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LIVER > LIVER > Flashcards

LIVER Flashcards

1
Q

Budd-Chiari syndrome

A

thrombosis of IVC (intrahepatic)
Or
Hepatic veins

Often hypercoagulable state

POST sinusoidal portal hypertension

Jaundiced

Diagnosed CT scan or duplex ultrasound

Initial management heparinization

Majority will require:
Nonselective portosystemic shunt (side to side)

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2
Q

most common cause of death with fulminant hepatic failure complication

A

cerebral edema from intracranial hypertension

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3
Q

Intracranial hypertension associated with contraindication liver transplant

A

intracranial pressure greater than 50

Cerebral perfusion less than 40

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4
Q

focal nodular hyperplasia

A

over colloid scan-technetium 99

easily not symptomatic no risk of rupture no risk of malignancy

Central scar enhances on the arterial phase

Peripheral

KUPFFER cells’s cells positive

embryologic vascular injury

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5
Q

preoperative portal vein embolization

A

and is atrophy to planned area of resection causes compensatory hypertrophy

percutaneous transhepatic approach

Indicated when remnant of the liver volume expected to be less than 40% with normal liver function and less than 50% with abnormal liver function

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6
Q

with factors his warfarin block in the liver

A

vitamin K dependent:

2, 7, 9, 10

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7
Q

clotting factor is shortness half-life

A

7

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8
Q

deficiency and factor VII

A

prolonged INR

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9
Q

compare pyogenic abscess with amoebic abscess

A

anemic 10-1 male
Pyogenic 1.5-1 male

Abscesses of the liver all comers 75% RIGHT

pyogenic multiple
pathogenic and amoebic alcohol

Pyogenic perk drainage
Amoebic metronidazole

amoebic mortality 2-4%
Pyogenic mortality–20%

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10
Q

liver hemangioma

A

most common benign tumor of the liver
More and one in
Most asymptomatic
Giant cavernous hemangioma greater than 5 cm-rarely associated with KASABACH-MERRITT syndrome
diagnosis CT scan and MRI; radial labeled RBC scan reserved with CT/MRI nondiagnostic

if surgical resection indicated: Enucleate

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11
Q

KASABACH-MERRITT syndrome

A

seen with hemangioma of when there is intervascular coagulation and platelet trapping causing activation and consumption of coagulation factors

can lead to congestive heart failure-this is seen and cared

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12
Q

describe MRI findings of hemangioma

A

T1 and low signal intensity with peripheral nodular enhancement

T2 high signal intensity

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13
Q

most common cause of pre-sinusoidal intrahepatic hypertension

A

schistosomiasis (liver fluke)- intrahepatic
left common congenital hepatic fibrosis
Portal vein splenic vein thromboses extrahepatic

associated with preserved liver function when pre-sinusoidal

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14
Q

Intrahepatic portal hypertension causes

A

cirrhosis:
alcoholism
hemachromatosis
Wilson’s disease

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15
Q

Post- to thesinusoidal portal hypertension

A

Budd-Chiari (intrahepatic IVC)

Congenital web

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16
Q

TIPS

A

indication: Variceal bleeding
Also useful for ascites
Nonselective shunt

Increase encephalopathy

one year patency approximately 50%

absolute contraindication:
Polycystic liver disease
right heart failure - significant increase in venous return

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17
Q

Distal splenorenal shunt

A

not used emergent setting-time-consuming

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18
Q

Medial caval shunt

A

Best choice for urgent bleeding without compromising future transplantation efforts

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19
Q

primary bile acid

A

colic acid
chenodeoxycholic acid
made in the liver from cholesterol then conjugated in hepatocytes

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20
Q

secondary bile acids

A

deoxycholic acid
lithocholic acid

formed by intestinal bacteria modification of primary bile acid

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21
Q

where our bile acids resorbed passively

A

jejunum and ileum

the distal ileum resection resulting fat malabsorption and fat soluble vitamin deficiencies

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22
Q

effective eating food on the concentration of bile acid

A

bypass the concentration and the liver decreases by inhibition cholesterol 7 hydroxylase - resultant increase bile acid secretion in the liver

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23
Q

average size of adult liver

A

1500 g

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24
Q

round ligament

A

obliterated umbilical vein

Enters front edge of the falciform ligament

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25
Q

the falciform ligament

A

connected to round ligament (obliterated umbilical vein)

Separate segments 3 from segment 4

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26
Q

Couinaud line

A

line drawn from hepatic vein to common bile duct

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27
Q

what percentage of blood supply to the liver comes from hepatic artery

A

25%

75% of hepatic blood comes from portal vein but this is not percentage of oxygenated blood

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28
Q

replaced right hepatic artery

A

was common variant

Originates from SMA

traverses posterior to the portal vein and takes a right lateral position before dividing into the liver parenchyma

