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![Liver – B S / V D / L D
▪ It is a unique organ with dual blood supply.
Hepatic blood flow is around 1500 ml/minute
of which portal vein contributes 80% and
hepatic artery 20%.
▪ Hepatic artery, portal vein and bile duct are
located in the free edge of the lesser omentum
until it enters the liver. [Porta Hepatis]
▪ Venous drainage is usually through the three
major hepatic veins, right, left, and middle
which drain into the IVC.
▪ Lymphatic drainage – drain in 4 directions:
- thoracic duct
- hepatic nodes
- celiac nodes
- pericardial nodes](https://image.slidesharecdn.com/liver-abscesstumour-250405001109-77e2984f/75/Liver-Surgical-Anatomy-Abscess-and-Liver-Tumours-6-2048.jpg)
Uploaded byUthamalingam Murali
Liver - Surgical Anatomy, Abscess and Liver - Tumours
This PPT includes - two topics - Liver abscess & Liver timours which is very much essential for MBBS - Students. The students should know the causes, clinical features & management aspects of the above liver diseases. Also it includes the latest staging system of liver tumours.
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Liver - Surgical Anatomy, Abscess and Liver - Tumours
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- 3. Liver – SurgicalAnatomy ▪ The liver is the largest organ in the body – weighing 1.5 kg – 70 kg man. ▪ The liver parenchyma is entirely covered by a thin capsule called ‘Glissons capsule’ and by visceral peritoneum in all but for the posterior surface of liver termed ‘bare area’. ▪ Liver has 4 lobes—right lobe, left lobe, quadrate lobe and caudate lobe. ▪ Supporting structures are right triangular ligament, left triangular ligament and falciform ligament. ▪ The liver regenerates to 90–100% of its previous volume following resection. ▪ The liver comprises approximately 100 000 hexagonal functional units known as lobules with a central vein surrounded by 6 hepatic portal veins & 6 hepatic arteries.
- 4. Liver – SegmentalAnatomy ▪ Liver is divided into functional right and left units / lobes by a line between the left of the gallbladder fossa and the middle hepatic vein - Cantlie’s line creating Couniaud’s segments. There are 8 segments: ▪ Segments I, II, III, and IV are of left lobe. ▪ Segments V, VI, VII, VIII are of right lobe. ▪ Segment I is the caudate lobe of the liver and has independent supply of portal and hepatic veins. This hepatic vein directly joins IVC. ▪ Right lobe is having right hepatic artery, right branch of portal vein, and right hepatic duct. ▪ Left lobe is having left hepatic artery, left branch of portal vein and left hepatic duct. GB FOSSA TO IVC
- 6. Liver – BS / V D / L D ▪ It is a unique organ with dual blood supply. Hepatic blood flow is around 1500 ml/minute of which portal vein contributes 80% and hepatic artery 20%. ▪ Hepatic artery, portal vein and bile duct are located in the free edge of the lesser omentum until it enters the liver. [Porta Hepatis] ▪ Venous drainage is usually through the three major hepatic veins, right, left, and middle which drain into the IVC. ▪ Lymphatic drainage – drain in 4 directions: - thoracic duct - hepatic nodes - celiac nodes - pericardial nodes
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- 8. Learning Objectives ▪ Listthe types of infections of liver. ▪ Describe the aetiology, C/F, complications, investigations and treatment of Amoebic liver abscess. ▪ Discuss about – Pyogenic liver abscess
- 9. Liver Infections -Types Condition C. Agent Viral Hepatitis Hepatitis A, B, C Ascending Cholangitis Enteric bacteria Pyogenic liver abscess Strep. / E. coli Amoebic liver abscess E. histolytica Hydatid liver disease Echinococcus
- 10. Amoebic Liver Abscess ▪It is common in India and other tropical countries and it is caused by a parasite Entamoeba histolytica. ▪ It is more common in alcoholics and cirrhotic patients. ▪ It is the commonest extra-intestinal presentation of amoebiasis. ▪ It is often called as tropical abscess. ▪ Malnutrition, patients on steroid therapy, immunosuppression, cirrhosis and alcoholism increases the infection rate and also rate of amoebic liver abscess.
- 11. A L A- Pathology ▪ The amoebic cyst is ingested and develops into trophozoite form in the colon & passes through the bowel wall to reach the liver through portal veins - form of micro-abscesses all over the liver. ▪ In 80% of cases it is single large abscess, in 20% it is multiple, may involve both lobes. ▪ It is more common in right posterior-superior region (80%) because of streamline effect. ▪ Pus is chocolate coloured, classically called as anchovy sauce – due to liquefaction necrosis, thrombosis of blood vessels and lysis of RBC & liver cells.
