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Surgery > Liver > Flashcards

Liver Flashcards

1
Q

Who divided liver into functional segment ?

A

Couinaud

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2
Q

Liver is divided into left and right by which line

A

Cantlie’s line (it is an imaginary line joining the ICV groove to the medial edge of gall bladder fossa)

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3
Q

Which vein lies beneath the cantlie’s line

A

Middle hepatic vein

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4
Q

Left side of the liver segment includes

A

4A , 2 , 3 and 4B segment

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5
Q

Right side of the liver segment includes

A

5,6,7 and 8 segment

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6
Q

Left hemi liver division based on the left hepatic vein (LHV)

A

Left medial (4A and 4B) and Left lateral (2 and 3)

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7
Q

LHV lies beneath the

A

Falciform ligament

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8
Q

Left hemi liver division based on the left portal vein tribuitary is

A

Left superior (2 and 4A) and Left inferior(3 and 4B)

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9
Q

The right hemi liver division based on right hepatic vein (RHV)

A

Anterior (5,8) and posterior (6&7)

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10
Q

The right hemi liver is divided into superior and inferior segment based on

A

Right portal vein tributary.

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11
Q

Which structure divide the liver into various segment

A

Portal vein ( Single best answer )
Hepatic vein

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12
Q

Which Liver segment forms the gall bladder fossa

A

4B & 5

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13
Q

Which Liver segment removed during radical cholecystectomy for gall bladder cancer

A

Segment 4B and 5

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14
Q

Right Posterosuperior segment (segment 7) is known as

A

Bare area of liver

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15
Q

Right Posterosuperior segment (segment 7 / bare area) is most commonly affected by

A

Amoebic Liver abscess

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16
Q

Which segment is known as independent segment

A

Segment - 1 (caudate lobe)

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17
Q

Segment 1 is called as independent segment because

A

• It receives blood from both sides.
• It drains bile into both sides.
• The venous drainage is directly into the IVC via the short veins.

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18
Q

50% of caudate lobe tissue, encircles the IVC and is called

A

Caval ligament (it is important while mobilizing the liver during liver resection)

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19
Q

Segment 1 is further subdivided into

A

Segment 9 and Spigelian lobe

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20
Q

Segment one is involved early in

A

Colangiocarcinoma

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21
Q

In Budd Chiari syndrome (hepatic, Venus outlaw, obstruction) segment one undergoes hyper trophy because

A

It has direct drainage into the IVC 

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22
Q

Liver pedicle is present at

A

Hilum of the liver

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23
Q

Liver pedicle is formed by which three structures

A

Portal vein (posterior) ;
common bile duct (Dextral, right side )
hepatic artery (left side)

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24
Q

Liver pedicle form, which sign on a duplex, scan

A

Mickey Mouse sign 

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25
Q

Which other structure form Mickey Mouse sign on a duplex, scan

A

Varicose veins at the saphenofemoral Junction

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26
Q

What is Pringles maneuver?

A

The liver pedicle can be compressed at the forum of winslow and is called Pringles maneuver

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27
Q

Pringles maneuver helps to

A

Control, bleeding in the liver and to figure out the source of bleeding 

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28
Q

Blood supply of the liver

A

80% by portal vein and 20% by hepatic artery (right hepatic artery is the larger artery and supplies. Majority of the liver.)

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29
Q

What is portal vein trifunction

A

It is the most common variation in which portal vein, splits directly into the left , right anterior and right posterior

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30
Q

Which portal triad has longer extrahepatic course

A

Left portal triad which runs transversely at the base of segment 4 it is known as Hilar plate

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31
Q

What are the functions of the liver?

A

• maintaining core body temperature. • • • pH balance and correction of acidosis.
• Synthesis of clotting factors.
• Glucose metabolism.
• Bilirubin formation from hemoglobin degradation.
• Drug and hormone metabolism and excretion.
• Removal of gut endotoxins § foreign antigens.

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32
Q

What is the imaging investigation of choice in liver

A

Triple phase CT scan

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33
Q

What is child Turcotte pugh score

A

I assesses the function of the liver. The score also has a prognostic significance in predicting the risk of morbidity or mortality in a patient undergoing liver resection.

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34
Q

What does child Turcotte pugh score includes

A

1) Encephalopathy
2) ascites
3) bilirubin level
4) albumin level
5) prothrombin time ; seconds prolonged and INR


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35
Q

Pediatric end-stage liver disease (PELD) scoring system incorporates the following criteria:

A

• Albumin.
• Total bilirubin
• INR.
• Growth failure.
• Age (< I year).

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36
Q

Liver trauma is suspected if

A

• Injury to right upper abdomen.
• Fracture of 9 - 11 ribs on the right side.
• Bruising over right chest wall (lower).

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37
Q

What are the 4Ps during exploratory laparotomy?

A

• Push.
• Plug.
• Pringle’s maneuver
• Packing.

