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9. Liver

Openbaar

1 / 323 Image occlusion

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2 / 323 Image occlusion

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3 / 323 Image occlusion

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4 / 323 Image occlusion

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5 / 323 Image occlusion

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6 / 323 Image occlusion

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7 / 323 V&A

What divides the liver into the right and left lobes?

The falciform ligament separates the liver into right and left lobes.

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8 / 323 V&A

What is Cantlie's Line?

Cantlie's Line is a functional division of the liver, along the gallbladder fossa and inferior vena cava.

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9 / 323 V&A

What surrounds the bare area of the liver?

The bare area is not covered by Glisson's capsule.

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10 / 323 V&A

What segments form the left hemiliver?

Segment II
Segment III
Segment IV

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11 / 323 V&A

What are the four sections of the liver based on the hepatic artery?

Right anterior section (segments V & VIII)
Right posterior section (segments VI & VII)
Left medial section (segment IV)
Left lateral section (segments II & III)

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12 / 323 Invul

The liver can be divided into 8 functional segments also known as Couinaud segments.

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13 / 323 Multiple choice

Which ligament is not part of the liver anatomy?

Bare Area

Right Triangular Ligament

Falciform Ligament

Coronary Ligament

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14 / 323 V&A

What is the primary purpose of the caudate lobe?

The caudate lobe contains 3 sub-segments: spiegel lobe, paracaval, and caudate process.

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15 / 323 V&A

What does the liver weigh approximately?

The liver weighs about 1.5 kg.

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16 / 323 V&A

What ligament is a remnant of the obliterated umbilical vein?

The Round Ligament (ligamentum teres).

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17 / 323 V&A

What ligaments attach the liver to the anterior abdominal wall?

Falciform Ligament
Coronary Ligament
Left and Right Triangular Ligament

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18 / 323 V&A

What supplies 75% of the liver's blood?

The portal vein.

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19 / 323 V&A

What is the primary arterial blood supply to the liver?

The hepatic artery proper (25%).

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20 / 323 V&A

What drains segment V, VI, VII, and VIII of the liver?

The Right hepatic vein.

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21 / 323 V&A

What anatomical variant arises from the SMA?

Replaced right hepatic artery (10-15%).

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22 / 323 V&A

How do segment V & VIII drain into the liver?

Via the right anterior sectoral duct (RASD).

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23 / 323 Invul

The three main hepatic veins form sagittal planes and include the Right hepatic vein, Middle hepatic vein, and Left hepatic vein.

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24 / 323 Invul

The portal vein divides into the right and left portal vein branches.

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25 / 323 V&A

What is the significance of the caudate lobe's venous drainage?

It drains directly to the IVC.

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26 / 323 V&A

What drains the segments VI and VII of the liver?

The right posterior sectoral duct (RPSD).

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27 / 323 V&A

What is a common anatomical variant involving the biliary system?

RPSD draining into LHD (15%).

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28 / 323 V&A

What stimulates the contraction of the gallbladder?

CCK (Cholecystokinin)

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29 / 323 V&A

What are the two factors governing bile secretion?

Enterohepatic circulation
Gut hormones (CCK & secretin)

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30 / 323 V&A

What is the consequence of a lack of bile?

Malabsorption of fats and fat-soluble vitamins (A, D, E, K)

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31 / 323 Invul

Bile is diverted from the liver into the gallbladder due to high tone in the sphincter of Oddi.

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32 / 323 V&A

What is the role of the liver in carbohydrate metabolism?

Glycogenesis
Glycogenolysis

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33 / 323 V&A

What process occurs to amino acids during starvation?

Gluconeogenesis - conversion back to glucose

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34 / 323 V&A

What is lipogenesis?

Conversion of glucose to glycerol + FFA forming TG (triglycerides)

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35 / 323 V&A

What is the Cori Cycle?

Lactate is converted to glucose in the liver and returned to the muscle.

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36 / 323 V&A

What vitamin is activated in a two-stage hydroxylation process?

Vitamin D

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37 / 323 V&A

What is synthesized in the liver besides immunoglobulin?

Plasma proteins such as albumin and clotting factors.

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38 / 323 V&A

What regulates iron homeostasis?

The synthesis of Hepcidin in the liver.

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39 / 323 V&A

Which cells in the liver are responsible for phagocytosis?

Kupffer cells.

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40 / 323 V&A

What is the role of the liver in detoxification?

Detoxify peptide hormones, drugs, and toxins.

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41 / 323 V&A

What forms the main storage for fat-soluble vitamins?

Vitamin A
Vitamin D
Vitamin E
Vitamin K
Vitamin B12

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42 / 323 Multiple choice

What substance is converted by the liver in the Cori Cycle?

Fatty acids

Lactate

Amino acids

Glucose

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43 / 323 V&A

What is the definition of portal hypertension?

Portal Hypertension is defined as the Hepatic venous pressure gradient (HVPG) ≥ 6mmHg. Normal is 3-5mmHg.

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44 / 323 V&A

What is the normal portal flow rate?

1-1.5 L/min is the normal portal flow rate.

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45 / 323 V&A

What indicates high risk of developing gastroesophageal varices?

Portal HTN ≥ 10mmHg indicates high risk of gastroesophageal varices.

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46 / 323 V&A

What pressure level poses a high risk for variceal bleed?

Portal HTN ≥ 12mmHg indicates high risk of variceal bleed.

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47 / 323 V&A

Which organs are drained by portal veins?

Small intestines
Large intestines
Stomach
Spleen
Pancreas
Gallbladder

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48 / 323 V&A

What forms the portal vein?

The SMV and the splenic vein unite behind the neck of the pancreas to form the portal vein.

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49 / 323 Invul

The portal trunk divides into two lobar veins: the right branch that drains the cystic vein and the left branch which drains the umbilical and paraumbilical vein (caput medusae in portal HTN).

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50 / 323 V&A

What is a consequence of portal hypertension due to cirrhosis?

Portal hypertension results from mechanical obstruction of the portal venous system.

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51 / 323 V&A

What are the key issues with cirrhosis affecting portal hypertension?

Architecture distortion
Regenerative parenchymal nodules
Disruption of liver architecture

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52 / 323 Invul

According to Ohm's Law, the relationship between voltage (V), current (I), and resistance (R) is given by: V = IR. Poiseuille's Law states that R = 8hL/pr^4.

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53 / 323 V&A

What impact does decreasing portal vascular radius have on resistance?

Dramatic increase in portal vascular resistance occurs with decreased vascular radius.

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54 / 323 Invul

The diagram illustrating portal hypertension pathophysiology and collateral circulation shows key elements such as splanchnic vasodilation and TIPS (Transjugular Intrahepatic Portosystemic Shunt). diagram

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55 / 323 Invul

Illustration of the liver and its venous drainage highlights esophageal, paraumbilical, and rectal varices. image description

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56 / 323 V&A

What is a major cause of pre-sinusoidal portal hypertension?

Portal Vein Thrombosis
Splenic Vein Thrombosis
Congenital Atresia

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57 / 323 V&A

What is a common cause of sinusoidal portal hypertension?

Cirrhosis
Massive Fatty Change
Hemochromatosis

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58 / 323 V&A

What are some causes of post-sinusoidal portal hypertension?

Hepatic vein thrombosis
IVC thrombosis
Congenital IVC malformation

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59 / 323 V&A

What condition is associated with Budd Chiari Syndrome?

Rare thromboembolic disorder of hepatic veins/IVC leading to post-sinusoidal portal hypertension.

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60 / 323 V&A

What are key ultrasound findings for portal hypertension?

Dilated splenic & superior mesenteric veins ≥ 11mm
Splenomegaly > 12cm
Dilated portal vein ≥ 13mm

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61 / 323 Invul

In portal hypertension, ascites occurs due to: increased fluid shift leading to increased lymphatic drainage from liver which overwhelms thoracic duct capacity, resulting in percolation of hepatic lymph into the peritoneal cavity.

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62 / 323 V&A

What is a significant complication of portal hypertension?

Ascites
Hepatic Encephalopathy
Portal Hypertensive Gastropathy

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63 / 323 Multiple choice

What causes spontaneous bacterial peritonitis (SBP) in ascites?

Chronic alcoholism

Dilated portal vein

Hemochromatosis

Increased fluid shift (Starling's law)

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64 / 323 V&A

What are some symptoms of Hepatic Encephalopathy?

Hyperammonemia
Neuro-toxicity
Exacerbated by portosystemic shunting

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65 / 323 V&A

Which anatomical area is affected by oesophageal varices?

Portal circulation through oesophageal branch of left gastric vein.

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66 / 323 V&A

What is Caput Medusae related to?

Varicosity caused by systemic circulation through superficial epigastric veins.

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67 / 323 V&A

What does progressive liver cirrhosis lead to?

Obstruction of intra-hepatic vasculature causing portal hypertension.

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68 / 323 V&A

What is released due to portal HTN in cirrhotic patients?

Increased splanchnic nitric oxide (NO).

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69 / 323 V&A

What stimulates RAAS in cirrhotic patients?

Renal hypoperfusion.

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70 / 323 V&A

What is the effect of aldosterone in ascites treatment?

Increases retention of salt and water.

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71 / 323 V&A

What is the diuretic of choice for cirrhotic patients with ascites?

Spironolactone (aldosterone antagonist).

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72 / 323 V&A

What are common symptoms of ascites?

Progressive abdominal distension
Weight gain
Shortness of breath
Early satiety

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73 / 323 V&A

What physical signs confirm the diagnosis of ascites?

Abdominal distension
Flank dullness
Shifting dullness
Umbilical eversion

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74 / 323 V&A

What does the SAAG ≥ 1.1g/dL indicate?

Porta hypertension; common cause is liver cirrhosis.

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75 / 323 V&A

What can a SAAG <1.1g/dL indicate?

Malignancy or infection such as peritoneal tuberculosis.

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76 / 323 V&A

What investigations are performed for suspected ascites?

Biochemical tests (FBC, U/E/Cr, LFT)
Imaging (Ultrasound/CT)

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77 / 323 V&A

What does a peritoneal tap assess?

Fluid color and appearance to distinguish between conditions.

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78 / 323 Multiple choice

What is the common indication for a peritoneal tap in ascites?

Diagnostic

Curative

Preventive

Therapeutic

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79 / 323 V&A

What is a common microbiological test for ascitic fluid?

Gram stain smear, culture (aerobic / anaerobic), cytology

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80 / 323 V&A

What are the laboratory tests included in the analysis of ascitic fluid?

LDH
TG
Glucose
TB culture
ProBNP

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81 / 323 V&A

What is the recommended low salt diet for ascites?

2000mg / day or 88mol/day

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82 / 323 V&A

When should fluid restriction be considered?

If serum sodium <125mmol/L

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83 / 323 V&A

What is the typical pharmacological treatment for diuresis in ascites?

Spironolactone 100mg
Furosemide 40mg (Max 400mg:160mg)

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84 / 323 V&A

What is the recommended antibiotic for suspected spontaneous bacterial peritonitis?

IV ceftriaxone or oral quinolones (e.g., ciprofloxacin)

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85 / 323 V&A

What is the purpose of therapeutic paracentesis?

To manage tense ascites and prevent complications.

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86 / 323 V&A

What is the procedure for therapeutic paracentesis?

Site: 2FB above and 2FB lateral to ASIS
Use aseptic technique, LA, US-guided

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87 / 323 V&A

Why is albumin administered after paracentesis?

To prevent paracentesis-induced circulatory dysfunction.

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88 / 323 V&A

What surgical options are available for liver disease-related ascites?

