Liver & Spleen- Surgery Final Exam

Front 1

40 yo F. Hx of OCP; abdominal pain + palpable mass on exam near the liver.

Back 1

HEPATIC ADENOMA: benign tumor.
increased risk of hepatocellular cancer if > 5cm and spontaneous hemorrhage

Hint 1

TX: surgical resection
alternative contraception methods
avoid preggers

Front 2

CT findings: classic central stellate star
spokeswheel pattern on ateriography

Back 2

FOCAL NODULAR HYPERPLASIA
benign lesion; central scar w/ fibrous septa & nodular hyperplasia

Hint 2

NO malignant potential
TxL surgeical resection & embolization; can observe if poor sx canidate

Front 3

RUQ pain, fever, leukocytosis, elevated alk phose.

Back 3

hepatic abscess
MCC: E coli, klebisella, proteus.
bacterial seeding from diverticulitis or biliary tree

Hint 3

Tc: CT or US guided aspiration
Drain placement
antibiotics

Front 4

Pt w/ hx of cirrhosis secondary to Hep B. Dull RUQ pain, hepatomegaly, palpable abd mass, wt loss, ascities, jaundice, fever, anemia, splenamegaly

Back 4

hepatocellular carcinoma suspected!
w/u: US, CT, MRI*
angiography reserved for chemoembolization
Percutaneous core bx
Serum AFP - correlates to tumor burden.
Dx: AFP > 200 + demondtrable mass = diagnostic
MC primary malignancy of liver

Hint 4

non sx therapy: transplant, ethanol injection, radiofrequency ablation (RFA), arterial embolization
Sx: Pre - op chemoembolization
resection w/ clear margins
post op chemo

Front 5

Good surgical candidate for resection of haptocellular carcinoma?

Back 5

dz confined to liver
tumor amendable to complete resection
- >5cm & cirrhosis makes for a poor sx candidate.
what are the complications of the sx?

Hint 5

perioperatively: BLOOD LOSS. do preop portein vein embolization (pringle maneuver).
Post op: hemorrhage. monitor serum bilirubin, albumin, & K+
w/ preexisting dysfunction.
--> Tx w/ fresh frozen plasma for rising INR > 2.
**Up to 85% of liver can be resected with prior good functioning! will regenerate 4 - 6 weeks post op.

Front 6

Manifestations of portal hypertension (causes elevated portal pressure as a result from resistance to blood flow)

Back 6

esophageal varices, caput medusae, splenomagaly, hemorrhoids, acities, bleeding, & hepatic encephalopathy
List causes of portal vein hypertension?

Hint 6

Pre - hepatic: Thrombus of portal vein
hepatic: cirrhosis (*MC), carcinoma or mets, fribrosis
Posthepatic: Budd - Chiari syndrome (thrombosis of hepatic veins), metastatic dz (obstructive), RV HF.

Front 7

pt w/ metastatic cancer to the liver presents w/ hematemesis, melena, hematochezia. what is the diagnostic test of choice for your suspicion?

Back 7

EGD: esophageal varices from portal hypertension. because there is 50% mortality w/ acute bleeds of these varices, what is the initial treatment of variceal bleeding?

Hint 7

Inital (same as all upper GI bleeds):
Large bore IVS x2, IV fluid, foley cath, type and cross blood, send labs, correct coagulopathy (vit K; fresh frozen plasma) +/- intubation to protect airway

Front 8

if esophageal varices cause bleeding, what is the initial tx options? if bleeding continues?

Back 8

1. endoscopic band ligation

2. variceal tamponade (use sengstaken - blakemore tube that has an esophageal balloon for tamponading a bleed) & Beta blockers.

3. TIPS. what is it?

Hint 8

TIPS (transjugular intrahepatic porto - systemic Shunt)
access is obtained thru IJV to selectively shunt blood from portal system to SVC.

Front 9

Total vs. selective portal - systemic shunts

Back 9

Total: complete disconnection of liver from portal system + INCREASED risk of ENCEPHALOPATHY!

Selective: decompresses the varices by eliminating the gastroesophageal venous plexous WITHOUT decompressing the portal vain = maintains portal blood flow.

What is a peritoneal - jugular shunt?

Hint 9

controls ascites

Front 10

pt with confusion, obtundation, tremor, asterixis, and a sweet smelling breath. recent hx of an infection that was accompanied by constipation & dehydration.

Back 10

hepatic encephalopathy from severe liver disease (late) - from increased ammonia levels causing hyperammonemia.

tx?

Hint 10

LACTULOSE

Front 11

what is the cause of esophageal, retroperitoneal varices and hemorrhoids in portal htn?

