LIVER. HISTOLOGY PORTAL VEIN CENTRAL VEIN HEPATIC ARTERY BILE DUCT ZONE 1 ZONE 2 ZONE 3

LIVERLIVER

HISTOLOGYHISTOLOGY

PORTAL VEIN

CENTRAL VEIN

HEPATIC ARTERY

BILE DUCT

ZONE 1

ZONE 2

ZONE 3

LIVER FUNCTIONLIVER FUNCTION

SYNTHESISSYNTHESIS Albumin, clotting factors, fibrinogen, complement, Albumin, clotting factors, fibrinogen, complement,

alpha1-antitrypsisnalpha1-antitrypsisn

ENZYME PRODUCTIONENZYME PRODUCTION AST, ALT, GT, Alk phosAST, ALT, GT, Alk phos

DETOXIFICATIONDETOXIFICATION METABOLISE DRUGSMETABOLISE DRUGS BILE PRODUCTIONBILE PRODUCTION

CLASSIFICATION OF JAUNDICECLASSIFICATION OF JAUNDICE

PRE-HEPATICPRE-HEPATIC heamolysisheamolysis

INTRA-HEPATICINTRA-HEPATIC hepatitis, cirrhosis, congenital hepatitis, cirrhosis, congenital

hyperbiliruniaemiahyperbiliruniaemia

POST-HEPATICPOST-HEPATIC gallstones, tumours, strictures, gallstones, tumours, strictures,

biliary atresiabiliary atresia

Unconjugated bilirubin

Conjugated bilirubin (water soluble)

CAUSES OF LIVER DISEASECAUSES OF LIVER DISEASE

TOXINS

ORGANISMS

GALLSTONESTUMOURS

TYPES OF LIVER DISEASETYPES OF LIVER DISEASE

ACUTE (cell necrosis + inflammation)ACUTE (cell necrosis + inflammation) virus, alcohol, drugs, gallstonesvirus, alcohol, drugs, gallstones

CHRONIC (continued inflammation)CHRONIC (continued inflammation) chronic hepatitis (viruses, alcohol, drugs, chronic hepatitis (viruses, alcohol, drugs,

autoimmune)autoimmune) iron overload (Haemochromatosis)iron overload (Haemochromatosis) Wilson’s diseaseWilson’s disease alpha1-antitrypsin deficiencyalpha1-antitrypsin deficiency

CLINICOPATHOLOGICAL FEATURESCLINICOPATHOLOGICAL FEATURES

MALAISEMALAISE HEPATOMEGALYHEPATOMEGALY JAUNDICEJAUNDICE RAISED BILIRUBINRAISED BILIRUBIN RAISED TRANSAMINASESRAISED TRANSAMINASES

RECOVERYRECOVERY LIVER FAILURE - LIVER FAILURE - if severeif severe CHRONIC DISEASECHRONIC DISEASE

ASYMPTOMATICASYMPTOMATIC

CIRRHOSISCIRRHOSIS PORTAL PORTAL

HYPERTENSIONHYPERTENSION oesophageal varicesoesophageal varices

LIVER FAILURELIVER FAILURE oedema, ascities, oedema, ascities,

comacoma HEPATOMAHEPATOMA

ACUTE CHRONIC

CIRRHOSIS - MORPHOLOGYCIRRHOSIS - MORPHOLOGY

MICRONODULAR <3MM

(commonest cause is alcohol)

MACRONODULAR >3MM

(greater risk of carcinoma)

Diffuse HepatomegallyDiffuse Hepatomegally

InflammationInflammation Parasite------hydatidParasite------hydatid Protozoal -------- amaobic, kala azarProtozoal -------- amaobic, kala azar Pyogenic ---- pyogenic liver abcessPyogenic ---- pyogenic liver abcess Bacterial -----miliary TB , typhoid, Bacterial -----miliary TB , typhoid,

BrucelosisBrucelosis Viral ----- infective hepatitis, yellow feverViral ----- infective hepatitis, yellow fever Spirochetal syphilisSpirochetal syphilis Richetsial ----- typhusRichetsial ----- typhus

Diffuse HepatomegallyDiffuse Hepatomegally Blood diseasesBlood diseases

AnaemiasAnaemias LeukemiasLeukemias LymphomaLymphoma

Liver congestionLiver congestion Budd chiarriBudd chiarri Tricusped stenosisTricusped stenosis Constrictive pericarditisConstrictive pericarditis Right heart failureRight heart failure Veno-occlusive diseaseVeno-occlusive disease

Diffuse HepatomegallyDiffuse Hepatomegally Liver cirrhosisLiver cirrhosis

CardiacCardiac BiliaryBiliary Early stages of othesEarly stages of othes

Liver tumorsLiver tumors HCCHCC SecondariesSecondaries

Metabolic Metabolic Fatty liverFatty liver Gaucher’s (lipoid storage)Gaucher’s (lipoid storage) Von Gierki’s disease ( gycogen storage)Von Gierki’s disease ( gycogen storage) AmyloidosisAmyloidosis

Localized HepatomegallyLocalized Hepatomegally Cystic Cystic

Hydatid liver cystHydatid liver cyst Amoebic liver abscessAmoebic liver abscess

SolidSolid Congenital ------ Riedel’s lobeCongenital ------ Riedel’s lobe TumorsTumors

Benign ----- haemangiomaBenign ----- haemangioma Malignant Malignant

HCCHCC SecondariesSecondaries

Hepatic CystsHepatic Cysts The term hepatic cyst usually refers to The term hepatic cyst usually refers to

solitary non-parasitic cysts of the liver, solitary non-parasitic cysts of the liver, also known as simple cysts. also known as simple cysts.

Most patients with simple cysts are Most patients with simple cysts are asymptomatic and require no treatment. asymptomatic and require no treatment.

When the cysts become large and cause When the cysts become large and cause symptoms such as pain, treatment is symptoms such as pain, treatment is warranted. warranted.

Today, laparoscopic unroofing of large Today, laparoscopic unroofing of large simple cysts has become the preferred simple cysts has become the preferred treatment option.treatment option.

The cause of simple liver The cause of simple liver cystscysts

The cause of simple liver cysts is The cause of simple liver cysts is unknown, but cysts are believed to be unknown, but cysts are believed to be congenital in origin. congenital in origin.

The cysts are lined by biliary-type The cysts are lined by biliary-type epithelium and perhaps result from epithelium and perhaps result from progressive dilatation of biliary progressive dilatation of biliary microhamartomas. microhamartomas.

Because liver cysts seldom contain bile, Because liver cysts seldom contain bile, the current hypothesis is that the the current hypothesis is that the microhamartomas fail to develop normal microhamartomas fail to develop normal connections with the biliary tree. connections with the biliary tree.

DD of cystic lesionsDD of cystic lesions Congenital Congenital

Simple cystsSimple cysts multiple cysts arising in the setting of multiple cysts arising in the setting of

congenital polycystic liver diseasecongenital polycystic liver disease Traumatic Traumatic

HematomaHematoma BilomaBiloma

Parasitic or hydatid (echinococcal) cysts Parasitic or hydatid (echinococcal) cysts Abscesses.Abscesses.

