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Surgery > Fiser ABSITE Ch. 31 Liver > Flashcards

Fiser ABSITE Ch. 31 Liver Flashcards

1
Q

What is the #1 hepatic artery variant?

A

right hepatic artery off SMA, courses behind pancreas, posterolateral to the common bile duct

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2
Q

What variant of the left hepatic artery is found in about 20% of the population?

A

left hepatic artery off left gastric artery

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3
Q

What is the most common variant of the common hepatic artery?

A

off SMA

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4
Q

What lobes of the liver does the falciform ligament separate?

A

medial and lateral segments of the left lobe

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5
Q

What does the falciform ligament carry?

A

remnant of the umbilical vein

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6
Q

What carries the obliterated umbilical vein to the undersurface of the liver?

A

ligamentum teres

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7
Q

What separates the right and left lobes of the liver?

A

cantle’s line drawn from the gallbladder fossa to the IVC

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8
Q

What is the peritoneum that covers the liver called?

A

Glisson’s capsule

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9
Q

The portal triad enters and the gallbladder lies under what two segments of liver?

A

IV and V

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10
Q

What are liver macrophages called?

A

Kupffer cells

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11
Q

What is the orientation of the contents of the hepatoduodenal ligament?

A

CBD lateral, hepatic artery medial and portal vein posterior

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12
Q

What is clamped in the Pringle maneuver?

A

portal hepatis

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13
Q

What are the four borders of the foramen of Winslow?

A

anterior - portal triad, posterior - IVC, inferior - duodenum, superior - liver

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14
Q

What 3 vessels form the portal vein and what is their configuration?

A

IMV enters the splenic vein, SMV joins the splenic vein

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15
Q

How many portal veins in the liver? and what % of the blood supply do they provide?

A

2 portal veins in the liver, 2/3 of the blood supply

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16
Q

What are the hepatic arteries? and veins?

A

right, left and middle, same as the veins

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17
Q

In 80% of the population what is the configuration of the hepatic veins entering the IVC?

A

Middle hepatic vein joins left hepatic vein before going into the IVC. In the other 20%, all 3 go directly into the IVC.

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18
Q

What is unique about the blood supply and drainage of the caudate lobe?

A

Caudate lobe - receives separate right and left portal and arterial blood flow; drains directly into IVC via separate hepatic veins

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19
Q

What membrane of the liver does nutrient uptake occur?

A

sinusoidal membrane

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20
Q

What is the usual energy source for the liver?

A

ketones

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21
Q

What is the only water soluble vitamin stored in the liver?

A

B12

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22
Q

What are the 2 most common problems with hepatic resection?

A

bleeding and bile leak

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23
Q

Which hepatocytes are most sensitive to ischemia?

A

central lobular (acinar zone III)

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24
Q

What % of the liver can be safely resected?

A

75%

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25
Q

Bilirubin is conjugated to what in the liver which improves water solubility?

A

glucuronic acid

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26
Q

What comprises 85% of bile? what is the main phospholipid in bile?

A

bile salts, lecithin

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27
Q

In bile, what is used to make bile acids?

A

cholesterol

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28
Q

What two molecules are bile acids conjugated to in order to make them more water soluble?

A

taurine or glycine

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29
Q

What are the two primary bile acids? the two secondary (dehydroxylated primary acids by bacteria in gut)?

A

primary - cholic and chenodeoxycholic; secondary - deoxycholic and lithocholic

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30
Q

What level of bilirubin is necessary for jaundice?

A

> 2.5

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31
Q

What is the maximum bilirubin possible (unless pt has underlying renal disease, hemolysis or bile duct-hepatic vein fistula)?

A

30

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32
Q

What disease is the abnormal uptake of bilirubin resulting in mildly high unconjugated bilirubin?

A

Gilbert’s disease

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33
Q

What disease is the inability to conjugate bilirubin; deficiency of glucuronyl transferase; high unconjugated bilirubin -> life threatening disease.

A

Crigler-Najjar disease

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34
Q

Physiologic jaundice of newborn has high unconjugated bilirubin and is the result of which immature enzyme?

A

glcuronyl transferase

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35
Q

There are two syndromes that have a high conjugated bilirubin. Which one is a deficiency in storage ability and which one is a deficiency in secretion ability?

A

Rotor’s syndrome is a deficiency in storage ability. Dubin-Johnson syndrome is a deficiency in secretion ability.

36
Q

In hep B which Ig dominates in the first 6 months? which one then takes over?

A

IgM then IgG

37
Q

In Hep B which Anti-HB rises 10-12 weeks after infection? and 12-14? and 14-16?

A

10-12 weeks Anti HBc; 12-14 weeks Anti-HBe; 14-16 weeks Anti-HBs

38
Q

What Ab is elevated in a pt who is vaccinated against Hep B

A

Anti-HBs

39
Q

If a pt has elevated anti-HBc and elevated anti-HBs antibodies and no HBs antigens, what does that mean?

A

pt had infection with recovery and subsequent immunity

40
Q

What is the most common viral hepatitis leading to liver TXP?

A

Hep C (long incubation period)

41
Q

Hepatitis D is a cofactor for which other Hepatitis?

A

Hep B

42
Q

What does Hepatitis E cause?

A

fulminant hepatic failure in pregnancy, most often in 3rd trimester

43
Q

What is the most common cause of liver failure?

A

cirrhosis

44
Q

What is the best indicator of synthetic function in pts with cirrhosis?

A

prothrombin time (PT)

45
Q

What is the mortality of acute fulminant hepatic failure? The course of what sx determines the outcome?