Back 11

esophageal: coronary vein backs up into azygous system
retroperitoneal: small mesenteric veins draining retroperitoneally into lumbar veins
Hemorrhoids: superior hemorrhoidal vein (usually drains into the inferior) backs up into the middle and inferior hemorrhoidal veins.

which of these are most worrisome?

Hint 11

esophageal (50% mortality)

Front 12

what are the MC malignant tumors of the liver?

Back 12

METASTATIC. all solid tumors. GI tract is MC primary site. represents widespread dz that would not have indications for surgical tx. what is the exception to this??

Hint 12

Colorectal carcinoma!
Wedge resection of liver mets increases 5 yr survival + chemo.

Front 13

If pt. with liver mets cant tolerate sx, has multiple tumors, has recurrent liver mets, or poor anatomic access, what would the treatment be?

Back 13

radiogrequency ablation

Describe tx?

Hint 13

Under u/s or CT guidance, the probe is advanced into the tumor and heated, causing a sphere of cell lysis

Front 14

for metastatic liver tumors that are very small in size (<2cm), what would the treatment be?

Back 14

Ethanol Injection

describe tx?

Hint 14

95% ethanol injected directly into the tumor under U/S or CT guidance

Front 15

how is arterial embolization used to treat metastatic liver cancer?

Back 15

Combines injection of chemotherapeutic agents with embolization

when is it used? what agents are commonly used?

Hint 15

unresectable liver tumor
Can be staged to treat either lobe
*must have good liver function
Embolization: with Gelfoam
Chemotherapy: Doxorubicin, mitomycin or cisplatin

Front 16

treatment of ascites?

Back 16

Diuretics
Sodium restriction
Paracentesis
Peritoneal-jugular shunt- controls ascites

Front 17

Most common developmental anomaly is presence of accessory spleens in addition to a normal spleen. what are the Most common sites for accessory spleens? what is the best way to evaluate for them?

Back 17

splenic hilum, splenocolic ligament, gastrocolic ligament, splenorenal ligament, omentum.

- Nuclear medicine study:
Technetium 99m-labelled RBCs or indium 111 labeled platelets

what are the consequences of not recognizing the presence of an accessory spleen?

Hint 17

Failure to recognize accessory spleens may lead to relapse of various hematologic disorders after splenectomy

Front 18

deformed cells, particulate matter, or cells marked for destruction by antibody (opsonins) are removed in?

Back 18

RED pulp: in open circulation. without vessles, blood slowly percolates through

Front 19

Splenectomy usually followed by?

Back 19

thrombocytosis
spleen stores 30% of the platelets.

what else may be hindered after spleen removal?

Hint 19

Spleen provides both specific and non-specific immune responses

Front 20

Due to its position and size, the spleen is difficult to palpate. discomfort on palpation signals what type of processes?

Back 20

infectious process, splenic infarction, trauma

what would be MOST useful for evaluating splenic size, presence of injury, cysts, abscess?

Hint 20

CT

CT used to also guide percutaneous drainage
US can show cysts or abcess
Angiography used for bleeding and for embolization of bleeding/ injured vessels

Front 21

treatment for Neoplastic disease spread to the spleen

Back 21

Incidental splenectomy (removal of hilar nodes or direct extension of tumor into spleen)

what are the common sites that spread to the spleen?

Hint 21

Large renal cell ca, left adrenal tumor and retroperitoneal sarcoma may extend into the spleen

Front 22

list indications for splenectomy

Back 22

Hematologic conditions (Autoimmune/ erythrocyte dz)
Trauma
Hypersplenism
Neoplastic disease
Cysts, abscesses, primary tumor

What is the most common?

Hint 22

Hematologic conditions

Front 23

what should NOT be given pre - op to a pt having a splenectomy until after the splenic artery is ligated?

Back 23

platelets!

what else should be given pre OP to pt w/ AI dz?

Hint 23

corticosteroids

Front 24

Pt in a car accident with evidence of blunt trauma to her abdomen. BP 60/80, HR 150, RR 35. what is your first assessment of this pt indicate?

Back 24

UNSTABLE splenic injury
Criteria:
→ Penetrating injury + signs of intraperitoneal hemorrhage
→ Hemodynamically unstable w/ blunt abd trauma

tx options?

Hint 24

Splenectomy performed for severe injury

Splenorrhaphy can be attempted for less severe injury

Angiographic embolization can be performed in responders to resuscitation

Front 25

What scenario is the spleen most prone to injury?

Back 25

MC injured after blunt trauma (prone to blunt compression injury & capsular tears (avulsion) from rapid deceleration)

Treatment for the stable pt?

Hint 25

Evaluation: CT
Tx: Bed red; NPO

Monitoring
Serial exams + hemoglobin levels

Front 26

Risks w/ non – operative management of a splenic injury??

