General Surgery: Liver

Front 1

Falciform ligament

Back 1

Contains ligamentum teres, a remnant of the umbilical vein

Front 2

How many segments of the liver are there?

Back 2

8

Front 3

Resection of what percent of the normal liver parenchyma remains compatible with life?

Back 3

80%

Front 4

Portal vein

Back 4

Valveless vein formed at junction of SMV and splenic vein

*Provides 75% of liver's blood supply

Front 5

Pringle Maneuver

Back 5

Compression of structures within the hepatoduodenal ligament (portal vein and hepatic artery)
*Used during some abdominal surgeries

Front 6

Where do left and right hepatic veins drain?

Back 6

Directly into the IVC

Front 7

Where does the middle hepatic vein drain?

Back 7

Into the left hepatic vein

Front 8

The Portal Triad

Back 8

1) Portal vein
2) Hepatic artery
3) Bile duct

Front 9

Hepatic Lobule

Back 9

Contains central hepatic vein with portal triads along the periphery

Front 10

Kupffer cells

Back 10

Leukocytes attached to luminal surface of liver endothelial cells --> "liver macrophages"

Front 11

Pyogenic liver abscesses account for what % of liver abscesses?

Back 11

80%

Front 12

Routes of infection for pyogenic liver abscess

Back 12

1) Ascending biliary tree infections
2) Portal venous system
3) Bacteremia via hepatic artery
4) Direct extension from adjacent infection (i.e., appendicitis, diverticulitis)
5) Primary infection after liver trauma

Front 13

Bugs most commonly found in pyogenic liver abscesses

Back 13

1) Enteric gram-negative rods (Klebsiella, Proteus, E.coli)
2) Anaerobes (Bacteriodes)

Front 14

Common signs & symptoms of pyogenic liver abscess

Back 14

1) Fever
2) Chills
3) Weight loss
4) RUQ pain
5) Leukocytosis
6) Elevated LFTs
7) Sepsis

Front 15

Treatment of pyogenic liver abscess

Back 15

Broad-spectrum antibiotics and drainage of abscess

Front 16

Etiology of amebic liver abscess

Back 16

Entamoeba histolytica

*Most abscesses occur in right lobe

Front 17

How is Entamoeba histolytica transported to the liver?

Back 17

Fecal/ oral contact
After intestinal infestation, trophozoite is transported via portal venous system

*Intestinal infestation precedes abscess by several weeks

Front 18

Aspirate of amoebic abscess

Back 18

"Anchovy-paste" --> due to necrotic tissue and blood

Front 19

Signs & symptoms of amoebic abscess

Back 19

1) Hepatomegaly
2) Jaundice
*Fever, RUQ pain, nausea/vomiting, diarrhea

Front 20

Best diagnostic test for amoebic liver abscess

Back 20

Serum test for antibodies to E. histolytica is highly specific

Front 21

Antibiotic treatment of amoebic abscess

Back 21

Metronidazole

Front 22

Parasite responsible for Hydatid liver cysts

Back 22

Echinoccus species

*Most common in the right lobe of the liver

Front 23

Major risk factor for hydatid cysts

Back 23

Contact with dogs that eat carrier animals (i.e., sheep)

Front 24

Presentation of hydatid cysts

Back 24

1) Vague abdominal pain
2) Jaundice, fever, nausea

Front 25

Diagnosis of hydatid cysts

Back 25

1) ELISA against Echinococcus
2) EOSINOPHILIA (10-30%)
3) LFT abnormal in 25%
4) CT scan --> CALCIFIED WALL of cyst
*Echinococcus is a tapeworm --> Treat w/ mebendazole

Front 26

Treatment of hydatid cyst

Back 26

1) Surgical drainage of cyst
2) Injection of HYPERtonic saline (kills remaining organisms)
3) Resection of cyst wall
4) Antibiotic therapy (Mebendazole)

Front 27

Complication of hydatid cyst treatment

Back 27

Cyst contents can spill into peritoneal cavity and result in life-threatening anaphylactic reaction

Front 28

MC benign tumors of the liver

Back 28

Hemangiomas - dilated endothelial-lined vascular spaces

Front 29

Sequestration of platelets within hemangioma

Back 29

Kasabach-Merritt Syndrome --> thrombocytopenia

Front 30

Diagnosis of liver hemangioma

Back 30

Tagged-RBC scan

*Needle biopsy avoided due to risk of hemorrhage

Front 31

Benign liver tumor seen exclusively in women 30 - 50 years old

Back 31

Hepatic adenoma (liver cell adenoma)

Front 32

Greatest risk factor for hepatic adenoma

Back 32

Oral contraceptives

*Also diabetes, type I glycogen storage disease, and anabolic storage

Front 33

Signs & Symptoms of hepatic adenoma

Back 33

1) RUQ pain
2) Palpable mass
3) Hepatomegaly
4) Acute abdominal pain and hypotension --> Tumor rupture

Front 34

What % of hepatic adenomas transform into malignant HCC?