A

80% mortality, encephalopathy

46
Q

What is the main medical tx for hepatic encephalopathy and how does it work?

A

lactulose is a cathartic that gets rid of bacteria in the gut and acidifies the colon preventing NH3 uptake by converting it to ammonium (titrate to 2-3 stools per day)

47
Q

What should you limit the protein intake to in hepatic encephalopathy?

A

Less than 70 g/day

48
Q

Other than the mainstay, lactulose, name three other medical treatments for hepatic encephalopathy.

A

Neomycin, L-dopa, bromocriptine

49
Q

When you do a paracentesis for ascites what do you need to replace and what is the dose?

A

albumin, 1g for every 100cc removed

50
Q

What is increased aldosterone caused by in ascites?

A

impaired hepatic metabolism and impaired GFR

51
Q

Hepatorenal syndrome has the same appearance as prerenal azotemia what is the tx (2)?

A

stop diuretics, give volume

52
Q

What is the cause of postpartium liver failure with ascities and how do you dx?

A

hepatic vein thrombosis

53
Q

Sx of SBP (spontaneous bacterial peritonitis) include fever, abdominal pain, positive cultures and PMNs greater than what level in the fluid?

A

250

54
Q

SBP (spontaneous bacterial peritonitis) is most commonly mono-organism; if it is not then you need to worry about what?

A

bowel perforation

55
Q

What is the most common organism in SBP (spontaneous bacterial peritonitis)?

A

E. coli

56
Q

What is a risk factor for SBP (spontaneous bacterial peritonitis) in children?

A

SLE

57
Q

What is the tx for SBP (spontaneous bacterial peritonitis)?

A

3rd -generation cephalosporin; pts usually respond within 48 hrs

58
Q

What is 90% effective at treating esophageal varices?

A

sclerotherapy

59
Q

Name 2 medical treatments for esophageal varices and how they work.

A

vasopressin (splanchnic artery constriction); octreotide (decreased portal pressure by decreased blood flow)

60
Q

In pts with esophageal varices who are on vasopressin and have CAD should get what additional medical tx?

A

NGT

61
Q

What is the name of the tube for esophageal varices that has a risk of esophageal rupture and is hardly used anymore?

A

Sengstaken-Blakemore

62
Q

What is the role for propanolol in esophageal varices?

A

may help prevent rebleeding; no good role acutely

63
Q

Pts who develop strictures after sclerotherapy for esophageal varices are easily managed with what tx? what if they develop refractory variceal bleeding, what tx?

A

dilatation, TIPS for refractory bleeding

64
Q

What does TIPS stand for?

A

transjugular intrahepatic portosystemic shunt

65
Q

What is the mortality of bleeding varices with 1st episode? What % will rebleed and what is the mortality with each subsequent bleeding episode?

A

33%, 50%, 50%

66
Q

50% of portal hypertension in children is caused by what?

A

portal vein thrombosis

67
Q

What is the normal port vein pressure?

A

Less than 12 mmHg

68
Q

What procedure would you do for a Child’s A cirrhotic that just has bleeding as a symptom? What if the pt is Child’s B or C with indication for shunt (bleeding, progression of coagulopathy, visceral hypoperfusion, refractory ascites)?

A

splenorenal shunt (more durable) for A; TIPS for B or C

69
Q

Pts with TIPS are at risk for developing what?

A

encephalopathy

70
Q

What is the most common cause of massive hematemesis in children?

A

portal HTN due to extrahepatic thrombosis of the portal vein

71
Q

What is the tx for Budd-Chiari syndrome?

A

portacaval shunt (needs to connect to the IVC above the obstruction)

72
Q

Isolated gastric varices without elevation of pressure in the rest of the portal system can be caused by what?

A

Splenic vein thrombosis

73
Q

What is most often the cause of splenic vein thrombosis?

A

pancreatitis

74
Q

What is the treatment for splenic vein thrombosis?

A

splenectomy

75
Q

What is the organism in amebic liver abscesses?

A

Entamoeba Histalytica

76
Q

Risk factors for Entamoeba histalytica include ETOH and travel to Mexico. How do you dx?

A

CT characteristics, elevated LFTs, white count, serology (cultures are often sterile since the protozoa exists only in peripheral rim)

77
Q

What is the tx for amebic liver abscesses?

A

Flagyl; aspiration if refractory of contaminated; surgery only for free rupture

78
Q

What is the organism in hydatid liver cysts?

A

Echinococcus

79
Q

How do you dx echinococcus infections (2 tests)?

A

Positive Casoni skin test, positive indirect hemagglutination

80
Q

Abdominal CT shows liver lesion with ectocyst (calcified) and endocyt. What is that characteristic of?

A

hydatid cyst

81
Q

What is the tx for hydatid cyst?

A

preop albendazole, surgical removal (may wan to inject cyst with alcohol at time of removal to kill organsims) need to get all of cyst wall

82
Q

Why don’t you aspirate hydatid cysts?

A

can leak out and cause anaphylactic shock

83
Q

Pt with hydatid cyst has jaundice, elevated LFTs or cholangitis. What do you need to do preop?

A

ERCP to check for communication with the biliary system

84
Q

Maculopapular rash, increased eosinophils. Sigmoid colon has fine granulation tissue, petechiae, ulcers and can cause variceal bleeding. What is the dx and what is the tx?

A

Schistosomiasis

85
Q

80% of liver abscess are what type? what is the number one organism?

A

pyogenic, E. coli

Surgery (33 decks)

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