Liver Flashcards
(26 cards)
With regard to heaptic anatomy, the falciform ligament divides the ____________ from the __________
Left medial section, right lobe
- The plane between the gallbladder fossa and the IVC (referred to us Cantlie’s line ) divides he right and left lobes
- The falciform ligament along with the round, triangular and coronary ligaments may be divided in abloodless plane during liver resection
The most common variant of normal heaptic artery anatomy is
- Replaced right heaptic artery (10-15 %) from the SMA
- Replaced left heaptic artery from the left gastric (3-10%)
- Replaced right and left heaptic arteries (1-2%)
- Completely replaced common hepatic artery from the SMA (1-2%)
Standard arterial anatomy:
- Common hepatic artery arise form the celiac trunk
- divides into gastroduodenal and proper hepatic artery
- Proper heaptic artery gives rise to right gastric artery (variable)
- The proper hepatic artery then divides into the right and left heaptic artery
Systemic venous drainaige of the liver
- There are 3 heaptic veins
- Right
- Middle
- Left
- RIGHT : segments V to VIII
- MIDDLE : IV, V, VIII
- LEFT: II, III
- IVC : Caudate (I)
With respect to the enterohepatic circualtion of bile, where are the majority of bile salts reabsorbed?
Terminal ileum
Which of the following compounds is not synthesized predominantly by the liver
Factor VIII
- ALbumin : 10 g
- Long half life (15-20 days)
The gold standard for identifying liver lesions by imaging is
Intraoperative ultrasound
- it can identidy 20-30% more lesions than other preoperatove imaging modalities
- applications
- tumor staging
- visualization of intehepatic vascular structures
- guidance of resections plane by assessment of the relationship of a mass to the vessels,
- biopsy of lesions and ablation of tumors
The most common cause of acute lever failure in the US
Drug/toxin
- Acute liver failure is defined as development of hepatic encephalopathy within 26 weeks of severe liver injury in a patient with no history of liver disease or portal hypertension
- in developing countries:
- viral infections
A patient with painless jaundice and is found to have cirrhosis. they have no history of alvohil abuse but do note a history of diabetes mellitus and oseudogout, They also mention that multiple members in the family have suffered from cirrhosis, What is the most likely etiology for their cirrhosis?
Hemochromatosis
- most common metabolic cause of cirrhosis and should be suspected if apatient presents with skin hyperpigmentation diabetes mellitusm pseudogout, cardiomyopathy, or a family history of cirrhosis
- Chonic hepatitis C - most common cause of chronic liver disease in the US
Physiologic changes noted in patients with cirrhosis
- Elevated resting energy expenditure
- Reduced muscle and fat stores
- Icnreased cardiac output and heart rate
- Decreased vascular resitance
- Hypoalbuminemia
- Spider angiomata
- feminization of males
- portal hypertension
- caput medusae
Clinically significant portal hypertension is evident when
hepatic venous pressure gradient exceeds 10 mmHg
- HVPH = WHVP-FHVP
- Portal Hypertension
- Presinusoidal
- Sinistral/extrahepatic (splenic vein thrombosis, splenomegaly)
- Intraheaptic (Schsitosomiasos, congenital heaptic fibrosis, idopathic portal fibrosis)
- Sinusoidal
- Postsinusoidal
- intraheaptic (Vascular occlusive disease)
- post heaptic (Budd chiari, CHF, IVC webs)
- Presinusoidal
Management of an acute variceal hemorrhage
- Endoscopy with variceal band ligation
- Short term antibiotic prophylaxis (ceftriaxone)
- Vasopressin
- somatostanin analouges
- Administration of blood producrs and crystalloid (target Hgb 8)
- Nonselective B blockers (prevention)
Likelihood of a recurrent variceal bleed within 2 years when no other therapies was done
70%
grading scales for liver disease
- Model for end stage liver disease (MELD)
- predict mortality after TIPS
- Creatinine, bilirubin, INR, Dialysis, sodium
- Child Turcotte Pugh (CTP)
- predicting risk of portocaval shunt procedures
- bilirubin, albumin, INR, presence of encephalopathy, presence of ascites
- Orthoptic liver transplantation
CTP class and overallrisk of mortality
- A 10%
- B 30%
- C 75-80%
The most common complication following a TIPS
Encephalopathy
- TIPS is a percutaneous procedure used for treatment of patients who have gastroesophageal varices in the setting of portal hypertension
- Creates an uintraheaptic shunt between th portal and systemic circulation
- endovascular access through the jugular vein to a hepatic vein radical and subsequent creation of needle tract that connects it to a branch of the portal vein
- Stent is placed
Initial management of pyogenic liver
- Broad specturm IV anntibiotics
- Surgical drainage and or resection
- Percutaneous fine needle aspiration and culturee
Pyogenic liver abscess are most commonly seen on the right lobe of the liver with E. Coli the most common pathogen
(40% are polymicrobial while 20% are culture negative)
The msot common cause of benign hepatic lesion is the
Simple cyst
- More common in female
- Percutaneous cyst aspiration or sclerotherapy for large cysts that may cause mass effect
- hemangiomas are the most common SOLID BENIGN MASSES
Liver lesion that carry a significant risk of spontaenous rupture
Adenoma
- Hemangiomas are congenital vascular lesions
- 1 to 25cm
- women
- generally asymptomatic
- rupture is rare
A patient presents with a CT result that describes a well circumscribed lesion that demonstrates homogenous enhancement during arterial phase, isodensity on the venous phase, and a central scar.
Reassurance and observation
(focal nodular hyperplasia)
What is the annual conversion rate to HCC for patients with cirrhosis?
2-6%
Mayo clinical protocol for treatment of hilar cholangiocarcinoma
PAtients with hilar cholangiocarcinoma and Priamry sclerosing cholangitis
Patients with unresectable cholangiocarcinoma
patients with tumor less than 3cm in radial dimension and no evidence of intrahepatic or extraheaptic metastases
- this treatment comprises external beam radiation, 5 FU based chemotherapy and iridium 192 brachytherapy followed by operative staging and OLT in patients without metastaic disease
- 70% 5 year survival rate
A patient undergoes routine cholecystectomy and is incidentally found to have gallbladder carcinoma that is staged as T1. Further treatment is _____–
No further treatment
T2 or more = reoperation with central hilar resection and hilar lymphadenectomy
*********
Reopertation with formal lobectomy and bile duct resection
Primary determinant of sustainability for resection when evaluating a patient with hepatic colorectal mets.
Predicted volume of heaptic remant
Milan criteria for transplantation
Patients with 1 tumor less than 5cm or up to 3 tumors less than 3 cm and no evidence of gross intravascular or extrahepatic spread