Back 34

10%

Front 35

Treatment of hepatic adenoma

Back 35

Surgical excision - based on risk of rupture and malignant transformation

*Some adenomas regress upon discontinuation of OCP

Front 36

Focal Nodular Hyperplasia (FNH)

Back 36

Benign and often asymptomatic tumor of the liver not associated with rupture or malignant transformation

*CENTRAL STELLATE SCAR on CT scan
*Contains Kupffer cells

Front 37

Simple liver cysts

Back 37

Generally solitary
Blue hue
Contain von Meyenburg complexes - islands of biliary ductal epithelium

Front 38

Indications for resection of simple liver cysts

Back 38

1) Symptoms
2) Rupture
3) Hemorrhage
4) Infection
5) Indeterminate diagnosis

Front 39

Childhood Polycystic Liver Disease

Back 39

Autosomal recessive
Cyst formation in liver and kidney
High mortality in infancy & childhood due to renal failure

Front 40

Adult Polycystic Liver Disease

Back 40

Autosomal dominant
Women 30 - 80 years old
Cysts in liver and kidney
Associated with cerebral aneurysms

Front 41

MC primary malignant tumor of the liver

Back 41

Hepatocellular Carcinoma (HCC)

*More common in men

Front 42

Risk factors for HCC

Back 42

1) Cirrhosis (macronodular)
2) Hepatitis B
3) Hepatitis C, Carcinogens, Hemochromatosis, Tyrosinemia, and much more

Front 43

Symptoms of HCC

Back 43

1) Fatigue
2) Malaise
3) Anorexia
4) Weight loss
5) Abdominal pain
6) Shoulder pain
7) Ascites

Front 44

Diagnosis of HCC

Back 44

1) Alpha-Fetoprotein (AFP) - elevated in 40-70% of patients
2) US, CT, MRI

Front 45

Treatment of HCC

Back 45

1) Surgical resection
2) Systemic chemotherapy (little benefit)

Front 46

5-year survival with resection of HCC

Back 46

31%

Front 47

Major limiting factor in surgical resection of liver tumors

Back 47

Cirrhosis

Front 48

Rate of HCC recurrence after total hepatectomy and liver transplantation

Back 48

50%

Front 49

AFP in FHCC

Back 49

Typically not elevated

Front 50

Variant of HCC most commonly seen in adolescents and young adults

Back 50

Fibrolamellar Hepatocellular Carcinoma (FHCC)

*Overall survival better than with HCC --> greater resectability

Front 51

MC tumors of the liver

Back 51

Metastatic tumors

Front 52

Tumors that frequently spread to the liver

Back 52

1) Colorectal, Lung, Breast
2) Melanoma
3) Neuroendocrine (carcinoid)
4) Visceral malignancies
5) Renal cell carcinoma

Front 53

Diagnosis of metastatic liver cancer

Back 53

Imaging studies

Front 54

For which primary tumor has liver resection for metastatic lesions shown benefit?

Back 54

Colorectal cancer

Front 55

Contraindications to hepatic resection of liver metastasis

Back 55

Metastatic lesions in other regions of the body (i.e., lung, brain)

Front 56

Hepatoblastoma

Back 56

Primary malignant liver tumor seen in boys younger than 2 years old

*Associated with hemihypertrophy and Beckwith-Wiedeman Syndrome

Front 57

Cholangiocarcinoma

Back 57

Primary malignant tumors of biliary ducts

*Can be intrahepatic

Front 58

Normal portal venous pressure

Back 58

Less than 12 mmHg

Front 59

Pathology of Caput Medusa

Back 59

Elevated portal pressure -->
Reconstitution and dilation of umbilical vein -->
Varicosities around umbilicus

Front 60

Causes of portal HTN

Back 60

1) Schistosomiasis
2) Portal vein thrombosis
3) Cirrhosis (alcoholic or viral)
4) Budd-Chiari syndrome (hepatic vein occlusive disease)
5) Constrictive pericarditis
6) CHF

Front 61

4 Major consequences of portal HTN

Back 61

1) Ascites
2) Portosystemic venous shunts and varicies
3) Congestive splenomegaly
4) Hepatic encephalopathy

