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Year 3 General Surgery > Liver Pathology > Flashcards

Liver Pathology Flashcards

1
Q

what does liver failure lead to?

A
  • increased susceptibility to infection
  • increased susceptibility to toxins and drugs
  • increased blood ammonia due to failure to clear ammonia via urea cycle leading to hepatic encephalopathy
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2
Q

define acute liver failure

A

rapid failure of the liver’s metabolic and synthetic function in a patient without a known pre-existing liver disease

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3
Q

how is acute liver failure classified?

A

based on the time interval between the initial onset of jaundice and the development of encephalopathy

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4
Q

what are the causes of acute liver failure?

A

paracetamol overdose - UK

acute viral hepatitis - worldwide

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5
Q

what is the presentation of acute liver failure?

A
  • jaundice
  • presence of risk factors (e.g. known paracetamol overdose)
  • hepatomegaly
  • signs of liver encapholapthy (lethargy, poor memory, liver asterixis, confusion)
  • abdominal pain
  • nausea and vomiting
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6
Q

What investigations would you carry out in acute liver failure?

A
  • LFTs - high bilirubin, very high ALT and AST in paracetamol overdose
  • clotting screen - PT time increased
  • U&Es - renal failure is a known complication of ALF
  • FBC
  • Blood type and screen
  • ABG - acidosis and lactate
  • paracetamol level
  • viral hepatitis serology
  • autoimmune hepatitis markers
  • pregnancy test
  • abdominal ultrasound with doppler (hepatic vessel thrombosis, hepatomegaly)
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7
Q

how would you manage acute liver failure?

A
  • hospitalisation
  • liver transplant assessment
  • neurological status monitoring for encephalopathy
  • monitor blood glucose, electrolytes and blood cultures (increased risk of infection)
  • look for underlying cause and treat (acetylcysteine for paracetamol overdose, methylprednisolone for autoimmune hepatitis)
  • fluid resuscitation and maintenance
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8
Q

what type of tumours are most liver cancers?

A

metastatic (90%)

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9
Q

what is the main primary liver cancer? from where does this cancer arise?

A

hepatocellular carcinoma (thought to arise from hepatic stem cells)

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10
Q

what are the causes and risk factors of hepatocellular carcinoma?

A
  • viral hepatitis
  • chronic alcoholism
  • family history of liver disease
  • primary biliary cirrhosis
  • hereditary haemochromatosis
  • aflatoxin exposure
  • smoking
  • advanced age (>70)
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11
Q

what is the presentation of hepatocellular carcinoma?

A

vague, non-specific symptoms

  • fatigue
  • fever
  • weight loss
  • lethargy
  • dull ache in right upper quadrant (uncommon but characteristic of hepatocellular carcinoma)
  • ascites
  • jaundice
  • irregular, enlarged, craggy, tender liver
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12
Q

what investigations are carried out when suspecting hepatocellular carcinoma?

A
  • LFTs (raised AST and ALT - AST:ALT ratio >2, likely alcoholic liver disease)
  • Alpha fetoprotein - raised in most cases
  • routine bloods - platelets low, clotting prolonged
  • imaging - US, Staging CT, MRI liver, biopsy or percutaneous fine-needle aspiration (not advised if tumour is operable as can lead to seeing of the tumour)
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13
Q

what is the management of hepatocellulr carcinoma?

A
  • surgical resection or transplantation
  • image-guided ablation
  • alcohol ablation
  • transarterial chemoembolisation (TACE)
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14
Q

what is the criteria used to decide suitability for liver transplant?

A

milan criteria:

  • one lesion smaller than 5 cm or 3 lesions smaller than 3 cm
  • no extra-hepatic manifestations
  • no vascular infiltration
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15
Q

which cancers commonly metastasise to the liver?

A
  • bowel
  • breast
  • pancreas
  • stomach
  • lung
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16
Q

how are metastatic cancers of the liver managed?

A
  • surgery if the metastasis is confined to the liver and primary tumour is under control
  • transarterial embolisation
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17
Q

what are simple liver cysts?

A

fluid-filled epithelial-lined sacs

18
Q

what is the presentation of simple liver cysts?

A
  • usually asymptomatic
  • often detected incidentally on imaging
  • abdominal pain
  • nausea
  • early satiety (mass effect)
19
Q

what investigations are carried out for simple liver cysts?

A
  • LFTs - typically normal
  • Tumour markers - CEA and CA19-9 can sometimes be elevated
  • ultrasound - black spherical well-defined mass with no septations
20
Q

what is the management of simple liver cysts?

