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Section II General Surgery P203Surgical Recall Sixth > Liver, C52 P345-357 > Flashcards

Liver, C52 P345-357 Flashcards

1
Q

ANATOMY
What is the name of the
liver capsule?
P345

A

Glisson’s capsule

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2
Q

ANATOMY
What is the “bare” area?
P345

A

Posterior section of the liver against the
diaphragm that is “bare” without peritoneal
covering

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3
Q

ANATOMY
What is Cantle’s line?
P345 (picture)

A

Line drawn from the gallbladder to a
point just to the left of the inferior vena
cava, which transects the liver into the
right and left lobes

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4
Q 
ANATOMY
Which ligament goes from
the anterior abdominal wall
to the liver?
P345
A

Falciform ligament

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5
Q

ANATOMY
What does the falciform
ligament contain?
P345

A 
Ligamentum teres (obliterated umbilical
vein)
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6
Q

ANATOMY
What is the coronary
ligament?
P345

A

Peritoneal reflection on top of the liver
that crowns (hence “coronary”) the liver
and attaches it to the diaphragm

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7
Q

ANATOMY
What are the triangular
ligaments of the liver?
P345

A

Right and left lateral extents of the

coronary ligament, which form triangles

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8
Q

ANATOMY
What is the origin of the
hepatic arterial supply?
P346

A

From the proper hepatic artery off of the
celiac trunk (celiac trunk to common
hepatic artery to proper hepatic artery)

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9
Q

ANATOMY
Identify the arterial
branches of the celiac trunk:
P346 (picture)

A
  1. Celiac trunk
  2. Splenic artery
  3. Left gastric artery
  4. Common hepatic artery
  5. Gastroduodenal artery
  6. Proper hepatic artery
  7. Left hepatic artery
  8. Right hepatic artery
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10
Q

ANATOMY
What is the venous supply?
P346

A 
Portal vein (formed from the splenic
vein and the superior mesenteric vein)
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11
Q

ANATOMY
What is the hepatic venous
drainage?
P346

A 
Via the hepatic veins, which drain into
the IVC (three veins: left, middle, and
right)
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12
Q

ANATOMY
What sources provide
oxygen to the liver?
P347

A

Portal vein blood—50%

Hepatic artery blood—50%

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13
Q

ANATOMY
From what sources does the
liver receive blood?
P347

A

Portal system—75%

Hepatic artery system—25%

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14
Q

ANATOMY
Identify the segments of the
liver (French system).
P347 (picture)

A

(see picture)

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15
Q 
ANATOMY
What is the overall arrangement
of the segments in the
liver?
P347 (picture)
A

Clockwise, starting at segment 1

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16
Q 
ANATOMY
What is the maximum
amount of liver that can be
resected while retaining
adequate liver function?
P347
A

>80%; if given adequate recovery time,
the original mass can be regenerated
(Remember Prometheus!)

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17
Q

ANATOMY
What are the signs/symptoms
of liver disease?
P347

A 
Hepatomegaly, splenomegaly, icterus,
pruritus (from bile salts in skin), blanching
spider telangiectasia, gynecomastia,
testicular atrophy, caput medusae, dark
urine, clay-colored stools, bradycardia,
edema, ascites, fever, fetor hepaticus
(sweet musty smell), hemorrhoids,
variceal bleeding, anemia, body hair loss,
liver tenderness, palmar erythema
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18
Q

ANATOMY
Which liver enzymes are
made by hepatocytes?
P348

A

AST and ALT (aspartate aminotransferase

and alanine aminotransferase)

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19
Q

ANATOMY
What is the source of
alkaline phosphatase?
P348

A 
Ductal epithelium (thus, elevated with
ductal obstruction)
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20
Q

ANATOMY
What is Child’s class?
(Child-Turcotte-Pugh)
P348

A

Classification system that estimates
hepatic reserve in patients with hepatic
failure and mortality

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21
Q

ANATOMY
What comprises the Child’s
classification?
P348

A

Laboratory: bilirubin, albumin
Clinical: encephalopathy, ascites,
prothrombin time (PT)

