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129 Cards in this Set
- Front
- Back
What is the #1 hepatic artery variant?
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right hepatic artery off SMA, courses behind pancreas, posterolateral to the common bile duct
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What variant of the left hepatic artery is found in about 20% of the population?
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left hepatic artery off left gastric artery
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What is the most common variant of the common hepatic artery?
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off SMA
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What lobes of the liver does the falciform ligament separate?
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medial and lateral segments of the left lobe
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What does the falciform ligament carry?
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remnant of the umbilical vein
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What carries the obliterated umbilical vein to the undersurface of the liver?
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ligamentum teres
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What separates the right and left lobes of the liver?
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cantlie's line aka portal fissure
(drawn from the gallbladder fossa to the IVC) |
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What is the peritoneum that covers the liver called?
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Glisson's capsule
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The portal triad enters and the gallbladder lies under what two segments of liver?
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IV and V
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What are liver macrophages called?
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Kupffer cells
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What is the orientation of the contents of the hepatoduodenal ligament?
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CBD lateral, hepatic artery medial and portal vein posterior
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What is clamped in the Pringle maneuver?
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portal hepatis
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What are the four borders of the foramen of Winslow?
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anterior – portal triad, posterior – IVC, inferior – duodenum, superior – liver
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What 3 vessels form the portal vein and what is their configuration?
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IMV enters the splenic vein, SMV joins the splenic vein
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How many portal veins in the liver? and what % of the blood supply do they provide?
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2 portal veins in the liver, 2/3 of the blood supply
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What are the hepatic arteries? and veins?
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right, left and middle, same as the veins
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In 80% of the population what is the configuration of the hepatic veins entering the IVC?
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Middle hepatic vein joins left hepatic vein before going into the IVC. In the other 20%, all 3 go directly into the IVC.
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What is unique about the blood supply and drainage of the caudate lobe?
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Caudate lobe – receives separate right and left portal and arterial blood flow; drains directly into IVC via separate hepatic veins
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What membrane of the liver does nutrient uptake occur?
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sinusoidal membrane
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What is the usual energy source for the liver?
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ketones
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What is the only water soluble vitamin stored in the liver?
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B12
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What are the 2 most common problems with hepatic resection?
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bleeding and bile leak
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Which hepatocytes are most sensitive to ischemia?
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central lobular (acinar zone III)
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What % of the liver can be safely resected?
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75%
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Bilirubin is conjugated to what in the liver which improves water solubility?
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glucuronic acid
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What comprises 85% of bile? what is the main phospholipid in bile?
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bile salts, lecithin
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In bile, what is used to make bile acids?
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cholesterol
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What two molecules are bile acids conjugated to in order to make them more water soluble?
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taurine or glycine
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What are the two primary bile acids? the two secondary (dehydroxylated primary acids by bacteria in gut)?
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primary – cholic and chenodeoxycholic
secondary – deoxycholic and lithocholic |
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What level of bilirubin is necessary for jaundice?
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>2.5
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What is the maximum bilirubin possible (unless pt has underlying renal disease, hemolysis or bile duct–hepatic vein fistula)?
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30
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What disease is the abnormal uptake of bilirubin resulting in mildly high unconjugated bilirubin?
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Gilbert's disease
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What disease is the inability to conjugate bilirubin; deficiency of glucuronyl transferase; high unconjugated bilirubin –> life threatening disease.
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Crigler–Najjar disease
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Physiologic jaundice of newborn has high unconjugated bilirubin and is the result of which immature enzyme?
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glcuronyl transferase
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There are two syndromes that have a high conjugated bilirubin. Which one is a deficiency in storage ability and which one is a deficiency in secretion ability?
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Rotor's syndrome is a deficiency in storage ability. Dubin–Johnson syndrome is a deficiency in secretion ability.
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In hep B which Ig dominates in the first 6 months? which one then takes over?
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IgM then IgG
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In Hep B which Anti–HB rises 10–12 weeks after infection? and 12–14? and 14–16?
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10–12 weeks Anti HBc
12–14 weeks Anti–HBe 14–16 weeks Anti–HBs |
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What Ab is elevated in a pt who is vaccinated against Hep B
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Anti–HBs
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If a pt has elevated anti–HBc and elevated anti–HBs antibodies and no HBs antigens, what does that mean?
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pt had infection with recovery and subsequent immunity
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What is the most common viral hepatitis leading to liver TXP?
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Hep C (long incubation period)
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Hepatitis D is a cofactor for which other Hepatitis?
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Hep B
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What does Hepatitis E cause?
