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*OldSurgery > Liver > Flashcards

Liver Flashcards

1
Q

what is the largest single gland of the body?

A

liver

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2
Q

what are the three hepatic veins

A

right middle and left

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3
Q

where does the caudate lobe drain?

A

directly into the IVC

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4
Q

what is 75% of the blood supply of the liver?

A

portal vein

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5
Q

Origin of the portal vein formed by confluence of the

A

SMV and splenic vein

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6
Q

what is the order of biliary drainage

A

Bile canaliculi → segmental bile ducts (drain the segments) → right and left hepatic ducts → common hepatic duct → common bile duct at point of insertion of the cystic duct

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7
Q

why would you resect a benign liver lesion?

A

Hemorrhage or risk of hemorrhage
Risk of malignant transformation
Inability to exclude malignancy

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8
Q

what is the most common benign hepatic tumor?

A

cavernous hemangioma

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9
Q

who typically gets cavernosu hemangiomas

A

women 30-50 years old

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10
Q

when are cavernous hemangiomas usually found?

A

incidental on x-ray

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11
Q

if symptomatic present with RUQ pain or fullness. (pain uncommon <8-10 cm)

A

hemangioma

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12
Q

PE findings w/ hemangioma

A

rare but may see hepatomegaly or arterial bruit in the RUQ

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13
Q

very rare presentations of hemangioma

A

CHF
Jaundice
Spontaneous or traumatic rupture – hemorrhagic shock
Early satiety, nausea and vomiting
Thrombocytopenia may be present from sequestration and destruction of platelets in large lesions

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14
Q

dx of hemangioma

A

CT/MRI
FNA (risk of hemorrhage)
U/S

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15
Q

what will a hemangioma look like on US

A

well-circumscribed

uniformly hyperechoic lesions

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16
Q

what type CT do you want for a hemangioma

A

contrast enhanced, triple phase w/ delayed imaging

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17
Q

in arterial phase filled in periphery then there is more central filling with delayed phase.

A

hemangioma

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18
Q

how will a hemangioma look like on MRI

A

T1- low signal intensity

T2- high signal intensity

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19
Q

what will a hemangioma look like on RBC scan (useful if MRI is non-diagnostic)

A

delayed centripetal filling

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20
Q

Follow-up for hemangioma

A

US at 6 months and at 12 months after initial diagnosis

if no change in size- probs don’t need long term follow up

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21
Q

indications for resection of hemangioma

A

Severe symptoms
Inability to obtain a firm diagnosis
Rapid growth
Rupture

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22
Q

what can you do to decrease risk of bleeding w/ hemangioma

A

May embolize if hemorrhage or pre-resection to shrink tumor to decrease risk of bleeding

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23
Q

how is embolization done

A

catheter in femoral artery

go to hepatic artery and inject things into artery to get it to stop bleeding

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24
Q

what can be used for embolization

A

Coils, ethanol, sodium tetradecyl sulfate cyanoacrylate, polyvinyl alcohol (PVA), microspheres, gelatin sponge (Gelfoam)

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25
Q

2nd most common benign liver lesion

Usually well circumscribed lesion with central scar

A

focal nodular hyperplasia

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26
Q

who do focal nodular hyperlasia often occur in?

A

females of reproductive age

associated w/ OCP (possibly)

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27
Q

are focal nodular hyperplasias symptomatic

A

no, and usually have normal LFTS

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28
Q

is there risk w/ focal nodular hyperplasia?

A

Nope- Rarely ruptures and no risk of malignant transformation (unlike adenoma)

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29
Q

ways to diagnose a FNH

A

dynamic CT w/ delayed imaging (look for central scar)

US- characteristics spoke-whell vascular

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30
Q

what will FNH look like on a technetium scan?

A

Technetium sulphur colloid scan helpful b/c FNH contains Kupffer cells – increased uptake

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31
Q

what needs to be done if pain is present with FNH

A

look for other causes of pain

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32
Q

has a strong associated w/ estrogen use- mostly OCP found in women 30-50 y/o more common in women who have been on OCP longer.

A

hepatic adenoma

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33
Q

are hepatic adenomas at a higher risk of hemorrhaging

A

yes

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34
Q

where are there higher risks of hepatic adenomas bleedng

A

long term OCP
pergnancy
tumor >4 cm

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35
Q

what does US show w/ hepatic adenoma

A

hypoechoic lesion, subcapsular (7% pedunculated), well circumscribed lesion
Nonspecific

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36
Q

what study is the best for hepatic adenoma to detect fat and hemorrhage

A

MRI

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37
Q

what have more kupffer cells hepatic adenoma or FNH?