Liver transplantation
Transjugular Intrahepatic Porto-Systemic Shunts (TIPSS)
Peritoneovenous shunts

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89 / 323 V&A

What should be controlled pre-operatively in cirrhotic patients?

Ascites

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90 / 323 V&A

What is the risk of abdominal operations in patients with advanced cirrhosis?

High risk of complications, especially portal hypertension.

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91 / 323 V&A

What is performed prior to major abdominal operations in high MELD score patients?

Transjugular Intrahepatic Portosystemic Shunt (TIPSS).

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92 / 323 V&A

What does hepatomegaly refer to?

Hepatomegaly refers to the abnormal enlargement of the liver.

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93 / 323 V&A

What are common symptoms of hepatomegaly?

Asymptomatic
Abdominal pain
Nausea, vomiting
Fever
Signs of jaundice

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94 / 323 V&A

What should a clinical examination for hepatomegaly include?

Palpable organomegaly
Tenderness
Signs of ascites
Digital Rectal Examination

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95 / 323 Invul

Common presentations of hepatomegaly include: abdominal pain, nausea, vomiting, and fever.

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96 / 323 V&A

What are signs of chronic liver disease?

Gynaecomastia
Clubbing of fingernails
Palmar erythema
Lower limb edema

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97 / 323 Multiple choice

What is a common risk factor for malignant lesions in hepatomegaly?

Ongoing weight loss

Sudden fever

History of liver cirrhosis

High blood pressure

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98 / 323 Invul

Symptoms of portal hypertension may include splenomegaly and ascites.

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99 / 323 V&A

What is a physiological cause of liver abnormalities?

Riedel's Lobe Hyperextended Chest

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100 / 323 V&A

Name a bacterial infection that can affect the liver.

Pyogenic Liver Abscess Tuberculosis

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101 / 323 V&A

Which viral infections are known to affect the liver?

Hepatitis EBV CMV HIV

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102 / 323 V&A

What are some alcohol-related liver conditions?

Fatty Liver Cirrhosis

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103 / 323 V&A

Which metabolic diseases can affect the liver?

Wilson's Disease Haemochromatosis Infiltration - amyloidosis

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104 / 323 V&A

What are some malignant liver conditions?

Hepatocellular Carcinoma Hepatic Angiosarcoma Cholangiocarcinoma

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105 / 323 V&A

What is a vascular/cardiac disorder that affects the liver?

Right Heart Failure (RHF) Budd-Chiari Syndrome

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106 / 323 Invul

A benign hepatic neoplasm can be a Haemangioma, Hepatic Adenoma, or Focal nodular Hyperplasia.

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107 / 323 V&A

What types of hepatic abscesses exist?

Pyogenic Abscess Amoebic Abscess

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108 / 323 V&A

What are the two types of hepatic cysts?

Non Parasitic Cyst Echinococcal Cysts

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109 / 323 Invul

Intrahepatic obstruction causes of portal hypertension include Cirrhosis and Wilson's Disease.

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110 / 323 V&A

What is a post-hepatic obstruction condition for portal hypertension?

Budd-Chiari Syndrome IVC Thrombosis

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111 / 323 Invul

Factors associated with Hepatic Angiosarcoma include exposure to vinyl chloride, arsenic.

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112 / 323 V&A

What is a Full Blood Count used for?

To detect any anemia or signs of infections.

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113 / 323 V&A

What does a Liver Function Test indicate?

Presence of hyperbilirubinemia and deranged liver enzymes.

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114 / 323 V&A

What are Tumour Markers used for?

Their presence can indicate suspicion of malignancy.

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115 / 323 V&A

What imaging techniques are used for liver examination?

Ultrasound Liver
CT Scan
MRI

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116 / 323 Invul

An Ultrasound of the liver can reveal a simple cyst as: - well defined smooth walls - posterior acoustic enhancement.

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117 / 323 Invul

A CT Scan of a haemangioma shows: - early peripheral nodular enhancement - centripetal filling.

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118 / 323 Invul

The MRI of a Hepatic Adenoma reveals: - hypervascular enhancement on arterial phase - lack of central scar.

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119 / 323 Invul

In Focal Nodular Hyperplasia (FNH), the Doppler appearance shows: - central feeding artery - tortuous spoke-wheel vascularity.

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120 / 323 Invul

For Hepatocellular Carcinoma (HCC), imaging might show: - hypervascular enhancement on arterial phase - portal venous washout.

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121 / 323 Multiple choice

Which imaging technique is NOT typically used for liver examination?

CT Scan

MRI

Endoscopy

Ultrasound Liver

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122 / 323 V&A

What are liver hemangiomas characterized by?

Benign vascular lesions consisting of widened (dilated) blood vessels, not true neoplasms.

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123 / 323 V&A

What is the female to male ratio for liver hemangiomas?

5-6:1, predominantly in middle-aged women.

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124 / 323 V&A

What is the usual presentation of a liver hemangioma?

Usually asymptomatic; may cause nonspecific abdominal pain when larger than 5cm.

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125 / 323 V&A

What imaging technique is most accurate for liver hemangiomas?

Ultrasound, with 70-80% accuracy and pathognomonic compressibility of the lesion.

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126 / 323 V&A

What does a CT scan of a hemangioma show?

Peripheral enhancement in the arterial phase and peripheral to central enhancement over time.

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127 / 323 Invul

The majority of liver hemangiomas are treated with observation if they are asymptomatic and smaller than 4cm.

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128 / 323 V&A

What should never be done for diagnosing liver hemangiomas?

Biopsy, due to risk of severe and fatal hemorrhage.

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129 / 323 V&A

What syndrome is associated with large hemangiomas?

Kasabach-Merritt syndrome, which leads to thrombocytopenia and consumptive coagulopathy.

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130 / 323 Multiple choice

What is a common treatment for symptomatic or complicated liver hemangiomas?

Radiation therapy

Surgical removal

Observation

Chemotherapy

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131 / 323 V&A

What are the symptoms of large liver hemangiomas?

Nonspecific abdominal fullness
Abdominal pain
Rarely, life-threatening hemorrhage

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132 / 323 V&A

What is the definition of Focal Nodular Hyperplasia (FNH)?

FNH is a benign tumour characterized by a central stellate scar and is considered a regenerative process, not a result of arterial malformation.

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133 / 323 V&A

What is the epidemiology of FNH?

Second commonest benign liver tumour
More common in females (6-8:1) aged 30 to 50 years
Associated with AVMs and hepatic haemangioma.

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134 / 323 V&A

What symptoms are associated with FNH?

Asymptomatic (incidental on imaging)
Right upper quadrant pain
Rarely ruptures or bleeds.

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135 / 323 V&A

How is FNH diagnosed?

CT: Bright homogenous enhancement, hypoattenuating central scar.
Sulphur colloid scan: Positive for kupffer cells.
MRI: Central scar hyperintense on T2 weighted images.

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136 / 323 V&A

What is the treatment for FNH?

Conservative management for asymptomatic patients.
Surgery for symptomatic patients, with liver resection preferred.

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137 / 323 Invul

FNH is a benign tumour characterized by a central stellate scar and is considered a regenerative process.

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138 / 323 Invul

FNH is the second commonest benign liver tumour, more common in females aged 30 to 50 years.

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139 / 323 Invul

Symptoms of FNH include: - asymptomatic - right upper quadrant pain.

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140 / 323 Invul

Diagnosis of FNH involves: - CT with bright enhancement and hypoattenuating scar - sulphur colloid scan - MRI.

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141 / 323 Invul

FNH treatment options are: - conservative management for asymptomatic patients - surgery for symptomatic patients.

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142 / 323 V&A

What are hepatic adenomas?

Benign proliferation of hepatocytes; should not be confused with hepatoma (HCC).

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143 / 323 V&A

What is the female to male ratio for hepatic adenomas?

10:1, primarily found in young women.

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144 / 323 V&A

What are common presentations of hepatic adenomas?

Asymptomatic or symptomatic with spontaneous rupture and intraperitoneal hemorrhage.

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145 / 323 V&A

What percentage of hepatic adenomas may rupture?

25-35%, with nearly 100% of ruptures in lesions >5cm.

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146 / 323 V&A

What are common diagnosis methods for hepatic adenomas?

CT (triphasic), sulphur colloid scan, and MRI.

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147 / 323 V&A

What is the treatment for small, asymptomatic hepatic adenomas?

Conservative management with close observation and possible discontinuation of OCPs.

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148 / 323 V&A

What is indicated for symptomatic hepatic adenomas or those >4-5cm?

Surgical resection.

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149 / 323 Invul

Hepatic adenomas are characterized by a benign proliferation of hepatocytes, distinct from hepatoma which refers to HCC.

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150 / 323 Invul

The risk factors for hepatic adenomas include anabolic steroids, oestrogen, and progesterone preparation (e.g., OCP).

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151 / 323 Invul

A significant risk of hepatic adenomas is malignant transformation to well-differentiated HCC, with a risk of ~5%.

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152 / 323 Multiple choice

What characteristic is NOT associated with imaging findings in hepatic adenomas?

No true lobules

Sharply defined borders

More common in right lobe

Homogenous enhancement during arterial phase

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153 / 323 Multiple choice

What should be done if a patient has an acute hemorrhage from hepatic adenoma?

Discontinue all medications

Proceed to hepatic angioembolization followed by surgery

Immediate liver transplant

Complete bed rest without intervention

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154 / 323 V&A

What are liver cysts commonly detected through?

Imaging, as they are mostly asymptomatic.

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155 / 323 V&A

What percentage of liver cysts are simple ones?

5-20%

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156 / 323 Invul

Nonparasitic liver cysts include: - Simple Liver Cysts - Polycystic Liver Disease - Neoplastic Cysts - Echinococcal Cysts.

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157 / 323 V&A

What symptoms may occur due to symptomatic liver cysts?

RUQ tenderness - Palpable Hepatomegaly - Bleeding, Infection, Torsion, Rupture

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158 / 323 V&A

What are common complications of a simple liver cyst?

Infection - Intracystic hemorrhage - Pain

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159 / 323 Multiple choice

What is a common extrahepatic manifestation of Polycystic Liver Disease?

Kidney Stones

Heart Disease

Lung Cancer

Cerebral Aneurysm

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160 / 323 V&A

What management is used for symptomatic simple liver cysts?

Percutaneous aspiration with sclerotherapy - Laparoscopic 'unroofing'

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161 / 323 Invul

Neoplastic cysts can include: - Cystadenoma - Cystadenocarcinoma - IPMN-B.

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162 / 323 V&A

What is a potential treatment for suspected cystadenoma?

Formal resection or enucleation.

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163 / 323 V&A

What can blunt trauma lead to regarding liver cysts?

Intra-hepatic hematomas or bilomas developing into traumatic hepatic cysts.

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164 / 323 V&A

What should be done for suspected cystic malignancies?

Proceed with biopsy or formal hepatic resection.

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165 / 323 V&A

What is the primary cause of Cystic Echinococcosis?

Infestation with tapeworm of the genus Echinococcus, primarily E. granulosus.

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166 / 323 V&A

What is a definitive host for Echinococcus?

Dogs serve as the definitive hosts for Echinococcus.

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167 / 323 V&A

What can humans be classified as regarding Echinococcus?

Humans are considered dead-end hosts for Echinococcus.

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168 / 323 V&A

What are common organs affected by hydatid cysts?

Liver
Lung
Bone
Kidney
Spleen
CNS

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169 / 323 V&A

What is the first-line imaging technique for diagnosing hydatid cysts?

Ultrasound is the first-line imaging technique for diagnosing hydatid cysts.

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170 / 323 V&A

What serological tests can aid in the diagnosis of Echinococcosis?

