the liver - medinfo2.psu.ac.ththe liver. lobar and segmental anatomy. ... treatment. 1. abscess >...

THE LIVERTHE LIVER

Lobar and segmental anatomyLobar and segmental anatomy

Vascular anatomy (dual blood supplies)

75% 25%

Infectious disease of liverInfectious disease of liver

�� PyogenicPyogenic liver abscess liver abscess

�� Amebic liver abscessAmebic liver abscess

EtiologyEtiology

Liver invasion by bacteria:Liver invasion by bacteria:

�� Ascending infection in Ascending infection in

the the biliarybiliary tracttract

�� Vascular seeding Vascular seeding

(portal or arterial)(portal or arterial)

�� Direct invasion from a Direct invasion from a

nearby sourcenearby source

�� Traumatic implantationTraumatic implantation

Origins and causes of Origins and causes of pyogenicpyogenic liver abscessliver abscess

BiliaryBiliary tracttract LithiasisLithiasis

CholangiocarcinomaCholangiocarcinoma

StricturesStrictures

BiliaryBiliary--enteric enteric anastomosisanastomosis

BiliaryBiliary proceduresprocedures

Portal veinPortal vein AppendicitisAppendicitis

DiverticulitisDiverticulitis

Crohn'sCrohn's diseasedisease

Hepatic arteryHepatic artery Bacterial Bacterial endocarditisendocarditis

Dental infectionDental infection

Direct extensionDirect extension Gall bladder Gall bladder empyemaempyema

Perforated peptic ulcerPerforated peptic ulcer

SubphrenicSubphrenic abscessabscess

TraumaTrauma Abdominal traumaAbdominal trauma

ChemoembolizationChemoembolization

Ethanol injection or radiofrequency Ethanol injection or radiofrequency

ablationablation

CryptogenicCryptogenic

EtiologyEtiology

Depended on cause of abscessDepended on cause of abscess

�� BiliaryBiliary

gramgram--negative aerobic bacilli and negative aerobic bacilli and enterococcienterococci

�� Pelvic/Pelvic/intraperitonealintraperitoneal

Mixed aerobic and anaerobic (Mixed aerobic and anaerobic (BacteroidesBacteroides fragilisfragilis))

�� HematogenousHematogenous/trauma/trauma

Single (Single (StaphStaph aureusaureus, Strep, Strep))

MicrobiologyMicrobiology

Fever (90%)Fever (90%)

RUQ, RUQ, epigastricepigastric painpain

Jaundice (25%)Jaundice (25%)

ChillsChills

AnorexiaAnorexia

Weight lossWeight loss

Nausea, vomitingNausea, vomiting

Weakness, malaiseWeakness, malaise

Clinical manifestationClinical manifestation

↑↑ alkaline alkaline phosphatasephosphatase (80%)(80%)

↑↑ bilirubinbilirubin (20(20--50%)50%)

leukocytosisleukocytosis (70(70--90%)90%)

CXRCXR

�� R R hemidiaphragmhemidiaphragm elevationelevation

�� R basilar infiltrateR basilar infiltrate

�� Unilateral pleural effusionUnilateral pleural effusion


1.Imaging1.Imaging

�� Ultrasound : initial testUltrasound : initial test

�� CT : If suspected CT : If suspected intraabdominalintraabdominal pathologypathology

�� MRI : no benefit over CT scanMRI : no benefit over CT scan

2.Microbial cultures2.Microbial cultures (aerobic, anaerobic)(aerobic, anaerobic)

