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MBBS Surgery > Liver > Flashcards

Liver Flashcards

1
Q

Division of the liver

A

Anatomy: by falciform ligament to L&R lobe
Functional: line between IVC and GB (cantlie line), line in which middle hepatic vein runs

8functional seg: couinaud segments

  • transverse plane: level of main branches of portal vein
  • sagittal plane: right, middle and left hepatic veins

segment 1= caudate lobe

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2
Q

post liver resection monitoring?

A 
freq blood sugars 
phosphorous lvl (help liver regen)
LFTs
INR prolongation may occur
Dosage of analgesia (dec hepatic clearance)
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3
Q

Causes of portal hypertension

A

Pre hepatic

  • portal vein thrombosis
  • biliary atresia
  • massive splenomeg (rise in splenic vein blood flow)

Hepatic
- cirrhosis, massive fatty change, hemochrombtosis, Wilson, schistosomiasis, Caroli dz, congenital hepatic fibrosis

Post hepatic
- budd chiari, IVC thrombosis, constrictive pericarditis, severe right side RF, congenital IVC malformation

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4
Q

Types of liver nodule

A 
NEOPLASM
Benign
- hemangioma
- focal nodular hyperplasia
- hepatic adenoma
- bile duct harmatomas
- cysts
Malignant
- Pri: HCC, cholangioCA
- Sec

ABSCESS: pyogenic or amoebic

CYST

  • no-para: simple liver cyst, polycystic, neoplastic
  • ecchinococcal cyst (hydatid)
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5
Q

Most common benign liver tumour

  • a/w
  • complications
  • ix and their findings
  • tx
A

Liver haemangioma
- outgrowth of endothelium

a/w: steroids, preg, OCP

cx: pain from liver capsule stretch, mass effect, HF due to large arteriovenous shunt, Kasabach Merritt syndrome - consumptive coagulopathy of plt and clotting factors, life threatening bleed by biopsy

Us: well defined, lobulated, homogenous hypo echoic mass, compressible
Triphasic CT - brightest and uniformly enhanced in delayed phase
MRI: bright on T2 images

TX: watch, resect, RT/ embolise

DO NOT BIOPSY

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6
Q

Hepatic adenoma

  • associations
  • complications
  • ix and findings
  • tx
A

a/w OCP (estrogen, progesterone), pregnancy, steroids

rupture, intra peritoneal hemorrhage
malignant change

triphasic CT: early enhancement from peripheries with centripetal progression

sx resection when

  • symptomatic
  • > 4-5cm
  • cannot rule out CA
  • male gender
  • prior to pregnancy (higher risk of rupture)
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7
Q

Liver abscess

  • what to watch for if c/s grows klebsiella
  • mgx
A

all liver abscess, rule out amoebic - entamoeba histolytic

watch for ocular symptoms - klebsiella endopthalmitis

<3cm: ABx via PICC (4-6w)
>3cm: drainage (open, lap, percutaneous IR)

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8
Q

Complications of portal htn

A 
ascites > SBP
splenomegaly
hepatic encephalopathy
portosystemic shunting
portal hypertensive gastropathy (gastric mucosa friability and dilated blood vessels)
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9
Q

sites of portosystemic connections

A
  1. oesophageal
    - P: oesophageal branch of left gastric vein
    - S: eso branch of azygos vein
  2. rectal
    - P: superior rectal vein
    - S: mid/ inf rectal vein
  3. Paraum
    - P: paraumbilical vein
    - S: superficial epigastric veins
  4. retroperitoneal
    - P: R, middle, L colic veins
    - S: renal veins, suprarenal vein, paravert veins
  5. intrahepatic:
    - P: L branch of portal vein
    - S: IVC
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10
Q

approach to ascites

A 
malignant - peritoneal mets
benign
- cardio
- renal
- liver
- GI
- inflam: pancreatitis, serositis
- infection: TB
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11
Q

Interpretation of paracentesis (SAAG)

A 
send for SAAG
>1.1: portal hypertension causes
<1.1: 
- peritoneal carcinomatosis
- infx: tb, serositis
- infm: pancreatitis, panc ascites
- trauma: chylous
- renal: nephrotic
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12
Q

what to send for in peritoneal tap

A

cytology - cell count and differential
microB: gram stain, culture (aerobic, anerobic), TB culture
biochemistry: albumin, protein conc, LDH, TG, glucose

serum albumin, LDH, NT-proBNP

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13
Q

diagnosis of SBP

A

+ve ascite fluid bac c/s

ascitic fluid PMN >250cell/mm3 (or WBC>500cell/mm3)

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14
Q

how to mgx ascites

A

conservative

  • low salt diet
  • fluid restrict
  • monitor weight and urine sodium

pharmaco

  • diuresis: spironolactone 100mg
  • add 40mg furosemide if also have pedal deem
  • antibiotics (if SBP): ceftriaxone IV or PO ciprofloxacin

therapeutic paracentesis

  • cooploop (pigtail catheter via seldinger technique > drain)
  • IV albumin 20% infusion
  • site: 2FB above and lat to ASIS, us guided
  • 8mg IV alb for every 1L ascites fluid drained (prevents paracentesis induced circulatory dysfunction - hypoTN, recurrent ascites, HRS)

sx: liver transplant
shunt - TIPSS (transjugular intrahepatic portosys shunt)

