The Liver

Multiple Choice

What is the Couinaud segmental anatomy for the caudate lobe of the liver?

• 1

• 2

• 4a

• 4b

• 6

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Multiple Choice

What Couinaud segment is bounded by the falciform ligament/umbilical fissure medially and Cantlie's line/middle hepatic vein laterally?

• 1

• 3

• 4

• 5

• 8

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Multiple Choice

What Couinaud segment is bounded by Cantlie's line/middle hepatic vein medially and the right hepatic vein laterally?

• 1

• 3

• 4

• 5

• 8

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Multiple Choice

A 40-year-old man presents to the ED with complaints of nausea, anorexia, and fever 1 week after returning from a 2-month vacation in Mexico. He also reports having a fever and diarrhea. His WBC count is 14,000/µL. An ultrasound shows a 5-cm hypoechoic, smooth-walled lesion in the right lobe of the liver. What is the most appropriate treatment for this patient?

• Percutaneous drainage

• Metronidazole for 2 weeks

• Percutaneous drainage plus metronidazole

• Fluoroquinolones plus metronidazole

• Chloroquine

This patient likely has an amebic abscess. Metronidazole is the drug of choice for amebic liver abscess.​ Amebic liver abscesses can almost always be treated with medical therapy alone. Percutaneous drainage is considered in cases of poor response to antiamebic agents, when superinfection is suspected, or when there is a risk of rupture. Open surgical drainage is almost never required and is recommended only in severe, complicated cases.

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Multiple Choice

A 60-year-old woman is undergoing chemotherapy for liver metastasis from rectal cancer. She was admitted to the hospital 3 days ago with fever, leukocytosis, and right upper quadrant pain. CT reveals a 9-cm abscess of the right lobe of her liver as well as multiple liver metastases. Despite 72 hours of antibiotic and antifungal coverage with ceftriaxone, metronidazole, and fluconazole, she continues to have pain and high fevers. What is the most appropriate next step?

• Broadening of her antibiotic coverage

• Percutaneous drainage of the abscess

• FNA of the abscess to obtain fluid or tissue for culture

• Operative drainage of the abscess

• ELISA to rule out a hydatid cyst

The most appropriate next step for the patient is percutaneous drainage. She has been on appropriate antibiotic coverage for a pyogenic abscess, and increasing her antibiotic coverage is unlikely to better control the infection. FNA for culture is unlikely to change her need for drainage and exposes her to the need for two procedures. Most pyogenic liver abscesses can be managed with percutaneous drainage and rarely require operative drainage. This patient’s history is most concerning for a pyogenic abscess of the liver, not a hydatid cyst.

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Multiple Choice

A previously healthy 23-year-old woman presents to the ED reporting RUQ and RLQ abdominal pain for 1 week. Her RLQ pain briefly subsided but has been worsening over the past several days. Her RUQ pain has been present for the past 2 days. She also complains of nausea, emesis, fever, and chills. A CT scan reveals perforated appendicitis with an abscess but also demonstrates the findings noted in the image. What is the most appropriate treatment for this patient?

• Admit the patient, make her NPO, and administer IV antibiotics.

• Consult IR for drainage of both abscesses with a planned interval laparoscopic appendectomy.

• Plan an open appendectomy.

• Plan a laparoscopic appendectomy with aspiration of the liver lesion.

• Plan a laparoscopic appendectomy and laparoscopic cholecystectomy.

Although admission, NPO, and IV antibiotics are appropriate measures, perforated appendicitis with abscess and hepatic abscess formation from portal vein seeding are unlikely to resolve completely with IV antibiotics alone. An open appendectomy alone does not address the hepatic abscess. The patient has had perforated appendicitis for 1 week and will likely have significant intra-abdominal adhesions, which increase her operative risk. The image displayed demonstrates a hepatic abscess, not acute cholecystitis, so laparoscopic cholecystectomy is not indicated.

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Multiple Choice

A 43-year-old man with a history of colon cancer and chronic lower back pain undergoes MRI of the lumbar spine that shows an incidental lesion in the right lobe of the liver. Follow-up CT of the liver confirms a 3-cm mass in segment 6. Which of the CT imaging findings described below is most concerning for a metastatic lesion?

