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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
2nd most common benign liver lesion | Usually well circumscribed lesion with central scar
focal nodular hyperplasia
26
who do focal nodular hyperlasia often occur in?
females of reproductive age | associated w/ OCP (possibly)
27
are focal nodular hyperplasias symptomatic
no, and usually have normal LFTS
28
is there risk w/ focal nodular hyperplasia?
Nope- Rarely ruptures and no risk of malignant transformation (unlike adenoma)
29
ways to diagnose a FNH
dynamic CT w/ delayed imaging (look for central scar) | US- characteristics spoke-whell vascular
30
what will FNH look like on a technetium scan?
Technetium sulphur colloid scan helpful b/c FNH contains Kupffer cells – increased uptake
31
what needs to be done if pain is present with FNH
look for other causes of pain
32
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.
hepatic adenoma
33
are hepatic adenomas at a higher risk of hemorrhaging
yes
34
where are there higher risks of hepatic adenomas bleedng
long term OCP pergnancy tumor >4 cm
35
what does US show w/ hepatic adenoma
hypoechoic lesion, subcapsular (7% pedunculated), well circumscribed lesion Nonspecific
36
what study is the best for hepatic adenoma to detect fat and hemorrhage
MRI
37
what have more kupffer cells hepatic adenoma or FNH?
FNH
38
what is diagnostics for a hepatic adenoma?
resection
39
indicatiosn for hepatic adenoma resection
``` 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 ```
40
if you are going to observe a patient w/ hepatic adenoma what should be done
tell them to d/c OCPs | immediate imaging w/ signs of hemorrhage
41
if there is a free rupture of a hepatic adenoma what needs to be done
hepatic artery embolization
42
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
simple cysts
43
diagnosis for simple cels
CT_ thin wall w/ homogenous low density interior
44
Tx for simple cysts
only if large and cause symptoms | will recur w/ aspiration so needs surgical tx (must unroof cyst wall)
45
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
polycystic liver disease
46
how do patients w/ polycystic liver disease present
abdominal pain as cysts enlarge
47
will hepatic function decline with polycystic liver disease
it is rare | ocasionally can lead to hepatic fibrosis, portal HTN, liver failure
48
how to confirm polycystic liver disease
Ultrasound or CT scan | will see multiple liver cysts
49
when should people w/ polycystic liver dz be considered for surgery
clearly disabling pain
50
is a premalignant lesion with transformation to cystadenocarcinoma (malignant) 10% risk often misdiagnosed as liver cysts
cystadenoma
51
who are cystadenocarcinomas more common in
females >40
52
how sill a cysatenoma prsent on CT and US
usually appear multiloculated with internal septations, heterogeneous density, and irregularities in the cyst wall
53
what must you rule out with cystadenoma?
hydatid cyst
54
diagnosis for cystadenoma
FNA (could be missed) | surgical excision
55
treatment for cystadenoma
resection
56
cyst caused by parasites of the genus Echinococcus - E. granulosus or E. multilocularis Rare in the US
parastic (hydatid) liver cyst
57
where is the parasite causing hydatid liver cysts often found?
areas of sheep farming and exposure to canines
58
3 ways hydatid liver cysts can rupture
``` biliary tree (jaundice or cholangitis) diaphragm (chest) peritoneal cavity (anaphylactic shock) ```
59
should hydatid liver cysts be biopsied?
