Pr. Dr. Ayman Reda

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Pr. Dr. Ayman Reda
GENERAL SURGERY DEPARTMENT

• LIVER DISEASE

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Liver function tests

• TB
• DB
• Alk. Ph.
• AST
• ALT
• ALB.
• PT

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Imaging the liver

• Imaging modality
  Principal indication
• Ultrasound
  Standard first-line
  investigation
• Spiral CT
  Anatomical planning for liver
  surgery
• MRI
  Alternative to
  spiral CT
• MRCP
  Non-invasive cholangiography
• ERCP
  Imaging the biliary tract when endoscopic
• 
  intervention is anticipated (e.g. ductal
  stones)
• PTC Biliary
  tract imaging when ERCP impossible or failed
• Angiography
  To detect vascular involvement by tumour
• Nuclear medicine To quantify
  biliary excretion and tumour spread
• Laparoscopy laparoscopic ultrasound
• To detect peritoneal tumour
  spread and superficial liver metastases

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Pyogenic Abscess

• Aetiology The aetiology of a pyogenic liver
  abscess is unexplained in the majority of
  patients.
• A)sourse
• 1-biliary tree 2-portal vain 3-artirial
  4-direct extension
• B) PF It has an increased incidence in the
  elderly, diabetics and the immunosuppressed.
• C) Organisms most common organisms are
  Streptococcus milleri and Escherichia coli, but
  other enteric organisms such as Streptococcus
  faecalis, Klebsiella and Proteus vulgaris also
  occur, and mixed growths are common
• Clinical features
• Fever, jaundice, and right upper quadrant pain
  and tenderness.
• Ultrasound and CT are the mainstays in
  diagnostic modalities for hepatic abscess.
• Differentiating pyogenic abscess from other
  cystic infective diseases of the liver such as
  amebic abscess or echinococcal cyst is important
  because of differences in treatment.
• Treatment by antibiotics and precautious derange
  .
• First-line antibiotics to be used are a
  penicillin, aminoglycoside and metronidazole or a
  cephalosporin and metronidazole.
• Percutaneous drainage without ultrasound guidance
  should be avoided as an empyema may follow
  drainage through the pleural space.
• A source for the liver abscess should be sought,
  particularly from the colon.
• Atypical clinical or radiological findings
  should raise the possibility of a necrotic
  neoplasm.

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Amebic Abscess

• Etiology Entamoeba Hhistolytica
• A) Sourse portal vain , Rt Colon
• B) pathology liquefaction necrosis of the liver,
  producing a cavity full of blood and liquefied
  liver tissue. The appearance of this fluid is
  typically described as anchovy sauce, and the
  fluid is odorless unless secondary bacterial
  infection has taken place.
• Clinical features
• Fever low grade , anorexia, history of dysentery,
  and right upper quadrant pain and tenderness.
• Ultrasound and CT are the mainstays in diagnostic
  modalities for hepatic abscess.
• Stool .
• Treatment metronidazole (750 mg orally three
  times per day for 10 days), which is curative in
  over 90 of patients.

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Hydatid Cyst

• Hydatid disease or echinococcosis is a zoonosis
  that caused by echinochococus granulosus and
  occurs primarily in sheep( inermediat
  host)-grazing areas of the world but is common
  worldwide because the dog is a definitive host.
• Human is blinded host ,infected by eating
  vegetables contaminated with egg ,or plying with
  dogs
• Echinococcosis is endemic in Mediterranean
  countries, the Middle East, the Far East, South
  America, Australia, New Zealand, and East Africa.
  Humans contract the disease from dogs, and there
  is no human-to-human transmission.

