31-surgery - surgical aspects of liver diseases

8/7/2019 31-Surgery - Surgical Aspects of Liver Diseases

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Surgical aspects of liverSurgical aspects of liver

diseasesdiseases


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Liver anatomyLiver anatomy


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INFECTIOUS DISEASESINFECTIOUS DISEASES

Pyogenic AbscessPyogenic Abscess

Amoebic liver abscessAmoebic liver abscessHydatid diseaseHydatid disease


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Pyogenic liver abscessesPyogenic liver abscesses

AetiologyAetiology

Most pyogenic liver abscesses areMost pyogenic liver abscesses aresecondary to infection originating in thesecondary to infection originating in theabdomen.abdomen. CholangitisCholangitis due to stones ordue to stones orstrictures is the commonest cause,strictures is the commonest cause,followed by abdominal infection due tofollowed by abdominal infection due to

diverticulitis or appendicitisdiverticulitis or appendicitis. In. In 1515% of% ofcases no cause can be found (cryptogeniccases no cause can be found (cryptogenicabscesses)abscesses)


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Origins and causes of pyogenic liverOrigins and causes of pyogenic liver

abscessabscessxx BiliarytractBiliarytract

Gall stonesGall stones

CholangiocarcinomaCholangiocarcinoma

StricturesStricturesxx Portal veinPortal vein

AppendicitisAppendicitis

DiverticulitisDiverticulitis

Crohn's diseaseCrohn's diseasexx HepaticarteryHepaticartery

Dental infectionDental infection

Bacterial endocarditisBacterial endocarditis

xx DirectextensionDirectextension of:of:

Gall bladder empyemaGall bladder empyema

Perforated peptic ulcerPerforated peptic ulcer

Subphrenic abscessSubphrenic abscessxx TraumaTrauma

xx IatrogenicIatrogenic

Liver biopsyLiver biopsy

Blocked biliary stentBlocked biliary stentxx CryptogenicCryptogenic

xx SecondaryinfectionofSecondaryinfectionoflivercystlivercyst


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MicrobiologyMicrobiology

Most patients presenting with pyogenic liverMost patients presenting with pyogenic liverabscesses have a polymicrobial infection usuallyabscesses have a polymicrobial infection usuallywithwith Gram egative aerobic and anaerobicGram egative aerobic and anaerobicorganismsorganisms. Most organisms are of bowel origin,. Most organisms are of bowel origin,withwith Escherichia coli, Klebsiella pneumoniae,Escherichia coli, Klebsiella pneumoniae,bacteroides, enterococci, anaerobicbacteroides, enterococci, anaerobicstreptococci, and microaerophilic streptococcistreptococci, and microaerophilic streptococci

being most commonbeing most common. Staphylococci, haemolytic. Staphylococci, haemolyticstreptococci, andstreptococci, and Streptococcus milleriStreptococcus milleriareareusually present if the primary infection isusually present if the primary infection isbacterial endocarditis or dental sepsisbacterial endocarditis or dental sepsis


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ClinicalfeaturesClinicalfeatures

x Right upper quadrant pain and tendernessx Right upper quadrant pain and tenderness

x Nocturnal fevers and sweatsx Nocturnal fevers and sweatsx Anorexia and weight lossx Anorexia and weight loss

x Raised right hemidiaphragm in chestx Raised right hemidiaphragm in chest

radiographradiographx Raised white cell count and erythrocytex Raised white cell count and erythrocyte

sedimentation rate with mild anaemiasedimentation rate with mild anaemia


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TreatmentTreatment

Antibiotics should includeAntibiotics should include penicillin, an aminoglycoside,penicillin, an aminoglycoside,and metronidazoleand metronidazole. In elderly people and those with. In elderly people and those withimpaired renal function aimpaired renal function a third generation cephalosporinthird generation cephalosporin

should be used instead of an aminoglycoside. Theshould be used instead of an aminoglycoside. Theregimen should be modified after culture has identifiedregimen should be modified after culture has identifiedthe infective organism.the infective organism.

Treatment is continued for two to four weeksTreatment is continued for two to four weeks

Antibiotics alone are effective in only a few patients, andAntibiotics alone are effective in only a few patients, andmost patients will requiremost patients will require percutaneous aspiration orpercutaneous aspiration orcatheter drainagecatheter drainage guided by ultrasonography orguided by ultrasonography orcomputed tomographycomputed tomography..


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Amoebic liver abscessAmoebic liver abscess

Entamoeba histolyticaEntamoeba histolytica

The abscess isThe abscess is usually solitary and affectsusually solitary and affects

the right lobe inthe right lobe in 8080% of cases% of cases. The. Theabscess contains sterile pus andabscess contains sterile pus and

reddish-brown (anchovy paste) liquefiedreddish-brown (anchovy paste) liquefied

necrotic liver tissue. Amoebae arenecrotic liver tissue. Amoebae are

occasionally present at the periphery ofoccasionally present at the periphery ofthe abscess.the abscess.


