Chapter 10 : Liver Diseases

Glisson system = the base of liver surgery, includes biliary system, arterial system, and venous system 1st hilum: pinch hepatic artery at hilar to stop liver hemorrhage/ bleeding 2nd hilum: consists of left, middle, & right hepatic vein. If they are ruptured, massive bleeding will result 3rd Hilum: between IVC (Inferior vena cava) & liver

Couinauds segmental anatomy of the liver: Liver is divided into 8 segments based on the hepatic venous distribution Segment I :located right in front of IVC. We need to separate liver before we can perform resection. Also, it is the most difficult to resect this segment because it receives both blood supply from hepatic artery and portal vein , and located posteriorly. Segment VI ,VII :are also located posteriorly

Hepatic Trauma: Penetrating trauma: bullets, knives, etc Blunt trauma: fall from height, crash Clinical manifestations: hypovolemic shock: Cyanosis,Cold clammy skinThready pulse,Fast heart rate, Low Blood Pressure Lab findings: anemia (fast blood loss) leukocytosis >15000109/L Imaging scan: Ultrasonic: intra-abdominal fluid CT scan: most accurate technique

Treatment: non-operative Patients with stable minor injuries may be managed expectantly, including: contained subcapsular intrahepatic hematoma unilabor fracture no injuries to other organs stable minor injuries : Haemodynamically stable following resuscitation No persistent or increasing abdominal pain or tenderness No other peritoneal injuries that require laparotomy <4 units of blood transfusion required Indications for laparotomy: Stab or gunshot wounds that have penetrated the abdomen Signs of peritonitis Unexplained shock----uncontrolled shock after resus Uncontrolled haemorrhage Clinical deterioration during observation How to stop bleeding: Pringles maneuver: Remove dead or devitalised liver tissue Ligate or repair damaged blood vessels and bile ducts Primary Liver Cancer: Hepatocellular carcinoma (80%) Intrahepatic Chlangiocarcinoma (15%) Mixed form (5%) Hepatocellular carcinoma: Commonest malignant tumour worldwide 80 % occur with cirrhotic livers Established viral infection 10 years to develop chronic hepatitis 20 years to develop cirrhosis 30 years to develop carcinoma Risk Factors: most important risk factor is cirrhosis from any cause: 1. Hepatitis B (integrates in DNA) 2. Hepatitis C 3. Alcohol 4. Aflatoxin

 HCC Has no special symptoms Lab findings: Alpha fetoprotein (AFP) > 400 ng/ml , seen in > 70% of patients AFP negtive account for 30% of HCC patients , thus AFP negative can not be used to exclude HCC Other liver function disorder is decided by the level of cirrhosis CA199 in cholangiocarcinoma Imaging: 3 phagic CT scan (common, artery, venous): Early arterial perfusion (fast come)- tumor appears to be lighter than normal Early venous excretion (fast go Angiography: Ball in Hand shape PET : shows high metabolic rate of cancer Diagnosis: In common situation, the diagnosis of HCC is determined by two parts: Liver mass detected by imaging technique Serum AFP > 400ng/ml last weapon you should use for diagnosis : BIOPSY Treatment: Arterial Chemoembolization <2 cm tumors: -Inject chemotherapy selectively in hepatic artery (doxorubicin) -Then inject an embolic agent (gelatin foam particles) -Only in patients with early cirrhosis -No role for systemic chemotherapy Radiofrequency Ablation <2 cm tumors Alcohol Injection-alcohol draws H2O out from tumor <2 cm tumors Partial hepatectomy >2 cm tumors

Transplantation (Milan criteria for HCC)- used to assess success of liver transplantation Tumors 5 cm or < in diameter in patients with single hepatocellular carcinoma No more than 3 tumor nodules Each has 3 cm or < in diameter in patients with multiple tumors

Metastatic Neoplasms: most common site for blood born metastases Common primaries : colon, breast, lung, stomach, pancreases, and melanoma Mild cholestatic picture (ALP, LDH) with preserved liver function Imaging or FNA (fine needle aspiration) Treatment depends on the primary cancer In some cases resection or chemoembolization is possible If the primary cancer cant be resected, then metastatic/ secondary cancer will be left untouched Colorectal liver metastasis: 8-10 % of patients undergoing curative resection of colorectal tumours have isolated liver metastasis suitable for liver resection 5-year survival after resection 30 % Metastatic cancer originated from colon, can be treated by resection,prognosis is good. Metastatic cancer originated from stomach, is inoperable and prognosis is poor . Liver resection: A fit patient with a healthy liver will regenerate a 75 % resection within three months Segmental anatomy with each of the eight segments supplied by its own branch of the hepatic artery, portal vein and bile ducts Mortality lower than 5 %

