Chapter 31 - Liver Flashcards
1
Q
What is the #1 hepatic artery variant?
A
Right hepatic off of SMA, 20%; courses behind pancreas, posterolateral to CBD
2
Q
What is the most common variant of the left hepatic artery?
A
Left hepatic off left gastric artery; found in gastrohepatic ligament medially
3
Q
What is the most common variant of the common hepatic artery?
A
Common hepatic off of SMA
4
Q
What is the course of the falciform ligament? What does it contain?
A
Separates medial and lateral segments of the left lobe; attaches liver to anterior abdominal wall; extends to umbilicus and carries remnant of the umbilical vein
5
Q
What is the course of the ligamentum teres? What does it contain?
A
Extends from falciform ligament on the undersurface of the liver; carries the obliterated umbilical vein
6
Q
What separates the right and left lobe of the liver?
A
Line drawn from the middle of the gallbladder fossa to IVC (Cantlie’s line)
7
Q
What is the name of the peritoneum that covers the liver?
A
Glisson’s capsule
8
Q
What are the triangular ligaments?
A
Lateral and medial extensions of the coronary ligament on the posterior surface of the liver
9
Q
The portal triad enters what segments?
A
IV and V
10
Q
Gallbladder lies under what segments?
A
IV and V
11
Q
What is contained in the hepatoduodenal ligament?
A
Bile duct, portal vein, hepatic artery
12
Q
What are the positions of the contents of the portal triad?
A
Portal veing posteriorly, common bile duct laterally, hepatic artery medially
13
Q
What are the borders of the foramen of Winslow?
A
Anterior: portal traid, posterior: IVC, inferior: duodenum, superior: liver
14
Q
Portal veins carry what % of blood to the liver?
A
2/3 of hepatic blood flow
15
Q
The middle hepatic artery most commonly branches from where?
A
Left hepatic artery
16
Q
Primary and secondary tumors of the liver are most commonly supplied by what blood vessel?
A
Hepatic artery
17
Q
The middle hepatic vein joins the left hepatic vein in what % of patients?
A
80%; other 20% go directly to IVC
18
Q
Blood supply to the caudate lobe?
A
Receives separate right and left portal and arterial flow; drains directly into IVC via separate hepatic veins
19
Q
Alkaline phosphatase normally located where?
A
Canalicular membrane
20
Q
Where does nutrient uptake occur?
A
Sinusoidal membrane
21
Q
What is the normal energy source for liver?
A
Ketones; glucose is converted to glycogen and stored
22
Q
Where is urea synthesized?
A
Urea
23
Q
What factors are NOT made in the liver?
A
VonWillebrand and factor VIII
24
Q
What is the only water-soluble vitamin stored in the liver?
A
B12
25
What are the most common complications of hepatic resection?
Bleeding and bile leak
26
What zone is most susceptible to ischemia?
Acinar zone III, hepatocytes
27
What % of the liver can be safely resected?
75%
28
What is the breakdown of Hgb?
Hgb --> heme --> biliverdin --> bilirubin
29
Bilirubin is conjugated to what in the liver?
Glucuronic acid by glucuronyl transferase; improves water solubility
30
Where does urobilinogen come from? Reabsorbed and released where?
Breakdown of bilirubin by bacteria in the terminal ileum; reabsorbed in blood, released in urine
31
Components of bile?
Bile salts, proteins, phospholipids (lecithin), cholesterol, bilirubin
32
Bile acids are conjugated to what?
Taurine or glycine, improves water solubility; primary bile acids: cholic and chenodeoxycholic, secondary: deoxycholic and lithocholic
33
What is lecithin?
Main biliary phospholipid, solubilizes cholesterol and emulsifies fats in the intestine
34
Where is the 1st place jaundice is evident?
Under the tongue
35
What is the ddx for elevated unconjugated bilirubin?
Prehepatic causes (hemolysis), hepatic deficiencies of uptake or conjugation
36
What is the ddx for elevated conjugated bilirubin?
Secretion defects into bile ducts; excretion defects into GI tract (stones, strictures, tumor)
37
What is Gilbert's disease?
Abnormal uptake; mildly high unconjugated bilirubin
38
What is Crigler-Najjar?
Inability to conjugate; deficiency of glucuronyl transferase; high unconjugated bilis, life-threatening
39
What is physiologic jaundice of newborn?
Immature glucuronyl transferase
40
What is Rotor's syndrome?
Deficiency in sotrabe ability; high conjugated bilirubin
41
What is Dubin-Johnson syndrome?
Deficiency in secretion ability; high conjugated bilirubin
42
What does it mean if you have elevated anti-HBs abs only?
