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ABSITE > 31 Liver > Flashcards

31 Liver Flashcards

1
Q

Hepatic artery variants

A

Right hepatic artery off superior mesenteric artery (most common 20%) - courses behind pancreas, posterolateral to the CBD
Left hepatic artery off left gastric artery (20%) - found in gastrohepatic ligament medially

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2
Q

Falciform ligament

A

Separates medial and lateral segments of the left lobe
Attaches liver to anterior abdominal wall
Extends to umbilicus and carries remnant of the umbilical vein

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3
Q

Ligamentum teres

A

Carries the obliterated umbilical vein to the under surface of the liver
Extends from the falciform ligament

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4
Q

Cantlie’s line (portal fissure)

A

Line drawn from the middle of the gallbladder fossa to IVC

Separates the right and left liver lobes

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5
Q

Sections of the liver

A

Right lobe: anterior (8, 5) and posterior (7,6)

Left lobe: left medial section (1, 4) and left lateral section (2,3)

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6
Q

Liver segment - I

A

Caudate

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7
Q

Liver segment - II

A

Superior left lateral segment

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8
Q

Liver segment - III

A

Inferior left lateral segment

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9
Q

Liver segment - IV

A

Left medial segment (quadrate lobe)

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10
Q

Liver segment - V

A

Inferior right anteromedial segment

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11
Q

Liver segment - VI

A

Inferior right posterolateral segment

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12
Q

Liver segment - VII

A

Superior right posterolateral segment

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13
Q

Liver segment - VIII

A

Superior right anteromedial segment

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14
Q

Glisson’s capsule

A

Peritoneum that covers the liver

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15
Q

Bare area

A

Area on the posterior-superior surface of the liver not covered by Glisson’s capsule

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16
Q

Triangular ligaments

A

Lateral and medial extensions of the coronary ligament on the posterior surface of the liver, made up of peritoneum

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17
Q

Portal triad enters via:

A

Segments IV and V

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18
Q

Gallbladder lies under:

A

Segments IV and V

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19
Q

Relationship of structures within the hepatoduodenal ligament

A

Lateral - CBD
Portal vein (posterior)
Medial - Proper hepatic artery

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20
Q

Kupffer cells

A

Liver macrophages

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21
Q

Contents of the portal triad

A

Common bile duct (lateral)
Portal vein (posterior)
Proper hepatic artery (medial)
Come together in the hepatoduodenal ligament (porta hepatis)

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22
Q

Pringle maneuver

A

Porta hepatis clamping

Will NOT stop hepatic vein bleeding

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23
Q

Foramen of Winslow

A 
Entrance to the lesser sac
Anterior - portal triad
Posterior - IVC
Inferior - duodenum
Superior - liver
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24
Q

Portal vein forms from:

A

Superior mesenteric vein joining the splenic vein (no valves)
Inferior mesenteric vein drains into the splenic vein

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25
Q

Portal vein branches

A

2 branches - providing 2/3 of hepatic blood flow
Left - segments II, III, IV
Right - segments V, VI, VII, VIII

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26
Q

Arterial blood supply to the liver

A

Right left and middle hepatic arteries
Middle hepatic artery is a branch of left hepatic artery
Hepatic artery supplies most primary and secondary tumors

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27
Q

Hepatic venous drainage

A

3 hepatic veins - drain into IVC
Left - II, III, superior IV
Middle - V, inferior IV
Right - VI, VII, VIII

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28
Q

Variation of the middle hepatic vein

A

80% drain into left hepatic vein

20% drain directly into the IVC

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29
Q

What do accessory right hepatic veins drain?

A

Medial aspect of the right lobe, directly into IVC

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30
Q

Blood supply of caudate lobe

A

Receives separate right and left portal and arterial blood flow
Drains directly into the IVC via separate hepatic veins

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31
Q

Alkaline phosphatase origin

A

Canalicular membrane

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32
Q

Where does nutrient uptake occur?