A

FNH

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38
Q

what is diagnostics for a hepatic adenoma?

A

resection

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39
Q

indicatiosn for hepatic adenoma resection

A 
unable to differentiate b/w HCC and hepatic adenoma
symptomatic
evidence of bleeding
poor follow up
lives in remote area
>5cm
elevated alpha-fetoprotein
patients wanting to become pregnant
pregnancy in second trimester
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40
Q

if you are going to observe a patient w/ hepatic adenoma what should be done

A

tell them to d/c OCPs

immediate imaging w/ signs of hemorrhage

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41
Q

if there is a free rupture of a hepatic adenoma what needs to be done

A

hepatic artery embolization

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42
Q

Congenital or aquired
Lined by biliary-type epithelium
The fluid in the cyst has an electrolyte composition that mimics plasma – not bile
Usually asymptomatic
dull RUQ pain if large or bloating, early satiety

A

simple cysts

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43
Q

diagnosis for simple cels

A

CT_ thin wall w/ homogenous low density interior

44
Q

Tx for simple cysts

A

only if large and cause symptoms

will recur w/ aspiration so needs surgical tx (must unroof cyst wall)

45
Q

Congenital and usually associated with autosomal dominant polycystic kidney disease
Cysts are numerous and enlarge
Rarely arises in childhood
Observed at the time of puberty and increase in adulthood

A

polycystic liver disease

46
Q

how do patients w/ polycystic liver disease present

A

abdominal pain as cysts enlarge

47
Q

will hepatic function decline with polycystic liver disease

A

it is rare

ocasionally can lead to hepatic fibrosis, portal HTN, liver failure

48
Q

how to confirm polycystic liver disease

A

Ultrasound or CT scan

will see multiple liver cysts

49
Q

when should people w/ polycystic liver dz be considered for surgery

A

clearly disabling pain

50
Q

is a premalignant lesion with transformation to cystadenocarcinoma (malignant) 10% risk
often misdiagnosed as liver cysts

A

cystadenoma

51
Q

who are cystadenocarcinomas more common in

A

females >40

52
Q

how sill a cysatenoma prsent on CT and US

A

usually appear multiloculated with internal septations, heterogeneous density, and irregularities in the cyst wall

53
Q

what must you rule out with cystadenoma?

A

hydatid cyst

54
Q

diagnosis for cystadenoma

A

FNA (could be missed)

surgical excision

55
Q

treatment for cystadenoma

A

resection

56
Q

cyst caused by parasites of the genus Echinococcus - E. granulosus or E. multilocularis
Rare in the US

A

parastic (hydatid) liver cyst

57
Q

where is the parasite causing hydatid liver cysts often found?

A

areas of sheep farming and exposure to canines

58
Q

3 ways hydatid liver cysts can rupture

A 
biliary tree (jaundice or cholangitis)
diaphragm (chest)
peritoneal cavity (anaphylactic shock)
59
Q

should hydatid liver cysts be biopsied?

A

Can cause peritoneal seeding and possibly anaphylaxis

60
Q

what is also noted in people w/ hydatid liver cysts

A

eosiniphilia

echinococcal antibody titers

61
Q

do hydatid cysts affect only the liver

A

no, can affect other organs

62
Q

tx for hydatid liver cysts

A

chemo if disseminated (albendazol)

PAIR

63
Q

what is PAIR for unilocular hydatid cysts

A

Puncture
Aspiration
Injection (scolicidal agent)
Reaspiration

64
Q

surgical treatment for hydatid liver cysts

A

Total cystectomy or hepatic resection
Partial cystectomy with omentoplasty
Surgical PAIR with omentoplasty

65
Q

cause of pyogenic liver abscess

A

instrumentation
ascending colangitis
via portal vein b/c GI infection (diverticulitis)

66
Q

causes of fungal liver abscess

A

In pts with long term biliary stents, associated with recurrent cholangitis

67
Q

how will a patient w/ a liver abscess present

A

RUQ pain, fever, and leukocytosis
Alk phos likely elevated
peritonitis if ruptures

