HEPATOLOGY > SURGERY: LIVER ANATOMY > Flashcards

SURGERY: LIVER ANATOMY Flashcards

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1
Q

Functional Segments of Liver are known as

A

Couinaud segment

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2
Q

Cantlie’s line

A

Cholecysto-Caval line
Imaginary line joining the IVC and GALL BLADDER

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3
Q

Which vein lies below Cantlie’s line

A

Middle Hepatic Vein

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4
Q

Couinaud segments
🧠⚡Start from A(1) in clockwise direction ⚡

🧠⚡All Longitudinal divisions are formed by HEPATIC VEINS ⚡
🧠⚡Remember H not with H ⚡

🧠⚡All Horizontal divisions are formed by PORTAL VEINS⚡

A

Left hemi liver: 4A, 2, 3, 4B
Right Hemi Liver: 5 6 7 8

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5
Q

Left Hemiliver is divided into

⭐ Divided by

A

⭐ Divided by : Left Hepatic Vein
Left Medial
Left Lateral

⭐ Divided by : Left Portal Vein
Left Superior
Left Inferior

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6
Q

Vein that lies below Falciform ligament

A

Left Hepatic Vein

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7
Q

Right Hemiliver division

⭐ Divided by :

A

⭐ Divided by : Right Hepatic Vein
Right Anterior
Right Posterior

⭐ Divided by : Right Portal Vein
Right Superior
Right Inferior

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8
Q

Right Hemiliver division

⭐ Divided by :

A

⭐ Divided by : Left Hepatic Vein
Left Medial
Left Lateral

⭐ Divided by : Left Portal Vein
Left Superior
Left Inferior

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9
Q

SINGLE BEST ANSWER for STRUCTURE DIVIDING LIVER INTO FUNCTIONAL SEGMENTS

A

Portal Veins

Other: Hepatic vein

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10
Q

Major FISSURES of LIVER are

A

⭐ site of 3 Major Hepatic Veins
Right
Middle
Left

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11
Q

Minor Fissures in Liver

A

Formed by PORTAL VEINS
1. Right Portal vein
2. Left Portal vein
3. Fissure of Ganz

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12
Q

Sectors of Liver

A
  1. Right Posterior
  2. Right Anterior
  3. Left Lateral
  4. Left Medial
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13
Q

Which sectors form the GALL BLADDER FOSSA

A

4B and 5

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14
Q

Which segments are removed in RADICAL CHOLECYSTECTOMY

A

Segment 4B and 5

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15
Q

Bare area of Liver corresponds to which Segment

A

Segment 7

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16
Q

⚡⚡ MOST COMMON segment of Lover affected by Amoebic Liver Abscess

A

Segment 7

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17
Q

Caudate Lobe: Segment

Quadrate Lobe: Segment

A

Caudate Lobe: Segment 1

Quadrate Lobe: Segment 4

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18
Q

Caudate Lobe
Special Features

A

⭐ Recieves Blood from Both sides
⭐ Drains BILE into Both sides
⭐ Directly drains to IVC

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19
Q

Majority of Caudate Lobe lies

A

Toward Left side of IVC

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20
Q

CAVAL LIGAMENT

Formed by?
Function?

A

⭐ 50% of Caudate Lobe encircles the IVC ➡️ known as CAVAL Ligament

⭐ Mobilising the LIVER during Liver Resection

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21
Q

Segment 1 is divided into

A
  1. Segment 9
  2. Spigelian lobe
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22
Q

Which segment is INVOLVED EARLY in CHOLANGIOCARCINOMA

A

Segment 1

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23
Q

Which segment undergoes HYPERTROPHY in BUDD CHIARI Syndrome

A

Segment 1
(Direct connection with IVC)