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Pathology

• Three weeks after infection, a visible hydatid
  cyst
• develops that then slowly grows in a spherical
  manner.
• A pericyst, a fibrous capsule derived from
• host tissues, develops around the hydatid cyst.
• The cyst wall itself has two layers,
• an outer laminated membrane (ectocyst) and
• an inner germinal membrane (endocyst).
• Brood capsules are small intracystic cellular
  masses in which future worm heads develop into
  scoleces. In a definitive host the scoleces would
  develop into an adult tapeworm, but in the
  intermediate host they can only differentiate
  into a new hydatid cyst.
• Freed brood capsules and scoleces are found in
  the hydatid fluid and form the so-called hydatid
  sand. Daughter cysts are true replicas of the
  mother cyst.
• Hydatid cysts can die with degeneration of the
  membranes, development of cystic vacuoles, and
  calcification of the wall. Calcification of a
  hydatid cyst, however, does not always imply that
  the cyst is dead.

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Clinical picture

• About three fourths of hydatid cysts are located
  in the right liver and are singular.
• The clinical presentation of a hydatid cyst is
  largely asymptomatic until complications occur.
• The most common presenting symptoms are abdominal
  pain, dyspepsia, and vomiting. The most frequent
  sign is hepatomegaly. Jaundice and fever are each
  present in about 8 of patients
• Infection of a hydatid cyst can occur and present
  like a pyogenic abscess.
• Rupture of the cyst into the biliary tree or
  bronchial tree or free rupture into the
  peritoneal, pleural, or pericardial cavities can
  occur. Free ruptures can result in disseminated
  echinococcosis and/or a potentially fatal
  anaphylactic reaction.

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INVESTIGATION

• In cases of diagnostic uncertainty a battery of
  serologic tests are available to evaluate
  antibody response. casoni, enzyme-linked
  immunosorbent assay (ELISA). HA,CF.
• Ultrasound is most commonly used worldwide for
  the diagnosis of echinococcosis because of its
  availability, affordability, and accuracy.
• Calcifications in the wall of the cyst are highly
  suggestive of hydatid disease and can be helpful
  in the diagnosis
• CT or MRI.
• In patients with suspected biliary involvement,
  ERC.

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Treatment

• Surgical (exept-in patients with small,
  asymptomatic, calcified ,non growing cysts,
  conservative management is appropriate.)
• The surgical options range from liver resection
  or local excision of the cysts to de-roofing with
  evacuation of the contents.
• Precaution preoperative corticosteroids have
  been recommended but are not universally used.
  The anesthesiologist should have epinephrine and
  corticosteroids available for the potential of an
  anaphylactic reaction. Packing off of the abdomen
  is important because rupture can result in
  anaphylaxis and diffuse seeding. Usually the cyst
  is then aspirated through a closed suction system
  and flushed with a scolicidal agent such as
  hypertonic saline. When bile duct communication
  is diagnosed at operation or preoperatively, it
  must be meticulously searched for. Simple suture
  repair is often sufficient, but major biliary
  repairs or approaches through the common bile
  duct may be necessary.
• Albendazol

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NEOPLASMS

• Benign Neoplasms
• Liver cell adenoma (LCA) is a relatively rare
  benign proliferation of hepatocytes in the
  context of a normal liver. It is predominantly
  found in young women (aged 20 to 40), and long
  term use of oral contraceptive dramatically
  increases the incidence of this tumor.
• Angiography will demonstrate a well
  developed peripheral arterialisation of the
  tumour. Confirmation of the nature of these
  lesions is required by either percutaneous biopsy
  or resection with histological confirmation.
  These tumours are thought to have malignant
  potential, and resection is therefore the
  treatment of choice.
• Focal nodular hyperplasia (FNH) is the second
  most common benign tumor of the liver and is
  predominantly discovered in young women. FNH is
  usually a small (lt5 cm) nodular mass arising in a
  normal liver that involves the right and left
  liver equally. The mass is characterized by a
  central fibrous scar with radiating septa,
  although no central scar is seen in about 15 of
  cases

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• Hemangioma
• Hemangioma is the most common benign tumor of the
  liver. It occurs in women more commonly than men
  (31 ratio) and at a mean age of about 45.
• Small capillary hemangiomas are of no clinical
  significance, whereas the larger cavernous
  hemangiomas more often come to the attention of
  the liver surgeon
• Cavernous hemangiomas have been associated with
  FNH and are considered congenital vascular
  malformations.
• Enlargement of hemangiomas is by ectasia rather
  than neoplasia. The tumors are usually singular,
  are less than 5 cm in diameter, and occur equally
  in the right and left liver.
• Lesions greater than 5 cm are arbitrarily called
  giant hemangiomas. Involution or thrombosis of
  hemangiomas can result in dense fibrotic masses
  that may be difficult to differentiate from
  malignancy

