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Appendix > Liver 2 > Flashcards

Liver 2 Flashcards

1
Q

In the past pyogenic liver abscesses were a result of what?

A

infections from the intestinal tract such as acute appy and diverticulitis

which spread to liver via portal circulation

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2
Q

What are causes of pyogenic liver abscesses now?

A

usually from biliary tract dx or cryptogenic

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3
Q

Most common liver abscesses seen in US?

A

pyogenic liver abscess

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4
Q

What bugs do we see with pyogenic liver abscess?

A

40/40% mono/polymicrobial

20% culture negative

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5
Q

Most common bacteria seen in pyogenic liver abscesses?

A

2/3 are gram negative bacteria

e.coli in 2/3 of cases (strept. faecalis, klebsiella other bugs)

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6
Q

Pyogenic liver abscesses can be single or multiple but tend to be found on which side of liver more frequently?

A

right lobe

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7
Q

Clinical presentation and labs seen in someone w/pyogenic liver abscess?

A

clinically; RUQ pain, fever, jaundice (1/3)

labs: leukocytosis, increased ESR, ALK

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8
Q

What do we see on US of suspected pyogenic liver abscess?

A

round or oval hypoechoic lesions w/well defined borders

variable number of internal echoes

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9
Q

Initial therapy for pyogenic liver abscess?

A

IV abx for at least 8 weeks
(need gram neg and anaerobic coverage)

surgical drainage laparoscopically or open may become necessary if initial therapy fails

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10
Q

Do we do catheter drainage of pyogenic liver abscess?

A

effective in small number of pts

fluid is usually viscous and does not drain well

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11
Q

Distribution of pyogenic liver abscesses in the liver?

A

75% right lobe

20% left lobe

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12
Q

Causes of pyogenic liver abscesses?

A

infections from biliary tree are most common identifiable cause

obstruction causes bile stasis, bacterial overgrowth, and infection and extention into liver

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13
Q

What is pyelophlebitis?

A

the portal venous system drains the GI system; thus any infectious d/o of GI tract can result in ascending portal vein infection

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14
Q

Most common organisms cultured from pyogenic liver bascesses?

A

e.coli

klebsiella

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15
Q

Pyogenic liver abscesses tend to occur in what age group?

A

50-60s

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16
Q

Abx for pyogenic liver abscesses?

A

ampicillin + metronidazole

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17
Q

Most common type of liver abscess worldwide?

A

amebic liver abscess

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18
Q

Male vs female predominance of amebiasis?

A

10;1 male

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19
Q

Amebic liver abscess caused by?

A

ameoba histolytica

affecting 10% of world’s population

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20
Q

Who gets amebiasis?

A

males 20-40 with travel to endemic tropical areas

mexico, india, central america

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21
Q

Some risk factors for contracting amebiasis?

A

immunosuppression

heavy etoh use

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22
Q

Life cycle of entamoeba histolytica?

A

exists as cysts outside body (vegetative form)
cyst passes thru stomach and small bowel

transforms into a trophozoite in colon
invades colonic mucosa, forming flask-shaked ulcers
carried to liver

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23
Q

How does abscess of amoeba hystolitica appear?

A

common in R-lobe of liver

has a necrotic central portion that contains thick-reddish brown pus like material–:> anchovy paste

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24
Q

Anchovy or chocolate like paste is assc w/?

A

amebiasis from entamoeba histolytica

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25
Q

Should be considered in pts who travel to endemic areas that have RUQ pain, fever, hepatomegaly, hepatic abscess;

A

amebiasis

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26
Q

Labs seen in amebiasis?

A

elevated LFTs and jaundice are rare

mildly elevated ALK

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27
Q

How is E. histolytica obtained?

A

fecal oral route

ingesting cyst from environment

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28
Q

What’s the anchovy paste seen in E. histolytica abscess?

