Liver By: Anagheem sheyyab - PowerPoint Presentation

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Liver

By:

Anagheem

sheyyab

Slide2

It is the largest abdominal organ (1500gm).

triangular in shape.

Located beneath the right

hemidiaphragm

with variable

extentions

to the left .

attached to the under surface of the diaphragm by

suspensory

ligaments that enclose a 'bare area', the only part of its surface without a peritoneal covering.

the hepatic portal system connects the capillaries of the gastrointestinal tract with the capillaries in the liver. Nutrient-rich blood leaves the gastrointestinal tract and is first brought to the liver for processing before being sent to the heart.

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two functional lobes (called

hemilivers

).

Each hemiliver is further divided into four segments corresponding to the main branches of the hepatic artery and portal vein. normally receives 100-130 ml of blood per minute per Kg body weight and has a dual blood supply, 75% coming from the portal vein and 25% from the hepatic artery (off the celiac artery). The principal venous drainageof the liver is by the right, middle and left hepatic veins, which enter the inferior vena cava.

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Functions:

Production of :Bile, plasma

protiens

and coagulation factors.Fat soluble vitamins metabolism and/or storage.storage of : protiens(A.A),glucose(glycogen), fat(cholestrol)Bilirubin matabolism

.

Detoxification.

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Liver

Abscess:

mass

filled with pus inside the liverClassified into : • Pyogenic liver abscess: which is most often polymicrobial, accounts for 80% of hepatic abscess. • Amoebic liver abscess: due to

Entamoeba

histolytica

accounts for 10% of cases.

• Fungal abscess: most often due to Candida species, accounts for less than 10% of cases.

• Iatrogenic abscess: caused by medical interventions

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Pyogenic

abscess

Multiple organisms are usually isolated; however, they commonly include Escherichia coli, Staphylococcus

aureus and anaerobes.Causes:infection from the biliary system (e.g. ascending cholangitis) Infection may spread through the portal vein from abdominal sepsis

by direct spread from a contiguous organ.

may follow blunt or penetrating injury.

Can be predisposed by alcoholism, metastatic cancer, and diabetes mellitus

in one-third of patients the source of infection is indeterminate (cryptogenic)

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Presentation:

Classic triad of

pyogenic

liver abscess:Fever ,Malaise & Right upper quadrant pain Other symptoms :Anorexia and weight loss , Nausea and vomiting . Respiratory symptoms may be present if the inflammation reached the overlying pleura resulting in pleural effusion Physical examination:

- Jaundice

- Tender

hepatomegaly

-

Intercostal

tenderness

-

Epigastric

tenderness

- Decreased breath sounds in right lower lobe of the lung

- Features of sepsis -The symptoms of

pyogenic

liver abscess are often non-specific (e.g., fever, weight loss, etc.)-.

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Investigations:

Labs: CBC , LFT, ESR, CRP, Blood culture(+

ive

in 50%).Plain radiographs :elevation of the diaphragm, pleural effusion and basal lobe collapse.USS or CT is used to define the abscess (which is often irregular and thick-walled) and to facilitate percutaneous aspiration for culture.ERCP may be useful if biliary obstruction is thought to beresponsible.

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Management :

Multible

small abscesses : antibiotics alone

Solitary abscess : percutaneous drainage. open or laproscopic drainage. +Broad spectrum antibiotics can be used for up to 8 weeks (IV for 2 weeks followed by 6 weeks oral).

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Amebic abscess

presentation:

right upper quadrant pain

anorexia, weight loss Nausea. night sweats. Physical Examination: -tender enlargement of the liver -jaundice (uncommon). Other features may result from lung and pleural involvement and include basal pulmonary collapse and pleural effusion.

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Investigation:

CBC,LFT, Direct and indirect serological tests (CF, IHA and

ELISA) to detect amoebic protein, stools examination for

amebaetrophozoites or cysts. USS and CT: usually large,solitary,thin-walled,poorly defined abscess in the right lobe, and contains brown sterile pus resembling anchovy sauce.

