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97 Cards in this Set
- Front
- Back
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Most common malignant tumor of the liver?
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hepatocellular carcinoma
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Why use PET SCAN for possible tumors?
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to detect intra- and extrahepatic disease.
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How does a hepatic cyst appear on its best imaging modality?
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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 |
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What is the most common benign tumor of the liver?
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hepatic hemangioma
1-20% of the general population women 5:1 10% of cases have mutliple lesions <10% have calcifications |
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What would be a hallmark sign of a hepatic hemangioma?
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a central scar
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How does a hepatic hemangioma look on ultrasound?
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-small hyperechoic mass with faint acoustic enhancement
-large >2cm- hypoechoic or hyperechoic -no flow by color doppler -DDx includes HCC and Mets |
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How does contrast show up in a hepatic hemangioma case?
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Peripheral filling first, then moves centrally, slowly!
aka Blood fills OUT TO IN! -can use this to ESTABLISH Dx! |
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2nd most common benign tumor of the liver?
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focal nodular hyperplasia
-most in women 3rd-5th decades -oral contraceptives promote growth but don't induce formation |
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Class finding leading to Dx of FNH?
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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! |
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Keys to Dx'ing hepatic adenoma?
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-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 |
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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?
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hepatic adenoma
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2 main complications of cirrhosis?
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1) portal HTN
2) HCC |
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Ultrasound findings of a cirrhotic liver:
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-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 |
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Hyperdense liver on a plain CT is key to a Dx of...
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hemochromatosis
-or on MRI, see a "Black Liver" on T1-T2 |
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What's the most common primary cancer of the liver?
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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 |
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3 predominant patterns of HCC Presentation:
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1) solitary mass +/- satellite nodules
2) multiple discrete masses 3) diffuse, ill-defined infiltration of the liver parenchyma |
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If you see a patient with an elevated AFP and possible cirrhosis, what do you need to rule out?
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HCC
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Hep B/C and lesion in the liver =
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HCC until proven otherwise.
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How might contrast on CT or MR move through an HCC tumor?
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aterial enhancement with delayed enhancement of the capsule
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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 |
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How do you Dx fibrolamellar carcinoma?
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by CT
-histology shows blue lamellar bands of fibrosis separating the malignant hepatocytes into cords |
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Intrahepatic cholangiocarcinoma:
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-8% of all primary hepatic malignancy
-male predominance 1.6:1 -only 10% intrahepatic -adenocarcinoma with abundant sclerosis -DDx: difficult with other adenocarcinomas |
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What's the key imaging for intrahepatic cholangiocarcinoma?
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on CT:
-central fibrosis -DELAYED enhancement -may also see capsular retraction |
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If you see an infant that presents with >15% of total fractionated serum bilirubin as conjugated, then that child has...
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*cholestasis*
-consider phsyiologic or breast milk jaundice vs. cholestasis -also look at liver synthetic function: ammonia, PT, albumin, glucose, bilirubin |
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Most common cause of cholestasis in newborns?
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-biliary atresia
-most common cause for OLT in peds, too -most common cause of death due to liver disease in children, as well |
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How does a biliary atresia patient present?
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-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 |
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How do you treat biliary atresia, and by when?
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-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! |
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A1A Deficienct CHARAC:
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-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 |
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Most common form of intrahepatic cholestasis:
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-alagille syndrome
-mutation of jagged 1 -gene encodes several ligans for notch receptor |
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Tx of Alagille syndrome:
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-ursodeoxycholic acid
-transplant for advanced cirrhosis |
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See a Low GGT with cholestasis, think:
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PFIC I and/or II
-check for sepsis or BAD |
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See a High GGT with cholestasis:
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-think PFIC III
-hepatocyte couple -w/o the MDR3 protein get sclerosis of the bile duct, giving the high GGT |
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How do you treat PFICs?
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-ursodeoxycholic acid
-biliary diversion another option |
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Where do you see chickenwire fibrosis?
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in alcoholic cirrhosis
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Which Hep viruses can lead to cirrhosis?
