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135 Cards in this Set

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What is the name of the liver capsule?

Glisson's capsule

What is the "bare" area of the liver?

Posterior section of the liver against the diaphragm that is "bare" without peritoneal covering

What is Cantle's line?

Line drawn from the gallbladder to a point just to the left of the IVC, which transects the liver into the right and left lobes


 

Line drawn from the gallbladder to a point just to the left of the IVC, which transects the liver into the right and left lobes


Which ligament goes from the anterior abdominal wall to the liver?

Falciform ligament

What does the falciform ligament contain?

Ligamentum teres (obliterated umbilical vein)

What is the coronary ligament?

Peritoneal reflection on top of the liver that crowns (hence "coronary") the liver and attaches it to the diaphragm

What are the triangular ligaments of the liver?

Right and left lateral extents of the coronary ligament, which forms triangles

What is the origin of the hepatic arterial supply?

From the proper hepatic artery off of the celiac trunk (celiac trunk to common hepatic artery to proper hepatic artery)

What is structure 1?


 

What is structure 1?


Celiac trunk

Celiac trunk

What is structure 2?


 

What is structure 2?


Splenic artery

Splenic artery

What is structure 3?


 

What is structure 3?


Left gastric artery

Left gastric artery

What is structure 4?


 

What is structure 4?


Common hepatic artery

Common hepatic artery

What is structure 5?


 

What is structure 5?


Gastroduodenal artery

Gastroduodenal artery

What is structure 6?


 

What is structure 6?


Proper hepatic artery

Proper hepatic artery

What is structure 7?


 

What is structure 7?


Left hepatic artery

Left hepatic artery

What is structure 8?


 

What is structure 8?


Right hepatic artery

Right hepatic artery

What is the venous supply to the liver?

Portal vein (formed from splenic vein and superior mesenteric vein)

What is the hepatic venous drainage?

Via the hepatic veins, which drain into the IVC (three veins: left, middle, and right)

What sources provide O2 to the liver?

- Portal vein blood (50%)


- Hepatic artery blood (50%)

From what sources does the liver receive blood?

- Portal system (75%)


- Hepatic artery system (50%)

What is the overall arrangement of the sgements in the liver?

Clockwise, starting at segment 1


 

Clockwise, starting at segment 1


What is the maximum amount of liver that can be resected while retaining adequate liver function?

>80%; if given adequate recovery time, the original mass can be regenerated!

What are the signs/symptoms of liver disease?

- Hepatomegaly


- Splenomegaly


- Icterus


- Pruritus (from bile salts in skin)


- Blanching


- Spider telangiectasia


- Gynecomastia


- Testicular atrophy


- Caput medusae


- Dark urine


- Clay-colored stools


- Bradycardia


- Edema


- Ascites


- Fever


- Fetor hepaticus (sweet musty smell)


- Hemorrhoids


- Variceal bleeding


- Anemia


- Body hair loss


- Liver tenderness


- Palmar erythema

Which liver enzymes are made by hepatocytes?

AST and ALT

What is the source of alk phos?

Ductal epithelium (thus, elevated with ductal obstruction)

What is Child's class?

Classification that estimates hepatic reserve in patients with hepatic failure and mortality

What comprises the Child's classification?

- Lab: bilirubin, albumin


- Clinical: encephalopathy, ascites, prothrombin time (PT)

How can the criteria comprising the modified Child's classification be remembered?

"A BEAP":


- Ascites



- Bilirubin


- Encephalopathy


- Albumin


- PT

What are the criteria for Child's class A?

- Ascites: none


- Bilirubin: 3.5


- PT:

- Ascites: none


- Bilirubin: <2


- Encephalopathy: none


- Albumin: >3.5


- PT: <1.7

What are the criteria for Child's class B?

- Ascites: controlled


- Bilirubin: 2-3


- Encephalopathy: minimal


- Albumin: 2.8-3.5


- PT: 1.7-2.2

- Ascites: controlled


- Bilirubin: 2-3


- Encephalopathy: minimal


- Albumin: 2.8-3.5


- PT: 1.7-2.2

What are the criteria for Child's class C?

- Ascites: uncontrolled


- Bilirubin: >3


- Encephalopathy: severe


- Albumin: 2.2

- Ascites: uncontrolled


- Bilirubin: >3


- Encephalopathy: severe


- Albumin: <2.8


- PT: >2.2

What is the operative mortality for a portocaval shunt vs overall intra-abdominal operations with cirrhosis in Child class A?