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Management:

Empirical

tx

in areas where the problem is endemic. metronidazole with chloroquine phosphate usually results in rapid resolution. Needle aspiration if : -No clinical response within 72 hours -There was superinfection (treated as pyogenic

abscess).

-The abscess is large.

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Portal HTN

Portal venous system contributes 75% of liver blood supply & 72%of O2

spply

. Normal pressure 5-10 mmHg.Causes of portal HTN:Presinusoidal

Extrahepatic

:

Splenic

vein thrombosis ,

Splenomegaly

,

Splenic

A-V fistula

Intrahepatic

:

Schistosomiasis

, Congenital hepatic

fibrosis , Idiopathic portal fibrosis ,

Myeloproliferative

Disorders ,

Sarcoid

2. Sinusoidal :

Intrahepatic

cirrhosis

3. Post sinusoidal

Intrahepatic

: Vascular occlusive disease

Posthepatic

: Budd

Chiari

, CCF ,IVC web , Constrictive

pericarditis

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Schistosomiasis

acute and chronic parasitic disease caused by blood flukes 

exposure to infested water of agricultural, domestic, occupational, and recreational activities.Presentation:abdominal pain, diarrhoea, and bloody stool, hepatomegaly.Dx:detection of parasite eggs in stool or serum antibodies.

Causes

Perisinosoidal

portal HT

Tx:Praziquantel

Single dose 40-70 mg/kg.

Education

Hygiene

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Budd

Chiari

syndrome:

Occlusion of one of the hepatic vv resulting in Congestive Hepatopathy that could be :Primary due to Thrombosis. Secondary due to Compresion ( by tumors).

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Varices

30% of patients with compensated cirrhosis

60% of patients with decompensated cirrhosis 1/3 of all patients with varices will experience variceal bleedingEach episode 20-30% mortality if untreated

70% of patients who survive the initial episode will experience recurrent

haemorrhage

within 2 years

Prevention:

non selective B-blockers .

Prophylactic endoscopic surveillance

and band ligation

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surgical options:

Shunting:

1-Portocaval

2-Mesocaval 3-Distal lienorenal (Warren)Non shunting: 1-Sigiura

2-Liver transplant

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Liver

cysts:

fluid

filled sacs in the liver,barely affect liver function no need for tx unless symptomatic Congenital.Benign cystadenomaPolycystic liver disease

Caroli’s

disease:

Biliary

lithiasis

33%

Cholangitis

Biliary

abscesses

Cholangiocarcinoma

7%

Traumatic:

seromas

,

bilomas

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Hydatid

cyst

Infestatin

by Echinococcus granuloses (mainly affects liver) and Echinococcus multilocularis (mainly affects lung).

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The

hydatid

cyst consists of:

Outer adventitial layer of granulation tissue (pericyst) that represents the host immune response.germinal epithelium (endocyst) produces hydatid fluid Daughter cyst producing (scolices).

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Presentation

:

Asymptomatic

Abdominal pain and heaviness due to hepatomegaly & vomiting Rupture into the biliary tree or peritoneal cavity,causing an acute anaphylactic reaction. secondary infection and biliary obstruction (

psuedostones

) with jaundice.

Chest or pulmonary symptoms may occur

secondary to the coexistence of a

hydatid

cyst in

the lung

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Investigations:

CBC w/ differentials (

eosinophilia

) in 30% of pt.serological tests (IHA, CF, ELISA). The Casoni test.X-ray(calcifications or signet ring), US , CT (thick walled cyst).Management :Hydatid cyst of the liver must be treated surgically.

Albendazole

10 mg/kg/day for 3–6 weeks before

surgery should be given to

sterilise

the cyst.

PAIR method :

Puncture with ultrasound guided needle Aspiration.

installation of alcohol or hypertonic saline as

scolicidal

.

Re-aspiration after leaving the solution for 2 minutes.

