LIVER DISEASEDr.Mohmmadzadeh

Anatomy •Largest solid organ of body•Weight : 1.5 kg•From the nipple line in 4th intercostal

down to the costal margin•Falciform ligament & ligamentum teres

hepaticus

Portal vein

•A valveless vein•Confluence of the smv & splenic vein•75% of total liver blood•Normal pressure 3-5 mmHg

Hepatic veins

•Three hepatic veins•Right H.V drains segments V,VI,VII,VIII•Middle H.V drains segments

IVA,IVB,V,VIII•Left H.V drains segments II,III

Hepatic artery

•From celiac trunk & give off gastroduodenal & right gastric artery

•Cystic artery from right hepatic artery

Biliary system

•Canaliculi canal of Hering small duct R & L hepatic ducts common hepatic duct common bile duct

•Normal CBD is less than 10 mm

Synthetic functions

•Coagulation factors•Albumin a variety of acute-phase proteins

& cytokines

Carbohydrate metabolism

•Critical storage site of glycogen•Metabolization of lactate % Cori cycle

Lipid metabolism

•Synthesis of lipoproteins, triglycerides,•Gluconeogenesis from fatty acics•Cholestrol metabolism

Bilirubin metabolism

•A product of heme metabolism•Glucuronidated in liver & actively

secreted in bile•One liver sector is adequate for bilirubin

secretion•Electrolyte composition of bile is similar

to plasma

Radiologic evaluation of liver

•Ultrasound : cirrhosis or fatty liver cystic or solid nature of

tumors for screening in high-risk

population of HCC IOUS•CT-scan : smallest detectable lesion 1 cm cystic or solid nature•MRI : more sensitive for early HCC

•PET scan : hepatic metastsis of colorectal cancer

less useful for HCC•Angiogeraphy•Percutaneous biopsy•Diagnostic laparascopy

Cystic diseases of the liver

•Congenital cysts

•Polycystic liver disease

Congenital cyst

•Most common benign lesion•Dose not contain bile•Recurrence of simple aspiration is high•PAIR •Wide cyst fenestration

Polycystic liver disease

•An autosomal dominant presenting in adulthood

•Three general anatomic presentation•PAIR•Fenestration•Resection of cyst•Formal lobectomy•Transverse hepatectomy

Benign solid liver tumors

•Hepatic adenoma•Focal nodular hyperplasia

•Hemangioma •Hamartoma

Hepatic adenoma

•In reproductive –aged women•In women who used OCPs•Pathology : sheets of hepatocytes ith no

nonparanchymal cells or bile ducts•75% symptomatic•They can rupture•Radiographycally difficult to distinguish

from FNH•Management : cessation of OCPs -

surgery-RFA

FNH

•Asymptomatic ,does not rupture ,no malignant

•Two third of lesions have central scar•Resection in symptomatic lesions

Hemangioma •A common benign lesion discovered

incidentally•Chronic low-intestity RUQ pain•US , CT-scan , MRI•Atypical hemangioma : Tc99 -labeled red

cell•Resection in symptomatic lesions

Hamartoma •Most common liver lesion in laparotomy•Peripheral ,firm & smooth•Usually less than 1-3 mm

Pyogenic liver abscesses

•In past : appendicitis & pylephlebitis•Currently : biliary tract manipulation ,

diverticular disease ,IBD ,systemic infections , ERCP, cryptogenic (one third )

•RUQ pain, fever, jaundice•US ,CT•Percutaneous aspiration•Laparoscopy

Amebic abscess

•A recent history of diarrhea is uncommon•Sweating & chills for one week ,RUQ pain

& tenderness•Positive fluorescent antibody test •Mild liver enzymes abnormality•Metronidazole at least for one week•Aspiration

Computed tomographic scan finding for an adenoma.

Classic appearance of hemangioma on magnetic resonance imaging.

Appearance of a giant adenoma on computed tomography.

Computed tomographic appearance of fibronodular hyperplasia lesion.

Magnetic resonance imaging appearance of a fibronodular hyperplasia lesion in the

right liver, seen on T1-weighted (A) and T2-weighted (B) images.

Hepatocellular carcinoma• Hepatocellular carcinoma (HCC) is the most

common primary malignancy of the liver and one of the most common malignancies worldwide, accounting for more than 1 million death annually

• The geographic distribution of HCC is clearly related to the incidence of hepatitis B virus (HBV) infection.

• HCC is two to eight times more common in males than in females in low and high incidence areas

• In general, the incidence of HCC increases with age, but a tendency to develop HCC earlier in high incidence areas has been noted.

Ethiology •Hepatic viral infections•Environmental exposure•Alcohol use ,smoking•Genetic & metabolic diseases•Cirrhosis •OCPs

Clinical Presentation• Most commonly, patients presenting with HCC are

men 50 to 60 years of age who complain of right upper quadrant abdominal pain and weight loss and have a palpable mass.

• Nonspecific symptoms of advanced malignancy such as anorexia, nausea, lethargy, and weight loss are common. .

• Another common presentation of HCC is hepatic decompensation in a patient with known mild cirrhosis or even in patients without previously recognized cirrhosis

Diagnosis• Radiologic investigation is a critical part of

the diagnosis of HCC

• ultrasound, CT, and MRI

• Ultrasound plays a significant role in screening and early detection of HCC

• definitive diagnosis and treatment planning rely on CT and MRI.

AFP measurements • AFP measurements can be very helpful in

the diagnosis of HCC.

• An AFP level greater than 20ng/mL is noted in about three fourths of documented cases of HCC.

• False-positive elevations of serum AFP can be seen in inflammatory disorders of the liver, such as chronic active viral hepatitis

Treatment Options for Hepatocellular Carcinoma•Surgical Resection

Orthotopic liver transplantation•Ablative EtOH injection

Acetic acid injection Thermal ablation (cryotherapy, radiofrequency ablation, microwave)