Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + TEST TAKING TIP Download Section PDF Listen +++ ++ Test Taking Tip Familiarity with the distinction between benign liver tumors is critical. Know the diagnostic modalities necessary to identify hepatic adenomas, focal nodular hyperplasia (FNH), hemangiomas, as well as infectious etiologies such as pyogenic, amebic, or hydatid cysts. + ANATOMY Download Section PDF Listen +++ +++ List the ligaments of the liver: ++ The falciform ligament, coronary ligaments, and the right and left triangular ligaments. +++ What structures are contained within the hepatoduodenal ligament? ++ Porta hepatis: proper hepatic artery, portal vein, common bile duct (CBD) +++ What line divides the liver into left and right lobes? ++ Cantlie line (runs from the middle of the gallbladder fossa anteriorly to the inferior vena cava posteriorly) +++ How many Couinaud segments are in the liver? ++ 8 +++ Which segments are removed in a right hepatectomy? ++ Segments 5 to 8 +++ Which segments are removed in a right trisegmentectomy? ++ Segments 4 to 8 +++ Which segments removed are in a left hepatectomy? ++ Segments 2 to 4 +++ Which segments are removed in a left lateral trisegmentectomy? ++ Segments 2 and 3 +++ Which segments are removed in a left trisegmentectomy? ++ Segments 2, 3, 4, 5, 8 +++ How much percentage of blood flow does the portal vein supply to the liver? ++ 70% +++ What percentage of cardiac output accounts for hepatic blood flow? ++ 25% +++ How much of the liver's oxygen supply is provided by the hepatic artery? ++ 50% ++ FIGURE 15-1. Couinaud's liver segments (I through VIII) numbered in a clockwise manner. The left lobe includes segments II to IV, the right lobe includes segments V to VIII, and the caudate lobe is segment I. (Reproduced from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz's Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 15-2. Hepatic resection nomenclature and anatomy. Hepatic segments removed in the formal major hepatic resections are indicated. The International Hepato-Pancreato-Biliary Association (IHPBA) Brisbane 2000 terminology also is presented. IVC, inferior vena cava; LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. (Reproduced from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz's Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ How much does the portal vein contribute to total hepatic blood flow? ++ Two-thirds +++ How many hepatic veins are there? ++ Three (right, middle, and left) +++ What is the approximate length of the CBD? ++ Approximately 7 cm +++ What is normal CBD diameter? ++ 0.5 to 1.5 cm +++ What is the arterial supply of the bile ducts? ++ Primarily the right hepatic artery +++ Where does the sympathetic innervation of the gallbladder originate? ++ Celiac axis +++ What is the parasympathetic innervation of gallbladder? ++ Vagus nerve +++ What are ducts of Luschka? ++ Accessory ducts directly from the liver bed into the gallbladder + PHYSIOLOGY Download Section PDF Listen +++ +++ How much bilirubin is produced daily in normal adults? ++ About 250 to 350 mg +++ How much bilirubin is produced from turnover of senescent red blood cells? ++ Approximately 85% +++ What is the most common cause of hyperbilirubinemia in adults? ++ Cholelithiasis +++ What is the major metabolite of heme? ++ Bilirubin +++ What is the name of sinusoidal macrophages? ++ Kupffer cells +++ What is the half-life of albumin? ++ 20 days +++ What is the half-life of transferrin? ++ 6 days +++ Which major protein is produced by the liver? ++ Albumin +++ What are bile acids conjugated with to form bile salts? ++ Glycine and taurine +++ What is the major site of bile acid reabsorption? ++ Distal ileum +++ What autosomal recessive disorder causes an increase in conjugated bilirubin without elevation of liver function tests (LFTs)? ++ Dubin-Johnson syndrome +++ What percentage of the population has gallstones? ++ Approximately 10% +++ What group of Indians in southern Arizona are at high risk for gallstones? ++ Pima Indians +++ What population is at lowest risk for developing