31: Liver Flashcards
Which kind of liver abscess usually appears as a single abscess in the right lobe of the liver and is associated with elevated LFTs?
Amebic liver abscess
[UpToDate: Amebic liver abscesses are most commonly found in the right lobe; 70% to 80% are solitary subcapsular lesions, although multiple lesions can be present. Localization in the left lobe predisposes to extension into the pericardial sac.
On ultrasound, the abscess appears as a round, well-defined hypoechoic mass. On CT scan, it appears as a low-density mass with a peripheral enhancing rim. On MRI, the abscess appears as low-signal intensity on T1-weighted images and high-signal intensity on T2-weighted images. After healing, the periphery of the abscess may calcify as a thin, round ring.
On gallium citrate and technetium-labeled sulfur colloid radionuclide liver scans, amebic abscesses are “cold” (with a bright rim in some cases), whereas pyogenic abscesses are “hot.” Radiographic findings must be interpreted in the appropriate clinical context with consideration of the differential diagnoses, including pyogenic abscess and malignancy.
Serial imaging is generally not helpful since lesions may appear to increase in size or number on ultrasound following initiation of treatment, even with appropriate therapy and clinical improvement. Treated lesions may become anechoic, calcified, or may persist as cystic-appearing lesions. Complete radiologic resolution may take two years or more. Therefore, persistent abnormalities on ultrasound imaging should not prompt retreatment or additional testing in a patient who is clinically well.
A chest radiograph abnormality will be observed in approximately 50% of patients with an amebic liver abscess, most commonly elevation of the right hemidiaphragm. This finding does not necessarily signal pulmonary involvement in the infection.]

What is the sequence of breakdown products of hemoglobin?
Hemoglobin -> Heme -> Biliverdin -> Bilirubin

What is the treatment for focal nodular hyperplasia of the liver?
Conservative therapy (No resection)
[UpToDate: The natural history of FNH is one of stability and lack of complications. Lesions generally do not change over time, although they occasionally become smaller. However, as mentioned above, enlargement of FNH in the setting of OCPs and during pregnancy have been reported. There is no evidence for malignant transformation of FNH.
Patients who are suspected of having FNH based upon the evaluation described above should be managed conservatively. If a diagnosis remains unclear, a liver biopsy may be helpful, but may also be misleading since only resection will be definitive. Follow-up studies at three and six months will often be sufficient to confirm the stability of the lesion and its benign nature, after which no long-term follow-up is required routinely. Surgery should be reserved for the rare, very symptomatic FNH lesion, and the highly suspicious lesion, which has eluded diagnosis by all other modalities.
We generally do not insist that oral contraceptives and other estrogen containing preparations should be discontinued. However, it is reasonable to obtain a follow-up imaging study in 6 to 12 months in women who continue taking these drugs. Small FNH do not appear to pose a significant risk to a successful pregnancy, although close observation is strongly recommended and resection may be prudent for large (>8 cm) FNH.]
Diagnose:
- HBsAg: -
- Anti-HBs: +
- HBeAg: -
- Anti-HBe: -
- Anti-HBc: -
Immunized against HBV
According to Couinaud’s nomenclature, which numbered liver segment is the superior right posterolateral segment?
Segment VII