Immunoelectrophoresis
ELISA

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171 / 323 V&A

What is the percutaneous treatment technique for hydatid cysts?

The PAIR technique (Puncture, Aspiration, Injection, Re-aspiration) is used.

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172 / 323 V&A

What risks are associated with the PAIR technique for treating hydatid cysts?

Anaphylactic shock
Secondary echinococcosis
Chemical cholangitis
Biliary fistula

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173 / 323 V&A

What surgical options are available for treating hydatid cysts?

Radical: pericystectomy
Conservative: unroofing of cyst

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174 / 323 V&A

What medications are used to treat Echinococcosis?

Albendazole +/- praziquantel are used for treatment.

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175 / 323 V&A

What is the treatment approach for inactive silent cysts?

The approach is typically to watch and wait.

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176 / 323 V&A

What is Alveolar Echinococcosis primarily treated with?

Radical Liver Resection or Liver Transplantation.

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177 / 323 V&A

What is the annual incidence of hepatocellular carcinoma (HCC) in Singapore for males?

18 / 100,000

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178 / 323 V&A

What is the annual incidence of hepatocellular carcinoma (HCC) in Singapore for females?

4.6 / 100,000

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179 / 323 V&A

HCC is the 4th most frequent cancer death among which gender?

Females

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180 / 323 V&A

Hepatocellular carcinoma is primarily diagnosed in what decades of life?

Fifth and sixth decades

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181 / 323 V&A

What percentage of liver cancers are HCCs?

85%

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182 / 323 V&A

What is the most common risk factor for developing HCC?

Chronic liver disease (CLD)

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183 / 323 V&A

What virus infection is associated with increased HCC risk due to DNA damage?

Hepatitis B Virus (HBV)

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184 / 323 V&A

The risk of HCC approaches 2-4% annually in patients with which condition?

Cirrhosis

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185 / 323 V&A

Alcoholic cirrhosis increases the risk of HCC by how many times?

5 times

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186 / 323 V&A

Chronic Hepatitis C accounts for what fraction of HCC cases in the USA?

1/3

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187 / 323 Invul

Non-alcoholic steatohepatitis (NASH) increases the risk of HCC by 20x.

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188 / 323 V&A

Diet high in red meat and saturated fats is linked to what cancer?

Hepatocellular carcinoma (HCC)

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189 / 323 V&A

What toxin found in moldy food is linked to HCC?

Aflatoxins B1

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190 / 323 V&A

Chronic HBV along with which lifestyle factor has a synergistic effect on HCC risk?

Alcohol consumption

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191 / 323 V&A

What condition is characterized by inflammation of the biliary tree often leading to HCC?

Primary Sclerosing Cholangitis

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192 / 323 V&A

Recurrent infection in the biliary tree due to pyogenic cholangitis can lead to which cancer?

Hepatocellular carcinoma (HCC)

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193 / 323 V&A

What is the process of pathogenesis associated with?

Chronic inflammatory process
Ongoing hepatocellular damage
High cellular regeneration leading to genetic mutation accumulation

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194 / 323 V&A

What classification represents worse clinical outcomes?

Proliferative Class
Associated with HBV infection
High AFP levels
High tumor grade

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195 / 323 V&A

What factors characterize the Non-proliferative Class?

Non-proliferative Class
HCV infection
Alcohol abuse
Low tumor grade
Better clinical outcomes

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196 / 323 V&A

What are the histological subtypes of liver cancer?

Non-Fibrolamellar
Fibrolamellar (FLC) - more common in younger patients, no Hep B association

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197 / 323 V&A

What are the main characteristics of liver cirrhosis?

Bridging fibrosis
Regenerative parenchymal nodules
Disruption of liver architecture

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198 / 323 V&A

How often should patients with cirrhosis undergo monitoring?

Every 6 months
Ultrasound of the liver
Serum AFP measurement

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199 / 323 V&A

What is the MELD score used for?

Predicting prognosis in cirrhosis patients
Assessing mortality risk after TIPSS
Prioritizing liver transplantation

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200 / 323 V&A

What factors are included in the MELD score calculation?

Serum bilirubin
INR
Serum creatinine
Constant for liver disease etiology

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201 / 323 V&A

What does a MELD score of 15 indicate?

6% mortality risk at 3 months

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202 / 323 V&A

What outcomes are best with a MELD score less than 14?

Best outcomes with TIPSS
Poor outcomes with scores >24

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203 / 323 V&A

What does an increase in MELD points indicate?

Post-op mortality risk increases by 1% for each point up to 20
Increases by 2% for each point above 20

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204 / 323 V&A

What criteria are included in the PELD score?

Age
Presence of growth failure
Albumin instead of creatinine

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205 / 323 V&A

What is the typical presentation of patients with HCC during screening?

Patients are often asymptomatic. HCC can be an incidental finding during ultrasound screening for chronic hepatitis B.

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206 / 323 V&A

What are common local signs & symptoms of HCC?

Upper abdominal pain (dull & persistent)
Early satiety/vomiting
Constitutional symptoms: low energy, loss of appetite, malaise
Pyrexia
Jaundice (5-10%)

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207 / 323 Invul

Patients with HCC may experience upper abdominal pain, early satiety/vomiting, and constitutional symptoms such as low energy, loss of appetite.

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208 / 323 V&A

What is Budd-Chiari syndrome?

It is the occlusion of hepatic, intrahepatic, or portal veins causing portal hypertension and congestive hepatopathy, often leading to ascites.

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209 / 323 V&A

What are the features of decompensated chronic liver disease?

Worsening liver function
Hepatic encephalopathy
Jaundice
Ascites
Spontaneous bacterial peritonitis

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210 / 323 Multiple choice

What is a possible severe complication of a liver tumor?

Hepatic fibrosis

Cirrhosis

Hepatocellular carcinoma

Tumour rupture

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211 / 323 V&A

What symptoms are associated with portal hypertension?

Ascites
Lower limb oedema
Haematemesis
Congestive splenomegaly

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212 / 323 Invul

Portal hypertension can present with symptoms such as ascites, lower limb oedema, and haematemesis.

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213 / 323 V&A

What are paraneoplastic syndromes associated with HCC?

Hypoglycemia
Erythrocytosis
Hypercalcemia

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214 / 323 Invul

Common paraneoplastic syndromes include hypoglycemia due to high metabolic demands and erythrocytosis from tumour-produced erythropoietin.

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215 / 323 V&A

What is Hepatorenal Syndrome (HRS)?

A reversible form of acute renal failure in a patient with advanced liver disease without identifiable renal pathology.

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216 / 323 V&A

What are the two types of Hepatorenal Syndrome?

Type 1: Rapid renal function impairment, doubling serum creatinine > 221 in < 2 weeks.
Type 2: Subtle course, serum creatinine < 221, develops diuretic-resistant ascites.

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217 / 323 V&A

What leads to the renal hypoperfusion in HRS?

Advanced cirrhosis leads to portal hypertension & splanchnic arterial vasodilation
Decreased vascular resistance causes effective arterial hypovolemia.

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218 / 323 V&A

What is the initial therapy for Hepatorenal Syndrome?

Octreotide
Midodrine
Vasopressin analogue.
Can progress to dialysis dependence.

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219 / 323 V&A

What can reverse Hepatorenal Syndrome?

Liver transplant, even after dialysis dependence.

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220 / 323 V&A

What are common causes of Hepatic Encephalopathy?

High nitrogenous waste (BGIT)
Infections (e.g., sepsis)
Medications (e.g., benzodiazepines)
Electrolyte imbalances.
High protein diet.

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221 / 323 V&A

What is Stage 0 of Hepatic Encephalopathy?

Lack of detectable changes in personality or behavior.

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222 / 323 V&A

What characterizes Stage 1 of Hepatic Encephalopathy?

Shortened attention span
Impaired math skills
Hypersomnia or insomnia
Asterixis can be detected.

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223 / 323 V&A

What are the symptoms of Stage 3 Hepatic Encephalopathy?

Gross disorientation, semi-stupor to stupor, bizarre behaviors.

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224 / 323 V&A

What is the treatment for Hepatic Encephalopathy?

Lactulose
Low protein diet (<70g/day)
Branched-chain amino acids.
Neomycin for ammonia-producing bacteria if required.

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225 / 323 V&A

What is the gold standard diagnostic approach for hepatocellular carcinoma?

A triphasic CT scan with arterial and portal venous phase contrast imaging.

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226 / 323 V&A

What does the arterial phase of a triphasic CT scan show?

Early enhancement with lesions appearing hyper-dense relative to hypo-dense hepatic parenchyma.

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227 / 323 V&A

What indicates tumor washout in a triphasic CT scan?

Hypo-density of a nodule in the delayed phase compared to surrounding hepatic parenchyma.

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228 / 323 Invul

The radiological hallmark of HCC includes: arterial hypervascularity and venous/late phase washout.

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229 / 323 V&A

What does HCC's tendency to invade the portal vein indicate?

An enhancing portal vein thrombus.

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230 / 323 V&A

What is the role of a lipiodol contrast CT scan?

To detect areas of tumor that may not be clear in pre-lipiodol CT, as lipiodol is retained in HCC.

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231 / 323 V&A

What is the significance of detecting Alpha-FetoProtein (AFP) levels?

A rise in serum AFP in a cirrhosis patient suggests the development of HCC.

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232 / 323 V&A

What imaging modality is most accurate for distinguishing HCC from dysplastic nodules?

MRI scan (dynamic, contrast-enhanced).

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233 / 323 V&A

What are the complications to assess during HCC diagnosis?

Tumor burden, liver function, and patient's performance status.

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234 / 323 V&A

What does the MRI appearance of HCC typically show?

Highly intense on T2 images and low-intensity on T1-weighted images.

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235 / 323 V&A

What is the role of ultrasound in liver cirrhosis?

Ultrasonography is often used for screening in the setting of liver cirrhosis.

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236 / 323 V&A

What is detected using contrast-enhanced ultrasound in HCC?

It is used for detecting arterial enhancement in HCC.

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237 / 323 V&A

What may biopsies risk during HCC assessment?

Biopsies have a risk of bleeding and needle tract seeding.

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238 / 323 V&A

What does the Child-Pugh Score assess?

It assesses liver function using LFTs + PT/INR/APTT.

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239 / 323 V&A

What is the maximum surgical mortality for Class B in Child-Pugh Score?

The surgical mortality for Class B is 20-30%.

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240 / 323 V&A

What does a Class C rating in Child-Pugh Score signify?

Class C indicates not for resection and a surgical mortality of 75-80%.

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241 / 323 V&A

What indicates post-resection liver function adequacy?

Indocyanine green (ICG) assessment indicates post-resection liver function adequacy.

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242 / 323 V&A

What is the FLR threshold for normal liver function?

For normal liver, FLR should be 20% of the standardized liver volume (SLV).

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243 / 323 V&A

What is the significance of ECOG performance scale?

ECOG scale assesses patient activity level from fully active (0) to disabled (higher).

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244 / 323 Invul

The Child-Pugh Score is based on: - Albumin - Bilirubin - Coagulation - Distension - Encephalopathy

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245 / 323 V&A

What are the levels of physical activity restriction for patients?

1: Restricted in physically strenuous activity, otherwise fully ambulatory
2: ADL independent, up and about > 50% of waking hours
3: ADL dependent, confined to bed/chair > 50% of waking hours
4: ADL dependent, totally confined to bed/chair

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246 / 323 V&A

What investigations are considered for low Hb from BGIT?

FBC: low Hb from BGIT
U/E/Cr: dehydration, possible nephropathy
Other tests: PT/PTT, LFT, GXM, ECG, CXR, CT TAP

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247 / 323 V&A

What is the purpose of CT TAP imaging?

