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ABSITE > Ch 31 Liver > Flashcards

Ch 31 Liver Flashcards

1
Q

____ separates medial and lateral segments of left lobe and carries remnants of _____

A

falciform ligament; umbilical vein

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2
Q

2 hepatic artery variants

A
  1. RHA off SMA (20%) behind pancreas, posterolateral to CBD

2. LHA off left gastric (20%) found in gastrohepatic ligament medially

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3
Q

_____ carries the obliterated umbilical vein to the undersurface of the liver

A

ligamentum teres//extends from falciform

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4
Q

________ line separates right and left lobes and extends from ____ to ____

A

Cantlie’s line or portal fissurel drawn from middle of gallbadder fossa to IVC

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5
Q

L liver segments

A

I, II, III, IV

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6
Q

R liver segments

A

V, VI, VII, VIII

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7
Q

Describe location of L segments

A

4 medial (in center of liver)
2 and 3 lateral with 2 above 3
1 behind 4

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8
Q

Describe location of R segments

A

5, 6, 7, 8 clockwise with 5 inferomedial/anterior to 6

*think of the liver as a mitered corner

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9
Q

___ segment is the caudate lobe

A

I

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10
Q

___ segment is the quadrate lobe

A

IV/Left medial

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11
Q

____ covers the liver

A

glisson’s capsule/peritoneum

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12
Q

_____ is a bare area not covered’ by glisson’s capsule

A

area on the posterior superior surface of liver

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13
Q

_____ are the extensions of the coronary ligament that connect the liver to the ____ and are made of

A

right and left triangular; diaphragm; peritoneum

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14
Q

the portal triad enters which segments?

A

IV and V

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15
Q

the gallbladder lies under which segments?

A

IV and V

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16
Q

_____are liver macrophages

A

Kupffer cells

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17
Q

the portal triad includes ____ (3) and runs in the _______

A

cbd (lateral)
portal vein (posterior)
PHA (medial)
hepatoduodenal ligament/porta hepatis

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18
Q

the _____ maneuver involves clamping the portal triad //caveat?

A

pringle maneuver

does not stop hepatic vein bleeding or IVC bleeding

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19
Q

You do the pringle maneuver and then mobilize the R lobe. You see a rush of blood.

A

Injury to a hepatic vein likely

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20
Q

You do the pringle maneuver and then mobilize the R lobe. You see a hematoma.

A

Injury to IVC likely –> pack the liver, sternotomy, Rummel tourniquet on IVC, repair vessel

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21
Q

Structures in foramen of winslow

A

anterior - portal triad
posterior - ivc
inferior - duodenum
superior - liver

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22
Q

what structures form the portal vein

A

smv and splenic vein (no valves) come together

imv enters the splenic vein

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23
Q

portal veins/volume of flow/which segments

A

2 in liver; 2/3 of hepatic blood flow
L - segments II, III, IV
R - V, VI, VII, VIII

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24
Q

What is the blood supply of the caudate?

A

separate right and left portal and arterial blood flow; drains directly into IVC with separate veins

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25
Q

Arterial and venous blood supply of the liver

A

R/L/MHA (mha branch of LHA)
R/L/MHV (mhv join LHV 80% before going to IVC/20% directly to IVC)

L - II,II, superior IV
M - inferior IV, V
R - VI, VII, VIII

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26
Q

Which vessel supplies most primary and secondary liver tumors

A

hepatic artery

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27
Q

_____ drains medial aspect of R lobe directly to IVC

A

accessory right hepatic veins (inferior phrenic veins also dump into IVC)

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28
Q

AlkPhos is normally released from the _____ membrane

A

canalicular

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29
Q

Nutrient uptake in the liver takes place in the ____ membrane

A

sinusoidal

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30
Q

___ is the usual source of energy for liver

A

ketones; glucose stored as glycogen/excess glucose converted to fat

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31
Q

where are vwf and factor VIII made?

