31 Liver Flashcards by Ryan Lee

What is the #1 hepatic artery variant?

right hepatic artery off SMA, courses behind pancreas, posterolateral to the common bile duct

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What variant of the left hepatic artery is found in about 20% of the population?

left hepatic artery off left gastric artery

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What is the most common variant of the common hepatic artery?

off SMA

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What lobes of the liver does the falciform ligament separate?

medial and lateral segments of the left lobe

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What does the falciform ligament carry?

remnant of the umbilical vein

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What carries the obliterated umbilical vein to the undersurface of the liver?

ligamentum teres

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What separates the right and left lobes of the liver?

cantle’s line drawn from the gallbladder fossa to the IVC

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What is the peritoneum that covers the liver called?

Glisson’s capsule

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The portal triad enters and the gallbladder lies under what two segments of liver?

IV and V

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What are liver macrophages called?

Kupffer cells

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What is the orientation of the contents of the hepatoduodenal ligament?

CBD lateral, hepatic artery medial and portal vein posterior

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What is clamped in the Pringle maneuver?

portal hepatis

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What are the four borders of the foramen of Winslow?

anterior - portal triad, posterior - IVC, inferior - duodenum, superior - liver

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What 3 vessels form the portal vein and what is their configuration?

IMV enters the splenic vein, SMV joins the splenic vein

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How many portal veins in the liver? and what % of the blood supply do they provide?

2 portal veins in the liver, 2/3 of the blood supply

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What are the hepatic arteries? and veins?

right, left and middle, same as the veins

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In 80% of the population what is the configuration of the hepatic veins entering the IVC?

Middle hepatic vein joins left hepatic vein before going into the IVC. In the other 20%, all 3 go directly into the IVC.

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What is unique about the blood supply and drainage of the caudate lobe?

Caudate lobe – receives separate right and left portal and arterial blood flow; drains directly into IVC via separate hepatic veins

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What membrane of the liver does nutrient uptake occur?

sinusoidal membrane

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What is the usual energy source for the liver?

ketones

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What is the only water soluble vitamin stored in the liver?

B12

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What are the 2 most common problems with hepatic resection?

bleeding and bile leak

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Which hepatocytes are most sensitive to ischemia?

central lobular (acinar zone III)

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What % of the liver can be safely resected?

75%

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Bilirubin is conjugated to what in the liver which improves water solubility?

glucuronic acid

What comprises 85% of bile? what is the main phospholipid in bile?

bile salts, lecithin

In bile, what is used to make bile acids?

cholesterol

What two molecules are bile acids conjugated to in order to make them more water soluble?

taurine or glycine

What are the two primary bile acids? the two secondary (dehydroxylated primary acids by bacteria in gut)?

primary - cholic and chenodeoxycholic | secondary - deoxycholic and lithocholic

What level of bilirubin is necessary for jaundice?

>2.5

What is the maximum bilirubin possible (unless pt has underlying renal disease, hemolysis or bile duct-hepatic vein fistula)?

What disease is the abnormal uptake of bilirubin resulting in mildly high unconjugated bilirubin?

Gilbert's disease

What disease is the inability to conjugate bilirubin; deficiency of glucuronyl transferase; high unconjugated bilirubin -> life threatening disease.

Crigler-Najjar disease

Physiologic jaundice of newborn has high unconjugated bilirubin and is the result of which immature enzyme?

glcuronyl transferase

There are two syndromes that have a high conjugated bilirubin. Which one is a deficiency in storage ability and which one is a deficiency in secretion ability?

Rotor's syndrome is a deficiency in storage ability. Dubin-Johnson syndrome is a deficiency in secretion ability.

In hep B which Ig dominates in the first 6 months? which one then takes over?

IgM then IgG

In Hep B which Anti-HB rises 10-12 weeks after infection? and 12-14? and 14-16?

10-12 weeks Anti HBc 12-14 weeks Anti-HBe 14-16 weeks Anti-HBs

What Ab is elevated in a pt who is vaccinated against Hep B

Anti-HBs

If a pt has elevated anti-HBc and elevated anti-HBs antibodies and no HBs antigens, what does that mean?

pt had infection with recovery and subsequent immunity

What is the most common viral hepatitis leading to liver TXP?

Hep C (long incubation period)

Hepatitis D is a cofactor for which other Hepatitis?

Hep B

What does Hepatitis E cause?

fulminant hepatic failure in pregnancy, most often in 3rd trimester

What is the most common cause of liver failure?

cirrhosis

What is the best indicator of synthetic function in pts with cirrhosis?

prothrombin time (PT)

What is the mortality of acute fulminant hepatic failure? The course of what sx determines the outcome?