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38
Q

What is pringles maneuver

A

• In Pringle’s maneuver, the hepatic pedicle is pressed at the foramen of winslow.
• Bleeding from the liver can either reduce or remain the same after the maneuver. If it reduces, the bleeding is either from the portal vein or hepatic artery.
• If the bleeding remains the same, the bleed is from hepatic veins.
• The maneuver can only be performed up to 15 mins in one go to avoid liver parenchymal damage.

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39
Q

What is Packing of liver

A

• The left and right triangular ligaments (attaches liver to diaphragm) are cut to mobilize the liver.
• It is then packed with mops which can be placed for ~ 24 -48 hours.
• The bleeding usually stops due to the tamponade effect of the mops.

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40
Q

Definitive management of liver trauma

A

• Laceration: Repair.
• Hepatic artery injury: 6-0 prolene vascular anastomosis.
• Portal vein injury: 5-0 prolene repair.
• Angioembolization may also be performed to control the bleed

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41
Q

What is Quincke’s Triad

A

1) Jaundice
2) upper gastrointestinal hemorrhage, (melena/ black tarry stools)most common presenting symptoms
3) Pain

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42
Q

IOC for haemobilia

A

IOC : CT

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43
Q

Quincke’s Triad is seen in

A

Haemobilia

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44
Q

IOC for Bilhemia

A

ERCP

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45
Q

Lab Investigation for amoebic liver abscess

A

Raised PT/INR

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46
Q

Lab Investigation for pyogenic liver abscess

A

Raised ALP

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47
Q

Anchovy Sauce Pus is seen in (devoid of neutrophils)

A

Amoebic liver abscess

48
Q

most commonly involved segment in amoebic liver abscess is

A

segment 7 (bare area.

49
Q

The chances of amoebic liver abscesses are less during ………. and there is more susceptibility during……

A

menstruation ; pregnancy.

50
Q

most common organism (overall causing pyogenic liver abscess:

A

Escherichia coli.

51
Q

most common in Asia:.

A

Klebsiella

52
Q

most common organism in children with chronic granulomatous disease:

A

Staphylococcus aureus.

53
Q

management of amoebic liver abscess :

A

Double strength metronidazole (800 mg TID) is started if the patient is responding, it is continued for a - 3 weeks. —- A 10 day course of Diloxanide furoate (uminal amoebicide) is given after the metronidazole course.

54
Q

Other indications for aspiration or insertion of pigtail catheter:

A

• Abscess cavity > 5 cm in size.
• Pregnant patient.
• Impending rupture.
• Left lobe liver abscess: slim chance of rupture into the pericardium.

55
Q

Most common site of rupture of liver abscess is

A

Sub diaphragmatic space

56
Q

Hydatid disease of liver is caused by

A

achinococcus granulosus or rarely by
E. multilocularis.

57
Q

E multilocularis leads to………. as it can lead to multiple and multiseptate cysts.

A

malignant hydatid

58
Q

The definitive host for Echinococcus is

A

dog. Sheep is an intermediate host.
Man is an accidental intermediate host. most common organ affected: Liver > lungs.
Route of spread is only via the portal vein.

59
Q

The cyst has three layers:

A

• Pericyst: Host reaction and not a true layer.
• Ectocyst.
• Endocyst: Gives rise to daughter cyst. Hydatid fluid is present here.

60
Q

If the hydatid fluid leaks into the circulation, it can cause.

A

anaphylaxis

61
Q

Surgical procedures for hydatid cyst :

A

• Cystopericystectomy (cyst along with the pericyst).
• Liver resection: If there are multiple cysts in one lobe.
• Capitonage: The cyst is removed, and the cavity is spirally sutured

62
Q

According to brisbane classification of Liver resection right hepatectomy included

A

Removal of segments 5,6,7,8

63
Q

According to brisbane classification of Liver resection left hepatectomy included

A

Removal of segments 2,3,4A,4B

64
Q

According to brisbane classification of Liver resection left trisectinectomy(extended left) included

A

Removal of segments 2,3,4A,4B,5,8

65
Q

According to brisbane classification of Liver resection right trisectinectomy(extended right) included

A

Removal of segments 5,6,7,8,4A,4B.

66
Q

Which position is used in the liver resection

A

Mild Trendelenburg position

67
Q

What is the imaging investigation of choice for liver tumors/liver cancer

A

Triple phase CT

68
Q

LIRADS score

A

LR 1 : 100% benign.
LR 2 : Probably benign.
LR 3 : Intermediate probability for HCC.
LR 4 : Probably HCC.
LR 5: 100% definite HCC.

69
Q

Most common benign tumor of the liver

A

Hemangioma

70
Q

Second, most common benign tumor of the liver

A

Focal nodular hyperplasia

71
Q

Most common malignant liver tumor

A

Metastasis

72
Q

Most common primary malignant liver tumor

A

Hepatocellular carcinoma

73
Q

Most common primary malignant liver tumor in children

A

Hepatoblastoma

74
Q

What is Kassabach merrit syndrome?