�� AspirationAspiration

3.Serology3.Serology

�� R/O AmebicR/O Amebic

DiagnosisDiagnosis

1.Abscess management1.Abscess management

2.Underlying cause management2.Underlying cause management

TreatmentTreatment

1.Abscess management1.Abscess management

(1) IV ATB(1) IV ATB

33rdrd gengen cephalosporinscephalosporins+ + metronidazolemetronidazole

oror ampicillin+gentamicin+metronidazoleampicillin+gentamicin+metronidazole

x 10x 10--14 days14 days then then

continue oral ATB until continue oral ATB until 44--6 weeks6 weeks

(2) Drain abscess(2) Drain abscess

-- PercutaneousPercutaneous drainage**drainage**

-- PercutaneousPercutaneous needle aspirationneedle aspiration

-- Surgical drainageSurgical drainage

PCD success rate > PNAPCD success rate > PNA

But PNA may consider in But PNA may consider in unilocularunilocular

abscess < 5 cmabscess < 5 cm

SurgerySurgery

1.Tx primary pathologic process1.Tx primary pathologic process

2.Failed PCD2.Failed PCD

�� PyogenicPyogenic liver abscessliver abscess

�� Amebic liver abscessAmebic liver abscess

EntamoebaEntamoeba histolyticahistolytica

Trophozoite Cyst

PathogenesisPathogenesis

Symptoms like Symptoms like pyogenicpyogenic liver abscessliver abscess but but

delay onset and less sepsisdelay onset and less sepsis

Male : female = 10 : 1, Age < 50 yrsMale : female = 10 : 1, Age < 50 yrs

1/3 diarrhea but 70% of pt : stool exam 1/3 diarrhea but 70% of pt : stool exam negneg

CBC : CBC : leucocytosisleucocytosis without without eosinophiliaeosinophilia

LFT : elevate ALP, LFT : elevate ALP, transminasestransminases


1.circulating amebic antibody 1.circulating amebic antibody (sens&spec95%)(sens&spec95%)

+ +

2.Imaging study : 2.Imaging study : USG USG

CT scan whenCT scan when

No response to medicationNo response to medication

Diagnosis uncertainDiagnosis uncertain

Suspicious complicationSuspicious complication

DiagnosisDiagnosis

MetronidazoleMetronidazole 750 mg 750 mg popo tidtid x 10 days x 10 days

IntraluminalIntraluminal amebicidalamebicidal agentsagents

((IodoquinolIodoquinol, , paromomycinparomomycin ,,diloxanidediloxanide furoatefuroate))

PNA not indicate in every patients but PNA not indicate in every patients but

selected inselected in

TreatmentTreatment

1.1.abscess > 5 cmabscess > 5 cm

2.2.abscess at Lt lobe liverabscess at Lt lobe liver

3.3.secondary bacterial infectionsecondary bacterial infection

4.4.clinical not improve in 3clinical not improve in 3--5 days after 5 days after

medicationmedication

5.5.amebic cytology inconclusive amebic cytology inconclusive

(cannot R/O (cannot R/O pyogenicpyogenic))

6.6.pregnancy pregnancy

(contraindication for (contraindication for metronidazolemetronidazole))

GI portal veinGI portal veinbiliarybiliary tract tract

infectioninfection

Cause Cause

amebaamebabacteria bacteria OrganismOrganism

imaging, imaging,

serologyserology

history, imaging history, imaging

aspiration, aspiration,

hemoculturehemoculture

DiagnosisDiagnosis

amebicidalamebicidalantibiotic + antibiotic +

drainage drainage

Treatment Treatment

right loberight loberight loberight lobeLocationLocation

> 80 % > 80 % 50 % 50 % Solitary Solitary

10 : 110 : 12 : 12 : 1M : FM : F

2020--4040> 50 > 50 Age ( yr)Age ( yr)

ALAALAPLAPLA

Benign liver tumorsBenign liver tumors

Benign liver tumorBenign liver tumor

HepatocyteHepatocyte : hepatic adenoma: hepatic adenoma

: focal nodular hyperplasi: focal nodular hyperplasia a

MesenchymalMesenchymal tissue : tissue : hamartomahamartoma

: : hemangiomahemangioma

HeterotopicHeterotopic tissue : adrenal resttissue : adrenal rest

: pancreatic rest: pancreatic rest

Cavernous Cavernous hemangiomahemangioma

The most common benign tumor of liverThe most common benign tumor of liver

Mean age 50 years; female predominant Mean age 50 years; female predominant

““Giant Giant HemangiomaHemangioma”” –– size size ≥≥ 10 cm10 cm

Pathogenesis Pathogenesis –– not well understoodnot well understood

AsymptomAsymptom

Symptom :Symptom :

