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Hepatobiliary Disease

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Text of Hepatobiliary Disease

  • Advisor : dr. Sjaiful Bachri, SpB

    Melissa L. Thenata

    Fakultas Kedokteran Universitas Tarumanagara

  • Liver Structure

    Largest gland in the body

    (1.5 Kg)

    Under the diaphragm, within

    the rib cage in the upper

    right quadrant of the

    abdomen

  • Liver Structure

    4 lobes: major (left and right),

    minor (caudate and quadrate)

    Ducts: common hepatic, cystic

    from gall bladder, common bile

    choledochus (join pancreatic

    duct at hepatopancreatic

    ampulla)

  • Liver Structure

    Liver lobules hexagonal structures consisting of hepatocytes

    Hepatocytes radiate outward from a central vein

    At each of the six corners of a lobule is a portal triad

    Liver sinusoids

  • Liver Structure

    Hepatocytes produce bile

    Bile flows through canals

    called bile canaliculi to a

    bile duct

    Bile ducts leave the liver

    via the common hepatic

    duct

  • Liver Function

    Regulating homeostasis of carbohydrate, lipid and amino

    acid metabolism.

    Storing nutrients such as glycogen, fats and vitamin B12, A

    and K.

    Producing and secreting plasma proteins and lipoproteins,

    including clotting factors and acute phase proteins.

  • Liver Function

    Synthesizing and secreting bile salts for lipid digestion.

    Detoxifying and excreting bilirubin, other endogenous waste

    products and exogenous metal ions, drugs and toxins

    (xenobiotics).

    Clearing toxins and infective agents from the portal venous

    blood whilst maintain systemic immune tolerance to antigens

    in the portal circulation.

  • Gall Bladder Structure

    Thin-walled green muscular sac

    On the inferior surface of the liver

    Stores bile that is not immediately needed for digestion

    When the muscular wall of the gallbladder contracts bile is

    expelled into the bile duct

  • Gall Bladder Structure

  • Gall Bladder Function

    Stores 60 mL of bile, released when food containing fat

    enters the digestive tract.

    The bile, produced in the liver, emulsifies (breaks down) fats

    and neutralizes acids in partly digested food.

  • Biliary Atresia

    Obliteration or discontinuity of the extrahepatic biliary system,

    resulting in obstruction to bile flow, in the first few weeks of life.

    Inflammatory process from an unknown cause affects the bile duct

    in the newborn infant.

    Destruction of the extrahepatic bile ducts, causing obstructive

    jaundice and liver failure.

    Kasai procedure, surgical correction of this abnormality before 8

    weeks of age produces the best outcome.

  • Choledochal Cyst

    Cystic dilatation of the intra- or extrahepatic ducts is a rare

    condition, usually presenting before the age of 16 years.

    Symptoms : cholangitis, pancreatitis, stone formation and jaundice.

    Infants may occasionally present with an abdominal mass.

    The cause of this condition is debated.

  • Choledochal Cyst

    Cysts are classified according

    to their site and shape,

    although 80% are fusiform

    abnormalities of the

    extrahepatic bile duct. Type

    II cysts are extremely rare.

  • Choledochal Cyst

    Treated by surgical excision

    of the cyst with the

    formation of a roux-en-Y

    anastomosis to the biliary

    duct.

  • Hepatobiliary Trauma

    The liver is the most commonly injured solid abdominal organ,

    despite its relative protected location.

    Treatment of traumatic liver injuries is based on patient

    physiology, mechanism and degree of injury, associated

    abdominal and extra-abdominal injuries and local expertise.

  • Hepatobiliary Trauma

    Liver Organ Injury Scale

    Grade Description

    I Hematoma Subcapsular,

  • Hepatobiliary Trauma

    Liver Organ Injury Scale

    Grade Description

    IV Hematoma Parenchymal disruption involving 25% - 75% of hepatic lobe or 1-3 Couinaud segments within a single lobe

    V Laceration Parenchymal disruption involving >75% of hepatic lobe >3 Couinaud segments within a single lobe

    Vascular Juxtahepatic venous injuries; ie. Retrohepatic vena cava/central major hepatic vein

    VI Hepatic avulsion

  • Management of Hepatic Trauma

  • Gall Bladder Cancer

    Highly aggressive malignancy, usually presents at an advanced,

    incurable stage, 5th most common gastrointestinal tumor

    The median survival is less than 6 months after diagnosis

    Women : Men = 2 6 : 1

    The incidence steadily increases with age

    Risk factor : obesity, a high-carbohydrate diet, smoking, and

    alcohol use

  • Gall Bladder Cancer

    Gall bladder cancer arises in the setting of chronic

    inflammation. In the vast majority of patients (>75%), the

    source of this chronic inflammation is cholesterol gallstones.

