Liver Flashcards
Viral hepatitis predisposes to…
hepatocellular carcinoma
Patient presents with malaise, fatigue, nausea, anorexia, dark urine, scleral icterus, jaundice, mild bruising and bleeding. Labs indicate AST/ALT greater than 500U/L, PT elevated, and bilirubin elevated. Dx?
Viral hepatitis
How to diagnose viral hepatitis?
serological testing
When to do liver biopsy for hepatitis?
When it is chronic hepatitis- necessary for staging
Which hepatitis are RNA viruses?
Hep A, C,D, E
Which hepatitis is DNA Virus?
Hep B
Which hepatitis are transmitted through fecal-oral?
A and E
Which hepatitis is transmitted though blood/sexual contact?
B, C, D
which hepatitis has vaccine available?
A and B (D covered via B)
Tx for hepatitis B
Supportive in ICU for fulminant disease. Chronic disease treated with interferon-alpha-2b and Lamivudine
Tx for chronic HCV
Inerferon alpha, ribavirin
Tx for hepatitis D
interferon-alpha
Which hepatitis is very dangerous for pregnant women?
E
Chronic non-viral hepatitis could be caused by..
Autoimmune chronic active hepatitis, SLE, Wilson’s disease, and Primary biliary cirrhosis
Diagnosis of chronic non-viral hepatitis by…
serological testing to r/o viral disease, biochemical testing to r/o wilson’s, etc, liver biopsy, no blood exposure, absence of alcohol and drug use, +ANA, SMA, or anti LKM1, total serum gamma-globulin or IgG more than 1.5x normal.
Tx for autoimmune hepatitis
prednisone, azathioprine
Most common causes of cirrhosis
alcohol abuse and Hepatitis C
Survival from cirrhosis influenced by
Liver function, presence of (esophageal) varices, portal pressure
Effects of alcohol on liver
Toxic to liver- collagen deposition, hepatic steatosis causing alcoholic hepatitis causing cirrhosis
Complications from cirrhossis
Liver failure, bleeding from esophageal varices
Child Pugh Classification
used to assess the prognosis of cirrhosis and determine necessity of liver transplantation
Grade A-C on Child Pugh Score
Grade A- 1 to 6. Grade B- 7 to 9. Grade C- 10 to 15.
Which type of patients would benefit from portal decompressive procedures?
Patients with esophageal varices (that have cirrhosis)- help to take pressure off portal system
What is pyelophlebitis
Infection in the hepatic portal vein
Cause of pyogenic abscess
Most commonly results from ascending cholangitis, also pyelophlebitis, or infection via hepatic artery in bacteremia
Routes in which pyogenic abscess can occur
Biliary route (infection in bile duct- ascending cholangitis), infection in portal vein (pyelophlebitis), or infection in hepatic artery during bacteremia, direct extension, or trauma
Pyogenic abscess caused from ____ are usually polymicrobial
pyelophlebitis or cholangitis
Pyogenic abscess from ____ are single organism
systemic circulation via hepatic artery
Where is liver pyogenic abscess usually located?
Right lobe of liver 3/4
Patient presents with fever, jaundice, RUQ pain, night sweats, malaise, anorexia, N/V, diarrhea, chest pain, and cough. You are concerned of a liver problem and do a CT which reveals an abscess in the liver. How would you differentiate whether it is amebic or pyogenic abscess?
E. Histolytica serology- positive in amebic abscess, Technetrium-99 will stick to wall of pyogenic abscess and show increased leukocytosis. Ask about patients travel history- E. histolytica is endemic in tropical regions.
Tx for pyogenic abscess
Drainage (percutaneously), and antibiotics for more than 2 weeks. Culture the aspirate. Surgical drainage may be necessary if percutaneous drainage fails or ir abscess is complicated and related to malignancy, stones, or stricture
Diagnostic tests for amebic abscess
Technetrium-99 scanning negative, E. histolytica serology positive, elevated PT- most common lab abnormality., CT
Male, 30 years old, presents with fever, jaundice, RUQ pain, N/V, diarrhea, chest pain, night sweats, cough. Patient had previous travel to India, and is heavy drinker. Also has HIV. Elevated PT, technetium-99 scanning negative. Anchovy paste, liquiefactive necrosis, odorless.
amebic abscess- do E. histolytica serology to confirm.
How is amebic abscess transmitted
fecal oral route. E. histolytica parasite cyst ingested, releases trophozoites in small intestine. They invade the colon and travel to the liver via portal system.
Describe infection produced by amebic abscess
liquefactive necrosis producing a cavity
“anchovy paste” refers to
Blood and liquefied liver found in amebic abscess
What part of liver is resistant to the amebic abscess process?
Glisson’s capsule
You are suspicious of Amebic abscess in patient. Lab results and history are somewhat inconsistent. What to do?
Trial patient with antiamebic drugs like metronidazole. Should see improvement in 3 days. If no improvement, diagnostic aspiration- pyogenic abscess would show bacteria and leukocytes. Amebic abscess would show anchovy paste.
Tx in known amebic abscess
Antiamebic agent- metronidazole for 10 days and luminal agent (iodoquinol). If abscesses more than 5 cm or if in left lobe, therapeutic aspiration.
Hydatic cyst transmission. (Host, etc)
Host is dog. Dog passes Echinococcus eggs from tapeworm that are shed in the feces and ingested by human. In the duodenum, the embryo releases oncosphere containing hooklets that penetrates the duodenal mucosa and enters bloodstream- travels to liver via portal vein creating a hyatid cyst.