To suspect metastatic disease.

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248 / 323 V&A

What procedures are done if hepatic lesions are suspected?

OGD
Colonoscopy

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249 / 323 Invul

The Barcelona Clinic Liver Cancer management algorithm includes treatment options like: - resection - transplantation - ablation - chemoembolization - systemic therapies.

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250 / 323 Multiple choice

Which systemic drugs are first-line for liver cancer treatment?

Paracetamol

Ibuprofen

Lenvatinib

Aspirin

Sorafenib

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251 / 323 Multiple choice

What is included in the management algorithm regarding survival?

Immediate cure

Estimated survival time

Surgical complication risks

Patient's weight

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252 / 323 V&A

What does the diagram for the Barcelona Clinic Liver Cancer management algorithm illustrate?

It details stages, liver function, performance status, tumor burden, treatment options, and estimated survival time.

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253 / 323 V&A

What is the treatment of choice for non-cirrhotic patients with HCC?

Surgical resection, especially for solitary tumors at early stage (i.e. 0 or A).

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254 / 323 V&A

What percentage of HCC patients are amenable to surgery?

Only about 10-20%.

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255 / 323 V&A

What is the 5-year survival rate for patients treated with surgical resection?

60%, but with a high recurrence rate of 70%.

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256 / 323 V&A

What is a major concern for patients undergoing hepatectomy?

High recurrence rates due to the 'field-change' effect in the liver.

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257 / 323 V&A

What is the balance required in hepatectomy?

Between adequate resection margins (~1cm) and preservation of functional liver.

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258 / 323 V&A

What monitoring is essential post-operation for liver assessment?

Vitals signs, urine output, biochemical markers (FBC, LFTs, INR).

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259 / 323 V&A

What kind of drugs should be avoided post-operation?

Hepatotoxic drugs.

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260 / 323 V&A

What is the definitive treatment for HCC that replaces the cirrhotic liver?

Liver transplantation.

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261 / 323 V&A

What are the Milan criteria for liver transplantation?

Single tumor <5cm
Max 3 tumors with none >3cm
No evidence of vascular invasion.

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262 / 323 V&A

What is the UCSF criteria for liver transplantation?

Single tumor <6.5cm
Max 3 tumors with none >4.5cm & cumulative size <8cm.

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263 / 323 V&A

What is bridging therapy in the context of liver transplantation?

Using RFA, TACE, Y-90 to shrink disease until a donor's liver is available.

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264 / 323 Invul

The treatment modalities for HCC management include curative and palliative approaches, such as: - Curative: Surgical resection, liver transplantation. - Palliative: Local (radiofrequency ablation), regional (TACE), systemic (Sorafenib).

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265 / 323 V&A

What is a contraindication for liver resection?

Metastatic disease
Multicentric disease affecting both lobes

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266 / 323 V&A

What factors increase postoperative mortality in cirrhotic patients?

Liver failure
Bleeding
Infection

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267 / 323 V&A

What Child's status allows for resection in cirrhotic patients?

Child's A
Good Child's B

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268 / 323 V&A

What ICG result indicates tolerance for major liver surgery?

< 10% remains after 15 minutes

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269 / 323 V&A

What FLR requirement is needed for patients with normal liver?

20% of pre-operative liver volume

</blockquote>

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270 / 323 V&A

What is the appropriate management for tumors > 2.5cm in size?

Multiple RFA deployments

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271 / 323 V&A

What is a contraindication for Radiofrequency Ablation (RFA)?

Tumor at hilar plate
Biliary stricture/fistula risks

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272 / 323 V&A

What is the best therapy for early-stage HCC not suitable for resection?

Radiofrequency ablation (RFA)

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273 / 323 V&A

What are major complications of Trans-arterial Chemoembolization (TACE)?

Portal vein thrombosis
Decompensated cirrhosis

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274 / 323 V&A

What is the typical method of entry for TACE?

Via the femoral artery

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275 / 323 V&A

What can be performed to encourage hypertrophy of the liver?

Portal vein embolization

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276 / 323 V&A

What indicates increased resistance to flow during liver resection?

Worsened portal hypertension

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277 / 323 V&A

What condition can cause fever secondary to cytokine release?

Tumour lysis.

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278 / 323 V&A

What are the symptoms associated with tumour lysis?

Abdominal pain
Nausea
Vomiting

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279 / 323 V&A

What do raised ALT and AST levels reflect?

Ischemic hepatitis due to hepatic failure.

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280 / 323 V&A

Why should TACE not be used for Child's class C cirrhosis?

It can cause hepatic failure due to infarction.

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281 / 323 V&A

What does Yttrium-90 do when injected into the hepatic artery?

It irradiates the tumor, inducing tumor necrosis.

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282 / 323 V&A

What is Sorafenib and its effect on survival?

Multi-kinase inhibitor that improves median survival by 3 months.

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283 / 323 V&A

What is the estimated 5-year survival rate for HCC with treatment?

18%.

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284 / 323 V&A

What is the median survival length for untreated HCC?

3 to 6 months.

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285 / 323 Invul

Trans-arterial embolization (TAE) is a technique used to treat tumors in the liver.

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286 / 323 Multiple choice

What is the outcome of combining TACE with systemic drugs like Sorafenib?

Does not improve survival

Increases tumor size

Significantly improves survival

Reduces side effects

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287 / 323 V&A

What percentage of liver tumors are secondary malignancies?

90% of liver tumors are secondary malignancies.

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288 / 323 V&A

Which cancer is the most common cause of secondary liver malignancy?

Colorectal cancer.

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289 / 323 V&A

What are the types of liver metastases classified by origin?

Neuroendocrine and non-neuroendocrine liver metastases.

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290 / 323 Invul

Colorectal liver metastases are detected in 20-25% of patients as synchronous lesions and up to 40% as metachronous lesions.

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291 / 323 V&A

What signs indicate metastasis to liver parenchyma?

Fullness in RUQ
Hard, irregular hepatomegaly
Constitutional symptoms (i.e. LOW, LOA)
Jaundice as a late sign

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What is a common complication from extensive liver metastasis?

Liver failure with ascites and coagulopathy.

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What should be done for patients with metastatic disease to the liver?

They should be discussed at a multidisciplinary tumor board and referred to a medical oncologist.

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294 / 323 Invul

For colorectal liver metastases, liver resection is recommended due to the tumour biology's favourable nature.

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295 / 323 V&A

What is the overall frequency of recurrence for liver metastases after 5 years?

60-80% recurrence at 5 years.

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296 / 323 Multiple choice

What is a characteristic imaging finding for liver metastases on CT?

Hyperdense on arterial phase

Uniform density

Hypodense on arterial phase

Cystic appearance

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What is a hepatic abscess?

A pus-filled area in the liver, usually in the right lobe, occurring secondary to bacterial sepsis.

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What organisms can cause a hepatic abscess?

Klebsiella
E. coli
Proteus vulgaris
Streptococcus milleri/faecalis
Staphylococcus epidermidis
Bacteroides fragilis

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What are the risk factors for hepatic abscess?

Diabetes
Immunocompromised status
Underlying hepatobiliary disease
Elderly age

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What is the most common route of infection for hepatic abscess?

Biliary tree: direct spread from biliary infections (60%).

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What are common clinical presentations of hepatic abscess?

Spiking fever
Abdominal pain
Jaundice
Hepatomegaly
Nonspecific symptoms

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302 / 323 V&A

What is the most definitive imaging technique for diagnosing hepatic abscess?

CT scanning is used to exclude liver tumors and confirm diagnosis.

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What laboratory findings indicate a hepatic abscess?

Leukocytosis
Elevated CRP/ESR
Deranged LFTs
Blood/pus cultures (e.g. Klebsiella)

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304 / 323 Invul

A hepatic abscess often arises due to infections in the biliary system, with a common cause being ascending cholangitis.

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305 / 323 V&A

What should be done if resuscitation is needed?

Resuscitate if necessary.

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306 / 323 V&A

What is crucial for monitoring patients?

Close monitoring of vitals with strict IO charting.

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307 / 323 V&A

What complications should be watched for?

Klebsiella endophthalmitis, especially in diabetic patients.

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308 / 323 V&A

What are the empirical antibiotics for pyogenic liver abscess?

IV ceftriaxone 1gm every 12 hours
Metronidazole 500mg every 8 hours

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309 / 323 V&A

What is the total duration of antibiotic treatment?

4-6 weeks, counting from the drainage date.

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310 / 323 V&A

When is drainage indicated?

If abscess > 3cm.

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What is required for a colonoscopy in patients >50 years with DM and K pneumoniae PLA?

To rule out colonic malignant lesions.

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312 / 323 V&A

What is a contraindication for percutaneous drainage?

Ascites.

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313 / 323 V&A

What is the gold standard for treating liver abscesses?

Open drainage (OD).

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314 / 323 V&A

What are the advantages of laparoscopic drainage?

Shorter surgery duration
Less blood loss
Faster recovery

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315 / 323 V&A

What is the definition of hepatic amoebic abscess?

Hepatic amoebic abscess is caused by liquefaction necrosis, filled with blood and liquefied liver tissue, resembling 'anchovy sauce'.

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316 / 323 V&A

How much more frequent is hepatic amoebic abscess in adult men compared to women?

7-10 times more frequent.

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What protozoan causes amoebiasis?

Entamoeba histolytica.

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What is the transmission route of hepatic amoebic abscess?

Transmission is faecal-oral; humans are the principal host.

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What is a common clinical presentation of hepatic amoebic abscess?

Persistent fever
Right upper quadrant pain
Diarrhoea (in <1/3 of patients)

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What is a diagnostic method for hepatic amoebic abscess?

Ultrasound or CTAP is used to confirm the presence of a liver abscess.

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What is the first-line treatment for hepatic amoebic abscess?

Metronidazole (750mg oral TDS or IV 500mg QDS for 7-10 days).

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What complications can arise from hepatic amoebic abscess?

Rupture causing peritonitis
Bacterial superinfection
Free rupture into the peritoneal cavity

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What is the mortality rate in complicated cases of hepatic amoebic abscess?

Mortality can be as high as 20%.

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Flashcards in this deck (323)

Bezig met zoeken...

What divides the liver into the right and left lobes?

The falciform ligament separates the liver into right and left lobes.

anatomy liver
What is Cantlie's Line?

Cantlie's Line is a functional division of the liver, along the gallbladder fossa and inferior vena cava.

anatomy liver
What surrounds the bare area of the liver?

The bare area is not covered by Glisson's capsule.

anatomy liver
What segments form the left hemiliver?
- Segment II
- Segment III
- Segment IV
anatomy liver
What are the four sections of the liver based on the hepatic artery?
- Right anterior section (segments V & VIII)
- Right posterior section (segments VI & VII)
- Left medial section (segment IV)
- Left lateral section (segments II & III)
anatomy liver
The liver can be divided into 8 functional segments also known as Couinaud segments.

anatomy liver
Which ligament is not part of the liver anatomy?

Bare Area

Right Triangular Ligament

Falciform Ligament

Coronary Ligament

anatomy liver
What is the primary purpose of the caudate lobe?

The caudate lobe contains 3 sub-segments: spiegel lobe, paracaval, and caudate process.

anatomy liver
What does the liver weigh approximately?

The liver weighs about 1.5 kg.

anatomy liver
What ligament is a remnant of the obliterated umbilical vein?

The Round Ligament (ligamentum teres).

anatomy liver
What ligaments attach the liver to the anterior abdominal wall?
- Falciform Ligament
- Coronary Ligament
- Left and Right Triangular Ligament
anatomy ligaments liver
What supplies 75% of the liver's blood?

