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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
ANATOMY What does the MELD score stand for? P348
Model for End-stage Liver Disease
26
ANATOMY What is measured in the MELD score? P348
INR, T.Bili, serum creatinine (SCR); | find good MELD calculators online
27
``` 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
28
``` ANATOMY What is the mortality in cirrhotic patients for emergent nontransplant surgery? P349 ```
14% increase in mortality per 1 point of | the MELD score
29
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
30
``` TUMORS OF THE LIVER What is the most common primary malignant liver tumor? P349 ```
Hepatocellular carcinoma (hepatoma)
31
TUMORS OF THE LIVER What is the most common primary benign liver tumor? P349
Hemangioma
32
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
33
TUMORS OF THE LIVER What are the associated imaging studies? P349
CT scan, ultrasound, A-gram
34
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)
35
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)
36
TUMORS OF THE LIVER What is a right trisegmentectomy? P349
Removal of all the liver tissue to the right | of the falciform ligament
37
``` TUMORS OF THE LIVER What are the three common types of primary benign liver tumors? P349 ```
1. Hemangioma 2. Hepatocellular adenoma 3. Focal nodular hyperplasia
38
``` TUMORS OF THE LIVER What are the four common types of primary malignant liver tumors? P350 ```
1. Hepatocellular carcinoma (hepatoma) 2. Cholangiocarcinoma (when intrahepatic) 3. Angiosarcoma (associated with chemical exposure) 4. Hepatoblastoma (most common in infants and children)
39
``` TUMORS OF THE LIVER What chemical exposures are risk factors for angiosarcoma? P350 ```
Vinyl chloride, arsenic, thorotrast | contrast
40
TUMORS OF THE LIVER What is a “hepatoma”? P350
Hepatocellular carcinoma
41
TUMORS OF THE LIVER What are the other benign liver masses? P350
Benign liver cyst, bile duct hamartomas, | bile duct adenoma
42
TUMORS OF THE LIVER What is a liver “hamartoma”? P350
White hard nodule made up of normal | liver cells
43
HEPATOCELLULAR ADENOMA What is it? P350
Benign liver tumor
44
HEPATOCELLULAR ADENOMA Describe the histology. P350
Normal hepatocytes without bile ducts
45
HEPATOCELLULAR ADENOMA What are the associated risk factors? P350
Women, birth control pills (Think: ABC = Adenoma Birth Control), anabolic steroids, glycogen storage disease
46
HEPATOCELLULAR ADENOMA What is the female:male ratio? P350
9:1
47
HEPATOCELLULAR ADENOMA What is the average age of occurrence? P350
30–35 years of age
48
HEPATOCELLULAR ADENOMA What are the signs/symptoms? P350
RUQ pain/mass, RUQ fullness, | bleeding (rare)
49
HEPATOCELLULAR ADENOMA What are the possible complications? P350
Rupture with bleeding (33%), necrosis, | pain, risk of hepatocellular carcinoma
50
HEPATOCELLULAR ADENOMA How is the diagnosis made? P350
CT scan, U/S, +/– biopsy (rule out | hemangioma with RBC-tagged scan!)
51
HEPATOCELLULAR ADENOMA What is the treatment: Small? P351
Stop birth control pills—it may regress; if not, surgical resection is necessary
52
``` HEPATOCELLULAR ADENOMA What is the treatment: Large (>5 cm), bleeding, painful, or ruptured? P351 ```
Surgical resection
53
FOCAL NODULAR HYPERPLASIA (FNH) What is it? P351
Benign liver tumor
54
FOCAL NODULAR HYPERPLASIA (FNH) Describe the histology. P351
Normal hepatocytes and bile ducts | adenoma has no bile ducts
55
FOCAL NODULAR HYPERPLASIA (FNH) What is the average age of occurrence? P351
≈40 years
56
FOCAL NODULAR HYPERPLASIA (FNH) What are the associated risk factors? P351
Female gender
57
FOCAL NODULAR HYPERPLASIA (FNH) Are the tumors associated with birth control pills? P351
Yes, but not as clearly associated as with | adenoma
58
FOCAL NODULAR HYPERPLASIA (FNH) How is the diagnosis made? P351
Nuclear technetium-99 study, U/S, | CT scan, A-gram, biopsy
59
FOCAL NODULAR HYPERPLASIA (FNH) What is the classic CT scan finding? P351
Liver mass with “central scar” | Think: focal = central
60
FOCAL NODULAR HYPERPLASIA (FNH) What are the possible complications? P351
Pain (no risk of cancer, very rarely | hemorrhage)
61
FOCAL NODULAR HYPERPLASIA (FNH) Is there a cancer risk with FNH? P351
No (there is a cancer risk with adenoma)
62
FOCAL NODULAR HYPERPLASIA (FNH) What is the treatment? P351
Resection or embolization if patient is symptomatic; otherwise, follow if diagnosis is confirmed; stop birth control pills
