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LIVER Flashcards

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1
Q

Budd-Chiari syndrome

A

thrombosis of IVC (intrahepatic)
Or
Hepatic veins

Often hypercoagulable state

POST sinusoidal portal hypertension

Jaundiced

Diagnosed CT scan or duplex ultrasound

Initial management heparinization

Majority will require:
Nonselective portosystemic shunt (side to side)

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2
Q

most common cause of death with fulminant hepatic failure complication

A

cerebral edema from intracranial hypertension

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3
Q

Intracranial hypertension associated with contraindication liver transplant

A

intracranial pressure greater than 50

Cerebral perfusion less than 40

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4
Q

focal nodular hyperplasia

A

over colloid scan-technetium 99

easily not symptomatic no risk of rupture no risk of malignancy

Central scar enhances on the arterial phase

Peripheral

KUPFFER cells’s cells positive

embryologic vascular injury

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5
Q

preoperative portal vein embolization

A

and is atrophy to planned area of resection causes compensatory hypertrophy

percutaneous transhepatic approach

Indicated when remnant of the liver volume expected to be less than 40% with normal liver function and less than 50% with abnormal liver function

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6
Q

with factors his warfarin block in the liver

A

vitamin K dependent:

2, 7, 9, 10

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7
Q

clotting factor is shortness half-life

A

7

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8
Q

deficiency and factor VII

A

prolonged INR

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9
Q

compare pyogenic abscess with amoebic abscess

A

anemic 10-1 male
Pyogenic 1.5-1 male

Abscesses of the liver all comers 75% RIGHT

pyogenic multiple
pathogenic and amoebic alcohol

Pyogenic perk drainage
Amoebic metronidazole

amoebic mortality 2-4%
Pyogenic mortality–20%

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10
Q

liver hemangioma

A

most common benign tumor of the liver
More and one in
Most asymptomatic
Giant cavernous hemangioma greater than 5 cm-rarely associated with KASABACH-MERRITT syndrome
diagnosis CT scan and MRI; radial labeled RBC scan reserved with CT/MRI nondiagnostic

if surgical resection indicated: Enucleate

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11
Q

KASABACH-MERRITT syndrome

A

seen with hemangioma of when there is intervascular coagulation and platelet trapping causing activation and consumption of coagulation factors

can lead to congestive heart failure-this is seen and cared

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12
Q

describe MRI findings of hemangioma

A

T1 and low signal intensity with peripheral nodular enhancement

T2 high signal intensity

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13
Q

most common cause of pre-sinusoidal intrahepatic hypertension

A

schistosomiasis (liver fluke)- intrahepatic
left common congenital hepatic fibrosis
Portal vein splenic vein thromboses extrahepatic

associated with preserved liver function when pre-sinusoidal

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14
Q

Intrahepatic portal hypertension causes

A

cirrhosis:
alcoholism
hemachromatosis
Wilson’s disease

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15
Q

Post- to thesinusoidal portal hypertension

A

Budd-Chiari (intrahepatic IVC)

Congenital web

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16
Q

TIPS

A

indication: Variceal bleeding
Also useful for ascites
Nonselective shunt

Increase encephalopathy

one year patency approximately 50%

absolute contraindication:
Polycystic liver disease
right heart failure - significant increase in venous return

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17
Q

Distal splenorenal shunt

A

not used emergent setting-time-consuming

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18
Q

Medial caval shunt

A

Best choice for urgent bleeding without compromising future transplantation efforts

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19
Q

primary bile acid

A

colic acid
chenodeoxycholic acid
made in the liver from cholesterol then conjugated in hepatocytes

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20
Q

secondary bile acids

A

deoxycholic acid
lithocholic acid

formed by intestinal bacteria modification of primary bile acid

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21
Q

where our bile acids resorbed passively

A

jejunum and ileum

the distal ileum resection resulting fat malabsorption and fat soluble vitamin deficiencies

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22
Q

effective eating food on the concentration of bile acid

A

bypass the concentration and the liver decreases by inhibition cholesterol 7 hydroxylase - resultant increase bile acid secretion in the liver