<5% vs overall = 10%

What is the operative mortality for a portocaval shunt vs overall intra-abdominal operations with cirrhosis in Child class B?

<15% vs overall = 30%

What is the operative mortality for a portocaval shunt vs overall intra-abdominal operations with cirrhosis in Child class C?

~33% vs overall = 75%

What does the MELD score stand for?

Model for End-stage Liver Disease

What is measured in the MELD score?

- INR


- T. bili


- Serum creatinine


What is the mortality in cirrhotic patients for non-emergent non-transplant surgery?

Increased in mortality by 1% per 1 point in the MELD score until 20, then 2% for each MELD point

What is the mortality in cirrhotic patients for emergent non-transplant surgery?

14% increase in mortality per 1 point of the MELD score

What is the most common liver cancer?

Metastatic disease outnumbers primary tumors 20:1, primary site is usually the GI tract

What is the most common primary malignant liver tumor?

Hepatocellular Carcinoma (hepatoma)

What is the most common primary benign liver tumor?

Hemangioma

What lab tests comprise the workup for the liver metastasis?

- LFTs (AST and alk phos are most useful)


- CEA for suspected primary colon cancer

What are the associated imaging studies to workup a liver metastasis?

- CT scan


- U/S


- A-gram

What is a right hepatic lobectomy?

Removal of the R lobe of the liver (ie, removal of all the liver tissue to the left of Cantle's line)

What is a left hepatic lobectomy?

Removal of the left lobe of the liver (ie, removal of all the liver tissue to the right of Cantle's line)

What is a right trisegmentectomy?

Removal of all the liver tissue to the right of the falciform ligament

What are the three common types of primary benign liver tumors?

1. Hemangioma


2. Hepatocellular adenoma


3. Focal nodular hyperplasia

What are the four common types of primary malignant liver tumors?

1. Hepatocellular carcinoma (hepatoma)


2. Cholangiocarcinoma (when intrahepatic)
3. Angiosarcoma (associated with chemical exposure)


4. Hepatoblastoma (most common in infants and children)

What chemical exposures are risk factors for angiosarcoma?

- Vinyl chloride


- Arsenic


- Thorotrast contrast

What is a hepatoma?

Hepatocellular carcinoma

What are the other benign liver masses?

- Benign liver cyst


- Bile duct hamartoma


- Bile duct adenoma

What is a liver "hamartoma"?

White hard nodule made up of normal liver cells

What is a hepatocellular adenoma?

Benign liver tumor

What are the histologic findings of a hepatocellular adenoma?

Normal hepatocytes without bile ducts

What are the associated risk factors for hepatocellular adenoma?

- Women


- Birth control pills (think: ABC = adenoma birth control)


- Anabolic steroids


- Glycogen storage disease

What is the female:male ratio with hepatocellular adenoma?

9:1

What is the average age of occurrence for hepatocellular adenoma?

30-35 years of age

What are the signs/symptoms of hepatocellular adenoma?

RUQ pain / mass, RUQ fullness, bleeding (rare)

What are the possible complications of hepatocellular adenoma?

- Rupture with bleeding (33%)


- Necrosis


- Pain


- Risk of hepatocellular carcinoma

How do you diagnose hepatocellular adenoma?

- CT scan


- U/S


- +/- biopsy (rule out hemangioma with RBC-tagged scan!)

What is the treatment for a small hepatocellular adenoma (<5cm)?

Stop birth control pills - it may regress; if not, surgical resection is necessary

What is the treatment for a large (>5cm), bleeding, painful, or ruptured hepatocellular adenoma?

Surgical resection

What is focal nodular hyperplasia (FNH)?

Benign liver tumor

What is the histologic appearance of focal nodular hyperplasia (FNH)?

Normal hepatocytes and bile ducts (adenoma has no bile ducts)

What is the average age of occurrence for focal nodular hyperplasia (FNH)?

~40 years

What are the associated risk factors for focal nodular hyperplasia (FNH)?

Female gender

Is focal nodular hyperplasia (FNH) associated with birth control pills?

Yes, but not as clearly associated as with adenoma

How do you diagnose focal nodular hyperplasia (FNH)?

