Liver lesion SARAH AWAISHEH, BAU - PowerPoint Presentation

Slide1

Liver lesion

SARAH AWAISHEH, BAU

Slide2

Liver anatomy

It is the largest abdominal organ

1500g 

ribs & cc’s (6-10 on 

R

, 6 & 7 on 

L

)

Two lobes



Cantle’s line

Two surfaces :

                 

-

Diaphragmatic surface



‘bare area’ of the liver

                   -  Visceral surface



With the exception of the fossa of the gallbladder and porta hepatis, it is covered with peritoneum.

Slide3

Liver anatomy

Protected by rib cage

Glisson’s capsule

8 ligaments :

Coronary ligament : anterior and posterior fold

Triangular ligament : right and left

Falciform

ligament :Sickle-shaped

Ligamentum

teres

Ligamentum

venosum

Lesser

omentum

:

hepatogastric

ligament, hepatoduodenal ligament 

Slide4

Slide5

Liver anatomy

Hepatic artery 25%

Dual supply :

Portal vein 75%



72% of the Oxygen

venous drainage by the right, middle and left hepatic veins

 

Slide6

physiological functions

Production of :plasma

protiens

and coagulation factors.

Fat soluble vitamins metabolism

storage of :

protiens

(A.A), glucose(glycogen), fat(

cholestrol

) Detoxification

Slide7

Portal Hypertension:

sustained elevation of venous portal pressure more than 10 mmHg (15-20 mmHg )

Normal pressure 5-10 mmHg

There are 6 potential routes of portal –systemic collateral blood flow (

ares

of communication):

Slide8

Region

Name of clinical condition

Portal circulation

Systemic circulation

Esophageal

Esophageal varices

Esophageal branch of 

left gastric vein

Esophageal branches of 

azygos vein

Rectal

Rectal varices

Superior rectal vein

Middle rectal veins

 and 

inferior rectal veins

Paraumbilical

Caput medusae

Paraumbilical veins

Superficial epigastric vein

Retroperitoneal

Splenorenal shunt

[3]

Splenic vein

Renal vein

, 

suprarenal vein

, 

paravertebral vein

, and 

gonadal vein

(no clinical name)

[4]

Right colic vein

, 

middle colic vein

, 

left colic vein

Retroperitoneal veins of Retzius

Intrahepatic

Hepatic pseudolesions

[5]

Perihepatic veins of Sappey

Superior epigastric vein

Patent ductus venosus

Left branch of portal vein

Inferior vena cava

Slide9

Etiology:

1.

Presinusoidal

Extrahepatic : Intrahepatic :

Splenic vein thrombosis Schistosomiasis (Egypt )

Splenomegaly Congenital hepatic fibrosis

Splenic A-V fistula Idiopathic portal fibrosis

Myeloproliferative disorders

scardiosis

Slide10

etiology…

2. Sinusoidal

3. Post sinusoidal

Posthepatic

Intrahepatic

Budd Chiari

Cardiac cirrhosis

IVC web

Congestive

Hepatopathy Primary Thrombosis Secondary Compresion

Slide11

signs & symptoms

Splenomegaly

esophageal

varice

Caput medusa

Hemorrhoids

spider

angioma

, palmer erythema

Ascitisasteraxis

(hepatic flap)

fetor

hepaticus

Jaundice

confusion and drowsiness

Slide12

signs & symptoms…

esophageal varices :

30% of patients with compensated cirrhosis

60% of patients with decompensated cirrhosis

(development of jaundice, ascites, variceal hemorrhage, or hepatic encephalopathy )

1/3 of all patients with varices will experience variceal bleeding

Each episode 20-30% mortality if untreated

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

haemorrhage

within 2 years

Slide13

esophageal varices

Slide14

Treatement

of esophageal varices :

Management can be divided into :

the active bleeding episode,

the prevention of

rebleeding

,

the prophylactic measures to prevent the first hemorrhage

Slide15

Initial management of active bleeding episode

I.Resuscitation

:

IV line insertion ( 2 large bore cannulas) and IV fluid

Admission to ICU

Obtain blood for grouping and

crossmatching

(blood transfusion without over transfusion just until hemoglobin 9)

Correct coagulopathy: use fresh frozen plasma /Platelets/ coagulation factors Antibiotics

Vasopressin

(octreotide) / IV

II. Urgent endoscopy: both diagnostic and therapeutic (Variceal banding / Injection sclerotherapy)

Slide16

If initial attempt failed

Blackmore-

Sengstaken

tube

for temporary blood bleeding control

four ports

1- for gastric aspiration

2- for gastric balloon ( 500 ml)

3- for esophageal balloon (200 ml) 4- for esophageal aspiration prevent aspiration pneumonia

do not leave it in situ for more than 24-36 h (risk of perforation and necrosis)

Slide17

▪

Transjagular

intrahepatic

portocaval

shunt

(TIPS): an expandable covered metal shunt

Used when bleeding cannot be stopped after 2 sessions of endoscopic therapy within 5 days.

Advantages: it reduces the portal vein pressure by creating a total shunt and doesn’t have the risk of general anesthesia and surgery.

Disadvantages: increased risk of portosystemic encephalopathy.

Slide18

▪ Surgical shunt:

Shunting:

Portocaval

(increase incidence of encephalopathy)

Mesocaval

stent

Distal lienorenal (Warren) (most used

Non shunting: Sigiura ( bleeding uncontrollable)

Liver transplant

Slide19

Schistosomiasis

parasitic disease caused by blood flukes

exposure to infested water

Presentation: abdominal pain,

diarrhea,

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

Slide20

Liver Abscess

mass filled with pus inside the liver

Classified 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

Slide21

Amebic abscess

Entamoeba histolytica enter mesenteric venules.

travel to the liver where they typically form one or more abscesses.

The right lobe of the liver is more commonly affected than the left lobe.

amebic abscess have characteristic chocolate appearance.

Slide22

Investigation:

CBC,LFT, Direct and indirect serological tests (CF, IHA and ELISA) to detect amoebic protein, stools examination for amebae trophozoites or cysts.

Imaging:

USS and CT: usually large, solitary, thin-walled, poorly defined abscess in the right lobe.

Slide23

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.