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24
Q

Mickey Mouse SIGN on Duplex Scan
Seen in

A
  1. Liver Pedicle
  2. Varicose veins at Sapheno-femoral junction
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25
Mickey Mouse in Medicine 1. Mickey Mouse Pelvis 2. Mickey Mouse Sign 3. Mickey Mouse Cast 4. Mickey Mouse Sign on Duplex Scan 5. Mickey Fenn
1. Mickey Mouse Pelvis ⭐ Down Syndrome (Outward flaring of Iliac Wings) 2. Mickey Mouse Sign ⭐ Paget's disease (⬆️ Radiotracer uptake in Bone scan of pedicles and spinous process of Vertebra) ⭐ Anencephaly ⭐ Progressive Supra nuclear Palsy ⭐ Hutch Diverticulum: IVU/CT 3. Mickey Mouse Cast ⭐ Dysmorphic RBC Cast in Glomerular Hematuria 4. Mickey Mouse Sign on Duplex Scan ✨ Liver Pedicle ✨ Varicose veins at Sapheno-femoral junction 5. Mickey Fenn ⭐ Chloral hydrate ➕ Alcohol
26
Liver Pedicle 🧠⚡Ant ➡️ Post: DAVE ⚡
⭐ Ducts ( Rt and Left Hepatic Duct) ⭐ Artery ( Rt and Left Hepatic Artery) ⭐ Vein ⭐ Epiploic Foramen of Winslow
27
Rouvier's Sulcus 🧠⚡ROG ⚡
Fissure of Ganz
28
Pringle's maneuver
Compressing the Liver Pedicle at the FREE EDGE of Lesser Omentum (OR) FORAMEN of Winslow ⬇️ Helps to control Bleeding in Liver Helps to Detect Source of Bleeding
29
Blood Supply of Liver
80%: Portal Vein 20%: Hepatic Artery
30
Which Hepatic Artery is Larger?
Right HEPATIC ARTERY
31
Segments removed ⭐ Left Trisectorectomy ⭐ Right Trisectorectomy
⭐ Left Trisectorectomy (Extended Left Hepatectomy) 4A, 4B, 2, 3, 5, 8 ⭐ Right Trisectorectomy (Extended Right Hepatectomy) 5,6,7,8, 4A,4B
32
Posterior Relations of Liver
33
Space of Disse Contains?
Area between Hepatocyte and Sinusoid Contains: 1. Ito cells 2. Microvilli of adjacent hepatocytes 3. Fine collagen Fibers (type 3)
34
Cells that store Vitamin A in LIVER
Ito cells (OR) Hepatic STELLATE Cells
35
Origin of Ito cells
Mesenchymal cells
36
The 2 states of Ito cells
1. Dormant state: Store Vitamin A 2. Active state: Get activated by LIVER INJURY and replace damaged Hepatocytes with collagenous scar tissue ➡️ Fibrosis
37
Cells responsible for FIBROSIS in Cirrhosis
Ito cells
38
Lymph produced in the liver is drained by
1. Peri sinusoidal Space of DISSE 2. Peri Portal cleft of Mall
39
Porta Hepatis ⭐ STRUCTURES Entering at PORTA HEPATIS ⭐ STRUCTURES Exiting at PORTA HEPATIS
Deep Transverse Fissure that is situated on the INFERIOR SURFACE of RIGHT LOBE of LIVER STRUCTURES Entering at PORTA HEPATIS 1. HEPATIC ARTERY 2. PORTAL VEIN 3. HEPATIC NERVOUS PLEXUS STRUCTURES Exiting at PORTA HEPATIS 1. Bile Duct Lt and Right 2. Lymphatics
40
Fibrous sheath that surrounds Duct, Hepatic artery, Portal Vein in each Liver Segment is known as
Valoean sheath
41
Valoean sheath is a continuation of
Glisson's capsule
42
Glisson in medicine
43