The portal vein.

physiology blood_supply liver
What is the primary arterial blood supply to the liver?

The hepatic artery proper (25%).

physiology blood_supply liver
What drains segment V, VI, VII, and VIII of the liver?

The Right hepatic vein.

anatomy venous_drainage liver
What anatomical variant arises from the SMA?

Replaced right hepatic artery (10-15%).

anatomy variations vascular
How do segment V & VIII drain into the liver?

Via the right anterior sectoral duct (RASD).

anatomy biliary_system
The three main hepatic veins form sagittal planes and include the Right hepatic vein, Middle hepatic vein, and Left hepatic vein.

anatomy venous_drainage liver
The portal vein divides into the right and left portal vein branches.

physiology blood_supply liver
What is the significance of the caudate lobe's venous drainage?

It drains directly to the IVC.

anatomy venous_drainage liver
What drains the segments VI and VII of the liver?

The right posterior sectoral duct (RPSD).

anatomy biliary_system
What is a common anatomical variant involving the biliary system?

RPSD draining into LHD (15%).

anatomy variations biliary_system
What stimulates the contraction of the gallbladder?

CCK (Cholecystokinin)

physiology gallbladder
What are the two factors governing bile secretion?
- Enterohepatic circulation
- Gut hormones (CCK & secretin)
physiology bile
What is the consequence of a lack of bile?

Malabsorption of fats and fat-soluble vitamins (A, D, E, K)

physiology bile
Bile is diverted from the liver into the gallbladder due to high tone in the sphincter of Oddi.

physiology gallbladder
What is the role of the liver in carbohydrate metabolism?
- Glycogenesis
- Glycogenolysis
metabolism carbohydrates
What process occurs to amino acids during starvation?

Gluconeogenesis - conversion back to glucose

metabolism proteins
What is lipogenesis?

Conversion of glucose to glycerol + FFA forming TG (triglycerides)

metabolism lipids
What is the Cori Cycle?

Lactate is converted to glucose in the liver and returned to the muscle.

physiology metabolism
What vitamin is activated in a two-stage hydroxylation process?

Vitamin D

physiology vitamins
What is synthesized in the liver besides immunoglobulin?

Plasma proteins such as albumin and clotting factors.

physiology proteins
What regulates iron homeostasis?

The synthesis of Hepcidin in the liver.

physiology iron
Which cells in the liver are responsible for phagocytosis?

Kupffer cells.

physiology immunity
What is the role of the liver in detoxification?

Detoxify peptide hormones, drugs, and toxins.

physiology detoxification
What forms the main storage for fat-soluble vitamins?
- Vitamin A
- Vitamin D
- Vitamin E
- Vitamin K
- Vitamin B12
physiology storage
What substance is converted by the liver in the Cori Cycle?

Fatty acids

Lactate

Amino acids

Glucose

physiology cori_cycle
What is the definition of portal hypertension?

Portal Hypertension is defined as the Hepatic venous pressure gradient (HVPG) ≥ 6mmHg. Normal is 3-5mmHg.

medicine portal_hypertension
What is the normal portal flow rate?

1-1.5 L/min is the normal portal flow rate.

medicine flow_rate
What indicates high risk of developing gastroesophageal varices?

Portal HTN ≥ 10mmHg indicates high risk of gastroesophageal varices.

medicine risk
What pressure level poses a high risk for variceal bleed?

Portal HTN ≥ 12mmHg indicates high risk of variceal bleed.

medicine risk
Which organs are drained by portal veins?
- Small intestines
- Large intestines
- Stomach
- Spleen
- Pancreas
- Gallbladder
anatomy portal_veins
What forms the portal vein?

The SMV and the splenic vein unite behind the neck of the pancreas to form the portal vein.

anatomy portal_veins
The portal trunk divides into two lobar veins: the right branch that drains the cystic vein and the left branch which drains the umbilical and paraumbilical vein (caput medusae in portal HTN).

anatomy portal_hypertension
What is a consequence of portal hypertension due to cirrhosis?

Portal hypertension results from mechanical obstruction of the portal venous system.

pathophysiology cirrhosis
What are the key issues with cirrhosis affecting portal hypertension?
- Architecture distortion
- Regenerative parenchymal nodules
- Disruption of liver architecture
pathophysiology cirrhosis
According to Ohm's Law, the relationship between voltage (V), current (I), and resistance (R) is given by: V = IR. Poiseuille's Law states that R = 8hL/pr^4.

physics vascular_flow
What impact does decreasing portal vascular radius have on resistance?

Dramatic increase in portal vascular resistance occurs with decreased vascular radius.

pathophysiology resistance
The diagram illustrating portal hypertension pathophysiology and collateral circulation shows key elements such as splanchnic vasodilation and TIPS (Transjugular Intrahepatic Portosystemic Shunt).

pathophysiology portal_hypertension
Illustration of the liver and its venous drainage highlights esophageal, paraumbilical, and rectal varices.

anatomy varices
What is a major cause of pre-sinusoidal portal hypertension?
- Portal Vein Thrombosis
- Splenic Vein Thrombosis
- Congenital Atresia
portal hypertension pre-sinusoidal
What is a common cause of sinusoidal portal hypertension?
- Cirrhosis
- Massive Fatty Change
- Hemochromatosis
portal hypertension sinusoidal
What are some causes of post-sinusoidal portal hypertension?
- Hepatic vein thrombosis
- IVC thrombosis
- Congenital IVC malformation
portal hypertension post-sinusoidal
What condition is associated with Budd Chiari Syndrome?

Rare thromboembolic disorder of hepatic veins/IVC leading to post-sinusoidal portal hypertension.

budd_chiari portal_hypertension
What are key ultrasound findings for portal hypertension?
- Dilated splenic & superior mesenteric veins ≥ 11mm
- Splenomegaly > 12cm
- Dilated portal vein ≥ 13mm
ultrasound portal_hypertension investigations
In portal hypertension, ascites occurs due to: increased fluid shift leading to increased lymphatic drainage from liver which overwhelms thoracic duct capacity, resulting in percolation of hepatic lymph into the peritoneal cavity.

portal_hypertension ascites
What is a significant complication of portal hypertension?
- Ascites
- Hepatic Encephalopathy
- Portal Hypertensive Gastropathy
complications portal_hypertension
What causes spontaneous bacterial peritonitis (SBP) in ascites?

Chronic alcoholism

Dilated portal vein

Hemochromatosis

Increased fluid shift (Starling's law)

ascites sbp
What are some symptoms of Hepatic Encephalopathy?
- Hyperammonemia
- Neuro-toxicity
- Exacerbated by portosystemic shunting
hepatic_encephalopathy portal_hypertension
Which anatomical area is affected by oesophageal varices?

Portal circulation through oesophageal branch of left gastric vein.

oesophageal_varices portal_circulation
What is Caput Medusae related to?

Varicosity caused by systemic circulation through superficial epigastric veins.

caput_medusae portal_hypertension
What does progressive liver cirrhosis lead to?

Obstruction of intra-hepatic vasculature causing portal hypertension.

pathophysiology cirrhosis
What is released due to portal HTN in cirrhotic patients?

Increased splanchnic nitric oxide (NO).

pathophysiology cirrhosis
What stimulates RAAS in cirrhotic patients?

Renal hypoperfusion.

pathophysiology cirrhosis
What is the effect of aldosterone in ascites treatment?

Increases retention of salt and water.

treatment ascites
What is the diuretic of choice for cirrhotic patients with ascites?

Spironolactone (aldosterone antagonist).

treatment ascites
What are common symptoms of ascites?
- Progressive abdominal distension
- Weight gain
- Shortness of breath
- Early satiety
clinical ascites
What physical signs confirm the diagnosis of ascites?
- Abdominal distension
- Flank dullness
- Shifting dullness
- Umbilical eversion
physical_exam ascites
What does the SAAG ≥ 1.1g/dL indicate?

Porta hypertension; common cause is liver cirrhosis.

diagnosis ascites
What can a SAAG <1.1g/dL indicate?

Malignancy or infection such as peritoneal tuberculosis.

diagnosis ascites
What investigations are performed for suspected ascites?
- Biochemical tests (FBC, U/E/Cr, LFT)
- Imaging (Ultrasound/CT)
investigations ascites
What does a peritoneal tap assess?

Fluid color and appearance to distinguish between conditions.

diagnosis ascites
What is the common indication for a peritoneal tap in ascites?

Diagnostic

Curative

Preventive

Therapeutic

investigations ascites
What is a common microbiological test for ascitic fluid?

Gram stain smear, culture (aerobic / anaerobic), cytology

microbiology ascites
What are the laboratory tests included in the analysis of ascitic fluid?
- LDH
- TG
- Glucose
- TB culture
- ProBNP
laboratory ascites
What is the recommended low salt diet for ascites?

2000mg / day or 88mol/day

diet ascites
When should fluid restriction be considered?

If serum sodium <125mmol/L

fluid_restriction ascites
What is the typical pharmacological treatment for diuresis in ascites?
- Spironolactone 100mg
- Furosemide 40mg (Max 400mg:160mg)
pharmacology ascites
What is the recommended antibiotic for suspected spontaneous bacterial peritonitis?

IV ceftriaxone or oral quinolones (e.g., ciprofloxacin)

antibiotics sbp
What is the purpose of therapeutic paracentesis?

To manage tense ascites and prevent complications.

procedure ascites
What is the procedure for therapeutic paracentesis?
- Site: 2FB above and 2FB lateral to ASIS
- Use aseptic technique, LA, US-guided
procedure paracentesis
Why is albumin administered after paracentesis?

To prevent paracentesis-induced circulatory dysfunction.

albumin ascites
What surgical options are available for liver disease-related ascites?
- Liver transplantation
- Transjugular Intrahepatic Porto-Systemic Shunts (TIPSS)
- Peritoneovenous shunts
surgery ascites liver_disease
What should be controlled pre-operatively in cirrhotic patients?

Ascites

surgery cirrhosis
What is the risk of abdominal operations in patients with advanced cirrhosis?

High risk of complications, especially portal hypertension.

surgery cirrhosis risks
What is performed prior to major abdominal operations in high MELD score patients?

Transjugular Intrahepatic Portosystemic Shunt (TIPSS).

surgery cirrhosis meld
What does hepatomegaly refer to?

Hepatomegaly refers to the abnormal enlargement of the liver.

medical definitions
What are common symptoms of hepatomegaly?
- Asymptomatic
- Abdominal pain
- Nausea, vomiting
- Fever
- Signs of jaundice
medical symptoms
What should a clinical examination for hepatomegaly include?
- Palpable organomegaly
- Tenderness
- Signs of ascites
- Digital Rectal Examination
medical examination
Common presentations of hepatomegaly include: abdominal pain, nausea, vomiting, and fever.

medical presentation
What are signs of chronic liver disease?
- Gynaecomastia
- Clubbing of fingernails
- Palmar erythema
- Lower limb edema
medical liver_disease
What is a common risk factor for malignant lesions in hepatomegaly?

Ongoing weight loss

Sudden fever

History of liver cirrhosis

High blood pressure

medical diagnosis
Symptoms of portal hypertension may include splenomegaly and ascites.

medical portal_hypertension
What is a physiological cause of liver abnormalities?

Riedel's Lobe Hyperextended Chest

physiology liver
Name a bacterial infection that can affect the liver.

Pyogenic Liver Abscess Tuberculosis

infective liver
Which viral infections are known to affect the liver?

Hepatitis EBV CMV HIV

infective viral liver
What are some alcohol-related liver conditions?

Fatty Liver Cirrhosis

alcoholic liver
Which metabolic diseases can affect the liver?