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29
Q

replaced left hepatic artery

A

from left gastric artery

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30
Q

completely replaced common hepatic artery

A

comes off of the SMA

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31
Q

what is right hepatic vein drain

A

segments 5 through 8

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32
Q

middle hepatic vein drain

A

segment for

Also drains 5 and 8

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33
Q

left hepatic vein drains

A

segments 2 and 3

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34
Q

caudate lobe drainage

A

this a segment one

Direct venous transients into inferior vena cava

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35
Q

a medial acid associated with conjucation of bile acids

A

glycine

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36
Q

mechanism of injury of acetaminophen overdose to liver

A

toxic metabolites the P450

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37
Q

Naturally occurring portal venous shunt

A 
GE junction
Anal canal
Falciform ligament
Splenic venous bed
LEFT renal vein
Retroperitoneum
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38
Q

Normal portal venous pressure

A

5-10

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39
Q

liver test most specific for liver disease

A

a

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40
Q

function of AST and ALT

A

AST
glutamic-oxaloacetic transaminase

( found in the liver, cardiac muscle, skeletal muscle, kidney, brain, pancreas, long, RBC)

aspartate acid or alanine to ketoglutaric acid to produce oxaloacedtic acid

ALT

(found predominately in the liver)
Glutamic-pyruvic transaminase
GPT

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41
Q

alkaline phosphatase

A

also found and bony kidney

42
Q

treatment of acetaminophen overdose

A

Activated charcoal may help

N-acetylcysteine is the antidote

43
Q

indirect bilirubin

A

unconjugated
Associated with:
Intrahepatic cholestasis
Hepatocyte dysfunction

Direct causes of increased indirect bili:
Hemolytic disorders
Resorption of hematoma

44
Q

direct bilirubin

A

conjugated
Associated with:
Obstruction-
Biliary atresia, pancreatic cancer, murky syndrome

45
Q

Gilbert’s syndrome

A

diminished activity of glucuronyltransferase

increase unconjugated (indirect) bilirubin

Symptoms are self-limited did not require treatment even with bilirubin of 5.2 and flulike illness

46
Q

T most common cause of acute liver failure

A

USA: Drug ingestion

Were wide: Viral infection-
hepatitis B
Hepatitis A!
hepatitis E

47
Q

electrolyte finding associated with improved prognosis for patient with acute liver failure

A

HYPO-phosphatemia

the still needs to be corrected with IV administration of phosphorus

48
Q

Child’s class

A

Bili less than 2/2-3/greater than 3

Albumin: Greater than 3.5/2.8-3.5/less than 2.8

INR: Less than 1.7/1.7-2.2/2.2

Encephalopathy: None/controlled/uncontrolled

Ascites: None/antral/uncontrolled

A.: 5-6 surgical mortality 10%
B.: 7-9 surgical mortality 30%
C.: 10–15 surgical mortality 75-80%

49
Q

pre-sinusoidal portal hypertension causes

A 
PRE-sinusoidal
EXTRA-hepatic (Sinistral / Left):
Splenic vein thrombosis
Splenomegaly
Splenic AV fistula
INTRA-hepatic:
 schistosomiasis
Congenital fibrosis
Nodular hyperplasia
Myeloproliferative disorder
 graft-versus-host disease
 idiopathic fibrosis
50
Q

sinusoidal portal hypertension

A 
SINUSOIDAL
 INTRA- hepatic
Cirrhosis:
Viral
Alcohol
Primary biliary cirrhosis
 primary sclerosing cholangitis
Autoimmune hepatitis
 metabolic abnormality
51
Q

post surgical portal hypertension causes

A

POST-sinusoidal
INTRA-hepatic:
vascular occlusive disease

POST-hepatic:
 Budd-Chiari
Congestive heart failure
IVC caval web
Constrictive pericarditis
52
Q

management of child B massive variceal bleed

A

Somatostatin (octreotide) bolus plus continuous infusion IV-splenic vasoconstriction can be missed in 5 days or longer

second choice:
vasopressin 0.2-0.8 IV Dashcode and vasoconstrictor - only given short term

EGD lavaged

53
Q

treatment of bleeding varices in the greater curvature of the stomach in a patient with patent splenic vein

A

gastric varices along greater curvature implies splenic vein source

?first try gastric variceal obturation with:
N-butyl-cyanoacrylate (glue?)