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Hep B and C
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What do you see microscopically with Hep B?
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ground glass hepatocytes
-1% get cirrhosis |
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4 "S's" of Biliary Cirrhosis:
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1) sirrhosis- primary biliary cirrhosis
2) sclerosing- primary sclerosing cholangitis 3) stones: lithiasis- secondary biliary cirrhosis 4) sarcoidosis |
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Inability to secrete Copper leads to...
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Wilson's Disease!
-see kayser-fleischer rings |
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3 keys to Dx of Wilson's Disease, according to Bejarano:
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1) low ceruloplasmin
2) increased liver copper 3) increased urine copper |
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Woman, 3rd-5th decade of live, taking oral contraceptives, solitary tumor, could bleed into peritoneum, and may be multiple, what is it?
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liver cell adenoma
-microscopically, see sheets of liver cells and BVs...typical organization of liver tissue is gone |
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Most common hepatic neoplasm:
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hepatocellular carcinoma
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Which hepatitis viruses put you at risk for HCC?
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B and C, which also put you at risk for cirrhosis.
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Acute Hep B infection detected by...
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HBsAg, but can also see IgM anti-HBc, and also HBV DNA
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Typical Chronic Hep B infection shows...
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elevated HBsAg, HBeAg, and ALT elevtation, along side a consistently high HBV DNA after infection has been around for months (ALT is a spike).
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Acute HCV Ifx presentation:
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-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 |
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Chronic HCV infection Px's with...
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HCV RNA and HCV Core Ag elevated, with anti-HCV elevating over time and ALT jumping up and down
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Primary goal of HCV therapy?
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-eradicate HCV infection
Secondary: -slow disease progression -improve histology -reduce risk of HCC -improve health-related QOL |
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Who is at risk of dying from a Hep E infection?
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pregnant women, especially in the 3rd trimester, there's a mortality rate of 12-25%
-illness severity increases with age |
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NAFLD Stages:
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Fatty Liver
to Steatohepatitis to Steatohepatitis with fibrosis to Cirrhosis (Decrease in fat) |
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3 Factors- for sure- in NAFLD and NASH:
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1) obesity
2) hyperlipidema 3) insulin resistance/glucose insensitivity |
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Classic Px of NAFLD/NASH Pt.:
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obese
female Type 2 diabetic hypertriglyceridemia insulin resistance |
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How do you Dx NASH?
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-usually elevated ALT is a common cause for referral
normal ALT: Male- 30 Women- 19 |
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Single-most important risk factor for development of ALD?
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amount of alcohol ingested!
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If you see an AST/ALT ratio >2 but <300U/L, what disease should you think of?
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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 |
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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 |
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Most common and significant place to see collaterals for the GI system?
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gastroesophageal varices
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***O'Brien TEST QUESTION***
What's the most lethal complication of chronic liver disease? |
hemorrhage from gastroesophageal varices
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What is the most common site of variceal bleeding?
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distal esophagus
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What does TIPS connect?
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-direct connection b/n hepatic veins and the portal venous system
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Most common form of decompensation in portal HTN patients?
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ascites and cirrhosis
-see a periph BP of 90/60 because there's a high BP centrally |
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SAAG of >1.1 is associated with
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portal HTN
-serum-albumin to ascites protein gradient <1.1 is everything else |
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How do you Dx a suspected SBP patient?
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-ascites PMN cell count >250 is the main diagnostic test
-often Tx with IV cefotaxime |
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Most common liver tumor in childhood?
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hepatoblastoma
-highly likely seen in 1st 3 years of life -3 options: resection transplant DEATH |
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Hepatocellular carcinoma ranks where in terms of liver tumors?
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-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 |
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What's causing the cases of HCC?
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1) HCV
2) HBV 3) HCV and EtOH |
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How do you screen for HCC?
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Ultrasound and serum AFP
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How do you DIAGNOSE HCC?
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AFP >500 is diagnostic
-gonna likely see cirrhosis, too |
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Best Tx for HCC?