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22
Q 
ANATOMY
How can the criteria
comprising the modified
Child’s classification be
remembered?
P348
A

Use the acronym: “A BEAP”:
Ascites

Bilirubin
Encephalopathy
Albumin
PT (prothrombin time)
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23
Q 
ANATOMY
Define Child’s classification:
A
B
C
P348
A

Ascites Bili Enceph ALB PT INR
———– —– ———— —— ———
none 3.5 1.7
controlled 2–3 minimal 2.8–3.5 1.7–2.2
uncontrolled 3 severe <2.8 2.2
(Think: As in a letter grading system, A is
better than B, B is better than C)

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24
Q

ANATOMY
What is the operative mortality for a portocaval
shunt vs. overall intraabdominal operations with
cirrhosis in the following Child’s classes:
A?
B?
C?
P348

A

A: <15% vs. overall = 30%

C: =33% vs. overall = 75%

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25
Q

ANATOMY
What does the MELD score
stand for?
P348

A

Model for End-stage Liver Disease

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26
Q

ANATOMY
What is measured in the
MELD score?
P348

A

INR, T.Bili, serum creatinine (SCR);

find good MELD calculators online

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27
Q 
ANATOMY
What is the mortality in
cirrhotic patients for
nonemergent nontransplant
surgery?
P349
A

Increase in mortality by 1% per 1 point
in the MELD score until 20, then 2% for
each MELD point

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28
Q 
ANATOMY
What is the mortality in
cirrhotic patients for
emergent nontransplant
surgery?
P349
A

14% increase in mortality per 1 point of

the MELD score

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29
Q

TUMORS OF THE LIVER
What is the most common
liver cancer?
P349

A

Metastatic disease outnumbers primary
tumors 20:1; primary site is usually the
GI tract

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30
Q 
TUMORS OF THE LIVER
What is the most common
primary malignant liver
tumor?
P349
A

Hepatocellular carcinoma (hepatoma)

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31
Q

TUMORS OF THE LIVER
What is the most common
primary benign liver tumor?
P349

A

Hemangioma

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32
Q

TUMORS OF THE LIVER
What lab tests comprise the
workup for liver metastasis?
P349

A

LFTs (AST and alkaline phosphatase are
most useful), CEA for suspected primary
colon cancer

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33
Q

TUMORS OF THE LIVER
What are the associated
imaging studies?
P349

A

CT scan, ultrasound, A-gram

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34
Q

TUMORS OF THE LIVER
What is a right hepatic
lobectomy?
P349

A

Removal of the right lobe of the liver
(i.e., all tissue to the right of Cantle’s line
is removed)

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35
Q

TUMORS OF THE LIVER
What is a left hepatic
lobectomy?
P349

A

Removal of the left lobe of the liver
(i.e., removal of all the liver tissue to the
left of Cantle’s line)

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36
Q

TUMORS OF THE LIVER
What is a right
trisegmentectomy?
P349

A

Removal of all the liver tissue to the right

of the falciform ligament

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37
Q 
TUMORS OF THE LIVER
What are the three common
types of primary benign
liver tumors?
P349
A
  1. Hemangioma
  2. Hepatocellular adenoma
  3. Focal nodular hyperplasia
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38
Q 
TUMORS OF THE LIVER
What are the four common
types of primary malignant
liver tumors?
P350
A
  1. Hepatocellular carcinoma (hepatoma)
  2. Cholangiocarcinoma (when
    intrahepatic)
  3. Angiosarcoma (associated with chemical
    exposure)
  4. Hepatoblastoma (most common in
    infants and children)
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39
Q 
TUMORS OF THE LIVER
What chemical exposures
are risk factors for
angiosarcoma?
P350
A