A

vascular epithelium (not liver)

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32
Q

what is the only water soluble vitamin stored in liver

A

b12

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33
Q

most common problems with hepatic resection (2)

A

bile leak, bleeding

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34
Q

which hepatocytes are most susceptible to ischemia

A

central lobular (acinar zone III//by central veins)

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35
Q

maximum amt liver that can be safely resected

A

75%

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36
Q

Hgb downstream breakdown (3)

A

hgb, heme, biliverdin, bilirubin)

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37
Q

what improves water solubility of bilirubin and what molecule is implicated?

A

liver conjugation to glucoronic acid with glucoronyl transferase

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38
Q

Where does conjugated bilirubin go?

A

bile –> ileum –> bacterial breakdown in terminal ileum –> conversion to urobilinogen (colorless)–>
1/2 –> converted to stercobilin –> feces
1/2 –> absorped through PV –> circulation –> kidney releases in urine as (oxidized in circulation) urobilin (yellow) –> excess conjugated bilirubin turns urine cola dark (i.e. in biliary obstruction, cbili enters circulation and peed out)

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39
Q

Composition of bile

A 
85% bile salts 
proteins
lecithin (phospholipids)
cholesterol
bilirubin
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40
Q

_____ determines final bile composition/density

A

Na/K ATPase mediates reabsorption of water in gallbladder

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41
Q

Primary bile acids

A

cholic and chenodeoxycholic

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42
Q

Secondary bile acids

A

deoxycholic and lithocholic (dehydroxylated primary bile acids by bacteria in gut)

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43
Q

What improves the water solubility of bile salts?

A

conjugation to taurine and glycine

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44
Q

___ is the main biliary phospholipid

A

lecithin

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45
Q

Jaundice occurs at bilirubin > ___ and is first evident ___

A

2.5; under the tongue

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46
Q

Maximum bilirubin is ___ unless (3 conditions)

A

30; renal disease, hemolysis, bile duct-hepatic vein fistula

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47
Q

Causes of elevated unconjugated bilirubin

A

deficient/reduced hepatic uptake, deficiency in glucoronyl transferase, hemolysis/prehepatic

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48
Q

Causes of increased conjugated bilirubin

A

posthepatic biliary obstruction (stones, strictures, tumor), absence of gut bacteria (e.g. from abx)

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49
Q

What disease? abnormal conjugation; mild defect in glucoronyl transferase

A

Gilbert

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50
Q

What disease? inability to conjugate; severe deficiency of glucoronyl transferase, high unconjugated bilirubin, life threatening

A

Crigler-Najjar

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51
Q

What disease? immature glucoronyl transferase; high unconjugated bilirubin

A

physiologic jaundice of newborns

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52
Q

What disease? deficiency in storage; high conjugated bilirubin

A

Rotor’s

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53
Q

What disease? deficiency in secretion; high conjugated bilirubin

A

Dubin-Johnson (black liver)

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54
Q

bilirubin encephalopathy is also known as

A

kernicterus –> common in crigler najjar prior to bililamps

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55
Q

Which hepatitis can cause acute hepatitis

A

All of them

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56
Q

Which hepatitis can cause fulminant hepatic failure

A

B,D,E (rare with A and C)

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57
Q

which hepatitis can cause chronic hepatitis

A

B,C,D

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58
Q

which hepatitis can cause chronic hepatoma

A

B,C,D

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59
Q

Hepatitis - RNA or DNA?