    10-25% is caused by calcification of the gallbladder (porcelain

    gallbladder)

    Most common type of gallbladder cancer is adenocarcinoma.

    Gallbladder cancer can spread by direct invasion through the

    gallbladder wall into the liver or peritoneal cavity.

  • Gall Bladder Cancer

    The symptoms of gallbladder cancer overlap with the

    symptoms of gallstones and biliary colic. Abdominal pain may

    be of a more diffuse and persistent nature than the classic

    right upper quadrant pain of gallstone disease.

    Jaundice, anorexia, and weight loss often indicate more

    advanced disease.

  • Gall Bladder Cancer

    Table 2. Summary of the Tumor-Node-Metastasis (TNM) Staging System*

    Stage Description

    1

    2

    3

    4A

    4B

    Mucosal or muscular invasion (T1N0M0)

    Perimuscular-tissue invasion (T2N0M0)

    Transmural invasion, liver invasion < 2 cm; lymph node metastasis to

    hepatoduodenal ligament (T3N0M0, T13 N1M0)

    Liver invasion > 2 cm (T4N0M0, T4N1M0)

    Distant nodal (outside porta hepatis) or hematogenous metastasis

    (TxN2M0, TxNxM1)

  • Gall Bladder Cancer

    The work-up for right-upper-quadrant pain or biliary colic

    generally starts with an ultrasound examination of the

    gallbladder.

    Laboratory tests should include liver function tests and

    hematocrit. Advanced cases may demonstrate anemia and

    elevated alkaline phosphatase and bilirubin.

    Tumor markers, CEA and CA 19-9, may be of help and should

    be considered if gallbladder cancer is suspected.

  • Gall Bladder Cancer

    Further radiologic work-up such as CT-scan, MRI, or needle

    biopsy are indicated if gallbladder cancer is suspected.

    The most common and most effective treatment is surgical

    removal of the gallbladder (cholecystectomy) with part of liver

    and lymph node dissection.

    Chemotherapy has not shown significant activity in gallbladder

    carcinoma. Typically, 5-fluorouracil (5-FU) has been used with

    response rates of 10-24% in advanced disease.

  • Gall Bladder Cancer

    Gemcitabine has shown activity in gallbladder cancer. There is

    an increased response rate with gemcitabine combination with

    cisplatinum and capecitabine.

    Currently, no clearly defined standard exists for chemotherapy

    in gallbladder cancer. Patients should be encouraged to

    participate in clinical trials.

  • Cholangiocarcinoma

    Cholangiocarcinomas are malignancies of the biliary duct system

    that may originate in the liver and extrahepatic bile ducts, which

    terminate at the ampulla of Vater.

    The etiology of most bile duct cancers remains undetermined.

    However, one of the most commonly recognized risk factors is

    primary sclerosing cholangitis.

    Cholangiocarcinoma arises from the intrahepatic or extrahepatic

    biliary epithelium. More than 90% are adenocarcinomas.

  • Cholangiocarcinoma

    Cholangiocarcinomas tend to grow slowly and to infiltrate the

    walls of the ducts, dissecting along tissue planes.

    Local extension occurs into the liver, porta hepatis, and regional

    lymph nodes of the celiac and pancreaticoduodenal chains.

    Symptoms of cholangiocarcinoma include jaundice, clay-colored

    stools, bilirubinuria (dark urine), pruritus, weight loss, and

    abdominal pain.

  • Cholangiocarcinoma

    The diagnosis and staging of cholangiocarcinoma require a

    multimodality approach involving laboratory, radiologic,

    endoscopic, and pathologic analysis.

    The most studied serum tumor markers are the CA 19-9, is

    currently the most commonly used tumor marker for

    cholangiocarcinoma.

    Surgical resection with curative intent is the treatment of

    choice for extrahepatic cholangiocarcinoma.

  • Gallstones

    Two major types of gallstones: cholesterol and

    pigment stones. Cholesterol gallstones contain50%

    cholesterol monohydrate. Pigment stones have 20%

    cholesterol and are composed primarily of calcium

    bilirubinate.

    Predisposing factors include demographic/genetics,

    obesity, weight loss, female sex hormones, age, ileal

    disease, pregnancy, type IV hyperlipidemia, and

    cirrhosis.

  • Gallstones

    Many gallstones are

    silent. Symptoms occur

    when stones p

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