A

blood and liquified liver tissue

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29
Q

On CT, these abscesses tend to be peripherally located, round, non enhancing rim with peripheral edema;

A

amebic liver abscess

located peripherally bc it ameba can’t degrade glisson’s capsule

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30
Q

Treatment of choice for an amebic liver abscess?

A

750 mg metronidazole 3x/day for 7-10 days

curative in 90%

clinical improvement seen in 3 days

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31
Q

When do we consider aspiration for amebic liver abscesses?

A

abscesses larger than 5 cm
failure of abx therapy
abscesses in left liver

(these abscesses ass w/higher risk of rupture)

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32
Q

Most common complication of amebic liver abscess?

A

rupture into peritoneum, pleural cavity, pericardium

size of abscess is greatest risk factor for rupture

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33
Q

What causes hydatid cysts?

A

infection by the tapeworm echinococus granulosus

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34
Q

Hydatid cysts are more common in what areas of the world?

A

sheep-grazing areas (New Zealand, Africa, Greece, Spain)

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35
Q

Hydatid cysts affect what organs?

A

liver 70% of the time

30% lung, spleen, brain, bones

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36
Q

A hydatid cyst has how many layers?

A

2 layers

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37
Q

Where do we find most hydatid cysts in the liver?

A

75% right liver

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38
Q

How do we describe hydatid cysts on imaging?

A

well-defined hypodense lesions with a distinct wall

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39
Q

Treatment of hydatid cysts?

A

surgical–> due to high risk of rupture and secondary infection

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40
Q

Initial treatment for small asymptomatic cysts?

A

albendazole

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41
Q

During surgical resection of a hydatid cyst, care must be taken to ?

A

not rupture the cysts

cyst contents can induce an anaphylactic reaction

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42
Q

How does Ascaris lumbricoides get to the liver?

A

common in Far East

retrograde movement in the bile ducts from GI tract

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43
Q

What’s the complications of Ascariasis?

A

can serve as nidus for intrahepatic gallstones
can block CBD
can cause cholangitis

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44
Q

Tx for ascariasis?

A

piperazine citrate
mebendazole
albendazole

ERCP extraction of worm

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45
Q

Tx for hepatic schistosomiasis?

A

praziquantel 40-75 mg/kg as single dose

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46
Q

Cornerstone of current antiviral therapy for Hep b?

A

pegylated interferon

tenofovir/entecavir

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47
Q

Side effects of pegylated interferon?

A

flu like sx, mood changes
bone marrow suppression
stimulation of autoimmunity

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48
Q

Leading indication of liver transplant in US, Europe and Japan?

A

cirrhosis due to Hep C

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49
Q

What are some common benign liver lesions?

A

cysts
adenomas
FNH
hemangiomas

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50
Q

This benign liver lesions seen in women 20-40 and often associated w/steroid use such as chronic oral contraceptive pills:

A

hepatic adenoma

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51
Q

Female to male ratio of hepatic adenomas?

A

10;1 female

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52
Q

Histologically this benign liver lesion is described as cords of benign hepatocytes containing increased glycogen and fat:

A

hepatic adenoma

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53
Q

How does a hepatic adenoma appear on CT?

A

well-circumscribed heterogenous mass w/early enhancement during the arterial phase

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54
Q

This benign liver lesion can be seen in premenopausal women older than 30 and are typically solitary, although multiple lesions can occur:

A

adenomas

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55
Q

Prior or current use of estrogens is a risk factor for this benign liver lesion:

A

hepatic adenomas

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56
Q

Why is it recommended we surgically remove hepatic adenomas?

A

carry a significant risk of spontaneous rupture (10-25%)

risk of malignant transformation to HCC

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57
Q

What do we see on MRI of suspected adenoma?

A

well demarcated heterogenous mass containing fat or hemorrhage

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58
Q

What are two risks associated with hepatic adenomas?

