Liver

Question 1

MCC of SBP

Answer 1

E. coli (40-50%

MC bacterial infection in pts w/ cirrhosis.

PMN >500 ascitic fluid

Tx: 3rd-gen cephalosporin (Rocephin)

Question 2

Well-circumscribed, heterogeneous mass, transient homogeneous enhancement in arterial phase, large sub capsular feeding vessels

Answer 2

Adenoma

Question 3

Peripheral nodular enhancement in early phase

Centripetal filling in late phase

Answer 3

Hemangioma

Question 4

Rapid enhancement, hyperintense lesions, central scar

Answer 4

Focal nodular hyperplasia (FNH)

Question 5

Nonrim, arterial phase enhancement relative to liver parenchyma
non peripheral washout - hypoenhancement compared to liver in portal, venous or delayed phase
enhancing capsule appearance - smooth border around most or all of lesion that enhances in portal, venous or delayed phase of contrast

Answer 5

HCC

Question 6

Peripheral rim enhancement throughout both arterial and venous phases

Answer 6

Intrahepatic cholangiocarcinoma

Question 7

Imaging findings of mets to liver

Answer 7

Enhancement pattern depends on primary cancer

Mets from colon, stomach, pancreas -> lower attenuation
Mets from NETs, renal cell carcinoma, breast, melanoma, thyroid CA –> rapidly enhancing on arterial phase

Question 8

MC primary malignant tumor of the liver in kids

Answer 8

Hepatoblastoma

Occurs in kids, usually <2 yo, high AFP

Question 9

Tx of hepatic hemangioma

Answer 9

Indications for tx:
symptomatic
enlargement of lesion
atypical imaging characteristics

enucleate if peripherally located
resect if deeply located

Question 10

Pyogenic Liver abscess

Answer 10

MCC - hepatobiliary malignancies or biliary tree instrumentation

Pure fungal abscess common in immunocompromised pt, usually after chemo for heme cancers

P/w: fevers, chills, jaundice, RUQ pain

MC pathogen - Candida
2nd & 3rd MC - Aspergillus & Cryptococcus

Tx: Abx & drainage. (fungal - caspofungin, micafungin; voriconazole)

Question 11

Absolute CI for Liver Transplant

Answer 11

Current uncontrolled sepsis
Active alcohol or drug use
Inadequate social support
Unstable cardiopulmonary disease/R heart failure
Intracranial hemorrhage (recent)
Elevated intracranial pressures

Question 12

MELD score

Answer 12

Pts >12
Ranges 0-40
Assigns special points in pts w/ HCC

Initially used to determine mortality over 3 months following TIPS, prioritize pts for liver transplant

Uses Bili, INR, creat

Question 13

Hepatorenal syndrome

Answer 13

Complication of end-stage cirrhosis
2/2 severe splanchnic vasodilation and arterial hypovolemia –> decreased renal blood flow

Tx: Albumin + vasoconstrictive agent (terlipressin - MC, ornipressin, midodribe + octreotide, norepinephrine), TIPS, liver or liver/kidney transplant

Prevention hypovolemia, give albumin ppx in pts w/ SBP

Question 14

Indications for surgical resection of hepatic adenomas

Answer 14

Size >5cm
Symptomatic
Bleeding
Suspicion for malignancy
Male gender

Question 15

Major hepatectomy steps

Answer 15

1) cholecystectomy
2) cannulation of cystic duct for IOC to detect any bile leakage after liver resection
3) Expose and ligate hepatic artery
4) Portal vein is last structure in porta hepatic to be divided
5) Outflow is ligated

Question 16

Hepatitis vaccines

Answer 16

HBV tx: vaccine (3 IM doses); >90% seroconversion efficacy among immunocompetent persons; efficacy decreases with age (>90% in kids, <50% in 6th decade)
Hep B immune globulin: efficacy 85-95% to prevent newborn infections, 75% needle sticks or sexual exposure

Hep A vaccine: routine childhood regimen

HDV tx: alpha-interferon but vaccine against HBV

HEV tx: none

Question 17

PSC

Answer 17

Chronic cholestasis progressing to advanced biliary cirrhosis and eventual death from liver failure

Dx: MRCP/ERCP -> diffuse dilations and strictures intra and extra hepatic biliary ducts, “beads on a string”

Tx: no med tx, EGD with balloon dilation/stent, liver transplant

Surveillance:

• Cholangio carcinoma with Abd US, MRI/MRCP q6 mo to 1 year, annual CA 19-9
• GB Ca with RUQ US q6 mo to 1 year
• CRC with Colo at dx and q1-2 years
• HCC with Abd US or MRI/MRCO q6 mo to 1 year

Question 18

Hepatic hemangiomas

Answer 18

MC benign liver tumor
MC dx in 30-50 yo
MC in W
More likely to be symptomatic in young women; or large lesions >4cm
No risk of rupture, no malignant transformation risk
imaging: delayed or late filling

Question 19

Orthotopic liver transplantation technique

Answer 19

3 methods used for recipient hepatectomy during orthotropic liver transplantation:

1) Bicaval technique: excision of recipient liver en bloc w/ retrohepatic IVC after canal clamps placed in supra hepatic and infra hepatic position. reimplantation of cava occurs in interposition. disadvantages includes requiring dissection posterior to vena cava, leading to bleeding
2) Piggyback technique: leaves vena cava in continuity and hepatic veins are divided within substance of liver. only requires single vena canal anastomosis, limits warms ischemic time
3) Cavocavostomy (side-to-side canal technique): shorter vena canal clamping time, vena canal clamp is placed longitudinally, occluding anterior third of vena cava, lower incidence of canal stenosis as cavoplasty is performed, lower risk of hepatic vein outflow complications