Podcast
Questions and Answers
Which of the following is NOT a contraindication for PAIR?
Which of the following is NOT a contraindication for PAIR?
Cysto-biliary communication occurs when bile is aspirated during PAIR.
Cysto-biliary communication occurs when bile is aspirated during PAIR.
True
What is the surgical approach when PAIR is contraindicated due to multiple cysts in one segment of the liver?
What is the surgical approach when PAIR is contraindicated due to multiple cysts in one segment of the liver?
Liver resection
In cases of cysto-biliary communication, a __________ agent may lead to chemical cholangitis.
In cases of cysto-biliary communication, a __________ agent may lead to chemical cholangitis.
Signup and view all the answers
Match the following surgical options with their correct descriptions:
Match the following surgical options with their correct descriptions:
Signup and view all the answers
What type of tumor is hepatoblastoma?
What type of tumor is hepatoblastoma?
Signup and view all the answers
Hepatoblastoma is commonly associated with the APC gene mutation.
Hepatoblastoma is commonly associated with the APC gene mutation.
Signup and view all the answers
What syndrome is hepatoblastoma associated with?
What syndrome is hepatoblastoma associated with?
Signup and view all the answers
Hepatoblastoma is a tumor of ________ hepatocytes.
Hepatoblastoma is a tumor of ________ hepatocytes.
Signup and view all the answers
Match the conditions with their related features:
Match the conditions with their related features:
Signup and view all the answers
What is one of the criteria for liver tumor resection under the Milan criteria?
What is one of the criteria for liver tumor resection under the Milan criteria?
Signup and view all the answers
The most common site of metastasis for HCC is the liver.
The most common site of metastasis for HCC is the liver.
Signup and view all the answers
What is one treatment option for advanced HCC with multiple tumors in one lobe?
What is one treatment option for advanced HCC with multiple tumors in one lobe?
Signup and view all the answers
The ___ technique involves associating liver partition with portal vein ligation for staged hepatectomy.
The ___ technique involves associating liver partition with portal vein ligation for staged hepatectomy.
Signup and view all the answers
Match the following terms related to HCC with their descriptions:
Match the following terms related to HCC with their descriptions:
Signup and view all the answers
What is the primary scolicidal agent commonly used in the management of liver cysts?
What is the primary scolicidal agent commonly used in the management of liver cysts?
Signup and view all the answers
CE4 and CE5 cysts typically require immediate treatment.
CE4 and CE5 cysts typically require immediate treatment.
Signup and view all the answers
What classification stage describes a solid or calcified cyst?
What classification stage describes a solid or calcified cyst?
Signup and view all the answers
The first line treatment for liver cyst management is __________ for a minimum of 7-10 days before intervention.
The first line treatment for liver cyst management is __________ for a minimum of 7-10 days before intervention.
Signup and view all the answers
Match the types of liver cysts with their characteristics:
Match the types of liver cysts with their characteristics:
Signup and view all the answers
What is the most common benign tumor of the liver?
What is the most common benign tumor of the liver?
Signup and view all the answers
Hepatocellular Carcinoma (HCC) is the most prevalent primary malignant tumor in adults.
Hepatocellular Carcinoma (HCC) is the most prevalent primary malignant tumor in adults.
Signup and view all the answers
What investigatory method is primarily used for liver tumors?
What investigatory method is primarily used for liver tumors?
Signup and view all the answers
The LI-RADS score of 100% definite HCC is classified as __________.
The LI-RADS score of 100% definite HCC is classified as __________.
Signup and view all the answers
Match the following LI-RADS scores with their descriptions:
Match the following LI-RADS scores with their descriptions:
Signup and view all the answers
What is the recommended management for a large and symptomatic focal nodular hyperplasia (FNH)?
What is the recommended management for a large and symptomatic focal nodular hyperplasia (FNH)?
Signup and view all the answers
Focal nodular hyperplasia is more commonly found in males than females.
Focal nodular hyperplasia is more commonly found in males than females.
Signup and view all the answers
What is the primary investigation technique used for diagnosing focal nodular hyperplasia?
What is the primary investigation technique used for diagnosing focal nodular hyperplasia?
Signup and view all the answers
In hepatic adenomas, there is a strong association with __________.
In hepatic adenomas, there is a strong association with __________.
