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97 Cards in this Set

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Most common malignant tumor of the liver?
hepatocellular carcinoma
Why use PET SCAN for possible tumors?
to detect intra- and extrahepatic disease.
How does a hepatic cyst appear on its best imaging modality?
best modality to use- Ultrasound

-appears:
anechoic
imperceptible wall
enhanced through transmission

-cyst shows similar density to gall bladder- they're both fluid-filled
AND
contrast-negative
What is the most common benign tumor of the liver?
hepatic hemangioma
1-20% of the general population

women 5:1
10% of cases have mutliple lesions

<10% have calcifications
What would be a hallmark sign of a hepatic hemangioma?
a central scar
How does a hepatic hemangioma look on ultrasound?
-small hyperechoic mass with faint acoustic enhancement
-large >2cm- hypoechoic or hyperechoic

-no flow by color doppler
-DDx includes HCC and Mets
How does contrast show up in a hepatic hemangioma case?
Peripheral filling first, then moves centrally, slowly!

aka Blood fills OUT TO IN!
-can use this to ESTABLISH Dx!
2nd most common benign tumor of the liver?
focal nodular hyperplasia

-most in women 3rd-5th decades
-oral contraceptives promote growth but don't induce formation
Class finding leading to Dx of FNH?
using contrast on a CT, have enhancement during arterial phase and WASHOUT/disappearance during the portal phase

NOTE: central scar in the delay will still be enhanced!
Keys to Dx'ing hepatic adenoma?
-typically a young woman
-oral contraceptives and androgen therapy involved

HEMORRHAGIC NECROSIS OCCURS!

-may see in a glycogen storage disease type I patient

-no bile duct/portal tract involvement

-OFTEN AREAS OF HEMORRHAGE OR INFARCTION inside the tumors
See a woman who takes oral contraceptives, has a big mass in the liver, a low hemaotcrit, and she's bleeding, what might be the diagnosis?
hepatic adenoma
2 main complications of cirrhosis?
1) portal HTN
2) HCC
Ultrasound findings of a cirrhotic liver:
-increase echogenecity
-nodular contour
-enlarged caudate lobe and lateral segment of the left lobe
-atrophy of right lobe and medical segment of left lobe
-regenerative nodules
-prominent portal vein

Big 3:
1) lumpy liver
2) prominent caudate lobe
3) prominent portal vein
Hyperdense liver on a plain CT is key to a Dx of...
hemochromatosis

-or on MRI, see a "Black Liver" on T1-T2
What's the most common primary cancer of the liver?
Hepatocellular carcinoma

-etiology factors: Hep B/d & C, alcohol, hemochromatosis, and various carcinogens

Heapto carcinogenesis:
-multistep process in cirrhotic liver
-de novo in non-cirrhotic liver

U.S. male/female : 2.5:1
SE Asia, Africa, Japan: male/female: 5:1
3 predominant patterns of HCC Presentation:
1) solitary mass +/- satellite nodules
2) multiple discrete masses
3) diffuse, ill-defined infiltration of the liver parenchyma
If you see a patient with an elevated AFP and possible cirrhosis, what do you need to rule out?
HCC
Hep B/C and lesion in the liver =
HCC until proven otherwise.
How might contrast on CT or MR move through an HCC tumor?
aterial enhancement with delayed enhancement of the capsule
Patient Px's with:

-young: 5-35 y/o
-AFP levels normal
-man or woman
-no preexisting liver disease
Fibrolamellar carcinoma

-has large, lobulated central scar
-single mass
-vascular/biliary obstruction is common, invasion though is rare
How do you Dx fibrolamellar carcinoma?
by CT

-histology shows blue lamellar bands of fibrosis separating the malignant hepatocytes into cords
Intrahepatic cholangiocarcinoma:
-8% of all primary hepatic malignancy
-male predominance 1.6:1
-only 10% intrahepatic

-adenocarcinoma with abundant sclerosis

-DDx: difficult with other adenocarcinomas
What's the key imaging for intrahepatic cholangiocarcinoma?
on CT:
-central fibrosis
-DELAYED enhancement

-may also see capsular retraction
If you see an infant that presents with >15% of total fractionated serum bilirubin as conjugated, then that child has...
*cholestasis*

-consider phsyiologic or breast milk jaundice vs. cholestasis

-also look at liver synthetic function: ammonia, PT, albumin, glucose, bilirubin
Most common cause of cholestasis in newborns?
-biliary atresia
-most common cause for OLT in peds, too
-most common cause of death due to liver disease in children, as well
How does a biliary atresia patient present?
-direct hyperbilirubinemia at 2-6 weeks of age
-well appearing, thriving infant
-dark urine
-acholic stools
-hepatosplenomegaly
-INC Alk Phos and GGTP and mild increase of ALT and AST
How do you treat biliary atresia, and by when?
-do a hepatoportoenterostomy, in which you'll achieve biliary drainage in >80% if sugery before 90 days of age, but in less than 20% of older than 90 days.