• Peripheral-to-central enhancement on delayed phase

• Enhancement of a central scar on delayed phase

• A hypodense, low-attenuation lesion with mild enhancement on arterial phase

• Thin-walled fluid-filled structure with no septations or calcifications on arterial phase

• Well-circumscribed mass with bright enhancement on arterial phase

The hypodense, low-attenuation lesion with mild enhancement on arterial-phase CT is most suspicious for metastatic disease. Depending on the patient’s history, a biopsy may be needed to help guide treatment. Hepatocellular carcinoma appears as a heterogeneous, poorly circumscribed mass with bright arterial enhancement and quick washout. The scan with peripheral-to-central enhancement describes a hemangioma. The scan with enhancement of a central scar is typical of focal nodular hyperplasia. The thin-walled fluid-filled structure describes a simple cyst. The well-circumscribed mass is a hepatic adenoma.

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Multiple Choice

A 48-year-old healthy woman is found to have a 6-cm incidental lesion in the right lobe of her liver. Further workup with contrast-enhanced MRI shows a lobulated, enhancing lesion with a well-demarcated border and a central fibrous scar. What should subsequent management include?

• Surgical resection because of potential for malignant degeneration

• Surgical resection to avoid possible rupture and hemorrhage

• Observation

• Steroid therapy

• Transarterial chemoembolization (TACE)

The radiologic findings are highly suggestive of focal nodular hyperplasia (FNH), in which lesions are benign with no bleeding or malignant potential. If the patient is asymptomatic and the lesion is stable on subsequent imaging, no further intervention is necessary. Although it is reasonable to consider short-term surveillance to ensure that no growth occurs, long-term surveillance is unnecessary. Surgical resection may be recommended if a patient is symptomatic or if a definitive diagnosis cannot be made and a hepatic adenoma or hepatocellular carcinoma cannot be ruled out entirely. Transarterial chemoembolization (TACE) is a treatment option for hepatocellular carcinoma.

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Multiple Choice

A 57-year-old man with hepatitis C and cirrhosis presents to the office for evaluation of RUQ pain. He has lost about 10 lbs over 6 months. He is noted to have RUQ tenderness. Ultrasound shows a large mass measuring 8 cm in the right hepatic lobe. There are no gallstones. You order serum AFP, which comes back elevated. You then decide to order a contrast-enhanced CT. Which findings would you likely see?

• Peripheral enhancement with centripetal progression

• Nodular enhancement during arterial phase

• Strong homogenous enhancement of the mass during arterial phase

• Rapid contrast washout during venous phase with central scar

• Rapidly enhancing, well-circumscribed mass with complete pseudocapsule

There is a clear association between hepatitis B and C and HCC as well as cirrhosis. CT findings typically consist of rapidly enhancing, well-circumscribed mass with rapid washout and pseudocapsule. Hepatic adenoma is predominantly found in young women of childbearing age and is often associated with oral contraceptive pill use. Two major risks associated are rupture and malignant transformation. CT findings consist of heterogenous-appearing mass with early peripheral enhancement and centripetal progression.

Hemangioma is the most common benign tumor of the liver. Rapid enhancement in a nodular pattern is seen during the arterial phase.

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Multiple Choice

A 56-year-old man with a known history of alcohol-related Childs B cirrhosis presents with RUQ pain and weight loss. Clinical examination is notable for mild abdominal distention. Contrast-enhanced CT scan demonstrates a 1.5-cm lesion in the segment 5 of the liver. In the arterial phase, there is homogenous intense enhancement than the surrounding liver. In the portal venous phase, there is washout of the contrast (highly suggestive of hepatocellular carcinoma). The patient’s only liver function abnormality is a total bilirubin of 2.1 mg/dL. What is the next best step in the management of his liver lesion?

• Contrast-enhanced MRI

• Ultrasound-guided FNA biopsy

• Right hepatectomy

• Serum alpha-fetoprotein level

• Contrast-enhanced ultrasound

If typical features of HCC on imaging (arterially enhancing mass with washout of contrast material in delayed phases) are observed, diagnosis of HCC is presumed. For lesions larger than 2 cm, a single study may suffice. However, for lesions 1 to 2 cm in size, contrast-enhanced CT and MRI in a sequential fashion increase the sensitivity. Contrast-enhanced ultrasound is not universally available and hence not recommended. AFP does not play a critical role in the diagnosis of HCC any more due to lack of sensitivity and specificity. FNA biopsy is recommended in equivocal or lesions with atypical imaging features. Right hepatectomy without establishing diagnosis is not appropriate.