Vinyl chloride, arsenic, thorotrast

contrast

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40
Q

TUMORS OF THE LIVER
What is a “hepatoma”?
P350

A

Hepatocellular carcinoma

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41
Q

TUMORS OF THE LIVER
What are the other benign
liver masses?
P350

A

Benign liver cyst, bile duct hamartomas,

bile duct adenoma

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42
Q

TUMORS OF THE LIVER
What is a liver “hamartoma”?
P350

A

White hard nodule made up of normal

liver cells

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43
Q

HEPATOCELLULAR ADENOMA
What is it?
P350

A

Benign liver tumor

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44
Q

HEPATOCELLULAR ADENOMA
Describe the histology.
P350

A

Normal hepatocytes without bile ducts

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45
Q

HEPATOCELLULAR ADENOMA
What are the associated risk
factors?
P350

A

Women, birth control pills (Think:
ABC = Adenoma Birth Control),
anabolic steroids, glycogen storage
disease

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46
Q

HEPATOCELLULAR ADENOMA
What is the female:male
ratio?
P350

A

9:1

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47
Q

HEPATOCELLULAR ADENOMA
What is the average age of
occurrence?
P350

A

30–35 years of age

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48
Q

HEPATOCELLULAR ADENOMA
What are the signs/symptoms?
P350

A

RUQ pain/mass, RUQ fullness,

bleeding (rare)

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49
Q

HEPATOCELLULAR ADENOMA
What are the possible
complications?
P350

A

Rupture with bleeding (33%), necrosis,

pain, risk of hepatocellular carcinoma

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50
Q

HEPATOCELLULAR ADENOMA
How is the diagnosis made?
P350

A

CT scan, U/S, +/– biopsy (rule out

hemangioma with RBC-tagged scan!)

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51
Q

HEPATOCELLULAR ADENOMA
What is the treatment:
Small?
P351

A

Stop birth control pills—it may
regress; if not, surgical resection
is necessary

52
Q 
HEPATOCELLULAR ADENOMA
What is the treatment:
Large (>5 cm), bleeding,
painful, or ruptured?
P351
A

Surgical resection

53
Q

FOCAL NODULAR HYPERPLASIA (FNH)
What is it?
P351

A

Benign liver tumor

54
Q

FOCAL NODULAR HYPERPLASIA (FNH)
Describe the histology.
P351

A

Normal hepatocytes and bile ducts

adenoma has no bile ducts

55
Q

FOCAL NODULAR HYPERPLASIA (FNH)
What is the average age of
occurrence?
P351

A

≈40 years

56
Q

FOCAL NODULAR HYPERPLASIA (FNH)
What are the associated
risk factors?
P351

A

Female gender

57
Q

FOCAL NODULAR HYPERPLASIA (FNH)
Are the tumors associated
with birth control pills?
P351

A

Yes, but not as clearly associated as with

adenoma

58
Q

FOCAL NODULAR HYPERPLASIA (FNH)
How is the diagnosis made?
P351

A

Nuclear technetium-99 study, U/S,

CT scan, A-gram, biopsy

59
Q

FOCAL NODULAR HYPERPLASIA (FNH)
What is the classic CT scan
finding?
P351

A

Liver mass with “central scar”

Think: focal = central

60
Q

FOCAL NODULAR HYPERPLASIA (FNH)
What are the possible
complications?
P351

A

Pain (no risk of cancer, very rarely

hemorrhage)

61
Q

FOCAL NODULAR HYPERPLASIA (FNH)
Is there a cancer risk with FNH?
P351

A

No (there is a cancer risk with adenoma)

62
Q

FOCAL NODULAR HYPERPLASIA (FNH)
What is the treatment?
P351

A

Resection or embolization if patient
is symptomatic; otherwise, follow if
diagnosis is confirmed; stop birth
control pills

63
Q

FOCAL NODULAR HYPERPLASIA (FNH)
Why does embolization work
with FNH?
P351

A

FNH tumors are usually fed by one

major artery

64
Q

HEPATIC HEMANGIOMA
What is it?
P352

A

Benign vascular tumor of the liver

65
Q

HEPATIC HEMANGIOMA
What is its claim to fame?
P352

A

Most common primary benign liver

tumor (up to 7% of population)