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15
Q

triggers of hepatic encephalopathy

A 
GI bleed
infx - SBP, UTI (blood/urine cs)
hypoK, metabolic alkalosis (UECR)
Renal failure
Hypovolemia
Hypoxia
Sedatives/ tranquilisers
hypoglycemia (h/c)
constipation (DRE, axr)
HCC (AFP)
vascular occlusion (hepatic vein or portal vein thrombosis)
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16
Q

Meds to give in variceal bleed

A

IV broad spec abx 7 days - ciprofloxacin 500mg bd or ceftriaxone 1g/day

IV somatostatin 250ug bolus followed by 250ug/h infusion for 3-5days

IV esomeprazole bolus 80mg IV then 40mg IV BD

IV vit K 10mg

17
Q

options to manage variceal UGBIT

A

endoscopy - variceal band ligation, sclerotherapy

TIPSS - acute decompression

Emergency shunt sx

  • risk of encephalopathy, higher mortality
  • selective vs non selective

Sugiura procedure

18
Q

Cx of splenectomy

A
  1. GA
  2. intra op: bleeding, injury to surrounding organs
  3. early: wound - infection, seroma, hematoma, pulmonary cx - atelectasis, pneumonia, pleura effusion, subphrenic abscess, acute portal vein thrombosis, thrombocytosis, ileus
  4. late - post splenectomy infections by encapsulated bac (strep pneumonia, H flu, N meningitides)
19
Q

variceal bleed prophylaxis
primary
secondary

A

Pri: non selective beta blockers

sec: 
band ligation (3wkly until gone)
non selective beta blockers - propranolol, nadolol)

block beta 1: dec cardiac output
block beta 2: cause splanchnic vasoconstriction, reduce portal flow and pressure

if CI for BB, use long acting nitrates (isosorbide mononitrate)

20
Q

How do you assess risk of hemorrhage in pt with varices

A 
site: GEJ
size - grading
I: small straight varices not disappearing with insufflation
II: large tortuous but <1/3
III: >1/3 lumen
child c
red signs - endoscopic stigmata of recent hemorrhage
- red wale marks
- cherry red spots
- hematocystic spots
- diffuse erythema
previous hemorrhage
21
Q

who needs primary variceal prophylaxis

A
  • large (grade 3) varices OR

- grade 2 + endoscopic red signs/ child c cirrhosis

22
Q

Causes of hepatomegaly

A 
MASSIVE (CRAM)
- Ca: HCC, mets
- RHF, TR
- alc liver dz w fatty infiltration
- myeloprolfierative dz
MODERATE (HHH)
- above +
- haematological (CML, lymphoma)
- hemochromatosis/ amyloidosis
- heavy (fat)
MILD (ABC)
- above +
- Abscess - infx (viral , bac , parasitic , amoebic abscess
- biliary obstruction
- cirrhosis
23
Q

Causes of splenomegaly

A 
MASSIVE (MIC)
- myelofibrosis
- infections
- CML
MODERATE (PALS)
above +
- portal htn
- anemia hemolytic (thal, HS)
- lymphoproliferative (lymphoma, CLL)
- storage (gaucher)
MILD (AIIM)
above +
- autoimmune: SLE, RA, PAN
- infection: viral hep, IMS, endocarditis
- infiltration: sarcoid, amyloid
- myeloproliferative
24
Q 
Sources of AST
ALT
- causes of mild elevation
- mod elevation
- marked elevation (>1000)
A

AST: liver, cardiac, skeletal muscle, kidney, brain, pancreas, lung, RBC

ALT

  • mild: NAFLD, chronic viral infx, med induced injury
  • mod: acute viral hep
  • marked: ischemic hep, toxic ingestion (paracetamol), fulminant hepatitis (massive necrosis of liver parenchyma)
25
Q

Sources of ALP

- how to differentiate

A

liver (bile duct epithelium), bone, kidney, placenta, malignant tumours (bronchial ca)
- heat inactivation: labile (bone) vs stable (liver)

26
Q

What is the best test of hepatic synthetic function

A

Acute: clotting factors (except factor VIII)

NOT albumin - half life of 15-20days

27
Q

Focal nodular hyperplasia

  • RF
  • diagnosis
  • tx
A

RF: young adults, females, Assoc with AVM, hepatic haemangioma, HHT (Osler weber Rendu)

Diagnosis

  • CT: bright arterial contrast enhancement with hypoattenuating centratl scar, isoattenuating on portal venous phase, delayed phase show hyperatten of central scar
  • MRI: central scar is hyper intense on T2

Tx

  • conservative
  • watch for tumour growth during pregnancy and post part period

MBBS Surgery (18 decks)

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