gallstones? ++ Sub-saharan Africans +++ How are gallstones classified? ++ Cholesterol, black pigment, or brown-pigment stones +++ What is the main composition of black pigmented stones? ++ Calcium bilirubinate +++ What is the main composition of brown pigmented stones? ++ Calcium salts of unconjugated bilirubin +++ What causes gallstone formation? ++ Cholesterol supersaturation, accelerated crystal nucleation, and gallbladder hypomotility +++ What are the 2 primary bile acids? ++ Cholate and chenodeoxycholate +++ What is the most common inherited cause of hyperbilirubinemia? ++ Gilbert syndrome (decreased activity of the enzyme glucuronyl transferase) +++ Which enzyme found in the cells of the bile duct rises with bile duct obstruction? ++ Alkaline phosphatase +++ The liver is the site of synthesis of all of the coagulation factors except: ++ von Willebrand factor +++ What is type I Crigler–Najjar syndrome? ++ Severe unconjugated hyperbilirubinemia, kernicterus, bilirubin deposits in the brain causing severe motor dysfunction and retardation. +++ What is type II Crigler–Najjar syndrome? ++ Less severe form, enzyme activity is 10% of normal +++ Which substance is metabolized by gut bacteria to lactic acid that converts ammonia to ammonium salt? ++ Lactulose +++ List the secondary bile salts: ++ Lithocholate, deoxycholate, and ursodeoxycholate +++ What hormone is a potent stimulator of gallbladder contraction? ++ Cholecystokinin + BENIGN BILIARY DISEASE Download Section PDF Listen +++ +++ Is prophylactic cholecystectomy recommended in diabetics? ++ No +++ What is the incidence of endoscopic retrograde cholangiopancreatography (ERCP)-induced pancreatitis? ++ About 5% +++ Which is a rapid, noninvasive imaging study that provides detailed biliary tree and pancreatic duct images equal to those of ERCP? ++ Magnetic resonance cholangiopancreatography (MRCP) +++ What percentage of pigmented stones and cholesterol stones are seen on plain abdominal films? ++ 50% and 20%, respectively +++ What is the principal imaging modality for the diagnosis of cholelithiasis? ++ Ultrasonography +++ What is the sensitivity of ultrasonography for stones greater than 2 mm? ++ >95% +++ What is the probability of complications requiring surgery in a patient with a history of biliary colic? ++ 1% to 2% per year +++ What is the surgical management of uncomplicated biliary colic and documented gallstones? ++ Elective laparoscopic cholecystectomy +++ What percentage of patients with acute cholecystitis have positive enteric bacteria culture from the bile? ++ 50% +++ What is hydrops of the gallbladder? ++ Chronic cystic duct obstruction and gallbladder distention with clear mucoid fluid. +++ What is Mirrizzi syndrome? ++ Impacted stone in the gallbladder neck causing extrinsic compression of the common (hepatic) duct +++ What is porcelain gallbladder? ++ Calcification of the gallbladder wall; cholecystectomy is indicated to prevent carcinoma +++ What is Murphy sign? ++ Inspiratory arrest upon right upper quadrant (RUQ) palpation +++ What percentage of patients with gallstones have CBD stones? ++ 15% to 20% +++ What is the most common cause of cholangitis? ++ Stone impacted in the CBD (85% of the time) +++ Which organisms are most commonly cultured from bile? ++ Escherichia coli, Klebsiella, Pseudomonas, Proteus, enterococci +++ What is the constellation of RUQ pain, jaundice, and fever? ++ Charcot triad +++ What is Reynolds pentad? ++ Altered mental status and hypotension plus Charcot triad +++ Which autoimmune disease is associated with destruction of extrahepatic and intrahepatic bile ducts? ++ Primary sclerosing cholangitis +++ What is the type I choledochal cyst? ++ Saccular or fusiform dilatation of the common hepatic and CBDs +++ What is the type II choledochal cyst? ++ This choledochal cyst is characterized as a diverticulum protruding from the CBD +++ What is a type III choledochal cyst? ++ Choledochocele; found in the intraduodenal portion of the CBD +++ What is a type IV choledochal cyst? ++ Choledochal cyst that involves the extrahepatic bile duct and intrahepatic ducts +++ What is a type V choledochal cyst? ++ Caroli disease (multiple intrahepatic cysts) +++ List the areas where dilated collateral veins are seen in severe cirrhotics draining into the systemic circulation: ++ Hemorrhoidal, azygos, renal, and adrenal veins +++ What is the most common cause of hemobilia? ++ Iatrogenic trauma to the liver and biliary tree +++ What is the first test to rule out hemobilia? ++ Esophagogastroduodenoscopy +++ What is the first-line therapy for hemobilia? ++ Angiography (embolization) + BENIGN LIVER DISEASE Download Section PDF Listen +++ +++ What is the treatment of pyogenic liver abscess? ++ Antibiotics and percutaneous drainage +++ What is the antibiotic course for pyogenic liver abscess? ++ Broad-spectrum intravenous antibiotics for 2 to 3 weeks followed by 4 to 6 weeks of oral antibiotics +++ What is the most common cause of hydatid disease? ++ Echinococcus granulosus +++ What cyst may rupture and result in anaphylactic shock? ++ Echinococcal cyst +++ What skin test is used in the diagnosis of hydatid disease? ++ Casoni test (intradermal injection of hydatid fluid) +++ What in the wall of a liver cyst is highly suggestive of hydatid disease? ++ Calcifications +++ What abnormality may be seen on complete blood count in about 25% of patients with echinococcal cyst? ++ Eosinophilia +++ What is the medical treatment of choice for Echinococcus? ++ Mebendazole/albendazole +++ What technique describes percutaneous management of hydatid cysts in patients who refuse or cannot undergo surgery? ++ PAIR—Percutaneous Aspiration, Injection, and Reaspiration +++ What is the most common scolicidal agent used in hydatid cyst injection? ++ 20% sodium chloride solution +++ What are surgical options for hydatid cysts? ++ Partial cystectomy, pericystectomy, partial hepatectomy +++ What is the recurrence rate of postoperative hydatid cysts? ++ About 20% +++ What parasite causes amebiasis if transmitted through a fecal-oral route? ++ Entamoeba histolytica +++ What is the appropriate treatment of cyst rupture and bile duct obstruction? ++ ERCP with papillotomy +++ What liver abscess typically described as having anchovy paste appearance? ++ Amebic liver abscess +++ What is the treatment of amebic abscess? ++ 750 mg of metronidazole 3 times a day for 10 days +++ What is the most common cause of intrahepatic presinusoidal hypertension worldwide? ++ Schistosomiasis +++ What is Budd-Chiari syndrome? ++ Hepatic venous outflow obstruction +++ What are some causes of Budd-Chiari syndrome? ++ Polycythemia vera, factor V Leiden mutation, thrombocytosis, Protein C and S, antithrombin III, antiphospholipid antibody syndrome. ++ FIGURE 15-3. Computed tomographic scans showing classic appearance of benign liver lesions. Focal nodular hyperplasia (FNH) is hypervascular on arterial phase, isodense to liver on venous phase, and has a central scar (upper panels). Adenoma is hypovascular (lower left panel). Hemangioma shows asymmetrical peripheral enhancement (lower right panel). (Reproduced from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz's Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ What are possible sequelae of hepatic adenomas? ++ Rupture or malignancy +++ What liver tumor is associated with oral contraceptive pill use? ++ Hepatic adenoma +++ How would you manage a patient with hepatic adenoma who wants to get pregnant? ++ Elective resection of hepatic adenoma +++ What liver mass is characterized by a central stellate scar seen on computed tomography (CT) imaging? ++ FNH +++ What is the indication for resection of FNH? ++ Symptomatic FNH or an enlarging lesion +++ What is Kasabach-Merritt syndrome? ++ Hepatic hemangioma, thrombocytopenia, and consumptive coagulopathy +++ What is the most common benign liver tumor? ++ Hemangioma +++ What are the 2 types of hepatic hemangioma? ++ Capillary hemangioma (clinically insignificant) and cavernous hemangioma +++ What diagnostic tests are indicated? ++ CT with IV contrast +++ Should biopsy be performed for a suspected hepatic hemangioma? ++ No (hemorrhage risk!) +++ Which hepatitis virus is transmitted