66
Q

HEPATIC HEMANGIOMA
What are the signs/symptoms?
P352

A

RUQ pain/mass, bruits

67
Q

HEPATIC HEMANGIOMA
What are the possible
complications?
P352

A

Pain, congestive heart failure, coagulopathy,
obstructive jaundice, gastric outlet
obstruction, Kasabach-Merritt syndrome,
hemorrhage (rare)

68
Q

HEPATIC HEMANGIOMA
Define Kasabach-Merritt
syndrome?
P352

A

Hemangioma and thrombocytopenia and

fibrinogenopenia

69
Q

HEPATIC HEMANGIOMA
How is the diagnosis made?
P352

A

CT scan with IV contrast, tagged red

blood scan, MRI, ultrasound

70
Q

HEPATIC HEMANGIOMA
Should biopsy be performed?
P352

A

No (risk of hemorrhage with biopsy)

71
Q

HEPATIC HEMANGIOMA
What is the treatment?
P352

A

Observation (>90%)

72
Q

HEPATIC HEMANGIOMA
What are the indications for
resection?
P352

A

Symptoms, hemorrhage, cannot make a

diagnosis

73
Q

HEPATOCELLULAR CARCINOMA
What is it?
P352

A

Most common primary malignancy of the

liver

74
Q

HEPATOCELLULAR CARCINOMA
By what name is it also
known?
P352

75
Q

HEPATOCELLULAR CARCINOMA
What is its incidence?
P352

A

Accounts for 80% of all primary

malignant liver tumors

76
Q

HEPATOCELLULAR CARCINOMA
What are the geographic
high-risk areas?
P352

A

Africa and Asia

77
Q

HEPATOCELLULAR CARCINOMA
What are the associated risk
factors?
P352

A

Hepatitis B virus, cirrhosis, aflatoxin
(fungi toxin of Aspergillus flavus); Other
risk factors: -1-antitrypsin deficiency,
hemochromatosis, liver fluke (Clonorchis
sinensis), anabolic steroids, polyvinyl
chloride, glycogen storage disease (type I)

78
Q 
HEPATOCELLULAR CARCINOMA
What percentage of patients
with cirrhosis will develop
hepatocellular carcinoma?
P353
79
Q

HEPATOCELLULAR CARCINOMA
What are the signs/symptoms?
P353

A 
Dull RUQ pain, hepatomegaly (classic
presentation: painful hepatomegaly),
abdominal mass, weight loss,
paraneoplastic syndromes, signs of portal
hypertension, ascites, jaundice, fever,
anemia, splenomegaly
80
Q

HEPATOCELLULAR CARCINOMA
What tests should be
ordered?
P353

A

Ultrasound, CT scan, angiography, tumor

marker elevation

81
Q

HEPATOCELLULAR CARCINOMA
What is the tumor marker?
P353

A

Elevated -fetoprotein

82
Q

HEPATOCELLULAR CARCINOMA
What is the most common
way to get a tissue diagnosis?
P353

A

Needle biopsy with CT scan, ultrasound,

or laparoscopic guidance

83
Q

HEPATOCELLULAR CARCINOMA
What is the most common
site of metastasis?
P353

84
Q

HEPATOCELLULAR CARCINOMA
What is the treatment of
hepatocellular carcinoma?
P353

A

Surgical resection, if possible

(e.g., lobectomy); liver transplant

85
Q 
HEPATOCELLULAR CARCINOMA
What are the treatment
options if the patient is not a
surgical candidate?
P353
A

Percutaneous ethanol tumor injection,
cryotherapy, and intra-arterial
chemotherapy

86
Q

HEPATOCELLULAR CARCINOMA
What are the indications for
liver transplantation?
P353

A

Cirrhosis and NO resection candidacy
as well as no distant or lymph node
metastases and no vascular invasion;
the tumor must be single, 3 cm

87
Q

HEPATOCELLULAR CARCINOMA
What is the prognosis under the following conditions:
Unresectable?
P353