Use of VALOEAN SHEATH
Facilitate surgical control of Right and Left Vasculo-biliary pedicles of Liver
44
Painful HEPATOMEGALY seen in 🧠⚡We HAVe Cardiac⚡
1. Weil's disease 2. Hepatoma & HCC 3. Actinomycosis 4. Abscess: Pyogenic 5. Amoebiasis 6. Viral Hepatitis 7. Cardiac Failure
45
💊💉 MANAGEMENT of HCC
46
Functional Liver Reserve is found by
Fibroscan
47
Milan's CRITERIA used for
Possibility of LIVER TRANSPLANT ro a patient with < 25% FLR
48
ALPP'S PROCEDURE Used for
Associated Liver Partition & Portal vein ligation for Staged Hepatectomy
49
💊💉 Palliative MANAGEMENT for HCC 🧠⚡MR HIT⁴ ⚡
1. Microwave Ablation 2. Radiofrequency ablation 3. HIFU (High Frequency Ultrasonic therapy) 4. Intralesional ETHANOL (Percutaneous) 5. Tyrosine Kinase ⛔ ✨ Sunitinib ✨ Sorafenib ✨ Regorafenib 6. TACE (Trans arterial Chemo embolization) 7. TARE (Trans arterial Radio embolization with Ytterium spheres) 8. Thermal ablation ✨ Cryo ✨ Radiofrequency ✨ Microwave ✨ Nd:Yag
50
Tyrosine Kinase ⛔ 🧠⚡RSS ⚡
✨ Sunitinib ✨ Sorafenib ✨ Regorafenib
51
Radiofrequency ablation can be done for tumours upto
3 cm
52
⚡⚡ MOST IMPORTANT PROGNOSTIC FACTOR IN HCC
Stage of Disease
53
⚡⚡ MOST COMMON SITE OF DISTANT METASTASIS IN HCC
LUNGS
54
PROGNOSTIC SCORES IN HCC 🧠⚡OBC ⚡
1. Okuda 2. BCLC (Barcelona Clinic Score) 3. CLIP (Cancer of Liver Italian Program) 4. CUPI (Chinese University Prognostic Index)
55
OKUDA Score 🧠⚡BATA⚡
Bilirubin Ascites Tumor size Albumin
56
BCLC Score 🧠⚡ PCT⚡
1. Performance status score 2. Child Pugh score 3. Tumour size
57
CLIP Score 🧠⚡PCT-A⚡
1. Portal Vein Thrombosis 2. Child Pugh Score 3. Tumor size 4. AFP
58
Performance Status Scores
1. Karnofsky score 2. ECOG score
59
🌸 TYPES of HCC
1. Pushing: Push against Parenchyma BEST PROGNOSIS 2. Hanging 3. Infiltrating
60
Non Cirrhotic Liver ➕ Singe Large HARD (Scirrhous) Liver Tumour ➕ Well Demarcated & Encapsulated ➕ Central Fibrotic Area ➕ Good Resectability
Fibrolamellar Varient
61
Fibrolamellar Varient Serum MARKERS
✨ Neurotensin B ⬆️ ⬆️ ✨ ⬆️ S. unsaturated Vitamin B12 binding Capacity AFP NORMAL
62
Prognosis of Fibrolamellar Varient HCC
Good Prognosis ➕ Recurrance VERY HIGH
63
Large Polygonal Cells embedded in FIBROUS STROMA forming Lamellar structures
Fibrolamellar Varient
64
⚡⚡ MOST COMMON Age of Presentation of HEPATOBLASTOMA
< 18 months
65
ASSOCIATIONS OF HEPATOBLASTOMA 🧠⚡FB⚡
1. FAP: Familial Adenomatous Polyposis 2. Beckwith Wiedmann Syndrome 3. Prematurity & Low Birth Weight
66
🧑🏻‍⚕️ Clinical Features of HEPATOBLASTOMA
1. Mass in Abdomen 2. Anemia 3. Thrombocytopenia
67
⭐ ANEMIA is seen in which Liver Cancer? ⭐ POLYCYTHEMIA is seen in which Liver Cancer?
⭐ ANEMIA is seen in which Liver Cancer? 🎯 HEPATOBLASTOMA ⭐ POLYCYTHEMIA is seen in which Liver Cancer? 🎯 HCC
68
Tumour marker of HEPATOBLASTOMA
