LIVER-part 2 Dr. Saad M Attash 2018
المرحلة الرابعة جراحة العدد 6 8\3\2018تسلسل 10
Hydatid disease of the liver Geographical distributionPrevalent in sheep –rearing parts of the world. In the Middle East the disease commonly seen in Iraq, Yemen, Libya & Egypt.Aetiology Causative organism: tapeworm Echinococcus granulosus pathology---GROSS- the liver may be the site of a single or multiple hydatid cysts.- the cyst fluid is usually colorless & clear, but may be yellowish if the cyst establishes a communication with the bile ducts.- scolices are found in this fluid, therefore, may cause a severe anaphylactic reaction if it gets to the circulation.---MICROSCOPIC- the parasite forms a double-layer cyst wall. The inner thin germinal layer( endocyst) shows many folds forming brood capsules they contain the head of the future worm (scolices). This is the living part of the parasite that secretes the hydatid fluid, & moreover form its own enveloping outer laminated membrane layer.- the host react to the intrusion of the parasite by surrounding the cyst by a third outermost adventitial fibrous tissue layer.
Clinical features 1- asymptomatic for years & may be discovered with US that is done for another purpose. 2- the usual presentation is by chronic RT upper quadrant pain & hepatomegaly. 3- rarely presented with complication. 4- in 70% of cases , the cyst is felt as a well-defined painless fluctuant swelling. Fate - the majority of cysts continue to enlarge gradually. - in the others the parasite dies & the cyst is calcified. Complications 1- secondary infection. 2- rupture of the cyst in the biliary passages causing jaundice. 3- rupture in the peritoneal cavity causing dissemination & an anaphylactic reaction.
Investigations 1- US or CT. 2- Haemagglutination or complement fixation test---- Casoni`s test false positive 40%.
TREATMENT 1- except for small & asymptomatic cysts ,the treatment is by surgical removal. Scolicidal agent e.g hypertonic NaCl 25% or povidone iodine. 2- medical treatment Treatment with mebendazole or albendazole is not a good substitute for surgery. Indications 1- elderly frail patient. 2- recurrence. 3- post operative to prevent recurrence. mebendazole 400-600 mg 3 times daily for one month.
Liver tumours Benign 1- true neoplasms---liver cell adenoma(LCA). 2- non-neoplastic lesions---haemangioma & focal nodular hyperplasia. Malignant 1- primary hepatocytes-----hepatocellular carcinoma(HCC). 2- bile duct----------------------cholangiocarcinoma. 3- mixed--------------------------cholangiohepatoma. 4- secondary--------------------from GIT, pancreas, or breast cancer. Liver cell adenoma Is true benign neoplasm of hepatocyte. Aetiology Only in women- contraceptive pills is incriminated-cessation---regression. Pathology Soft,well-circumscribed, & light yellow- multiple in 1/3 of cases. Complications: rare 1- malignant transformation. 2- spontaneous rupture -----internal hemorrhage.
Clinical features - commonly asymptomatic discovered incidentally by US or at laparotomy. - large size--- RT upper quadrant pain. Investigations - US , CT, or MRI. - liver function tests & alpha- fetoprotein are normal. Treatment - liver resection is indicated if doubt exists as to the possibility of malignancy , & for large symptomatic tumour. - contraceptive pills is discontinued & regular checking for size of tumour.
Haemangioma Commonest benign tumours of the liver. Diagnosis US, angiography, MRI, CT with contrast. Treatment Asymptomatic --- no surgery--- involution& calcification. Excision is reserved for the rare lesions that produce pain or bleeding. .
Focal nodular hyperplasia Harmless lesion of the liver whose main importance is the difficult differentiation from other focal lesions. Aetiology Contraceptive pills stimulate development &growth of FNH. Diagnosis The pathognomonic stellate scar can be seen on CT scan. Treatment - most cases require no treatment. - contraceptive pills should be discontinued. - cases that are suspicious of malignancy are explored & subjected to frozen section examination which is diagnostic
Primary liver cancer - commoner in men - Hepatocellular cacinoma( HCC) is the main primary liver malignancy& is prevalent in the Far East& in equatorial African nations( Mozambique). - cholangiocarcinoma arise from intrahepatic bile ducts is much less common than HCC. Aetiology The following conditions are associated with the development of HCC 1- HBV & HCV. 2- Liver cirrhosis. 1&2 --- 90% 3- Aflatoxin ingestion. Formed by fungus Aspergillus flavus which grow on grains that are stored in moist warm conditions.
-Gross appearance yellow in color , it assumes one of different appearance: 1- massive form : i.e forming a localized mass. 2- nodular form. 3- diffuse form. Complications of HCC 1- Spread by lymphatic &venous routes producing porta hepatis nodal enlargement , peritoneal nodules, & less commonly lung deposits. 2- Spontaneous rupture may produce a contained subcapsular hematoma, or massive intraperitoneal hemorrhage.
CholangiocarcinomaIs an adenocarcinoma spread widely inside &outside of the liver.Hepatocholangiocarcinoma Mixed type that behaves like HCC.Hepatoblastoma This is form of HCC that occurs in children. It is termed hepatoblastoma because of the similarity to foetal liver cells.Clinical features1- deterioration of health of known cirrhotic.2- accidentally discovered.3- early detection programme( area where HCC is a common) – US--- alpha-fetoprotein .4- tender mass mistaken for an amoebic liver abscess.5- late cases- pain, jaundice, ascites, hepatomegaly, anorexia, loss of weight and probably massive intraperitoneal haemorrhage.
Investigations Lab.tests 1- S.Alkaline phosophatase is elevated. 2- S. alpha-fetoprotein is elevated in HCC & testicular teratoma->200 ng/ml is suggestive- .>2000ng/ml is diagnostic of HCC. Return to normal after successful tumour resection. Re-elevation in the follow up period signifies a recurrence. Imaging 1- US-CT-MRI. 2- hepatic angiography. 3- chest x-ray & CT scan to search for chest metastases. Treatment 1- resection. 2- systemic chemotherapy. 3- intra-arterial selective chemotherapy. 4- chemoembolization. 5- percutaneous ethanol injection---necrosis.
Liver metastases 20 times > primary Sources 1- portal circulation-commonest- colon ,rectum, pancreas, stomach. 2- hepatic artery- lung, breast, kidney, uterus or ovaries. 3- lymphatics. 4- direct spread- gall bladder, stomach, or colon Clinical features In addition to the manifestations of primary tumour. 1-weight loss, anorexia, fatigue. 2- RT upper abdominal pain. 3- jaundice. 4- ascites. 5- palpable hepatomegaly. Investigations : anaemia-alk.ph- bilirubin.US-CT-MRI. Treatment Chemotherapy--resection