liver by michael brillantes, md, fpcs, fpsgs. i.anatomy -1/50 of total body weight -surgically...
TRANSCRIPT
![Page 1: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/1.jpg)
LIVER
By
Michael Brillantes, MD, FPCS, FPSGS
![Page 2: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/2.jpg)
I. Anatomy
-1/50 of total body weight
-Surgically divided into the right and
left lobe by a line through the IVC and
gallbladder (Cantlie’s line)
![Page 3: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/3.jpg)
-left lobe divided into medial and lateral
segments by falciform ligament
-blood supply hepatic a. - 25%
portal v – 75%
![Page 4: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/4.jpg)
II. Liver function
A.Circulatory function- material absorbed from the GI tract are brought to the liver through the dual blood supply to be used in the metabolic pool
![Page 5: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/5.jpg)
B. Biliary passages- channel of exit for
materials secreted by the liver through the
dual blood supply to be used in the
metabolic pool
![Page 6: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/6.jpg)
C. Reticuloendohelial system- contains
phagocytic Kupffer cells and endothelial
cells
D. Metabolic Activity- anabolic and
catabolic activities
![Page 7: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/7.jpg)
III. Function Tests
a. Albumin – half- life is 21 days; decrease means a chronic liver disease (more than 3 wks)
![Page 8: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/8.jpg)
B. Carbohydrates and Lipids- hepatic
disease causes decrease in glycogenesis
with resultant hyperglycemia
![Page 9: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/9.jpg)
C. Enzymes
1.Alkaline phospatase- increase indicates
an obstructive pathology
![Page 10: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/10.jpg)
2. SGOT and SGPT- increase indicates liver
cellular damage; SGPT more applicable for
hepatic disease
3. Dye excretion
![Page 11: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/11.jpg)
4. Coagulation factors
a. Vit. K dependent clotting factors II, VII, IX, and X
b. Inability to synthesize prothrombin
![Page 12: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/12.jpg)
IV. Special Studies
A. Needle Biopsy- provides pathologic diagnosis
B. Ultrasound, CT scan, MRI
C. Angiography
![Page 13: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/13.jpg)
V. Pathology
A.Trauma- 2nd most commonly injured organ
1. Clinical manifestation- shock, abdominal pain, spasm, and rigidity
![Page 14: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/14.jpg)
2. Diagnostic- CT scan is the most useful
- may also use ultrasound, paracentesis or peritoneal lavage
![Page 15: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/15.jpg)
3. Treatment
a.Correct shock- IVF and blood
b.Surgery
i. Control bleeders- perihepatic packaging, ligation of bleeders, Pringle maneuver
ii.Debridement
iii.External drainage
![Page 16: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/16.jpg)
4. Complications
a.Recurrent bleeding- inadequate homostasis or loss of coagulation factors secondary to massive transfusions
b.Intraabdominal sepsis
![Page 17: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/17.jpg)
C. Hematobilia- free communication between blood vessel and biliary tree
- triad of abdominal pain, GI bleeding, and previous trauma
- jaundice may be present
![Page 18: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/18.jpg)
B. Hepatic Absdess
1. Pyogenic- most commonly due to
cholangitis secondary to CBD obstruction;
septicemia second most common etiology
![Page 19: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/19.jpg)
- Fever with “picket fence” pattern, hepatomegally and tenderness
-organism- usually e. coli
-usually found in the right lobe, solitary or multiple
![Page 20: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/20.jpg)
- Presents with hepatic tenderness and fever
a.Diagnostic
i. CBC- leukocytosis, with count up to 18-20,000
![Page 21: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/21.jpg)
ii. Radiograph- immobility or elevation of right hemidiaphragm
iii. Ultrasound or CT scan
![Page 22: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/22.jpg)
b. Treatment
I .Antibiotics- IV for 2 wks, followed by 1 month oral form
II. Drainage- percutaneous under ultrasound or CT guidance, or open
![Page 23: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/23.jpg)
2. Amebic- reaches the liver via the portal vein from an ulceration in the bowel wall
-organism- e. histolytica
-occurs in the right lobe, usually solitary, with characteristic “anchovy paste”
![Page 24: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/24.jpg)
-Fever and liver pain, assoc. woth tender hepatomegally
-33% with antecedent diarrhea
![Page 25: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/25.jpg)
a.Diagnostic
i. CBC- leukocytosis
ii. Indirect heme agglutinstion test