- 12. A L A– Clinical Features ▪ Systemic: Fever / Chills & rigors / LOA & Jaundice. ▪ Abdominal: Pain & tenderness / Mass – RH / Localized guarding & rigidity & skin edema. ▪ Thoracic: Dry cough / Right sided chest pain / Right shoulder pain & Intercostal tenderness. ▪ F O Complications: Rupture / Infection / Liver failure.
- 13. Course & Sequelae– A L A ▪ It can rupture into lungs - commonest site of rupture. ▪ It can rupture into the peritoneum causing peritonitis - requires emergency laparotomy. ▪ It can rupture into pleural cavity leading to empyema & Rupture into bronchus can cause broncho-pleural fistula. ▪ Rupture into bare-area of liver causing retroperitoneal abscess. ▪ Rupture into the intestines, or to the skin (Amoebiasis cutis). ▪ Most dangerous complication is rupture into pericardial cavity (cardiac tamponade). ▪ Septicaemia and liver failure can occur in a patient with amoebic liver abscess with cirrhosis.
- 14. A L A- Investigations ▪ Basic tests – Hb%↓/TC↑. ▪ LFT. ▪ Stool exam. ▪ Serological tests – IHA / ELISA. ▪ Culture – Pus. ▪ Chest X-ray. ▪ U/S – abd – anechoic / hypo. ▪ CECT – abdomen. ▪ Tꟲ-99 scan - differentiate
- 15. A L A– Medical Treatment Drugs Dose Oral Metronidazole - 10-14 days I.V – Metronidazole 800mg tds 500 mg tds Tinidazole – 5 days 600 mg bd Cefotaxime / Ciprofloxacin (I.V / Oral – to control secondary infection) Dihydroemetine – 5 days Chloroquine – 10-14 days 1.5 mg/kg/day 250 mg bd
- 16. A L A- Treatment • U/S guided wide bore needle aspiration. • Indications - Large abscess > 10 cm - Failure – drug treatment - Large Lt. lobe abscess - Abscess in pregnancy • ↓ U/S guidance pigtail catheter is placed into the abscess cavity PC to drain the pus. • Catheter and abscess cavity has to be washed and irrigated at regular intervals with normal saline. Aspiration P C Drainage
- 17. A L A– Surgical Treatment • Even after repeated aspirations if abscess cavity fills again • Thick pus • Multi-loculated abscess • Left lobe abscess, because of danger of rupture into pericardial cavity • Ruptured abscess • Caudate lobe abscess • Multiple abscesses • Through trans-peritoneal approach, abscess area is opened, • Pus is evacuated. • Malecot’s catheter is placed and brought out through a separate stab incision. • The catheter is kept in situ until drainage stops completely. • Separate drain to be placed into the peritoneal cavity. Indications Procedure
- 18. Pyogenic Liver Abscess ▪A. Biliary sepsis – 35% {commonest route} Empyema GB Cholangitis Instrumentation Stone disease ▪ B. Portal vein sepsis – 20% Appendicitis Diverticulitis IBD / PID / CRC ▪ C. Distant infections – 15% Pneumonia Upper UTI Endocarditis Osteomyelitis • D. Super added infections - • Amebic liver abscess • Hydatid cyst • E. Trauma – 4-10% • F. Cryptogenic liver abscess – 20% • G. Direct extension – From • Suppurative cholecystitis • Sub-phrenic abscess • Perforation • Peri-nephric abscess
- 19. Pyogenic Liver Abscess •E. coli – commonest • Klebsiella • Proteus • Pseudomonas • Clostridia • Enterococci • Strep. faecalis • Rt. lobe – commonly involved • Usually solitary – 60% • Acute in nature • Common in diabetics • M = F • Old age – 55 years Organisms Pathology
- 20. Pyogenic Liver Abscess •Pain – R H • Fever + Rigors • Jaundice - Late • I C - Tenderness • Tender soft liver • F O - Toxicity • Const. symptoms • Basic tests • L F T • Chest X-ray • U/S │CT - scan • Blood culture • Culture – Pus C / F Diagnosis
- 21. P L A– Treatment ▪ Systemic Antibiotics: - Cephalosporins + Metronidazole ▪ Percutaneous drainage --> Drainage tube/catheter are placed under US / CT guidance into the liver abscess. ▪ Open drainage → Recurrent abscess / large > 5 cm / failure - PCD. ▪ Treating – primary cause is essential.