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surgical resection, transplant is #2 on top of the local ablative methods
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What transporter helps with bile-salt uptake?
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sodium-taurocholate cotransporter (NTCP)
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What transporter helps with bilirubin uptake?
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Sodium-INdependent organic-anion transporter, OATP
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How is the bile-salt export process conducted?
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through the sister of the P-glycoprotein bile-salt export pump, dumping the bile salts out into the canaliculi
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What are all the clinical manifestations of cholestasis?
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-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 |
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Definition of Autoimmune hepatitis:
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chronic hepatocelular inflammation of uknown etiology characterized by the presence of autoantibodies and hypergammaglobulinemia
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What Abs do you see in AIH?
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Type 1: ANA and/or ASMA
Type 2: Anti LKM-1 Type 3: Anti SLA/LP |
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If you see the AMA antibody on lab work, what are you most likely to suspect?
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Primary Biliary Cirrhosis
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Most common source of liver abscess?
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-infections of the biliary tract
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Clinical manifestations of Schistosomiasis:
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Immediate: maculopapular eruption
Acute: -fever, headache, generalized myalgias, RUQ pain, bloody diarrhea -eosinophilia and mos thave positive serologic tests |
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Acute liver failure syndrome involves what 4 things:
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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 |
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ALF clinical features, 4 main ones, what are they:
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1) elevated bilirubin and jaundice
2) inc. ammonia, hepatic encephalopathy and intracranial HTN 3) hypglycemia 4) coagulopathy |
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What's the biggest cause of ALF?
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In the U.S.: acetaminophen
Worldwide: HBV |
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On the labwork, what really tips you off to ALF?
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Aminotransferases in the 1000's
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How do you treat ALF induced by acetaminophen?
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-consider activated charcoal, but DEFINITELY USE N-acetylcysteine as early as possible!
-repletes glutathione stores |
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True/False:
Hep C can cause ALF? |
FALSE
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Wilson's disease causes 2-3% of ALF cases, and if you don't treat it what happens?
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Death without OLT!
-acutely lower those copper levels |
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How do you treat an AIH patient presenting with ALF?
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treat with corticosteroids, and Tx as though it's ALF primarily.
Corticosteroids do work in these patients! But, they might need OLT. |
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Hallmark finding leading you to consider cholestatic liver disease:
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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 |
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Intrahepatic cholestasis shows what lab values?
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ALT > 5X elevated
with INC Alk Phos vs. Extrahepatic: ALT 2-5X elevation with INC Alk Phos |
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EXTRAhepatic cholestasis shows what lab values?
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Extrahepatic:
ALT 2-5X elevation with INC Alk Phos vs. ALT > 5X elevated with INC Alk Phos |
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Hallmark finding for a Dx of Primary Biliary Cirrhosis?
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AMA + antibodies
-may also see IgM commonly elevated -see chronic cholestatic liver disease and non-suppurative destructive cholangitis, too |
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Autoimmune cholangitis lab report shows:
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AMA negative
BUT 95% will be ANA+ASMA+, so they're double-positive for ANA/ASMA, but negative for AMA |
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Classic histologic finding related to PBC?
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florid duct lesion
-may see PBC associated with Sjorgen's syndrome or rental tubular acidosis |
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How do you treat PBC?
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ursodeoxycholic acid
-PBC, though, is one of the most frequent indications for liver transplantation |
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70-80% of PSC cases are associated with...
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inflammatory bowel disease
-most commonly ulcerative colitis, but Crohn's is possible too 40 y/o men are the ones getting this disease |
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How do you Dx PSC?
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ERCP
if you're lucky, the histology will show you the onion-skin appearance, but that's in <10% of cases |
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PSC puts patients at a predisposition for...
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cholangiocarcinoma and colon cancer
-Tx with USCA is under study, but basically just get them on the OLT list |
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When PSC is found in the presence of CUC, what risk rises?
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the OR for colon cancer, compared to CUC alone is now 4.79
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7-15% of PSC patients progress to have...
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cholangiocarcinoma
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