Liver, Biliary System And Spleen Flashcards by Denisse Tiangco

Liver primordium and bile duct arise from ventral endodermal outgrowth of foregut at

3rd and 4th week

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Liver promordium penetrates septum transversum to become bud early in

5th week

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Kupffer, hepatic stroma and hepatic vessels arise from

septum transversum mesoderm

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Prolif of mesenchymal cells in dorsal mesogastrium at 5th week

Spleen promordium

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Divided into eight segments corresponding to venous drainage but related to arterial blood supply and biliary drain

Segmental

French Couinaud

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Two lobes divided by interlobar fissure Cantlie’s line)

Lobat (American)

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Runs from left side of GB fossa to IVC

Cantlie’s line

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Caudal lobe

Segment I

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Segment II,III,IV

Left lobe

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Segment V,VI,VII,VIII

Right lobe

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Caudate lobe drains

directly to IVC

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Functional unit of liver

Made up of biliary ductule, hepatic arteriole, portal venule (afferent)

Acinar unit

Portal triad

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Liver zone are defined according to

Oxygen and solute concentration gradient

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Closest to triad

Least susceptible to ischemic insult but most susceptible to toxic or chemical injury

Zone 1

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Adjacent to terminal hepatic vein

Most susceptible to ishcemic injury

Zone 3

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Bile from caudate lobe drains into

Left hepatic ductal system

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GB is located under segment

4 and 5

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Normal GB wall thickness

<4 mm

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Source of postoperative bile leaks when correct operative technique is followed
Postulated to run from liver bed directly to GB or whether drainage ducts running from subsegments of liver along GB join cystic duct or CBD

Ducts of Luschka

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Normal CBD size

<5 mm if <50 y/o

Inc by 1mm/decade after 50

Normally enlarged up to 12 mm following cholecystectomy

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Relation of hepatic bile duct to right branch of porta vein

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Right hepatic artery runs

the common hepatic duct

behind

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Layers of GB

Mucosa
Muscularis
Subserosa
Serosa

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GB contains no

Submucosa

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Mucosa lining of GB

columnar epithelium specialized for water absorption

Sinuses from invagination of epithelium through fibromuscular layer from inflammation and inc luminal pressure in GB (cholangitis, acute cholecystitis)

Rokitansky-Aschoff sinus

Hepatic artery relation to Portal Vein

Hepatic artery relation to CBD

Medial

Exists in 17% of patients | Comes off as SMA to run lateral to CBD

Replaced right HA

Occurs in 10% of patients and usually comes off of splenic or left gastric artery

Replaced left HA

Liver tumors are supplied primarily by

Hepatic artery True for both primary and metastatic tumor

Converges with hepatic vein before entering IVC in 80% of cases Remaining 20% drain directly into IVC

Middle HV

Carries 75% of total blood flow to liver

Portal vein But PV and HA give 50% of O2 supply to liver

Liver drainage

``` 3 HVs Left HV (II, III, IV) Middle HV (V, inferior IV) Right HV (VI, VII, VIII) ```

There is sparing of caudate lobe in Budd Chiari because

There is a separate HV draining it directly to IVC

85% of spleen Mononuclear phagocyte Clearing of nucleated remnant from immature RBC, clearing of damaged or dead RBC

Red pulp

15% of spleen Lymphoid cell, mostly B Clearing of bloodborne antigen: bacteria without preexistinf antibody, poorly opsonized bacteria, foreign particle, cellular debris

White pulp

BS of biliary system

Cystic artery from R HA and vein | Cystic vein absent and drainage through surface vein into liver bed

BS of spleen

Splenic artery L gastroepiploic artery Short gastric artery Splenic vein posterior inferior to splenic artery and drains to PV

Innveration of liver

Sympa: T7-T10 Parasympathetic: right and left vagus synapse with peripheral nerve fibers that run anterior and posterior to HA

Lymph drainage of liver

Perisinusoidal space of Disse and clefts of Mall Porta hepatis Cysterna chili Thoracic duct Opposite of PV blood and does not follow HV flow

Oxidation (CYP450), reduction, hydroxylation, hydrolysis to expose functional groups

Phase I

Reactions involve conjugation to alter solubility

Phase II

Dec permeability of sinusoidal epithelial cells alters lymphatic drainage leading to ascites

ascites

Rate limiting enzyme in bile acid production

cholesterol 7alpha-hydroxylase

Made primarily by endothelial cells and the liver to some degree Restoration of normal levels in some successful liver transplants in patients with Hemophilia A

Factor 8

Nutrient stores in liver