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SymptomsofamoebicliverabscessSymptomsofamoebicliverabscess

x Painx Pain

x Enlarged liver with maximal tenderness over abscessx Enlarged liver with maximal tenderness over abscess

x Intermittent fever (x Intermittent fever (3838--3939C)C)x Night sweatsx Night sweats

x Weight lossx Weight loss

x Nauseax Nausea

x Vomitingx Vomiting

x Coughx Cough

x Dyspnoeax Dyspnoea


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TreatmentTreatment

Ninety five per cent of uncomplicatedNinety five per cent of uncomplicatedamoebic abscesses resolve withamoebic abscesses resolve withmetronidazolemetronidazole alone (alone (800800 mg, three timesmg, three timesa day for five days).a day for five days).

After the amoebic abscess has beenAfter the amoebic abscess has been

treated, patients are prescribedtreated, patients are prescribed diloxanidediloxanidefuroatefuroate 500500 mg, eight hourly for sevenmg, eight hourly for sevendays, to eliminate intestinal amoebae.days, to eliminate intestinal amoebae.


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Hydatid disease of the liverHydatid disease of the liver

Echinococcus granulosusEchinococcus granulosus


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PresentationPresentation

Liver enlargement and right upper quadrant painLiver enlargement and right upper quadrant painComplications include rupture of the cyst into theComplications include rupture of the cyst into theperitoneal cavity, which results in urticaria,peritoneal cavity, which results in urticaria,anaphylactic shock, eosinophilia, andanaphylactic shock, eosinophilia, andimplantation into the omentum and otherimplantation into the omentum and otherviscera.viscera.

Cysts may compress or erode into a bile ductCysts may compress or erode into a bile duct

causing pain, jaundice, or cholangitis,causing pain, jaundice, or cholangitis,or the cyst may become infected secondary to aor the cyst may become infected secondary to abile leak.bile leak.


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DiagnsosisandtreatmentDiagnsosisandtreatment

Ultrasonography and computed tomographyUltrasonography and computed tomography

Eosinophilia is present inEosinophilia is present in 4040% of patients% of patients

The diagnosis is confirmed by haemagglutinationThe diagnosis is confirmed by haemagglutination

and complement fixation testsand complement fixation tests

ERCP in jaundiced patientsERCP in jaundiced patients

All symptomatic cysts require surgical removal toAll symptomatic cysts require surgical removal to

prevent complicationsprevent complications


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Liver tumorsLiver tumors

Incidentalsolidlivertumors: DiagnosticfrequencyforvariousIncidentalsolidlivertumors: Diagnosticfrequencyforvarious

histologieshistologies

TumorRelative frequencyTumorRelative frequency

HemangiomaHemangioma 5252%%

Focal nodular hyperplasiaFocal nodular hyperplasia 1111%%

Metastatic tumor (TxNxMMetastatic tumor (TxNxM11)) 1111%%

Hepatocellular adenomaHepatocellular adenoma 88%%

Focal fatty infiltrationFocal fatty infiltration 88%%

Hepatocellular carcinomaHepatocellular carcinoma 66%%

Extrahepatic processExtrahepatic process 33%%

(e.g., abscess, adrenal tumor)(e.g., abscess, adrenal tumor)Other benign hepatic processOther benign hepatic process 11%%


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Benign tumoursBenign tumours

Usually asymptomatic. Although most needUsually asymptomatic. Although most need

no treatment, it is important to be able tono treatment, it is important to be able to

differentiate them from malignant lesions.differentiate them from malignant lesions.

HaemangiomasHaemangiomas

The commonest benign solid tumours ofThe commonest benign solid tumours ofthe liverthe liver


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LivercelladenomaLivercelladenomaLiver cell adenoma became more prevalent with theLiver cell adenoma became more prevalent with the

widespread use ofwidespread use oforal contraceptivesoral contraceptives in thein the 19601960s, buts, but

the reduced oestrogen content of modern contraceptivesthe reduced oestrogen content of modern contraceptiveshas made it less common.has made it less common.

The risk of rupture isThe risk of rupture is 1010%, and malignant transformation is%, and malignant transformation is

found infound in 1010% of resected specimens. Patients should% of resected specimens. Patients should

have liver resection to prevent these eventshave liver resection to prevent these events..


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FocalnodularhyperplasiaFocalnodularhyperplasia

not related to use of oral contraceptivesnot related to use of oral contraceptives

usually asymptomaticusually asymptomatic

Not premalignantNot premalignant

Mass lesions usually contain a central stellate scarMass lesions usually contain a central stellate scar

on computed tomography and magnetic resonanceon computed tomography and magnetic resonance

imaging.imaging.It does not require treatment unless symptomaticIt does not require treatment unless symptomatic


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Malignant tumorsMalignant tumors

PrimaryPrimary

Hepatocellular carcinomaHepatocellular carcinoma

Intrahepatic CholangiocarcinomaIntrahepatic Cholangiocarcinoma

HepatoblastomaHepatoblastoma

MetastaticMetastatic

ColorectalColorectalNeuroendocrineNeuroendocrine

Noncolorectal, NonNoncolorectal, Non--neuroendocrineneuroendocrine


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31-surgery - surgical aspects of liver diseases

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