80% mortality, encephalopathy

What is the main medical tx for hepatic encephalopathy and how does it work?

lactulose is a cathartic that gets rid of bacteria in the gut and acidifies the colon preventing NH3 uptake by converting it to ammonium (titrate to 2-3 stools per day)

What should you limit the protein intake to in hepatic encephalopathy?

<70 g/day

Other than the mainstay, lactulose, name three other medical treatments for hepatic encephalopathy.

Neomycin, L-dopa, bromocriptine

When you do a paracentesis for ascites what do you need to replace and what is the dose?

albumin, 1g for every 100cc removed

What is increased aldosterone caused by in ascites?

impaired hepatic metabolism and impaired GFR

Hepatorenal syndrome has the same appearance as prerenal azotemia what is the tx (2)?

stop diuretics, give volume

What is the cause of postpartium liver failure with ascities and how do you dx?

hepatic vein thrombosis. Dx: SMA arteriogram with venous phase contrast

Sx of SBP include fever, abdominal pain, positive cultures and PMNs greater than what level in the fluid?

250

SBP is most commonly mono-organism; if it is not then you need to worry about what?

bowel perforation

What is the most common organism in SBP?

E. coli

What is a risk factor for SBP in children?

SLE

What is the tx for SBP?

3rd -generation cephalosporin; pts usually respond within 48 hrs

What is 90% effective at treating esophageal varices?

sclerotherapy

Name 2 medical treatments for esophageal varices and how they work.

vasopressin (splanchnic artery constriction) | octreatide (decreased portal pressure by decreased blood flow)

In pts with esophageal varices who are on vasopressin and have CAD should get what additional medical tx?

NTG

What is the name of the tube for esophageal varices that has a risk of esophageal rupture and is hardly used anymore?

Sengstaken-Blakemore

What is the role for propanolol in esophageal varices?

may help prevent rebleeding; no good role acutely

Pts who develop strictures after sclerotherapy for esophageal varices are easily managed with what tx? what if they develop refractory variceal bleeding, what tx?

dilatation, TIPS for refractory bleeding

What does TIPS stand for?

transjugular intrahepatic portosystemic shunt

What is the mortality of bleeding varices with 1st episode? What % will rebleed and what is the mortality with each subsequent bleeding episode?

33%, 50%, 50%

50% of portal hypertension in children is caused by what?

portal vein thrombosis

What is the normal port vein pressure?

<12 mmHg

What procedure would you do for a Child's A cirrhotic that just has bleeding as a symptom?

consider splenorenal shunt (more durable); otherwise TIPS

What if the pt is Child's B or C with indication for shunt (bleeding, progression of coagulopathy, visceral hypoperfusion, refractory ascites)?

splenorenal shunt (more durable) for A. TIPS for B or C

Pts with TIPS are at risk for developing what?

encephalopathy

What is the most common cause of massive hematemesis in children?

portal HTN due to extrahepatic thrombosis of the portal vein

What is the tx for Budd-Chiari syndrome?

portacaval shunt (needs to connect to the IVC above the obstruction)

Isolated gastric varices without elevation of pressure in the rest of the portal system can be caused by what?

Splenic vein thrombosis

What is most often the cause of splenic vein thrombosis?

pancreatitis

What is the treatment for splenic vein thrombosis?

splenectomy

What is the organism in amebic liver abscesses?

Entamoeba Histalytica

Risk factors for Entamoeba histalytica include ETOH and travel to Mexico. How do you dx?

CT characteristics, elevated LFTs, white count, serology (cultures are often sterile since the protozoa exists only in peripheral rim)

What is the tx for amebic liver abscesses?

Flagyl; aspiration if refractory of contaminated; surgery only for free rupture

What is the organism in hydatid liver cysts?

Echinococcus

How do you dx echinococcus infections (2 tests)?

Positive Casoni skin test, positive indirect hemagglutination

Abdominal CT shows liver lesion with ectocyst (calcified) and endocyt. What is that characteristic of?

hydatid cyst

What is the tx for hydatid cyst?

preop albendazole, surgical removal (may wan to inject cyst with alcohol at time of removal to kill organsims) need to get all of cyst wall

Why don't you aspirate hydatid cysts?

can leak out and cause anaphylactic shock

Pt with hydatid cyst has jaundice, elevated LFTs or cholangitis. What do you need to do preop?

ERCP to check for communication with the biliary system

Maculopapular rash, increased eosinophils. Sigmoid colon has fine granulation tissue, petechiae, ulcers and can cause variceal bleeding. What is the dx and what is the tx?

Schistosomiasis. Tx: praziquantel and control variceal bleeding

80% of liver abscess are what type? what is the number one organism?

pyogenic, E. coli