LIVER LESION SARAH AWAISHEH, BAU

LIVER ANATOMY

• It is the largest abdominal organ 1500g

• ribs & cc’s (6-10 on R, 6 & 7 on L)

• Two lobes Cantle’s line

• Two surfaces :

- Diaphragmatic surface ‘bare area’ of the liver

- Visceral surface With the exception of the fossa of the gallbladder and porta hepatis, it is

covered with peritoneum.

LIVER ANATOMY

• Protected by rib cage

• Glisson’s capsule

• 8 ligaments :

Coronary ligament : anterior and posterior fold

Triangular ligament : right and left

Falciform ligament :Sickle-shaped

Ligamentum teres

Ligamentum venosum

Lesser omentum : hepatogastric ligament, hepatoduodenal ligament

LIVER ANATOMY

Hepatic artery 25%

Dual supply :

Portal vein 75% 72% of the Oxygen

• venous drainage by the right, middle and left hepatic veins

PHYSIOLOGICAL FUNCTIONS

Production of :plasma protiens and coagulation factors.

Fat soluble vitamins metabolism

storage of : protiens(A.A), glucose(glycogen), fat(cholestrol)

Detoxification

PORTAL HYPERTENSION:

sustained elevation of venous portal pressure more than 10 mmHg (15-20 mmHg )

Normal pressure 5-10 mmHg

There are 6 potential routes of portal –systemic collateral blood flow (ares of communication):

Region Name of clinical

condition Portal circulation Systemic circulation

Esophageal Esophageal varices Esophageal branch

of left gastric vein

Esophageal branches

of azygos vein

Rectal Rectal varices Superior rectal vein

Middle rectal

veins and inferior rectal

veins

Paraumbilical Caput medusae Paraumbilical veins Superficial epigastric

vein

Retroperitoneal

Splenorenal shunt[3] Splenic vein

Renal vein, suprarenal

vein, paravertebral vein,

and gonadal vein

(no clinical name)[4] Right colic vein, middle

colic vein, left colic vein

Retroperitoneal veins

of Retzius

Intrahepatic

Hepatic

pseudolesions[5]

Perihepatic veins of

Sappey Superior epigastric vein

Patent ductus venosus Left branch of portal

vein Inferior vena cava

ETIOLOGY:

1. Presinusoidal

Extrahepatic : Intrahepatic :

Splenic vein thrombosis Schistosomiasis (Egypt )

Splenomegaly Congenital hepatic fibrosis

Splenic A-V fistula Idiopathic portal fibrosis

Myeloproliferative disorders

scardiosis

ETIOLOGY…

2. Sinusoidal

3. Post sinusoidal Posthepatic Intrahepatic

Budd Chiari

Cardiac cirrhosis

IVC web

Congestive Hepatopathy

Primary Thrombosis

Secondary Compresion

SIGNS & SYMPTOMS

Splenomegaly

esophageal varice

Caput medusa

Hemorrhoids

spider angioma, palmer erythema

Ascitis

asteraxis (hepatic flap)

fetor hepaticus

Jaundice

confusion and drowsiness

SIGNS & SYMPTOMS…

esophageal varices :

30% of patients with compensated cirrhosis

60% of patients with decompensated cirrhosis (development of jaundice, ascites, variceal hemorrhage, or hepatic encephalopathy )

1/3 of all patients with varices will experience variceal bleeding

Each episode 20-30% mortality if untreated

70% of patients who survive the initial episode will experience recurrent haemorrhage within 2 years

ESOPHAGEAL VARICES

TREATEMENT OF ESOPHAGEAL VARICES :

Management can be divided into :

I. the active bleeding episode,

II. the prevention of rebleeding,

III. the prophylactic measures to prevent the first hemorrhage

INITIAL MANAGEMENT OF ACTIVE BLEEDING EPISODE

I.Resuscitation:

• IV line insertion ( 2 large bore cannulas) and IV fluid

• Admission to ICU

• Obtain blood for grouping and crossmatching (blood transfusion without over transfusion just until hemoglobin 9)

• Correct coagulopathy: use fresh frozen plasma /Platelets/ coagulation factors

• Antibiotics

• Vasopressin

• (octreotide) / IV

II. Urgent endoscopy: both diagnostic and therapeutic (Variceal banding / Injection sclerotherapy)

If initial attempt failed Blackmore-Sengstaken tube for temporary blood bleeding control four ports

1- for gastric aspiration 2- for gastric balloon ( 500 ml) 3- for esophageal balloon (200 ml) 4- for esophageal aspiration prevent aspiration pneumonia do not leave it in situ for more than 24-36 h (risk of perforation and necrosis)

▪ TRANSJAGULAR INTRAHEPATIC PORTOCAVAL SHUNT

(TIPS): an expandable covered metal shunt

Used when bleeding cannot be stopped after 2 sessions of endoscopic therapy within 5 days.

Advantages: it reduces the portal vein pressure by creating a total shunt and doesn’t have the risk of general

anesthesia and surgery.

Disadvantages: increased risk of portosystemic encephalopathy.

▪ SURGICAL SHUNT:

Shunting: Portocaval (increase incidence of encephalopathy)

Mesocaval stent

Distal lienorenal (Warren) (most used

Non shunting: Sigiura ( bleeding uncontrollable)

Liver transplant

SCHISTOSOMIASIS

parasitic disease caused by blood flukes

exposure to infested water

Presentation: abdominal pain,

diarrhea,

bloody stool,

hepatomegaly.

Dx: detection of parasite eggs in stool or serum antibodies.

Causes Perisinosoidal portal HT

Tx: Praziquantel Single dose 40-70 mg/kg.

Education

Hygiene

LIVER ABSCESS

mass filled with pus inside the liver

Classified into :

• Pyogenic liver abscess: which is most often polymicrobial, accounts for 80% of hepatic abscess.

• Amoebic liver abscess: due to Entamoeba histolytica accounts for 10% of cases.

• Fungal abscess: most often due to Candida species, accounts for less than 10% of cases.

• Iatrogenic abscess: caused by medical interventions

AMEBIC ABSCESS

• Entamoeba histolytica enter mesenteric venules.

• travel to the liver where they typically form one or more abscesses.

• The right lobe of the liver is more commonly affected than the left lobe.

• amebic abscess have characteristic chocolate appearance.

Investigation:

CBC,LFT, Direct and indirect serological tests (CF, IHA and ELISA) to

detect amoebic protein, stools examination for amebae trophozoites or

cysts.

Imaging:

USS and CT: usually large, solitary, thin-walled, poorly defined abscess in

the right lobe.

MANAGEMENT:

o Empirical tx in areas where the problem is endemic.

o metronidazole with chloroquine phosphate usually results in rapid resolution.

o Needle aspiration if : -No clinical response within 72 hours

-There was superinfection (treated as pyogenic abscess).

-The abscess is large.