ABSITE Review - Liver Flashcards
What is the #1 and #2 hepatic artery variant?
#1 R hepatic artery off SMA (20%) - courses behind pancreas, POSTEROLATERAL to the CBD #2 L hepatic artery off L gastric (20%) - found in gastrohepatic ligament
What is the falciform ligament?
Separates the medial and lateral segments of the L lobe; attaches liver to anterior abdominal wall; extends to umbilicus and carries umbilical vein.
What is the ligamentum teres?
Carries the obliterated umbilical vein to the undersurface of the liver; extends from the falciform ligament
What are the segments of the liver?
I - caudate
II - superior left lateral segment
III - inferior left lateral segment
IV - left medial segment (quadrate)
V - inferior right anterolateral segment
VI - inferior right posterolateral segment
VII - superior right posterolateral segment
VIII - superior right anteromedial segment
Where is the bare area of liver?
Posterior-superior surface of liver not covered by Glisson’s capsule
Where the portal triad enters the liver?
Segments IV and V
What is other name for liver macrophages?
Kupffer cells
What is in the portal triad and their location within it?
Portal vein posteriorly, CBD laterally, hepatic artery medially
What is the Pringle maneuver?
Porta hepatis clamping; will not stop hepatic vein bleeding
What is the positioning of the Foramen of Winslow?
Anterior - portal triad
Posterior - IVC
Inferior - Duodenum
Superior - Liver
What two veins form the portal vein?
Forms from SMv joining splenic vein (no valves)
How many portal veins are in the liver and what segment they drain?
Left - II, III, IV
Right - V, VI, VII, VIII
Where the middle hepatic artery usually comes off?
Middle heaptic artery MC a branch off the Left hepatic artery
Which segment each hepatic veins drain?
Left - II, III, sup IV
Middle - V, inf IV
Right - VI, VII, VIII
What is the arterial supplay and venous drainage of the caudate lobe?
Receives separate right and left portal and arterial blood flow; drains directly into IVC via separate hepatic veins
What is the usual energy source of the liver?
Ketones
Where is urea synthesized?
Liver
Which factors are not made in the liver?
vWF, factor VIII (endothelium)
Which is the only water soluble vitamin stored in the liver?
B12
What are the Mc problems after a hepatic resection?
Bleeding and bile leak
Which hepatocytes are the most sensitive to ischemia?
Central lobular (acinar zone III)
How much liver can be safely resected?
75%
What are the two primary bile acids?
Cholic and chenodeoxycholic
What are the two secondary bile acids?
Deoxycholic and lithocolic
What is the main biliary phospholipid?
Lecithin
Where is the first place to look for jaundice?
Under the tongue
What is Gilbert’s disease?
Abnormal uptake; mildly high unconjugated bilirubin
What is Crigler-Najjar disease?
Inability to conjugate; deficiency of glucoronyl transferase; high unconjugated bilirubin –> life-threatening
What is physiologic jaundice of newborn?
Immature glucoronyl transferase; high unconjugated bilirubin
What is Rotor’s syndrome?
Deficiency in storage ability; high conjugated bilirubin
What is Dubin-Johnson syndrome?
Deficiency in secretion ability; high conjugated bilirubin
What types of hepatitis can cause chronic hepatitis and hepatoma?
B, C and D
What is the tyoe of hepatitis that is DNA?
Hepatitis B
What is the marker of Hepatitis B vaccination?
Increase anti-HBs antibodies
What is the MCC of liver failure?
Cirrhosis
What is the best indicator of synthetic function in a patient with cirrhosis?
Prothrombin time
What is the treatment for hepatic encephalopathy?
Lactulose - cathartic that gets rid of bacteria in the gut and acidifies colon (preventing NH3 uptake by converting it to ammonium)
Limit protein intake
Branched-chain amino acids
What is the most likely cause of hepatic failure with ascites postpartum?
Hepatic vein thrombosis
Dx - SMA arteriogram with venous phase contrast
What is the MC bacteria in SBP?
