Liver Flashcards

Question

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 ```

Answer 1

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.

Answer 2

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.

Answer 3

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

Answer 4

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

Answer 5

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%

Answer 6

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.

Answer 7

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

Answer 8

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.

Answer 9

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.

Answer 10

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

Answer 11

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.

Answer 12

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

Answer 13

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.

Answer 14

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.

Answer 15

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.

Answer 16

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

Answer 17

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

Answer 18

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.

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

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

Answer 23

E Results in decreased hepatic wedge pressure

Answer 24

E Milan Criteria to assess suitability for transplant

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

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

Answer 32

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.

Answer 33

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

Answer 34

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

Answer 35

A Leukopenia is due to splenic sequestration

Answer 36

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

Answer 37

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

Answer 38

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

Answer 39

A (but would also order a triphasic CT)

Answer 40

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

Answer 41

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

Answer 42

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%)

Answer 43

B Hemangioma most common, FNH is second most common

Answer 44

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)

Answer 45

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

Answer 46

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

Answer 47

D. Triphasic CT or MRI Liver are both reasonable options

Liver Flashcards

(78 cards)