A

Consumption coagulopathy in large hemangiomas

75
Q

In arterial phase of liver hemangioma, which enhancement is seen

A

Peripheral nodular enhancement

76
Q

In venous / Washout phase of liver hemangioma, which enhancement is seen

A

Homogeneous enhancement

77
Q

An MRI, which sign is seen in liver hemangioma

A

Light bulb, sign,

78
Q

other condition is showing lightbulb sign

A

Pheochromocytoma

79
Q

What is Peliosis hepatis

A

Multiple cavernous hemangiomas of the liver

80
Q

Classical finding on imaging of FNH

A

Central stellate scar (dilated
central arteriole radiates out in a spoke wheel fashion).
It is absent in 15% of patients.
Biopsy is done in these patients to rule out hepatocellular carcinoma.

81
Q

other condition showing central stellate scar:

A

Oncocytoma

82
Q

Which cells are present in FNH

A

Kupffer cells

83
Q

Kupffer cells are present in FNH which shows

A

Hot spot on sulphur colloid scan.

84
Q

What is the management of FNH

A

Observation

85
Q

What is the benign liver tumor with strongest association with OCP intake

A

Hepatic adenoma/liver cell adenoma

86
Q

HPE of Hepatic adenoma/liver cell adenoma

A

Sheets of hepatocytes , no bile ducts and no kupffer cells (differentiates it from FNH in sulphur colloid scan)

87
Q

Mgt of Hepatic adenoma/liver cell adenoma

A

Small liver cell adenomas < 2 cm : Stop OCPs.
monitor with serial scans.
Liver cell adenomas > 2 cm : Resection.

88
Q

Highest risk of bleeding seen in

A

Inflammatory liver cell adenomas

89
Q

Von Meyenburg disease

A

Multiple liver hamartoma syndrome.
• multiple cystic liver hamartomas (< 1,5 cm).
• Failure of regression of embryonic biliary duct.
• usually asymptomatic,
• Investigation of choice: CECT.
• Increased risk of cholangiocarcinoma.
• Can be associated with polycystic kidney disease.
• management: Observation.

90
Q

RF for HCC

A

HBV&raquo_space; HCV

91
Q

IOC for HCC

A

Triple phase CT

92
Q

In PNS most common is

A

Hypoglycemia

93
Q

Most common biochemical PNS

A

Hypercholesterolemia

94
Q

Tumor marker in HCC

A

• Alfa feto protein: Non specific
useful for follow up and detection of recurrence.
• PINKA 2 (Protein induced vitamin K antagonism) :
Also Known as Des gamma carboxy prothrombin.
• Glycipan.
• HepPar-1.
• Neurotensin B : Raised in fibrolamellar variant.

95
Q

What are the three types of HCC

A

1) Hanging type
2) Pushing type
3) Infiltrative type

96
Q

PELD incorporates following criteria

A

• Albumin.
• Total bilirubin.
• INR.
• Growth failure.
• Age < I year.

97
Q

Mgt of liver child pugh A liver tumor

A

Adequate functional liver reserve (>25%), resectable tumour - Liver resection.

98
Q

Mgt of liver child pugh B liver tumor

A

Functional liver reserve < 25% -> Transplantation if patients meet the MILAN criteria.

99
Q

What to do if patient do not meet MILAN criteria(inadequate

A

> NIMURA technique/Associating
Liver Partition with Portal vein ligation for Staged hepatectomy (ALPPS) procedure : Portal vein embolization on the side of the tumour results in compensatory hypertrophy on the other side. This increases the functional liver reserve & facilitates resection.

100
Q

What is MILAN Criteria

A

Single tumour < 5 cm.
1 - 3 tumours < 3 cm with no distant metastasis/vascular invasion.

101
Q

TACE used for

A

Multinodular disease

102
Q

TARE is used for

A

Multinodular disease (Yttrium spheres are used )

103
Q

Immunotherapy for HCC

A

Sorafenib: used for advanced disease (gross vascular involvement).
Nivolumab: used for advanced metastatic disease.

104
Q

Principle of TACE and TARE:

A

If there are multiple tumours (multinodular disease), artery supplying these tumours will be embolized causing shrinkage of tumour area.

105
Q

Prognostic indicator for HCC according to OKUDA

A

B : serum bilirubin
A : Ascites
T : tumor size
A : albumin

106
Q

Prognostic indicator for HCC according to CLIP

A

Tumor size ;
Child pugh score ;
AFP ;
Portal vein thrombosis

107
Q

Barcelona clinic liver cancer staging includes ;

A

• Tumour size.
• Child pugh score.
• performance status (ECOG and Karofsky score).

108
Q

MC site of mets of HCC

A

Lungs

109
Q

Mimp prognostic factor of HCC is

A

Stage of the disease

110
Q

Tumor marker of fibrolamellar variant of HCC

A

Neurotensin B

111
Q

Q. A patient with hydatic disease of the liver is found to have water lily sign on imaging. According to the latest hydatid cyst classification, it falls under which category?

A

CE3a

112
Q

Most common tumor associated with arsenic / vinyl chloride:

A

Angiosarcoma

113
Q

Most common tumor rupture spontaneously causing hemoperitoneum:

A

Hepatic adenoma

114
Q

Most common primary benign tumor:

A

Cavernous hemangioma

115
Q

Most common tumor overall:

A

Metastatic tumor

Surgery (30 decks)

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