Liver, C52 P345-357 Flashcards
ANATOMY
What is the name of the
liver capsule?
P345
Glisson’s capsule
ANATOMY
What is the “bare” area?
P345
Posterior section of the liver against the
diaphragm that is “bare” without peritoneal
covering
ANATOMY
What is Cantle’s line?
P345 (picture)
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
ANATOMY Which ligament goes from the anterior abdominal wall to the liver? P345
Falciform ligament
ANATOMY
What does the falciform
ligament contain?
P345
Ligamentum teres (obliterated umbilical vein)
ANATOMY
What is the coronary
ligament?
P345
Peritoneal reflection on top of the liver
that crowns (hence “coronary”) the liver
and attaches it to the diaphragm
ANATOMY
What are the triangular
ligaments of the liver?
P345
Right and left lateral extents of the
coronary ligament, which form triangles
ANATOMY
What is the origin of the
hepatic arterial supply?
P346
From the proper hepatic artery off of the
celiac trunk (celiac trunk to common
hepatic artery to proper hepatic artery)
ANATOMY
Identify the arterial
branches of the celiac trunk:
P346 (picture)
- Celiac trunk
- Splenic artery
- Left gastric artery
- Common hepatic artery
- Gastroduodenal artery
- Proper hepatic artery
- Left hepatic artery
- Right hepatic artery
ANATOMY
What is the venous supply?
P346
Portal vein (formed from the splenic vein and the superior mesenteric vein)
ANATOMY
What is the hepatic venous
drainage?
P346
Via the hepatic veins, which drain into the IVC (three veins: left, middle, and right)
ANATOMY
What sources provide
oxygen to the liver?
P347
Portal vein blood—50%
Hepatic artery blood—50%
ANATOMY
From what sources does the
liver receive blood?
P347
Portal system—75%
Hepatic artery system—25%
ANATOMY
Identify the segments of the
liver (French system).
P347 (picture)
(see picture)
ANATOMY What is the overall arrangement of the segments in the liver? P347 (picture)
Clockwise, starting at segment 1
ANATOMY What is the maximum amount of liver that can be resected while retaining adequate liver function? P347
>80%; if given adequate recovery time,
the original mass can be regenerated
(Remember Prometheus!)
ANATOMY
What are the signs/symptoms
of liver disease?
P347
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
ANATOMY
Which liver enzymes are
made by hepatocytes?
P348
AST and ALT (aspartate aminotransferase
and alanine aminotransferase)
ANATOMY
What is the source of
alkaline phosphatase?
P348
Ductal epithelium (thus, elevated with ductal obstruction)
ANATOMY
What is Child’s class?
(Child-Turcotte-Pugh)
P348
Classification system that estimates
hepatic reserve in patients with hepatic
failure and mortality
ANATOMY
What comprises the Child’s
classification?
P348
Laboratory: bilirubin, albumin
Clinical: encephalopathy, ascites,
prothrombin time (PT)
ANATOMY How can the criteria comprising the modified Child’s classification be remembered? P348
Use the acronym: “A BEAP”:
Ascites
Bilirubin Encephalopathy Albumin PT (prothrombin time)
ANATOMY Define Child’s classification: A B C P348
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)
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: <15% vs. overall = 30%
C: =33% vs. overall = 75%
ANATOMY
What does the MELD score
stand for?
P348
Model for End-stage Liver Disease
ANATOMY
What is measured in the
MELD score?
P348
INR, T.Bili, serum creatinine (SCR);
find good MELD calculators online
ANATOMY What is the mortality in cirrhotic patients for nonemergent nontransplant surgery? P349
Increase in mortality by 1% per 1 point
in the MELD score until 20, then 2% for
each MELD point
ANATOMY What is the mortality in cirrhotic patients for emergent nontransplant surgery? P349
14% increase in mortality per 1 point of
the MELD score
TUMORS OF THE LIVER
What is the most common
liver cancer?
P349
Metastatic disease outnumbers primary
tumors 20:1; primary site is usually the
GI tract
TUMORS OF THE LIVER What is the most common primary malignant liver tumor? P349
Hepatocellular carcinoma (hepatoma)
TUMORS OF THE LIVER
What is the most common
primary benign liver tumor?
P349
Hemangioma
TUMORS OF THE LIVER
What lab tests comprise the
workup for liver metastasis?
P349
LFTs (AST and alkaline phosphatase are
most useful), CEA for suspected primary
colon cancer
TUMORS OF THE LIVER
What are the associated
imaging studies?
P349
CT scan, ultrasound, A-gram
TUMORS OF THE LIVER
What is a right hepatic
lobectomy?
P349
Removal of the right lobe of the liver
(i.e., all tissue to the right of Cantle’s line
is removed)
TUMORS OF THE LIVER
What is a left hepatic
lobectomy?
P349
Removal of the left lobe of the liver
(i.e., removal of all the liver tissue to the
left of Cantle’s line)
TUMORS OF THE LIVER
What is a right
trisegmentectomy?
P349
Removal of all the liver tissue to the right
of the falciform ligament
TUMORS OF THE LIVER What are the three common types of primary benign liver tumors? P349
- Hemangioma
- Hepatocellular adenoma
- Focal nodular hyperplasia
TUMORS OF THE LIVER What are the four common types of primary malignant liver tumors? P350
- Hepatocellular carcinoma (hepatoma)
- Cholangiocarcinoma (when
intrahepatic) - Angiosarcoma (associated with chemical
exposure) - Hepatoblastoma (most common in
infants and children)
TUMORS OF THE LIVER What chemical exposures are risk factors for angiosarcoma? P350
Vinyl chloride, arsenic, thorotrast
contrast
TUMORS OF THE LIVER
What is a “hepatoma”?
P350
Hepatocellular carcinoma
TUMORS OF THE LIVER
What are the other benign
liver masses?
P350
Benign liver cyst, bile duct hamartomas,
bile duct adenoma
TUMORS OF THE LIVER
What is a liver “hamartoma”?
P350
White hard nodule made up of normal
liver cells
HEPATOCELLULAR ADENOMA
What is it?
P350
Benign liver tumor
HEPATOCELLULAR ADENOMA
Describe the histology.
P350
Normal hepatocytes without bile ducts
HEPATOCELLULAR ADENOMA
What are the associated risk
factors?
P350
Women, birth control pills (Think:
ABC = Adenoma Birth Control),
anabolic steroids, glycogen storage
disease
HEPATOCELLULAR ADENOMA
What is the female:male
ratio?
P350
9:1
HEPATOCELLULAR ADENOMA
What is the average age of
occurrence?
P350
30–35 years of age
HEPATOCELLULAR ADENOMA
What are the signs/symptoms?
P350
RUQ pain/mass, RUQ fullness,
bleeding (rare)
HEPATOCELLULAR ADENOMA
What are the possible
complications?
P350
Rupture with bleeding (33%), necrosis,
pain, risk of hepatocellular carcinoma
HEPATOCELLULAR ADENOMA
How is the diagnosis made?
P350
CT scan, U/S, +/– biopsy (rule out
hemangioma with RBC-tagged scan!)