PyogenicPyogenic Amoebic Amoebic

Cystic tumorsCystic tumors Benign Benign malignantmalignant

liver cystsliver cysts

Simple cystsSimple cysts generally cause no symptoms generally cause no symptoms or produce right upper quadrant pain and or produce right upper quadrant pain and have a typical radiographic appearance. have a typical radiographic appearance.

Polycystic liver diseasePolycystic liver disease can arise in can arise in childhood or adult life as part of a childhood or adult life as part of a congenital disorder associated with congenital disorder associated with polycystic kidney disease. polycystic kidney disease.

Hydatid cystsHydatid cysts are caused by infection with are caused by infection with the tapeworm the tapeworm Echinococcus granulosus.Echinococcus granulosus.

Liver AbscessLiver Abscess

Portal vein

Hepatic artery

Biliaryumbilicus

Direct byEmpyema thoracisSubphrenic abcessPenetrating lesioncholecystitis

Empyema thoracis

Subphrenic abcess

Penetrating lesion

cholecystitis

Pyogenic liver abscess Pyogenic liver abscess (Etiology) (Etiology) Biliary disease Biliary disease

Biliary disease accounts for 21-30% of Biliary disease accounts for 21-30% of reported casesusually reported casesusually

Associated with choledocholithiasis, Associated with choledocholithiasis, Benign and malignant tumors, Benign and malignant tumors, Postsurgical strictures. Postsurgical strictures. Biliary-enteric anastomoses Biliary-enteric anastomoses

Infection via the portal system Infection via the portal system (portal pyemia)(portal pyemia)

Hematogenous (via the hepatic Hematogenous (via the hepatic artery)artery)

No evident causeNo evident cause

MicrobiologyMicrobiology::

The most common microorganisms The most common microorganisms isolated from blood and abscess isolated from blood and abscess cultures are as follows: cultures are as follows: Escherichia coliEscherichia coli - 33% - 33% Klebsiella pneumoniaeKlebsiella pneumoniae - 18% - 18% BacteroidesBacteroides species - 24% species - 24% Streptococcal species - 37% Streptococcal species - 37% Microaerophilic streptococci - 12%Microaerophilic streptococci - 12%

Pyogenic liver abscessPyogenic liver abscess The right hepatic lobe is affected more The right hepatic lobe is affected more

often than the left by a factor of 2:1. often than the left by a factor of 2:1. Bilateral involvement is seen in 5% of Bilateral involvement is seen in 5% of

cases. cases. The predilection for the right lobe can be The predilection for the right lobe can be

attributed to anatomic considerations. attributed to anatomic considerations. The right hepatic lobe receives blood from The right hepatic lobe receives blood from

both the superior mesenteric and portal veins.both the superior mesenteric and portal veins. whereas the left lobe receives inferior whereas the left lobe receives inferior

mesenteric and splenic drainage. mesenteric and splenic drainage. It also contains a denser network of biliary It also contains a denser network of biliary

canaliculi.canaliculi.

SymptomsSymptoms

Young, 70 % maleYoung, 70 % male FeverFever ChillsChills Vomiting & anorexia in 1/3 of casesVomiting & anorexia in 1/3 of cases Abdominal painAbdominal pain Weight lossWeight loss

SignsSigns

Right upper quadrant tendernessRight upper quadrant tenderness HepatomegalyHepatomegaly Normal abdominal findingsNormal abdominal findings Jaundice and is usually associated Jaundice and is usually associated

with biliary tract disease or the with biliary tract disease or the presence of multiple abscesses.presence of multiple abscesses.

Chest findings: Decreased breath Chest findings: Decreased breath sounds in the right basilar lung zones, sounds in the right basilar lung zones, with signs of atelectasis and effusionwith signs of atelectasis and effusion

ComplicationsComplications

Recurrent septicemiaRecurrent septicemia Extension and rupture may occur Extension and rupture may occur

in in Peritoneal cavity Peritoneal cavity

general peritonitis or general peritonitis or subphrenic collectionsubphrenic collection

Through the diaphragm~> Through the diaphragm~> empyema thoracisempyema thoracis

Signs of complicationsSigns of complications

Signs of Signs of peritoneal irritationperitoneal irritation, such as , such as rebound tenderness, guarding, and rebound tenderness, guarding, and absence of bowel sounds, are present when the absence of bowel sounds, are present when the

abscess ruptures in the peritoneal cavity. abscess ruptures in the peritoneal cavity. Peritonitis occurs in 2-7% of cases.Peritonitis occurs in 2-7% of cases.

Pericardial friction rubPericardial friction rub can be audible when can be audible when the abscess extends into the pericardium. the abscess extends into the pericardium. This sign is associated with very high This sign is associated with very high mortality.mortality.

Signs of pleural effusionSigns of pleural effusion are present when are present when the abscess ruptures in the pleural cavity.the abscess ruptures in the pleural cavity.

Lab Studies: Lab Studies: Complete blood cell countComplete blood cell count

AnemiaAnemia is observed in 50-80% of patients. is observed in 50-80% of patients. Leukocytosis Leukocytosis of more than 10,000/mm3 in of more than 10,000/mm3 in

75-96% of patients.75-96% of patients. Liver function testsLiver function tests

An elevated An elevated alkaline phosphatasealkaline phosphatase level in level in 100% of patients.100% of patients.

An elevated An elevated aspartate aminotransferaseaspartate aminotransferase levellevel

An elevated An elevated alanine aminotransferasealanine aminotransferase level, level, An elevated An elevated bilirubinbilirubin level is observed in level is observed in

50% of patients.50% of patients. Prothrombin timeProthrombin time: This is elevated in 80% : This is elevated in 80%

of patients of patients

Diagnosis Diagnosis

Plain X rayPlain X ray detect gas in the abscess cavitydetect gas in the abscess cavity Chest basal collapse & sympathetic Chest basal collapse & sympathetic

effucsioneffucsion Elevation of diaphragmatic copulaElevation of diaphragmatic copula

U/S and CTU/S and CT with enhancement are the with enhancement are the two mostly used diagnostic accurate two mostly used diagnostic accurate methods. methods.

Liver scanLiver scan by rose bengal or radio-active by rose bengal or radio-active colloidal gold ( less use)colloidal gold ( less use)

Angiography Angiography ( invasive so less use)( invasive so less use)

Treatment Treatment Medical therapy: Medical therapy: The most dramatic change in the treatment The most dramatic change in the treatment

of pyogenic liver abscess has been the of pyogenic liver abscess has been the emergence of CT-guided drainage. emergence of CT-guided drainage.

Prior to this modality, open surgical Prior to this modality, open surgical drainage was the treatment most often drainage was the treatment most often employed, with mortality rates as high as employed, with mortality rates as high as 70%. 70%.

The current approach includes 3 steps. The current approach includes 3 steps. Initiation of antibiotic therapy Initiation of antibiotic therapy Diagnostic aspiration and drainage of the Diagnostic aspiration and drainage of the

abscess abscess Surgical drainage in selected patients Surgical drainage in selected patients

TreatmentTreatmentAntibiotic therapyAntibiotic therapy Regimens using beta-lactam/ beta-lactamase Regimens using beta-lactam/ beta-lactamase

inhibitor combinations or inhibitor combinations or Second-generation cephalosporins with Second-generation cephalosporins with

anaerobic are excellent empiric choices for the anaerobic are excellent empiric choices for the coverage of coverage of enteric bacilli and anaerobes.enteric bacilli and anaerobes.