-w/o surgery, need transplant by age 2!
A1A Deficienct CHARAC:
-most common metabo condition affecting liver in infants
-most pats. asympto
-20% w/ cholestasis in newborn period, jaundice clears in most pts. by 4 months

-liver OLT if advanced cirrhosis

DON'T have acholic stool
Most common form of intrahepatic cholestasis:
-alagille syndrome

-mutation of jagged 1
-gene encodes several ligans for notch receptor
Tx of Alagille syndrome:
-ursodeoxycholic acid

-transplant for advanced cirrhosis
See a Low GGT with cholestasis, think:
PFIC I and/or II

-check for sepsis or BAD
See a High GGT with cholestasis:
-think PFIC III
-hepatocyte couple
-w/o the MDR3 protein get sclerosis of the bile duct, giving the high GGT
How do you treat PFICs?
-ursodeoxycholic acid
-biliary diversion another option
Where do you see chickenwire fibrosis?
in alcoholic cirrhosis
Which Hep viruses can lead to cirrhosis?
Hep B and C
What do you see microscopically with Hep B?
ground glass hepatocytes
-1% get cirrhosis
4 "S's" of Biliary Cirrhosis:
1) sirrhosis- primary biliary cirrhosis

2) sclerosing- primary sclerosing cholangitis
3) stones: lithiasis- secondary biliary cirrhosis
4) sarcoidosis
Inability to secrete Copper leads to...
Wilson's Disease!

-see kayser-fleischer rings
3 keys to Dx of Wilson's Disease, according to Bejarano:
1) low ceruloplasmin
2) increased liver copper
3) increased urine copper
Woman, 3rd-5th decade of live, taking oral contraceptives, solitary tumor, could bleed into peritoneum, and may be multiple, what is it?
liver cell adenoma

-microscopically, see sheets of liver cells and BVs...typical organization of liver tissue is gone
Most common hepatic neoplasm:
hepatocellular carcinoma
Which hepatitis viruses put you at risk for HCC?
B and C, which also put you at risk for cirrhosis.
Acute Hep B infection detected by...
HBsAg, but can also see IgM anti-HBc, and also HBV DNA
Typical Chronic Hep B infection shows...
elevated HBsAg, HBeAg, and ALT elevtation, along side a consistently high HBV DNA after infection has been around for months (ALT is a spike).
Acute HCV Ifx presentation:
-months:
HCV RNA
ALT elevation
HCV core Ag


over time see huge increase in anti-HCV

If suspicious of Hep C- send for HCV RNA if anti-HCV was negative
Chronic HCV infection Px's with...
HCV RNA and HCV Core Ag elevated, with anti-HCV elevating over time and ALT jumping up and down
Primary goal of HCV therapy?
-eradicate HCV infection

Secondary:
-slow disease progression
-improve histology
-reduce risk of HCC
-improve health-related QOL
Who is at risk of dying from a Hep E infection?
pregnant women, especially in the 3rd trimester, there's a mortality rate of 12-25%

-illness severity increases with age
NAFLD Stages:
Fatty Liver
to
Steatohepatitis
to
Steatohepatitis with fibrosis
to
Cirrhosis (Decrease in fat)
3 Factors- for sure- in NAFLD and NASH:
1) obesity
2) hyperlipidema
3) insulin resistance/glucose insensitivity
Classic Px of NAFLD/NASH Pt.:
obese
female
Type 2 diabetic
hypertriglyceridemia
insulin resistance
How do you Dx NASH?
-usually elevated ALT is a common cause for referral

normal ALT:
Male- 30
Women- 19
Single-most important risk factor for development of ALD?
amount of alcohol ingested!
If you see an AST/ALT ratio >2 but <300U/L, what disease should you think of?
Alcoholic liver disease!

If AST and/or ALT are in the 1000's, it wouldn't be due solely to alcohol, something else would have to be involved
O'Brien TEST QUESTION:

What is the main site of resistance to portal BFlow?
the liver is the main site of resistance to portal blood flow

2 causes of increases in resistance leading to portal HTN:
1) vascular resistance to BFlow
2) increased BFlow entering the portal system
Most common and significant place to see collaterals for the GI system?
gastroesophageal varices
***O'Brien TEST QUESTION***

What's the most lethal complication of chronic liver disease?
hemorrhage from gastroesophageal varices
What is the most common site of variceal bleeding?
distal esophagus
What does TIPS connect?
-direct connection b/n hepatic veins and the portal venous system
Most common form of decompensation in portal HTN patients?
ascites and cirrhosis


-see a periph BP of 90/60 because there's a high BP centrally
SAAG of >1.1 is associated with
portal HTN

-serum-albumin to ascites protein gradient

<1.1 is everything else
How do you Dx a suspected SBP patient?
-ascites PMN cell count >250 is the main diagnostic test

-often Tx with IV cefotaxime
Most common liver tumor in childhood?
hepatoblastoma

