Liver Flashcards
Causes of hepatic adenomas
- oral contraceptives
- anabolic androgens
- glycogen storage disease.
When is surgery indicated for hepatic adenomas?
Surgical resection if
- size>5cm
- symptomatic
- increased size despite discontinue estrogens/ androgens
How can you tell the difference between FNH and fibrolamellar HCC (FLHCC)?
fibrolamellar hepatocellular carcinoma (FLHCC) may mimick FNH.
Both FNH and FLHCC appear in normal liver, unlike HCC that is most frequently seen in a cirrhotic liver.
In distinction to FNH, FLHCC is
- large (> 5 cm)
- frequently has calcifications (>70%)
- a blunt central scar
- usually there is lymphadenopathy
FNH
- size <5cm
- No calcification, haemorrhage or necrosis
Organism
Entamoeba histolytica
Investigations for amoebic abscess
Serology
- ELISA for E. histolytica however negative serology is helpful for exclusion of disease, but positive serology cannot distinguish between acute and previous infection
Stool
- for M/C/S (including ova, cysts, parasites) and PCR for Entamoeba histolytica.
- simultaneous liver abscess and amebic colitis is uncommon, so stool microscopy and polymerase chain reaction (PCR) are usually negative in the setting of liver abscess
Managment of amoebic abscess
Tissue agent
- oral metronidazole for 10 days. Cure rate >90%
Luminal agents (eliminate intraluminal cysts)
- paromycin for 7 days
Complications of amoebic abscess
- Amebic colitis = fulminant colitis, bowel perforation/necrosis
- Pulmonary - empyema
- Brain – CNS infection (brain abscess)
- Skin – perianal ulceration
Management of hydatid cyst
Contraindications for TACE
- Macrovascular invasion with thrombus in the main portal vein and/or portal vein obstruction
- Encephalopathy
- Biliary obstruction
- Child-Pugh C cirrhosis
what is the pathophysiology of portal HTN
Vascular resistance and blood flow are 2 key elements.
Vascular resistance (first step)
Structural component
- Liver disease = reduced portal vascular radius due to fibrosis/vascular occlusion è increased vascular resistance (Poiseuille’s law is Resistance = 8hL/pr4). Hence smaller vessels = more resistance in sinusoidal microcirculation è sinusoidal portal hypertension
Dynamic component
- Active contraction of myofibroblasts and vascular smooth muscles in portal venules
Blood flow (second step)
- Portal HTN causes collaterals to develop (VEGF induced)
- splanchnic blood flow increased because of local vasodilators and sphlanchnic vasodilation causes increased portal inflow which exacerbates portal HTN
What are the imaging features suggestive of hydatid cyst?
- daughter cysts
- peripheral/marginal calcification
- pulmonary cysts
- internal floating shadows
What are the differentials and characteristics of liver cysts?
abscess
- marginal enhancement
- air loculi
- halo (peripheal oedema) in aemobic
Hydatid cyst
- marginal calcification
- daughter cyst
- lung cysts
- internal floating shadows
Haemangioma
- peripheral nodular enhancement
- uptake of contrast on delayed filled images
Rare (Biliary cystadenoma/carcinoma)
- internal septations
- large
What are the important features to note about fibrolamellar HCC?
- accounts for 1-9% of HCC
- occurs in normal liver
- AFP levels are normal
- can mimick FNH but it has a central scar with calcifications (FNH no calcification)
What are the indications for liver transplant?
As per TSANZ
- Hepatocellular Cancer
- San Francisco criteria:
- Single tumour ≤ 6.5cm in maximum diameter
- Multiple tumours ≤ 3 in number with the largest diameter being ≤ 4.5cm and a total tumour diameter of ≤ 8.0cm
- No extra-hepatic spread
- Cirrhosis (all forms)
- Decompensated liver disease
- Correctable extrahepatic manifestations of cirrhosis e.g. hepatopulmonary syndrome, failure of growth and/or neurodevelopment
- Alcoholic Liver Disease
Liver failure following -
- 6 months abstinence
- Considered at low risk for continued alcohol abuse