A

spontaneous intraperitoneal rupture

transformation to HCC

59
Q

How do we handle someone who has a spontaneous intraperitoneal rupture from a hepatic adenoma?

A

hepatic artery embolization if available

once stabilized and resuscitated–> laparotomy and resection of mass indicated

60
Q

How do we manage symptomatic vs asymptomatic hepatic adenomas?

A

asymptomatic pts on OCP–> can be observed after cessation of OCP

symptomatic pts–> mass needs to be removed

61
Q

On CT you see a well circumscribed lesion with a central scar, what is it?

A

benign liver lesion; FNH

62
Q

2nd most common benign liver tumor and mostly found in young women:

A

FNH

63
Q

This liver mass is characterized by a central fibrous scar with radiating septae;

A

FNH

64
Q

What is the central scar seen in FNH?

A

often contains a large artery that branches out into multiple smaller arteries in a spoke wheel pattern

65
Q

What causes FNH?

A

theory unknown

speculated to arise from vascular malformations

66
Q

What do we see on imaging of CT and MRI of suspected FNH?

A

homogenous mass w/central scar that enhances rapidly on arterial phase

67
Q

Can FNH progress to malignancy?

A

NO

68
Q

What does CT show in someone suspected of having FNH?

A

rapid enhancement on arterial phase

isodense or invisible in background of liver on venous phase

69
Q

Unlike adenomas, FNH do NOT:

A

rupture spontaneously

do not progress to malignancy

70
Q

Surgical tx for FNH?

A

management is usually reassurance

sx can be recommended when pts symptomatic or HCC cannot be excluded

71
Q

When either hepatic adenomas or FNH are suspected, what medications should be stopped?

A

OCPs

72
Q

This is the most common benign liver tumor:

A

hemangiomas

73
Q

Most common benign liver tumors?

A

hemangiomas

74
Q

Age and sex distribution of hemangiomas?

A

3;1 female

approx. age 45

75
Q

Do hemangiomas spontaneously rupture?

A

RARE RARE

76
Q

These benign liver lesions are described as large endothelial line vascular spaces and represent congenital vascular lesions that contain fibrous tissue and small blood vessels that eventually grow;

A

hemangiomas

77
Q

How are most hemangiomas discovered?

A

incidentally w/little clinical significance

78
Q

On biphasic CT how do we describe hemangiomas?

A

asymmetrical nodular peripheral enhancement that is isodense w/large vessels

exhibit progressive centripetal enhancement fill-in over time

79
Q

What liver lesions shows a pattern of peripheral nodular enhancement?

A

hemangiomas

80
Q

This is an associated syndrome associated w/hemangiomas:

A

Kasbach-Merrit syndrome

81
Q

WHat’s Kassbach-Merrit syndrome?

A

assc w/ hemangiomas

thrombocytopenia
consumptive coagulopathy

82
Q

These lesions show a typical peripheral nodular enhancement pattern:

A

hemangiomas

83
Q

Do we biopsy hemangiomas?

A

NO, dangerous

biopsy is not recommended

84
Q

What’s the natural hx of a liver hemangioma?

A

normally a benign course

most remain stable over long periods of time

low risk of rupture or hemorrhage

85
Q

When do we resect hemangiomas?

A

rupture
significant change in size
development of Kassbach-Merrit syndrome

86
Q

Hemangiomas can be seen in kids, and large hemangiomas can cause this in children:

A

CHF due to arterio-venous shunting

87
Q

Symptomatic hemangiomas in children are treated how?

A

therapeutic embolization

medical therapy for CHF

resection may be necessary for symptomatic lesions or rupture

88
Q

This makes up 12% of all pediatric liver tumors:

A

hemangiomas

89
Q

Most common primary malignancy of the liver?

A

HCC

90
Q

Assc risk factors with HCC?

A

HBV infection
cirrhosis
smoking
etoh use

91
Q

Most common malignant tumor seen in the liver?