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Multiple Choice

A 35-year-old male presents to the ED obtunded, with the following vital signs: HR 126 beats/min, BP 82/43 mm Hg, respiratory rate 15 breaths/min, and oxygen saturation 100% on nonrebreather. 1 month ago, he underwent a CT A/P to rule out kidney stones; a 12-cm mass in the right lobe of his liver occupying segments 5, 6 and 7, without a defined capsule, was apparent. He did not have kidney stones, and was discharged from the ED. Otherwise, his PMH is unremarkable. He denies taking any medications but admits to using androgenic steroids. What is the most definitive step in management?

• Emergent laparotomy

• Cessation of steroids

• CT of the abdomen and pelvis

• ICU admission and intravenous fluid resuscitation

• Percutaneous liver embolization

This patient has a large hepatic adenoma that has ruptured into the peritoneal cavity and is in hemorrhagic shock. He needs an immediate damage control laparotomy for control of hemorrhage without any delay. Percutaneous embolization can be used for lesions whose hemorrhage is difficult to control intraoperatively or those that are in anatomically difficult positions. This patient will require aggressive resuscitation and intensive care admission; however, this will not stop the hemorrhage. The patient will need to cease his steroid use, although this will not help him in the immediate time frame.

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Multiple Choice

A 60-year-old man is scheduled for a laparoscopic partial left hepatectomy for a peripheral segment 3 hepatocellular carcinoma measuring 3.5 cm. During surgery, he is found to have direct tumor invasion into the segment 3 portal vein and one small satellite tumor. What should the operative plan for this patient be?

• Tumor ablation with microwave energy

• Tumor ablation with radiofrequency energy

• Subsegmental hepatectomy to include both tumors

• Segments 2 and 3 bisegmentectomy

• Left hepatectomy

Primary liver tumors associated with direct portal vein invasion with or without intrasegmental multifocality should be treated with segmental hepatectomy. As long as the patient is a good operative candidate to tolerate a left lateral sectorectomy (2 + 3 bisegmentectomy), microwave or radiofrequency energy are usually reserved for poor operative candidates or for patients with surgically initially unresectable disease. With the tumor invading the segmental portal vein, a subsegmental hepatectomy would provide inadequate oncologic resection; thus, this approach is wrong in this case even if both the tumors are included in the specimen. On the other hand, a left hepatectomy would resect way too much hepatic parenchyma because it would include not only the left lateral sector but also the left medial sector.

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Multiple Choice

A laparoscopic liver cyst fenestration procedure is planned for a healthy woman with a symptomatic 8-cm cyst in segment 4 of the liver. At the time of operation, ultrasound reveals multiple septations within the cyst and nodularity within the peripheral cyst wall. What is the most appropriate action?

• Cyst fenestration

• Cyst aspiration

• Complete cyst excision

• Cyst fluid analysis

• Cyst wall biopsy

The ability of ultrasound to accurately characterize a liver cyst is superior to all other imaging modalities. Findings of internal cyst septations within a cyst should raise concern for a cystic neoplasm for which fenestration or marsupialization is not appropriate. Complete cyst excision should be the goal even if it requires a formal hepatectomy. Thus, the other choices are incorrect because they would not provide adequate oncologic resection.

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Multiple Choice

What is the most common replaced left hepatic artery variant?

• SMA

• IMA

• Left gastric artery

• Aorta

• Left renal artery

Multiple Choice

What is the most common replaced right hepatic artery variant?

• SMA

• IMA

• RIght gastric artery

• Aorta

• Right renal artery

Multiple Choice

What ligament attaches the liver to the anterior abdominal wall?

• Right triangular ligament

• Left triangular ligament

• Round ligament

• Coronary ligament

• Falciform ligament

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Multiple Choice

What animals expose humans to Echinococcus/hydatid?

• Dogs

• Cats

• Ducks

• Sheep

• Rats

Multiple Choice

What animals are the intermediate host for Echinococcus/hydatid?

• Dogs

• Cats

• Ducks

• Sheep

• Rats

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Multiple Choice

Where within the portal triad is the hepatic artery located?

• Medial

• Lateral

• Posterior

Multiple Choice

Where within the portal triad is the portal vein located?

• Medial

• Lateral

• Posterior

Multiple Choice

Where within the portal triad is the common hepatic duct located?

• Medial

• Lateral

• Posterior

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