Signup and view all the answers
Match the following features or management options with their corresponding conditions:
Match the following features or management options with their corresponding conditions:
Signup and view all the answers
What is the main source of bleeding during a liver resection?
What is the main source of bleeding during a liver resection?
Signup and view all the answers
Patient operated with high central venous pressure (CVP) has a lower mortality rate than those with low CVP during liver resection.
Patient operated with high central venous pressure (CVP) has a lower mortality rate than those with low CVP during liver resection.
Signup and view all the answers
What is the principle technique used to minimize bleeding during liver resection?
What is the principle technique used to minimize bleeding during liver resection?
Signup and view all the answers
Most bleeding during liver resection comes from the __________.
Most bleeding during liver resection comes from the __________.
Signup and view all the answers
Match the surgical practice with its outcome during liver resection:
Match the surgical practice with its outcome during liver resection:
Signup and view all the answers
What is a characteristic feature of hepatocellular carcinoma (HCC) observed in imaging studies?
What is a characteristic feature of hepatocellular carcinoma (HCC) observed in imaging studies?
Signup and view all the answers
The incidence of HCC increases with exposure to Thorotrast.
The incidence of HCC increases with exposure to Thorotrast.
Signup and view all the answers
What clinical sign may indicate advanced liver disease and is considered a late sign in HCC?
What clinical sign may indicate advanced liver disease and is considered a late sign in HCC?
Signup and view all the answers
HCC is more common in males, particularly in the __________ to __________ decade of life.
HCC is more common in males, particularly in the __________ to __________ decade of life.
Signup and view all the answers
Which of the following symptoms is commonly associated with paraneoplastic syndromes in HCC?
Which of the following symptoms is commonly associated with paraneoplastic syndromes in HCC?
Signup and view all the answers
Match the risk factors with their corresponding details:
Match the risk factors with their corresponding details:
Signup and view all the answers
The triple-phase CT scan is primarily used to assess liver function scores in HCC patients.
The triple-phase CT scan is primarily used to assess liver function scores in HCC patients.
Signup and view all the answers
What is the primary tumor marker that is increased in hepatocellular carcinoma?
What is the primary tumor marker that is increased in hepatocellular carcinoma?
Signup and view all the answers
A core biopsy is used when the diagnosis is __________ after a CT scan.
A core biopsy is used when the diagnosis is __________ after a CT scan.
Signup and view all the answers
Match the tumor markers with their relevant descriptions:
Match the tumor markers with their relevant descriptions:
Signup and view all the answers
What prevents the downward displacement of the spleen?
What prevents the downward displacement of the spleen?
Signup and view all the answers
The splenic enlargement occurs laterally.
The splenic enlargement occurs laterally.
Signup and view all the answers
What is the location of the spleen in relation to the ribs?
What is the location of the spleen in relation to the ribs?
Signup and view all the answers
The _______, which is related to the spleen, contains short gastric vessels.
The _______, which is related to the spleen, contains short gastric vessels.
Signup and view all the answers
Match the following ligaments with their descriptions:
Match the following ligaments with their descriptions:
Signup and view all the answers
Study Notes
Contraindications of PAIR
- PAIR (Percutaneous Aspiration and Injection) is not suitable for all liver cysts.
- Dead or calcified cysts are unsuitable for PAIR.
- Deep-seated cysts are not good candidates for PAIR.
- Cysts with an impending rupture are not suitable for PAIR.
- Multi-septate cysts are generally not suitable for PAIR, especially if multiple uniloculated cysts are present.
- Extra hepatic cysts are unsuitable for PAIR.
Cysto-biliary Communication
- If bile is aspirated from a liver cyst, PAIR should be abandoned.
- This is because scolicidal agents can cause chemical cholangitis.
B. Surgery
- An alternative approach is to perform surgery when PAIR is contraindicated.
- Options include:
- Cystopericystectomy: Removal of the cyst.
- Liver resection: Resecting the liver segment containing the cyst.
- Capitonnage: Closing the cyst cavity after removing cyst contents, by spiralling closure.
Hepatoblastoma
- Hepatoblastoma is a tumor of fetal hepatocytes, a rare but aggressive liver cancer found in children.
- It can be associated with Familial Adenomatous Polyposis (FAP) Syndrome due to mutations in the APC gene.
- Treatment is based on the Barcelona Clinic Liver Group (BCLC) staging system for HCC.