A

metastatic colorectal cancer

92
Q

Major risk factors for HCC?

A

hep b/c
etoh cirrhosis
hemochromatosis
NASH

93
Q

HCC are typically hypervascular with blood supplied primarily from?

A

hepatic artery

94
Q

How do HCC lesions appear on CT?

A

hypervascular on the arterial phase

hypodense during delayed phase

95
Q

HCC has a tendency to invade what structure?

A

portal vein

presence of an enhancing portal vein thrombus is highly suggestive of HCC

96
Q

Most cases of HCC are related to what?

A

HBV infection; 50-55%

HCV infection; 20-25%

97
Q

This is a powerful hepatotoxin produced by aspergillus species, which acts as a carcinogen and increases risk of HCC:

A

aflatoxin

98
Q

Classic presentation of someone with HCC?

A

male 50-60

RUQ pain + weight loss + palpable mass

99
Q

What tumor marker can be helpful in assessment of HCC?

A

AFP

AFP > 20 ng/ml seen in 75% of cases of documented HCC

100
Q

When do we use AFP levels in someone with HCC?

A

used to monitor treated pts with recurrence

101
Q

Classic features of HCC on MRI or CT?

A

arterially enhancing mass with washout of contrast in delayed phases

102
Q

Where does HCC normally metastasize to?

A

lung
bone
peritoneum

103
Q

Why do we need a preop chest CT in pts with HCC?

A

normally mets to lung and pts are usually asymptomatic

104
Q

What’s the treatment of choice for HCC?

A

liver resection

105
Q

Other treatment options for HCC that’s not surgical?

A

ablative techniques
embolization
liver transplant

106
Q

In which classes of Child-Pugh do we offer surgery for HCC?

A

Class A
Class B questionable
No to class C

107
Q

Do we use the TNM staging system for HCC?

A

NO

it does not accurately predict survival
liver function not taken into account
TNM relies on pathology which is usually not present in HCC

108
Q

What tx option has the highest long term survival for HCC?

A

complete excision of HCC by hepatectomy or partial hepatectomy and liver transplant

*** 10-20 % of pts are considered to have resectable disease

109
Q

These patients with HCC do not tolerate resections;

A

pts w/Child Pugh Class B/C

pts w/portal htn

110
Q

What’s percutaneous ethanol injection?

A

useful technique to ablate small tumors in liver

111
Q

This is a variant of HCC?

A

fibrolamellar HCC

112
Q

How is fibrolamellar HCC different from HCC?

A

seen in younger pts without hx of cirrhosis

well demaracted, with central fibrotic scar (makes it difficult to distinguish from FNH)

113
Q

Fibrolamellar HCC is not assc with elevated AFP, but produces high levels of?

A

neurotensin

114
Q

WHich has a better progonosis HCC or Fibrolamellar HCC?

A

fibrolamellar HCC

but recurrence is common (80%)

115
Q

This is the second most common primary malignancy in the liver:

A

cholangiocarcinoma (bile duct ca)

116
Q

Where does cholangiocarcinoma usually develop?

A

can be intra-hepatic or extra-hepatic

40-60% present at biliary confluence
10% present as intra-hepatic liver masses

117
Q

What’s a Klatskin tumor?

A

hilar cholangiocarcinoma

originates at wall of bile duct at the hepatic duct confluence

usually presents with obstructive jaundice

118
Q

Most common risk factors for developing cholangiocarcinomas?

A

historically PSC, choledocho cystic disease

nowadays HIV, HBV, cirrhosis, DM

119
Q

Factors associated with poor outcomes in pts with cholangiocarcinoma?

A

intrahepatic mets
LN mets
vascular invasion
positive margins

120
Q

Most common primary hepatic tumor of childhood?

A

hepatoblastoma

almost all cases seen before age 3

121
Q

Angiosarcomas of the liver are assc with what ?

A

vinyl chloride

thorotrast

122
Q

The most common malignant tumors of the liver are?

