Chapter 13, part 2 Flashcards
What may cause amebic liver abscesses?
Entamoeba histolytica
Who is at highest risk for amebic liver abscesses?
Alcoholic pts
Homosexuals
Tx of amebic liver abscess
Medical management
10-14 day course of metronidazole
No role for surgical management
Tx of hydatid liver dz
Surgical resection of the hydatid cyst constitutes definitive therapy
In hydatid liver dz, what may result in anaphylactic shock?
Cyst rupture
Cirrhosis of the liver
Characterized by the replacement of nl functioning hepatocytes with fibrous connective tissue and regenerative hepatic nodules
Common causes of cirrhosis
Chronic HBV or HCV infection Exposure to hepatotoxins such as alcohol A1-antitrypsin deficiency Hemochromatosis Wilson's dz
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
Presentation of cirrhosis
Varies May be relatively well compensated or asymptomatic Encephalopathy Jaundice Coagulopathy Complications of portal HTN: -Gastroesophageal varices -Ascites
What is the best option in pts with isolated gastric variceal bleeding secondary to splenic vein thrombosis?
Splenectomy
What is the best option in pts with gastric varices secondary to portal HTN?
Insertion of a transjugular intrahepatic portosystemic shunt (TIPS)
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
Tx of gastroesophageal variceal bleeding
Endoscopic band ligation
For gastroesophageal variceal bleeding, what should be done if endoscopic band ligation fails?
TIPS procedure
What may be required with massive gastroesophageal variceal bleeding?
Control with a Sengstaken-Blakemore tube prior to the initiation of more definitive therapy
When TIPS fails to stop gastroesophageal variceal bleeding or is unavailable, what may be required?
Surgical portosystemic shunts
Which surgical portosystemic shunt is the shunt of choice for gastroesophageal variceal bleeding?
Portacaval shunt
What is an alternative to shunt surgery for gastroesophageal variceal bleeding?
Esophageal devascularization and transection procedures
How can refractory ascites be treated?
Surgical placement of a LeVeen shunt
Complications of a LeVeen shunt
Infection of the shunt
Coagulopathy secondary to systemic fibrinolysis
When is a LaVeen shunt not recommended?
Cirrhotic pts with ascites
What are the two measures of severity of liver dz in the cirrhotic pt?
Child MELD (Model for End-stage Liver Dz) score
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
When elective surgery is performed in a cirrhotic pt, what needs to be done?
A preoperative evaluation for liver transplantation should be considered.
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