E coli
What is the treatment for esophageal varices?
Sclerotherapy, Vasopressin (splanchnic artery constriction), Octreotide (decrease portal pressure by decrease blood flow), Propanolol
What are the three types of portal HTN? Give some examples of each.
Presinusoidal obstruction - schistomiasis, congenital hepatic fibrosis, portal vein thrombosis
Sinusoidal obstruction - cirrhosis
Postsinusoidal obstruction - Budd-Chiari syndrome (hepatic vein occlusive disease), constrictive pericarditis, CHF
What is the normal portal vein pressure?
<12 mmHg
When is a TIPS indicated?
Used for protracted bleeding, progression of coagulopathy, visceral hypoperfusion, refractory ascites.
What is a splenorenal shunt?
Ligate Left adrenal vein, left gonadal vein, inferior mesenteric vein, coronary vein, and pancreatic branches of splenic vein
Used only for Child’s A cirrhotics who present just with bleeding
What is Budd-Chiari syndrome?
Occlusion of hepatic veins and IVC
Dx - angio, CT scan, liver biopsy sinusoidal dilatation, congestion, centrilobular congestion
Tx - portacaval shunt
What is the MCC of splenic vein thrombosis?
Pancreatitis
How is an amebic infection diagnosed? What is the treatment?
Entamoeba histolytica
Tx - Flagyl
What are the risk factor for an amebic abscess? Which liver lobe is most commonly involved?
Travel to Mexico, ETOH, fecal-oral transmission
Right lobe of liver
What is the agent that cause Hydatid cyst? How it can be diagnosed?
Echinococcus
Dx - Positive Casoni skin test, positive indirect hemagglutination
Which animals are carrier of Echinococcus?
Sheeps
Can you aspirate a hydatid cyst? What is the treatment?
No!!! It can leak and cause an anaphylactic shock.
Tx - Preop ERCP if jaundice, increase LFTs or cholangitis. Preop albendazole
Surgical removal (may want to inject cyst with alcohol at time of removal to kill organisms); need to get all the cyst wall
In 80% of the liver abscesses, the MCC is?
Pyogenic abscess
What are the risk factors for liver adenomas?
Women, steroid use, OCPs, type I collagen storage disease
How are liver adenomas diagnosed?
MRI demonstrates hypervascular tumor, has peripheral blood supply
No Kupffer cells in adenomas, thus no uptake on sulfur colloid scan (cold)
What is the treatment for liver adenomas?
Asymptomatic - stop OCPs, if no regression –> pt needs resection
Symptomatic - tumor resection for bleeding and malignancy risk; embolization if multiple and unresectable
What is usually describe as a central stellate scar?
Focal nodular hyperplasia
How is FNH diagnosed? What is the treatment?
Dx - Abdominal CT; has Kupffer cells, so will take up sulfur colloid on liver scan
MRI/CT scan demonstrates a hypervascular tumor
Tx- conservative mgmt
What is the MC benign hepatic tumor?
Hemangioma
How is FNH diagnosed? What is the treatment?
Dx - MRI and CT scan show peripheral to central enhancement, hypervascular lesion
Tx - conservative unless symptomatic, then surgery +/- embolization, XRT and steroids for unresectable disease
What are the risk factors of HCC?
HBV (#1), HCVm ETOH, hemochromatosis, alpha-1-antitrypsin deficiency, primary sclerosing cholangitis, aflatoxins, hepatic adenoma, steroids, pesticides
What marker correlates with HCC tumor size?
AFP
What are the risk factors for hepatic sarcoma?
PVC, Thorotrast, arsenic
What are the risk factors asocciated with cholangiosarcoma?
Clonorchiasis infection, ulcerative colitis, hemochromatosis, primary sclerosing cholangitis, choledochal cyst
What is the difference in vascularity of primary vs metastatic liver tumors?
Primary - hypervascular
Metastatic - hypovascular