AFP ⬆️ ⬆️
69
Liver Malignancy with NORMAL AFP?
Fibrolamellar Varient of HCC
70
💊💉 MANAGEMENT of ✨ Localized HEPATOBLASTOMA ✨ Metastasized HEPATOBLASTOMA
✨ Localized HEPATOBLASTOMA 🎯 Surgery ➕ Chemoradiation ✨ Metastasized HEPATOBLASTOMA 🎯 Resection of Hepatic Tumour ➕ Resection (OR) Chemo of Pulmonary Metastasis
71
⚡⚡ MOST COMMON MALIGNANT MESENCHYMAL TUMOUR OF LIVER
Angiosarcoma
72
Angiosarcoma is ASSOCIATED with which syndromes
1. Hemochromatosis 2. NF1
73
Hepatic BRUIT ➕ ➕ CENTRAL HYPOVASCULARITY & PERIPHERAL CONTRAST STAINING ➕ VASCULAR LAKES ➕ ON Biopsy: Presence of DILATED SINUSOIDS
Angiosarcoma
74
Factor 8 Staining Liver Tumor
Epitheloid Hemangioendothelioma
75
Epitheloid Hemangioendothelioma
✨ B/L Multiple Lesions ✨ High Output Cardiac Failure ✨ Fulminant Liver Failure ✨ Hypervascular Tumour ✨ Malignant conversion to Angiosarcoma
76
💊💉 MANAGEMENT of Epitheloid Hemangioendothelioma
Total Hepatectomy ➕ Liver transplant
77
🩺 IOC for Epitheloid Hemangioendothelioma
CECT ⬇️ HYPERVASCULAR TUMOUT
78
Liver Tumour ASSOCIATED with HIGH OUTPUT CARDIAC FAILURE
1. Liver HEMANGIOMA 2. Epitheloid Hemangioendothelioma
79
ASSOCIATIONS of Epitheloid Hemangioendothelioma
1. OCP 2. Vinyl Chloride
80
Use of CK7 & CK20
To detect the original location of Metastasis in LIVER ⭐ Tumour of Unknown Origin
81
CK7➕ & CK20⛔ 🧠⚡ 7 tumours of the ♀️ ⚡
1. Endometrial Carcinoma 2. Cervical Cancer 3. Ovary cancer (except Mucinous) 4. Breast Cancer 5. Thyroid Cancer 6. Salivary Gland Cancer 7. Lung Adenocarcinoma 8. Mesothelioma
82
CK7⛔ & CK20➕ 🧠⚡ 2.0 ➡️ MC⚡
1. Merkel Cell Cancer 2. Colorectal Cancer
83
CK7⛔ & CK20⛔ 🧠⚡Steroid producing cells⚡
1. Adrenal Cortex Cancer 2. RCC: Clear Cell 3. HEPATOCELLULAR Cancer HCC 4. PROSTATE CANCER 5. Squamous cell Cancer
84
CK7➕ & CK20➕ 🧠⚡ Please USE Ovary⚡
1. Pancreatic Ca 2. Urothelial Ca 3. Stomach Ca 4. Extrahepatic Bile Duct Ca 5. Ovarian Mucinous Cancer
85
⚡⚡ MOST COMMON SITE OF COLORECTAL CANCER METASTASIS
Liver
86
Colorectal Cancer METASTASIS Cytokertin Profile
CK7 ⛔ CK20 ➕
87
Predictors of POOR OUTCOME of Colorectal Cancer with Liver METASTASIS
1. LN ➕ 1° Tumour 2. Disease free interval < 12 months 3. > 1 tumour 4. Tumour size > 5cm 5. CEA level > 200ng/ml 6. Synchronous lesion
88
Metachronous Ca vs synchronous Ca
89
⚡⚡ MOST COMMON INDICATION OF LIVER TRANSPLANT IN CHILDREN ⚡⚡ MOST COMMON INDICATION OF LIVER TRANSPLANT IN ADULTS
⚡⚡ MOST COMMON INDICATION OF LIVER TRANSPLANT IN CHILDREN 🎯 EHBA ⚡⚡ MOST COMMON INDICATION OF LIVER TRANSPLANT IN ADULTS 🎯 NON-CHOLESTATIC ✨ Hepatitis B & C ✨ Alcoholic Liver Disease ✨ Cryptogenic
90
INDICATION OF LIVER TRANSPLANT IN ADULTS
🎯 NON-CHOLESTATIC ✨ Hepatitis B & C ✨ Alcoholic Liver Disease ✨ Cryptogenic 🎯 CHOLESTATIC ✨ 1° BILIARY CIRRHOSIS ✨ 1° SCLEROSING CHOLANGITIS 🎯 AUTOIMMUNE 🎯 MALIGNANCY 🎯 MISCELLANEOUS