A

Sinusoidal membrane

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33
Q

Where is urea synthesized?

A

In the liver

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34
Q

What coagulation factors are NOT synthesized in the liver?

A

vWF, factor VIII (endothelium)

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35
Q

What vitamins are stored in the liver?

A

Fat soluble and B12

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36
Q

What are the most common problems with hepatic resection?

A

Bleeding

Bile leak

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37
Q

Which hepatocytes are most sensitive to ischemia?

A

Central lobular (acinar zone III)

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38
Q

What is bilirubin the product of?

A

Breakdown of hemoglobin

Hbg –> heme –> biliverdin –> bilrubin

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39
Q

How is the water solubility of bilirubin improved?

A

Conjugated to glucuronic acid (glucoronyl transferase)

Occurs in the liver

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40
Q

What form of bilirubin is actively secreted into bile?

A

Conjugated bilirubin

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41
Q

How is bilirubin processed after it is secreted in bile?

A

Free bilirubin is created via bacterial breakdown of conjugated bilirubin in the terminal ileum
It is reabsorbed and converted into urobiligen, which is released as urobilin in the urine

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42
Q

What causes cola colored urine?

A

Excess urobilinogen

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43
Q

What is the content of bile?

A 
Bile salts (85%)
Protein
Phospholipids (lecithin)
Cholesterol
Bilirubin
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44
Q

What determines the final composition of bile?

A

Active resorption of water via Na/K ATPase

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45
Q

What is cholesterol’s role in bile?

A

Used to make bile salts/acids

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46
Q

What are bile salts conjugated to? Why?

A

Taurine, glycine

Improves water solubility

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47
Q

Primary bile acids (Salts)

A

Cholic and chenodeoxycholic

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48
Q

Secondary bile acids (salts)

A

Deoxycholic and lithocholic

Dehydroxylated primary bile acids via bacteria in gut

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49
Q

Role of bile in digestion

A

Bile solubilizes cholesterol and emulsifies fats in the intestine, forming micelles, which enter enterocytes by fusing with the membrane

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50
Q

Minimum bilirubin level for jaundice? Where do you see it first?

A

Bilirubin >2.5

Under the tongue

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51
Q

Maximum bilirubin level?

A

30

Unless underlying renal disease, hemolysis or bile duct-hepatic vein fistula

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52
Q

Causes of elevated unconjugated bilirubin

A

Prehepatic - hemolysis

Hepatic deficiencies of uptake or conjugation

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53
Q

Causes of elevated conjugated bilirubin

A

Secretion defects into bile ducts

Excretion defects into GI tract (stones, strictures, tumors)

54
Q

Gilbert’s disease

A

Abnormal conjugation

Mild defect in glucuronyl transferase

55
Q

Crigler-Najjar disease

A

Inability to conjugate
Severe deficiency in glucuronyl transferase
High unconjugated bilirubin - life-threatening disease

56
Q

Physiologic jaundice of newborn

A

Immature glucuronyl transferase

High unconjugated bilirubin

57
Q

Rotor’s syndome

A

Deficiency in storage ability

High conjugated bilirubin

58
Q

Dubin-Johnson syndrome

A

Deficiency in secretion ability

High conjugated bilirubin

59
Q

Fulminant hepatic failure - which viral hepatitis?

A

B, D and E (rare with A and C)

60
Q

Chronic hepatitis and hepatoma - which viral hepatitis?

A

B, C and D

61
Q

Hepatitis A

A

RNA
Fecal/oral
Serious consequences uncommon

62
Q

Hepatitis B

A

DNA - funny replication with reverse transcriptase

Associated with both acute and chronic hepatitis

63
Q

Anti-HBc antibodies (hep B)

A

Core antibody
IgM elevated first 6mo after exposure
IgG >6mo
NOT in vaccination

64
Q

Hep B vaccination

A

Elevated anti-HBs (surface) antibodies only

65
Q

Elevated anti-HBc antibody
Elevated anti-HBs antibody
Negative HbsAg

A

Patient had infection with recovery

Has immunity

66
Q

Hepatitis C

A

RNA
Long incubation period
Not associated with acute hepatitis - associated with chronic hepatitis
Most common viral hepatitis leading to liver TXP

67
Q

Hepatitis D

A

RNA
Cofactor for hepatitis B
Worse prognosis

68
Q

Hepatitis E

A

RNA

Fulminant hepatic failure in pregnancy (3rd trimester)

69
Q

Most common cause of liver failure?

