Liver Flashcards
Who divided liver into functional segment ?
Couinaud
Liver is divided into left and right by which line
Cantlie’s line (it is an imaginary line joining the ICV groove to the medial edge of gall bladder fossa)
Which vein lies beneath the cantlie’s line
Middle hepatic vein
Left side of the liver segment includes
4A , 2 , 3 and 4B segment
Right side of the liver segment includes
5,6,7 and 8 segment
Left hemi liver division based on the left hepatic vein (LHV)
Left medial (4A and 4B) and Left lateral (2 and 3)
LHV lies beneath the
Falciform ligament
Left hemi liver division based on the left portal vein tribuitary is
Left superior (2 and 4A) and Left inferior(3 and 4B)
The right hemi liver division based on right hepatic vein (RHV)
Anterior (5,8) and posterior (6&7)
The right hemi liver is divided into superior and inferior segment based on
Right portal vein tributary.
Which structure divide the liver into various segment
Portal vein ( Single best answer )
Hepatic vein
Which Liver segment forms the gall bladder fossa
4B & 5
Which Liver segment removed during radical cholecystectomy for gall bladder cancer
Segment 4B and 5
Right Posterosuperior segment (segment 7) is known as
Bare area of liver
Right Posterosuperior segment (segment 7 / bare area) is most commonly affected by
Amoebic Liver abscess
Which segment is known as independent segment
Segment - 1 (caudate lobe)
Segment 1 is called as independent segment because
• It receives blood from both sides.
• It drains bile into both sides.
• The venous drainage is directly into the IVC via the short veins.
50% of caudate lobe tissue, encircles the IVC and is called
Caval ligament (it is important while mobilizing the liver during liver resection)
Segment 1 is further subdivided into
Segment 9 and Spigelian lobe
Segment one is involved early in
Colangiocarcinoma
In Budd Chiari syndrome (hepatic, Venus outlaw, obstruction) segment one undergoes hyper trophy because
It has direct drainage into the IVC 
Liver pedicle is present at
Hilum of the liver
Liver pedicle is formed by which three structures
Portal vein (posterior) ;
common bile duct (Dextral, right side )
hepatic artery (left side)
Liver pedicle form, which sign on a duplex, scan
Mickey Mouse sign 
Which other structure form Mickey Mouse sign on a duplex, scan
Varicose veins at the saphenofemoral Junction
What is Pringles maneuver?
The liver pedicle can be compressed at the forum of winslow and is called Pringles maneuver
Pringles maneuver helps to
Control, bleeding in the liver and to figure out the source of bleeding 
Blood supply of the liver
80% by portal vein and 20% by hepatic artery (right hepatic artery is the larger artery and supplies. Majority of the liver.)
What is portal vein trifunction
It is the most common variation in which portal vein, splits directly into the left , right anterior and right posterior
Which portal triad has longer extrahepatic course
Left portal triad which runs transversely at the base of segment 4 it is known as Hilar plate
What are the functions of the liver?
• 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.
What is the imaging investigation of choice in liver
Triple phase CT scan
What is child Turcotte pugh score
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.
What does child Turcotte pugh score includes
1) Encephalopathy
2) ascites
3) bilirubin level
4) albumin level
5) prothrombin time ; seconds prolonged and INR

Pediatric end-stage liver disease (PELD) scoring system incorporates the following criteria:
• Albumin.
• Total bilirubin
• INR.
• Growth failure.
• Age (< I year).
Liver trauma is suspected if
• Injury to right upper abdomen.
• Fracture of 9 - 11 ribs on the right side.
• Bruising over right chest wall (lower).
What are the 4Ps during exploratory laparotomy?
• Push.
• Plug.
• Pringle’s maneuver
• Packing.
What is pringles maneuver
• 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.
What is Packing of liver
• 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.
Definitive management of liver trauma
• 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
What is Quincke’s Triad
1) Jaundice
2) upper gastrointestinal hemorrhage, (melena/ black tarry stools)most common presenting symptoms
3) Pain
IOC for haemobilia
IOC : CT
Quincke’s Triad is seen in
Haemobilia
IOC for Bilhemia
ERCP
Lab Investigation for amoebic liver abscess
Raised PT/INR
Lab Investigation for pyogenic liver abscess
Raised ALP
Anchovy Sauce Pus is seen in (devoid of neutrophils)
Amoebic liver abscess
most commonly involved segment in amoebic liver abscess is
segment 7 (bare area.
The chances of amoebic liver abscesses are less during ………. and there is more susceptibility during……
menstruation ; pregnancy.
most common organism (overall causing pyogenic liver abscess:
Escherichia coli.
most common in Asia:.
Klebsiella
most common organism in children with chronic granulomatous disease:
Staphylococcus aureus.
management of amoebic liver abscess :
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.
Other indications for aspiration or insertion of pigtail catheter:
• Abscess cavity > 5 cm in size.
• Pregnant patient.
• Impending rupture.
• Left lobe liver abscess: slim chance of rupture into the pericardium.
