Liver Flashcards
Budd Chiari Syndrome - what is it? Most common causes (list 3)?
Obstruction of the hepatic veins
Most common causes
- Myeloproliferative disorder [MC]
- Polycythemia vera [MC]
- OCP use
- Collagen vascular disease
- Coagulation cascade disorder (Protein C or S deficiency)
- Tumors
Budd Chiari Syndrome - Describe the typical patient population
In non-Asian countries: women in the third or fourth decade of life (30 to 50 y/o)
Asian Countries: slightly more common in men, with a median age of 45 y/o
Budd Chiari Syndrome secondary to a focal venous obstruction (web). Treatment?
Thrombolysis and angioplasty
Budd Chiari Syndrome secondary to reversible liver damage with a patent IVC. Treatment?
Portosystemic shunt > TIPS
[Clinical symptoms can be relieved in 85% of patients over 4 years. Concern about longterm results of TIPS]
Budd Chiari Syndrome secondary to reversible liver damage with a obstructed IVC. Treatment?
mesoatrial shunt
Budd Chiari Syndrome with irreversible liver damage. Treatment? [Bonus: what is the long-term survival rate if they receive this treatment?]
Liver transplant
Long-term Survival rate of 65-85%
What are some risk factors for hepatocellular carcinoma [name 5]?
- Hepatitis B (50-55%) or C (25-30%) infection
- Cirrhosis
- Alcohol abuse
- Tobacco use [poor association]
- Nonalcoholic fatty liver disease in obese patients/NASH
- Stage 4 Biliary cirrhosis
- Aflatoxin [from Aspergillus spp]
- Hemochromatosis/Alpha-1-antitrypsin deficiency/Wilson disease
- OCP or steroid use [weak evidence]
Hepatocellular carcinoma - describe your typical patient presentation
50-60 y/o MALE (2-8x M>F, increases with age) that is an alcoholic with RUQ abd pain, weight loss, and palpable mass
Patient with HepC, IVDU, cirrhosis with screening ultrasound showing three nonspecific nodules 4 to 8mm in one lobe of the liver concerning for hepatocellular carcinoma. What do you do next?
- Obtain serum alpha-fetoprotein (AFP) level
2. Repeat liver ultrasound and AFP in 3 to 6 months to monitor for change
Bonus Point: What are the proposed mechanisms for the increase of hepatocellular carcinoma seen with Hepatitis B?
- Insertional mutagenesis into hepatocytes (HepB genome is found in the HCC genome)
- cirrhosis and chronic inflammation (even though cirrhosis is not a pre-requisite for the development of HBV-related HCC)
Hepatocellular carcinoma. How do you diagnosis HCC?
- Imaging modality
- Lab tests?
Imaging:
- Ultrasound (for screening)
- Contrast-enhanced triple-phase CT and MRI scan (for diagnosis)
Labswork:
- AFP (low sensitivity and specificity)
Can you diagnose hepatocellular carcinoma on Imaging only? If so, what does it look like? Do you need a pre-excisional biopsy?
Yes.
Looks like an arterial enhancing mass with washout of contrast material in delayed phases
No. You do not need a biopsy, can cause tumor spillage, rupture or bleeding.
For high risk hepatocellular carcinoma patient, what is the next step if you discover a <1 cm lesion on ultrasound? 1 to 2cm lesion? >2cm lesion?
< 1cm lesion: AFP with repeat screening ultrasound and AFP in 3 to 6 months
1-2 cm lesion: contrast enhanced CT and MRI (5362% sensitivity, 100% specificity, PPV 95-100%, NPV 80-84%)
> 2cm lesion: single study may suffice (CT or MRI)
Where does hepatocellular carcinoma metastasis to? What tests do we do to evaluate for metastasis ?
- lung (CT Chest - must have),
- bone (bone scan - not performed unless +symptom/signs)
- peritoneum (CT Abdomen/pelvis w/ contrast imaging - usually seen with HCC)
How do you directly assess for portal hypertension? What are some clinical signs?
Evaluate Hepatic vein wedge pressure
Signs: splenomegaly, cirrhotic appearing liver, intrabdominal varices, thrombocytopenia