Post-vaccination
43
What does it mean if you have elevaated anti-HBc and anti-HBs antibodies, but no HBs antigen
Had infection with recovery and subsequent immunity
44
What is the most common viral hepatitis leading to liver transplant?
Hepatitis C (RNA)
45
What hepatitis type is a cofactor for hepatitis B?
Hepatitis D
46
What is the hepatitis which will cause fulminant hepatic failure in pregnancy?
Hepatitis E
47
What is the most common cause of liver failure?
Cirrhosis
48
What is the best indicator of synthetic function in patients with cirrhosis?
PT
49
What is the mortality of acute fulminant hepatic failure?
80%
50
What is hepatic encephalopathy caused by?
Liver failure that leads to inability to metabolize; causes buildup of ammonia, mercantanes, methane thiols, and false neurotransmitters
51
Causes of encephalopathy other than liver failure?
GI bleeding, infection (SBP), electrolyte imbalance, drugs
52
Treatment for hepatic encephalopathy?
Lactulose - cathartic that gets rid of bacteria in gut and acidifies colon (preventing NH3 uptake by converting it to ammonium), titrate to 2-3 stool/day; limit protein intake, branched chain amino acids, no abx, neomycin, dopamine receptor antagonists
53
What is the mechanism of cirrhosis?
Hepatocyte destruction --> fibrosis and scarring of liver --> increased hepatic pressure --> portal venous congestion --> lymphatic overload --> leakage of splanchnic and hepatic lymph into peritoneum --> ascites
54
Treatment for ascites from hepatic/splanchnic lymph?
Decrease NaCl, diuretics, paracentesis, TIPS, peritoneovenous shunts, prophylactic abx, water restriction
55
Complications of peritoneovenous shunts?
DIC
56
What is the prophylaxis for SBP?
Cipro 750mg/wk
57
What is the cause of elevated aldosterone in liver failure?
Impaired hepatic metabolism and impaired GFR
58
What is hepatorenal syndrome? Treatment?
Same appearance as prerenal azotemia; stop diuretics, give volume
59
What is the cause of postpartum liver failure with ascites? Diagnosis?
Hepatic vein thrombosis; SMA arteriogram with venous phase contrast
60
How is the diagnosis of SBP made?
PMNs >250 in fluid, (+)cultures
61
What are the bacteria that cause SBP?
#1 E. coli, pneumococci, streptococci; most commonly mono-organism (if not need to worry about bowel perforation)
62
Risk factors for SBP?
Prior SBP, variceal hemorrhage, low-protein ascites, nephrotic syndrome, SLE in children
63
Treatment of SBP?
3rd generation cephalosporins
64
Treatment for esophageal varices?
Sclerotherapy (90% effective), vasopressin, octreotide, Sengstaken-Blakemore tube (to control, risk of rupture of esophagus), correct coags, blood transfusion
65
Use of propranolol for esophageal varices?
May help prevent rebleeding, no good role acutely
66
Treatment for refractory variceal bleeds?
TIPS
67
Mortality with bleeding varices?
33% with 1st episode; 50% with each subsequent bleeding episodes
68
Causes of presinusoidal obstruction causing portal hypertension?
Schistosomiasis, congenital hepatic fibrosis, portal vein thrombosis
69
Most common cause of portal HTN in children?
Portal vein thrombosis
70
Cause of sinusoidal obstruction leading to portal HTN?
Cirrhosis
71
Cause of postsinusoidal obstruction causing portal HTN?
Budd-Chiari syndrome (hepatic vein occlusive disease), constrictive pericarditis, CHF
72
What is the normal portal vein pressure?
<12mmHg
73
What are the collaterals between the portal vein and systemic venous system of the lower esophagus?
Coronary veins
74
Use of TIPS? Complications?
Used for protracted bleeding, progression of coagulopathy, visceral hypoperfusion, refractory ascites; development of encephalopathy
75
What patients are candidates for splenorenal shunt? Contraindications?
Child's A cirrhotics who present with bleeding only; contraindicated in refractory ascites (can worsen)
76
What does the Child's class correlate with?
Mortality after shunt
77
What is the most common cause of massive hematemesis in children?
Portal HTN (most commonly from extrahepatic thrombosis of portal vein)
78
What is Budd-Chiari syndrome? Presentation?
Occlusion of hepatic veins and IVC; RUQ pain, hepatosplenomegaly, ascites, fulminant hepatic failure, muscle wasting, variceal bleeding
79
How is Budd-Chiari diagnosed? Treatment?
Angio, CT scan; liver biopsy shows sinusoidal dilation, congestion, centrilobular congestion; portacaval shunt
80
Where do primary infection which cause amebic liver abscess occur?
Amebic colitis
81
Risk factors for amebic liver abscess?