Metronidazole or clindamycin should be added Metronidazole or clindamycin should be added for the coverage of for the coverage of Bacteroides fragilisBacteroides fragilis if other if other employed antibiotics offer no anaerobic employed antibiotics offer no anaerobic coverage. coverage.

If If fungal pathogensfungal pathogens are a possibility, empiric are a possibility, empiric anti-fungal therapy should be considered. anti-fungal therapy should be considered. Initial therapy for fungal abscess is currently Initial therapy for fungal abscess is currently amphotericin B. amphotericin B.

TreatmentTreatmentDuration of treatmentDuration of treatment has always been has always been

debated. debated. Currently Currently 4-6 weeks4-6 weeks of therapy is of therapy is

recommended for solitary lesions that recommended for solitary lesions that have been adequately drained.have been adequately drained.

Multiple abscesses are more problematic Multiple abscesses are more problematic and can require up to and can require up to 12 weeks of 12 weeks of therapytherapy. .

Both the clinical and radiographic Both the clinical and radiographic progress of the patient should guide the progress of the patient should guide the length of therapy length of therapy

SurgerySurgeryThe 5 indications for open surgical drainage The 5 indications for open surgical drainage

are as follows: are as follows: Abscess Abscess not amenable to percutaneousnot amenable to percutaneous

drainage drainage secondary to location, and/or secondary to location, and/or the presence of a complicated, the presence of a complicated, multiloculated, thick-walled abscess with viscid multiloculated, thick-walled abscess with viscid

pus.pus. Coexistence of intra-abdominal diseaseCoexistence of intra-abdominal disease that that

requires operative management e.g. requires operative management e.g. peritonitisperitonitis

Failure ofFailure of antibiotic therapy antibiotic therapy Failure ofFailure of percutaneous aspiration percutaneous aspiration Failure ofFailure of percutaneous drainage percutaneous drainage

SurgerySurgery

A transperitoneal approach allows for A transperitoneal approach allows for abscess drainage and abdominal abscess drainage and abdominal exploration exploration

Anterior ----- RT sub-costal approachAnterior ----- RT sub-costal approach

Posterior ---- extra-pleural Posterior ---- extra-pleural extraperitoneal , through the bed of extraperitoneal , through the bed of the last ribthe last rib

Amoebic liver abscessAmoebic liver abscess

Amebic liver abscess is the most Amebic liver abscess is the most frequent extra-intestinal manifestation frequent extra-intestinal manifestation of of Entamoeba histolyticaEntamoeba histolytica infection. infection.

This infection is caused by the protozoa This infection is caused by the protozoa E histolyticaE histolytica, which ascends the portal , which ascends the portal venous system. venous system.

Amebic liver abscess is an important Amebic liver abscess is an important cause of space-occupying lesions of the cause of space-occupying lesions of the liver, mainly in developing countries. liver, mainly in developing countries.

Amoebic liver abscessAmoebic liver abscess

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

This has been attributed to the fact that This has been attributed to the fact that the right lobe is supplied predominantly by the right lobe is supplied predominantly by

the superior mesenteric vein, the superior mesenteric vein, whereas the left lobe is supplied by the whereas the left lobe is supplied by the

splenic vein. splenic vein. The pus is usually chocolate colored due The pus is usually chocolate colored due

to lyses of hepatocytes and RBCs.to lyses of hepatocytes and RBCs.

Clinically Clinically

The signs and symptoms of The signs and symptoms of amebic liver abscess often areamebic liver abscess often are nonspecificnonspecific, resembling those of , resembling those of pyogenic liver abscess or pyogenic liver abscess or other febrile diseases. other febrile diseases.

There is an acute onset of There is an acute onset of fever with rigors and fever with rigors and abdominal pain which comes out abdominal pain which comes out

of the blue with short durationof the blue with short duration

Clinically Clinically Young age. Young age.

The pain most frequently is located in the The pain most frequently is located in the right upper quadrant and may radiate to right upper quadrant and may radiate to the right shoulder or scapular area.the right shoulder or scapular area.

Pain increases with coughing, walking, Pain increases with coughing, walking, and deep breathing, and it increases when and deep breathing, and it increases when patients rest on their right side.patients rest on their right side.

The pain usually is constant, dull, and The pain usually is constant, dull, and aching.aching.

Jaundice (<10% of cases) mostly Jaundice (<10% of cases) mostly occurs in complicated cases with occurs in complicated cases with multiple abscesses or a large abscess multiple abscesses or a large abscess compressing the biliary tract.compressing the biliary tract.

Physical signs of amoebic liver Physical signs of amoebic liver abscessabscess

Signs of complicationsSigns of complications

Signs of peritoneal irritation, such as Signs of peritoneal irritation, such as rebound tenderness, guarding, and rebound tenderness, guarding, and absence of bowel sounds, are present when the absence of bowel sounds, are present when the

abscess ruptures in the peritoneal cavity. abscess ruptures in the peritoneal cavity. Peritonitis occurs in 2-7% of cases.Peritonitis occurs in 2-7% of cases.

Pericardial friction rub can be audible when Pericardial friction rub can be audible when the abscess extends into the pericardium. the abscess extends into the pericardium. This sign is associated with very high This sign is associated with very high mortality.mortality.

Signs of pleural effusion are present when Signs of pleural effusion are present when the abscess ruptures in the pleural cavity.the abscess ruptures in the pleural cavity.

Course and Course and complicationscomplications

Resoltion

Dormant abscess

Secondary infection

calcification

Destroy liver architecture

rupture

Lab Studies:Lab Studies:

Approximately three fourths of Approximately three fourths of patients with an amebic liver patients with an amebic liver abscess have abscess have leucocytosis mainly leucocytosis mainly eosiophiliaeosiophilia..

Serology detect by Serology detect by IHATIHAT

Stool detectStool detect E histolytica E histolytica

Imaging Studies: Imaging Studies: Plain X rayPlain X ray

detect gas in the abscess cavitydetect gas in the abscess cavity Chest basal collapse & sympathetic Chest basal collapse & sympathetic

effucsioneffucsion Elevation of diaphragmatic copulaElevation of diaphragmatic copula

UltrasonographyUltrasonography is the preferable initial is the preferable initial diagnostic test. diagnostic test. It is rapid, has a low cost, and is only It is rapid, has a low cost, and is only

slightly less sensitive than CT scan. slightly less sensitive than CT scan. The lesions tend to be round or oval with The lesions tend to be round or oval with

well-defined margins and lack prominent well-defined margins and lack prominent peripheral echoes. peripheral echoes.

The lesions are primarily hypoechoicThe lesions are primarily hypoechoic..

Imaging Studies: Imaging Studies:

CT scanCT scan is sensitive (88-95%), but is sensitive (88-95%), but the findings are not specific.the findings are not specific.