91
INDICATION OF LIVER TRANSPLANT IN CHILDREN
🎯 EHBA 🎯 IEM 🎯 CHOLESTATIC ✨ PSC ✨ ALAGILLE Syndrome 🎯 AUTOIMMUNE 🎯 VIRAL HEPATITIS 🎯 MISCELLANEOUS
92
KING COLLEGE CRITERIA USED FOR
Possibility of TRANSPLANT in ACUTE LIVER FAILURE
93
KING COLLEGE CRITERIA in ALF DUE TO: Acetaminophen Poisoning 🧠⚡PCM⚡
A. pH < 7.3 (OR) Lactate > 3.5 (OR) B. 3 out of 3: 🎯 PT > 100s 🎯 Creatinine > 300 micromol/L (3.4 mg/dl) 🎯 Mental Status ➡️ Hepatic Encephalopathy Grade 3 (OR) 4
94
KING COLLEGE CRITERIA in ALF DUE TO: NON-Acetaminophen Poisoning 🧠⚡ABCDE ⚡
A. PT > 100s (OR) B. 3 out of 5: 🎯 Age < 10 or > 40 🎯 Bilirubin > 17.5 mg/dl 🎯 Coagulopathy with INR > 3.5 (OR) PT > 50s 🎯 Duration BETWEEN Jaundice & Encephalopathy > 7 days (Not Hyperacute) 🎯 Etiology: ✨ Wilson ✨ Hepatitis C & E ✨ Idiosyncratic Drug reaction
95
Types of LIVER TRANSPLANT
1. Orthotopic 2. Heterotopic 3.Auxiliary Transplant
96
Difference between TOTAL ORTHOTOPIC LIVER TRANSPLANTATION (OLTX ) & Auxiliary ORTHOTOPIC LIVER transplantation (A-OLTX)
97
TOTAL ORTHOTOPIC LIVER TRANSPLANTATION (OLTX ) INDICATIONS 🧠⚡FBC⚡
1. Fulminant Hepatic Failure 2. 1° Biliary Cirrhosis 3. Cirrhosis
98
Lifelong IMMUNOSUPPRESSION is needed in which type of Liver Transplant
TOTAL ORTHOTOPIC LIVER TRANSPLANTATION (OLTX)
99
Auxiliary ORTHOTOPIC LIVER transplantation (A-OLTX) INDICATION 🧠⚡CNG Too High Price⚡
1. Crigler Najjar Syndrome Type 1 2. Neimann Pick Disease 3. Galactosemia 4. Tyrosinemia 5. Hereditary Familial Hypercholestrolemia Others in age < 40yrs 1. Reversible Fulminant Hepatic Failure 2. Non-cirrhotic Metabolic Liver Disease 3. Hyperacute Liver Failure with Acetaminophen Overdose 4. No Hemodynamic Instability
100
Enhancing Lesions in LIVER 🧠⚡Medical Hospitals Hate All Families⚡
1. METASTASIS ( hypervascular) 2. HCC 3. HEMANGIOMA 4. ADENOMA 5. FOCAL NODULAR HYPERPLASIA
101
Technitium Scan in Hepatic Diseases
102
⚡⚡ MOST COMMON Anomaly of HEPATIC ARTERY
Right Hepatic Artery arising from Superior Mesenteric Artery
103
Fissure for Ligamentum Venosum
Venous Fissure
104
Preferential Flow of Portal Vein is towards
Right Side
105
SNAKE SKIN APPEARANCE OF GASTRIC MUCOSA
Portal Hypertension Gastropathy ⬇️ Diffuse dilatation of Mucosal & Submucosal Venous Plexus of stomach ASSOCIATED with overlying Gastritis
106
NORMAL Portal Blood Flow
1-1.5 L/min
107
🎯 NORMAL Portal venous Pressure 🎯 NORMAL HVPG: Hepatic Venous Pressure Gradient
🎯 NORMAL Portal venous Pressure ⭐ 5-10 mmHg 🎯 NORMAL HVPG: Hepatic Venous Pressure Gradient ⭐ 1-5 mmHg
108
Portal HYPERTENSION is considered when ⭐ Portal Venous Pressure ⭐ HVPG
⭐ Portal Venous Pressure 🎯 > 10 mmHg ⭐ HVPG 🎯 ≥ 6 mmHg
HEPATOLOGY
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