Division of the liver
Anatomy: by falciform ligament to L&R lobe
Functional: line between IVC and GB (cantlie line), line in which middle hepatic vein runs
8functional seg: couinaud segments
- transverse plane: level of main branches of portal vein
- sagittal plane: right, middle and left hepatic veins
segment 1= caudate lobe
post liver resection monitoring?
freq blood sugars phosphorous lvl (help liver regen) LFTs INR prolongation may occur Dosage of analgesia (dec hepatic clearance)
Causes of portal hypertension
Pre hepatic
- portal vein thrombosis
- biliary atresia
- massive splenomeg (rise in splenic vein blood flow)
Hepatic
- cirrhosis, massive fatty change, hemochrombtosis, Wilson, schistosomiasis, Caroli dz, congenital hepatic fibrosis
Post hepatic
- budd chiari, IVC thrombosis, constrictive pericarditis, severe right side RF, congenital IVC malformation
Types of liver nodule
NEOPLASM Benign - hemangioma - focal nodular hyperplasia - hepatic adenoma - bile duct harmatomas - cysts Malignant - Pri: HCC, cholangioCA - Sec
ABSCESS: pyogenic or amoebic
CYST
- no-para: simple liver cyst, polycystic, neoplastic
- ecchinococcal cyst (hydatid)
Most common benign liver tumour
- a/w
- complications
- ix and their findings
- tx
Liver haemangioma
- outgrowth of endothelium
a/w: steroids, preg, OCP
cx: pain from liver capsule stretch, mass effect, HF due to large arteriovenous shunt, Kasabach Merritt syndrome - consumptive coagulopathy of plt and clotting factors, life threatening bleed by biopsy
Us: well defined, lobulated, homogenous hypo echoic mass, compressible
Triphasic CT - brightest and uniformly enhanced in delayed phase
MRI: bright on T2 images
TX: watch, resect, RT/ embolise
DO NOT BIOPSY
Hepatic adenoma
- associations
- complications
- ix and findings
- tx
a/w OCP (estrogen, progesterone), pregnancy, steroids
rupture, intra peritoneal hemorrhage
malignant change
triphasic CT: early enhancement from peripheries with centripetal progression
sx resection when
- symptomatic
- > 4-5cm
- cannot rule out CA
- male gender
- prior to pregnancy (higher risk of rupture)
Liver abscess
- what to watch for if c/s grows klebsiella
- mgx
all liver abscess, rule out amoebic - entamoeba histolytic
watch for ocular symptoms - klebsiella endopthalmitis
<3cm: ABx via PICC (4-6w)
>3cm: drainage (open, lap, percutaneous IR)
Complications of portal htn
ascites > SBP splenomegaly hepatic encephalopathy portosystemic shunting portal hypertensive gastropathy (gastric mucosa friability and dilated blood vessels)
sites of portosystemic connections
- oesophageal
- P: oesophageal branch of left gastric vein
- S: eso branch of azygos vein - rectal
- P: superior rectal vein
- S: mid/ inf rectal vein - Paraum
- P: paraumbilical vein
- S: superficial epigastric veins - retroperitoneal
- P: R, middle, L colic veins
- S: renal veins, suprarenal vein, paravert veins - intrahepatic:
- P: L branch of portal vein
- S: IVC
approach to ascites
malignant - peritoneal mets benign - cardio - renal - liver - GI - inflam: pancreatitis, serositis - infection: TB
Interpretation of paracentesis (SAAG)
send for SAAG >1.1: portal hypertension causes <1.1: - peritoneal carcinomatosis - infx: tb, serositis - infm: pancreatitis, panc ascites - trauma: chylous - renal: nephrotic
what to send for in peritoneal tap
cytology - cell count and differential
microB: gram stain, culture (aerobic, anerobic), TB culture
biochemistry: albumin, protein conc, LDH, TG, glucose
serum albumin, LDH, NT-proBNP
diagnosis of SBP
+ve ascite fluid bac c/s
