Liver Flashcards
Entamoeba liver abscess
- male vs. female
- transmission route
- treatment?
- cansoni skin test?
- what confirms the diagnosis?
- right or left lobe?
- male vs. female.
- 7-10 times more common in men than women
- fecal-oral transmission
- treatment: flagyl
- cansoni: echonicoccal cyst
- serology confirms diagnosis
- right lobe preponderance
- Most common cause of liver abscess
- What % of pyogenic liver abscesses are due to biliary spread?
- What % of them have underlying malignancy?
- Biliary spread
- biliary disease: 35-40%.
- Underlying malignancy: ~40% of the biliary diseases
Hepatic adenoma.
- When to resect? Why?
- What’s the probability of malignant transformation?
- Which subtype of hepatic adenoma has the highest risk of malignant transformation?
- Any symptomatic or > 5cm (some say >3-4cm), or pregnant/planning to be pregnant. can rupture. or men (much higher rate of malignancy)
- 5% chance of malig transformation
- b-catenin mutated adenomas
tangent: neurotensin: fibrolamellar HCC. better prognosis
- How much change is made in cardiac output when you do a complete vascular occlusion?
- How much of the cardiac output does the liver get normally?
- What % of blood supply to the liver comes from the portal vein vs. hepatic artery?
- What % of oxygen supply come from them?
- What % of liver do you absolutely need to survive post-hepatectomy.
- 40-60% decrease in cardiac output
- Normally the liver gets ~20% of the cardiac output
- Blood flow: 75% comes from the portal vein. 25% from hepatic artery.
- O2 supply: 50/50
- Need 30%
- Liver resections Which segments are taken in right lobectomy?
- Which segments are taken in right trisegmentectomy (aka right extended hepatectomy)
- Left lobectomy?
- Left trisegmentectomy (aka left extended hepatectomy)
- Left lateral segmentectomy?
- Left medial segmentectomy?
- right lobectomy: 5, 6, 7, 8
- right trisegmentectomy: 5, 6, 7, 8 + 4
- Left lobectomy: 2, 3, 4
- Left trisegmentectomy: 2, 3, 4 + 5, 8
- Left lateral segmentectomy: 2, 3
- Left medial segmentectomy: 4
- Pringle How much clamp on time vs off?
- How much total clamp off time can someone have?
15 min on 5 min off Total 120min ischemia time.
- What is the most common cause of Budd chiari syndrome?
- Thrombolytic Rx can be used within what timeframe?
- Myeloproliferative disorder
- Within 3-4 weeks of onset
HCC
- Resection margin?
- T/F: main portal vein involvement is not a contraindication for resection
- what is the Milan criteria?
- role of adjuvant therapy?
- Margin: 2cm
- generally when portal vein is involved resection IS contraindicated
- Milan criteria: 1 tumor <5cm or 3 tumors each <3cm
- no good adj option
Pyogenic liver abscess
- most common cause
- which organism affects mortality?
- most common cause: biliary
- which organism affects mortality: k. Pneumoniae
Liver CT. Peripheral enhancement
Hemangioma
Hepatic vein pressure gradient. What’s normal? What’s portal hypertension?
HVPG is the difference between WHVP (wedge hepatic venous pressure) and FHVP (free hepatic venous pressure) Normal HVPG: 5 or less. Abnormal: 6 or greater
Liver CT Sulfur colloid uptake
Focal nodular hyperplasia. Sulfur colloid uptake is by kupffer cells. Adenomas don’t have kupffer cells Focal nodular hyperplasia has kupffer cells.
Liver CT Heterogenous mass with early enhancement on the arterial phase
Adenoma
Liver CT Central stellate scar
Focal nodular hyperplsia
What is the most important scan for evaluating colorectal Mets to liver? PET? arterial phase CT? venous phase CT?
Venous phase CT
What is a triple phase CT?
arterial phase Venous phase Delayed phase
- MCC of liver failure in Asia.