If this fails:
TIPS

54
Q

basic definition of Budd-Chiari syndrome

A

obstruction of hepatic venous OUTFLOW

this is hepatic vein to IVC (NOT portal vein)

55
Q

Most common organism isolated from hepatic abscess ( and others in order prevalence)

A

Escherichia coli over 60%

strep faecalis
Klebsiella
Proteus vulgaris

anaerobic colon
Bacteroides fragilis

Endocarditis or indwelling catheter:
Staphylococcus
Streptococcus

56
Q

Described the relationship of the structures in the hepatoduodenal ligament

A

common bile duct right anterior

Hepatic artery left anterior

Portal vein posterior

57
Q

developmental cause of focal nodular hyperplasia

A

and right disturbance and liver blood flow - Lesions are usually in periphery of liver

58
Q

Normal portal vein pressure

A

3-5

59
Q

Best screening for hepatocellular carcinoma

A

Ultrasound and AFP

60
Q

disadvantage of side-to-side shunt

A

increases in encephalopathy and liver is bypassed and no longer clearing

61
Q

what does TIPS stand for

A

transjugular intrahepatic portacaval shunt

62
Q

when do you resect hepatic adenoma

A

greater than or equal to 3 cm strongly recommended

greater than 4 cm resected

symptomatic

less than 3 cm asymptomatic observe

63
Q

CT findings of hepatic adenoma

A

Fully enhances

64
Q

When do you use tips

A

good for varices
not as good for ascites but can help
bad for encephalopathy

65
Q

medical treatment of ascites

A

6 L paracentesis and albumin

Spironolactone - counteract aldosterone that is wrapped up because of INTERVASCULAR decreased sodium

furosemide not as good

66
Q

new antidiuretic hormone

A

Vaptamn

67
Q

meld score needed to get on transplant list

A

greater than equal to 15

68
Q

meld score needed to get a liver

A

20-25

69
Q

How many meld points to give for dialysis

A

4

70
Q

what mild score represents a good candidate for liver meniscectomy

A

less than or equal to 8

greater than or equal to 11 at high risk for meniscectomy

71
Q

describe fetus umbilical vein

A

arterial blood from placenta to left portal vein ductus venosum
Round ligament
Falciform ligament
IVC

72
Q

ductus venosus

A

Umbilical vein
-to-
vena cava

“shunts less than a third of the blood flow of the umbilical vein directly to the inferior vena cava

This allows oxygenated blood from the placenta to bypass the liver.

In conjunction with the other fetal shunts, the foramen ovale and ductus arteriosus, it plays a critical role in preferentially shunting oxygenated blood to the fetal brain.

73
Q

ductus arteriosus

A

(right ventricle blood goes to):

pulmonary artery
-to-
aorta

“pulmonary artery to the proximal descending aorta”

called ligamentum arteriosum once it is closed-site of aortic tear blunt trauma

74
Q

patent ductus arteriosus

A

pulmonary artery to the proximal descending aorta remained open

left-to-right shunt

leads to pulmonary hypertension and possibly congestive heart failure and cardiac arrhythmias.

treatment:
Closure may be induced with NSAIDs because these drugs inhibit prostaglandin

Prostaglandins are responsible for maintaining the ductus arteriosus by dilation of the vascular smooth muscles.

75
Q

Umbilical arteries

A

Called arteries - but carrying deoxygenated blood to drain both halves of the fetus

Umbilical arteries supply deoxygenated blood from the fetus to the placenta

76
Q

umbilical vein

A

carries oxygenated blood from the placenta

77
Q

Fibrolamellar hepatocellular carcinoma

A

young
No cirrhosis
Not associated strongly with hepatitis B

78
Q

Replaced right hepatic artery described course

A

SMA
Posterior portal vein
Behind the pancreas
Behind cystic artery

79
Q

what vein is middle hepatic vein associated with

A

left

80
Q

Porta hepatis

A

hepatoduodenal ligament

Right (And a bit anterior to the hepatic artery) common bile duct

left ( in the bit posterior to common bile duct) hepatic artery

Posterior portal vein

81
Q

describes selective shunt and its disadvantages

A

all portal blood flow into vena cava

Not good for Budd-Chiari syndrome

82
Q

with marker is most specific for liver function and one marker is no specific for liver necrosis

A

ALT-liver function

AST-or necrosis

83
Q

Milan criteria for liver transplant

A

Less than 5 cm
less than or equal to
3 tumors less than 3 cm

84
Q

Retzius veins

A

retroperitoneal

85
Q

Where our Mallory-Weiss tears found

A

lesser curve right side

86
Q

where is Borhave injury found

A

left chest and mediastinum

87
Q

management of esophageal perforation over 48 hours

A 
no primary repair or a graft chest decortication washout
 cervical exclusion?
NG tube
Open  gastrostomy
 feeding J.

Consider covered stent

88
Q

Treatment of Schatzki ring

A

If asymptomatic-
observe

If symptomatic-
Dilate and perform and gastric fundoplication

89
Q

choledochal cyst.