Liver: Part 2
- Localized HCC:
- For patients with Child-Pugh B/C and inadequate FLR (Functional Liver Reserve) of 25%.
- Liver resection is the recommended approach.
- Milan criteria:
- Applies to HCC with favorable prognosis.
- Single tumor ≤ 5cm or 1-3 tumors ≤ 3cm.
- No metastasis.
- Non-Milan Criteria:
- Nimura technique or ALPPS (Associating Liver Partition with Portal vein ligation for Staged hepatectomy)
- Procedure:
- Portal vein embolisation is used to trigger hypertrophy of the other lobe.
- This increases the volume of functional liver tissue for eventual resection.
- Advanced or metastatic HCC:
- Palliative treatment options:
- Radiofrequency Ablation (RFA) for tumors ≤ 3cm.
- Percutaneous Ethanol Injection.
- Multiple tumors in one lobe:
- Trans-arterial chemoembolisation/TACE
- Trans-arterial radioembolisation/TARE (Using Yttrium spheres)
- Metastatic HCC: Immunotherapy with Sorafenib (Tyrosine kinase inhibitor) or Pembrolizumab/Nevolumab
- Palliative treatment options:
- FLR: Assessed using Fibroscan.
- Liver resections exceeding 25% are feasible.
- Prognostic indicators for HCC:
- CLIP (Cancer of the Liver Italian Program)
- Okuda stage
- BCLC (Barcelona Clinic Score)
- Stage of disease is the most significant prognostic factor.
- Lung is the most common site of metastasis.
- Fibrolamellar variant:
- Often affects young patients.
- Tumor markers:
- Neurotensin B is increased.
- AFP is not elevated.
- Good prognosis, typically found in non-cirrhotic livers.
- Equal prevalence in males and females.
Liver Cyst Classification and Management
- Liver cysts can be classified using WHO and Gharbi classifications.
- The classifications categorise cysts based on their characteristics, including membrane detachment, presence of daughter cysts, and solid/calcified formations.
- CE4 and CE5 cysts are considered inactive and usually do not require treatment.
- Albendazole (minimum 7-10 days before intervention) is the first-line treatment option.
- Interventional modalities (PAIR) are used for active cysts:
- Percutaneous aspiration of fluid (under image guidance)
- Injection of scolicidal agents:
- Hypertonic saline (most common agent)
- Ethanol
- Absolute Alcohol
- Cetrimide solution
- Mebendazole solution
- Re-aspiration
- Hydatid fluid, if leaked into circulation, can trigger anaphylaxis.
- Formalin is not considered a scolicidal agent due to its potential to cause chemical cholangitis.
LIVER: PART 2
- Triple phase CT (Contrast CT) is the investigation of choice for all liver tumors.
- LIRADS (Liver Imaging Reporting and Data System) scoring helps classify liver lesions based on CT scan findings:
- LR-1: 100% Benign
- LR-2: Probably benign (Follow-up done)
- LR-3: Intermediate probability for HCC (Follow-up/biopsy)
- LR-4: Probably HCC
- LR-5: 100% Definite HCC
- Common liver tumors:
- Most common benign tumor: Hemangioma
- Second most common benign tumor: Focal Nodular Hyperplasia (FNH)
- Most common malignant tumor: Metastasis/Secondaries to Liver
- Most common primary malignant tumor: Hepatocellular Carcinoma (HCC)
- Most common primary malignant tumor in children: Hepatoblastoma
Benign Tumors of Liver
-
I. LIVER HEMANGIOMAS
- Collections of blood vessels.
- Clinical features:
- More common in women than men.
- Often asymptomatic, diagnosed incidentally.
- Kassabach-Merritt Syndrome: Consumption coagulopathy in very large hemangiomas, leading to bleeding and pain.
- Investigations:
- Triple phase CT:
- Non-contrast phase: Hypodense
- Arterial phase: Peripheral nodular enhancement
- Washout phase: Homogeneous enhancement
- Triple phase CT:
Focal Nodular Hyperplasia (FNH)
- Proposed Etiology: Vascular insult to the liver (e.g., post-trauma or intervention).
- Clinical Features:
- More common in women than men.
- Asymptomatic, diagnosed incidentally.
- Investigations:
- Triple Phase CT: Central stellate scar, dilated arteriole + branches (Also seen in oncocytoma of the kidney).
