporizing measure before and after scope but not a definitive treatment. Blakemore or TIPS is in an option with GI bleed that is not stopping despite other therapies.

60

LIVER

Patient with polycythemia Vera with hepatic enlargement, shifting dullness and malaise could be caused by:

A. Hepatic vein thrombosis
B. Portal vein thrombosis
C. Mesenteric vein thrombosis
D. Cirrhosis

A

Budd chiari = occlusion of hepatic veins that drain the liver
Primary (75%) from thrombosis of hepatic vein due to polycythemia Vera, pregnancy, post partum, OCPs, paroxysmal nocturnal hemoglobinuria, HCC, Lupus
Secondary (25) from external compression of the hepatic vein

61

LIVER

Portal vein thrombosis causes all but:
A. Varices
B. Haemorrhoids
C. Ascites
D. Testicular atrophy

D

Gonadal veins drain into the left renal vein and directly into the IVC

62

LIVER

Portal vein thrombosis without cirrhosis has all but:
A. Increased hepatic wedge pressure
B. Increased intra splenic pressures
C. Varices
D. Leukopenia

A

Leukopenia is due to splenic sequestration

63

Poor prognostic factors in cirrhosis and shunts including the following except:

A. Platelets < 70
B. Bili > 30
C. Ascites
D. Hx of coma
E. INR > 2

A

Child Pugh criteria include: albumin, bilirubin, inr, ascites and encephalopathy

64

LIVER

What is the commonest complication seen when treating ascites lasix and aldactone in cirrhotics

A. Hepatic necrosis
B. Portal vein thrombosis
C. Renal failure
D. Angiocolitis
E. Hepatic encephalopathy

C

65

LIVER

Which diuretic is contraindicated in hepatic failure
A. Lasix
B. Spironolactone
C. Amiloride
D. HCTZ

D

Dyazide diuretics (HCTZ and triamterene) can cause coma, worsening of liver failure, etc

66

LIVER

Patient has hepatomegaly but 3 liver biopsies are normal. The most likely dx is

A. Amyloidosis
B. Metastasis
C. Sarcoidosis
D. Hemochromatosis
E. Cirrhosis

C

Sarcoidosis
-50-65% have granulomas on liver box but symptomatic hepatic sarcoidosis occurs in 5-15%. Most patients asymp. Elevated ALP and GGT. Abdominal pain and pruritus in 15% and hepatomegaly in 5-15%

Amylodosis
-Most common finding is hepatomegaly (81%). Other findings include ascites (42%), edema, purpura, splenomegaly, spider angiomata. Congo red stain is required for biopsy

67

LIVER

40F has typical biliary colic with gallstones on US. Also she has a 2.5 cm lesion in the R lobe of the liver. The most appropriate next step is:
A. FNA
B. Laparotomy
C. Uninfused CT Abdo
D. Triphasic CT Abdo

C

68

34F has epicanthic pain and at US a 5 cm hyperechoic area in the R lobe of the liver. What should be done as part of the initial work up?
A. Serum AFP
B. Liver enzymes
C. CT guided liver biopsy
D. Nuclear scan
E. MRI

A (but would also order a triphasic CT)

69

LIVER

Increased ALP with otherwise normal LEs may be found in:

A. Pagets
B. Mets
C. Cholangiocarcinoma
D. Pancreatic cancer

A

Paget's disease of the bone is a disorder of bone metabolism that the aging skeleton, it is characterized by accelerated rate of bone remodeling, resulting in overgrowth of bone at single or multiple sites and impaired integrity

70

LIVER

What test will differentiate between obstructive jaundice and intrahepatic cholestasis due to drugs:

A. ERCP
B. Antimitochondrial antibody
C. ALP
D. Liver Biopsy
E. SMAb

A

If ALP elevation is isolated, confirmed to be of hepatic origin (GGT also elevated), and persists over time, chronic cholestatic or infiltration liver diseases should be considered. Most common causes include partial bile duct obstruction, PSC, PBC, and drugs such as steroids and phenytoin. Infiltrative disease include sarcoidosis, granulomatous diseases, amyloidosis, and unsuspected cancer resulting in liver mets

71

LIVER

Transhepatic cholangiography is performed with new CHIBA needle. All of the following complications are less likely to occur except:

A. Bacteremia
B. Subphrenic abscess
C. Hemobilia
D. Hematoma
E. Intrahepatic hematoma

A?

Fine needle transhepatic cholangiography: a new approach to obstructive jaundice by J Ferrucci
-Bile cannot be aspirated via the small caliber needle so am injection withdrawal technique must be used for duct opacification. This explains why bacteremia is the most common complication (3.5%)
-Bile leak and hemorrhage (1-2%)

72

LIVER

What is the most common benign liver lesion.

A. Adenoma
B. Hemangioma
C. FNH
D. Bile duct Adenoma

B

Hemangioma most common, FNH is second most common

73

LIVER

52 M undergoes laparotomy, 2 mets are found at the edge of the right lobe of the liver. After an uneventful surgery, what is your next step?

A. Close and work up lesions
B. Biopsy, close and work up lesions
C. Wedge resection of liver
D. Formal right hepatecomy

A

Different from the other question with a lesion in free edge of left lateral segment because there are multiple lesions and would require more involved resection

If a lesion looks like cancer, you don't need to biopsy it (Dr. McKay)

74

LIVER

62M having an elective sigmoid resection for cancer. At laparotomy, a 1 cm hard lesions is seen on free edge of left lobe of liver. You complete the colectomy. Now what should be done?

A. L hepatic lobectomy
B. placements of hepatic arterial catheter for post op chemo
C. Wedge resection of mass
D. Close, resect in 3 months if no further mets has arisen

C

75

LIVER

Following hepatic resection, serum levels of each of the following needs to be closely monitored except:

A. Vit K
B. Fibrinogen
C. Albumin
D. Glucose
E. ALP

A

Fibrinogen--decr. Coagulopathy peaks POD 2-5. Correlates with extent of resection. Also INR will be elevated and Plts decreased
Albumin--reflects liver function
Glucose--high post op but low in liver failure
ALP--Low but increases with liver regeneration

76

LIVER

What is the optimal management of a diabetic on steroids who develops acute cholecystitis?

A. Immediate cholecystectomy
B. Delayed cholecystectomy at 6 weeks
C. Initial Abx and chole during this hospitalization
D. Drainage of gallbladder only

A

77

LIVER

Branch of the common hepatic artery

A. R gastric
B. Splenic artery
C. Gastroduodenal artery
D. L gastric
E. R gastroepoploic

C

Common hepatic artery beyond take off of GDA is hepatic artery proper
R gastric from hepatic artery proper.

78

LIVER

Female with pancreatitis underwent a CT scan revealing 2 lesions in dome of liver. What study would be appropriate to determine the diagnosis?

A. US
B. HIDA
C. Fine needle biopsy
D. CT with contrast
E. Angio

D.

Triphasic CT or MRI Liver are both reasonable options