- Nuclear technetium-99 study


- U/S


- CT scan


- A-gram


- Biopsy

What is the classic CT scan finding associated with focal nodular hyperplasia (FNH)?

Liver mass with "central scar" (think focal = central)

What are the possible complications of focal nodular hyperplasia (FNH)?

Pain (no risk of cancer, very rarely hemorrhage)

Is there a cancer risk with focal nodular hyperplasia (FNH)?

No (there is a cancer risk with adenoma)

What is the treatment of focal nodular hyperplasia (FNH)?

Resection or embolization if patient is symptomatic, otherwise follow if diagnosis is confirmed; stop birth control pills

Why does embolization work for focal nodular hyperplasia (FNH)?

FNH tumors are usually fed by one major artery

What is hepatic hemangioma?

Benign vascular tumor of the liver

What is a hepatic hemangiomas claim to fame?

Most common primary benign liver tumor (up to 7% of population)

What are the signs/symptoms of hepatic hemangioma?

RUQ pain/mass, bruits

What are the possible complications of hepatic hemangioma?

- Pain


- CHF


- Coagulopathy


- Obstructive jaundice


- Gastric outlet obstruction


- Kasabach-Merritt syndrome


- Hemorrhage (rare)

What is Kasabach-Merritt syndrome?

Hemangioma and thrombocytopenia and fibrinogenopenia

How do you diagnose hepatic hemangioma?

CT scan with IV contrast, tagged red blood scan, MRI, U/S

Should biopsy be performed on hepatic hemangioma?

No (risk of hemorrhage with biopsy)

What is the treatment of hepatic hemangioma?

Observation (>90%)

What are the indications for resection of hepatic hemangioma?

Symptoms, hemorrhage, cannot make a diagnosis

What is hepatocellular carcinoma?

Most common primary malignancy of the liver

What is a hepatocellular carcinoma also known as?

Hepatoma

What is the incidence of hepatocellular carcinoma?

Accounts for 80% of all primary malignant liver tumors

What are the geographic high-risk areas of hepatocellular carcinoma?

Africa and Asia

What are the associated risk factors of hepatocellular carcinoma?

- Hep B


- Cirrhosis


- Aflatoxin (fungi toxin of Aspergillus flavus)


- alpha-1 antitrypsin deficiency


- Hemochromatosis


- Liver fluke (Clonorchis sinensis)


- Anabolic steroids


- Polyvinyl chloride


- Glycogen storage disease (type I)

What percentage of patients with cirrhosis will develop hepatocellular carcinoma?

~5%

What are the signs/symptoms of hepatocellular carcinoma?

- Dull RUQ pain


- Hepatomegaly (classic presentation is painful)


- Abdominal mass


- Weight loss


- Paraneoplastic syndromes


- Signs of portal HTN


- Ascites


- Jaundice


- Fever


- Anemia


- Splenomegaly

What tests should be ordered to diagnose hepatocellular carcinoma?

- U/S


- CT scan


- Angiography


- Tumor marker elevation

What is the tumor marker associated with hepatocellular carcinoma?

Elevated alpha-fetoprotein

What is the most common way to get a tissue diagnosis of hepatocellular carcinoma?

Needle biopsy with CT scan, U/S, or laparoscopic guidance

What is the most common site of metastasis of hepatocellular carcinoma?

Lungs

What is the treatment of hepatocellular carcinoma?

- Surgical resection, if possible (eg, lobectomy)


- Liver transplant

What are the treatment options if the patient with hepatocellular carcinoma is not a surgical candidate?

Percutaneous ethanol tumor injection, cryotherapy, and intra-arterial chemotherapy

What are the indications for liver transplant in patients with hepatocellular carcinoma?

Cirrhosis and NO resection candidacy as well as no distant or lymph node metastases and no vascular invasion



The tumor must be single, <5 cm tumor or have three nodules, with none >3 cm

What is the prognosis for unresectable hepatocellular carcinoma?

Almost none survive a year

What is the prognosis for resectable hepatocellular carcinoma?

~35% are alive at 5 years

Which subtype of hepatocellular carcinoma has the best prognosis?

Fibrolamellar hepatoma (young adults)

What is a liver abscess?

Abscess (collection of pus) in the liver parenchyma

What are the types of liver abscess?

- Pyogenic (bacterial)


- Parasitic (amebic)


- Fungal

What is the most common location of liver abscess?

Right lobe > Left lobe

What are the sources of liver abscess?