-- RuptureRupture

-- CompressionCompression

-- KasabachKasabach Merritt syndromeMerritt syndrome

““Whatever the size, there is Whatever the size, there is no treatment for no treatment for

asymptomatic asymptomatic hemangiomahemangioma””

Rare growth and complicationRare growth and complication

TreatmentTreatment

Indications for surgical resectionIndications for surgical resection

�� Severe abdominal painSevere abdominal pain

�� Rapid enlargement of tumorRapid enlargement of tumor

�� Rupture or potential ruptureRupture or potential rupture

�� Indeterminate diagnosisIndeterminate diagnosis

�� ComplicationComplication

SurgerySurgery : : enucleationenucleation, liver resection or liver, liver resection or liver

transplantation transplantation

Focal nodular hyperplasiaFocal nodular hyperplasia

Benign tumor like lesionBenign tumor like lesion

Hyperplasia/regeneration processHyperplasia/regeneration process

No malignant potentialNo malignant potential

Rarely complicationRarely complication

Asymptomatic pt : no Asymptomatic pt : no TxTx

Indication for surgeryIndication for surgery

Indeterminate diagnosisIndeterminate diagnosis

Severe abdominal pain (R/O other causes)Severe abdominal pain (R/O other causes)

Prefer resection > Prefer resection > enucleationenucleation

TreatmentTreatment

Hepatic adenomaHepatic adenoma

Associated oral contraceptive use Associated oral contraceptive use

Risk of hemorrhage or rupture ~20Risk of hemorrhage or rupture ~20--40%40%

Increase risk of bleedingIncrease risk of bleeding

�� Women taking oral contraceptives Women taking oral contraceptives

�� During pregnancyDuring pregnancy

�� Tumor >4Tumor >4--5 cm5 cm

Risk of malignant transformationRisk of malignant transformation –– 10%10%

size < 4 cm cessation of pill + avoidance size < 4 cm cessation of pill + avoidance

pregnancypregnancy

indication for surgeryindication for surgery

: size > 4 cm: size > 4 cm

: don: don’’t shrink after cessation of pillt shrink after cessation of pill

: can: can’’t stop pill t stop pill

: plan become pregnancy: plan become pregnancy

: rupture: rupture

Procedure of choice = resectionProcedure of choice = resection

TreatmentTreatment

Simple hepatic cystSimple hepatic cyst

Asymptomatic : F.U.Asymptomatic : F.U.

TxTx when only symptomatic ptwhen only symptomatic pt

aspiration only recurrence 100 %aspiration only recurrence 100 %

Choice of treatmentChoice of treatment

1.PAIR (1.PAIR (percutaneouspercutaneous aspiration instillation and aspiration instillation and

reaspirationreaspiration))

2.Unroofing or fenestration 2.Unroofing or fenestration

3.Cystectomy or 3.Cystectomy or hepatectomyhepatectomy : rarely required: rarely required

TreatmentTreatment

BiliaryBiliary cystadenomacystadenoma

multimulti--loculationloculation , internal , internal septationseptation, calcification , papillary , calcification , papillary

projection, thick nodular wall.projection, thick nodular wall.