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fulminant hepatic failure in pregnancy, most often in 3rd trimester
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What is the most common cause of liver failure?
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cirrhosis
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What is the best indicator of synthetic function in pts with cirrhosis?
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prothrombin time (PT)
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What is the mortality of acute fulminant hepatic failure? The course of what sx determines the outcome?
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80% mortality, encephalopathy
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What is the main medical tx for hepatic encephalopathy and how does it work?
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lactulose is a cathartic that gets rid of bacteria in the gut and acidifies the colon preventing NH3 uptake by converting it to ammonium (titrate to 2–3 stools per day)
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What should you limit the protein intake to in hepatic encephalopathy?
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<70 g/day
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Other than the mainstay, lactulose, name three other medical treatments for hepatic encephalopathy.
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Neomycin, L–dopa, bromocriptine
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When you do a paracentesis for ascites what do you need to replace and what is the dose?
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albumin, 1g for every 100cc removed
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What is increased aldosterone caused by in ascites?
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impaired hepatic metabolism and impaired GFR
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Hepatorenal syndrome has the same appearance as prerenal azotemia what is the tx (2)?
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stop diuretics, give volume
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What is the cause of postpartium liver failure with ascities and how do you dx?
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hepatic vein thrombosis
Dx: SMA arteriogram with venous phase contrast |
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Sx of SBP include fever, abdominal pain, positive cultures and PMNs greater than what level in the fluid?
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250
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SBP is most commonly mono–organism; if it is not then you need to worry about what?
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bowel perforation
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What is the most common organism in SBP?
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E. coli
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What is a risk factor for SBP in children?
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hepatic thrombosis
(lupus?) |
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What is the tx for SBP?
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3rd –generation cephalosporin; pts usually respond within 48 hrs
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What is 90% effective at treating esophageal varices?
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sclerotherapy
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Name 2 medical treatments for esophageal varices and how they work.
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vasopressin (splanchnic artery constriction)
octreatide (decreased portal pressure by decreased blood flow) |
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In pts with esophageal varices who are on vasopressin and have CAD should get what additional medical tx?
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NTG
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What is the name of the tube for esophageal varices that has a risk of esophageal rupture and is hardly used anymore?
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Sengstaken–Blakemore
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What is the role for propanolol in esophageal varices?
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may help prevent rebleeding; no good role acutely
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Pts who develop strictures after sclerotherapy for esophageal varices are easily managed with what tx? what if they develop refractory variceal bleeding, what tx?
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dilatation, TIPS for refractory bleeding
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What does TIPS stand for?
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transjugular intrahepatic portosystemic shunt
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What is the mortality of bleeding varices with 1st episode? What % will rebleed and what is the mortality with each subsequent bleeding episode?
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33%, 50%, 50%
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50% of portal hypertension in children is caused by what?
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portal vein thrombosis
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What is the normal port vein pressure?
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<12 mmHg
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What procedure would you do for a Child's A cirrhotic that just has bleeding as a symptom?
What if the pt is Child's B or C with indication for shunt (bleeding, progression of coagulopathy, visceral hypoperfusion, refractory ascites)? |
splenorenal shunt (more durable) for A
TIPS for B or C |
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Pts with TIPS are at risk for developing what?
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encephalopathy
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What is the most common cause of massive hematemesis in children?
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portal HTN due to extrahepatic thrombosis of the portal vein
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What is the tx for Budd–Chiari syndrome?
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portacaval shunt (needs to connect to the IVC above the obstruction)
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Isolated gastric varices without elevation of pressure in the rest of the portal system can be caused by what?
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Splenic vein thrombosis
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What is most often the cause of splenic vein thrombosis?
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pancreatitis
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What is the treatment for splenic vein thrombosis?
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splenectomy
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What is the organism in amebic liver abscesses?
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Entamoeba Histalytica
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Risk factors for Entamoeba histalytica include ETOH and travel to Mexico. How do you dx?
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CT characteristics, elevated LFTs, white count, serology (absces cultures are often sterile since the protozoa exists only in peripheral rim)
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What is the tx for amebic liver abscesses?
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Flagyl; aspiration if refractory of contaminated; surgery only for free rupture
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What is the organism in hydatid liver cysts?
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Echinococcus
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How do you dx echinococcus infections (2 tests)?
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Positive Casoni skin test,
Positive serology |
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Abdominal CT shows liver lesion with ectocyst (calcified) and endocyt. What is that characteristic of?
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hydatid cyst
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What is the tx for hydatid cyst?
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preop albendazole 2 weeks
, surgical removal (may want to inject cyst with alcohol at time of removal to kill organsims) need to get all of cyst wall |
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Why don't you aspirate hydatid cysts?