- # 1, #2 causes of liver failure in the western world?
Asia- hep B Western: #1: EtOH #2: Hep C
- Mortality of variceal bleed?
- Which hemorrhoidal veins get dilated?
- Maintenance medication for variceal bleed?
- 20% mortality
- Middle and inferior hemorrhoidal veins.
- Propranolol (need a non selective b-blocker. b1 blockade decreases cardiac output. b2 blockade decreases splanchnic blood flow)
What is the most common organism in spontaneous bacterial peritonitis?
- e. Coli NOT klebsiella
- Cystadenoma of the liver. Common in what population?
- Treatment?
Women in 4th and 5th decade Enucleation is curative
Treatment for echinococcal cyst vs. entoemeba? which one may need surgery?
Echino: albendazole. May need surgery Entoemeba: metronidazole. No surgery
Liver MRI. bright on T2 with peripheral enhancement
Hemangioma
Liver lesion. Hyperintense on CT/MRI
Hepatic adenoma. Resect if >5cm or symptomatic with any size
Liver abscess. If you see this type of bacteria you should be concerned about colon cancer
E. Faecalis
What % of all pts with colorectal cancer will have Mets at diagnosis?
1/3
30% will have colonic obstruction at diagnosis
What % of all pts with colorectal cancer will develop metastases?
60% will eventually develop mets
Overall 5 year survival for colorectal cancer in all comers
~50%
Liver imaging. Enhance in arterial phase and wash out in portal venous phase
HCC
What is the Milan criteria
Can do liver transplant if:
- 1 lesion <5cm
- 3 lesions <3cm
- Any child’s class
- no invasion, no mets
What are the available chemo agents for cholangiocarcinoma? Can they do neoadj?
5FU or gemcitabine Yes. Can do neoadj
Available therapy for people with HCC who don’t meet the Milan criteria?
Sorafenib
Survival rate for people with HCC who meet Milan criteria and undergoes liver txp?
50-80% 5 yr survival. Best of any cancers
Post CCY gallbladder cancer. Goes into muscularis. Treatment
Segment 5/6 resection Portal lymph node dissection
Gallbladder cancer. Limited to lamina propria. Treatment?
Simple cholecystectomy is enough
- How much normal liver is required to live after liver resection?
- How much liver is required if you have a fatty liver?
- How much in a cirrhotic?
- 20-30% normal liver
- 30-40% with steatohepatitis
- 40-50% if cirrhosis
Purpose of portal vein embolization?
Allow remaining liver to hypertrophy. If you have a tumor in the right lobe and your left liver is dinky, you can embolize the right portal vein preoperatively and within 2 weeks you get compensatory hypertrophy of the left lobe
For pt with HCC if you see high bilirubin without obstruction, what does that mean?
You’ve already lost 50-75% of the hepatic function. Because liver has so much reserve. If your bili is high because your liver can’t function, you’re kind of hosed
Mortality rates for child A, B, C
A: 10% mortality B: 30% mortality C: 80% mortality For liver based surgery
5yr survival for liver resection for CRC met
35-40%
Pre-op factors that rduce overall survival for CRC liver met.
- # of liver lesions?
- size of the lesion?
- CEA level?
- disease free interval?
- Dukes criteria?
- of liver lesions > 4
- size of the lesion > 5cm
- CEA level > 200
- disease free interval < 12 months
- survival is better for Dukes B > dukes C > dukes D
Duke
- Stage A: Limited to muscularis propria; nodes not involved
- Stage B: Extending beyond muscularis propria; nodes not involved
- Stage C: Nodes involved but highest (apical) node spared
- Stage D: Distant metastatic spread
Presinusoidal vs sinusoidal vs postsinusoidal
- schistosomiasis
- restrictive epricarditis
- alcoholic cirrhosis
- primary biliary cirrhosis
- budd-chiari
- hep c cirrhosis
- schistosomiasis: presinusoidal
- restrictive epricarditis: postsinusoidal
- alcoholic cirrhosis: sinusoidal
- primary biliary cirrhosis: presinusoidal
- budd-chiari: postsinusoidal
- hep c cirrhosis: sinusoidal
Portal vein thrombosis in children. Treatment?