CystadenomaCystadenoma : : malignant 25 %malignant 25 %

TxTx of choice : of choice : resectionresection

TreatmentTreatment

Malignant liver tumorMalignant liver tumor

�� HepatocellularHepatocellular carcinomacarcinoma

�� CholangiocarcinomaCholangiocarcinoma

�� MetastaticMetastatic liver tumorliver tumor

HepatocellularHepatocellular carcinomacarcinoma

-- Liver cirrhosisLiver cirrhosis

-- Hepatitis B, CHepatitis B, C

-- AflatoxinAflatoxin

-- AlcoholAlcohol

-- HemochromatosisHemochromatosis

-- WilsonWilson’’s diseases disease

Risk factorsRisk factors

-- Symptom of cirrhosisSymptom of cirrhosis

-- Abdominal pain/mass, jaundice, feverAbdominal pain/mass, jaundice, fever

-- AsymptomAsymptom but incidental findingsbut incidental findings


DiagnosisDiagnosis

AASLDAASLD

(American Association for the Surgery of (American Association for the Surgery of

Liver Disease)Liver Disease)

Diagnosis Diagnosis guided by the size of the lesionguided by the size of the lesion

Lesion < 1 cm in diameterLesion < 1 cm in diameter

�� Follow with US q 3 Follow with US q 3 –– 6 months x 2 yrs6 months x 2 yrs

-- Stable lesion Stable lesion �� revert to routine surveillancerevert to routine surveillance

-- Enlarging lesion Enlarging lesion �� proceed according to sizeproceed according to size

Lesion 1 Lesion 1 –– 2 cm in diameter2 cm in diameter

�� 2 dynamic imaging studies2 dynamic imaging studies

-- Typical HCC x 2 technique Typical HCC x 2 technique �� DxDx HCCHCC

-- Others Others �� liver biopsyliver biopsy

Lesion > 2 cm in diameterLesion > 2 cm in diameter

�� One dynamic imagingOne dynamic imaging

-- Typical features of HCC Typical features of HCC �� DiagnosisDiagnosis

-- AFP > 200 AFP > 200 ng/mLng/mL �� DiagnosisDiagnosis

-- Atypical vascular pattern Atypical vascular pattern �� BiopsyBiopsy

HCCHCC

TreatmentTreatment

The BarcelonaThe Barcelona--ClinicClinic-- LiverLiver--Cancer (BCLC) Cancer (BCLC)

staging systemstaging system

Includes variables related to Includes variables related to

�� Tumor stage (Okuda)Tumor stage (Okuda)

�� Liver functional status (ChildLiver functional status (Child’’s s pughpugh))

�� Physical status (WHO)Physical status (WHO)

TreatmentTreatment

Okuda classificationOkuda classificationStageStage Tumor SizeTumor Size AscitesAscites AlbuminAlbumin BilirubinBilirubin

> 50 %> 50 %

( + )( + )< 50%< 50%

( ( -- ))( + )( + ) ( ( -- )) < 3 g/dl< 3 g/dl

( + )( + )> 3 g/dl> 3 g/dl

( ( -- ))> 3 mg/dl> 3 mg/dl

( + )( + )< 3 mg/dl< 3 mg/dl

( ( -- ))

II ( ( -- )) ( ( -- )) ( ( -- )) ( ( -- ))

IIII 1 or 2 ( + )1 or 2 ( + )

IIIIII 3 or 4 ( + )3 or 4 ( + )

ChildChild’’s s pughpugh classificationclassification

Clinical or laboratory Clinical or laboratory

featurefeature1 point1 point 2 points2 points 3 points3 points

Encephalopathy (grade)Encephalopathy (grade) 0 (absent)0 (absent) 1 1 –– 22 3 3 –– 44

AscitesAscites AbsentAbsent SlightSlight PoorlyPoorly

BilirubinBilirubin (mg/dl)(mg/dl) < 2.0< 2.0 2.0 2.0 –– 3.03.0 > 3.0> 3.0

Albumin (g/dl)Albumin (g/dl) > 3.5> 3.5 2.8 2.8 –– 3.53.5 < 2.8< 2.8

INRINR < 1.7< 1.7 1.7 1.7 –– 2.22.2 > 2.3> 2.3

Each feature is assigned 1, 2, or 3 points.Class A: 5 – 6 points; Class B: 7 – 9 points; Class C: 10 – 15 points

WHO performance statusWHO performance statusWorld Health Organization Performance Status gradesWorld Health Organization Performance Status grades