Back 26

associated injuries, delayed splenic rupture, splenic abscess, risks of transfusion
you have transfused 50% of the pts blood with a stable splenic injury. what should you do next?

Hint 26

Splenectomy performed for severe injury

Splenorrhaphy can be attempted for less severe injury

Angiographic embolization can be performed in responders to resuscitation

Front 27

incision and indications for a open splenectomy?

Back 27

via upper midline incision or left subcostal (Kehr) incision.
indicated For immediate control of bleeding secondary to trauma or a Massively enlarged spleen

Risks?

Hint 27

Important to avoid: Excessive traction & capsular avulsion; dividing short gastric vessels too close to stomach; injury to pancreatic tail

Front 28

Pt at increased risk for postsplenectomy sepsis?

Back 28

AGE: children <4 & adults >70
Reason for splenectomy: Highest risk if splenectomy done for hematologic disorders, rather than trauma
--> These pts are at risk for fatal sepsis at any time after sx.

what is the causitive organism?

Hint 28

Encapsulated organisms:
• Streptococcus pneumoniae
• Hemophilus influenzae
• Neisseria meningitides

Front 29

what has an Insidious onset; mimics cold/flu; Become septic +/- DIC in a few hrs → may die in 24-48 hrs; and could be prevented by a pre - op vaccine?

Back 29

postsplenectomy sepsis

what are the indications for vaccination?

Hint 29

Polyvalent pneumococcal vaccine plus vaccine against Hemophilus + meningococcus g
- Give vaccine at least 1 week before planned splenectomy; after emergency splenectomy give when patient recovered

Vaccine: NOT full protection

Front 30

what should you expect to see in pt labs post op splenectomy?

Back 30

WBC count increases by 50%;
Platelet count increases by 30% or more; some counts over 1 million

when should you intervene?

Hint 30

Transfuse if hemostasis is abnormal

ASA therapy indicated if platelet count over 750K

Front 31

post op complications splenectomy?

Back 31

Pulmonary: atelectasis, pneumonia

Subphrenic abscess: infected fluid collection from bleeding, pancreatic leak from injury to pancreatic tail

Pancreatitis, pancreatic fistula, pseudocyst

Injury to stomach, perforation

Persistent hemorrhage: usually after splenectomy for thrombocytopenia

Front 32

disorder of the spleen Characterized by CYTOPENIA: anemia leucopenia, thrombocytopenia; Increased cellular precursors to bone marrow: reticulocytes & megakaryocytes

Back 32

Hypersplenism: excess function → many processes that cause increase in immune or filtering fcts

what physical exam finding will you find?

Hint 32

Frequently results in SPLENOMEGALY (enlarged spleen)

Front 33

Hereditary Spherocytosis

Back 33

- Autosomal dominant, hemolytic anemia characterized by deficiency of spectrin
• Spectrin is a membrane component needed for RBC deformability → deficiency leads to defective & rigid RBCs
• Deformed RBCs can’t deform to enter splenic sinuses →sequestered in red pulp → causes splenomegaly & shortened life of RBCs.

Tx?

Hint 33

• Tx: Splenectomy – lengthens RBC life & normalizes hematocrit
• Splenectomy deferred until > 5 yoa; less risk of overwhelming postsplenectomy sepsis.
• Gallbladder should be inspected & removed if stone is present.

Front 34

disorder with defects in hemoglobin cause anemia & RBC sequestration w/ splenomegaly (can be massive & cause discomfort)?

Back 34

Thalassemia

tx?

Hint 34

Splenectomy: reduces transfusion requirements & discomfort (amoung highest risk OPSS)

Front 35

Pentad of thrombocytopenia, fever, microangiopathic hemolytic anemia, ARF, & mental status changes (critically ill; in ICU)

Back 35

TTP

Tx?

Hint 35

•Treatment: plasmapheresis, exchange transfusion, steroids, IVIG
•Splenectomy usually of little help, but sometimes done

Front 36

CHRONIC ITP: occurs in?

Back 36

young adults; MC in women

tx?

Hint 36

• Tx: initially treated w/ corticosteroids → if no response w/ elevated platelets OR w/ reoccurrence after steroids: SPLENECTOMY
• Platelet count < 30,000 at splenecomy: platelets transfused AFTER the splenic vessels are clamped
• Pt that initially responded to steroids recover better after splenectomy
• Refractory after splenectomy: tx w/ vincristine or IVIG

Front 37

- Characterized by antiplatelet AB made by spleen. causes decreased platelet count; normal/increased megakaryocytes in marrow (NO splenomegaly)

Back 37

Idiopathic Thrombocytopenic Purpura

ACUTE ITP is seen MC in what pt?

Hint 37

MC after viral illness; excellent prognosis in pt < 16 yoa (80%) permanent recovery)