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Presentation

• Most commonly, hemangiomas are asymptomatic and
  incidentally found.
• Large compressive masses may cause vague upper
  abdominal symptoms.
• Rapid expansion or acute thrombosis can, on
  occasion, cause symptoms. Spontaneous rupture of
  liver hemangiomas is exceedingly rare.
• An associated thrombocytopenia and consumptive
  coagulopathy Kasabach-Merritt syndrome .

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Investigation I of liver mass

• Adenoma homogeneous and hyperintense on T1- or
  T2-weighted magnetic resonance imaging (MRI) or
  CT, but 1020 have hemorrhagic areas, making
  appearance heterogeneous
• Hemangioma early peripheral enhancement with
  intravenous (IV) contrast on CT with delayed
  contrast enhancement due to small vessel uptake
  in the haemangioma., MRI, or tagged red cell scan
• Focal nodular hyperplasia CT or MRI shows
  stellate scar and enhancement with IV contrast
  Again, these appearances are not specific for
  focal nodular hyperplasia (FNH). A sulphur
  colloid liver scan may be useful.
• Cysts hypointense or water density on
  ultrasound, CT, or MRI with no septations

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• An asymptomatic patient with a secure diagnosis
  can therefore be simply observed.
• Symptomatic patients should undergo a thorough
  evaluation looking for alternative explanations
  for the symptoms but are candidates for resection
  if no other cause is found.
• Rupture, change in size, large and development
  of the Kasabach-Merritt syndrome are indications
  for resection

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Primary Hepatic Malignant Tumor

• Tumors include angiosarcoma, hepatoblastoma,
  hepatic adenocarcinoma,
• intrahepatic cholangiocarcinoma

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Hepatocellular Carcinoma

• A large number of associations between hepatic
  viral infections, environmental exposures,
  alcohol use, smoking, genetic metabolic diseases,
  cirrhosis , and the development of HCC have been
  recognized.
• Spread local ,lymphatic ,blood
• Most commonly, patients presenting with HCC are
  men 50 to 60 years of age who complain of right
  upper quadrant abdominal pain, weight loss, and a
  palpable mass.
• Ultrasound plays a significant role in screening
  and early detection of HCC, but definitive
  diagnosis and treatment planning usually rely on
  CT and/or MRI. Early arterial phase enhanced
  spiral CT scan and contrast MRI are the most
  useful investigations that are currently
  available.
• HCC take advantage of the hypervascularity of
  these tumors, and both imaging and enhancement
  patterns are critical

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Diagnosis
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Assessment

• Once the diagnosis of HCC has been made, an
  effort to stage the tumor must be made to develop
  an appropriate treatment plan.
• Most patients with HCC have two diseases, and
  survival is as much related to the tumor as it is
  to cirrhosis. Staging, therefore, includes an
  extent of disease work-up as well as an extent
  of cirrhosis work-up.
• In assessing the extent of disease, the common
  sites of metastases must be considered.
• Assessment of liver function is absolutely
  critical in considering treatment options for a
  patient with HCC.
• Staging laparoscopy has been employed as a
  staging tool in HCC

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Treatment

• Liver resection is considered the treatment of
  choice for HCC, and the risk of postoperative
  liver failure and/or death must be considered.
• Other successful treatments are available for
  HCC, such as ablative techniques, embolization
  techniques, and liver transplant therefore, a
  complete assessment of tumor and liver function
  must ensue.
• Methods of treatment
• Surgical Resection
• liver transplant
• Ablative
• Ethanol injection Acetic acid injection
• Thermal ablation
• Embolization Chemoembolization
• Radiotherapy
• Combination transarterial/ablative
• External beam radiation
• Systemic Chemotherapy Hormonal therapy
  Immunotherapy