What is the treatment for hepatorenal syndrome?
Stop diuretics and give volume
[No good therapy other than a liver transplant]
[UpToDate: The ideal therapy for hepatorenal syndrome is improvement of liver function from recovery of alcoholic hepatitis, treatment of decompensated hepatitis B with effective antiviral therapy, recovery from acute hepatic failure, or liver transplantation. The ability of liver function to improve with abstinence from alcohol and effective antiviral therapy of hepatitis B is remarkable.
However, when improvement of liver function is not possible in the short term, we recommend that medical therapy be instituted in an attempt to reverse the acute kidney injury associated with hepatorenal syndrome. Our suggestions regarding the choice of medical therapy depend upon several factors, including: whether the patient is admitted to the intensive care unit; the availability of certain drugs, for which there is national and regional variability; and whether the patient is a candidate for liver transplantation:
In patients with hepatorenal syndrome who are critically ill, we suggest initial treatment with norepinephrine in combination with albumin. Norepinephrine is given intravenously as a continuous infusion (0.5 to 3 mg/hr) with the goal of raising the mean arterial pressure by 10 mmHg, and albumin is given for at least two days as an intravenous bolus (1 g/kg per day [100 g maximum]). Intravenous vasopressin may also be effective, starting at 0.01 units/min and titrating upward as needed to raise the mean arterial pressure as noted below.
In patients with hepatorenal syndrome who are not critically ill, our suggestions depend upon the availability of certain drugs:
- Where terlipressin therapy is available, we suggest initial treatment with terlipressin in combination with albumin. Terlipressin is given as an intravenous bolus (1 to 2 mg every four to six hours), and albumin is given for two days as an intravenous bolus (1 g/kg per day [100 g maximum]), followed by 25 to 50 grams per day until terlipressin therapy is discontinued.
- Where terlipressin therapy is not available (principally the United States), we suggest initial treatment with a combination of midodrine, octreotide, and albumin. Midodrine is given orally (starting at 7.5 mg and increasing the dose at eight-hour intervals up to a maximum of 15 mg by mouth three times daily), octreotide is either given as a continuous intravenous infusion (50 mcg/hr) or subcutaneously (100 to 200 mcg three times daily), and albumin is given for two days as an intravenous bolus (1 g/kg per day [100 g maximum]), followed by 25 to 50 grams per day until midodrine and octreotide therapy is discontinued.
In highly selected patients who fail to respond to medical therapy with the above regimens and who are considered well enough to undergo the procedure, transjugular intrahepatic portosystemic shunt (TIPS) is sometimes successful. However, this procedure is associated with numerous complications and, because of the need for intravenous contrast, it may cause acute kidney injury. For this reason, some experts prefer dialysis as a first option (continuous renal replacement therapy) in most cases, particularly for patients whose serum creatinine remains above 1.5 mg/dL despite medical therapy.
In patients who fail to respond to the above therapies, develop severely impaired renal function, and either are candidates for liver transplantation or have a reversible form of liver injury and are expected to survive, we recommend dialysis as a bridge to liver transplantation or liver recovery.]

What is the usual energy source for the liver?
Ketones
[α-Ketoacids derived from the degradation of amino acids are the liver’s own fuel. In fact, the main role of glycolysis in the liver is to form building blocks for biosyntheses. Furthermore, the liver cannot use acetoacetate as a fuel, because it has little of the transferase needed for acetoacetate’s activation to acetyl CoA. Thus, the liver eschews the fuels that it exports to muscle and the brain.]
Cultures of an amebic liver abscess typically show what?
Nothing
[Cultures of abscess often sterile -> Protozoa (Entamoeba Histolytica) exist only in peripheral rim]
Most primary and secondary liver tumors are supplied by which artery?
Hepatic artery
Which Hepatitis Virus causes high mortality in pregnant women
HEV
Diagnose:
- HBsAg: +
- Anti-HBs: -
- HBeAg: +
- Anti-HBe: -
- Anti-HBc: IgM
Acute HBV

What are the 4 boundaries of the Foramen of Winslow?
- Anterior: Portal triad
- Posterior: IVC
- Inferior: Duodenum
- Superior: Liver

The portal triad (common bile duct, portal vein, and proper hepatic artery) enters which numbered segment(s) of the liver?
Segments IV and V

What is the # 1 cause of hepatocellular carcinoma worldwide?
Hepatitis B
Jaundice occurs when the total bilirubin reaches what level?
Greater than 2.5
What is the treatment for postpartum liver failure with ascites?
Heparin and antibiotics
A liver abscess caused by an infection with which organism is associated with a maculopapular rash, increased eosinophils, and variceal bleeding?
Schistosomiasis
[UpToDate: Manifestations of chronic infection are generally observed among individuals with ongoing exposure in endemic regions. Disease is caused by the host immune response to migrating eggs. In the bowel, inflammation can result in ulceration, blood loss, and scarring. In the liver, periportal fibrosis (Symmers’ pipestem fibrosis) can lead to portal hypertension and subsequent esophageal varices. In the bladder, granulomatous inflammation can result in development of pseudopolyps and/or urinary tract obstruction leading to renal failure.]

What conjugates bilirubin to glucuronic acid in the liver?
Glucuronyl transferase
[Improves water solubility]

What is a direct contraindication to a splenorenal shunt in a cirrhotic patient?
Refractory ascites
[This procedure can worsen ascites]
Which numbered segments of the liver are fed by the left portal vein?
Segments II, III, and IV

Best marker for chronic HBV infection
HBsAg longer than 6 months but no anti-HBs antibodies

How is Budd-Chiari syndrome diagnosed?
Angiogram with venous phase, CT angiogram
[Liver biopsy shows sinusoidal dilatation, congestion, and centrilobular congestion]
Which vein(s) act as collaterals between the portal vein and the systemic venous system of the lower esophagus (azygous vein)
Coronary veins

What are the King’s College criteria of poor prognostic indicators for non-acetaminopen-induced acute liver failure?
INR > 6.5
Or any 3 of the following:
- Age less than 10 or greater than 40
- Drug toxicity or undetermined etiology
- Jaundice greater than 7 days before encephalopathy
- INR greater than 3.5
- Bilirubin greater than 17 mg/dL












































































































