Chapter 13, part 2 Flashcards by Deborah Karp

What may cause amebic liver abscesses?

Entamoeba histolytica

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Who is at highest risk for amebic liver abscesses?

Alcoholic pts

Homosexuals

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Tx of amebic liver abscess

Medical management
10-14 day course of metronidazole
No role for surgical management

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Tx of hydatid liver dz

Surgical resection of the hydatid cyst constitutes definitive therapy

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In hydatid liver dz, what may result in anaphylactic shock?

Cyst rupture

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Cirrhosis of the liver

Characterized by the replacement of nl functioning hepatocytes with fibrous connective tissue and regenerative hepatic nodules

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Common causes of cirrhosis

Chronic HBV or HCV infection
Exposure to hepatotoxins such as alcohol
A1-antitrypsin deficiency
Hemochromatosis
Wilson's dz

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How are surgeons asked to manage cirrhosis?

Liver transplantation, the only curative and definitive therapy for end-stage cirrhosis
Manage complications of portal HTN
Any other surgical diseases that affect the rest of the population

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Presentation of cirrhosis

Varies
May be relatively well compensated or asymptomatic
Encephalopathy
Jaundice
Coagulopathy
Complications of portal HTN:
-Gastroesophageal varices
-Ascites

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What is the best option in pts with isolated gastric variceal bleeding secondary to splenic vein thrombosis?

Splenectomy

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What is the best option in pts with gastric varices secondary to portal HTN?

Insertion of a transjugular intrahepatic portosystemic shunt (TIPS)

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Contraindications to TIPS procedure

Right-sided heart failure with increased central venous pressure
Severe hepatic failure
Portal vein thrombosis
Severe hepatic encephalopathy
Active local or systemic infection

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Tx of gastroesophageal variceal bleeding

Endoscopic band ligation

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For gastroesophageal variceal bleeding, what should be done if endoscopic band ligation fails?

TIPS procedure

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What may be required with massive gastroesophageal variceal bleeding?

Control with a Sengstaken-Blakemore tube prior to the initiation of more definitive therapy

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When TIPS fails to stop gastroesophageal variceal bleeding or is unavailable, what may be required?

Surgical portosystemic shunts

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Which surgical portosystemic shunt is the shunt of choice for gastroesophageal variceal bleeding?

Portacaval shunt

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What is an alternative to shunt surgery for gastroesophageal variceal bleeding?

Esophageal devascularization and transection procedures

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How can refractory ascites be treated?

Surgical placement of a LeVeen shunt

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Complications of a LeVeen shunt

Infection of the shunt

Coagulopathy secondary to systemic fibrinolysis

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When is a LaVeen shunt not recommended?

Cirrhotic pts with ascites

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What are the two measures of severity of liver dz in the cirrhotic pt?

Child
MELD (Model for End-stage Liver Dz) score

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In terms of Child’s classification or MELD score, what is associated with the worst perioperative survival?

An emergent operation in a pt with a Child’s C classification or a MELD score >25

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When elective surgery is performed in a cirrhotic pt, what needs to be done?

A preoperative evaluation for liver transplantation should be considered.

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What are the most common benign solid tumors of the liver?

Hemangiomas

Presentation of hemangiomas

Abdominal pain or discomfort only after the hemangioma has grown to over 10 cm

Tx of hemangiomas

The great majority of hemangiomas should be observed and not resected unless there are significant sx When surgical intervention is warranted, the hemangioma can be enucleated

What is an additional indication for hemangioma resection?

Kasabach-Merritt syndrome

Tx of hepatic cysts

Require no intervention but must be distinguished from cystadenomas, which can undergo malignant degeneration.

What two neoplasms both affect young women of reproductive age and are associated with similar CT scan findings?

Focal nodular hyperplasia (FNH) and hepatic adenoma (HA)

What is the difference in tx between FNH and HA?

HA requires surgical resection, while FNH is treated nonsurgically

What most reliably distinguishes between FNH and HA?

MRI

What should be done if a definitive dx can't be made through imaging between FNH and HA?