Wilson's Disease Haemochromatosis Infiltration - amyloidosis

metabolic liver
What are some malignant liver conditions?

Hepatocellular Carcinoma Hepatic Angiosarcoma Cholangiocarcinoma

malignant liver
What is a vascular/cardiac disorder that affects the liver?

Right Heart Failure (RHF) Budd-Chiari Syndrome

vascular _cardiac liver
A benign hepatic neoplasm can be a Haemangioma, Hepatic Adenoma, or Focal nodular Hyperplasia.

benign neoplasm liver
What types of hepatic abscesses exist?

Pyogenic Abscess Amoebic Abscess

abscess liver
What are the two types of hepatic cysts?

Non Parasitic Cyst Echinococcal Cysts

cysts liver
Intrahepatic obstruction causes of portal hypertension include Cirrhosis and Wilson's Disease.

portal_hypertension liver
What is a post-hepatic obstruction condition for portal hypertension?

Budd-Chiari Syndrome IVC Thrombosis

portal_hypertension liver
Factors associated with Hepatic Angiosarcoma include exposure to vinyl chloride, arsenic.

malignant liver
What is a Full Blood Count used for?

To detect any anemia or signs of infections.

laboratory hematology
What does a Liver Function Test indicate?

Presence of hyperbilirubinemia and deranged liver enzymes.

laboratory liver
What are Tumour Markers used for?

Their presence can indicate suspicion of malignancy.

oncology diagnostics
What imaging techniques are used for liver examination?
- Ultrasound Liver
- CT Scan
- MRI
imaging liver
An Ultrasound of the liver can reveal a simple cyst as: - well defined smooth walls - posterior acoustic enhancement.

imaging liver
A CT Scan of a haemangioma shows: - early peripheral nodular enhancement - centripetal filling.

imaging haemangioma
The MRI of a Hepatic Adenoma reveals: - hypervascular enhancement on arterial phase - lack of central scar.

imaging adenoma
In Focal Nodular Hyperplasia (FNH), the Doppler appearance shows: - central feeding artery - tortuous spoke-wheel vascularity.

imaging fnh
For Hepatocellular Carcinoma (HCC), imaging might show: - hypervascular enhancement on arterial phase - portal venous washout.

imaging hcc
Which imaging technique is NOT typically used for liver examination?

CT Scan

MRI

Endoscopy

Ultrasound Liver

imaging liver
What are liver hemangiomas characterized by?

Benign vascular lesions consisting of widened (dilated) blood vessels, not true neoplasms.

pathology liver hemangioma
What is the female to male ratio for liver hemangiomas?

5-6:1, predominantly in middle-aged women.

epidemiology liver hemangioma
What is the usual presentation of a liver hemangioma?

Usually asymptomatic; may cause nonspecific abdominal pain when larger than 5cm.

presentation liver hemangioma
What imaging technique is most accurate for liver hemangiomas?

Ultrasound, with 70-80% accuracy and pathognomonic compressibility of the lesion.

diagnosis liver hemangioma
What does a CT scan of a hemangioma show?

Peripheral enhancement in the arterial phase and peripheral to central enhancement over time.

diagnosis liver hemangioma
The majority of liver hemangiomas are treated with observation if they are asymptomatic and smaller than 4cm.

treatment liver hemangioma
What should never be done for diagnosing liver hemangiomas?

Biopsy, due to risk of severe and fatal hemorrhage.

diagnosis liver hemangioma
What syndrome is associated with large hemangiomas?

Kasabach-Merritt syndrome, which leads to thrombocytopenia and consumptive coagulopathy.

complications hemangioma
What is a common treatment for symptomatic or complicated liver hemangiomas?

Radiation therapy

Surgical removal

Observation

Chemotherapy

treatment liver hemangioma
What are the symptoms of large liver hemangiomas?
- Nonspecific abdominal fullness
- Abdominal pain
- Rarely, life-threatening hemorrhage
presentation liver hemangioma
What is the definition of Focal Nodular Hyperplasia (FNH)?

FNH is a benign tumour characterized by a central stellate scar and is considered a regenerative process, not a result of arterial malformation.

medical definitions
What is the epidemiology of FNH?
- Second commonest benign liver tumour
- More common in females (6-8:1) aged 30 to 50 years
- Associated with AVMs and hepatic haemangioma.
medical epidemiology
What symptoms are associated with FNH?
- Asymptomatic (incidental on imaging)
- Right upper quadrant pain
- Rarely ruptures or bleeds.
medical symptoms
How is FNH diagnosed?
- CT: Bright homogenous enhancement, hypoattenuating central scar.
- Sulphur colloid scan: Positive for kupffer cells.
- MRI: Central scar hyperintense on T2 weighted images.
medical diagnosis
What is the treatment for FNH?
- Conservative management for asymptomatic patients.
- Surgery for symptomatic patients, with liver resection preferred.
medical treatment
FNH is a benign tumour characterized by a central stellate scar and is considered a regenerative process.

medical definitions
FNH is the second commonest benign liver tumour, more common in females aged 30 to 50 years.

medical epidemiology
Symptoms of FNH include: - asymptomatic - right upper quadrant pain.

medical symptoms
Diagnosis of FNH involves: - CT with bright enhancement and hypoattenuating scar - sulphur colloid scan - MRI.

medical diagnosis
FNH treatment options are: - conservative management for asymptomatic patients - surgery for symptomatic patients.

medical treatment
What are hepatic adenomas?

Benign proliferation of hepatocytes; should not be confused with hepatoma (HCC).

health pathology
What is the female to male ratio for hepatic adenomas?

10:1, primarily found in young women.

epidemiology gender
What are common presentations of hepatic adenomas?

Asymptomatic or symptomatic with spontaneous rupture and intraperitoneal hemorrhage.

presentation symptoms
What percentage of hepatic adenomas may rupture?

25-35%, with nearly 100% of ruptures in lesions >5cm.

risk rupture
What are common diagnosis methods for hepatic adenomas?

CT (triphasic), sulphur colloid scan, and MRI.

diagnosis imaging
What is the treatment for small, asymptomatic hepatic adenomas?

Conservative management with close observation and possible discontinuation of OCPs.

treatment management
What is indicated for symptomatic hepatic adenomas or those >4-5cm?

Surgical resection.

treatment surgery
Hepatic adenomas are characterized by a benign proliferation of hepatocytes, distinct from hepatoma which refers to HCC.

definition health
The risk factors for hepatic adenomas include anabolic steroids, oestrogen, and progesterone preparation (e.g., OCP).

risk_factors health
A significant risk of hepatic adenomas is malignant transformation to well-differentiated HCC, with a risk of ~5%.

risk malignancy
What characteristic is NOT associated with imaging findings in hepatic adenomas?

No true lobules

Sharply defined borders

More common in right lobe

Homogenous enhancement during arterial phase

diagnosis health
What should be done if a patient has an acute hemorrhage from hepatic adenoma?

Discontinue all medications

Proceed to hepatic angioembolization followed by surgery

Immediate liver transplant

Complete bed rest without intervention

treatment emergency
What are liver cysts commonly detected through?

Imaging, as they are mostly asymptomatic.

medicine liver
What percentage of liver cysts are simple ones?

5-20%

medicine liver
Nonparasitic liver cysts include: - Simple Liver Cysts - Polycystic Liver Disease - Neoplastic Cysts - Echinococcal Cysts.

medicine liver
What symptoms may occur due to symptomatic liver cysts?
- RUQ tenderness - Palpable Hepatomegaly - Bleeding, Infection, Torsion, Rupture
medicine liver
What are common complications of a simple liver cyst?
- Infection - Intracystic hemorrhage - Pain
medicine liver
What is a common extrahepatic manifestation of Polycystic Liver Disease?

Kidney Stones

Heart Disease

Lung Cancer

Cerebral Aneurysm

medicine liver
What management is used for symptomatic simple liver cysts?
- Percutaneous aspiration with sclerotherapy - Laparoscopic 'unroofing'
medicine liver
Neoplastic cysts can include: - Cystadenoma - Cystadenocarcinoma - IPMN-B.

medicine liver
What is a potential treatment for suspected cystadenoma?

Formal resection or enucleation.

medicine liver
What can blunt trauma lead to regarding liver cysts?

Intra-hepatic hematomas or bilomas developing into traumatic hepatic cysts.

medicine liver
What should be done for suspected cystic malignancies?

Proceed with biopsy or formal hepatic resection.

medicine liver
What is the primary cause of Cystic Echinococcosis?

Infestation with tapeworm of the genus Echinococcus, primarily E. granulosus.

parasitology cysticechinococcosis
What is a definitive host for Echinococcus?

Dogs serve as the definitive hosts for Echinococcus.

parasitology hosts
What can humans be classified as regarding Echinococcus?

Humans are considered dead-end hosts for Echinococcus.

parasitology hosts
What are common organs affected by hydatid cysts?
- Liver
- Lung
- Bone
- Kidney
- Spleen
- CNS
parasitology organs
What is the first-line imaging technique for diagnosing hydatid cysts?

Ultrasound is the first-line imaging technique for diagnosing hydatid cysts.

diagnosis imaging
What serological tests can aid in the diagnosis of Echinococcosis?
- Immunoelectrophoresis
- ELISA
diagnosis serology
What is the percutaneous treatment technique for hydatid cysts?

The PAIR technique (Puncture, Aspiration, Injection, Re-aspiration) is used.

treatment pair
What risks are associated with the PAIR technique for treating hydatid cysts?
- Anaphylactic shock
- Secondary echinococcosis
- Chemical cholangitis
- Biliary fistula
treatment risks
What surgical options are available for treating hydatid cysts?
- Radical: pericystectomy
- Conservative: unroofing of cyst
treatment surgery
What medications are used to treat Echinococcosis?

Albendazole +/- praziquantel are used for treatment.

treatment medications
What is the treatment approach for inactive silent cysts?

The approach is typically to watch and wait.

treatment inactive
What is Alveolar Echinococcosis primarily treated with?

Radical Liver Resection or Liver Transplantation.

treatment alveolarechinococcosis
What is the annual incidence of hepatocellular carcinoma (HCC) in Singapore for males?

18 / 100,000

epidemiology hcc
What is the annual incidence of hepatocellular carcinoma (HCC) in Singapore for females?

4.6 / 100,000

epidemiology hcc
HCC is the 4th most frequent cancer death among which gender?

Females

epidemiology hcc
Hepatocellular carcinoma is primarily diagnosed in what decades of life?

Fifth and sixth decades

epidemiology hcc
What percentage of liver cancers are HCCs?

85%

epidemiology hcc
What is the most common risk factor for developing HCC?

Chronic liver disease (CLD)

risk_factors hcc
What virus infection is associated with increased HCC risk due to DNA damage?

Hepatitis B Virus (HBV)

risk_factors hbv hcc
The risk of HCC approaches 2-4% annually in patients with which condition?

Cirrhosis

risk_factors hcc
Alcoholic cirrhosis increases the risk of HCC by how many times?

5 times

risk_factors hcc
Chronic Hepatitis C accounts for what fraction of HCC cases in the USA?

1/3

risk_factors hcc
Non-alcoholic steatohepatitis (NASH) increases the risk of HCC by 20x.

risk_factors hcc
Diet high in red meat and saturated fats is linked to what cancer?

Hepatocellular carcinoma (HCC)

risk_factors diet hcc
What toxin found in moldy food is linked to HCC?

Aflatoxins B1

risk_factors toxins hcc
Chronic HBV along with which lifestyle factor has a synergistic effect on HCC risk?

Alcohol consumption

risk_factors hcc
What condition is characterized by inflammation of the biliary tree often leading to HCC?