Benign Tumors and Cysts: Cysts Hemangioma *** Focal nodular hyperplasia Adenoma

Liver Cysts: Characteristics of simple cysts: Simple cysts of the liver contain serous fluid, do not communicate with the biliary tree, and do not have septations. 50% of cases, the cysts are singular. Histologically, a single layer of cuboidal or columnar cells that have no atypia , line these cysts. Simple cysts are generally regarded as congenital malformations.- Polycysts also considered as congenital malformations Thin walled Contain clear fluid Contain no septa or debris Surrounded by normal liver tissue asymptomatic Present in 1 % of population Treatment: Thick walled cysts and those containing septa, nodules or echogenic fluid may be cystic tumours Only symptomatic or > 10cm cysts need treatment most popular treatment is laparoscopic cyst fenestration (Deroofing) Deroofing can only be done on simple cysts. Deroofing one of cyst in polycysts, other cysts will enlarge Polycystic liver disease: Incidence 3 % Polycysts are commonly seen in patients with polycystic kidney disease. Histologically, similar to simple cysts Generally asymptomatic, large, numerous cysts may cause abdominal pain and distention Treatment : reserved for severe symptoms related to large cysts and complications Treatment is by percutaneous aspiration, fenestration, hepatic resection , or orthotopic liver transplantation. Liver transplantation only used with progressive disease after fenestration or resection with liver or renal dysfunction

Haemangiomas***: Incidence 3 % Malignant transformation and spontaneous rupture are rare Diagnosis by contrast enhanced CT Resection is indicated only for large symptomatic tumours Large & outside the liver resection is needed

Imaging: 3 phagic CT scan: Early arterial perfusion (fast come) Late venous excretion (slow go) Symptoms and Treatment: Most are asymptomatic Only symptomatic or >8-10cm need operative treatment partial hepatectomy In liver parenchyma, not suitable for resection Liver cell adenoma: Predominantly in women of childbearing age associated with steroid hormone use such as oral contraceptive pills (OCPs) female-to-male ratio is approximately 11:1 usually singular, but multiple lesions have been reported in 12% to 30% of cases cases with multiple adenomas are not associated with OCP use and dont have as dramatic a female preponderance.

Labs: AFP =Normal CT: usually demonstrates a well-circumscribed heterogenous mass that shows early enhancement during the arterial phase Treatment: Risk of malignant transformation 10 % Liver resection necessary

Focal nodular hyperplasia (FNH): 2nd most common benign tumor of the liver and predominantly discovered in young women Usually small (<5 cm) nodular mass arising in a normal liver that involves the right and left liver equally. Symptoms ,Labs and Treatment: AFP is normal Characterized by central fibrous scar with radiating septa Usually asymptomatic Not premalignant does not require treatment unless symptomatic Sometimes diagnosis difficult to establish histology should be determined after surgical resection

Hepatic Liver Abcess: Pyogenic liver abscess: Clinical Features : Right upper quadrant pain and tenderness Nocturnal fevers and sweats Anorexia and weight Raised right hemidiaphram in chest radiograph Raised white cell count with mild anaemia Origins and causes of pyogenic liver abscess: Biliary tract Gall stones, cholangiocarcinoma, strictures Portal vein Appendicitis, diverticulitis, Crohns disease Hepatic artery - endocarditis Direct extension of: Gallbladder empyema Trauma Treatment: When the diagnosis of pyogenic hepatic abscess is suspected, broad-spectrum IV antibiotics are started immediately to control ongoing bacteremia and its associated complications. Antibiotics Penicillin , aminoglycoside (or cephalosporin), metronidazole

Drainage requirements for liver abscesses: No multiple small abscesses that respond to antibiotics Percutaneous aspiration abscesses <6cm Percutaneous catheter drainage abscesses >6cm advantages are simplicity of treatment ,avoidance of general anesthesia and laparotomy Drainage requirements for liver abscesses : Open surgery Failed percutaneous drainage Very large or multilocular abscesses Associated intra-abdominal infection requiring surgery such as bile duct stones Amoebic liver abscess Epidemiology: 10 % of the worlds population chronically infected 3rd commonest parasitic cause of death Symptoms of amoebic liver abscess: Pain Enlarged liver with maximal tenderness over abscess Intermittent fever with night sweats Weight loss Nausea Vomiting Cough Dyspnoea Diagnosis: Serological tests Stool may contain protozoal cysts Abscess usually solitary right lobe in 80% of cases Abscess contains sterile pus and reddish-brown liquefied necrotic liver tissue Treatment: 95 % resolve with metronidazole alone (800 mg three times a day for five days) After the abscess diloxanide furate 500 mg, eight hourly for seven days to eliminate intestinal amoebae Surgery: Surgical drainage is required only if the abscess has ruptured causing amoebic peritonitis.

Hydatid disease: Presentation: Liver enlargement Right upper quadrant pain Rupture of the cyst into the peritoneal cavity urticaria, anaphylactic shock, eosinophilia Erosion into bile duct jaundice, cholangitis Diagnosis: Ultrasonography, computed tomography Serological tests CT shows hydatid cyst: daughter cysts containing hydatid are visible within main cyst Treatment I: Surgery 1. Aspiration of cysts and replacement by a scolicidal agent such as 0.5% sodium hypochlorite Surgery - 2. cysts are carefully shelled out by peeling endocyst off the host ectocyst layer along its cleavage plane Treatment II: Bile leakages are sutured cavity is drained and filled with omentum Liver resection seldom necessary Albendazole is given for two weeks postoperatively