Don’t need intervention. They will resolve
- What are the three different types of shunts?
- Where do Warren shunt, Eck fistula, and TIPS fall under?
1) non-selective - Eck fistula - TIPS 2) selective - Warren (distal splenorenal) 3) partial
Describe the blood flow after Warren shunt? You connect what to what?
You connect the splenic vein to left renal Blood backs up from portal -> through short gastric vein -> splenic vein -> left renal vein -> into the IVC Does not relieve ascites Less encephalopathy
What 5 things go into childs classification?
Bilirubin Albumin INR ascites Encephalopathy
Which things are shared between MELD and Childs?
Bilirubin INR
Elevated neurotensin level. What liver tumor? Better or worse prognosis than regular HCC?
Fibrolamellar HCC Better prognosis than regular HCC
what are the three most common organisms in spontaneous bacterial peritonitis?
- E. coli - vast majority. Over 50%
- Klebsiella pneumonia
- pneumococci
a 13F had trauma and grade IV liver injury. now p/w biloma on ultrasound. next step?
- HIDA to evaluate the extent of the leak
- ERCP for stenting
for effective percutaneous drainage, liver abscess needs to be at least what size?
at least 1cm
this single agent is usually enough for treatment of pyogenic liver abscess
carbapenem
other agents: cephalosporin + metronidazole
or zosyn
T/F: pyogenic liver abscesses mostly spread from the portal vein
F. it spreads usually from biliary
Which treatment for variceal hemorrhage is associated with the lowest incidence of encephalopathy?
- TIPS
- Warren shunt
- Portocaval shunt
- Mesocaval shunt
- Eck fistula
warren shunt has the lowest incidence of encephalopathy
describe the T staging for gallbladder cancer
when you do a CCY and it shows cancer, when is it okay to just watch vs. go back
T1a: The tumor has invaded the lamina propria.
T1b: The tumor has invaded the muscle layer.
T2: The tumor has invaded the perimuscular connective tissue (the layer between the muscle layer and the serosa) but has not extended beyond the serosa (the outer layer) or into the liver.
T3: The tumor extends beyond the gallbladder and/or has invaded the liver and/or 1 other adjacent organ or structure, such as the stomach, duodenum (part of the small bowel), colon, or pancreas.
T4: The tumor has invaded the main portal vein or hepatic artery or has invaded more than 1 organ or structure beyond the liver.
You have to go back and re-resect starting T1b
what is sorafenib used for?
advanced HCC with normal LFT’s
it prolongs survival
also for stage III desmoid tumors. (methotrextate + sorafenib)
stage I desmoid: sulindac
II: sulindac + raloxifene
III: methotrexate + sorafenib
IV: doxorubicin
what is the yearly risk of bleeding for esophageal varices?
each bleed has a mortality of what %?
15-20%
each bleed has a 20% mortality
what is the initial success rate of blakemore tube?
what is the rebleed rate after successful blakemore?
90%
50%
- what is the mortality of acute liver failure?
- what is the definition/criteria?
- most common cause in the US vs worlwide
- 60-80%
- < half a year (26wk), INR > 1.5, mental status, no h/o cirrhosis
- US: tylenol toxicity, worldwide: hep B
what is the relationship of right hepatic artery and common hepatic duct?
right hepatic artery runs posterior to common hepatic duct
early washout during the delayed or late phase of multi-phase CT scan
which liver lesion is this
hepatic adenoma or HCC
hemangiomas have delayed washout
adenomas and hemangiomas behave in opposite ways in terms of contrast washout and MRI intensity. HCC/adenoma: hyperintense on T1 and hypointense on T2
hemangiomas: hypointense on T1 and hyperintense on T2
- T/F: SBP has multiple orgnaisms
- what is the mortality rate for SBP?