A

Almost none survive a year

88
Q

HEPATOCELLULAR CARCINOMA
What is the prognosis under the following conditions:
Resectable?
P353

A

≈35% are alive at 5 years

89
Q

HEPATOCELLULAR CARCINOMA
Which subtype has the best
prognosis?
P353

A

Fibrolamellar hepatoma (young adults)

90
Q

ABSCESSES OF THE LIVER
What is a liver abscess?
P354

A

Abscess (collection of pus) in the liver

parenchyma

91
Q

ABSCESSES OF THE LIVER
What are the types of liver
abscess?
P354

A

Pyogenic (bacterial), parasitic (amebic),

fungal

92
Q 
ABSCESSES OF THE LIVER
What is the most common
location of abscess in the
liver?
P354
A

Right lobe > left lobe

93
Q

ABSCESSES OF THE LIVER
What are the sources?
P354

A 
Direct spread from biliary tract infection
    or
Portal spread from GI infection
    (e.g., appendicitis, diverticulitis)
Systemic source (bacteremia)
Liver trauma (e.g., liver gunshot wound)
Cryptogenic (unknown source)
94
Q

ABSCESSES OF THE LIVER
What are the two most
common types?
P354

A

Bacterial (most common in the United
States) and amebic (most common
worldwide)

95
Q 
ABSCESSES OF THE LIVER
BACTERIAL LIVER ABSCESS
What are the three most
common bacterial organisms
affecting the liver?
P354
A

Gram negatives: E. coli, Klebsiella, and

Proteus

96
Q 
ABSCESSES OF THE LIVER
BACTERIAL LIVER ABSCESS
What are the most common
sources/causes of bacterial
liver abscesses?
P354
A

Cholangitis, diverticulitis, liver cancer,

liver metastasis

97
Q

ABSCESSES OF THE LIVER
BACTERIAL LIVER ABSCESS
What are the signs/symptoms?
P354

A

Fever, chills, RUQ pain, leukocytosis,
increased liver function tests (LFTs),
jaundice, sepsis, weight loss

98
Q

ABSCESSES OF THE LIVER
BACTERIAL LIVER ABSCESS
What is the treatment?
P354

A

IV antibiotics (triple antibiotics with
metronidazole), percutaneous drainage
with CT scan or U/S guidance

99
Q 
ABSCESSES OF THE LIVER
BACTERIAL LIVER ABSCESS
What are the indications for
operative drainage?
P354
A

Multiple/loculated abscesses or if
multiple percutaneous attempts have
failed

100
Q

ABSCESSES OF THE LIVER
AMEBIC LIVER ABSCESS
What is the etiology?
P355

A 
Entamoeba histolytica (typically reaches
liver via portal vein from intestinal
amebiasis)
101
Q

ABSCESSES OF THE LIVER
AMEBIC LIVER ABSCESS
How does it spread?
P355

A

Fecal–oral transmission

102
Q

ABSCESSES OF THE LIVER
AMEBIC LIVER ABSCESS
What are the risk factors?
P355

A

Patients from countries south of the
U.S.–Mexican border, institutionalized
patients, homosexual men, alcoholic
patients

103
Q

ABSCESSES OF THE LIVER
AMEBIC LIVER ABSCESS
What are the signs/symptoms?
P355

A

RUQ pain, fever, hepatomegaly, diarrhea
Note: chills are much less common with
amebic abscesses than with pyogenic
abscesses

104
Q 
ABSCESSES OF THE LIVER
AMEBIC LIVER ABSCESS
Which lobe is most
commonly involved?
P355
A

Right lobe of the liver

105
Q 
ABSCESSES OF THE LIVER
AMEBIC LIVER ABSCESS
Classic description of
abscess contents?
P355
A

“Anchovy paste” pus

106
Q

ABSCESSES OF THE LIVER
AMEBIC LIVER ABSCESS
How is the diagnosis made?
P355

A

Lab tests, ultrasound, CT scan

107
Q 
ABSCESSES OF THE LIVER
AMEBIC LIVER ABSCESS
What lab tests should be
performed?
P355
A

Indirect hemagglutination titers for
Entamoeba antibodies elevated in >95%
of cases, elevated LFTs