Large symptomatic cysts are best managed by complete excision, together with the parasites contained within.

Omentoplasty

for remaining cavity

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Liver Tumors

can be benign or malignant, and primary or secondary.

secondary liver cancer are much more than Primary liver cancer.

Primary tumors may arise from the parenchymal cells, the epithelium of the bile ducts, or the supporting tissues.

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Benign hepatic tumors

Liver Cell Adenoma:

Uncommon. women (20-40 years of age).Risk factors :Pregnancy & OCP use (high estrogen level). The majority present as solitary, well-encapsulated lesions, but malignant transformation has been reported (to HCC).

generally present with right

hypochondrial

pain as a result of hemorrhage within the tumor & could be asymptomatic ..

Superficial tumors may rupture resulting in spontaneous bleeding and present with symptoms of

hemoperitoneum

.

LFTs and serum α-fetoprotein levels are usually normal.

may be detected by USS ,CT, MRI and isotope scan .

Percutaneous

biopsy should be avoided because of the risk of

haemorrhage

.

It's only treated by surgical excision.

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Focal nodular hyperplasia:

more common in females.

generally asymptomatic.

may regress with time or on withdrawal of the contraceptive pill. Do not undergo malignant transformation.Do not require excision unless symptomatic. Hyperplasia can be differentiated from adenoma by

lobulation

and the presence of a central fibrous scar (

stellate

scar), which is

often visible on ultrasound or CT

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Cavernous

Hemangioma

:

most common benign liver tumor and second in prevalence to metastatic tumors of the liver. mostly asymptomatic (small in size).detected on USS : dense hyperechoic lesion, or are found incidentally at laparotomy.

99technetium

labelled

to RBC's is of use for imaging of the tumor with C.T scan.

Heart failure occasionally develops, if there is a large

arteriovenous

communication.

Lesions discovered incidentally at

laparotomy

should be left alone; needle biopsy can be hazardous.

Large symptomatic lesions can be treated with

embolization

, laser therapy or corticosteroids but should only be

resected

by an experienced surgeon.

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Malignant hepatic tumors

Hepatocellular

carcinoma (

hepatoma) 5th common malignancy.common in Africa and the Far East but not the developed world .

Predesposing

factors :

-preexisting cirrhosis (2/3 of pt.)

-hepatitis B or C.

-

hemochromatosis

.

-

aflatoxin

is an important

hepatocarcinogen

.

Late diagnosis.

A

clinicopathological

variant of the tumor is

fibrolamellar

carcinoma, evident in male and females in the age of 20 to 40 years and presents as a single hard

scirrhous

tumour

.

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presentation

: abdominal pain, weight

loss, abdominal distension, fever & spontaneous intraperitoneal hemorrhage. *Jaundice only in advanced cirrhosis. LFTs are generally deranged. serial measurement of α- fetoprotein , CEA & ultrasound scanning can aid in early detection of HCC in susceptible individuals .Othrs: CT, MRI, PET scan and angiography .

Percutaneous

needle aspiration cytology and needle biopsy for histological confirmation should be reserved for patients who are not being considered for hepatic resection (risk of tumor dissemination and hemorrhage).

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Surgery.

Raditherapy

.

Chrmotherapy .Liver transplant.5 year survival rate is less than 10%.

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Cholangiocarcinoma

:

adenocarcinoma

of the biliary tree :Intrahepatic :in the small bile ducts within the liver, (less than 10% )Exrahepatic

:

Perihilar

cholangiocarcinoma

(

Klatskin

tumor) . 50%

distal

cholangiocarcinoma

.

Presentation: Jaundice, pain and

hepatomegaly

.

RF: chronic parasitic infestation of the

biliary

tree

choledochal

cysts (

caroli

disease).

Ulcerative colitis

sclerosing

cholangitis

hemochromatosis

.

although there may be coexisting

biliary

infection causing the tumor to masquerade as a hepatic abscess.

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Thank you