Primary Sclerosing Cholangitis

risk_factors hcc
Recurrent infection in the biliary tree due to pyogenic cholangitis can lead to which cancer?

Hepatocellular carcinoma (HCC)

risk_factors hcc
What is the process of pathogenesis associated with?
- Chronic inflammatory process
- Ongoing hepatocellular damage
- High cellular regeneration leading to genetic mutation accumulation
pathology pathogenesis
What classification represents worse clinical outcomes?
- Proliferative Class
- Associated with HBV infection
- High AFP levels
- High tumor grade
pathology classification
What factors characterize the Non-proliferative Class?
- Non-proliferative Class
- HCV infection
- Alcohol abuse
- Low tumor grade
- Better clinical outcomes
pathology classification
What are the histological subtypes of liver cancer?
- Non-Fibrolamellar
- Fibrolamellar (FLC) - more common in younger patients, no Hep B association
pathology histology
What are the main characteristics of liver cirrhosis?
- Bridging fibrosis
- Regenerative parenchymal nodules
- Disruption of liver architecture
pathology cirrhosis
How often should patients with cirrhosis undergo monitoring?
- Every 6 months
- Ultrasound of the liver
- Serum AFP measurement
pathology monitoring
What is the MELD score used for?
- Predicting prognosis in cirrhosis patients
- Assessing mortality risk after TIPSS
- Prioritizing liver transplantation
pathology meld
What factors are included in the MELD score calculation?
- Serum bilirubin
- INR
- Serum creatinine
- Constant for liver disease etiology
pathology meld
What does a MELD score of 15 indicate?
- 6% mortality risk at 3 months
pathology meld
What outcomes are best with a MELD score less than 14?
- Best outcomes with TIPSS
- Poor outcomes with scores >24
pathology meld
What does an increase in MELD points indicate?
- Post-op mortality risk increases by 1% for each point up to 20
- Increases by 2% for each point above 20
pathology meld
What criteria are included in the PELD score?
- Age
- Presence of growth failure
- Albumin instead of creatinine
pathology peld
What is the typical presentation of patients with HCC during screening?

Patients are often asymptomatic. HCC can be an incidental finding during ultrasound screening for chronic hepatitis B.

hcc screening
What are common local signs & symptoms of HCC?
- Upper abdominal pain (dull & persistent)
- Early satiety/vomiting
- Constitutional symptoms: low energy, loss of appetite, malaise
- Pyrexia
- Jaundice (5-10%)
hcc symptoms
Patients with HCC may experience upper abdominal pain, early satiety/vomiting, and constitutional symptoms such as low energy, loss of appetite.

hcc symptoms
What is Budd-Chiari syndrome?

It is the occlusion of hepatic, intrahepatic, or portal veins causing portal hypertension and congestive hepatopathy, often leading to ascites.

hcc budd-chiari
What are the features of decompensated chronic liver disease?
- Worsening liver function
- Hepatic encephalopathy
- Jaundice
- Ascites
- Spontaneous bacterial peritonitis
liver decompensation
What is a possible severe complication of a liver tumor?

Hepatic fibrosis

Cirrhosis

Hepatocellular carcinoma

Tumour rupture

hcc complications
What symptoms are associated with portal hypertension?
- Ascites
- Lower limb oedema
- Haematemesis
- Congestive splenomegaly
portal_hypertension symptoms
Portal hypertension can present with symptoms such as ascites, lower limb oedema, and haematemesis.

portal_hypertension symptoms
What are paraneoplastic syndromes associated with HCC?
- Hypoglycemia
- Erythrocytosis
- Hypercalcemia
hcc paraneoplastic
Common paraneoplastic syndromes include hypoglycemia due to high metabolic demands and erythrocytosis from tumour-produced erythropoietin.

hcc paraneoplastic
What is Hepatorenal Syndrome (HRS)?

A reversible form of acute renal failure in a patient with advanced liver disease without identifiable renal pathology.

medical renal
What are the two types of Hepatorenal Syndrome?
- Type 1: Rapid renal function impairment, doubling serum creatinine > 221 in < 2 weeks.
- Type 2: Subtle course, serum creatinine < 221, develops diuretic-resistant ascites.
medical renal
What leads to the renal hypoperfusion in HRS?
- Advanced cirrhosis leads to portal hypertension & splanchnic arterial vasodilation
- Decreased vascular resistance causes effective arterial hypovolemia.
medical pathophysiology
What is the initial therapy for Hepatorenal Syndrome?
- Octreotide
- Midodrine
- Vasopressin analogue.
- Can progress to dialysis dependence.
medical treatment
What can reverse Hepatorenal Syndrome?

Liver transplant, even after dialysis dependence.

medical treatment
What are common causes of Hepatic Encephalopathy?
- High nitrogenous waste (BGIT)
- Infections (e.g., sepsis)
- Medications (e.g., benzodiazepines)
- Electrolyte imbalances.
- High protein diet.
medical causes
What is Stage 0 of Hepatic Encephalopathy?

Lack of detectable changes in personality or behavior.

medical stages
What characterizes Stage 1 of Hepatic Encephalopathy?
- Shortened attention span
- Impaired math skills
- Hypersomnia or insomnia
- Asterixis can be detected.
medical stages
What are the symptoms of Stage 3 Hepatic Encephalopathy?

Gross disorientation, semi-stupor to stupor, bizarre behaviors.

medical stages
What is the treatment for Hepatic Encephalopathy?
- Lactulose
- Low protein diet (<70g/day)
- Branched-chain amino acids.
- Neomycin for ammonia-producing bacteria if required.
medical treatment
What is the gold standard diagnostic approach for hepatocellular carcinoma?

A triphasic CT scan with arterial and portal venous phase contrast imaging.

diagnosis hcc
What does the arterial phase of a triphasic CT scan show?

Early enhancement with lesions appearing hyper-dense relative to hypo-dense hepatic parenchyma.

diagnosis ct_scan
What indicates tumor washout in a triphasic CT scan?

Hypo-density of a nodule in the delayed phase compared to surrounding hepatic parenchyma.

diagnosis hcc
The radiological hallmark of HCC includes: arterial hypervascularity and venous/late phase washout.

diagnosis hcc
What does HCC's tendency to invade the portal vein indicate?

An enhancing portal vein thrombus.

diagnosis hcc
What is the role of a lipiodol contrast CT scan?

To detect areas of tumor that may not be clear in pre-lipiodol CT, as lipiodol is retained in HCC.

diagnosis lipiodol
What is the significance of detecting Alpha-FetoProtein (AFP) levels?

A rise in serum AFP in a cirrhosis patient suggests the development of HCC.

diagnosis afp
What imaging modality is most accurate for distinguishing HCC from dysplastic nodules?

MRI scan (dynamic, contrast-enhanced).

diagnosis mri
What are the complications to assess during HCC diagnosis?

Tumor burden, liver function, and patient's performance status.

assessment hcc
What does the MRI appearance of HCC typically show?

Highly intense on T2 images and low-intensity on T1-weighted images.

diagnosis mri
What is the role of ultrasound in liver cirrhosis?

Ultrasonography is often used for screening in the setting of liver cirrhosis.

ultrasound liver cirrhosis
What is detected using contrast-enhanced ultrasound in HCC?

It is used for detecting arterial enhancement in HCC.

hcc ultrasound diagnosis
What may biopsies risk during HCC assessment?

Biopsies have a risk of bleeding and needle tract seeding.

biopsy hcc risks
What does the Child-Pugh Score assess?

It assesses liver function using LFTs + PT/INR/APTT.

child-pugh liver assessment
What is the maximum surgical mortality for Class B in Child-Pugh Score?

The surgical mortality for Class B is 20-30%.

child-pugh surgical_mortality
What does a Class C rating in Child-Pugh Score signify?

Class C indicates not for resection and a surgical mortality of 75-80%.

child-pugh surgical_risk
What indicates post-resection liver function adequacy?

Indocyanine green (ICG) assessment indicates post-resection liver function adequacy.

icg liver_function
What is the FLR threshold for normal liver function?

For normal liver, FLR should be 20% of the standardized liver volume (SLV).

flr liver function
What is the significance of ECOG performance scale?

ECOG scale assesses patient activity level from fully active (0) to disabled (higher).

ecog performance assessment
The Child-Pugh Score is based on: - Albumin - Bilirubin - Coagulation - Distension - Encephalopathy

child-pugh assessment liver
What are the levels of physical activity restriction for patients?
- 1: Restricted in physically strenuous activity, otherwise fully ambulatory
- 2: ADL independent, up and about > 50% of waking hours
- 3: ADL dependent, confined to bed/chair > 50% of waking hours
- 4: ADL dependent, totally confined to bed/chair
health activity mobility
What investigations are considered for low Hb from BGIT?
- FBC: low Hb from BGIT
- U/E/Cr: dehydration, possible nephropathy
- Other tests: PT/PTT, LFT, GXM, ECG, CXR, CT TAP
health investigations diagnostics
What is the purpose of CT TAP imaging?

To suspect metastatic disease.

health imaging oncology
What procedures are done if hepatic lesions are suspected?
- OGD
- Colonoscopy
health procedures diagnostics
The Barcelona Clinic Liver Cancer management algorithm includes treatment options like: - resection - transplantation - ablation - chemoembolization - systemic therapies.

health management oncology
Which systemic drugs are first-line for liver cancer treatment?

Paracetamol

Ibuprofen

Lenvatinib

Aspirin

Sorafenib

health medication oncology
What is included in the management algorithm regarding survival?

Immediate cure

Estimated survival time

Surgical complication risks

Patient's weight

health management survival
What does the diagram for the Barcelona Clinic Liver Cancer management algorithm illustrate?

It details stages, liver function, performance status, tumor burden, treatment options, and estimated survival time.

health diagram oncology
What is the treatment of choice for non-cirrhotic patients with HCC?

Surgical resection, especially for solitary tumors at early stage (i.e. 0 or A).

hcc treatment surgery
What percentage of HCC patients are amenable to surgery?

Only about 10-20%.

hcc statistics
What is the 5-year survival rate for patients treated with surgical resection?

60%, but with a high recurrence rate of 70%.

hcc survival surgery
What is a major concern for patients undergoing hepatectomy?

High recurrence rates due to the 'field-change' effect in the liver.

hcc surgery recurrence
What is the balance required in hepatectomy?

Between adequate resection margins (~1cm) and preservation of functional liver.

hcc surgery hepatectomy
What monitoring is essential post-operation for liver assessment?

Vitals signs, urine output, biochemical markers (FBC, LFTs, INR).

hcc post-op monitoring
What kind of drugs should be avoided post-operation?

Hepatotoxic drugs.

hcc medications surgery
What is the definitive treatment for HCC that replaces the cirrhotic liver?

Liver transplantation.

hcc treatment transplant
What are the Milan criteria for liver transplantation?
- Single tumor <5cm
- Max 3 tumors with none >3cm
- No evidence of vascular invasion.
hcc transplant milan_criteria
What is the UCSF criteria for liver transplantation?
- Single tumor <6.5cm
- Max 3 tumors with none >4.5cm & cumulative size <8cm.
hcc transplant ucsf_criteria
What is bridging therapy in the context of liver transplantation?

Using RFA, TACE, Y-90 to shrink disease until a donor's liver is available.

hcc transplant bridging_therapy
The treatment modalities for HCC management include curative and palliative approaches, such as: - Curative: Surgical resection, liver transplantation. - Palliative: Local (radiofrequency ablation), regional (TACE), systemic (Sorafenib).

hcc treatment modalities
What is a contraindication for liver resection?
- Metastatic disease
- Multicentric disease affecting both lobes
surgery oncology
What factors increase postoperative mortality in cirrhotic patients?
- Liver failure
- Bleeding
- Infection
surgery risk
What Child's status allows for resection in cirrhotic patients?
- Child's A
- Good Child's B
surgery cirrhosis
What ICG result indicates tolerance for major liver surgery?