A

RNA except for B (DNA)

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60
Q

most common hepatitis leading to transplant

A

C

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61
Q

____ leads to fulminant hepatic failure in ___ trimester of pregnancy

A

hepatitis E in 3rd trimester

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62
Q

Hep B ab progression

A

infected: anti-HBc-IgM elevated in first six months and then IgG; HBsAg present
vaccination: elevated anti-HBs; no HBsAg
recovery: elevated anti-HBc and anti-HBs; no HBsAg

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63
Q

Most common cause of liver failure

A

cirrhosis

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64
Q

Best indicator of synthetic function in patient with cirrhosis

A

prothrombin time (PT)

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65
Q

mortality rate in acute liver failure and main determinant

A

80%; course of encephalopathy

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66
Q

King’s College Criteria for acetominophen induced ALF

A

ph6.5, creat >3.4, grade III/IV encephalopathy

67
Q

King’s College Criteria for non acetominophen induced ALF

A

INR>6.5
OR ANY 3 of:
age40, drug tox/undetermined etiology, jaundice >7days before encephalopathy, INR>3.5, bili >17

68
Q

pathophys of hepatic encephalopathy

A

liver failure –> inability to metabolize –> buildup of ammonia, mercatanes and false nt’s

69
Q

Differential for encephalopathy

A

liver, gi bleed, infection (SBP), electrolyte, drugs

70
Q

Tx and functions of hepatic encephalopathy

A
  1. lactulose (titrate to 2-3 stools/day) - removes gut bacteria, acidifies colon (prevents NH3 uptake by converting to ammonium)
  2. limit protein intake (
71
Q

Mechanism of cirrhosis

A

hepatocyte destruction –> fibrosis and scarring of liver –> increased hepatic pressure –> portal venous congestion –> lymphatic overload –> leakage of splanchnic and hepatic lymph into peritoneum –> ascites

72
Q

Albumin replacement for paracentesis

A

1 g for every 100 cc removed

73
Q

Tx of ascites

A

water restriction (1-1.5 L/day)
salt restriction (1-2g/day)
diuretics (spironolactone counterats hyperaldo seen in liver failure)
paracentesis
TIPS
prophylactic abx for sbp (norfloxacin if previous SBP or current UGI bleed)

74
Q

heptorenal syndrome findings and tx

A

progressive renal failure (sign of end stage liver disease); same lab findings as prerenal azotemia

Tx: stop diuretics, give volume, no good therapy other than liver txp

75
Q

Likely cause of postpartum liver failure with ascites -DX and Tx

A

hepatic vein thrombosis (has an infectious component)
Dx: SMA arteriogram with venous phase contrast
Tx: heparin and abx

76
Q

Findings in SBP

A

fever, abdominal pain

PMN>250 in fluid, positive cultures

77
Q

Causes of SBP

A

ecoli > pneumococci >streptococci

78
Q

Concern for SBP but with multiple species

A

–> probably bowel perforation (SBP typically monoorganism)

79
Q

Tx of SBP and response time

A

3rd gen cephalosporin –> response within 48 hours

80
Q

How do esophageal varices bleed?

A

rupture

81
Q

Tx of varices

A

tx: banding and sclerotherapy (95% effective)
temporize:
1. vasopressin (splanchnic artery constriction)
2. octreotide (reduce portal pressure)
prevent rebleed: propanolol

82
Q

Concern with vasopressin for treating varices

A

hx of CAD should not receive NTG while on vasopressin

83
Q

Tx of refractory variceal bleeding

A

TIPS

84
Q

Framework and differential for portal hypertension

A

pre-sinusoidal: schisto, congenital hepatic fibrosis, portal vein thrombosis (50% of phtn in kids)

sinusoidal: cirrhosis

post sinusoidal obstruction: budd chiari, constrictive pericarditis, CHF

85
Q

Normal portal vein pressure

A
86
Q

_____ act like collaterals between portal vein and systemic azygous vein

A

coronary veins

87
Q

major cause of portal htn in children

A

extrahepatic portal vein thrombosis; most common cause of massive hematemesis in children

88
Q

Consequences of portal hypertension

A

esophageal varices, ascites, splenomegaly, hepatic encephalopathy

89
Q

indications for TIPS

A

protracted bleeding, progression of coagulopathy, visceral hypoperfusion, refractory ascites

90
Q

Complication of TIPS

A

development of encephalopathy

91
Q

Describe TIPS

A

transjugular intrahepatic portosystemic shunt
catheter in hepatic vein via jugular vein.
needle passed through to a major portal vein branch, dilated with angioplasty and then stent