Stage 0Stage 0 Fully active, normal life, no symptomsFully active, normal life, no symptoms

Stage 1Stage 1 Minor symptoms, able to do light activityMinor symptoms, able to do light activity

Stage 2Stage 2 Capable of selfCapable of self--care but unable to carry out work activitiescare but unable to carry out work activities

Up for more than 50% waking hoursUp for more than 50% waking hours

Stage 3Stage 3 Limited self care capacityLimited self care capacity

Confined to bed or chair > 50% waking hoursConfined to bed or chair > 50% waking hours

Stage 4Stage 4 Completely disabledCompletely disabled

Confined to bed or chairConfined to bed or chair

Curative treatmentCurative treatment

1.Resection1.Resection

2.Liver transplantation2.Liver transplantation

3.Radiofrequency ablation3.Radiofrequency ablation

-- Primary Primary sclerosingsclerosing cholangitischolangitis

-- CholedochalCholedochal cystcyst

-- HepatolithiasisHepatolithiasis

-- Liver flukesLiver flukes

-- Prior Prior biliarybiliary--enteric enteric anastomosisanastomosis

-- Toxic substances : nitric oxide Toxic substances : nitric oxide

: nitrosamine : nitrosamine

: : thorotrastthorotrast

-- Congenital hepatic fibrosisCongenital hepatic fibrosis


-- Fever, anorexia, weight loss, Fever, anorexia, weight loss,

abdominal massabdominal mass

--““cholestaticcholestatic jaundicejaundice””

-- Progressive jaundice, dark urine, pale Progressive jaundice, dark urine, pale

stool, stool, prurituspruritus


LFT : direct LFT : direct hyperbilirubinemiahyperbilirubinemia, elevated , elevated

ALPALP

USG : USG : intrahepaticintrahepatic mass, bile duct dilatationmass, bile duct dilatation

CT scan or MRICT scan or MRI

+ tumor marker CA 19+ tumor marker CA 19--99

DiagnosisDiagnosis

Mainstay : Liver resectionMainstay : Liver resection

Other modalities for Other modalities for noncurativenoncurative treatmenttreatment

but poor outcomebut poor outcome

TreatmentTreatment

BILIARY SYSTEMSBILIARY SYSTEMS

Gallstone diseasesGallstone diseases

Gallstone diseaseGallstone disease

Female : male = 3:1Female : male = 3:1


Pregnancy Pregnancy Terminal Terminal ilealileal resectionresection

ObesityObesity Gastric surgery Gastric surgery

Crohn'sCrohn's disease disease Hemolytic anemiaHemolytic anemia

Bile = Bile = bilebile salts, phospholipids, cholesterolsalts, phospholipids, cholesterol

Gallstones due to Gallstones due to imbalanceimbalance rendering rendering

cholesterol & calcium salts insolublecholesterol & calcium salts insoluble

Pathogenesis involves 3 stagesPathogenesis involves 3 stages::

�� 1. cholesterol 1. cholesterol supersaturationsupersaturation in bilein bile

�� 2. crystal nucleation2. crystal nucleation

�� 3. stone growth3. stone growth

Asymptomatic gallstoneAsymptomatic gallstone

3% risk of developing symptoms/ year

2/3 will remain symptom free at 20000 years

No require treatment

Study from Cochrane review 2007

No RCT/meta-analysis about treatment of

asymptomatic gallstone

Some indication for prophylactic Some indication for prophylactic

cholecystectmycholecystectmy

1. Gallstone > 3 cm1. Gallstone > 3 cm

2. Calcified ( porcelain ) gallbladder2. Calcified ( porcelain ) gallbladder

3. Gallbladder polyp > 1 cm3. Gallbladder polyp > 1 cm

4. 4. SplenectomySplenectomy in hemolytic anemia patientin hemolytic anemia patient