Resection or core bx

What is the difference in presentation between FNA and HA

FNH nodules do not hemorrhage 40% of HA tumors contain intraparenchymal hemorrhage HA usually causes more sx than does FNH and may enlarge upon exposure to higher levels of circulating hormone

What sometimes results in regression of HA tumor size and improvement of sx?

Cessation of OCPs

What are the most common malignant hepatic neoplasms?

Metastatic tumors to the liver from the GI tract, breast, or lung

Tx of metastatic liver disease

Precludes surgical intervention, EXCEPT liver metastases from colorectal cancer

How have approaches to resectable synchronous lesions changed over the years?

Traditionally, staged resection Then, Simultaneous hepatic and colon resection- combined approach Recently, reverse approach- resecting liver metastases prior to the colorectal primary

When is a reverse approach indicated?

Pts with more extensive liver metastases and an asymptomatic colorectal primary

What is a more prevalent dz worldwide than in the USS in terms of liver tumors?

Hepatocellular carcinoma (HCC)

In the United States, what is hepatocellular carcinoma usually associated with?

Chronic hep C infection | Alcoholic cirrhosis

What is the primary risk factor for the development of hepatocellular carcinoma?

Cirrhosis of the liver of any etiology

Who is at highest risk for developing hepatocellular carcinoma?

Men over that age of 40 with HCV cirrhosis

How does hepatocellular carcinoma present?

May present as a RUQ mass, or more commonly, is discovered incidentally on cross-sectional imaging performed for another indication

Dx of hepatocellular carcinoma

Can be made without bx if the pt has a liver mass an an elevated alpha-fetoprotein level CT and MRI have become increasingly sensitive and specific for the dx of HCC

Screening for hepatocellular carcinoma

The NCI does not recommend a standard screening protocol in any population for this dz

What is the name of the criteria to screen HCC pts for liver transplant?

Milan

5-year disease-free survival is superior in HCC pts who undergo ______ compared to ________.

Transplantation; resection

Tx for noncirrhotic pt with HCC

Aggressive anatomic resection should be performed so long as the liver remnant will provide adequate hepatic mass to physiologically support the pt

In what category are the vast majority of pts with HCC?

>80% of pts are neither transplant candidates nor do they have resectable dz

Tx for unresectable HCC pts

``` Locally ablative therapies such as: Radiofrequency ablation (RFA) Percutaneous ethanol injection (PEI) Cryotherapy Transarterial chemoembolization ```

Risk factors for cholangiocarcinoma

Congenital choledochal cysts Primary sclerosing cholangitis Infection with the liver fluke Clonorchis sinensis

How can cholangiocarcinoma be further divided?

Intrahepatic or extrahepatic dz

Presentation of intrahepatic cholangiocarcinoma

Frequently confused with HCC | Usually present late in the dz

Tx of intrahepatic cholangiocarcinoma

Resection

Presentation of extrahepatic cholangiocarcinoma

Presents earlier than intrahepatic cholangiocarcinoma with obstructive jaundice

Tx of extrahepatic cholangiocarcinoma

Resection is the only curative modality

What has been done for certain pts with small, unresectable cholangiocarcinoma?

Orthotopic liver transplantation

What is the most common cancer of the biliary tree?

Gallbladder adenocarcinoma

Primary risk factors of gallbladder adenocarcinoma

Female gender | Gallstones

Who should undergo cholecystectomy due to polyp size being correlated with neoplastic transformation?

Any pt with a gallbladder polyp >1 cm

In gallbladder adenocarcinoma, what is associated with a high cure rate?

Resection of very early-stage tumors

What is recommended for any pt with T2 or resectable T3 gallbladder adenocarcinoma?

An extensive hepatic en bloc resection in addition to regional lymphadenectomy

Tx for angiosarcomas

Surgical resection

What are the most common primary malignant liver tumors afflicting children?

Hepatoblastomas

Presentation of hepatoblastomas

``` Abd pain Mass Bloating Nausea Vomiting Jaundice is rare ```

Initial tx of hepatoblastomas

Chemo | However, resection or transplantation remains the primary modality of therapy

What is useful for dx and f/u for hepatoblastomas?

Serum AFP