92
Q

_____ shunts can worsen ascites but reduce _____.

A

Splenorenal; encephalopathy

93
Q

Indication for splenorenal shunt

A

Child’s A with bleeding as only symptom –> this shunt is more durable; otherwise tips

94
Q

Indication for TIPS

A

Child’s B or C with shunt indication

95
Q

How does Child’s score correlate with mortality

A

only after open shunt placement
A: 2% mortality with shunt
B: 10% mortality with shunt
C: 50% mortality with shunt

96
Q

Child’s A score

A

5-6

97
Q

Child’s B score

A

7-9

98
Q

Child’s C score

A

> 9

99
Q

Child’s components

A

PT/INR, albumin, bilirubin, ascites, encephalopathy

“pour another beer at eleven”

100
Q

Dx and Tx of budd chiari syndrome

A

occlusion of hepatic veins or ivc

dx: angiogram with venous phase, CT angio
tx: portocaval shunt (need to connect to IVC above obstruction)

101
Q

Symptoms of budd-chiari

A

ruq pain, hsm, ascites, fulminant hepatic failure, muscle wasting, variceal bleeding

102
Q

____ can lead to isolated gastric varices without elevation of pressure in rest of the portal system

A

splenic vein thrombosis

*these varices can bleed

103
Q

Most common cause of splenic vein thrombosis

A

pancreatitis

104
Q

Tx of splenic vein thrombosis

A

splenectomy if symptomatic

105
Q

Amoebic abscess: labs, location, primary infection

A

increased WBC, LFTs with + serology for entamoeba histolyica usually single in right lobe; primary infection = amebic colitis

106
Q

risk factors for amoebic abscess

A

travel to mexico (fecal/oral), etoh

107
Q

____% of those with + entamoeba serology have infection

A

90

108
Q

Amebic abscess: clinical features

A

jaundice, hepatomegaly, fever, chills, RUQ pain

109
Q

Amoebas reach the liver via ____

A

portal veinydatid cyst

110
Q

Culture finding in amoebic abscess

A

culture negative –.> protozoa only exist in peripheral rim

111
Q

Dx of amoebic abscess

A

ct

112
Q

Tx amoebic abscess

A

flagyl, aspiration only if refractory, surgery only if free rupture

113
Q

Hydatid cyst caused by ___ and tends to be in ___ lobe

A

echinococcus; R

114
Q

Dx of hydatid cyst

A

+ casoni skin test, + serology, CT

115
Q

CT findings in hydatid cyst

A

ectocyst (calcified) and endocyst (double walled cyst)

116
Q

Echnococcus carrier is ____ and transmitted to humans via _____

A

sheep; dogs

117
Q

Tx of hydatid cyst

A

preop albendazole (2 weeks) then intra op alcohol injection to kill organisms, aspirate, then need to get cyst wall

118
Q

Why not aspirate hydatid cyst percutaneously?

A

spillage of cyst contents will cause anaphylactic shock

119
Q

What preop mgmt for hydatid cyst?

A
  1. 2 weeks preop albendazole

2. preop ERCP for jaudnice, increased lft, cholangitis to check for biliary communication

120
Q

Primary infection in schisto and findings at primary site

A

sigmoid colon –> fine granulation tissue, petechaie, ulcers

121
Q

Tx of schisto

A

praziquantel and control of variceal bleeding

122
Q

Clinical findings in schisto

A

maculopapular rash, increased eosinophils

123
Q

80% of liver abscesses

A

pyogenic

124
Q

symptoms of pyogenic abscess

A

fever, chills, weight loss, ruq pain, increased lfts, increased wbc, sepsis

125
Q

pyogenic abscess mortality

A

15% with sepsis

126
Q

pyogenic abscess location

A

increased in r lobe

127
Q

most common organism in pyogenic abscess

A

gnr - ecoli

128
Q

etiology of pyogenic abscess

A

typically secondary to contiguous infection from biliary tract

also from bacteremia from other infections (appendicitis, diverticulitis)

