LIVER Flashcards
Divides the liver into small LEFT lobe and large RIGHT lobe
Falciform ligament
Segmental Anatomy of the Liver
Segment 1 - Caudate IVC
Segment 2 and 3- L lateral segment L hepatic vein
Segment 4 - L medial segment middle hepatic vein
Segment 5 and 8 - R anterior lobe R hepatic vein, middle hepatic vein
Segment 6 and 7 - R posterior lobe
The most common variant of normal hepatic artery anatomy is
Replaced R hepatic artery from the SMA
Liver Function Tests
Hepatocellular Injury - AST and ALT
Abnormal Synthetic Function - albumin, clotting factors EXCEPT factor VIII
Cholestasis - total bilirubin, B2, alk phosphatase, GGTP
Measures liver synthetic function
serum albumin
prothrombin time
clotting factors (EXCEPT factor VIII)
PT and INR - best tests among the 3
prolonged PT - vitamin K deficiency or warfarin therapy
Indicators of integrity of hepatocellular membranes; increased levels reflect hepatocellular injury w/ leakage
AST and ALT
AST - liver, cardiac,muscle, skeletal muscle,kidney, brain, pancreas,lungs and RBC
ALT - more specific for liver disease
MODERATE increases - viral hepatitis
GREAT increases - ischemia, toxin ingestion (acetaminophen), fulminant hepatitis
Indicative of BILIARY OBSTRUCTION
alkaline phosphatase
liver and bones
half life -7 days
Early marker and sensitive test for hepatobiliary disease
GGTP
Jaundice becomes detectable when serum bilirubin level is
> 2.5 - 3 mg/dL
Final sequelae of chronic liver injury characterized by fibrous septa that leads to hepatic nodules
Cirrhosis
The gold standard or identi ying liver lesions by imaging is
Intraoperative Ultrasound
Physiologic changes noted in patients with cirrhosis
elevated resting energy expenditure
increased cardiac output and heart rate
decreased systemic vascular resistance and blood pressure
Presinusoidal Causes of Portal HPN
EXTRAHEPATIC
portal vein thrombosis
splenic vein thrombosis
INTRAHEPATIC congenital hepatic fibrosis primary biliary cirrhosis sarcoidosis schistosomiasis
Sinusoidal Causes of Portal HPN
steatohepatitis
Wilson disease
Postsinusoidal Causes of Portal HPN
EXTRAHEPATIC
Budd Chiari syndrome
Right hepatic failure
INTRAHEPATIC hemochromatosis laennec (alcoholic) cirrhosis secondary biliay cirrhosis posthepatitic cirrhosis
The most accurate method for measuring portal HPN
hepatic venography
HVPG = WHVP - FHVP
> 10 - portal HPN
Most significant manifestation of portal HPN
esophageal varices
Management of Acute Variceal Bleeding
MEDICAL
Vasopressin
Octreotide - preferred
SURGICAL
early endoscopy and variceal ligation or sclerotherapy
refractory bleeding surgical shunt - Child A transjugular intrahepatic portosystemic shunt (TIPS) - Child B and C
Congestive hepatopathy characterized by obstruction to hepatic venous outflow
Budd Chiari Syndrome
young women w/ myelofibrosis factor V Leiden mutation anti cardiolipin antibodies OCP
Management:
systemic anticoagulation
Predicts the risk of portocaval shunt procedure
Child Turcotte Pugh (CTP)
bilirubin albumin INR (+) encephalopathy (+) ascites
Predicts mortality after TIPS
Model for End Stage Liver Disease (MELD)
serum creatinine total bilirubin INR
Percutaneous procedure used for treatment of patients who have gastroesophageal varices in the setting of portal hypertension
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
creates an intrahepatic shunt b/w portal and systemic circulation — decreased portal pressure and blood flow through varices
MC complication of TIPS
Encephalopathy
Pyogenic Liver Abscess
R lobe
E.coli
correction of underlying cause
broad spectrum antibiotics at least 8 weeks
percutaneous aspiration
failure of medical management — surgical drainage/resection
Most frequently encountered liver lesion overall
Hepatic Cysts
MC benign solid masses in the liver
Hemangioma
women PAIN dual phase CT: asymmetrical peripheral enhancement w/ progressive centripetal enhancement MRI: hypointense on T1 and hyperintense on T2 enucleation or resection
Benign solid neoplasm that occurs in young women, typically solitary
Adenoma
prior or current use of OCP COMPLICATIONS - spontaneous rupture and hemorrhage, malignant degeneration resection
Occurs in young women and usually do not rupture spontaneously or degenerate into malignancy
Focal Nodular Hyperplasia
abdominal pain - usual indication for surgery CT/MRI - central scar Nuclear scan - hot
Primary Malignant Liver Tumors
Hepatocytes - Hepatocellular carcinoma (HCC)
Bile ducts - Cholangiocarcinoma
MC malignant liver tumor
Metastatic
from COLONIC carcinoma
2nd MC benign tumor of the liver
Focal Nodular Hyperplasia
Risk factors for Hepatocellular Carcinoma
Cirrhosis Hep B or C Alcoholic Hemochromatosis Non alcoholic steatohepatitis
Patient’s eligible or the Mayo Clinical protocol to treat hilar cholangiocarcinoma
hilar cholangiocarcinoma with PSC or patients with unresectable
hilar cholangiocarcinoma who have not received prior radiotherapy
Considered a primary determinant of suitability or resection when evaluating a patient with hepatic colorectal metastases
Predicted volume of hepatic remnant
The only FDA-approved systemic chemotherapeutic agent or HCC
Sorafenib
The primary indication for hepatic resection in cirrhotic patients
HCC