A

Cirrhosis (palpable liver, jaundice, ascites)

70
Q

Best indicator of synthetic function in patients with cirrhosis?

A

Prothrombin time (PT)

71
Q

Mortality in acute liver failure?

A

Fulminant hepatic failure has 80% mortality

Outcome determined by course of encephalopathy

72
Q

Criteria for urgent liver transplant listing?

A

King’s college criteria

Separated between acetaminophen-induced and other

73
Q

King’s college criteria for acetaminophen-induced ALF?

A 
Arterial pH <7.3 irrespective of coma grade
OR, all of the following:
- INR >6.5
- Creatinine >3.4
- Grade III/IV encephalopathy
74
Q

King’s college criteria for Non-acetaminophen-induced ALF?

A 
INR >6/5
OR, any 3 of the following:
- Age <10 or >40
- Drug toxicity or undetermined etiology
- Jaundice >7 days before encepholopathy
- INR >3.5
- Bilirubin >17
75
Q

Why does liver failure cause hepatic encephalopathy?

A

Inability to metabolize ammonia, mercantanes, and false neurotransmitters

76
Q

Causes, apart from liver failure, for encephalopathy?

A

GI bleed
Infection (SBP)
Electrolyte imbalance
Drugs

77
Q

Treatment of hepatic encephalopathy?

A 
Possible emoblization of previous therapeutic shunts or other major collaterals
Lactulose
Limit protein intake (<70g/day)
Add BCAA to diet
No Abx unless specific infection
Neomycin
78
Q

How does lactulose help with hepatic encephalopathy?

A

Cathartic that gets rid of bacteria in the gut
Acidifies the colon - prevents NH3 uptake by converting it to ammonium
Titrate to 2-3 stools/day

79
Q

How does neomycin help with hepatic encephalopathy?

A

Gets rid of ammonia-producing bacteria from the gut

80
Q

How does chronic cirrhosis cause ascites?

A 
Hepatocyte destruction -->
Fibrosis and scaring of liver -->
Increased hepatic pressure -->
Portal venous congestion -->
Lymphatic overload -->
Leakage of splanchnic and hepatic lymph into peritonium
--> Ascites
81
Q

Albumin dose with paracentesis for ascites

A

1g albumin for every 100cc removed

82
Q

Treatment of ascites

A

Water restrict ion(1-1.5L/day)
Decreased NaCl (1-2g/day)
Diuretics (spironolactone conteracts hyperaldosteronism seen with liver failure)
Paracentesis
TIPS
Prophylactics for SBP (Norfloxacin - if previous SBP or current UGI bleed)

83
Q

Why is aldosterone elevated with liver failure?

A

Impaired hepatic metabolism

Impaired GFR

84
Q

Hepatorenal syndrome

A

Progressive renal failure due to hepatic failure (end-stage)
Same lab findings as prerenal azotemia
Tx: Stop diuretics, give volume; liver TXP

85
Q

Asterixis

A

Neurological changes due to liver failure

Sign that it is getting worse

86
Q

Postpartum liver failure with ascites

A

Due to hepatic vein thrombosis - infectious component
Dx: SMA arteriogram with venous phase contrast
Tx: Heparin + abx

87
Q

Diagnostic criteria for SBP?

A

Fever
Abdominal pain
PMNs >250 in fluid
+/- positive cultures

88
Q

Bacteria causing SBP?

A

E. coli
Pneumococci
Streptococci

89
Q

Differentiating between SBP and bowel perf?