63
FOCAL NODULAR HYPERPLASIA (FNH) Why does embolization work with FNH? P351
FNH tumors are usually fed by one | major artery
64
HEPATIC HEMANGIOMA What is it? P352
Benign vascular tumor of the liver
65
HEPATIC HEMANGIOMA What is its claim to fame? P352
Most common primary benign liver | tumor (up to 7% of population)
66
HEPATIC HEMANGIOMA What are the signs/symptoms? P352
RUQ pain/mass, bruits
67
HEPATIC HEMANGIOMA What are the possible complications? P352
Pain, congestive heart failure, coagulopathy, obstructive jaundice, gastric outlet obstruction, Kasabach-Merritt syndrome, hemorrhage (rare)
68
HEPATIC HEMANGIOMA Define Kasabach-Merritt syndrome? P352
Hemangioma and thrombocytopenia and | fibrinogenopenia
69
HEPATIC HEMANGIOMA How is the diagnosis made? P352
CT scan with IV contrast, tagged red | blood scan, MRI, ultrasound
70
HEPATIC HEMANGIOMA Should biopsy be performed? P352
No (risk of hemorrhage with biopsy)
71
HEPATIC HEMANGIOMA What is the treatment? P352
Observation (>90%)
72
HEPATIC HEMANGIOMA What are the indications for resection? P352
Symptoms, hemorrhage, cannot make a | diagnosis
73
HEPATOCELLULAR CARCINOMA What is it? P352
Most common primary malignancy of the | liver
74
HEPATOCELLULAR CARCINOMA By what name is it also known? P352
Hepatoma
75
HEPATOCELLULAR CARCINOMA What is its incidence? P352
Accounts for 80% of all primary | malignant liver tumors
76
HEPATOCELLULAR CARCINOMA What are the geographic high-risk areas? P352
Africa and Asia
77
HEPATOCELLULAR CARCINOMA What are the associated risk factors? P352
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
``` HEPATOCELLULAR CARCINOMA What percentage of patients with cirrhosis will develop hepatocellular carcinoma? P353 ```
≈5%
79
HEPATOCELLULAR CARCINOMA What are the signs/symptoms? P353
``` Dull RUQ pain, hepatomegaly (classic presentation: painful hepatomegaly), abdominal mass, weight loss, paraneoplastic syndromes, signs of portal hypertension, ascites, jaundice, fever, anemia, splenomegaly ```
80
HEPATOCELLULAR CARCINOMA What tests should be ordered? P353
Ultrasound, CT scan, angiography, tumor | marker elevation
81
HEPATOCELLULAR CARCINOMA What is the tumor marker? P353
Elevated -fetoprotein
82
HEPATOCELLULAR CARCINOMA What is the most common way to get a tissue diagnosis? P353
Needle biopsy with CT scan, ultrasound, | or laparoscopic guidance
83
HEPATOCELLULAR CARCINOMA What is the most common site of metastasis? P353
Lungs
84
HEPATOCELLULAR CARCINOMA What is the treatment of hepatocellular carcinoma? P353
Surgical resection, if possible | (e.g., lobectomy); liver transplant
85
``` HEPATOCELLULAR CARCINOMA What are the treatment options if the patient is not a surgical candidate? P353 ```
Percutaneous ethanol tumor injection, cryotherapy, and intra-arterial chemotherapy
86
HEPATOCELLULAR CARCINOMA What are the indications for liver transplantation? P353
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
HEPATOCELLULAR CARCINOMA What is the prognosis under the following conditions: Unresectable? P353
Almost none survive a year
88
HEPATOCELLULAR CARCINOMA What is the prognosis under the following conditions: Resectable? P353
≈35% are alive at 5 years
89
HEPATOCELLULAR CARCINOMA Which subtype has the best prognosis? P353
Fibrolamellar hepatoma (young adults)
90
ABSCESSES OF THE LIVER What is a liver abscess? P354
Abscess (collection of pus) in the liver | parenchyma
91
ABSCESSES OF THE LIVER What are the types of liver abscess? P354
Pyogenic (bacterial), parasitic (amebic), | fungal
92
``` ABSCESSES OF THE LIVER What is the most common location of abscess in the liver? P354 ```
Right lobe > left lobe
93
ABSCESSES OF THE LIVER What are the sources? P354
``` 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
ABSCESSES OF THE LIVER What are the two most common types? P354
Bacterial (most common in the United States) and amebic (most common worldwide)
95
``` ABSCESSES OF THE LIVER BACTERIAL LIVER ABSCESS What are the three most common bacterial organisms affecting the liver? P354 ```
Gram negatives: E. coli, Klebsiella, and | Proteus
96
``` ABSCESSES OF THE LIVER BACTERIAL LIVER ABSCESS What are the most common sources/causes of bacterial liver abscesses? P354 ```
Cholangitis, diverticulitis, liver cancer, | liver metastasis
97
ABSCESSES OF THE LIVER BACTERIAL LIVER ABSCESS What are the signs/symptoms? P354
Fever, chills, RUQ pain, leukocytosis, increased liver function tests (LFTs), jaundice, sepsis, weight loss