5. 5. BariatricBariatric surgery surgery

6. Long term TPN6. Long term TPN

7. Transplant patient needed7. Transplant patient needed

immunosuppressive drug immunosuppressive drug

8. No access to medical care8. No access to medical care

Chronic Chronic cholecystitischolecystitis

Recurrent attack of Recurrent attack of biliarybiliary colic from colic from

recurrent cystic obstruction (from stone)recurrent cystic obstruction (from stone)

Aggravate by fatty meal/supine position Aggravate by fatty meal/supine position

when sleepwhen sleep

Diagnosis : Diagnosis : USUS


GallstoneGallstone

Procedure of choice :Procedure of choice :

Laparoscopic Laparoscopic cholecystectomycholecystectomy

TreatmentTreatment

Acute Acute cholecystitischolecystitis

-- Persistent cystic duct obstruction Persistent cystic duct obstruction leads to leads to

GB distension, wall inflammation & edemaGB distension, wall inflammation & edema

-- Can lead to: Can lead to: empyemaempyema, gangrene, rupture, gangrene, rupture

EpigastriumEpigastrium/RUQ pain /RUQ pain >24hr>24hr

Radiate to Radiate to interscapularinterscapular or or RtRt

scapular areascapular area

Anorexia, nausea/vomiting and fever Anorexia, nausea/vomiting and fever

Palpable/tender or even Palpable/tender or even visiblevisible RUQ massRUQ mass

Positive Murphy's signPositive Murphy's sign

( ( inspiratoryinspiratory arrest with deep palpation in the right arrest with deep palpation in the right subcostalsubcostal area) area)


LabLab : :

Moderate Moderate leucocytosisleucocytosis

(WBC 12,000(WBC 12,000--15,000 cells/mm3) 15,000 cells/mm3)

If WBC > 20,000 cells/mm3 : complicated If WBC > 20,000 cells/mm3 : complicated

cholecystitischolecystitis

Mild abnormal LFT, jaundice Mild abnormal LFT, jaundice no more than 4 no more than 4

mg/dlmg/dl

Study of choice = Study of choice = USUS

Gallstones, Gallstones, sonographicsonographic MurphyMurphy’’s signs sign

gallbladder wall thickening, distended gallbladder wall thickening, distended

gallbladder, gallbladder, pericholecysticpericholecystic fluidfluid

DiagnosisDiagnosis

-- NPONPO

-- IV fluid resuscitationIV fluid resuscitation

-- IV ATB cover gram IV ATB cover gram negneg aerobe/anaerobeaerobe/anaerobe

(3(3rdrd generation generation cephalosporinscephalosporins with good with good

anaerobic coverage or 2anaerobic coverage or 2ndnd generation generation

cephalosporinscephalosporins plus plus metronidazolemetronidazole))

TreatmentTreatment

Every patients must surgery Every patients must surgery except except

medically unfit patientsmedically unfit patients

Timing of surgeryTiming of surgery

Early VS. delayed Early VS. delayed cholecystectomycholecystectomy

(early = (early = SxSx in 3 days, in 3 days,

delayed = delayed = SxSx in 6in 6--10 wks after disease)10 wks after disease)

If patients present If patients present within 3 dayswithin 3 days of onset prefer of onset prefer

early early cholecystectomycholecystectomy

If patients present If patients present > 3 days> 3 days of onset prefer of onset prefer

delayed delayed cholecystectomycholecystectomy except in except in unresponseunresponse

to ATB or complicated to ATB or complicated cholecystitischolecystitis

Medically unfit patientsMedically unfit patients considerconsider

cholecystostomycholecystostomy and delayed and delayed cholecystectomycholecystectomy

if patients recover and fit for surgeryif patients recover and fit for surgery

CholedocholithiasisCholedocholithiasis

66--12% of gallstone patients12% of gallstone patients

Classified intoClassified into

(1) Primary CBD stone(1) Primary CBD stone

(2) Secondary CBD stone(2) Secondary CBD stone

Obstructive jaundice, Obstructive jaundice, cholangitischolangitis, gallstone , gallstone

pancreatitispancreatitis


LFTLFT : direct : direct hyperbilirubinemiahyperbilirubinemia, elevated , elevated