A

SBP is mono-organism

If it is a poly infection - consider perf

90
Q

Risk factors for SBP?

A

Ascites (required)
Prior SBP
Upper GI bleed (variceal hemorrhage)
Low-protein ascites

91
Q

Treatment of SBP?

A

3rd generation cephalosporins

Patients respond in 48 hours

92
Q

Treatment of esophageal varices

A

Banding and sclerotherapy (95% effective)
Vasopressin/octreotide (temporizing)
Sengstaken-Blakemore esophgeal tube
Propranolol (prevent re-bleed, not useful acutely)
TIPS for refractory bleeding

93
Q

Vasopressin - MOA in esophageal varices

A

Splanchnic artery constriction

If patient has hx of CAD - add NTG

94
Q

Octreotide - MOA in esophageal varices

A

Decreases portal pressures by decreasing blood flow

95
Q

Late complication from sclerotherapy? Tx?

A

Strictures

Dilation

96
Q

Causes of portal hypertension?

A

Pre-sinusoidal obstruction - schistosomiasis, congential hepatic fibrosis, portal vein thrombosis
Sinusoidal obstruction - cirrhosis
Post-sinusoidal obstruction - Budd-Chiari syndrome, constrictive pericarditis, CHF

97
Q

Normal portal vein pressure

A

<12 mmHg

98
Q

Which hepatic vein acts as collaterals between the portal vfein adn systemic venous system?

A

Coronary veins - portal vein to veins of lower esophagus (azygous vein)

99
Q

Complications of portal hypertension?

A

Esophageal variceal hemorrhage
Ascites
Splenomegaly
Hepatic encephalopathy

100
Q

Role of shunts in portal hypertension? Complications?

A

Decompress the portal system

Can increase risk of encephalopathy (bypassing the metabolism of liver)

101
Q

Transjugular intrahepatic portosystemic shunt

A

TIPS
Indication: protracted bleeding, progression of coagulopathy, visceral hypoperfusion, refractory ascites

Allows antegrade flow
Complication - encephalopathy

102
Q

Splenorenal shunt

A

Lower rate of encephalopathy
Ligate left adrenal vein, left gonadal vein, IMV, coronary vein and pancreatic branches of splenic vein
Indications - Child’s A cirrhotic presenting with just bleeding
CI: refractory ascites (can make it worse)

103
Q

Child’s B or C with indication for shunt

A

Treat with TIPS

104
Q

Child’s A with just bleeding symptoms

A

Consider splenorenal shunt (more durable)

Otherwise TIPS

105
Q

Child-Pugh Score

A

Assessment of liver failure
Assesses:
- Albumin (>3.5 - 3-3.5 - <3.0)
- Bilirubin (<2.5 - 2.5-4 - >4)
- Encephalopathy (none - minimal - refractory)
- Ascites (none - tx with meds - refractory)
- INR (<1.7 - 1.7-2.3 - >2.3)

Give 1-2-3 points for each category
A - 5-6; B - 7-9; C 10+

106
Q

Association of Child-Pugh Score with Shunt placement

A

Correlates with mortality after open shunt placement
Child’s A - 2%
Child’s B - 10%
Child’s C - 50%

107
Q

Budd-Chiari syndrome

A

Occlusion of hepatic veins of IVC
Sx: RUQ pain, hepatosplenomegaly, ascites, fulminant hepatic failure, muscle wasting, variceal bleeding
Dx: angiogram with venous phase, CT angiogram; liver bx (sinusoidal dilation, congetsion, centrilobular congestion)
Tx: Porta-caval shunt (connecting to IVC above the obstruction)

108
Q

Splenic vein thrombosis

A

Cause: Pancreatitis
Sx: Isolated gastric varices (without elevation of the rest of the portal system pressure), UGI bleed of the varices
Ts: Splenectomy if symptomatic

109
Q

Amebic liver abscess

A 
Single in right lobe of liver
Entamoeba histolytica
Reaches liver via portal vein
Culture of abscess negative
Dx: CT (rim enhancing lesion)
Tx: Flagyl, aspiration (if refractory), surgery (free rupture)
110
Q