-highly likely seen in 1st 3 years of life


-3 options:
resection
transplant
DEATH
Hepatocellular carcinoma ranks where in terms of liver tumors?
-most common primary liver cancer in the U.S.
-CLD is a major risk factor for the development of HCC
-85% of HCCs occur in patients with cirrhosis or pre-cirrhotic conditions
What's causing the cases of HCC?
1) HCV
2) HBV
3) HCV and EtOH
How do you screen for HCC?
Ultrasound and serum AFP
How do you DIAGNOSE HCC?
AFP >500 is diagnostic

-gonna likely see cirrhosis, too
Best Tx for HCC?
surgical resection, transplant is #2 on top of the local ablative methods
What transporter helps with bile-salt uptake?
sodium-taurocholate cotransporter (NTCP)
What transporter helps with bilirubin uptake?
Sodium-INdependent organic-anion transporter, OATP
How is the bile-salt export process conducted?
through the sister of the P-glycoprotein bile-salt export pump, dumping the bile salts out into the canaliculi
What are all the clinical manifestations of cholestasis?
-jaundice

-pruritus- itching, secondary to bile salts

-xanthomas, xanthelasmas- deposition of choles in skin

-steatorrhea

-osteoporosis- Vitamin D absorption impaired secondary to lack of bile salt secretion
Definition of Autoimmune hepatitis:
chronic hepatocelular inflammation of uknown etiology characterized by the presence of autoantibodies and hypergammaglobulinemia
What Abs do you see in AIH?
Type 1: ANA and/or ASMA
Type 2: Anti LKM-1
Type 3: Anti SLA/LP
If you see the AMA antibody on lab work, what are you most likely to suspect?
Primary Biliary Cirrhosis
Most common source of liver abscess?
-infections of the biliary tract
Clinical manifestations of Schistosomiasis:
Immediate: maculopapular eruption


Acute:
-fever, headache, generalized myalgias, RUQ pain, bloody diarrhea
-eosinophilia and mos thave positive serologic tests
Acute liver failure syndrome involves what 4 things:
1) coagulopathy (INR >1.5)
2) hepatic encephalopathy
3) no underlying liver disease
4) illness <26 weeks of duration

-Wilson's, AIH, vertically acquired HBV can be included if their disease has been recognized for <26 weeks
ALF clinical features, 4 main ones, what are they:
1) elevated bilirubin and jaundice
2) inc. ammonia, hepatic encephalopathy and intracranial HTN
3) hypglycemia
4) coagulopathy
What's the biggest cause of ALF?
In the U.S.: acetaminophen


Worldwide: HBV
On the labwork, what really tips you off to ALF?
Aminotransferases in the 1000's
How do you treat ALF induced by acetaminophen?
-consider activated charcoal, but DEFINITELY USE N-acetylcysteine as early as possible!

-repletes glutathione stores
True/False:

Hep C can cause ALF?
FALSE
Wilson's disease causes 2-3% of ALF cases, and if you don't treat it what happens?
Death without OLT!

-acutely lower those copper levels
How do you treat an AIH patient presenting with ALF?
treat with corticosteroids, and Tx as though it's ALF primarily.

Corticosteroids do work in these patients! But, they might need OLT.
Hallmark finding leading you to consider cholestatic liver disease:
Alk Phos >1.5-2.0

-GGT more specific for the lvier, but it's a lso very sensitive



ALT/AST: more seen in hepatocellular injury
AST/ALT ratio >2 in EtOH patients
Intrahepatic cholestasis shows what lab values?
ALT > 5X elevated
with
INC Alk Phos

vs.
Extrahepatic:
ALT 2-5X elevation
with
INC Alk Phos
EXTRAhepatic cholestasis shows what lab values?
Extrahepatic:
ALT 2-5X elevation
with
INC Alk Phos

vs.

ALT > 5X elevated
with
INC Alk Phos
Hallmark finding for a Dx of Primary Biliary Cirrhosis?
AMA + antibodies
-may also see IgM commonly elevated

-see chronic cholestatic liver disease and non-suppurative destructive cholangitis, too
Autoimmune cholangitis lab report shows:
AMA negative
BUT
95% will be ANA+ASMA+, so they're double-positive for ANA/ASMA, but negative for AMA
Classic histologic finding related to PBC?
florid duct lesion

-may see PBC associated with Sjorgen's syndrome or rental tubular acidosis
How do you treat PBC?
ursodeoxycholic acid

-PBC, though, is one of the most frequent indications for liver transplantation
70-80% of PSC cases are associated with...
inflammatory bowel disease
-most commonly ulcerative colitis, but Crohn's is possible too
40 y/o men are the ones getting this disease
How do you Dx PSC?
ERCP

if you're lucky, the histology will show you the onion-skin appearance, but that's in <10% of cases
PSC puts patients at a predisposition for...
cholangiocarcinoma and colon cancer

-Tx with USCA is under study, but basically just get them on the OLT list
When PSC is found in the presence of CUC, what risk rises?
the OR for colon cancer, compared to CUC alone is now 4.79
7-15% of PSC patients progress to have...
cholangiocarcinoma