``` Glycogen Triglyceride Vitamin B12 Iron Copper Fat soluble vitamin ```

``` 35, F Takes OCP RUQ pain Work up: 3cm hepatic adenoma Tx? ```

Stop OCP and observe If >4cm or symptoms persist, resection

Consumption thrombocytopenia related to hepatic hemangiomata Leads to DIC

Kasabach-Meritt Syndrome

``` Infection with Echinicoccus granulosum Sheep Primary host: dogs stool infecting Intermediate: humans RUQ pain, hepatomegaly, obstructive sx Leak lead to allergic symptoms Eosinophilia +indirect agglutination 85% +complement fixation test ```

Hydatid cyst

Hydatid cyst have predilection for

Right lobe of liver

Hydatid cyst abdominal CT:

cacified ectocyst, endocyst

Hydatid cyst tx

Preoperative Albendazole or Mebendazole with complete surgical removal including wall Intraoperative aspiration with injection of saline

Hydatic cyst course

Expansion -> rupture -> spread -> anaphylaxis -> death

Most common benign liver tumor | Not related to OCP use

Hemangioma

Asymptomatic Dx: CT contrast or MRI T2 bright Mx: observe (asymptomatic) Enucleation or lobectomy if with symptom or uncertain dx Radioablation or embolization of hepatic artery for poor candidate Complication: rupture (rare) hemorrhagic shock, acts like AV fistula, cardiac hypertrophy, CHF

Hemangioma

Common in women Ave age: 35 years old not related to OCP Asymptomatic Dx: CT shows hypervascular mass with HYPODRNSE STELLATE SCAR; hot on Tc macroaggregated albumin scan Biopsy shows hepatocyte and bile duct Mx: observe with serial CT, if symp resect Complication: no potential for malignant degeneration, low chance of rupture

Focal nodular hyperplasia

``` Reproductive age women Related to OCP use 75%- abdominal pain MRI, CT (lacks central scar) Cold on Tc macroaggregated albumin scan Biopsy: hepatocyte ``` Tx: discontinue OCP <4cm observe >4cm resect due to rupture and malignant degen 25% chance of rupture or hemorrhage Rare malignant degeneration

Hepatic adenoma

Cholestasis, fibrotic intrahepatic and extrahepatic biliary tree Men in 3rd-4th decade Autoimmune associated with ulcerative colitis, retroperitoneal fibrosis, insulin dep DM, Grave’s, Sjogren’s, Riedel’s, AI pancreatitis, MG

Primary sclerosing cholangitis

PSC is associated with HLA

HLA B8 | HLA DR3

PSC may progress to

Cirrhosis | Cholangiocarcinoma (20%)

PSC Dx:

Inc ALP and bilirubin ERCP: multiple dilatation and stricture of both intra and extrahepatic biliary tree Biopsy determine degree of fibrosis and cirrhosis

PSC Tx

None Endo or percutaneous dilation and stent are symptomatic relief If without significant hepatic fibrosis or cirrhosis, surgical resection of extrahepatic biliary tree with hepaticojejunostomy Advanced: liver transplant 10-20% will have recurrence Colectomy if with UC

Confirms diagnosis of PSC Rule out

ERCP and liver biopsy Cholangiocarcinoma

Most common in US (80%) Hematogenous spread from intraabdominal infection (diverticulutis, appendicitis) or ascending infection (cholangitis) Direct extension from intraperitoneal infection Stent placement, manipulation, trauma organism: Staph, Gram - (E coli, Kleb), Anaerobe (Bacteriodes fragilis) Fever, chills, liver tenderness/enlargement, jaundice Leukocytosis, + blood culture 40%, Confirm with CT/UTZ CT: HYPODENSE abscess wall enhances with IV contrast Mx: IV antibiotics 2 weeks followed by oral (1 month) CT UTZ guided aspiration/drain or surgical drain Prolong antibiotics if multiple abscess

Bacterial hepatic Abscesses

Most common worldwide Primary infection from colon spreading to liver via PV By entamoeba hystolitica Most commonly as single abscess on: Fever, RUQ, chills, sweating, hepatomegaly Antecedent diarrhea 25% Jaundice rare Anchovy paste abscess Leukocytosis, abdominal liver function Entamoeba hystolitica serology 90% + stool culture 15% Radiographically similar to bacterial Tx: metronidazole sx reserved to failed antibiotic therapy or complication (bacterial infection)

Amoebic abscesses

Chronic inflammation Hepatocyte destruction and regeneration Fibrosis Portal HTN By alcohol, Hepa B, C, prolonged cholestasis, metabolic (Wilson, alpha 1 antitrypsin)

Cirrhosis

Most common cause of cirrhosis in US worldwide

Alcohol HCV

AST and ALT in CLD

>3 times normal

AST/ALT in Alcoholic cirrhosis

Synthetic function of liver is best assessed by

Anemia Thrombocytopenia Inc PT and INR Inc AST and ALT >3

Cirrhosis

Confirms presence of cirrhosis and established cause

Liver biopsy

Helps determine extent of cirrhosis and predict operative mortality

Child Pugh classification