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23
Q

average size of adult liver

A

1500 g

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24
Q

round ligament

A

obliterated umbilical vein

Enters front edge of the falciform ligament

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25
the falciform ligament
connected to round ligament (obliterated umbilical vein) Separate segments 3 from segment 4
26
Couinaud line
line drawn from hepatic vein to common bile duct
27
what percentage of blood supply to the liver comes from hepatic artery
25% | 75% of hepatic blood comes from portal vein but this is not percentage of oxygenated blood
28
replaced right hepatic artery
was common variant Originates from SMA traverses posterior to the portal vein and takes a right lateral position before dividing into the liver parenchyma
29
replaced left hepatic artery
from left gastric artery
30
completely replaced common hepatic artery
comes off of the SMA
31
what is right hepatic vein drain
segments 5 through 8
32
middle hepatic vein drain
segment for | Also drains 5 and 8
33
left hepatic vein drains
segments 2 and 3
34
caudate lobe drainage
this a segment one | Direct venous transients into inferior vena cava
35
a medial acid associated with conjucation of bile acids
glycine
36
mechanism of injury of acetaminophen overdose to liver
toxic metabolites the P450
37
Naturally occurring portal venous shunt
``` GE junction Anal canal Falciform ligament Splenic venous bed LEFT renal vein Retroperitoneum ```
38
Normal portal venous pressure
5-10
39
liver test most specific for liver disease
a
40
function of AST and ALT
AST glutamic-oxaloacetic transaminase ( found in the liver, cardiac muscle, skeletal muscle, kidney, brain, pancreas, long, RBC) aspartate acid or alanine to ketoglutaric acid to produce oxaloacedtic acid ALT (found predominately in the liver) Glutamic-pyruvic transaminase GPT
41
alkaline phosphatase
also found and bony kidney
42
treatment of acetaminophen overdose
Activated charcoal may help N-acetylcysteine is the antidote
43
indirect bilirubin
unconjugated Associated with: Intrahepatic cholestasis Hepatocyte dysfunction Direct causes of increased indirect bili: Hemolytic disorders Resorption of hematoma
44
direct bilirubin
conjugated Associated with: Obstruction- Biliary atresia, pancreatic cancer, murky syndrome
45
Gilbert's syndrome
diminished activity of glucuronyltransferase increase unconjugated (indirect) bilirubin Symptoms are self-limited did not require treatment even with bilirubin of 5.2 and flulike illness
46
T most common cause of acute liver failure
USA: Drug ingestion Were wide: Viral infection- hepatitis B Hepatitis A! hepatitis E
47
electrolyte finding associated with improved prognosis for patient with acute liver failure
HYPO-phosphatemia the still needs to be corrected with IV administration of phosphorus
48
Child's class
Bili less than 2/2-3/greater than 3 Albumin: Greater than 3.5/2.8-3.5/less than 2.8 INR: Less than 1.7/1.7-2.2/2.2 Encephalopathy: None/controlled/uncontrolled Ascites: None/antral/uncontrolled A.: 5-6 surgical mortality 10% B.: 7-9 surgical mortality 30% C.: 10–15 surgical mortality 75-80%
49
pre-sinusoidal portal hypertension causes
``` PRE-sinusoidal EXTRA-hepatic (Sinistral / Left): Splenic vein thrombosis Splenomegaly Splenic AV fistula ``` ``` INTRA-hepatic: schistosomiasis Congenital fibrosis Nodular hyperplasia Myeloproliferative disorder graft-versus-host disease idiopathic fibrosis ```
50
sinusoidal portal hypertension
``` SINUSOIDAL INTRA- hepatic Cirrhosis: Viral Alcohol Primary biliary cirrhosis primary sclerosing cholangitis Autoimmune hepatitis metabolic abnormality ```
51
post surgical portal hypertension causes
POST-sinusoidal INTRA-hepatic: vascular occlusive disease ``` POST-hepatic: Budd-Chiari Congestive heart failure IVC caval web Constrictive pericarditis ```
52
management of child B massive variceal bleed
Somatostatin (octreotide) bolus plus continuous infusion IV-splenic vasoconstriction can be missed in 5 days or longer second choice: vasopressin 0.2-0.8 IV Dashcode and vasoconstrictor - only given short term EGD lavaged
53
treatment of bleeding varices in the greater curvature of the stomach in a patient with patent splenic vein
gastric varices along greater curvature implies splenic vein source ?first try gastric variceal obturation with: N-butyl-cyanoacrylate (glue?) If this fails: TIPS
54
basic definition of Budd-Chiari syndrome
obstruction of hepatic venous OUTFLOW this is hepatic vein to IVC (NOT portal vein)
55
Most common organism isolated from hepatic abscess ( and others in order prevalence)