None of the imagingNone of the imaging tests can tests can definitely differentiate a definitely differentiate a pyogenic liver abscess, an amebic pyogenic liver abscess, an amebic

abscess, or malignant disease. abscess, or malignant disease. Clinical, epidemiological, and Clinical, epidemiological, and

serological correlation is needed serological correlation is needed for diagnosis for diagnosis

Treatment Treatment Most uncomplicated amebic liver Most uncomplicated amebic liver

abscesses can be treated successfully abscesses can be treated successfully with with amebicidal drug therapy aloneamebicidal drug therapy alone. .

Use tissue amebicides to eradicate the Use tissue amebicides to eradicate the invasive trophozoite forms in the liver. invasive trophozoite forms in the liver.

After completion of treatment with After completion of treatment with tissue amebicides, administer luminal tissue amebicides, administer luminal amebicides for eradication of the amebicides for eradication of the asymptomatic colonization state. asymptomatic colonization state.

Treatment Treatment Failure to use luminal agents Failure to use luminal agents

can lead to relapse of infection can lead to relapse of infection in approximately 10% of in approximately 10% of patients. patients.

Luminal agents with proven Luminal agents with proven efficacy include efficacy include diloxanide furoate, diloxanide furoate, iodoquinol, and iodoquinol, and paromomycin.paromomycin.

TreatmentTreatment Metronidazole remains the drug of Metronidazole remains the drug of

choice for amebic liver abscess.choice for amebic liver abscess. 750 mg 3 times a day orally for 10 750 mg 3 times a day orally for 10

days, was reported to be curative days, was reported to be curative in 90% of patients with amebic in 90% of patients with amebic liver abscess. liver abscess.

The drug also is available for The drug also is available for intravenous administration for intravenous administration for those patients who are unable to those patients who are unable to take medication by the oral route.take medication by the oral route.

TreatmentTreatment Resolution of symptoms is fairly Resolution of symptoms is fairly

rapid and is observed within 3 rapid and is observed within 3 days in most of the patients, may days in most of the patients, may be longer time in endemic areas. be longer time in endemic areas.

That is why a therapeutic test is That is why a therapeutic test is justified for confirmation of justified for confirmation of diagnosis.diagnosis.

TreatmentTreatment

Surprisingly, in vivo resistance to Surprisingly, in vivo resistance to metronidazole by metronidazole by E histolyticaE histolytica has not been has not been reported, although metronidazole is a reported, although metronidazole is a frequently used drug. frequently used drug.

Usual adverse effects of metronidazole Usual adverse effects of metronidazole include include nausea, headache, and metallic taste. nausea, headache, and metallic taste. Abdominal cramps, vomiting, diarrhea, and Abdominal cramps, vomiting, diarrhea, and

dizziness also may occur.dizziness also may occur. Dark urine may occur from a metabolite of the Dark urine may occur from a metabolite of the

drug.drug.

TreatmentTreatment Tinidazole Tinidazole is better tolerated by is better tolerated by

patients, and it may be patients, and it may be administered once daily.administered once daily.

Chloroquine phosphateChloroquine phosphate may be may be substituted or added in the event of substituted or added in the event of failure of resolution of clinical failure of resolution of clinical

symptoms with metronidazole symptoms with metronidazole within 5 days or within 5 days or

intolerance to metronidazole or a intolerance to metronidazole or a nitroimidazolenitroimidazole..

TreatmentTreatment Aspiration of the abscess contentAspiration of the abscess content is is

indicated only if indicated only if Rupture of the abscess is imminent.Rupture of the abscess is imminent. if differentiation between amebic if differentiation between amebic

abscess and pyogenic abscess is critical. abscess and pyogenic abscess is critical. No response to antiamoebic therapy has No response to antiamoebic therapy has

occurred after 3-5 days. occurred after 3-5 days. Aspiration may be performed under Aspiration may be performed under

CT scan or sonographic guidance. CT scan or sonographic guidance. And send the collected specimen for And send the collected specimen for

Gram stain and cultures.Gram stain and cultures.

TreatmentTreatment Amebic liver abscesses only rarely Amebic liver abscesses only rarely

yield positive bacterial cultures yield positive bacterial cultures following secondary bacterial following secondary bacterial infection of the abscess cavity.infection of the abscess cavity.

Complications of aspirationComplications of aspiration The most common are infection The most common are infection

and bleeding.and bleeding. Other complications include Other complications include

amebic peritonitis or inadvertent amebic peritonitis or inadvertent puncture of an echinococcal cyst.puncture of an echinococcal cyst.

Hydatid diseaseHydatid disease


The parasite is known as echinococcus The parasite is known as echinococcus granulosus, multilocularis, which has granulosus, multilocularis, which has its final natural host, is the dog, and its final natural host, is the dog, and intermediate host man.intermediate host man.

The egg hatches in the duodenum and The egg hatches in the duodenum and the embryo penetrates to flow with the embryo penetrates to flow with portal blood and lodge in the liverportal blood and lodge in the liver


The parasite is formed of two layersThe parasite is formed of two layers Laminated layer which is the Laminated layer which is the

ectocyst and ectocyst and Germinal layer (endocyst) both Germinal layer (endocyst) both

are are Surrounded by advential fibrous Surrounded by advential fibrous

tissue layer from the host tissue layer from the host

Adventitial layer formed of compressed fibrous tissue from the host

Laminated layer or ectocyst, a parasitic layer secreted from the live germinal layer.

Germinal layer (endocyst), it is the living layer that secretes the ectocyst as well as the hydatid fliud,

Hydatid sand is formed of free brood capsules and free scolices

Clinical pictureClinical picture The infestation is contracted during The infestation is contracted during

childhood, but because the parasite childhood, but because the parasite grows very slowly, the hepatic masses grows very slowly, the hepatic masses cannot be palpated until later in life cannot be palpated until later in life (young adults and adults) the (young adults and adults) the mass is mass is usually smooth rounded tense massusually smooth rounded tense mass

Secondary infection results in tender Secondary infection results in tender hepatomegally, rigors and pyrexiahepatomegally, rigors and pyrexia (liver (liver abscess)abscess)

Complications Complications constitute the rest of the constitute the rest of the clinical picture spectrum clinical picture spectrum

Complications Complications Secondary infectionSecondary infection CalcificationCalcification Intra-biliary ruptureIntra-biliary rupture

Big radical (biliary colic, jaundice Big radical (biliary colic, jaundice +hydatid sand in stools)+hydatid sand in stools)

Small biliary radical (will lead to 2ndry Small biliary radical (will lead to 2ndry infection)infection)

Intra-abdominal ruptureIntra-abdominal rupture Upper abdominal pain + anaphylaxisUpper abdominal pain + anaphylaxis

Intra-thoracic ruptureIntra-thoracic rupture Other areas of ruptureOther areas of rupture (duodenum, (duodenum,

stomach, kidney or pericardium)stomach, kidney or pericardium)

Course and Course and complicationscomplications

Resoltion

Dormant abscess

Secondary infection

calcification

Destroy liver architecture

rupture

Intra-thoracic ruptureIntra-thoracic rupture

Intra-abdominal ruptureIntra-abdominal rupture

Main presentationsMain presentations1.1. Painless upper right abdominal massPainless upper right abdominal mass

1.1. the mass is rounded, smooth surfacedthe mass is rounded, smooth surfaced2.2. It feels tense cystic, firm or hardIt feels tense cystic, firm or hard