A

metastatic lesions

mostly from GI due to drainage of GI into portal vein

123
Q

For metastatic colorectal cancer to the liver do we resect?

A

mets from colon isolated to the liver can be resected with potential for long-term survival and cure

124
Q

For primary liver cancers or hepatic mets, gold standard treatment option is?

A

hepatic resection

125
Q

What is the rationale behind advocating for liver transplant in pts with HCC?

A

most cases of HCC (>80%) arise in setting of cirrhosis

cirrhotic liver does not have enough reserve to tolerate a resection

126
Q

How many liver transplants performed annually in US?

A

> 6K

with 1 year survival at 90%

127
Q

Milan criteria for liver transplant?

A

showed that survival rates were improved when liver transplant was limited to pts w/:

early stage I/II HCC
w/ one tumor < 5 cm
w/ 3 tumors no larger than 3 cm
absence of vascular invasion or extrahepatic spread

128
Q

Chemoembolization is most commonly used for unresectable HCC, how is it done?

A

injecting chemotheropeutic drugs combined with embolization particles into the hepatic artery that supplies the liver tumor

done via a percutaneous femoral approach

129
Q

Hepatic artery chemoembolization (AKA TACE), has what complications?

A

liver dysfunction/failure
hepatic abscess
hepatic artery thrombus

130
Q

This multikinase inhibitor has been approved by FDA for advanced unresectable HCC:

A

sorafenib

131
Q

What’s the SHARP trial?

A

showed survival benefit in pts with unresectable advance HCC with sorafenib

132
Q

Advantages and disadvantages of vascular stapling devices in liver surgery?

A

speedy transection, bloodless

cost is a disadvantage

133
Q

Some steps common to all hepatic surgeries:

A

make right subcostal incision w/wout left subcostal extension

explore abdomen, place Bookwalter
palpate liver, perform liver US
taken down round and falciform ligaments, expose anterior surface of hepatic veins

for left hepatectomy, divide left triangular ligament
for right hepatectomy, divide right coronary ligament

open gastrohepatic ligament, palpate porta, assess for accessory hepatic arteries

perform cholecystectomy (leave GB and cystic duct intact if involved by tumor)

134
Q

Pringle maneuver clamps the porta hepatis to control blood loss, but what’s a problem with it?

A

can cause ischemic damage and reperfusion damage to liver

some advocate 15 mins clamp on and 5 mins clamp off

135
Q

What is ischemic deconditioning with Pringle maneuver?

A

brief interruption of blood flow to an organ followed by a short re-perfusion period and then a more prolonged period of ischemia

136
Q

How much liver remnant is needed in a normal healthy person to prevent liver failure?

A

25-30% of total liver volume

137
Q

TACE, ablative therapy, and sorafenib are what type of therapies for HCC?

A

usually palliative

138
Q

Most common benign hepatic liver lesions?

A

hemangioma followed by FNH

139
Q

How does hemangioma present on imaging?

A

peripheral nodular enhancement on arterial phase

progressive centripetal fill-in on portal venous phase

140
Q

This benign liver lesion shows peripheral nodular enhancement on arterial phase and centripetal fill in on portal venous phase;

A

hemangioma

141
Q

Most serious complication of a percutaneous liver biopsy?

A

bleeding

usually presents 4 hrs following percutaneous drainage

pts have hypotension, tachycardia, abdominal pain

tx–> resuscitate w/crystalloids then blood products

142
Q

For pts with acalculous cholecystitis, who are decompressed with a PCT, do they need an interval cholecystectomy once they improve clinically?

A

not necessarily

143
Q

After a cholecystostomy tube is placed, how soon can we see resolution of symptoms?

A

usually within 24 hrs

144
Q

Cholecystostomt tubes are not beneficial for what?

A

gangrene of the gallbladder

perforation of the gallbladder

Appendix (39 decks)

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