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can leak out and cause anaphylactic shock
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Pt with hydatid cyst has jaundice, elevated LFTs or cholangitis. What do you need to do preop?
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ERCP to check for communication with the biliary system
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Maculopapular rash, increased eosinophils. Sigmoid colon has fine granulation tissue, petechiae, ulcers and can cause variceal bleeding. What is the dx and what is the tx?
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Schistosomiasis
Tx: praziquantel and control variceal bleeding |
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80% of liver abscess are what type? what is the number one organism?
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pyogenic, E. coli
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Treatment for hepatic adenoma
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Asx: stop OCP; if regression no further therapySx: tumor resection for bleeding & malignancy risk
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Do Hepatic adenomas have kupffer cells
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no – so no uptake on sulfur colloid scan
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What % hepatic adenomas rupures
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20% (with 80% symptomatic)
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What has central stellate scar
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focal nodular hyperplasia
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Does FNH require surgery
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no no malignancy risk
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What is the most common benign hepatic tumor
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hemangioma
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Do hemangiomas rupture? symptomatic?
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rare; most asymptomatic
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should you bx a hemangioma
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no risk hemorrhage
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Tx of hemangioma
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conservative unless symptomatic
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What is kasabach merritt syndrome? associated with?
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consumptive coagulapathy; hemagioma
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What is the #1 risk fx for HCC (others)
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hep B (hepc; etoh, hemochromatosis, aklpah1 antitrypsin def, psc, aflatoxins, hepatic adenoma, steroids, pesticide
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are primary bilary cirrhosis or wilson dx risk fx for hcc
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no
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What are risk factors for hepatic sarcoma
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pvc, thorotrast, arsenic
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Which are hyper/hypovascular primary/met liver tumor
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primary – hyper
metastatic –hypo |
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Liver infx that occur MC in Right lobe |
Amoebic abscess Ecchinococcus |
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Benign liver lesions that occur MC in R lobe |
adenoma solitary cysts |
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how does amoebic abscess occur |
primary colitis infx travels thru portal vein |
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how is schistosomiasis acquired |
thru skin contact in water |
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liver infx that can cause variceal bleeding |
schistosomiasis |
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schistosomiasis Tx: |
praziquantel and control of variceal bleeding |
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how are pyogenic abscesses acquired? |
Can occur following bacteremia from other types of infections (diverticulitis, appendicitis) Most commonly secondary to contiguous infection from biliary tract |
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how to dx pyogenic abscesses |
Dx: aspiration |
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how to tx pyogenic abscesses |
Tx: CT-guided drainage and antibiotics; surgical drainage for unstable condition and continued signs of sepsis |
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Most common benign hepatic tumor |
Hemangiomas |
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Hepatic adenomas Can become malignant in how many % of the time |
Can become malignant (5%) |
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when to resect adenoma when to embolize adenoma |
tumor resection for bleeding and malignancy risk; Symptomatic or > 4 cm embolization if multiple and unresectable |
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Hepatic adenomas has Kupffer cells? |
Dx: no Kupffer cells in adenomas, thus no uptake on sulfur colloid scan (cold) |
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Focal nodular hyperplasia has Kupffer cells? |
Dx: abdominal CT; has Kupffer cells, so will take up sulfur colloid on liver scan |
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Rare complications of hemangioma |
consumptive coagulopathy (Kasabach–Merritt syndrome) and CHF; these complications are usually seen in children |
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Solitary cysts look like.. |
walls have a characteristic blue hue |
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Metastases:primary ratio |
20:1 |
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Most common cancer worldwide |
HCC |
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best prognosisHepatocellular CA |
Fibrolamellar type (adolescents and young adults) |
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worstprognosis Hepatocellular CA |
Diffuse nodular type |
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AFP level correlates with |
tumor size |
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5-year survival rate with resection |
30% |
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contraindication to resection |
cirrhosis, portohepatic lymph node involvement, or metastases (only 15% resectable) |
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margins Hepatocellular CA |
Need 1-cm margin |
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Hepatic sarcoma Risk factors |
PVC, Thorotrast, arsenic → rapidly fatal |
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Primary liver tumors – generally ____vascular |
hyper |
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Metastatic liver tumors – generally ____vascular |
hypo |
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Isolated colon CA metastases to liver – can resect if |
leave enough liver for the patient to survive (75%) |
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5-year survival rate after resection for cure |
35% |
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tx for hemangioma if sxatic |
pre-op embolization, surgery if unresectable, steroids, poss xrt |