2.2. Upper abdominal painUpper abdominal pain and repeated and repeated anaphylactic reaction .The pain is anaphylactic reaction .The pain is stitching and may be associated with stitching and may be associated with rebound and rigidityrebound and rigidity

3.3. Acute abdomenAcute abdomen4.4. Biliary colicBiliary colic5.5. Infection of cystInfection of cyst6.6. Accidental discoveryAccidental discovery7.7. Calcified hydatidCalcified hydatid8.8. U/S for any other reasonU/S for any other reason

DiagnosisDiagnosis

Laboratory tests Laboratory tests CBC ~>eosinophilia CBC ~>eosinophilia Complement fixation test Complement fixation test Casoni intradermal test Casoni intradermal test

Radiological tests Radiological tests Plain x ray shows calcification in dead Plain x ray shows calcification in dead

parasites parasites Plain X ray for the chest is mandatory Plain X ray for the chest is mandatory U/S and /or CT are highly diagnosticU/S and /or CT are highly diagnostic

Treatment Treatment

Medical treatment Medical treatment Mebendazole or albendazole or Mebendazole or albendazole or

praziquantelpraziquantel MebendazoleMebendazole

30 mg/day for month30 mg/day for month Albendazole is used as adjuvant to Albendazole is used as adjuvant to

surgerysurgery10- 20 mg/kg/day for 4- 6 weeks10- 20 mg/kg/day for 4- 6 weeks

Treatment Treatment

Surgical treatmentSurgical treatment Initial stage involves protection of the Initial stage involves protection of the

operative field (colored towels soaked operative field (colored towels soaked in hypertonic saline in hypertonic saline

Second stage is to Second stage is to deflate the high pressure inside the deflate the high pressure inside the

cysts by aspiration and cysts by aspiration and non-complete replacement with non-complete replacement with

scolicidal fluid like hypertonic scolicidal fluid like hypertonic saline, or betadine, or cetrimide saline, or betadine, or cetrimide

Treatment Treatment Third stage is to Third stage is to suck the ectocystsuck the ectocyst

from within the adventitial layer from within the adventitial layer Forth stage is to Forth stage is to pack the residual pack the residual

cavitycavity with with Capitonage (mutiple purse string sutures)Capitonage (mutiple purse string sutures) MarsuplizationMarsuplization omental flap (omentoplasty)omental flap (omentoplasty) Filling the cavity with muscle pedicleFilling the cavity with muscle pedicle Suction drain inside big cysts and also for Suction drain inside big cysts and also for

the nearby peritoneal spacethe nearby peritoneal space

Treatment Treatment Some cysts can be excised in totoSome cysts can be excised in toto; ;

especially those hanging down from the especially those hanging down from the liver substance some other situations liver substance some other situations necessitates liver resectionsnecessitates liver resections

If huge cysts – If huge cysts – Roux en Y Roux en Y cystojujunostomycystojujunostomy

CBD explorationCBD exploration is done for cases with is done for cases with rupture into the biliary tree to clear it rupture into the biliary tree to clear it

Benign tumorsBenign tumors

Benign tumorsBenign tumors

Important benign tumors Important benign tumors Hemangioma Hemangioma Focal nodular hyperplasia Focal nodular hyperplasia Adenoma Adenoma

Less important tumors Less important tumors Hamartoma Hamartoma Cholangioma Cholangioma Biliary cystadenoma Biliary cystadenoma

HeamangiomaHeamangioma

Cavernous type, usually single Cavernous type, usually single subcapsular in subcapsular in adultsadults while while

Diffuse heamangiomatosis and Diffuse heamangiomatosis and the multicentric the multicentric hemangioendothelioma hemangioendothelioma predominates in predominates in infantsinfants. .

It is usually It is usually asymtomaticasymtomatic; yet, ; yet, pain, dyspepsia, and abdominal pain, dyspepsia, and abdominal mass are some manifestationsmass are some manifestations

HeamangiomaHeamangioma

Complications depend on the size Complications depend on the size and location of the tumor. and location of the tumor.

Large tumors can rupture Large tumors can rupture spontaneously or after blunt trauma.spontaneously or after blunt trauma.

In children, a triad of In children, a triad of high output cardiac failure, high output cardiac failure, abdominal mass, and abdominal mass, and cutaneous hemangiomata is diagnostic cutaneous hemangiomata is diagnostic

Diagnosis:Diagnosis:Hemangiomas present a diagnostic Hemangiomas present a diagnostic

challenge because challenge because They can be mistaken for They can be mistaken for

hypervascular malignancies of the hypervascular malignancies of the liver andliver and

Can coexist with (and occasionally Can coexist with (and occasionally mimic) other benign and malignant mimic) other benign and malignant hepatic lesions, including hepatic lesions, including focal nodular hyperplasia, focal nodular hyperplasia, hepatic adenoma, hepatic adenoma, hepatic cysts, hepatic cysts, hemangioendothelioma, hemangioendothelioma, hepatic metastasis, and hepatic metastasis, and primary hepatocellular carcinoma.primary hepatocellular carcinoma.

Diagnosis:Diagnosis: CT scansCT scans are usually diagnostic. The are usually diagnostic. The

lesion gradually concentrates injected lesion gradually concentrates injected dye slowly from the periphery to center.dye slowly from the periphery to center.

MRI with contrast enhancementMRI with contrast enhancement is highly is highly specific and can differentiate specific and can differentiate hemangiomas from other liver lesions. hemangiomas from other liver lesions. (high intensity area, T2 prolonged).(high intensity area, T2 prolonged).

U/S is characteristicU/S is characteristic (hyperechoic, well (hyperechoic, well defined borders, and posterior acoustic defined borders, and posterior acoustic enhancement), enhancement),

the accuracy of diagnosis is increased by the accuracy of diagnosis is increased by using using Doppler modeDoppler mode , however it is not , however it is not specific as the two previous modalitiesspecific as the two previous modalities

Diagnosis:Diagnosis: Single-photon emission Single-photon emission

computerized tomography computerized tomography (SPECT) with colloid Tc99m-(SPECT) with colloid Tc99m-labeled RBCs appears to be as labeled RBCs appears to be as sensitive and specific as MRI.sensitive and specific as MRI.

Biopsy is contraindicated. Biopsy is contraindicated.

Arteriography is no more needed Arteriography is no more needed for diagnosisfor diagnosis

TreatmentTreatmentTreatmentTreatment entails surgery or only entails surgery or only

assuranceassurance Surgery is indicated for Surgery is indicated for

symptomaticsymptomatic hemangiomas, hemangiomas, rapidly growingrapidly growing tumors, and tumors, and largelarge lesions (>10 cm). lesions (>10 cm). Surgery also should be performed if Surgery also should be performed if

hemangioma hemangioma cannot be differentiatedcannot be differentiated from from hepatocellular carcinoma.hepatocellular carcinoma.