Three species of Echinococcus
E. granulosus (most common), E. multilocularis, E. oligartus
Why are hydatid cysts a scary thing to have?
Because ppl infected are asymptomatic until complication (rupture or secondary infection)!- Rupture can cause disseminated amebiasis (intestinal infection caused by E. histolytica) and anaphylaxis
Diagnosis of Hydatic cyst
US, CT/MRI for surgical planning
Tx of hydatic cyst
surgical. Pre-op corticosteroids helpful, epinephrine and steroids during surgery to prevent anaphylaxis. Cyst aspirated through closed suction, hypertonic saline used to flush the cyst. Cyst is unroofed, excision, marsupialization, leaving the cyst open, omentoplasty, liver resection. Alternative: percystectomy or chemo with mebendazole/albendazole
Percutaneous aspiration and injection of scolicidal agents in tx of hydatic cyst success rate
70%- not always advisable because of spillage
Adenomatosis
Having more than 10 lesions in liver cell adenoma
Liver cell adenoma
Benign proliferation of hepatocytes in liver
possible complications/risks of hepatic/liver cell adenomas
rupture causing bleeding into abdomen or malignant transformation
What population is hepatic adenoma most commonly associated with
Women 20’s to 40’s- association with hormonal contraceptive use with high estrogen content
Diagnosis and tx of hepatic adenomas
Diagnosis based on CT or resection. Tx- resection! Also, avoid hormonal contraceptives with increased estrogen content, avoid pregnancy
List benign tumors of liver (what is most common?)
Liver cell adenoma, focal nodular hyperplasia, and hemangioma (MOST COMMON)
What is AFP
Alpha fetoprotein, biomarker that is indicative in hepatocellular carcinoma or liver cell adenoma that has progressed to malignancy (excludes women that are pregnant)
Etiology of focal nodular hyperplasia
Vascular malformation, associated with estrogen
Young woman presents with RUQ pain that has been going on for a long time. Has also had significant weight loss. CT shows a central scar resembling “spoke-wheel pattern” in liver and a 4.5 cm. nodular mass in both right and left liver lobes. AFP is normal. Suspicious of…
Focal nodular hyperplasia
Diagnostic tests and labs of focal nodular hyperplasia
CT shows large central artery in CENTRAL FIBROUS SCAR radiating out into a “spoke-wheel” pattern in liver. Otherwise, core biopsy and resection. AFP normal- benign
Tx of focal nodular hyperplasia
Resection if symptoms persist or if mass enlarges
Describe mass found in liver in focal nodular hyperplasia
less than 5cm involving both the right and left lobes equally
Giant hemangioma would be a mass how big?
more than 5cm
Kasabach-Merritt syndrome
Liver hemangioma, thrombocytopenia, and consumptive coagulopathy (DIC)- using all platelets and clotting factors so higher risks of bleeding/bruising
Are hemangiomas usually asymptomatic? What does this mean in terms of tx?
Yes, this is why they are usually left alone and observed. Rupture is rare as well.
Diagnosis of hemangioma
CT, but in this case do NOT do percutaneous biopsy! (Unlike for other benign tumors, is usually performed)
when would you resect hemangioma?
Usually just observe. Resect when rupture, growth, symptoms, or Kasabach-Merritt syndrome
How is resection performed in hemangioma?
enucleation with inlet control
Most common malignant tumor in liver?
Metastatic liver neoplasm
Most common primary malignancy liver tumor?
Hepatocellular carcinoma
Hepatocellular carcinoma associated with…
HBV, alcohol abuse, smoking, cirrhosis, aflatoxin, nitrites, hydrocarbons, solvents
Inherited metabolic liver diseases associated with Hepatocellular carcinoma
Wilson’s disease, hemochromatosis, alpha 1 antitrypsin deficiency
55 year old male with RUQ pain, weight loss, and palpable mass. Smokes, heavy drinker, and has HBV. AFP level high. Diagnosis?
Hepatocellular carcinoma- Mass seen on CT and elevated AFP. Biopsy to stage and operate.
Most patients with HCC have 2 diseases
HCC and cirrhosis, and associated with HBV
Tx of hepatocellular carcinoma. Who is candidate?
Resection. Class A on Child Purg Score of 1-6. Others- ablation, embolization, liver transplant
Benefit of staging laparoscopy in HCC
spares 1/5 of patients laparotomy
If HCC patient not a candidate for resection or liver transplantation, what other specific options do they have?
Percutaneous ethanol or acetic acid injection for tumors less than 2cm- chemically destroys tumor. 2. Radiofrequency ablation using thermal ablatiion- cold or heat to destroy tumor. 3. Trans-arterial chemoembolization- embolization of hepatic artery branches. 4. External beam radiation not helpful. systemic chemo not helpful
Central scar on CT characteristic of…
focal nodular hyperplasia AND fibrolamellar HCC- making it hard to distinguish between the 2!
Patient presents with RUQ pain, weight loss, and palpable mass. CT shows mass. AFP levels normal, neurotensin levels elevated
Fibrolamellar HCC- variant of HCC! Better prognosis than HCC, and not associated with cirrhosis
What is the most common primary liver tumor of CHILDHOOD?
Hepatoblastoma- often occuring before age 3
Child, age 2 has asymptomatic liver mass with AFP elevation. also has familial polyposis syndrome. Dx and tx?
Hepatoblastoma, neoadjuvant chemo followed by resection
Liver tumor associated with familial polyposis syndrome
Hepatoblastoma
Patient with constant inflammation of bile ducts (cholangitis). AFP normal, CEA elevated. Which liver cancer do you suspect?
Intrahepatic cholangiocarcinoma