ascitic fluid PMN >250cell/mm3 (or WBC>500cell/mm3)
how to mgx ascites
conservative
- low salt diet
- fluid restrict
- monitor weight and urine sodium
pharmaco
- diuresis: spironolactone 100mg
- add 40mg furosemide if also have pedal deem
- antibiotics (if SBP): ceftriaxone IV or PO ciprofloxacin
therapeutic paracentesis
- cooploop (pigtail catheter via seldinger technique > drain)
- IV albumin 20% infusion
- site: 2FB above and lat to ASIS, us guided
- 8mg IV alb for every 1L ascites fluid drained (prevents paracentesis induced circulatory dysfunction - hypoTN, recurrent ascites, HRS)
sx: liver transplant
shunt - TIPSS (transjugular intrahepatic portosys shunt)
triggers of hepatic encephalopathy
GI bleed infx - SBP, UTI (blood/urine cs) hypoK, metabolic alkalosis (UECR) Renal failure Hypovolemia Hypoxia Sedatives/ tranquilisers hypoglycemia (h/c) constipation (DRE, axr) HCC (AFP) vascular occlusion (hepatic vein or portal vein thrombosis)
Meds to give in variceal bleed
IV broad spec abx 7 days - ciprofloxacin 500mg bd or ceftriaxone 1g/day
IV somatostatin 250ug bolus followed by 250ug/h infusion for 3-5days
IV esomeprazole bolus 80mg IV then 40mg IV BD
IV vit K 10mg
options to manage variceal UGBIT
endoscopy - variceal band ligation, sclerotherapy
TIPSS - acute decompression
Emergency shunt sx
- risk of encephalopathy, higher mortality
- selective vs non selective
Sugiura procedure
Cx of splenectomy
- GA
- intra op: bleeding, injury to surrounding organs
- early: wound - infection, seroma, hematoma, pulmonary cx - atelectasis, pneumonia, pleura effusion, subphrenic abscess, acute portal vein thrombosis, thrombocytosis, ileus
- late - post splenectomy infections by encapsulated bac (strep pneumonia, H flu, N meningitides)
variceal bleed prophylaxis
primary
secondary
Pri: non selective beta blockers
sec: band ligation (3wkly until gone) non selective beta blockers - propranolol, nadolol)
block beta 1: dec cardiac output
block beta 2: cause splanchnic vasoconstriction, reduce portal flow and pressure
if CI for BB, use long acting nitrates (isosorbide mononitrate)
How do you assess risk of hemorrhage in pt with varices
site: GEJ size - grading I: small straight varices not disappearing with insufflation II: large tortuous but <1/3 III: >1/3 lumen child c red signs - endoscopic stigmata of recent hemorrhage - red wale marks - cherry red spots - hematocystic spots - diffuse erythema previous hemorrhage
who needs primary variceal prophylaxis
- large (grade 3) varices OR
- grade 2 + endoscopic red signs/ child c cirrhosis
Causes of hepatomegaly
MASSIVE (CRAM) - Ca: HCC, mets - RHF, TR - alc liver dz w fatty infiltration - myeloprolfierative dz MODERATE (HHH) - above + - haematological (CML, lymphoma) - hemochromatosis/ amyloidosis - heavy (fat) MILD (ABC) - above + - Abscess - infx (viral , bac , parasitic , amoebic abscess - biliary obstruction - cirrhosis
Causes of splenomegaly
MASSIVE (MIC) - myelofibrosis - infections - CML MODERATE (PALS) above + - portal htn - anemia hemolytic (thal, HS) - lymphoproliferative (lymphoma, CLL) - storage (gaucher) MILD (AIIM) above + - autoimmune: SLE, RA, PAN - infection: viral hep, IMS, endocarditis - infiltration: sarcoid, amyloid - myeloproliferative
Sources of AST ALT - causes of mild elevation - mod elevation - marked elevation (>1000)
AST: liver, cardiac, skeletal muscle, kidney, brain, pancreas, lung, RBC
ALT
- mild: NAFLD, chronic viral infx, med induced injury
- mod: acute viral hep
- marked: ischemic hep, toxic ingestion (paracetamol), fulminant hepatitis (massive necrosis of liver parenchyma)