In children after the first year there is In children after the first year there is usually spontaneous regression, before usually spontaneous regression, before that the prognosis is bad if there is heart that the prognosis is bad if there is heart failure failure

Adenomas (HA)Adenomas (HA)

Defined asDefined as benign tumor composed of benign tumor composed of hepatocytes in a normal liver (no portal hepatocytes in a normal liver (no portal tracts, central veins, bile ducts, or central tracts, central veins, bile ducts, or central scar with predominant arterial supply scar with predominant arterial supply

The pathogenesisThe pathogenesis is believed to be is believed to be related to a generalized vascular ectasia related to a generalized vascular ectasia that develops due to exposure of the that develops due to exposure of the vasculature of the liver to oral vasculature of the liver to oral contraceptives and related synthetic contraceptives and related synthetic steroids. steroids.

Adenomas (HA)Adenomas (HA)

Usually singleUsually single (10% multiple). (10% multiple). Variable in size (4 --30 cm)Variable in size (4 --30 cm)

Related to pillsRelated to pills (>4 years use), (>4 years use), slowly progressive course. Common slowly progressive course. Common in premenopausal women.in premenopausal women.

30% incidence of rupture30% incidence of rupture with with intraperitoneal hemorrhage, this intraperitoneal hemorrhage, this increases with pregnancyincreases with pregnancy

Can be premalignant or is confused Can be premalignant or is confused with low grade HCCwith low grade HCC

Adenomas (HA) (Diagnosis)Adenomas (HA) (Diagnosis)

Serum alpha-fetoprotein (AFP)Serum alpha-fetoprotein (AFP) levels are levels are within the reference range in patients with within the reference range in patients with hepatocellular adenoma. hepatocellular adenoma.

Elevations are noted in 50% of hepatocellular Elevations are noted in 50% of hepatocellular carcinoma (HCC) cases. carcinoma (HCC) cases.

Thus, finding an elevated AFP represents Thus, finding an elevated AFP represents either either primary carcinoma or primary carcinoma or an adenoma that has undergone malignant an adenoma that has undergone malignant

transformation. transformation. Surgical treatmentSurgical treatment is the rule whether is the rule whether

complicated or not.complicated or not.

LocalizationLocalization CT shows CT shows

diffuse arterial enhancement, diffuse arterial enhancement, occasional hyperdense area may occasional hyperdense area may

represent hemorrhage, andrepresent hemorrhage, and hypodense area representing necrosis hypodense area representing necrosis

MRI MRI no accumulation of gadolinium contrasts no accumulation of gadolinium contrasts

in the lesion +in the lesion + the presence of hyper-intense and hypo-the presence of hyper-intense and hypo-

intense areas confirms areas of intense areas confirms areas of hemorrhage and necrosis. hemorrhage and necrosis.

LocalizationLocalization

Arteriography shows Arteriography shows well-defined, round or ovoid, well-defined, round or ovoid,

hypervascular mass with hepatic arterial hypervascular mass with hepatic arterial branches entering from the periphery,branches entering from the periphery,

vessels within the mass are tortuous and vessels within the mass are tortuous and of varying calibers with flow moving of varying calibers with flow moving centrally from the periphery. centrally from the periphery.

Also avascular areas and intralesional Also avascular areas and intralesional hematomas are indicators of hematomas are indicators of hepatocellular adenoma hepatocellular adenoma

Focal nodular hyperplasia Focal nodular hyperplasia (FNH)(FNH)

Defined asDefined as a hyperplastic process in a hyperplastic process in which all the normal constituents of the which all the normal constituents of the liver are present but in an abnormally liver are present but in an abnormally organized pattern. Arteries in a dense organized pattern. Arteries in a dense stroma forming a stellate scar, which stroma forming a stellate scar, which contained bile ductules and no portal contained bile ductules and no portal radicles, support the lesionradicles, support the lesion

It is a result of responseIt is a result of response to to parenchymal injury. It may result from parenchymal injury. It may result from anomalous arterial supply to a local area anomalous arterial supply to a local area (hamartoma).(hamartoma).


Single and smallSingle and small. . Located subcapsularly, and may be Located subcapsularly, and may be

pedunculated.pedunculated. Most cases of FNH occur as a solitary lesion Most cases of FNH occur as a solitary lesion

(80-95%), but multiple lesions may occur. (80-95%), but multiple lesions may occur. Although FNH usually has no clinical Although FNH usually has no clinical

significance, recognition of the radiologic significance, recognition of the radiologic characteristics of FNH is important to avoid characteristics of FNH is important to avoid unnecessary surgery, biopsy, and follow-up unnecessary surgery, biopsy, and follow-up imaging. imaging.

No relation to pillsNo relation to pills, with female , with female predominance (males are also affected, and predominance (males are also affected, and age is a bit older than the adenoma). age is a bit older than the adenoma).


It is a static lesionIt is a static lesion increasing only slowly if increasing only slowly if at all, pregnancy is allowed and pills can be at all, pregnancy is allowed and pills can be used. However possible complications with pill used. However possible complications with pill use are reported.use are reported.

The hallmark featureThe hallmark feature of the lesion is found of the lesion is found on a cut specimen; the lesion appears as a on a cut specimen; the lesion appears as a central stellate scar with radiating fibrous central stellate scar with radiating fibrous septa dividing the tumor into lobules. septa dividing the tumor into lobules.

The central scar contains an arterial The central scar contains an arterial malformation with spiderlike branches malformation with spiderlike branches supplying the component nodules. supplying the component nodules.


Natural history is withoutNatural history is without risk and this risk and this postulates assurance and follow up (3-5 postulates assurance and follow up (3-5 cm) with little risk for rupture and cm) with little risk for rupture and bleedingbleeding

Malignant transformation of FNH has not Malignant transformation of FNH has not been reportedbeen reported

FNH must be differentiated from a FNH must be differentiated from a fibrolamellar variant of hepatocellular fibrolamellar variant of hepatocellular carcinoma, with which it shares imaging carcinoma, with which it shares imaging and gross features. and gross features.

Localization Localization

CT and U/SCT and U/S are diagnostic but are diagnostic but sometimes cannot differentiate sometimes cannot differentiate between the two lesions (HA aand between the two lesions (HA aand FNH)FNH)

Contrast enhanced CTContrast enhanced CT shows a shows a hypervascular mass with hypodense hypervascular mass with hypodense stellate scarstellate scar

MRI with gadoliniumMRI with gadolinium is the best is the best diagnostic procedure for FNHdiagnostic procedure for FNH

TUMOURS OF LIVERTUMOURS OF LIVER

METASTASES

(Pancreas, Bowel

Lung, Breast,

Melanoma)

HEPATOCELLULAR CARCINOMA

Hepatic Cell CarcinomaHepatic Cell Carcinoma

Hepatocellular carcinoma (HCC) is Hepatocellular carcinoma (HCC) is an aggressive hepatic neoplasm an aggressive hepatic neoplasm that most commonly affects adults. that most commonly affects adults.

Nevertheless, children who are Nevertheless, children who are affected with biliary atresia, affected with biliary atresia, infantile cholestasis, glycogen infantile cholestasis, glycogen storage diseases, and a wide array storage diseases, and a wide array of cirrhotic diseases of the liver are of cirrhotic diseases of the liver are predisposed to developing HCC. predisposed to developing HCC.

Hepatic Cell CarcinomaHepatic Cell Carcinoma

The 2 pathological subtypes are The 2 pathological subtypes are classic HCC and classic HCC and fibrolamellar carcinoma.fibrolamellar carcinoma.