Escherichia coli over 60% strep faecalis Klebsiella Proteus vulgaris anaerobic colon Bacteroides fragilis Endocarditis or indwelling catheter: Staphylococcus Streptococcus
56
Described the relationship of the structures in the hepatoduodenal ligament
common bile duct right anterior Hepatic artery left anterior Portal vein posterior
57
developmental cause of focal nodular hyperplasia
and right disturbance and liver blood flow - Lesions are usually in periphery of liver
58
Normal portal vein pressure
3-5
59
Best screening for hepatocellular carcinoma
Ultrasound and AFP
60
disadvantage of side-to-side shunt
increases in encephalopathy and liver is bypassed and no longer clearing
61
what does TIPS stand for
transjugular intrahepatic portacaval shunt
62
when do you resect hepatic adenoma
greater than or equal to 3 cm strongly recommended greater than 4 cm resected symptomatic less than 3 cm asymptomatic observe
63
CT findings of hepatic adenoma
Fully enhances
64
When do you use tips
good for varices not as good for ascites but can help bad for encephalopathy
65
medical treatment of ascites
6 L paracentesis and albumin Spironolactone - counteract aldosterone that is wrapped up because of INTERVASCULAR decreased sodium furosemide not as good
66
new antidiuretic hormone
Vaptamn
67
meld score needed to get on transplant list
greater than equal to 15
68
meld score needed to get a liver
20-25
69
How many meld points to give for dialysis
4
70
what mild score represents a good candidate for liver meniscectomy
less than or equal to 8 greater than or equal to 11 at high risk for meniscectomy
71
describe fetus umbilical vein
arterial blood from placenta to left portal vein ductus venosum Round ligament Falciform ligament IVC
72
ductus venosus
Umbilical vein -to- vena cava "shunts less than a third of the blood flow of the umbilical vein directly to the inferior vena cava This allows oxygenated blood from the placenta to bypass the liver. In conjunction with the other fetal shunts, the foramen ovale and ductus arteriosus, it plays a critical role in preferentially shunting oxygenated blood to the fetal brain.
73
ductus arteriosus
(right ventricle blood goes to): pulmonary artery -to- aorta "pulmonary artery to the proximal descending aorta" called ligamentum arteriosum once it is closed-site of aortic tear blunt trauma
74
patent ductus arteriosus
pulmonary artery to the proximal descending aorta remained open left-to-right shunt leads to pulmonary hypertension and possibly congestive heart failure and cardiac arrhythmias. treatment: Closure may be induced with NSAIDs because these drugs inhibit prostaglandin Prostaglandins are responsible for maintaining the ductus arteriosus by dilation of the vascular smooth muscles.
75
Umbilical arteries
Called arteries - but carrying deoxygenated blood to drain both halves of the fetus Umbilical arteries supply deoxygenated blood from the fetus to the placenta
76
umbilical vein
carries oxygenated blood from the placenta
77
Fibrolamellar hepatocellular carcinoma
young No cirrhosis Not associated strongly with hepatitis B
78
Replaced right hepatic artery described course
SMA Posterior portal vein Behind the pancreas Behind cystic artery
79
what vein is middle hepatic vein associated with
left
80
Porta hepatis
hepatoduodenal ligament Right (And a bit anterior to the hepatic artery) common bile duct left ( in the bit posterior to common bile duct) hepatic artery Posterior portal vein
81
describes selective shunt and its disadvantages
all portal blood flow into vena cava Not good for Budd-Chiari syndrome
82
with marker is most specific for liver function and one marker is no specific for liver necrosis
ALT-liver function AST-or necrosis
83
Milan criteria for liver transplant
Less than 5 cm less than or equal to 3 tumors less than 3 cm
84
Retzius veins
retroperitoneal
85
Where our Mallory-Weiss tears found
lesser curve right side
86
where is Borhave injury found
left chest and mediastinum
87
management of esophageal perforation over 48 hours
``` no primary repair or a graft chest decortication washout cervical exclusion? NG tube Open gastrostomy feeding J. ``` Consider covered stent
88
Treatment of Schatzki ring
If asymptomatic- observe If symptomatic- Dilate and perform and gastric fundoplication
89
choledochal cyst.
These cysts are thought to arise from an aberrant communication with the biliary and pancreatic ducts. There are five types of choledochal cysts, based on their size and characteristics. All require complete surgical resection because of an association with the development of cholangiocarcinoma.
90
Type I cysts