``` No ascites No neurologic disorder Bilirubin: <2 mgdl Albumin >3.5 mgdl PT 1-3 INR <1.7 Operative mortality: 10% ```

Child Pugh A

``` Minimal or controlled ascites Mininal or controlled neurologic disorder Bilirubin: 2-3 mgdl Albumin: 2.8-3.5 mgdl PT: 4-6 INR: 1.7-2.2 Operative mortality: 30% ```

Child Pugh B

``` Moderate-severe ascites Moderate severe COMA Bilirubin >3mgdl Albumin <2.8 mgdl PT >6 INR >2.2 Operative mortality: 70% ```

Child Pugh C

Child Pugh Classification

``` Prothrombin Bilirubin Albumin Ascites Neurologic ``` ProBAAN

Collaterals between short gastric veins to azygos result in

esophageal varices

Cirrhosis tx

Ascites: diuresis (spironolactone, furo), paracentesis and peritoneal jugular shunt

Acute infection of peritoneal fluid presenting with fever and abdominal pain Most commonly by: Suspect other etiology if polymicrobial flora and found on culture Confirm diagnosis by >250 PMN/ul in ascitic fluid that is + culture Treat with:

Spontaneous bacterial peritonitis E coli Third gen cephalosporin (cefotaxime)

Complications of cirrhosis

Variceal bleeding 33% mortaity in first episode With rebleed 50%? Portal HTN Liver failure: transplant

Variceal bleed tx

``` Endoscopy Rubber band ligation Sclerotherapy Vasopressin Ocreotide Transjugular intrahepatic portasystemic shunt TIPS ```

Abnormal inc in PV pressure (>12mmHg) Obstruction blocks flow Inc PV pressure Vasoconstriction Vasodilation and inc splanchnic flow Collaterals between portal and systemic circulation Hepatofugal PV flow (inc blood flow in PV reversed and blood flows out of liver)

Portal HTN

Collatera between portal and systemic circulation

``` coronary umbilical retroperitoneal hemorrhoidal short gastric vein ```

occlusion of major hepatic vein results into postsinusoidal portal HTN

Budd-chiari syndrome

Extrahepatic causes of portal HTN

``` Portal vein thrombosis Congenital Sepsis Trauma Malignant occlusion ```

Intrahepatic causes of portal vein HTN

Schistosomiasis | Congenital hepatic fibrosis

Sinusoidal cause of portal HTN

Cirrhosis

Postsinusoidal cause of portal htn

Budd Chiari | Veno-occlusive disease

Budd Chiari is common in RUQ pain Jaundice Ascites Hepatosplenomegaly

Women in hypercoagulable state

Budd Chiari tx

Anticoagulant Porta caval shunt Porta atrial shunt

Portal HTN complication

ascites esophageal varicea liver failure

Portal HTN Dx

Transcutaneous liver doppler uts: parenchyma and blood flow pattern Lab test confirms source of cirrhosis: HBV,HCV titers