ALP ALP

USUS : CBD obstruction, proximal BD: CBD obstruction, proximal BD

dilatationdilatation

DiagnosisDiagnosis

Sensitivity Specificity AccuracySensitivity Specificity Accuracy

TUSTUS 2020--80% 80% 95%95%

CT CT 2323--85% 85% 95% 95% 71% 71%

ERCP ERCP 7979--95% 95% 9292--100% 100% 97%97%

MRCPMRCP 7171--100% 100% 9393--100% 100%

EUSEUS 8888--96% 96% 9696--100% 100% 95%95%

IOC IOC 93.5% 93.5% 93.3%93.3%

DiagnosisDiagnosis

CholangitisCholangitis

PathogenesisPathogenesis

BacteribiliaBacteribilia + + intraductalintraductal hypertensionhypertension

MicrobiologyMicrobiology

Escherichia coliEscherichia coli

KlebsiellaKlebsiella pneumoniaepneumoniae

Streptococcus Streptococcus faecalisfaecalis

BacteroidesBacteroides fragilisfragilis

1.Fever with chills1.Fever with chills

2.RUQ pain2.RUQ pain

3.Jaundice3.Jaundice

��CharcotCharcot’’s triads triad

5% of patients = acute toxic 5% of patients = acute toxic cholangitischolangitis

(Charcot(Charcot’’s triad + hypotension + mental s triad + hypotension + mental

status change = status change = ReynoldReynold’’ss pentadpentad))


CBC : CBC : leucocytosisleucocytosis

LFT : LFT : hyperbilirubinemiahyperbilirubinemia, elevation of ALP and , elevation of ALP and

transaminasestransaminases

Initial imaging : US Initial imaging : US

Definite diagnosis :Definite diagnosis : ERC or PTCERC or PTC

If suspected cancer : CT or MRIIf suspected cancer : CT or MRI

DiagnosisDiagnosis

-- NPONPO

-- IV fluid resuscitationIV fluid resuscitation

-- IV ATBIV ATB

-- ERCP with drainage or PTBDERCP with drainage or PTBD

ATC : emergency ATC : emergency biliarybiliary drainagedrainage

TreatmentTreatment

Malignant neoplasm Malignant neoplasm

�� Gallbladder carcinomaGallbladder carcinoma

�� ExtrahepaticExtrahepatic cholangiocarcinomacholangiocarcinoma

Gallbladder carcinoma Gallbladder carcinoma

IncidenceIncidence

-- 55thth common GI cancercommon GI cancer

-- elderly ( > 70 yrs)elderly ( > 70 yrs)

-- F : M = 2F : M = 2--3 : 13 : 1

-- 7070--90 % +90 % +veve GSGS

-- < 0.5% GS +< 0.5% GS +veve GB cancerGB cancer

-- adenoadeno. CA.. CA. 90%90%

1) large GS > 3 cm1) large GS > 3 cm

2) calcified GB wall ( porcelain GB ) 2) calcified GB wall ( porcelain GB )

3) 3) choledochalcholedochal cystcyst

4) chronic inflammatory state : typhoid 4) chronic inflammatory state : typhoid

,,H.pyloriH.pylori

5) GB polyp > 1 cm5) GB polyp > 1 cm

6) anomalous 6) anomalous pancreaticobiliarypancreaticobiliary duct duct

junction ( APBDJ )junction ( APBDJ )