129
Q

Dx of pyogenic abscess

A

aspiration

130
Q

Tx of pyogenic abscess

A

ct guided drainage and antibiotics; surgical drainage for unstable condition and continued signs of sepsis

131
Q

4 benign liver tumors

A

adenomas, focal nodular hyperplasia, hemangiomas, solitary cysts

132
Q

Risk factors for hepatic adenoma

A

women, steroid use, ocps

133
Q

Symptoms of hepatic adenoma

A

80% symptomatic
20% risk of significant bleeding/rupture
symptoms: pain, hemodynamic instability (from rupture) palpable mass

134
Q

Malignant potential of hepatic adenoma

A

possible transformation

135
Q

Dx of hepatic adenoma

A

no kupffer cells in adenomas thus no uptake on sulfur colloid scan (cold); MRI shows hypervascular tumor

136
Q

Tx of hepatic adenoma

A

asymptomatic: stop ocps, if regression no more therapy; if no regression, resection
symptomatic: tumor resection for bleeding and malignancy risk; embolization for multiple and unresectable

137
Q

location of hepatic adenoma

A

R lobe preference

138
Q

lab findings in hepatic adenoma

A

elevated lfts

139
Q

focal nodular hyperplasia has a _____ sign that may look like cancer

A

central stellate star

140
Q

malignancy risk of focal nodular hyperplasia

A

none and unlikely to rupture

141
Q

Dx focal nodular hyperplasia

A

ct scan; has kupffer cells so will take up sulfur colloid on scan; mri/ct shows hypervascular tumor

142
Q

Tx focal nodular hyperplasia

A

conservative therapy

143
Q

Most common benign hepatic tumor

A

hemangioma

144
Q

hemangioma rupture risk

A

low; more in women

145
Q

Dx hemangioma

A

don’t biopsy –> rupture

MRI/CT show peripheral to central enhancement of hypervascular lesion

146
Q

Tx hemangioma

A

conservative unless symptomatic, then surgery +/- preop embolization; steroids (possible XRT) for unresectable disease

147
Q

Rare complications of hemangioma (2)

A

consumptive coagulopathy (kasabach merritt), CHF –> both typically in children

148
Q

Solitary cysts are msot common in ____ location in ____ population and are unique because ____

A

R lobe; women; blue hue

149
Q

Tx of solitary hepatic cysts

A

leave alone

150
Q

Metastasis:primary ratio in liver tumor

A

20:1

151
Q

Most common cancer worldwide

A

hcc

152
Q

risk factors for hcc

A

hep B (#1), hepC, etoh, hemochromatosis, alpha1antitrypsin deficiency, psc, aflatoxin, hepatic adenoma, steroid, pesticide

153
Q

primary hepatic diseases that are not risk factors for hcc

A

wilsons and pbc

154
Q

3 types of hcc with best prognosis

A

clear cell, lymphocyte infiltrative, fibrolamellar (adolescents and young adults)

155
Q

____ correlates with tumor size in hcc

A

afp level

156
Q

hcc survival rate with resection

A

30% at 5 years

157
Q

why can we not resect many hepatic tumors

A

cirrhosis; portohepatic involvement; metastases

158
Q

margin for hcc

A

1 cm

159
Q

tumor recurrence of hcc is most likely in ____ after resection

A

liver

160
Q

risk factors hepatic sarcoma

A

pvc, thorotrast, arsenic –> rapidly fatal

161
Q

management of colon CA mets to liver

A

resect if can leave sufficient liver

162
Q

survival of colon CA met resection in liver

A

35% @ 5 years after resection

163
Q

Vascularity of malignant liver tumors

A 
primary = hyper
met = hypo
164
Q

Recess of liver from which accessory bile ducts (e.g. luschka) communicate with gallbladder

A

Rouviere’s Sulcus aka incisura hepatis dextra, Gans incisura

ABSITE (3 decks)

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