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Metastatic Tumors

• Most common tumors of the liver 90 with
  extrahepatic metastases
• 20 of patients with metastatic colon cancer have
  metastasis to the liver
• Symptoms and signs include weight loss,
  fatigue, fevers, right upper quadrant pain
• Portography (or use of MRI) improves on
  sensitivity of CT for masses in liver
• history and physical examination, CT with
  portography,MRI if CT is nondiagnostic

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Surgical Complications of Portal Hypertension

• Causes include prehepatic , hepatic ,
  posthepatic
• Eg,cirrhosis, congenital hepatic fibrotic
  disorders,Budd-Chiari syndrome.
• Bleeding gastroesophageal varices are most
  important complication varices are related to
  degree of liver dysfunction
• Symptoms and signs include hematemesis, melena,
  jaundice,
• Encephalopathy
• Ultrasound shows dilated portal vein, possible
  thrombosis of portal vein or hepatic veins
• Esophagogastroscopy for diagnosis of varices

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Portosystemic collateral pathways
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Child-Pugh Criteria for Hepatic Functional Reserve

• Child-Pugh Criteria for Hepatic Functional
  Reserve
• Clinical and Laboratory Measurement
• Modified
• Grade A, 5 and 6 grade B, 79 grade C, 1015.

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Treatment

• During the attack of bleeding Hospitalization
  ,resuscitation ,prevention of encephalopathy
  ,correct coagulation defeset and stop bleeding by
  
• Sclerotherapy or banding of varices (by
  esophagogastroscopy),or
• Sengstaken-Blakemore tube placement,or
• TIPSS or
• Surgery
• In elective
• Surgery liver transplantation surgical
  portosystemic shunt (TIPSS vs total vs partial vs
  selective shunt ) or splenictomy
  devascularization
• Surgical shunt is indicated for Childs A
  (selective) or (partial)
• Medications ß-blockers, nitrates, vasopressin,
  octreotide (somatostatine) (during bleeding)
• Complications encephalopathy (for shunts),
  hemorrhage, shunt thrombosis survival is related
  to MELD (Model for End-Stage Liver Disease) or
  Child clasification

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Transjugular Intrahepatic Portosystemic Shunting
TIPSS
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Nonselective portosystemic shunts either
immediately or eventually divert all portalblood
flow from the liver into the systemic venous
circulation. Shown are the four main
variants(a) end-to-side portacaval shunt, (b)
side-to-side portacaval shunt, (c) interposition
shunt (portacaval1, mesocaval 2, and
mesorenal 3), and (d) conventional (proximal)
splenorenal shunt.
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The distal splenorenal shunt diverts portal flow
from the spleen and short gastricveins into the
left renal vein. The DSRS provides selective
shunting by preserving portal flowfrom the
mesenteric circulation. Potential sites of
collateralization (e.g., the left gastric
vein,the gastroepiploic vein, and the umbilical
vein) are routinely interrupted to
preservehepatopedal portal flow.
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By extensively devascularizing the
esophagogastric junction, this procedure may
provide a means of interrupting esophagogastric
varices without portosystemic shunting.
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Splenic Vein Thrombosis

• Upper GI hemorrhage with evidence of gastric
  varices without esophageal varices history of
  pancreatic or gastric disease isolated
  thrombosis in the splenic vein, diverting the
  splenic venous outflow to the short gastric
  vessels as collaterals
• 50 of cases are due to pancreatitis or
  pancreatic pseudocyst pancreatic cancer with
  splenic vein invasion is the second most common
  cause
• Symptoms and signs include upper GI hemorrhage,
  possible splenomegaly
• Gastroscopy shows bleeding as evidence of
  gastric varices, without evidence of esophageal
  varices also perform upper GI endoscopy

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Treatment of Splenic Vein Thrombosis

• Splenectomy is curative and indicated in all
  cases
• Even if patient is asymptomatic and has not
  experienced upper GI bleeding, splenectomy should
  be performed electively