Most common site of rupture of liver abscess is
Sub diaphragmatic space
Hydatid disease of liver is caused by
achinococcus granulosus or rarely by
E. multilocularis.
E multilocularis leads to………. as it can lead to multiple and multiseptate cysts.
malignant hydatid
The definitive host for Echinococcus is
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.
The cyst has three layers:
• Pericyst: Host reaction and not a true layer.
• Ectocyst.
• Endocyst: Gives rise to daughter cyst. Hydatid fluid is present here.
If the hydatid fluid leaks into the circulation, it can cause.
anaphylaxis
Surgical procedures for hydatid cyst :
• 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
According to brisbane classification of Liver resection right hepatectomy included
Removal of segments 5,6,7,8
According to brisbane classification of Liver resection left hepatectomy included
Removal of segments 2,3,4A,4B
According to brisbane classification of Liver resection left trisectinectomy(extended left) included
Removal of segments 2,3,4A,4B,5,8
According to brisbane classification of Liver resection right trisectinectomy(extended right) included
Removal of segments 5,6,7,8,4A,4B.
Which position is used in the liver resection
Mild Trendelenburg position
What is the imaging investigation of choice for liver tumors/liver cancer
Triple phase CT
LIRADS score
LR 1 : 100% benign.
LR 2 : Probably benign.
LR 3 : Intermediate probability for HCC.
LR 4 : Probably HCC.
LR 5: 100% definite HCC.
Most common benign tumor of the liver
Hemangioma
Second, most common benign tumor of the liver
Focal nodular hyperplasia
Most common malignant liver tumor
Metastasis
Most common primary malignant liver tumor
Hepatocellular carcinoma
Most common primary malignant liver tumor in children
Hepatoblastoma
What is Kassabach merrit syndrome?
Consumption coagulopathy in large hemangiomas
In arterial phase of liver hemangioma, which enhancement is seen
Peripheral nodular enhancement
In venous / Washout phase of liver hemangioma, which enhancement is seen
Homogeneous enhancement
An MRI, which sign is seen in liver hemangioma
Light bulb, sign,
other condition is showing lightbulb sign
Pheochromocytoma
What is Peliosis hepatis
Multiple cavernous hemangiomas of the liver
Classical finding on imaging of FNH
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.
other condition showing central stellate scar:
Oncocytoma
Which cells are present in FNH
Kupffer cells
Kupffer cells are present in FNH which shows
Hot spot on sulphur colloid scan.
What is the management of FNH
Observation
What is the benign liver tumor with strongest association with OCP intake
Hepatic adenoma/liver cell adenoma
HPE of Hepatic adenoma/liver cell adenoma
Sheets of hepatocytes , no bile ducts and no kupffer cells (differentiates it from FNH in sulphur colloid scan)
Mgt of Hepatic adenoma/liver cell adenoma
Small liver cell adenomas < 2 cm : Stop OCPs.
monitor with serial scans.
Liver cell adenomas > 2 cm : Resection.
Highest risk of bleeding seen in
Inflammatory liver cell adenomas
Von Meyenburg disease
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.
RF for HCC
HBV»_space; HCV
IOC for HCC
Triple phase CT
In PNS most common is
Hypoglycemia
Most common biochemical PNS
Hypercholesterolemia
Tumor marker in HCC
• 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.
What are the three types of HCC
1) Hanging type
2) Pushing type
3) Infiltrative type
PELD incorporates following criteria
• Albumin.
• Total bilirubin.
• INR.
• Growth failure.
• Age < I year.
Mgt of liver child pugh A liver tumor
Adequate functional liver reserve (>25%), resectable tumour - Liver resection.
Mgt of liver child pugh B liver tumor
Functional liver reserve < 25% -> Transplantation if patients meet the MILAN criteria.
What to do if patient do not meet MILAN criteria(inadequate
> 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.
What is MILAN Criteria
Single tumour < 5 cm.
1 - 3 tumours < 3 cm with no distant metastasis/vascular invasion.
TACE used for
Multinodular disease
TARE is used for
Multinodular disease (Yttrium spheres are used )
Immunotherapy for HCC
Sorafenib: used for advanced disease (gross vascular involvement).
Nivolumab: used for advanced metastatic disease.
Principle of TACE and TARE:
If there are multiple tumours (multinodular disease), artery supplying these tumours will be embolized causing shrinkage of tumour area.
Prognostic indicator for HCC according to OKUDA
B : serum bilirubin
A : Ascites
T : tumor size
A : albumin
Prognostic indicator for HCC according to CLIP
Tumor size ;
Child pugh score ;
AFP ;
Portal vein thrombosis
Barcelona clinic liver cancer staging includes ;
• Tumour size.
• Child pugh score.
• performance status (ECOG and Karofsky score).
MC site of mets of HCC
Lungs
Mimp prognostic factor of HCC is
Stage of the disease
Tumor marker of fibrolamellar variant of HCC
Neurotensin B
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?
CE3a
Most common tumor associated with arsenic / vinyl chloride:
Angiosarcoma
Most common tumor rupture spontaneously causing hemoperitoneum:
Hepatic adenoma
Most common primary benign tumor:
Cavernous hemangioma
Most common tumor overall:
Metastatic tumor