Can cause peritoneal seeding and possibly anaphylaxis
60
what is also noted in people w/ hydatid liver cysts
eosiniphilia | echinococcal antibody titers
61
do hydatid cysts affect only the liver
no, can affect other organs
62
tx for hydatid liver cysts
chemo if disseminated (albendazol) | PAIR
63
what is PAIR for unilocular hydatid cysts
Puncture Aspiration Injection (scolicidal agent) Reaspiration
64
surgical treatment for hydatid liver cysts
Total cystectomy or hepatic resection Partial cystectomy with omentoplasty Surgical PAIR with omentoplasty
65
cause of pyogenic liver abscess
instrumentation ascending colangitis via portal vein b/c GI infection (diverticulitis)
66
causes of fungal liver abscess
In pts with long term biliary stents, associated with recurrent cholangitis
67
how will a patient w/ a liver abscess present
RUQ pain, fever, and leukocytosis Alk phos likely elevated peritonitis if ruptures
68
how do liver abscesses appear on imaginings
cystic tend to have hypervascular walls
69
tx for small liver abscess
abx
70
tx for large liver abscess
abx plus percutaneous drainage or surgical if percutaneous drainage fails
71
Rare in the US caused by | Entamoeba histolytica
amedbic abscess
72
what will someone with amebic abscess present with
hx of diarrhea and weight loss
73
what will an amebic abscess look like on aspiration
sterile and anchovy paste
74
tx for amebic abscess
amebicidse (metroniadzole) | drainage not needed
75
most common liver malignancy
hepatocellular carcinoma (HCC)
76
what is the most common cause of a liver lesion
metastatic
77
cancer associated w/ cirrhosis secondary to hepatitis B and C or alcoholism or NASH
hepatocellular carcinoma (hepatoma)
78
cure for hepatocellular carcinoma
surgery (only possibl ein 5%)
79
where are metastatesse common w/ hepatomas
lung, portal vein, periportal nodes, bone, or brain
80
who do you suspect a hepatocellcular carcinoma in
Suspect in cirrhotic patients with sudden decompensation Jaundice/worsening jaundice Encephalopathy/worsening encephalopathy Ascites/worsening ascites
81
if AFP is >500-1000 what is it almost always
hepatocellular carcinoma
82
what is lab work w/ HCC used for?
determine severity and etiology of underlying liver dz
83
first way of screening for HCC
US (can miss small tumors)
84
what will a triphasic CT show with HCC
Hypervascular pattern with arterial enhancement and rapid washout during the portal venous phase extrahepatic dz can be seen
85
benefit of MRI to evaluate HCC
better for nodular cirrhotic livers
86
only chances for cure w/ HCC
surgical resection and liver transplantation
87
who can resection of HCC be done in
Childs A
88
who is a liver transplantation done in w/ HCC
cirrhotic B or C with tumors <3 cm
89
indications for tumor resection for HCC
adequate general health (ex- cardiopulmonary function) extrahepatic dz is excluded (except pulmonary mets and may be amenable to resection) anatomic location
90
treatment that may downstage tumor so patient is eligble for transplatation or resection
ablation
91
in children where are common sites for liver mets
common liver metastases are from a neuroblastoma, a Wilms tumor, or leukemia
92
how should resections be done?
Starting with laparoscopy and intraoperative U/S
93
Portal pressures ≥ 12 - 15 mm Hg (normal is 5-10)
portal HTN
94
complications w/ portal HTN
``` GI variceal bleeding Hepatorenal syndrome Ascites Hepatic encephalopathy Spontaneous (primary) peritonitis ```
95
what will portal HTN look like on PE
dilated veins on anterior abdominal wall caput medusa venous pattern on flanks paraumbilical hernia
96
what will you on imaging for portal HTN
splenomegaly collateral circulation dilation of IVC
97
what has the highest rate of morality w/ all the complications of cirrhosis
variceal bleeding
98
tx for acute bleed from variceal bleeding
``` 2 large bore IVs blood products tx coagulopathies urinary cath monitor in ICU ```
99
Drugs that can help tx of acute bleeding
``` IV somatostatin (splanchnic vasoconstriction) IV vasopressin ```
100
procedures that can help w/ an acute bleed due to portal HTN
endoscopy w/ sclerotherapy luminal tamponade TIPS
101
what is TIPS
transjugular intrahepatic portosystemic shunt | relieves pressure from collaterals
102
how to prevent recurrent bleeding w/ varices
``` beta blockade (decrease portal venous flow) ablation of varices TIPS (patient on transplant list) surgical shunts (patient not on transplant list) ```
103
indications for liver transplant
end stage liver disease, life-threatening complications of liver disease, correction of inborn errors of metabolism, and neoplasm
104
what is Child's class based on
``` albumin bilirubin ascites encephalopathy nutritional state ```
105
surgical problems w/ cirrhotics
``` 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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