68
Q

how do liver abscesses appear on imaginings

A

cystic tend to have hypervascular walls

69
Q

tx for small liver abscess

A

abx

70
Q

tx for large liver abscess

A

abx plus percutaneous drainage or surgical if percutaneous drainage fails

71
Q

Rare in the US caused by

Entamoeba histolytica

A

amedbic abscess

72
Q

what will someone with amebic abscess present with

A

hx of diarrhea and weight loss

73
Q

what will an amebic abscess look like on aspiration

A

sterile and anchovy paste

74
Q

tx for amebic abscess

A

amebicidse (metroniadzole)

drainage not needed

75
Q

most common liver malignancy

A

hepatocellular carcinoma (HCC)

76
Q

what is the most common cause of a liver lesion

A

metastatic

77
Q

cancer associated w/ cirrhosis secondary to hepatitis B and C or alcoholism or NASH

A

hepatocellular carcinoma (hepatoma)

78
Q

cure for hepatocellular carcinoma

A

surgery (only possibl ein 5%)

79
Q

where are metastatesse common w/ hepatomas

A

lung, portal vein, periportal nodes, bone, or brain

80
Q

who do you suspect a hepatocellcular carcinoma in

A

Suspect in cirrhotic patients with sudden decompensation
Jaundice/worsening jaundice
Encephalopathy/worsening encephalopathy
Ascites/worsening ascites

81
Q

if AFP is >500-1000 what is it almost always

A

hepatocellular carcinoma

82
Q

what is lab work w/ HCC used for?

A

determine severity and etiology of underlying liver dz

83
Q

first way of screening for HCC

A

US (can miss small tumors)

84
Q

what will a triphasic CT show with HCC

A

Hypervascular pattern with arterial enhancement and rapid washout during the portal venous phase
extrahepatic dz can be seen

85
Q

benefit of MRI to evaluate HCC

A

better for nodular cirrhotic livers

86
Q

only chances for cure w/ HCC

A

surgical resection and liver transplantation

87
Q

who can resection of HCC be done in

A

Childs A

88
Q

who is a liver transplantation done in w/ HCC

A

cirrhotic B or C with tumors <3 cm

89
Q

indications for tumor resection for HCC

A

adequate general health (ex- cardiopulmonary function)
extrahepatic dz is excluded (except pulmonary mets and may be amenable to resection)
anatomic location

90
Q

treatment that may downstage tumor so patient is eligble for transplatation or resection

A

ablation

91
Q

in children where are common sites for liver mets

A

common liver metastases are from a neuroblastoma, a Wilms tumor, or leukemia

92
Q

how should resections be done?

A

Starting with laparoscopy and intraoperative U/S

93
Q

Portal pressures ≥ 12 - 15 mm Hg (normal is 5-10)

A

portal HTN

94
Q

complications w/ portal HTN

A 
GI variceal bleeding
Hepatorenal syndrome
Ascites
Hepatic encephalopathy
Spontaneous (primary) peritonitis
95
Q

what will portal HTN look like on PE

A

dilated veins on anterior abdominal wall
caput medusa
venous pattern on flanks
paraumbilical hernia

96
Q

what will you on imaging for portal HTN

A

splenomegaly
collateral circulation
dilation of IVC

97
Q

what has the highest rate of morality w/ all the complications of cirrhosis

A

variceal bleeding

98
Q

tx for acute bleed from variceal bleeding

A 
2 large bore IVs 
blood products
tx coagulopathies
urinary cath
monitor in ICU
99
Q

Drugs that can help tx of acute bleeding

A 
IV somatostatin (splanchnic vasoconstriction)
IV vasopressin
100
Q

procedures that can help w/ an acute bleed due to portal HTN

A

endoscopy w/ sclerotherapy
luminal tamponade
TIPS

101
Q

what is TIPS

A

transjugular intrahepatic portosystemic shunt

relieves pressure from collaterals

102
Q

how to prevent recurrent bleeding w/ varices

A 
beta blockade (decrease portal venous flow)
ablation of varices
TIPS (patient on transplant list) 
surgical shunts (patient not on transplant list)
103
Q

indications for liver transplant

A

end stage liver disease, life-threatening complications of liver disease, correction of inborn errors of metabolism, and neoplasm

104
Q

what is Child’s class based on

A 
albumin
bilirubin
ascites
encephalopathy
nutritional state
105
Q

surgical problems w/ cirrhotics

A 
hemorrhage (venous collaterals)
impaired coagulation, poor wound healing
different metabolism of meds
impaired immune functions 
difficult fluid management (ascites)

*OldSurgery (22 decks)

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