A

These cysts are thought to arise from an aberrant communication with the biliary and pancreatic ducts.

There are five types of choledochal cysts, based on their size and characteristics.

All require complete surgical resection because of an association with the development of cholangiocarcinoma.

90
Q

Type I cysts

A

fusiform dilations of the common bile duct. T

hese are the most common

treated with resection,
cholecystectomy,
hepaticojejunostomy.

T

91
Q

Type II cysts

A

extrahepatic,
diverticular cysts
treated the same as Type I.

cholecystectomy,
hepaticojejunostomy.

92
Q

Type III cysts

A

located at the distal common bile duct at the junction with the duodenum

treated with cholecystectomy,
resection,
choledochojejunostomy.

93
Q

Type IV

A

multiple locations,
both intrahepatic and extrahepatic,

may require a liver resection of the involved segment.
.

94
Q

Type V cysts

A

intrahepatic

may lead to liver failure, necessitating liver transplantation for treatment

95
Q

cystadenoma

A

pre malignant potential

female: 40-50s

CT:
complex cyst
mural nodules

Tx:
enucleate
resect

96
Q

Echinococal

A

endemic areas, such as the southwestern United States, Scotland, Greece, or other parts of Europ

CT and MRI scans will demonstrate thick-walled cysts with calcifications containing debris. Septations and daughter cysts may also be identified within the cysts.

dx
hemoglutanin
elisa

tx:

Prior to surgical manipulation of these cysts, patients should be treated with albendazole or mebendazole. The surgeon should plan to perform a complete enucleation of all of the cysts.

97
Q

hemangioma

A

Benign

MRI:
Bright T2 with peripheral enhancement

CT:
Peripheral enhancement followed by central infilling

Kasabach-Merritt syndrome, which manifests as a coagulopathy resulting from intravascular coagulation, clotting, and fibrinolysis within the hemangioma. The localized coagulopathy can result in death in 20% to 30% of patients due to systemic fibrinolysis and thrombocytopenia.

No treatment is necessary for asymptomatic hemangiomas. Surgical resection should only be considered if patients develop symptoms or complications, or if malignancy cannot be excluded

laparoscopic enucleation or hepatic resection.

patients require an intervention but are not surgical candidates, radiation or hepatic artery embolization can be considered.

The main blood supply is from the arterial system, so extrahepatic ligation of the right or left hepatic artery can provide vascular control

98
Q

Focal nodular hyperplasia

A

(FNH) is the second most common benign hepatic lesion

normal hepatocytes in FNH

not stimulated by oral contraceptives.

A central scar is the most characteristic imaging feature,
(however, a central scar can also be seen with fibrolamellar hepatocellular carcinoma, hepatic adenomas, and metastatic lesions)

CT:
hypodense or isodense on the precontrast
enhances rapidly during the arterial phase of the scan. During this phase, the lesion contour is well demarcated, and the central scar is hypodense. The lesion’s enhancement decreases during the portal phase, and it becomes isodense to the liver on the delayed images, on which the central scar and septa can demonstrate increased uptake of contrast because of the slow uptake of contrast in these fibrotic elements.

MRI:
isointense or hypointense on T1-weighted MRI images,
isointense or slightly hyperintense on T2-weighted images.

The central scar is hypointense on T1-weighted images and strongly hyperintense on T2-weighted images.
Gadolinium administration results in hyperintensity of the lesion during the arterial phase, followed by isointensity during the portal venous phase. The central scar becomes hyperintense on delayed imaging.

MRI best
If neither CT nor MRI can make the diagnosis of FNH, a sulfur colloid scan can be performed. FNHs contain Kupffer cells, which take up sulfur colloid, whereas hepatic adenomas do not.

biopsy should be considered if imaging cannot firmly establish the diagnosis.

Tx:

no treatment for FNH, as long as the diagnosis has been confirmed with certainty.

no risk of malignant potential or complications in men or in women.

no evidence to support avoiding pregnancy or discontinuing oral contraceptives.

Follow-up of these lesions is not necessary, unless they become symptomatic.

Surgical resection is only indicated in symptomatic patients or in cases of diagnostic uncertainty. If liver resection is indicated, a margin of normal hepatic parenchyma is safer than enucleation because of large veins that frequently surround these lesions.

99
Q

central scar can also be seen with

A

fibrolamellar hepatocellular carcinoma, hepatic adenomas, and metastatic lesions)

100
Q

fibrolamellar hepatic cancer

A

NON cirrhotic patients
resection is better than transplant

may not have AFP postitive

may look like FNH

101
Q

estimates of functional liver reminent

A

normal 20-30 %
steatorrhea 30-40%
cirrhosis 40-50%
Over age 70 / hx of pre chemo > 50%

LIVER (1 decks)

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