The disease is either The disease is either cirrhomimetic (majority of cases) or cirrhomimetic (majority of cases) or non-cirrhomimetic (yet a significant non-cirrhomimetic (yet a significant

group of these have histological group of these have histological evidence in the portal tracts of ongoing evidence in the portal tracts of ongoing chronic liver disease.chronic liver disease.

EtiologyEtiology

The presence of necro- The presence of necro- inflammatory chronic liver disease inflammatory chronic liver disease (HBV, HCV, hemochromatosis, (HBV, HCV, hemochromatosis, alcoholism, hereditary alcoholism, hereditary tyrosinaemia)tyrosinaemia)

Afla -toxin contaminating nuts and Afla -toxin contaminating nuts and grains grains

Cl.senesis, for cholangiocarcinomaCl.senesis, for cholangiocarcinoma

Types Types Fibrolamellar typeFibrolamellar type (single mass) is different (single mass) is different

from the from the conventional typeconventional type (single mass, (single mass, multiple or diffuse types) inmultiple or diffuse types) in

Frequent occurrence in young patients Frequent occurrence in young patients Lack of the usual male predominance Lack of the usual male predominance Large eosinophilic hepatocytes (instead of Large eosinophilic hepatocytes (instead of

polygonal basophilic hepatocyts) are located polygonal basophilic hepatocyts) are located in lamellated fibrous stroma (instead of scanty in lamellated fibrous stroma (instead of scanty stroma, and separation by sinusoidal stroma, and separation by sinusoidal structures)structures)

Lack of significant association with cirrhosis Lack of significant association with cirrhosis Lack of the firm association with elevated AFPLack of the firm association with elevated AFP Increased vitamin B12 binding capacityIncreased vitamin B12 binding capacity More amenable to resection with favorable More amenable to resection with favorable

prognosis prognosis

TypesTypes

Rare types Rare types Cholangiocarcinoma Cholangiocarcinoma Cystadenocarcinoma Cystadenocarcinoma Sarcomas of the connective tissue Sarcomas of the connective tissue

componentscomponents Epithelioid hemangioendothelioma Epithelioid hemangioendothelioma

(intraperitoneal hemorrhage)(intraperitoneal hemorrhage) Hepatoblastoma (in female children, in the Hepatoblastoma (in female children, in the

third year, associated with high AFP, HCG)third year, associated with high AFP, HCG)

Clinical featuresClinical features Abdominal mass is the most common Abdominal mass is the most common

presentationpresentation Non specific group of symptoms (anorexia, Non specific group of symptoms (anorexia,

weight loss, abdominal vague pain, vomiting, weight loss, abdominal vague pain, vomiting, and fever)and fever)

Jaundice, and signs of liver insufficiency in Jaundice, and signs of liver insufficiency in those on top of cirrhosis (deterioration of those on top of cirrhosis (deterioration of health of a known cirrotic)health of a known cirrotic)

A palpable liver mass with a bruit and friction A palpable liver mass with a bruit and friction rub and ascites (can be blood stained) are the rub and ascites (can be blood stained) are the most common signs most common signs

Paraneoplsatic manifestations (hypercalcemia, Paraneoplsatic manifestations (hypercalcemia, hypoglycemia and erythrocytosis)hypoglycemia and erythrocytosis)

Liver function tests are usually abnormal Liver function tests are usually abnormal

Diagnosis Diagnosis

Tumors markers Tumors markers The most useful is AFP, yet the The most useful is AFP, yet the

reported sensitivity in detection of reported sensitivity in detection of HCC with cirrhosis is variable HCC with cirrhosis is variable (normal 20 ng/ml)>100 in a cirrhotic (normal 20 ng/ml)>100 in a cirrhotic indicate greater susceptibility to indicate greater susceptibility to develop HCC within 5 years.develop HCC within 5 years.

CEA is the second useful CEA is the second useful

Diagnosis Diagnosis Alpha-fetoproteinAlpha-fetoprotein Alpha-fetoprotein is a normal fetal serum Alpha-fetoprotein is a normal fetal serum

protein produced by the yolk sac and liver protein produced by the yolk sac and liver Progressive increases in serum levels are Progressive increases in serum levels are

seen in 70-90% of patients with HCC seen in 70-90% of patients with HCC Slightly increased and often fluctuating Slightly increased and often fluctuating

serum levels also seen in hepatitis and serum levels also seen in hepatitis and cirrhosis cirrhosis

In HCC serum levels correlate with tumor In HCC serum levels correlate with tumor size size

Rate of increase in serum levels correlate Rate of increase in serum levels correlate with growth of tumor with growth of tumor

Tumor resection results in a fall in serum Tumor resection results in a fall in serum concentrations concentrations

Serial assessment useful in measuring Serial assessment useful in measuring response to treatment response to treatment

Imaging techniques Imaging techniques

U/S and CTU/S and CT are the most useful are the most useful techniques to techniques to visualize the size, position, multiple deposits, visualize the size, position, multiple deposits, porta hepatis extension major veins invasion porta hepatis extension major veins invasion

and thrombosis, and thrombosis, and and get a guided needle biopsy get a guided needle biopsy

(controversial issue) (controversial issue)

Angiography is more invasive, but more Angiography is more invasive, but more diagnostic diagnostic

Imaging techniques Imaging techniques

MRIMRI is new but looks promising. is new but looks promising.

If surgical resection is anticipated, If surgical resection is anticipated, use MRI and use MRI and magnetic resonance magnetic resonance angiography (MRA)angiography (MRA) of the liver to of the liver to best determine tumor margins and best determine tumor margins and vasculature.vasculature.

Chest X rayChest X ray for the lung involvement for the lung involvement

TreatmentTreatment Surgery is the only hope for cureSurgery is the only hope for cure Objective is to excise the lesion safely Objective is to excise the lesion safely

with a margin of healthy liver tissue of 2 with a margin of healthy liver tissue of 2 cm or more. Most tumors are cm or more. Most tumors are irresectable due to: irresectable due to: Large size Large size Involvement of major vessels Involvement of major vessels Associated advanced cirrhosis .Cirrhotic Associated advanced cirrhosis .Cirrhotic

livers cannot regenerate unlike normal livers. livers cannot regenerate unlike normal livers. Metastatic disease or extra-hepatic spread. Metastatic disease or extra-hepatic spread.