iii. Ultrasound
iv. Aspiration of trophozoites
![Page 26: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/26.jpg)
b. Complications
i. Secondary bacterial infection
ii. rupture
![Page 27: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/27.jpg)
c. Treatment
i. Amebicidal drugs- Metronidazole 500 mg TID
ii. Surgery – indicated for persistence of abscess, secondary infection
![Page 28: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/28.jpg)
C. Cysts
1. Non- parasitic – usually solitary,
found in the right lobe, watery content,
with low internal pressure
![Page 29: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/29.jpg)
-polycystic liver assoc. with polycystic kiny in 51.6% of cases
-usually presents as a RUQ mass
![Page 30: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/30.jpg)
a.Classification
i. Blood or degenerative
ii.Dermoid
iii.Lymphatic
iv.Endothelial
v.Retention – polycystic liver
vi.Proliferative cysts- cystadenomas
![Page 31: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/31.jpg)
b. Diagnostic – ultrasound, CT scan, arteriography, scintillography, peritoneoscopy
c. Asymptomatic- no treatment
Symptomatic- drainage with unroofing or sclerotherapy
![Page 32: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/32.jpg)
2. Hydatid cysts- caused by Echinococcus granulosus
- with high internal pressure, causing rupture and anaphylactic reaction
![Page 33: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/33.jpg)
- Asymptomatic unless there are pressure symptoms on adjacent organs
a.Diagnostic- radiograph, ultrasound and CT scan
-Casoni’s skin test
![Page 34: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/34.jpg)
b. Treatment
i. small calcified cyst- no treatment
ii. Sterilizationof cyst prior to surgery with hypertonic saline or alcohol followed by surgical removal
![Page 35: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/35.jpg)
D. Benign Tumors
1. Classification
a. Hamartomas- tissues normally found in the organ but arranged in a disorderly manner
![Page 36: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/36.jpg)
b. Adenoma- associated with contraceptive
use; may transform into hepatocellular
carcinoma; high rate of bleeding
![Page 37: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/37.jpg)
c. Focal nodular hyperplasia- reaction to
injury or a response to a preexisting
vascular malformation
d. Hemangioma- most common nodule in the liver
![Page 38: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/38.jpg)
2. Diagnostic- ultrasound, CT scan, angiography
3. Treatment- excision if symptomatic
![Page 39: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/39.jpg)
E. Malignant lesions
1. Primary carcinoma- from Aspergillus flavus, kwashiorkor
![Page 40: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/40.jpg)
A.Classification
i. hepatoblastoma- usually affects children less than 2 years old.
![Page 41: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/41.jpg)
ii. Fibrolamellar carcinoma- adolescent and young adults; large solitary lesion
iii. Hepatocellular carcinoma- most common primary malignancy, usually follows postnecrotic cirrhosis (hepatitis B)
![Page 42: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/42.jpg)
-Manifested by mass, weight loss, abdominal pain, or intraperitoneal hemorrhage
![Page 43: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/43.jpg)
b. Diagnostic
i. Liver function test- alkaline phosphatase
ii. Alpha Feto Protein
![Page 44: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/44.jpg)
iii. Angiography
iv. Ultrasound, intraoperative ultrasound, CT scan, MRI
![Page 45: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/45.jpg)
c. Treatment- curative resection, chemotherapy with direct arterial infusion
![Page 46: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/46.jpg)
2. Other Primary Neoplasms
a.Sacroma- angiosacroma most common
b.Mesenchymoma
c.Infantile hemangioendothelioma
![Page 47: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/47.jpg)
3. Metastatic neoplasms
- most common malignant tumor of the liver
- reach the liver by portal vein, hepatic artery, lymphatics, direct extension
![Page 48: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/48.jpg)
-Symptoms are usually referable to the liver (i.e. pain, ascites, weight loss, anorexia and jaundice
![Page 49: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/49.jpg)
a.Diagnostic
i. alkaline phosphatase
ii. Serum marker referable to the primary carcinoma
iii. SGOT
iv. CT scan, MRI
![Page 50: LIVER By Michael Brillantes, MD, FPCS, FPSGS. I.Anatomy -1/50 of total body weight -Surgically divided into the right and left lobe by a line through](https://reader035.vdocuments.site/reader035/viewer/2022062618/55142dfe550346ec488b5e29/html5/thumbnails/50.jpg)
b. Treatment
i. Control primary tumor
ii.Check for other systemic metastases
iii.Patient should be able to tolerate a major resection
iv.Resection of metastasis should be feasible