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
What is the Okuda staging system for heptocellular carcinoma? Pros and cons?
Simple, older, effective system that takes liver function and tumor-related factors into account
A single point for each:
- tumor involving > 50% of liver
- ascites
- albumin < 3g/dL
- bilirubin > 3mg/dL
Stage 1 = 0 pts
Stage 2 = 1-2 pts
Stage 3 = 3-4 pts
Pro: reliably distinguish patients with prohibitively poor prognosis from those with potential for long term survival
What is the Cancer of the Liver Italian Program (CLIP) staging system for heptocellular carcinoma? Pros and cons?
Includes: Child-Pugh class, Tumor morphology, AFP level, and presence of portal vein thrombosis.
Pro: Most validated system
Con: Applies mainly to HBV-related HCC in China
What are the three types of hepatocellular carcinoma (applies to only >5cm in size)?
- Hanging (connected to liver by small vascular stalk; easily resectable; can grow large w/o affecting normal tissue)
- Pushing (well demarcated, fibrous capsule; displaces vascular structures rather than invades them; usually resectable)
- Infiltrative (invades vascular structures; often has +histologic margins)
What is the most common cause for pyogenic liver abscess? Most common bacteria?
Biliary obstruction and transplant related causes!!
(Traditionally thought of to be appendicitis and diverticulitis)
MC bacteria: Gram-negative aerobes and anerobes
What is the treatment of a pyogenic abscess that is:
1) single and < 5cm in diameter
2) single > 5cm in diameter
3) multiple small abscesses
1) aspiration
2) percutaneous catheter
3) long term IV antibiotics (4 to 6 weeks)
What does a liver abscess look like on Ultrasound? When is ultrasound the initial imaging modality of choice for a liver lesion?
Hypoechoic, +/- gas, +/- lack of central flow (== necrosis)
Ultrasound is initial imaging modality of choice for echinococcal cysts
What are the differences on CT for a bacterial/fungal vs. amebic abscess vs. echinococcal cyst?
CT IS GOLD STANDARD.
Bacterial/fungal abscess = multiple lesions
Amoebic abscess = single subdiaphragmatic lesion
Can see irregular borders /septations
EChinococcal cyst = multiple-fluid-filled septate cysts with daugther cells
What does a liver abscess look like on MRI?
T1 weighted: low central intensity
T2 weighted: hyper-intense with surrounding edema
For pyogenic liver abscess, what organisms do you want to cover? What are some antibiotics regimens you could use?
G- bacilli, G+ cocci and anaerobes
Common Abx regimens: 1) rocephin+flagyl, 2) piperacillin/tazobactam, 3) levofloxacin/ciprofloxacin + flagyl, 4) ertapenem or meropenem
Amebic liver abscess - MC organism? How does it get to the liver? Treatment?
Entamoeba histolytica
- Ingested orally –> causes tissue distruction/mucosal ulcerations + submucosal abscesses –> portal system –> liver
- Tx: Initial = Flagyl (TID x 10 days) or tinidazole (qday x 5 days). Subsequent tx = paromomycin or iodoquinol therapy (/kg, qday, x 7-20 days); If cannot use flagyl and no other drugs available (b/c pregnant) –> therapeutic aspiration
Eichinococcal liver cyst. Organism? Treatment options?
Echinococcus granulosus
Tx:
1) single cyst < 5cm = albendazole or mebendazole alone
2) Larger/persistent cysts –> Sx if anatomically emenable [must avoid spillage = anaphylaxis + seeding]
3) large/complex multicystic lesions w/o daughter cells = PAIR [puncture-aspiration-injection-reaspiration] w/ albendazole/mebendazole 4 hours before PAIR and x28 days after surgery
Mortality rate for pyogenic hepatic abscesses?
2 to 12 %
What are indications for surgical drainage of a pyogenic abscess? What would be your approach of choice [laparoscopic or open]?
- intraperitoneal rupture of abscess
- septic shock w/ liver abscess as source
- failed multiple percutaneous drainages
Laparoscopic»_space; open unless question regarding adequacy of complete drainage
When is percutanous drainage contraindicated for a pyogenic liver abscess?
- +ascites
- +abscess in close proximity to diaphragm or other critical strucutres
- viscous, purulent fluid or thickened loculations (consider surgery)
What is the retrospective locations of the contents of the portal triad?
1) hepatic artery proper = medial anterior
2) common hepatic duct = lateral anterior
3) Portal vein = posterior
If you were to perform a laparoscopic drainage of a liver abscess, where would you put your ports?
1) 12mm port: supra-umbilical [camera]
2) two 5mm ports: R lateral and LUQ
Goal = triangulate the liver