Transplantation is not indicated Transplantation is not indicated (disappointing)(disappointing)

Recurrence after resection is 50% in 3 years, Recurrence after resection is 50% in 3 years, it is high if the portal vein showed it is high if the portal vein showed thrombosis thrombosis

Postoperative Postoperative managementmanagement

Operative Operative blood lossblood loss should be should be promptly replacedpromptly replaced

Transient portal hypertensionTransient portal hypertension occurs occurs following lobectomies following lobectomies

JaundiceJaundice should be transient, and should be transient, and mild (one week) if persisted, CBD mild (one week) if persisted, CBD problem is there problem is there

Postoperative Postoperative managementmanagement

HypoglycemiaHypoglycemia is a real risk, needs is a real risk, needs close monitoring and correctionclose monitoring and correction

Coagulation defectsCoagulation defects should be should be expected and managed by fresh frozen expected and managed by fresh frozen plasma and vitamin K injections plasma and vitamin K injections

HypoalbuminemiaHypoalbuminemia is common in the is common in the first week due to the short half life of first week due to the short half life of albumin (8-24 hours), should be albumin (8-24 hours), should be supplemented by plasma or albumin supplemented by plasma or albumin infusions infusions

Non-surgical Non-surgical management management

Chemotherapy Chemotherapy Systemic or via hepatic artery infusionSystemic or via hepatic artery infusion low response rate (13%) and low response rate (13%) and high rate of side effects (chemical high rate of side effects (chemical

hepatitis, duodenitis with ulcerations, hepatitis, duodenitis with ulcerations, and biliary sclerosis)and biliary sclerosis)

Chemoembolisation Chemoembolisation TAE (trans arterial embolisaton) using TAE (trans arterial embolisaton) using

lipidol carrier for cisplatin or lipidol carrier for cisplatin or adriamycin) is a promising technique adriamycin) is a promising technique

Non-surgical Non-surgical management management

Radiotherapy Radiotherapy Alcohol injectionAlcohol injection

Percutanous U/S guided Percutanous U/S guided absolute ethanol injection is absolute ethanol injection is reporting better results than reporting better results than surgerysurgery

Liver SecondariesLiver SecondariesThe liver provides a fertile soil in which The liver provides a fertile soil in which

metastases can establish, because of metastases can establish, because of Rich, dual blood supply (The blood supply Rich, dual blood supply (The blood supply

of the liver is exceeded only by that of the of the liver is exceeded only by that of the lung, in terms of blood flow per minute.)lung, in terms of blood flow per minute.)

Humoral factors that promote cell growth. Humoral factors that promote cell growth. The fenestrations in the sinusoidal The fenestrations in the sinusoidal

endothelium allow a foothold into the endothelium allow a foothold into the space of Disse for tumor emboli arriving space of Disse for tumor emboli arriving via the blood stream. via the blood stream.

Liver SecondariesLiver Secondaries

The liver may be the site of metastasis The liver may be the site of metastasis from virtually any primary malignant from virtually any primary malignant neoplasm, but neoplasm, but

the most common primary sites are the the most common primary sites are the eye, colon, stomach, pancreas, breast, eye, colon, stomach, pancreas, breast, and lung. and lung.

In children, the most common liver In children, the most common liver metastases are from a neuroblastoma, metastases are from a neuroblastoma, a Wilms tumor, or leukemia a Wilms tumor, or leukemia

RoutesRoutesRoutesRoutes of transport to the liver (one cancer of transport to the liver (one cancer

can transport by more than one pathway) can transport by more than one pathway) Portal vein (stomach, colon, pancreas and Portal vein (stomach, colon, pancreas and

less commonly appendix)less commonly appendix) Hepatic artery (lung, breast, Hepatic artery (lung, breast,

hypernephroma, gonads, prostate and hypernephroma, gonads, prostate and malignant melanoma)malignant melanoma)

Direct spread (stomach, gall bladder and Direct spread (stomach, gall bladder and bleary ducts, hepatic colon flexure)bleary ducts, hepatic colon flexure)

Lymphatics (stomach, breast, female Lymphatics (stomach, breast, female genitals)genitals)

Clinical pictureClinical picture

Secondaries can take several Secondaries can take several forms forms

Multiple spherical Multiple spherical umbilicated nodules umbilicated nodules

Solitary big nodule Solitary big nodule Diffuse liver infilterationDiffuse liver infilteration

Clinical pictureClinical picture Patients can be totally asymptomatic Patients can be totally asymptomatic In massively involved cases In massively involved cases

The liver is enlarged (hard tender The liver is enlarged (hard tender nodular or irregular) nodular or irregular)

Pain in the right upper quadrant.Pain in the right upper quadrant. Jaundice, ascites or peritoneal deposits. Jaundice, ascites or peritoneal deposits.

The presence of ascites usually The presence of ascites usually indicates widespread tumors in the indicates widespread tumors in the liver, and it is regarded as a grave liver, and it is regarded as a grave prognostic sign.prognostic sign.

Anorexia, vomiting, and cachexia Anorexia, vomiting, and cachexia Evidence of primary tumor Evidence of primary tumor

Investigations Investigations

Tumor markers Tumor markers CEA is the most commonly CEA is the most commonly

elevated elevated Primary specific tumor markerPrimary specific tumor marker

Imaging techniquesImaging techniquesU/S and CT are the most U/S and CT are the most

commonly used modalitiescommonly used modalities

Investigations Investigations CT is the examination of choice for evaluating CT is the examination of choice for evaluating

liver metastases. liver metastases. The recent advent of The recent advent of helical (spiral) CT helical (spiral) CT

techniquestechniques and, more recently, and, more recently, Multisection CTMultisection CT have revolutionized the use have revolutionized the use

of CT in hepatic imaging.of CT in hepatic imaging. The most sensitive technique for detecting The most sensitive technique for detecting

liver metastases is liver metastases is CT arteriography (CTACT arteriography (CTA) ) and and CT arterioportography (CTAPCT arterioportography (CTAP). ).

Although these are invasive procedures, they Although these are invasive procedures, they are invaluable in accurately assessing the are invaluable in accurately assessing the number and position of the lesions prior to number and position of the lesions prior to hepatic resection. hepatic resection.

InvestigationsInvestigations

LaparoscopyLaparoscopy Now known as the best method to detect Now known as the best method to detect

liver secondaries since liver secondaries since Assessment of the disease (discretely Assessment of the disease (discretely

nodular, miliary or diffusely confluent)nodular, miliary or diffusely confluent) Permits safe targeted biopsyPermits safe targeted biopsy Determine disease operability (discretely Determine disease operability (discretely

nodular type)nodular type) Determine other peritoneal affections Determine other peritoneal affections

(omental cakes, or peritoneal deposits (omental cakes, or peritoneal deposits

TreatmentTreatmentSurgical resectionSurgical resection Less than 5% are suitable Less than 5% are suitable Best results are obtained with Best results are obtained with

colorectal primaries (10% amenable colorectal primaries (10% amenable for surgery); indicated only if for surgery); indicated only if Deposits are fewer than 4Deposits are fewer than 4 No extrahepatic metastases even if porta No extrahepatic metastases even if porta

hepatis LNhepatis LN Intraoperative U/S is mandatory to guide Intraoperative U/S is mandatory to guide

the 1 cm safety margin, and to detect the 1 cm safety margin, and to detect secondary deposits secondary deposits

5 years disease free survival is 20%5 years disease free survival is 20%

Chemotherapy Chemotherapy Intra hepatic artery infusions Intra hepatic artery infusions

are equivilant to I.V. infusions in are equivilant to I.V. infusions in response with a higher hepatic response with a higher hepatic morbidity.morbidity.

TAE is beneficial only in TAE is beneficial only in carcinoid syndrome, and carcinoid syndrome, and deposits from islet cell tumor.deposits from islet cell tumor.. .

Other Palliative Other Palliative

Cryotherapy using liquid Cryotherapy using liquid nitrogen is promising when nitrogen is promising when surgery is contraindicatedsurgery is contraindicated

Hyperthermia by high Hyperthermia by high intensity ultrasound is still intensity ultrasound is still experimental.experimental.

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