Liver

Question 1

With regard to heaptic anatomy, the falciform ligament divides the ____________ from the __________

Answer 1

Left medial section, right lobe

• The plane between the gallbladder fossa and the IVC (referred to us Cantlie’s line ) divides he right and left lobes
• The falciform ligament along with the round, triangular and coronary ligaments may be divided in abloodless plane during liver resection

Question 2

The most common variant of normal heaptic artery anatomy is

Answer 2

• Replaced right heaptic artery (10-15 %) from the SMA
• Replaced left heaptic artery from the left gastric (3-10%)
• Replaced right and left heaptic arteries (1-2%)
• Completely replaced common hepatic artery from the SMA (1-2%)

Standard arterial anatomy:

• Common hepatic artery arise form the celiac trunk
• divides into gastroduodenal and proper hepatic artery
• Proper heaptic artery gives rise to right gastric artery (variable)
• The proper hepatic artery then divides into the right and left heaptic artery

Question 3

Systemic venous drainaige of the liver

Answer 3

• There are 3 heaptic veins
  
  • Right
  • Middle
  • Left
• RIGHT : segments V to VIII
• MIDDLE : IV, V, VIII
• LEFT: II, III
• IVC : Caudate (I)

Question 4

With respect to the enterohepatic circualtion of bile, where are the majority of bile salts reabsorbed?

Answer 4

Terminal ileum

Question 5

Which of the following compounds is not synthesized predominantly by the liver

Answer 5

Factor VIII

• ALbumin : 10 g
  
  • Long half life (15-20 days)

Question 6

The gold standard for identifying liver lesions by imaging is

Answer 6

Intraoperative ultrasound

• it can identidy 20-30% more lesions than other preoperatove imaging modalities
• applications
  
  • tumor staging
  • visualization of intehepatic vascular structures
  • guidance of resections plane by assessment of the relationship of a mass to the vessels,
  • biopsy of lesions and ablation of tumors

Question 7

The most common cause of acute lever failure in the US

Answer 7

Drug/toxin

• Acute liver failure is defined as development of hepatic encephalopathy within 26 weeks of severe liver injury in a patient with no history of liver disease or portal hypertension
• in developing countries:
  
  • viral infections

Question 8

A patient with painless jaundice and is found to have cirrhosis. they have no history of alvohil abuse but do note a history of diabetes mellitus and oseudogout, They also mention that multiple members in the family have suffered from cirrhosis, What is the most likely etiology for their cirrhosis?

Answer 8

Hemochromatosis

• most common metabolic cause of cirrhosis and should be suspected if apatient presents with skin hyperpigmentation diabetes mellitusm pseudogout, cardiomyopathy, or a family history of cirrhosis
• Chonic hepatitis C - most common cause of chronic liver disease in the US

Question 9

Physiologic changes noted in patients with cirrhosis

Answer 9

• Elevated resting energy expenditure
• Reduced muscle and fat stores
• Icnreased cardiac output and heart rate
• Decreased vascular resitance
• Hypoalbuminemia
• Spider angiomata
• feminization of males
• portal hypertension
• caput medusae

Question 10

Clinically significant portal hypertension is evident when

Answer 10

hepatic venous pressure gradient exceeds 10 mmHg

• HVPH = WHVP-FHVP
• Portal Hypertension
  
  • Presinusoidal
    
    • Sinistral/extrahepatic (splenic vein thrombosis, splenomegaly)
    • Intraheaptic (Schsitosomiasos, congenital heaptic fibrosis, idopathic portal fibrosis)
  • Sinusoidal
  • Postsinusoidal
    
    • intraheaptic (Vascular occlusive disease)
    • post heaptic (Budd chiari, CHF, IVC webs)

Question 11

Management of an acute variceal hemorrhage

Answer 11

• Endoscopy with variceal band ligation
• Short term antibiotic prophylaxis (ceftriaxone)
• Vasopressin
• somatostanin analouges
• Administration of blood producrs and crystalloid (target Hgb 8)
• Nonselective B blockers (prevention)

Question 12

Likelihood of a recurrent variceal bleed within 2 years when no other therapies was done

Answer 12

70%

Question 13

grading scales for liver disease

Answer 13

• Model for end stage liver disease (MELD)
  
  • predict mortality after TIPS
  • Creatinine, bilirubin, INR, Dialysis, sodium
• Child Turcotte Pugh (CTP)
  
  • predicting risk of portocaval shunt procedures
  • bilirubin, albumin, INR, presence of encephalopathy, presence of ascites
• Orthoptic liver transplantation

Question 14

CTP class and overallrisk of mortality

Answer 14

• A 10%
• B 30%
• C 75-80%

Question 15

The most common complication following a TIPS

Answer 15

Encephalopathy

• TIPS is a percutaneous procedure used for treatment of patients who have gastroesophageal varices in the setting of portal hypertension
  
  • Creates an uintraheaptic shunt between th portal and systemic circulation
  • endovascular access through the jugular vein to a hepatic vein radical and subsequent creation of needle tract that connects it to a branch of the portal vein
  • Stent is placed

Question 16

Initial management of pyogenic liver

Answer 16

• Broad specturm IV anntibiotics
• Surgical drainage and or resection
• Percutaneous fine needle aspiration and culturee

Pyogenic liver abscess are most commonly seen on the right lobe of the liver with E. Coli the most common pathogen

(40% are polymicrobial while 20% are culture negative)

Question 17

The msot common cause of benign hepatic lesion is the

Answer 17

Simple cyst

• More common in female
• Percutaneous cyst aspiration or sclerotherapy for large cysts that may cause mass effect
• hemangiomas are the most common SOLID BENIGN MASSES

Question 18

Liver lesion that carry a significant risk of spontaenous rupture

Answer 18

Adenoma

• Hemangiomas are congenital vascular lesions
  
  • 1 to 25cm
  • women
  • generally asymptomatic
  • rupture is rare

Question 19

A patient presents with a CT result that describes a well circumscribed lesion that demonstrates homogenous enhancement during arterial phase, isodensity on the venous phase, and a central scar.

Answer 19

Reassurance and observation

(focal nodular hyperplasia)

Question 20

What is the annual conversion rate to HCC for patients with cirrhosis?

Answer 20

2-6%

Question 21

Mayo clinical protocol for treatment of hilar cholangiocarcinoma

Answer 21

PAtients with hilar cholangiocarcinoma and Priamry sclerosing cholangitis

Patients with unresectable cholangiocarcinoma

patients with tumor less than 3cm in radial dimension and no evidence of intrahepatic or extraheaptic metastases

• this treatment comprises external beam radiation, 5 FU based chemotherapy and iridium 192 brachytherapy followed by operative staging and OLT in patients without metastaic disease
• 70% 5 year survival rate

Question 22

A patient undergoes routine cholecystectomy and is incidentally found to have gallbladder carcinoma that is staged as T1. Further treatment is _____–

Answer 22

No further treatment

T2 or more = reoperation with central hilar resection and hilar lymphadenectomy

*********

Reopertation with formal lobectomy and bile duct resection

Question 23

Primary determinant of sustainability for resection when evaluating a patient with hepatic colorectal mets.

Answer 23

Predicted volume of heaptic remant

Question 24

Milan criteria for transplantation

Answer 24

Patients with 1 tumor less than 5cm or up to 3 tumors less than 3 cm and no evidence of gross intravascular or extrahepatic spread

Question 25

The only FDA approved systemic chemotherapy agent for HCC is

Answer 25

Sorafenib , multikinase inhibitor

Question 26

Brisbane 2000 hepatic resection terminology

Answer 26