fusiform dilations of the common bile duct. T hese are the most common treated with resection, cholecystectomy, hepaticojejunostomy. T
91
Type II cysts
extrahepatic, diverticular cysts treated the same as Type I. cholecystectomy, hepaticojejunostomy.
92
Type III cysts
located at the distal common bile duct at the junction with the duodenum treated with cholecystectomy, resection, choledochojejunostomy.
93
Type IV
multiple locations, both intrahepatic and extrahepatic, may require a liver resection of the involved segment. .
94
Type V cysts
intrahepatic | may lead to liver failure, necessitating liver transplantation for treatment
95
cystadenoma
pre malignant potential female: 40-50s CT: complex cyst mural nodules Tx: enucleate resect
96
Echinococal
endemic areas, such as the southwestern United States, Scotland, Greece, or other parts of Europ CT and MRI scans will demonstrate thick-walled cysts with calcifications containing debris. Septations and daughter cysts may also be identified within the cysts. dx hemoglutanin elisa tx: Prior to surgical manipulation of these cysts, patients should be treated with albendazole or mebendazole. The surgeon should plan to perform a complete enucleation of all of the cysts.
97
hemangioma
Benign MRI: Bright T2 with peripheral enhancement CT: Peripheral enhancement followed by central infilling Kasabach-Merritt syndrome, which manifests as a coagulopathy resulting from intravascular coagulation, clotting, and fibrinolysis within the hemangioma. The localized coagulopathy can result in death in 20% to 30% of patients due to systemic fibrinolysis and thrombocytopenia. No treatment is necessary for asymptomatic hemangiomas. Surgical resection should only be considered if patients develop symptoms or complications, or if malignancy cannot be excluded laparoscopic enucleation or hepatic resection. patients require an intervention but are not surgical candidates, radiation or hepatic artery embolization can be considered. The main blood supply is from the arterial system, so extrahepatic ligation of the right or left hepatic artery can provide vascular control
98
Focal nodular hyperplasia
(FNH) is the second most common benign hepatic lesion normal hepatocytes in FNH not stimulated by oral contraceptives. A central scar is the most characteristic imaging feature, (however, a central scar can also be seen with fibrolamellar hepatocellular carcinoma, hepatic adenomas, and metastatic lesions) CT: hypodense or isodense on the precontrast enhances rapidly during the arterial phase of the scan. During this phase, the lesion contour is well demarcated, and the central scar is hypodense. The lesion’s enhancement decreases during the portal phase, and it becomes isodense to the liver on the delayed images, on which the central scar and septa can demonstrate increased uptake of contrast because of the slow uptake of contrast in these fibrotic elements. MRI: isointense or hypointense on T1-weighted MRI images, isointense or slightly hyperintense on T2-weighted images. The central scar is hypointense on T1-weighted images and strongly hyperintense on T2-weighted images. Gadolinium administration results in hyperintensity of the lesion during the arterial phase, followed by isointensity during the portal venous phase. The central scar becomes hyperintense on delayed imaging. MRI best If neither CT nor MRI can make the diagnosis of FNH, a sulfur colloid scan can be performed. FNHs contain Kupffer cells, which take up sulfur colloid, whereas hepatic adenomas do not. biopsy should be considered if imaging cannot firmly establish the diagnosis. Tx: no treatment for FNH, as long as the diagnosis has been confirmed with certainty. no risk of malignant potential or complications in men or in women. no evidence to support avoiding pregnancy or discontinuing oral contraceptives. Follow-up of these lesions is not necessary, unless they become symptomatic. Surgical resection is only indicated in symptomatic patients or in cases of diagnostic uncertainty. If liver resection is indicated, a margin of normal hepatic parenchyma is safer than enucleation because of large veins that frequently surround these lesions.
99
central scar can also be seen with
fibrolamellar hepatocellular carcinoma, hepatic adenomas, and metastatic lesions)
100
fibrolamellar hepatic cancer
NON cirrhotic patients resection is better than transplant may not have AFP postitive may look like FNH
101
estimates of functional liver reminent
normal 20-30 % steatorrhea 30-40% cirrhosis 40-50% Over age 70 / hx of pre chemo > 50%

LIVER (1 decks)

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