- Direct spread from biliary tract infection


- Portal spread from GI infection (eg, appendicitis, diverticulitis)


- Systemic source (bacteremia)


- Liver trauma (eg, liver gunshot wound)


- Cryptogenic (unknown source)

What are the two most common types of liver abscess?

- Bacterial (most common in US)


- Amebic (most common worldwide)

What are the three most common bacterial organisms affecting the liver?

Gram negatives:


- E. coli


- Klebsiella


- Proteus

What are the most common sources / causes of bacterial liver abscesses?

- Cholangitis


- Diverticulitis


- Liver cancer


- Liver metastasis

What are the signs/symptoms of liver abscesses?

- Fever/chills


- RUQ pain


- Leukocytosis


- Increased LFTs


- Jaundice


- Sepsis


- Weight loss

What is the treatment of liver abscesses?

IV antibiotics (triple antibiotics with metronidazole), percutaneous drainage with CT scan or U/S guidance

What are the indications for operative drainage of a liver abscess?

Multiple / loculated abscesses or if multiple percutaneous attempts have failed

What is the etiology of amebic liver abscess?

Entamoeba histolytica (typically reaches liver via portal vein from intestinal amebiasis)

How does an amebic liver abscess spread?

Fecal-oral transmission

What are the risk factors for amebic liver abscesses?

- Patients from countries south of the US-Mexican border


- Institutionalized patients


- Homosexual men


- Alcoholic patients

What are the signs/symptoms of amebic liver abscesses?

- RUQ pain


- Fever


- Hepatomegaly


- Diarrhea



- Note: chills are much less common with amebic abscesses than with pyogenic abscesses

Which lobe is most commonly involved by amebic liver abscess?

Right lobe of liver

What is the classic description of amebic liver abscess contents?

"Anchovy paste" pus

How do you diagnose amebic liver abscess?

Lab tests, U/S, CT scan

What lab tests should be performed in a patient with amebic liver abscess?

Indirect hemagglutination titers for Entamoeba antibodies elevated in >95% of cases, elevated LFTs

What is the treatment of amebic liver abscesses?

Metronidazole IV

What are the indications for percutaneous surgical drainage of an amebic liver abscess?

Refractory to metronidazole, bacterial co-infection, or peritoneal rupture

What are the possible complications of large left lobe liver amebic absess?

Erosion into the pericardial sac (potentially fatal!)

What is a hydatid liver cyst?

Usually a right lobe cyst filled with Echinococcus granulosus

What are the risk factors for hydatid liver cyst?

Travel; exposure to dogs, sheep, and cattle (carriers)

What are the signs/symptoms of hydatid liver cyst?

- RUQ abdominal pain


- Jaundice


- RUQ mass

How do you diagnose a hydatid liver cyst?

Indirect hemagglutination antibody test (serologic testing), Casoni skin test, U/S, CT, radiographic imaging

What are the findings of hydatid liver cyst on AXR?

Possible calcified outline of cyst

What are the major risks for hydatid liver cyst?

- Erosion into the pleural cavity, pericardial sac, or biliary tree


- Rupture into the peritoneal cavity causing fatal anaphylaxis

What is the risk of surgical removal of echinococcal (hydatid) cysts?

Rupture or leakage of cyst contents into the abdomen may cause a fatal anaphylatic reaction

When should percutaneous drainage of a hydatid liver cyst be performed?

Never - may cause leaking into the peritoneal cavity and anaphylaxis

What is the treatment of hydatid liver cysts?

- Mebendazole, followed by surgical resection


- Large cysts can be drained and then injected with toxic irrigant (scoliocide) into the cyst unless aspirate is bilious (which means there is a biliary connection) followed by cyst removal

Which toxic irrigations are used with hydatid liver cysts?

- Hypertonic saline


- Ethanol


- Cetrimide

What is hemobilia?

Blood draining via the common bile duct into the duodenum

What is the diagnostic triad of hemobilia?

1. RUQ pain


2. Guaiac positive / upper GI bleeding


3. Jaundice

What are the causes of hemobilia?

- Trauma with liver laceration


- Percutaneous transhepatic cholangiography (PTC)


- Tumors

How do you diagnose hemobilia?

EGD (blood out of ampulla of Vater), A-gram

What is the treatment of hemobilia?

A-gram with embolization of the bleeding vessel