98
ABSCESSES OF THE LIVER BACTERIAL LIVER ABSCESS What is the treatment? P354
IV antibiotics (triple antibiotics with metronidazole), percutaneous drainage with CT scan or U/S guidance
99
``` ABSCESSES OF THE LIVER BACTERIAL LIVER ABSCESS What are the indications for operative drainage? P354 ```
Multiple/loculated abscesses or if multiple percutaneous attempts have failed
100
ABSCESSES OF THE LIVER AMEBIC LIVER ABSCESS What is the etiology? P355
``` Entamoeba histolytica (typically reaches liver via portal vein from intestinal amebiasis) ```
101
ABSCESSES OF THE LIVER AMEBIC LIVER ABSCESS How does it spread? P355
Fecal–oral transmission
102
ABSCESSES OF THE LIVER AMEBIC LIVER ABSCESS What are the risk factors? P355
Patients from countries south of the U.S.–Mexican border, institutionalized patients, homosexual men, alcoholic patients
103
ABSCESSES OF THE LIVER AMEBIC LIVER ABSCESS What are the signs/symptoms? P355
RUQ pain, fever, hepatomegaly, diarrhea Note: chills are much less common with amebic abscesses than with pyogenic abscesses
104
``` ABSCESSES OF THE LIVER AMEBIC LIVER ABSCESS Which lobe is most commonly involved? P355 ```
Right lobe of the liver
105
``` ABSCESSES OF THE LIVER AMEBIC LIVER ABSCESS Classic description of abscess contents? P355 ```
“Anchovy paste” pus
106
ABSCESSES OF THE LIVER AMEBIC LIVER ABSCESS How is the diagnosis made? P355
Lab tests, ultrasound, CT scan
107
``` ABSCESSES OF THE LIVER AMEBIC LIVER ABSCESS What lab tests should be performed? P355 ```
Indirect hemagglutination titers for Entamoeba antibodies elevated in >95% of cases, elevated LFTs
108
ABSCESSES OF THE LIVER AMEBIC LIVER ABSCESS What is the treatment? P355
Metronidazole IV
109
``` ABSCESSES OF THE LIVER AMEBIC LIVER ABSCESS What are the indications for percutaneous surgical drainage? P355 ```
Refractory to metronidazole, bacterial | co-infection, or peritoneal rupture
110
``` ABSCESSES OF THE LIVER AMEBIC LIVER ABSCESS What are the possible complications of large left lobe liver amebic abscess? P355 ```
Erosion into the pericardial sac | potentially fatal!
111
ABSCESSES OF THE LIVER HYDATID LIVER CYST What is it? P355
Usually a right lobe cyst filled with | Echinococcus granulosus
112
ABSCESSES OF THE LIVER HYDATID LIVER CYST What are the risk factors? P356
Travel; exposure to dogs, sheep, and | cattle (carriers)
113
``` ABSCESSES OF THE LIVER HYDATID LIVER CYST What are the signs/ symptoms? P356 ```
RUQ abdominal pain, jaundice, | RUQ mass
114
ABSCESSES OF THE LIVER HYDATID LIVER CYST How is the diagnosis made? P356
Indirect hemagglutination antibody test (serologic testing), Casoni skin test, ultrasound, CT, radiographic imaging
115
``` ABSCESSES OF THE LIVER HYDATID LIVER CYST What are the findings on AXR? P356 ```
Possible calcified outline of cyst
116
ABSCESSES OF THE LIVER HYDATID LIVER CYST What are the major risks? P356
Erosion into the pleural cavity, pericardial sac, or biliary tree Rupture into the peritoneal cavity causing fatal anaphylaxis
117
``` ABSCESSES OF THE LIVER HYDATID LIVER CYST What is the risk of surgical removal of echinococcal (hydatid) cysts? P356 ```
Rupture or leakage of cyst contents into the abdomen may cause a fatal anaphylactic reaction
118
``` ABSCESSES OF THE LIVER HYDATID LIVER CYST When should percutaneous drainage be performed? P356 ```
Never; may cause leaking into the | peritoneal cavity and anaphylaxis
119
ABSCESSES OF THE LIVER HYDATID LIVER CYST What is the treatment? P356
``` 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
``` ABSCESSES OF THE LIVER HYDATID LIVER CYST Which toxic irrigations are used? P356 ```
Hypertonic saline, ethanol, or cetrimide
121
ABSCESSES OF THE LIVER HEMOBILIA What is it? P356
Blood draining via the common bile duct | into the duodenum
122
ABSCESSES OF THE LIVER HEMOBILIA What is the diagnostic triad? P356
Triad: 1. RUQ pain 2. Guaiac positive/upper GI bleeding 3. Jaundice
123
ABSCESSES OF THE LIVER HEMOBILIA What are the causes? P356
``` Trauma with liver laceration, percutaneous transhepatic cholangiography (PTC), tumors ```
124
ABSCESSES OF THE LIVER HEMOBILIA How is the diagnosis made? P357
EGD (blood out of the ampulla of Vater), | A-gram
125
ABSCESSES OF THE LIVER HEMOBILIA What is the treatment? P357
A-gram with embolization of the bleeding | vessel

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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