Travel to Mexico, ETOH, fecal-oral transmission
82
Amebic abscess with show positive serology for what?
Entamoeba histolytica
83
Symptoms of amebic abscess?
Fever, chills, RUQ pain, elevated WBCs, jaundice, hepatomegaly
84
What will cultures of amebic abscess show? Aspiration?
Often sterile; protozoa exist only in peripheral rim; anchovy past
85
Diagnosis of amebic abscess? Treatment?
Based on CT findings; flagyl, aspiration if refractory or contaminanted; surgery only for free rupture
86
Hydatid cyst formed by what?
Echinococcus
87
Labs with show what with echinococcus?
Casoni skin test, positive indirect hemagglutination
88
What can happen with aspiration of echinococcal cyst?
Anaphylaxis
89
Diagnosis of echinococcus?
Abdominal CT shows ectocyst (calcified) and endocyst
90
When do you need a preop ERCP for echinococcus?
In patients with jaundice, increased LFTs, cholangitis to check for communication with biliary system
91
Treatment for hydatid cyst?
Preop albendazole, surgical removal; can inject cyst with alcohol at time of removal to kill organisms; need to get all of cyst wall
92
Characteristics of schistosomiasis?
Maculopapular rash, eosinophilia
93
Findings in sigmoid colon with schistosomiasis?
Fine granulation tissue, petechiae, ulcers
94
Treatment of schistosomiasis?
Praziquantel and control of variceal bleeding
95
80% of all abscesses are what?
Pyogenic abscess
96
Symptoms of pyogenic abscess?
Fever, chills, wt loss, RUQ pain, elevated LFTs/WBCs, sepsis
97
#1 organism in pyogenic abscess?
E. coli
98
Pyogenic abscess commonly secondary to what?
Contiguous infection from biliary tract; can also occur following bacteremia from other infections
99
Diagnosis of pyogenic abscess? Treatment?
Aspiration; CT guided drainage and antibiotics, surgical drainage for unstable condition and continued signs of sepsis
100
Hepatic adenomas occur in what patients?
Women, steroid use, OCPs, type I collagen storage disease
101
% of hepatic adenomas that are symptomatic?
20%, risk of significant bleeding
102
Hepatic adenomas are more common in which lobe?
Right
103
Symptoms of hepatic adenoma?
Pain, elevated LFTs, hypotension, palpable mass
104
Diagnosis of hepatic adenoma?
No Kupffer cells in adenomas, therefore no uptake on sulfur colloid scan (cole); MRI shows hypervascular tumor, has periphreral blood supply
105
Treatment for hepatic adenomas?
Asymptomatic: stop OCPs, if no regression needs resection; symptomatic: resectioin for bleeding and malignancy risk, embolization if multiple and unresectable
106
Characteristics of focal nodular hyperplasia?
Central stellate scar that may look like cancer
107
Malignancy risk with focal nodular hyperplasia?
No malignancy risk
108
Diagnosis of focal nodular hyperplasia?
CT; has Kupffer cells, will take up sulfur colloid on liver scan; CT/MRI shows hypervascular tumor
109
Treatment for focal nodular hyperplasia?
Conservative therapy
110
What is the most common benign hepatic tumor?
Hemangiomas
111
Should hemangiomas be biopsied?
No, risk of hemorrhage
112
Diagnosis of hemangiomas?
MRI and CT show periphreal to central enhancement; hypervascular lesion
113
Treatment of hemangiomas?
Conservative unless symptomatic, then surgery, ?embolization, XRT and steroids for unresectable disease
114
Rare complications of hemangiomas?
Consumptive coagulopathy (Kasabach-Merritt syndrome), CHF
115
Characteristic wall finding of solitary cysts?
Blue hue
116
Mets:primary ratio for malignant liver tumors?
20:1
117
What is the most common cancer worldwide?
HCC
118
Risk factors for HCC?
#1 worldwide Hep B, HCV, ETOH, hemochromatosis, alpha-1-antitrypsin deficiency, PSC, aflatoxins, hepatic adenoma, steroids, pesticides
119
What are the types of HCC?
Clear cell, lymphocyte infiltrative, fibrolamellar
120
HCC tumor size correlates with what?
AFP
121
What is the 5y survival of HCC?
30%
122
Margins needed for HCC resection?
1cm
123
What are risk factors for hepatic sarcoma?
PVC, thorotrast, arsenic; rapidly fatal
124
Risk factors for cholangiosarcoma?
Clonorchiasis infection, UC, hemochormatosis, PSC, choledochal cysts
125
What is the 5yr survival rate for colon cancer mets to the liver that are resected?
20%
126
Primary liver tumors are hyper or hypovascular? Mets?
Primary: hypervascular; mets: hypovascular