108
Q

ABSCESSES OF THE LIVER
AMEBIC LIVER ABSCESS
What is the treatment?
P355

A

Metronidazole IV

109
Q 
ABSCESSES OF THE LIVER
AMEBIC LIVER ABSCESS
What are the indications for
percutaneous surgical
drainage?
P355
A

Refractory to metronidazole, bacterial

co-infection, or peritoneal rupture

110
Q 
ABSCESSES OF THE LIVER
AMEBIC LIVER ABSCESS
What are the possible
complications of large left
lobe liver amebic abscess?
P355
A

Erosion into the pericardial sac

potentially fatal!

111
Q

ABSCESSES OF THE LIVER
HYDATID LIVER CYST
What is it?
P355

A

Usually a right lobe cyst filled with

Echinococcus granulosus

112
Q

ABSCESSES OF THE LIVER
HYDATID LIVER CYST
What are the risk factors?
P356

A

Travel; exposure to dogs, sheep, and

cattle (carriers)

113
Q 
ABSCESSES OF THE LIVER
HYDATID LIVER CYST
What are the signs/
symptoms?
P356
A

RUQ abdominal pain, jaundice,

RUQ mass

114
Q

ABSCESSES OF THE LIVER
HYDATID LIVER CYST
How is the diagnosis made?
P356

A

Indirect hemagglutination antibody test
(serologic testing), Casoni skin test,
ultrasound, CT, radiographic imaging

115
Q 
ABSCESSES OF THE LIVER
HYDATID LIVER CYST
What are the findings
on AXR?
P356
A

Possible calcified outline of cyst

116
Q

ABSCESSES OF THE LIVER
HYDATID LIVER CYST
What are the major risks?
P356

A

Erosion into the pleural cavity,
pericardial sac, or biliary tree
Rupture into the peritoneal cavity
causing fatal anaphylaxis

117
Q 
ABSCESSES OF THE LIVER
HYDATID LIVER CYST
What is the risk of surgical
removal of echinococcal
(hydatid) cysts?
P356
A

Rupture or leakage of cyst contents
into the abdomen may cause a fatal
anaphylactic reaction

118
Q 
ABSCESSES OF THE LIVER
HYDATID LIVER CYST
When should percutaneous
drainage be performed?
P356
A

Never; may cause leaking into the

peritoneal cavity and anaphylaxis

119
Q

ABSCESSES OF THE LIVER
HYDATID LIVER CYST
What is the treatment?
P356

A 
Mebendazole, followed by surgical
resection; large cysts can be drained
and then injected with toxic irrigant
(scoliocide) into the cyst unless aspirate is
bilious (which means there is a biliary
connection) followed by cyst removal
120
Q 
ABSCESSES OF THE LIVER
HYDATID LIVER CYST
Which toxic irrigations are
used?
P356
A

Hypertonic saline, ethanol, or cetrimide

121
Q

ABSCESSES OF THE LIVER
HEMOBILIA
What is it?
P356

A

Blood draining via the common bile duct

into the duodenum

122
Q

ABSCESSES OF THE LIVER
HEMOBILIA
What is the diagnostic triad?
P356

A

Triad:

  1. RUQ pain
  2. Guaiac positive/upper GI bleeding
  3. Jaundice
123
Q

ABSCESSES OF THE LIVER
HEMOBILIA
What are the causes?
P356

A 
Trauma with liver laceration, percutaneous
transhepatic cholangiography (PTC), tumors
124
Q

ABSCESSES OF THE LIVER
HEMOBILIA
How is the diagnosis made?
P357

A

EGD (blood out of the ampulla of Vater),

A-gram

125
Q

ABSCESSES OF THE LIVER
HEMOBILIA
What is the treatment?
P357

A

A-gram with embolization of the bleeding

vessel

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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