A
  • most cysts require no intervention
  • cysts >4cm, follow-up US at 3, 6 and 12 months to check for growth
  • if symptomatic - US-guided aspiration or laparoscopic de-roofing
21
Q

what is polycystic liver disease?

A

characterised bu the presence of >20 cysts in the liver

22
Q

what is polycystic kidney disease caused by?

A

one of two autosomal dominate conditions:

  • autosomal dominant polycystic kidney disease (mutations in PKD1 and PKD2 genes)
  • autosomal dominant polycystic liver disease
23
Q

what is the presentation of patients with polycystic liver disease?

A
  • majority are asymptomatic
  • abdominal pain as cysts grow in size
  • hepatomegaly
  • urinary tract symptoms if there is renal disease (PKD)
24
Q

what investigations re carried out when suspecting polycystic liver disease?

A
  • LFTs - normal (ALP can sometimes be raised)
  • Renal function tests
  • Ultrasound for definitive diagnosis
25
Q

what is the management of polycystic liver disease?

A
  • asymptomatic patients don’t need treatment
  • monitored regularly as the disease progresses
  • surgery - resection of severe areas
  • US-guided aspiration
  • laparoscopic de-roofing of cysts
26
Q

what are the indications for surgery in polycystic liver disease?

A
  • intractable symptoms
  • inability to rule out malignancy from imaging alone
  • prevention of malignancy
27
Q

what are cystoadenomas?

A

non-invasive mucinous cystic neoplasms

pre-malignant lesions (can undergo malignant transformation into cystadenocarcinomas)

28
Q

what is the presentation of cystic neoplasms?

A
  • usually asymptomatic
  • abdominal pain
  • anorexia
  • nausea
  • fullness
  • bloating
29
Q

what investigations are carried out when suspecting cystic neoplasm?

A
  • LFTs (often normal, ALP can be slightly elevated)
  • CEA and CA19-9 can be slightly elevated
  • US scan
  • CT imaging with contrast
  • **aspiration or biopsy should be avoided if cystic neoplasm is suspected - can cause seeding of malignancy)
30
Q

what are the features of a cystic neoplasm on imaging?

A
  • septations (divisions)
  • wall enhancement
  • nodularity
31
Q

how are cystic neoplasms managed?

A

liver lobe resection (both cyst adenomas and cystadenocarcinomas) -> histopathology to confirm diagnosis

32
Q

what are hydatid cysts?

A

cysts caused by infection with tapeworm echinococcus granulosus.

33
Q

what is the route of transmission of the causative organism of hydatid cysts?

A

faeco-oral

34
Q

what is the presentation of hydatid cysts?

A
  • can remain asymptomatic for many years
  • vague abdominal pain
  • jaundice or cholangitis (if biliary system involved)
  • vomiting
  • dyspepsia
  • early satiety
  • anaphylaxis if a cyst ruptures
35
Q

what are the investigations that are carried out when suspecting a hydatid cyst?

A
  • LFTs (often normal, unless biliary tree affected, then presents like cholangitis)
  • FBC - eosinophilia
  • echinococcal antibodies
  • Ultrasound scan (calcified, spherical lesions with multiple septations)
  • CT imaging with contrast
36
Q

what is the management of hydatid cysts?

A
  • if asymptomatic, monitor
  • cyst deroofing
  • radiological drainage and injection of a scolicidal agent (prevents dissemination of the parasite during surgery)
  • combination of anti-microbials
    • aspiration is not recommended as can rupture and cause anaphylaxis
37
Q

what are the common causes of liver abscess?

A
  • Cholecystitis
  • cholangitis
  • diverticulitis
  • appendicits
  • septicaemia
38
Q

what is the presentation of a liver abscess?

A
  • Fever
  • rigors
  • abdominal pain - RUQ tenderness
  • bloating
  • nausea
  • anorexia
  • weight loss
  • fatigue
  • jaundice
  • possible hepatomegaly
  • signs of shock if the abscess ruptures
39
Q

what investigations are carried out when suspecting liver abscess?

A
  • FBC (leucocytosis)
  • LFTs (raised ALP, deranged ALT, deranged bilirubin)
  • Blood culture
  • Ultrasound
  • CT imaging with contrast
40
Q

how does a liver abscess appear on ultrasound?

A
  • poorly defined lesion
  • hyper- and hypo-echoic areas (light and dark)
  • +/- gas bubbles
  • +/- septations
41
Q

how is a liver abscess managed?

A
  • resuscitation and stabilisation (don’t forget sepsis)
  • appropriate antibiotic therapy
  • drainage of abscess using image-guided (US or CT) aspiration
  • manage underlying cause
  • surgery if the abscess has ruptured or is refractory to antibiotic treatment

Year 3 General Surgery (9 decks)

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