Portal HTN tx

Surgical shunt: for well preserved liver function Child Pugh A and B requiring liver transplant in future >1 yr (Portocaval and mesocaval shunt) Liver transplant: Model for End stage Liver Disease (MELD) score For transplant

Caused by splenic vein thrombosis Resultant from pancreatitis Results in esophageal varices without main PV HTN Preserved liver function but bleeding occurs Tx: splenectomy

Sinistral portal HTN

Occlusion of PV Preserved liver function but my require portocaval shunt No role for TIPS Splenomegaly, hemorrhage

PV thrombosis

Portal vein thrombosis in childhood is caused by

umbilical vein catheterization

Portal vein thrombosis causes in adult

``` Malignancy HCC Cirrhosis (low heptopetal flow) Hyercoagulable state Dehydration Infection (schistosomiasis) ```

Dx of portal vein thrombosis confirmed by

Duplex Doppet UTZ CTA MRA

Portal vein thrombosis tx

Long term anticoagulation and clot lysis via transhepatic infusion through PV

50, M Hx of HBV found to have hepatic mass AFP elevated Lesion is HCC Apart from staging, what will determine resectability?

Child Pugh Classification since resection is limited to A or B

Most common cancer of liver worldwide Men, HBV, HCV, alcohol, hemochromatosis, alpha 1 anti, PSC, hepatic adenoma, steroid use, aflatoxin exposure and pesticide

HCC

Most common cause of HCC worldwide

HBV

Majority of liver cases are 1 out of 20 malignant cases are

Metastatic lesions HCC Lesions in liver require cancer workup to localize primary lesion

HCC is associated with

AFP >500 ng/dl

Dx for HCC

UTZ CT MRI

If AFP nondiagnostic and not surgical candidate, perform in HCC If candidate for surgery, CXR and Chest CT to

fine needle aspiration with cytology as confirmatory Perform exlap with or without biopsy Rule out malignancy

For Child Pugh A and B tx

Partial hepatectomy Neoadjuvant chemo and adjuvant for some

Transplantation for

tumor <5cm <3 tumors No PV or IVC involvement

Only 15-20% amenable to surgery because

tumor multicentricity Extensive involvement of both lobes PV invasion Lymphatic disease

If not for surgery, perform

HA embolization or tumor cryotherapy Radioablation Ethanol injection

Staging of HCC

Number of tumors Size Vascular invasion Overall prognosis poor 5yr survival for all comes <30%

``` Cancer of intra or extrahepatic bile duct Associated with PSC Ulcerative colitis Choledochal cyst Chronic bile duct infection ```

Cholangiocarcinoma

Parasite associated with cholangiocarcinoma

Chlonorchid sinensis

Inc ALP Inc bilirubin Inc GGT NORMAL Transaminase

Cholangiocarcinoma

Cholangiocarcinoma confirmed by

ERCP | MRI

Most common location of cholangiocarcinoma | Unresectable but if amenable, attempt resection of affected liver lobe and bile duct

Upper 1/3 of cholangiocarcinoma

Middle 1/3 cholangiocarcinoma sx:

Hepaticojejunostomy

Lower 1/3 cholangiocarcinoma sx:

Whipple procedure

Cholangiocarcinoma at junction of right and left hepatic ducts

Klatskin tumor

Median survival of cholangiocarcinoma

12-59 months after resection with overall 5 yr survival 20-42%

Most common type of gallstone in US | Failure of cholesterol and Ca salts to remain in solution as result imbalance of chole, lecithin and bile acid

Cholesterol

Black stone caused by precipitation of unconjugated bilirubin with Ca -> Ca bilirubin Found in association with hemolysis, cirrhosis, chronic TPN, ileal resection Brown related to chronic biliary infection (E coli)

Pigmented black stones

Obstruction of pancreatic duct by stone | 1/3 of acute pancreatitis cases

Gallstone pancreatitis

Less than 1% 25% of SBO in elderly who do not have adhesions Gallstone enters intestine via cholecystoduodenal fistula