< 10% remains after 15 minutes

surgery icg
What FLR requirement is needed for patients with normal liver?

<blockquote>

20% of pre-operative liver volume

</blockquote>

surgery flr
What is the appropriate management for tumors > 2.5cm in size?
- Multiple RFA deployments
treatment tumors
What is a contraindication for Radiofrequency Ablation (RFA)?
- Tumor at hilar plate
- Biliary stricture/fistula risks
treatment rfa
What is the best therapy for early-stage HCC not suitable for resection?

Radiofrequency ablation (RFA)

treatment hcc
What are major complications of Trans-arterial Chemoembolization (TACE)?
- Portal vein thrombosis
- Decompensated cirrhosis
treatment tace
What is the typical method of entry for TACE?

Via the femoral artery

treatment tace
What can be performed to encourage hypertrophy of the liver?

Portal vein embolization

surgery portal_vein
What indicates increased resistance to flow during liver resection?

Worsened portal hypertension

surgery physiology
What condition can cause fever secondary to cytokine release?

Tumour lysis.

oncology fever
What are the symptoms associated with tumour lysis?
- Abdominal pain
- Nausea
- Vomiting
symptoms oncology
What do raised ALT and AST levels reflect?

Ischemic hepatitis due to hepatic failure.

liver biochemistry
Why should TACE not be used for Child's class C cirrhosis?

It can cause hepatic failure due to infarction.

cirrhosis treatment
What does Yttrium-90 do when injected into the hepatic artery?

It irradiates the tumor, inducing tumor necrosis.

treatment radiation
What is Sorafenib and its effect on survival?

Multi-kinase inhibitor that improves median survival by 3 months.

medication oncology
What is the estimated 5-year survival rate for HCC with treatment?

18%.

prognosis hcc
What is the median survival length for untreated HCC?

3 to 6 months.

prognosis hcc
Trans-arterial embolization (TAE) is a technique used to treat tumors in the liver.

treatment tae
What is the outcome of combining TACE with systemic drugs like Sorafenib?

Does not improve survival

Increases tumor size

Significantly improves survival

Reduces side effects

treatment oncology
What percentage of liver tumors are secondary malignancies?

90% of liver tumors are secondary malignancies.

liver malignancy statistics
Which cancer is the most common cause of secondary liver malignancy?

Colorectal cancer.

cancer colorectal malignancy
What are the types of liver metastases classified by origin?

Neuroendocrine and non-neuroendocrine liver metastases.

liver metastases classification
Colorectal liver metastases are detected in 20-25% of patients as synchronous lesions and up to 40% as metachronous lesions.

liver colorectal statistics
What signs indicate metastasis to liver parenchyma?
- Fullness in RUQ
- Hard, irregular hepatomegaly
- Constitutional symptoms (i.e. LOW, LOA)
- Jaundice as a late sign
clinical liver symptoms
What is a common complication from extensive liver metastasis?

Liver failure with ascites and coagulopathy.

complications liver cancer
What should be done for patients with metastatic disease to the liver?

They should be discussed at a multidisciplinary tumor board and referred to a medical oncologist.

management liver oncology
For colorectal liver metastases, liver resection is recommended due to the tumour biology's favourable nature.

management liver colorectal
What is the overall frequency of recurrence for liver metastases after 5 years?

60-80% recurrence at 5 years.

statistics liver recurrence
What is a characteristic imaging finding for liver metastases on CT?

Hyperdense on arterial phase

Uniform density

Hypodense on arterial phase

Cystic appearance

imaging liver ct
What is a hepatic abscess?

A pus-filled area in the liver, usually in the right lobe, occurring secondary to bacterial sepsis.

pathology liver
What organisms can cause a hepatic abscess?
- Klebsiella
- E. coli
- Proteus vulgaris
- Streptococcus milleri/faecalis
- Staphylococcus epidermidis
- Bacteroides fragilis
microbiology bacteria
What are the risk factors for hepatic abscess?
- Diabetes
- Immunocompromised status
- Underlying hepatobiliary disease
- Elderly age
risk_factors health
What is the most common route of infection for hepatic abscess?

Biliary tree: direct spread from biliary infections (60%).

pathophysiology infection
What are common clinical presentations of hepatic abscess?
- Spiking fever
- Abdominal pain
- Jaundice
- Hepatomegaly
- Nonspecific symptoms
signs symptoms
What is the most definitive imaging technique for diagnosing hepatic abscess?

CT scanning is used to exclude liver tumors and confirm diagnosis.

imaging diagnosis
What laboratory findings indicate a hepatic abscess?
- Leukocytosis
- Elevated CRP/ESR
- Deranged LFTs
- Blood/pus cultures (e.g. Klebsiella)
investigations lab_tests
A hepatic abscess often arises due to infections in the biliary system, with a common cause being ascending cholangitis.

pathophysiology infection
What should be done if resuscitation is needed?

Resuscitate if necessary.

management treatment
What is crucial for monitoring patients?

Close monitoring of vitals with strict IO charting.

monitoring management
What complications should be watched for?

Klebsiella endophthalmitis, especially in diabetic patients.

complications klebsiella
What are the empirical antibiotics for pyogenic liver abscess?
- IV ceftriaxone 1gm every 12 hours
- Metronidazole 500mg every 8 hours
antibiotics treatment
What is the total duration of antibiotic treatment?

4-6 weeks, counting from the drainage date.

treatment antibiotics
When is drainage indicated?

If abscess > 3cm.

drainage management
What is required for a colonoscopy in patients >50 years with DM and K pneumoniae PLA?

To rule out colonic malignant lesions.

colonoscopy screening
What is a contraindication for percutaneous drainage?

Ascites.

contraindications drainage
What is the gold standard for treating liver abscesses?

Open drainage (OD).

drainage management
What are the advantages of laparoscopic drainage?
- Shorter surgery duration
- Less blood loss
- Faster recovery
laparoscopic treatment
What is the definition of hepatic amoebic abscess?

Hepatic amoebic abscess is caused by liquefaction necrosis, filled with blood and liquefied liver tissue, resembling 'anchovy sauce'.

medical definitions
How much more frequent is hepatic amoebic abscess in adult men compared to women?

7-10 times more frequent.

epidemiology gender
What protozoan causes amoebiasis?

Entamoeba histolytica.

microbiology protozoa
What is the transmission route of hepatic amoebic abscess?

Transmission is faecal-oral; humans are the principal host.

transmission infectious_diseases
What is a common clinical presentation of hepatic amoebic abscess?
- Persistent fever
- Right upper quadrant pain
- Diarrhoea (in <1/3 of patients)
clinical_presentation symptoms
What is a diagnostic method for hepatic amoebic abscess?

Ultrasound or CTAP is used to confirm the presence of a liver abscess.

diagnosis imaging
What is the first-line treatment for hepatic amoebic abscess?

Metronidazole (750mg oral TDS or IV 500mg QDS for 7-10 days).

management treatment
What complications can arise from hepatic amoebic abscess?
- Rupture causing peritonitis
- Bacterial superinfection
- Free rupture into the peritoneal cavity
complications risks
What is the mortality rate in complicated cases of hepatic amoebic abscess?

Mortality can be as high as 20%.

mortality complications

Studieaantekeningen

Surgical Anatomy of the Liver

Liver Anatomy

Divisions of the Liver

Anatomical division: Right and left lobes separated by the falciform ligament.
Functional division: Defined by the gallbladder fossa and inferior vena cava (Cantlie's Line).
Lobes and segments:
Left anatomical division: Segments II & III.
Functional segments: 4 main sections based on blood supply.

Liver anatomy illustration

Ligaments around the Liver

Round Ligament (ligamentum teres): Remnant of obliterated umbilical vein.
Falciform Ligament: Attaches liver to the anterior abdominal wall.
Coronary Ligament: Surrounds the liver; also left and right triangular ligaments.

Liver with ligaments labeled

Blood Supply

Arterial & Venous Blood Supply

Portal Vein: 75% of liver blood supply; formed by the confluence of splenic and superior mesenteric veins.
Hepatic Artery Proper: 25%; branches from the coeliac trunk.
Hepatic Veins:
Right hepatic vein: Drains segments V-VIII.
Middle hepatic vein: Drains segments IV, V, VIII.
Left hepatic vein: Drains segments II-III.

Portal vein anatomy illustration

Functions of the Liver

Physiological Functions

Bile Production: Governed by enterohepatic circulation and gut hormones (CCK).
Metabolism:
Carbohydrate: Glycogenesis and glycogenolysis.
Protein: Amino acid conversion and urea synthesis.
Lipids: Lipogenesis and lipolysis.

Function	Process
Carbohydrate	Gluconeogenesis, Glycogenesis
Protein	Amino acid degradation, Urea synthesis
Lipid	Lipogenesis, Lipolysis
Lactate	Cori Cycle (lactate to glucose)

Portal Hypertension

Definition

Portal Hypertension is defined as a hepatic venous pressure gradient (HVPG) ≥ 6 mmHg (normal: 3-5 mmHg). - Key pressure thresholds: - ≥ 10 mmHg: High risk of varices. - ≥ 12 mmHg: High risk of bleeding.

Pathophysiology

Caused by mechanical obstruction in the portal venous system (e.g., cirrhosis). Using Ohm's and Poiseuille's Law to understand relationships among flow, pressure, and resistance:
\[ V = IR \]
\[ Q = \frac{\Delta P}{R} \]

Portal hypertension diagram

Ascites

Pathogenesis (in Cirrhosis)

Portal hypertension leads to increased splanchnic NO release.
Decreased effective blood volume.
Renal hypoperfusion: activates RAAS, increases aldosterone, leading to salt and water retention.

Clinical Presentation

Symptoms: Abdominal distension, discomfort, shortness of breath, low-grade fever.

Investigations

Biochemical: Full blood count, liver function test, and serum-ascites albumin gradient (SAAG).

SAAG ≥ 1.1g/dL	Conditions
Liver Cirrhosis	Alcoholic Hepatitis, Portal Vein Thrombosis

Hepatocellular Carcinoma (HCC)

Epidemiology

Most common type of primary liver cancer, mainly in males.
Risk factors include chronic liver disease (cirrhosis) and hepatitis B/C.

Clinical Presentation

Asymptomatic
Local symptoms: abdominal pain, jaundice, weight loss.
General symptoms: fever, malaise, ascites.

Diagnosis

Imaging: Triphasic CT scans as the gold standard.
AFP levels may indicate HCC but are not definitive.

Liver cancer management flowchart

Management Approaches

Treatment Modalities for HCC

Curative

Surgical resection, liver transplantation (Milan Criteria).

Palliative

Local: RFA, microwave ablation.
Regional: TACE (Trans-arterial chemoembolization).
Systemic: Sorafenib.

Prognosis

Poor without treatment; approximately 5-year survival post-treatment is 18%.

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Flashcards in this deck (323)

Surgical Anatomy of the Liver

Liver Anatomy

Divisions of the Liver

Ligaments around the Liver

Blood Supply

Arterial & Venous Blood Supply

Functions of the Liver

Physiological Functions

Portal Hypertension

Definition

Pathophysiology

Ascites

Pathogenesis (in Cirrhosis)

Clinical Presentation

Investigations

Hepatocellular Carcinoma (HCC)

Epidemiology

Clinical Presentation

Diagnosis

Management Approaches

Treatment Modalities for HCC

Curative

Palliative

Prognosis