7) carcinogen : 7) carcinogen : azotolueneazotoluene , nitrosamine, nitrosamine


Porcelain gallbladderPorcelain gallbladder

CholedochalCholedochal cystcyst

SimilarSimilar cholecystitischolecystitis or or cholelithiasischolelithiasis

May May asymptomasymptom

2525--50% : jaundice50% : jaundice

50% of patients cannot 50% of patients cannot DxDx GB CA before GB CA before

surgerysurgery


Initial test : USInitial test : US

Imaging before Imaging before TxTx : MRCP: MRCP

CTCT

Tumor marker : CA 19Tumor marker : CA 19--99

PreopPreop tissue tissue DxDx : not necessary except : not necessary except

in advance CA before chemoin advance CA before chemo

DiagnosisDiagnosis

Gallbladder carcinomaGallbladder carcinoma

Tumor not beyond Tumor not beyond muscularismuscularis propriapropria

TTxx : : Simple Simple cholecystectomycholecystectomy

TreatmentTreatment

Tumor beyond Tumor beyond muscularismuscularis propriapropria but not but not

beyond beyond serosaserosa

TTxx : : Extended Extended cholecystectomycholecystectomy

(simple (simple cholcystecomycholcystecomy + segment IVb,5 + segment IVb,5

resection + regional resection + regional lymphadenectomylymphadenectomy))

TreatmentTreatment

Tumor perforate Tumor perforate serosaserosa, invade liver or , invade liver or

adjacent organsadjacent organs

TTxx :: Extended RT. Extended RT. HepatectomyHepatectomy

(IV(IV--VIII)VIII)

TreatmentTreatment

MetastaticMetastatic diseasesdiseases

TTxx : : palliation for pain or jaundicepalliation for pain or jaundice

(ERCP/PTBD)(ERCP/PTBD)

TreatmentTreatment

Classified intoClassified into

1)1) HilarHilar : : KlatskinKlatskin’’ss tumor, 2/3tumor, 2/3

2)2) MiddleMiddle

3)3) LowerLower

CholestaticCholestatic jaundice (painless) jaundice (painless)

Clinical Clinical cholangitischolangitis

Anorexia, weight lossAnorexia, weight loss


Initial test : USInitial test : US

Imaging before Imaging before TxTx : MRCP: MRCP

CT + ERCP/PTCCT + ERCP/PTC

Tumor marker : CA 19Tumor marker : CA 19--99

PreopPreop tissue tissue DxDx : not necessary except : not necessary except

in advance CA before chemoin advance CA before chemo

DiagnosisDiagnosis

HilarHilar lesionlesion : Bismuth: Bismuth--CorletteCorlette

TreatmentTreatment

Type I bile duct resection Type I bile duct resection ±± segment 1segment 1

Type II bile duct resection Type II bile duct resection ++ segment 1segment 1

Type Type IIIaIIIa Rt. Rt. hepatectomyhepatectomy

Type Type IIIbIIIb Lt. Lt. hepatectomyhepatectomy

Type IV palliationType IV palliation

TreatmentTreatment

Middle lesion : major common bile duct Middle lesion : major common bile duct

resectionresection

Distal lesion : Whipple operationDistal lesion : Whipple operation

TreatmentTreatment

Approach to jaundiceApproach to jaundice

JaundiceJaundice

Jaundice

Prehepatic Hepatic Posthepatic

Jaundice

Unconjugated ConjugatedHyperbilirubinemia Hyperbilirubinemia

Jaundice

Hemolytic Hepatocellular Cholestatic

JaundiceJaundice

Medical jaundice Surgical jaundice

Symptoms/signs of surgical jaundiceSymptoms/signs of surgical jaundice

Jaundice with dark urine, pale stool and Jaundice with dark urine, pale stool and prurituspruritus

Abdominal painAbdominal pain

History of previous History of previous biliarybiliary tract surgerytract surgery

Abdominal mass/RUQ mass/CourvoisierAbdominal mass/RUQ mass/Courvoisier’’s law s law

LFT : direct LFT : direct hyperbilirubinemiahyperbilirubinemia, elevated ALP, elevated ALP

UA : Bile+, UA : Bile+, urobilinogenurobilinogen --

Suspicion surgical jaundice Suspicion surgical jaundice ��

USUS then then

ERCP/PTCERCP/PTC

THANK YOUTHANK YOU

the liver - medinfo2.psu.ac.ththe liver. lobar and segmental anatomy. ... treatment. 1. abscess >...

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