Gallstone ileus

Imaging study of choice for gallstone related diseases

RUQ ultrasound

Pain by transient obstruction of cystic duct by gallstone Abrupt or transient RUQ epigastric pain, postprandial (fatty food) UTZ: Gallstone on RUQ Mx: avoidance of inciting factors elective cholecystectomy for symptomatic patients without serious comorbidities

Biliary colic

Gallbladder inflammation by gallstone obstruction of cystic duct RUQ pain + Murphy’s sign + fever Normal LFT WBC: 12-15 k/UL RUQ UTZ: Gallstones, Gallbladder wall thickening >4mm, pericholecystic fluid, + sonographic Murphy’s sign Mx: IV antibiotic cholecystectomy, percutaneous cholecystectomy tube in seriously ill

Acute cholecystitis

Gallstone in CBD RUQ epigastric pain, fever, chill, jaundice, acute pancreatitis Inc ALP/GGT RUQ UTZ: Dilated CBD >8mm Stone not well visualized if in distal duct ERCP with sphincterotomy for patients with previous cholecystectomy or preoperative CBD clearance Lap chole with intraoperative cholangiogram if preoperative clearance was not achieved

Choledocholithiasis

Bacterial infection of biliary tract Charcot triad Reynaud’s pentacld RUQ UTZ: Normal biliary tree, dilated CBD >8mm without clear CBD stone does not rule out cholangitis Supportive therapy with aggressive fluid resuscitation, electrolyte correction, broad spec IV, pain control Timely ductal drainage: ERCP, sphincterotomy and stone extrac

Acute cholangitis

Fever RUQ pain Jaundice

Charcot’s triad

Reynold’s pentad

``` Fever RUQ pain Jaundice Hypotension Altered mental status ```

gallstone lodges in the ileum at distance

1-2 ft proximal to ileocecal valve

Rare 1% Women Associated with chronic gallbladder inflammation Associated with porcelain gallbladder (diffuse Ca in gallbladder wall) Asymptomatic or similar to biliary colic for extended time

Gallbladder adenocarcinoma

Gallbladder adenocarcinoma is confirmed with

UTZ CT MRI MRCP

for cases incidentally found after cholecystectomy and with margins no extension through GB wall

no further treatment necessary

Gallbladder resection needs

en bloc till underlying liver depth of 2cm and regional lymphadenectomy Survival: 5 year 5%

35 y, M Shattered spleen after MVC Hemodynamically unstable taken emergently to OR for splenectomy Postop vaccine?

Pneumococcus Meningococcus H influenzae

Indication for splenectomy

Traumatic injury: >2 units pRBC transfusion, persistent decline in Hgb, peritonitis, significant intra-abdominal blood Hodgkin’s: for staging if without evidence of nodal or hepatic disease Rarely done unless staging will influence treatment Hematologic disorder: myeloproliferative disorder, refractory idioathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, hereditary spherocytosis and thalassemia major

In children, threshold to perform splenectomy is

40ml/kg transfused blood or instability

Benign implantation of splenic tissue following splenic rupture Retain function and clear particulate matter from RBCs with resultant norma blood smear

Splenosis

Post splenectomy complication

``` Pancreatic leak Abscess Left pleural effusion Infection (encapsulated) Thrombocytosis Splenic vein and PV thromboses ```

Clearing of damaged blood cells in the spleen occur in

red pulp

What segment in the liver will you find the GB

IV and V

72, F Biliary obstruction Medical factors necessitating preoperative percutaneous drainage

Cholangitis Immunosupression Renal insufficiency Coagulopathy

40 y, M UGIB from esophagea varices Medication?

Vasopressin | Ocreotide

25, F Protein C deficiency Acute RUQ pain and jaundice Occlusion of hepatic vein at IVC SYNDROME? Tx

Budd Chiari | Anticoagulation

75, F RUQ pain, jaundic, fever WBC= 16 k/uL with left shift Next step in management?

Reynold’s pentad Treat with aggressive fluid resuscitation Broad spec IV antibiotics Timely ERCP and sphincterotomy with stone extraction