Front 62

90% of UGIB in patients with portal HTN is due to…

Back 62

Esophageal varicies

Front 63

Mortality with acute variceal hemorrhage

Back 63

50%

Front 64

Initial treatment of acute variceal bleeds after resuscitation

Back 64

Endoscopic sclerotherapy

Front 65

Endoscopic sclerotherapy procedure

Back 65

Esophageal varicies are injected with sclerosing agent → bleeding stops in 90% of patients

Front 66

Complication of endoscopic sclerotherapy

Back 66

Late esophageal strictures (25% of patients)
*Easily managed with dilation

Front 67

Medical treatment of esophageal varicies

Back 67

1) Vasopressin and somatostatin (visceral vasoconstriction)
2) Propanolol (decreases portal pressure)
3) Balloon tamponade with Sengstaken-Blakemore tube

Front 68

Transjugular intrahepatic portocaval shunts (TIPS)

Back 68

Percutaneous portosystemic shunting of blood
*Often serves as a bridge to liver transplantation

Front 69

Complications associated with nonselective portosystemic shunts

Back 69

1) Hepatic encephalopathy (high rate)
2) Progressive hepatic failure (substantially reduced portal venous perfusion)

Front 70

Selective portosystemic shunts

Back 70

Preserve hepatic portal venous flow
More difficult to perform than nonselective shunts
Increased incidence of ascites
*MC is Warren shunt (distal splenorenal shunt)

Front 71

Contraindication to Warren shunt

Back 71

Refractory ascites

Front 72

Isolated elevation of portal venous pressure can lead to…

Back 72

Gastric varices

Front 73

MCC of splenic vein thrombosis

Back 73

Pancreatitis
*Also seen more commonly in pregnancy

Front 74

Treatment of splenic vein thrombosis

Back 74

Splenectomy (alone)

Front 75

MCC of liver failure

Back 75

Cirrhosis

Front 76

5 Clinical parameters in Child’s Classification of Liver Failure

Back 76

1) Bilirubin level
2) Albumin level
3) Severity of Ascites
4) Severity of Encephalopathy
5) Nutritional status

Front 77

Hepatic Encephalopathy

Back 77

1) Major complication of liver failure and portosystemic shunts
2) Neurological changes (altered consciousness, confusion, intellectual deterioration, asterixis)

Front 78

Precipitators of hepatic encephalopathy

Back 78

1) GI BLEEDING
2) Dehydration
3) Constipation
4) Sedatives
5) Excessive dietary protein

Front 79

Treatment of Hepatic Encephalopathy

Back 79

1) Enteral Neomycin and Lactulose
2) Protein restriction
3) Tx of precipitating events

*Lactulose mediates elimination of ammonia from the body

Front 80

Hepatorenal Syndrome

Back 80

Renal insufficiency or failure associated with hepatic failure

Front 81

Effect of liver transplant on hepatorenal syndrome

Back 81

Kidney function is restored

Front 82

Medical management of ascites

Back 82

1) Diuretics and dietary salt restriction (relief 95% of the time)
2) Spironolactone (to preserve K+ since ascites is associated with hyperaldosteronism)
3) Denver and LeVeen shunts – subcutaneous shunts that drain ascitic fluid from peritoneal cavity into central venous system

Front 83

Complication of Denver and LeVeen shunts

Back 83

Disseminated intravascular coagulation (DIC)

Front 84

Spontaneous Bacterial Peritonitis

Back 84

Fatal complication of persistent ascites
Infection in the abdominal cavity in absence of an obvious source for the infection

Front 85

Risk factors for spontaneous bacterial peritonitis

Back 85

1) Nephrotic syndrome
2) SLE, in children

*Occurs almost exclusively in people with portal hypertension (increased pressure over the portal vein), usually as a result of cirrhosis of the liver

Front 86

MC organism of spontaneous bacterial peritonitis

Back 86

E. coli
*Followed by Pneumococcus and hemolytic Streptococcus

Front 87

Characteristic findings of spontaneous bacterial peritonitis

Back 87

1) Fever
2) Abdominal pain
3) Serum Leukocytosis

Front 88

Diagnostic finding of spontaneous bacterial peritonitis

Back 88

1) WBCs >500/ml
2) Polymorphonuclear leukocytes within ascitic fluid (>250/mm^3)
3) Blood and ascitic cultures may be positive

Front 89

Treatment of spontaneous bacterial peritonitis

Back 89

Broad-spectrum antibiotics