Liver tumour and failure

Question 1

Liver cysts

Answer 1

usually simple
bile duct origin
common
usually asymptomatic

Question 2

Simple liver cysts

Answer 2

thin-walled
homogeneous
usually asymptomatic
treat if large/symptomatic

Question 3

Complex liver cysts

Answer 3

thickened walls
large septations
papilae
non-homogeneous
need to investigate

Question 4

Hemangioma

Answer 4

disorganized group of blood vessels
most common liver tumour
endothelial orgin
collagen scaffold
contrast retention on CT
may be multiple
usually asymptomatic

Question 5

Focal nodular hyperplasia

Answer 5

hyperplasia of normal liver cells
possibly related to presence of atrial-venous malformation
second most common liver tumour
rarely symptomatic
presence of central scar on CT

Question 6

Liver cell adenoma

Answer 6

benign neoplasm of hepatocyte origin
hormone sensitive - OCP
may be symptomatic
gross appearance: large, fleshy
histological: looks like a well-differentiated HCC
risk of rupture
may regress with cessation of OCP
risk of rupture and of malignant degeneration increases with size, so consider surgical removal if >5cm

Question 7

HCC

Answer 7

primary malignancy of hepatocytes
associated with cirrhosis (hep B, C, hemochromatosis most high risk)
may be multifocal

Question 8

HCC diagnosis

Answer 8

tumour marker: alphaFP (can go up with injury as well)

contrast CT - rapid enhancement on arterial phase, wash-out during venous phase

Question 9

HCC treatment

Answer 9

surgical resection - if the patient has underlying liver disease, cannot take out a large portion of liver
otehr: local ablation, chemoembolization, liver transplant, systemic chemotherapy
cannot do radiotherapy

Question 10

Cholangiocarcinoma

Answer 10

Malignant neoplasm of the bile duct epithelium
Risk factors: PSC, clonorchis infection, choledochal cysts
usually involve major bile ducts leading to obstructive jaundice
can also arise from intrahepatic ducts

Question 11

Cholangiocarcinoma treatment

Answer 11

surgical resection
early local extension common and often precludes surgery - difficult
stenting/bypass (Palliative), chemotherapy (poor results)

Question 12

Liver metastasis

Answer 12

more common than primary tumours in western countries

usually multifocal and systemic

Question 13

Liver metastasis diagnosis

Answer 13

may be hyper- or hypovascular
occasionally focal
poor blood supply

Question 14

Liver metastasis treatment

Answer 14

may be responsive to liver resection
ablation
chemotherapy

Question 15

Gallstone pathophysiology

Answer 15

Bile supersaturated –> precipitation of microscopic crystals, which grows over time
Occlusion of ducts by stones or sludge (gallbladder mucus + crystals)

Cholesterol stones (80%)

• associated with females, European/native Americans
  others: calcium, bilirubin, pigment, mixed stones

Question 16

Gallstone clinical presentation

Answer 16

1. Lithogenic - condition favour stone formation
2. Asymptomatic - do not require treatment
3. episodes of biliary colic during gallbladder wall tension in RUQ - right scapular tip radiation (Collins sign)
   - resolves in 30-90 min
   - sporadic, unpredictable
   - begins postprandially, intense/dull
4. complicated cholelithiasis
   - inflammation
   - infection - abscess, necrosis
   - progressive fibrosis and loss of function
   - GB adenocarcinoma, poor prognosis with invasion
   - large stone - cholecystoenteric fistula

Question 17

Gallstone workup

Answer 17

US

• most sensitive, specific
• EUS also accurate

CT: more expensive, less sensitive

• often used for abdominal pain workup
• superior to US for gallstones in distal common bile duct

MRI
ERCP

Question 18

Gallstone Tx

Answer 18

Once gallstones become symptomatic, surgical intervention with cholecystectomy indicated

• if uncomplicated, can do medical therapy if not a good surgical candidate
• medical treatments: oral bile salt therapy, contact dissolution, extracorporeal shockwave lithotripsy

Question 19

Classification of liver tumours

Answer 19

Congenital vs acquired
–> non-neoplastic vs neoplastic
–> cysic vs solid, benign vs malignant
if malignant –> primary vs metastatic

Question 20

Acute liver failure definition

Answer 20

no previous liver disease
Hyperacute: within 2 weeks
Acute: 8 weeks
Subacute: 24 weeks
Fulminant failure: severe enough to produce encephalopathy

Question 21

Etiology of acute liver failure

Answer 21

often not found
Viral: hepatitis A-E
Drugs& toxins
Metabolic: acute Wilson's disease( rare)
Autoimmune (very rare)

Question 22

Pathogenesis of liver cirrhosis

Answer 22

1) Lipocytes (Ito cells) in space of Disse - vitamin A storage
2) Inflammation activates/transforms Ito cells
3) Ito cells release factors leading to collagen deposition
4) Continued deposition –> fibrosis

Question 23

Decompensated cirrhosis

Answer 23

Clinical: ascites, bleeding esophageal/ gastric varices, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome

Lab: hypoalbuminemia, coagulopathy, hyperbilirubinemia (jaundice)