by the fecal-oral route via contaminated food? ++ Hepatitis A +++ Which tests indicate acute hepatitis B virus (HBV) hepatitis? ++ IgM, anti-HBc, HBsAg +++ Which tests indicate chronic HBV hepatitis? ++ HBsAg, IgG anti-HBc, IgG anti-HB +++ What is caput medusae? ++ Dilation of paraumbilical veins arising from the left portal vein and extending to the umbilicus producing umbilical and abdominal wall varices +++ Where can collaterals form as a result of portal hypertension? ++ Esophagus, retroperitoneum, rectum, abdominal wall +++ What are the 3 categories of portosystemic shunts? ++ Nonselective, selective, partial shunts +++ What are 2 basic types of nonselective shunts? ++ End-to-side portacaval shunt, side-to-side portosystemic shunts +++ What procedure has all but supplanted nonselective shunts? ++ Transjugular intrahepatic portosystemic shunt (TIPS) +++ What is the only commonly applied partial portosystemic shunt? ++ Interposition portacaval shunt + MALIGNANT HEPATOBILIARY DISEASE Download Section PDF Listen +++ +++ What is the surgical management of distal cholangiocarcinoma? ++ Pancreatoduodenectomy (Whipple) +++ What name is used to describe cholangiocarcinoma at the bifurcation of the common hepatic duct? ++ Klatskin tumor +++ What criteria for cholangiocarcinoma make it unresectable? ++ Bilateral hepatic artery involvement, encasement of the portal vein, bilateral hepatic duct involvement up to secondary radicals +++ What is the management of intrahepatic cholangiocarcinoma? ++ Hepatic resection +++ What is the management of perihilar cholangiocarcinoma? ++ Resection of the extrahepatic bile duct, cholecystectomy, and hepaticojejunostomy +++ Which potent hepatotoxin is produced by Aspergillus species? ++ Aflatoxin +++ What is the most common malignant hepatic tumor? ++ Metastases +++ What is the most common primary liver cancer worldwide? ++ Hepatocellular carcinoma (HCC) +++ What is the most common cause of HCC? ++ Hepatitis B and C +++ What distinct clinical variant of HCC is a well-circumscribed solitary lesion with a central scar? ++ Fibrolamellar carcinoma (better prognosis) +++ Which tumor marker may be helpful in the diagnosis of HCC? ++ α-Fetoprotein (AFP) +++ What are possible treatment options for HCC? ++ Partial hepatectomy, total hepatectomy with transplantation, ablation, embolization +++ This hepatic lesion does not produce AFP, but is associated with elevated neurotensin levels? ++ Fibrolamellar HCC +++ What is most common primary hepatic tumor of childhood? ++ Hepatoblastoma +++ What hepatic sarcoma is associated with vinyl chloride, thorotrast, and arsenic? ++ Angiosarcoma ++ FIGURE 15-4. Algorithm for diagnostic workup of an incidental liver lesion. The evaluation includes history and physical examination, blood work, imaging studies, and liver biopsy (if needed). AFP, α-fetoprotein; BUN, blood urea nitrogen; CA 19-9, cancer antigen 19-9; CEA, carcinoembryonic antigen; creat, creatinine; CBC, complete blood count; CT, computed tomography; EGD, esophagogastroduodenoscopy; Gyn, gynecologic; HTN, hypertension; MRI, magnetic resonance imaging; OCP, oral contraceptive pill; PAP, papanicolaou; US, ultrasound. (Reproduced from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz's Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 15-5. Algorithm for the management of hepatocellular carcinoma (HCC). The treatment algorithm for HCC begins with determining whether the patient is a resection candidate or liver transplant candidate. Bili, bilirubin level (in milligrams per deciliter); Child's, Child-Turcotte-Pugh class; lap, laparoscopic; LDLT, living-donor liver transplantation; LN, lymph node; MELD, model for end-stage liver disease; OLTx, orthotopic liver transplantation; Perc, percutaneous; RFA, radiofrequency ablation; TACE, transarterial chemoembolization; Tx, transplantation; UNOS, United Network for Organ Sharing; vasc., vascular. (Reproduced from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz's Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.) Graphic Jump LocationView Full Size||Download Slide (.ppt)