Echinococcus liver abscess

A

Hydatid cyst
Positive Casoni skin test, positive serology
Right love of liver
Dx: CT (calcified, double-walled cyst); ERCP (jaundice, increased LFTs, cholangitis to assess for communication with biliary tract)
Tx: pre-op albendazole (2 weeks), surgical removal (inject cyst with alcohol, get entire cyst wall)

DO NOT aspirate - anaphylactic shock

111
Q

Schistosomiasis liver abscess

A

Maculopapular rash, increased eosinophils
Sigmoid colon infection (fine granulation tissue, petechiae, ulcers)
Can cause variceal bleeding
Tx: praziquantel

112
Q

Pyogenic liver abscess

A

Sx: Fever, chills, wt loss, RUQ pain, increased LFTs, WBC, sepsis
Right lobe
E. coli
Contiugous infection from biliary tract or bacteremia
Dx: aspiration
Tx: CT-guided drainage and abx; surgical drainage for unstable condition and continued sepsis

113
Q

Benign liver tumors

A

Hepatic adenomas
Focal nodular hyperplasia
Hemangioma
Solitary cyst

114
Q

Hepatic adenoma

A

Steroids/OCP
Sx: Pain, increased LFT, hypotension (rupture), palpable mass
Dx: Negative sulfur colloid scan (no Kupffer cells), MRI hypervascular tumor
Tx:
Asymptomatic - stop OPCs, if no regression –> resection
Symptomatic - resection for bleeding/malignancy risk; embolization if multiple and unresectable

115
Q

Sulfur colloid scan

A

Used to liver tumors
Kupffer cells uptake sulfur colloid - positive scan
Hepatic adenomas have NO kupffer cells
Focal nodular hyperplasia does have kupffer cells

116
Q

Focal nodular hyperplasia

A

Central stellate scar - looks like cancer
No malignancy risk, unlikely to rupture
Dx: Abdomina CT, positive sulfur colloid scan (has kupffer cells), hypervasular tumor
Tx: conservative (no surgery)

117
Q

Hemangioma

A

Rare rupture
Avoid biopsy - risk of hemorrhage
Dx: MRI/CT - peripheral to central enhancement; hypervascular lesion
Tx: symptomatic - surgery +/- pre-op emobolization; steroids and possible XRT for unresectable

118
Q

Kasabach-Merritt syndrome

A

Consumptive coagulopathy due to hemangioma (rare, children)

119
Q

Rare complications of hemangioma seen in children?

A 
Consumptive coagulopathy (Kasabach-Merritt)
CHF
120
Q

What type of CT do you use to assess the liver?

A

Triple phase

  • Native
  • Portal
  • Arterial
121
Q

Solitary liver cysts

A 
Congenital
Women
Right lobe
Characteristic blue hue
Tx: nothing
122
Q

Hepatoma (HCC)

A

Most common cancer worldwide

AFP level correlates with tumor size

123
Q

Risk factors for HCC

A

Hep B, Hep C, ETOH, hemochromatosis, aslpha-1-antitrypsin deficiency, primary sclerosing cholangitis, alfatoxins, hepatic adenoma, steroids, pesticides

NOT - primary biliary cirrhosis, Wilson’s disease

124
Q

Best prognosis forms of HCC

A

Clear cell
Lymphocyte infiltrative
Fibrolamellar type (adolescent, young adults)

125
Q

Tumor marker for HCC

A

AFP

126
Q

Margins for HCC

A

1cm

127
Q

Risk factors for hepatic sarcoma

A

PVC, thorotrast, arsenic

128
Q

Isolated colon CA metastases to liver - treatment

A

Resection if there is >35% of (good) liver remaining

129
Q

Primary liver tumors CT apperance

A

Hypervascular

130
Q

Metastatic liver tumors CT apperance

A

Hypovascular

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