- Histopathology (HPE): Hepatocytes, atypical bile duct structures, Kupffer cells.
- Usually unencapsulated, showing "hot-spot" on a sulphur colloid scan.
- α-fetoprotein (AFP): Normal (helps differentiate FNH from HCC).
- Management: Observation
Hepatic Adenoma
- Benign liver tumor.
- 10% risk of malignant transformation.
- Clinical Features:
- Strongest association with oral contraceptive pills (OCPs).
- More common in women than men.
- Usually symptomatic: Hepatomegaly (+).
- Spontaneous rupture can lead to hemoperitoneum (most common non-traumatic cause).
Liver Resection
- Principle of Liver Resection:
- Major bleeding typically originates from the hepatic vein.
- Low central venous pressure (CVP) during surgery (50%) is associated with decreased mortality.
- Investigations:
- Triple phase CT: Fat content (Hypodense), Intratumoral hemorrhage (Hyperdense), Heterogenous lesion.
- AFP: May be raised in some patients
- HPE: Sheets of hepatocytes, no bile duct structures, no Kupffer cells.
- Management:
-
2cm: Close observation.
-
Hepatocellular Carcinoma (HCC)
- Risk factors:
- Chronic Hepatitis C infection.
- Alcohol abuse.
- Obesity.
- Thorotrast exposure (Contrast medium).
- Aflatoxin exposure.
- Diabetes mellitus.
- Non-alcoholic steatohepatitis (NASH) or non-alcoholic fatty liver disease (NAFLD).
- Clinical Features:
- More common in men.
- Often diagnosed in the 4th-5th decade.
- Hepatomegaly: Often hard and nodular.
- Jaundice (Late sign, as liver has a large reserve).
- Note: Thorotrast exposure increases the risk of:
- HCC.
- Cholangiocarcinoma.
- Renal cell carcinoma.
- Paraneoplastic Syndromes:
- These are unexplained by direct spread or metastasis.
- Common symptoms include:
- Hypoglycemia.
- Hypercholesterolemia.
- Cushing's syndrome.
- Gynecomastia.
Investigations
- Triple Phase CT: Helps differentiate HCC from metastasis. Classical and diagnostic findings:
- HCC:
- Non-contrast phase: Hypodense
- Arterial phase: Hyperdense
- Venous phase: Early washout
- Metastasis:
- Non-contrast phase: Hypodense
- Arterial phase: Hyperdense
- Venous phase: Early washout
- HCC:
- Core Biopsy: Performed when diagnosis is uncertain after CT scan or metastasis is suspected.
- Tumor Markers:
- AFP (increased)
- PIVKA-II (increased)
- Glypican
- HepPar-1
- Neurotensin B (increased, especially in Fibrolamellar variant)
- Liver Function Scores:
- Child-Turcotte-Pugh score.
- MELD score.
- PELD score.
- Images are mentioned, but descriptions are not available.
SPLEEN
-
Surface Anatomy
- Location: Along the axis of the 9th-11th ribs.
- Border: Inferior lateral border has a notch.
-
Applied aspect
- Splenic enlargement: Displaces the organ medially.
- Downward displacement: Prevented by the phrenicocolic ligament.
- Fracture of 9th-11th ribs on the left: May result in splenic trauma.
SPLENIC LIGAMENTS
-
Splenophrenic & splenicocolic ligaments: Avascular, can be cut surgically.
-
Gastrosplenic ligament: Contains the short gastric vessels.
-
Lienorenal ligament: Contains the splenic vessels and the tail of the pancreas.
-
The diagram shows the spleen's location, highlighting its relationship to other abdominal organs.
-
Key vessels and structures are labelled, including the coeliac trunk, portal vein, hepatic artery, gastroduodenal artery, aorta, splenic artery and vein, inferior and superior mesenteric vessels.
-
The diagram also shows a section of the spleen with its vascular supply highlighting how the splenic vessels are formed by the portal and superior mesenteric veins.
-
The inferior mesenteric vein also drains into the splenic vein.
-
The Falciform ligament and the lesser omentum are also visible in the diagram.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
This quiz explores the contraindications of Percutaneous Aspiration and Injection (PAIR) for liver cysts and discusses alternative surgical options. Understand the specific conditions that make PAIR unsuitable and learn about alternative approaches such as cystopericystectomy and liver resection for managing liver cysts.