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- 23. Learning Objectives • ClassifyLiver tumours. • List the types of benign tumours of liver and explain about them. • Describe the aetiology, clinical features, staging, diagnosis and treatment of Hepatocellular carcinoma. • Discuss - Secondaries in Liver
- 24. Tumors of Liver Benign •Haemangiomas • Hepatic adenomas • Focal Nodular Hyperplasia • Liver Cysts (Neoplastic) Malignant • Primary - Hepatoma – HCC – 80% - Cholangiocarcinoma – 20% - Hepatoblastoma • Secondaries
- 25. Haemangioma • They arethe commonest benign tumour of the liver. • It is usually solitary and Compressibility of tumour is diagnostic. • It is common in females (3:1) in 5th decade. It can occur in either lobes of liver. • Commonly they are asymptomatic (85%) but can compress the Gastro.Duo – area = abd.pain & vomiting. • It is congenital in origin and enlarges by ectasia. • Spontaneous rupture is very rare. • D/D – HCC / Vascular solitary mets. / Hepatic adenoma / Liver abscess.
- 26. Haemangioma • Complications: Occur> 8 cm in size - Bleeding & Rupture - Thrombosis & DIC - Infection • U/S & CT – scan can diagnose but MRI – more accurate. • Treatment: • Prior RT is given to reduce the size and then hemi- hepatectomy is done. • Surgery is done when size is large, symptomatic, impending rupture (or) any other complications.
- 27. Hepatic Adenoma • Theyare common in females (10:1). They present as a solitary nodular lesions in the liver. • It is said to be due to use of oral contraceptive pills (OCPs). • It is uncommon in males. It is relatively rare compared to FNH and haemangioma. • Upper abdominal pain (65%) is the commonest presentation. • They may rupture or turn into malignancy {10%}. U/S, CT scan are diagnostic but MRI is ideal tool. • Surgical resection {>5cm} is the ideal treatment. Limited resection is needed.
- 28. Focal Nodular Hyperplasia •It is 2nd most common benign tumour. Usually it presents as solitary nodule. • It is hyperplasia of liver containing all components of liver in disorganized pattern. They are more common in females – young & middle aged women. • It contains hepatic cells as well as Kupffer cells which is characteristic. • Usually asymptomatic, but vague pain abdomen may be the presentation. • It is difficult to differentiate from fibro-lamellar type of HCC. CT – scan shows central scar with stellate distribution of blood vessels. • They do not have any malignant potential & hence do not require any treatment.
- 29. Hepatoma – HC C • HCC is the commonest primary liver malignancy (90%), becoming 5th most common malignancy worldwide. • It is common in Japan, Mozambique, South East Asia, tropical Africa, Taiwan. • It is common in cirrhotic’s and hepatitis B and hepatitis C virus infection. • Male to female ratio is 4:1. • It is usually unicentric but occasionally can be multicentric. • Right lobe is commonly involved.
- 30. H C C– Etiology • Aflatoxin B1, a product of fungus aspergillus. It is powerful carcinogen. • Hepatitis B and hepatitis C virus infection. It is more common in individuals who have chronic positive status for HBs Ag and chronic carriers. • Alcoholic cirrhosis. It is co-carcinogen. / Smoking. • Clonorchis sinensis infestation. • Haemochromatosis, α1 antitrypsin deficiency. • Hepatic adenoma—potentially malignant. • Environment related chemicals like DDT, nitrite and nitrate related food products; trichloroethylene (dry cleaning solvents), herbicides.
- 31. HCC – Pathology& Spread Gross • Hanging type • Pushing type • Infiltrative Okuda • Multifocal • Indeterminate • Spreading • Expanding Variants • Fibro-lamellar • Mixed • Clear cell • Giant cell • Sarcomatoid Spread • Lymphatic • Blood • Direct
- 32. H C C– Clinical Features • Asymptomatic: Incidentally identified. • Symptomatic: Abdominal pain / LOW & LOA / FO – CLD / jaundice / Mass abdomen. • Symptoms - Complications: Haemoperitoneum / Jaundice. • Metastatic symptoms: Ascites / Lung & Bone sec. / Rectal deposits. • Para-neoplastic syndrome – 1%
- 33. Severity – CL D • INR • Serum Bilirubin • Serum Creatinine M E L D – Score (Model for End-Stage Liver Disease) Child – Turcotte – Pugh Classification
- 39. Hepatoma – Investigations •Basic tests. • LFT. • U/S – abd – Hyper-echoic • CECT scan – abd-reliable. • Tumour markers – AFP (70%)/PIVKA II. • CT – Angiography. • MRI scan. • Liver biopsy – Not always done.