- what is the treatment of choice for SBP?
- false. SBP usually from a single gram negative enteric organism
- Mortality rate 20-40%
- treatment: 3rd generation cephalo or fluoroquinolone
- usually patients are listed for liver transplant when MELD reaches what?
- what are the MELD exceptions?
- MELD > 15 then listed for liver txp
- MELD exceptions are non-lab value conditions that increase the MELD score, such as HCC, hepatorenal syndrome, cystic fibrosis, etc
what is the most common location of benign bile duct tumors?
- right hepatic duct
- left hepatic duct
- proximal common bile duct
- distal common bile duct
- periampullary region
periampullary region
pt presents with massive ascites and a liver abscess. next step?
surgical drainage. perc drainage is contraindicated in the presence of the ascites it can infect the ascites
SBP prophylaxis is indicated in a ascitic cirrhotic when? (2)
- GI bleed
- low protein count in ascitic fluid (<10-15 g/L)
- what is the appropriate surveillance after resection of GB cancer?
- most common site of recurrence?
- most common signs of recurrence?
- imaging every 6 months for the first 2 years then annually for 5 years
- most commonly carcinomatosis, intrahepatic, retroperitoneal
- if they recur, jaundice and ascites are common
Bismuth classification IV. treatment?
- neoadjuvant chemo
- liver transplant
Bismuth I: CBD lesion, not involving the bifurcation
Bismuth II: up to/involving bifurcation
Bismuth IIIa: right hepatic duct
Bismuth IIIb: left hepatic duct
Bismuth IV: intrahepatic ducts
cystic liver lesion with irregular walls and internal septations forming loculi. CT scan demonstrates the 10-cm cystic lesion in sections III and IVa with evidence of irregular papillary growths, thickened cyst walls, internal septations, and no calcification
diagnosis and treatment?
biliary cystadenoma. premalignant lesion. can progress to biliary cystadenocarcinoma.
Type I: limited large cysts. drainage/unroofing
Type II: diffuse moderate sized cysts with intervening normal parenchyma. needs surgical enucleation.
Type III: diffuse small cysts, no normal tissue. needs liver txp
- woman from india has a large liver cyst. what test will confirm the diagnosis?
- treatment based on size?
- indirect hemagglutination testing. same thing as serology
- size < 10cm: metronidazole. size > 10cm: perc drain
you’re suspecting somebody has a choledochal cyst. MRCP or ERCP first to “clarify the biliary anatomy”? why?
use MRCP. ERCP often not helpful because filling of the dilated biliary tree is difficult to achieve to define the biliary anatomy.
What is the rome III criteria?
for biliary dyskinesia. does not include GB EF although 35-40% is used at most institutions.
Rome III criteria involves
- pain duration > 30min
- recurrent symptoms at different intervals
- pain is severe enough to interrupt daily activities
- not relived by antacids, BM
sesap
For GB cancer,
- T/F: Less than 1% of port-site metastases occur at a non-extraction port
- T/F: If the GB is removed intact without spillage, port-site recurrence is rare
- T/F: prophyactic port-site excision is associated with decreased post-site metastasis
- what is the port site met rate for CRS cancer?
- False. up to 50% of port site mets are at non-extraction sites
- even without spillage, the port-site rate is high
- still no good evidence to suggest port-site excision decreases port-site mets
- CRS port site met rate <1%
sesap
for liver cancer, which one is still considered to have curative intent: transarterial chemoembolization or percutaneous tumor ablation?
tumo ablation is thought to be curative. transarterial chemoembolization is palliative
ruptured hepatocellular carcinoma:
- false. urgent resection does not improve overall survival
- tumor rupture doesnt worsen the long term survival
liver mass biopsied to be adenocarcinoma? what should you suspect? next step?
consider intrahepatic cholangiocarcinoma. BUT MORE COMMON is metastatic from elsewhere. 4D CT can be used to furger characterize the mass. def needs further met workup
