Liver Flashcards
MCC of SBP
E. coli (40-50%
MC bacterial infection in pts w/ cirrhosis.
PMN >500 ascitic fluid
Tx: 3rd-gen cephalosporin (Rocephin)
Well-circumscribed, heterogeneous mass, transient homogeneous enhancement in arterial phase, large sub capsular feeding vessels
Adenoma
Peripheral nodular enhancement in early phase
Centripetal filling in late phase
Hemangioma
Rapid enhancement, hyperintense lesions, central scar
Focal nodular hyperplasia (FNH)
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
HCC
Peripheral rim enhancement throughout both arterial and venous phases
Intrahepatic cholangiocarcinoma
Imaging findings of mets to liver
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
MC primary malignant tumor of the liver in kids
Hepatoblastoma
Occurs in kids, usually <2 yo, high AFP
Tx of hepatic hemangioma
Indications for tx:
symptomatic
enlargement of lesion
atypical imaging characteristics
enucleate if peripherally located
resect if deeply located
Pyogenic Liver abscess
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)
Absolute CI for Liver Transplant
Current uncontrolled sepsis Active alcohol or drug use Inadequate social support Unstable cardiopulmonary disease/R heart failure Intracranial hemorrhage (recent) Elevated intracranial pressures
MELD score
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
Hepatorenal syndrome
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
Indications for surgical resection of hepatic adenomas
Size >5cm Symptomatic Bleeding Suspicion for malignancy Male gender
Major hepatectomy steps
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
Hepatitis vaccines
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
PSC
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
Hepatic hemangiomas
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
Orthotopic liver transplantation technique
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