- 40. HCC – DefinitiveTreatment • Not Resectable • Tumor size ≤ 5 cm • Up to 3 nod - < 3 cm • No – PV / HV invasion • No extra-hepatic spread Orthotopic Liver Transplantation Indications – “Liver Transplant” HCC Non- Cirrhotic Hemi Hepatectomy Limited – 1 Lobe Cirrhotic Liver transplant
- 41. HCC – Adjuvant& P T Adjuvant • CT – CAMF • Sorafenib • Octreotide • Newer methods - Tamoxifen - Interferons - Interleukins R F A T A C E Palliative • RFA • PC – Ethanol/Acetic acid Inj. • TAC • TACE • HA - Ligation • Fractioned RT
- 42. Secondaries in Liver •It is the commonest malignant tumour in liver. • The incidence of primary : secondary : - 1 : 20. • Commonly secondaries in liver are multiple, multiple in one lobe (or) in both lobes. • It can be solitary (rare). Abdominal • Carcinoma in - stomach - colon - small bowel - esophagus - rectum - kidney - carcinoids Children Extra - ABD • Melanoma • Ca. breast / Lung / adrenal tumors • Bladder / prostate / testis • FCT
- 43. Classification Site • Colorectal –70%. • Neuroendocrine. • Non-colorectal & Non- neuroendocrine . Others • Precocious – Carcinoid / Colorectal cancer. • Synchronous –15-25% Carcinoma stomach. • Metachronous – 20-45% Melanoma / Ca. breast.
- 44. Secondaries in Liver– C/F │D/D • Multicentric hepatoma • Macronodular cirrhosis • Polycystic liver disease • Poor general condition. • Palpable liver which is hard, multi-nodular with umbilication. • LOA & LOW. • Virchow’s node. • Clinical features of primary. • Ascites ± • Jaundice ±
- 45. Sec. – Liver– Investigations • Basic tests. • LFT. • Primary – Identification. • Liver biopsy. • U/S – abdomen. • CT – TAP | MRI. • Tumour marker – CEA.
- 46. Treatment Basic • CT –Treatment of choice • Surgery – primary – colon / kidney • Solitary secondary - Primary + Resection Chemotherapy • Ca. stomach – Mitomycin & 5 Fu. • Ca. colon – FOLFOX Others • Microwave therapy • R F A • Laser hyperthermia • Hepatic artery ligation
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- 48. To Summarize • Types– Amoebic & Pyogenic. • Aetio-pathogenesis. • Clinical Features. • Course & Sequalae - ALA. • Investigative – Methods. • Treatment – M & S. ▪ Types – Benign Tumors. ▪ Aetio-pathogenesis – HCC. ▪ Clinical Features. ▪ Staging – Various. ▪ Treatment – Def / Adj / Palliative. ▪ Secondaries in Liver. “Liver Abscess” “Liver Tumours”
- 49. Question Time ▪ List5 sequalae of amoebic liver abscess. ▪ Mention the medical & surgical treatment of ALA. ▪ Write 5 differences between ALA & PLA. ▪ Mention the aetio-pathogenesis of pyogenic liver abscess. ▪ Identify the assessment parameters of CLD. ▪ Write the BLCC staging classification of HCC. ▪ List 4 extra-abdomen causes & classifications of secondaries in liver. ▪ Identify the adjuvant & palliative treatment methods of HCC.
- 50. A 45-year-old femaleunderwent an US for suspected right upper quadrant pain. The US of the biliary tract was normal but showed a solid lesion in the liver. Therefore, she had a CECT scan that showed a vascular lesion surrounding the solid mass with central scarring. State the likely diagnosis? – • a) Hemangioma. • b) Hepatocellular carcinoma. • c) Focal nodular hyperplasia. • d) Hydatid liver disease.
- 51. Which of thefollowing statements is incorrect regarding the anatomy of the liver? – • a) Functionally the liver is divided into 8 segments. • b) Caudate lobe is segment 1 of the liver. • c) Segments V to VIII constitute the functional right lobe of liver. • d) The falciform ligament divides the liver into functional right & left lobe.
- 52. Which of thefollowing is not a constituent factor in Child’s system to classify severity of chronic liver disease? – • a) Serum bilirubin. • b) Prothrombin time. • c) Serum albumin. • d) Encephalopathy.
- 53. A 35-year-old femalepresents with upper abdominal discomfort and CT scan shows a 5-cm well-circumscribed solid tumor in the liver, consistent with a hepatic adenoma. Which of the following is not true of the above diagnosis? – • a) Hepatic adenomas are benign. • b) 10% of hepatic adenomas can turn malignant. • c) There is an association with use of OCP’s. • d) The adenoma usually does not require excision.
- 54. Which of thefollowing is not true of amoebic liver abscess? – • a) Nearly all patients will require surgical drainage. • b) The liver lesion is caused by the trophozoite. • c) The first-line of investigation is ultrasound. • d) The ameba are derived from the gastrointestinal tract.
- 55. All of thefollowing are modalities of treatment for hepatocellular carcinoma, except – • a) Radiofrequency ablation. • b) Trans arterial catheter embolization. • c) Nd-YAG laser ablation. • d) Percutaneous acetic acid injection.
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