CYSTIC DISEASES OF LIVER

BY

DR NIKHIL AMEERCHETTY

Ms general surgery resident

E- mail nikhilameerchetty@gmail.com

CLASSIFICATION

1 INFECTIOUS HEPATIC CYSTS

Pyogenic Liver Abcess

Amebic Liver Abcess

Hydatid Cyst Of Liver

2 CONGENITAL HEPATIC CYSTS

Simple cysts

Polycystic liver disease

3 NEOPLASTIC HEPATIC CYSTS

Cystadenoma

Cystadenocarcinoma

4 TRAUMATIC HEPATIC CYST

INFECTIOUS HEPATIC CYSTS

PYOGENIC LIVER ABSCESS AMEBIC LIVER ABSCESS HYDATID CYST OF LIVER

PYOGENIC LIVER ABSCESS

EPIDEMIOLOGY

• The first description of hepatic abcess is credited to Hippocrates in the year 4000BC

• In 1938 ochsner’s classic described this disease

• 5–13 patients per 100,000 admissions prior to 1970,

• 15 cases per 100,000 admissions today.

• This rising incidence is attributed to a more aggressive management approach to hepatobiliary and pancreatic cancers as well as major improvements in diagnostic imaging.

PYOGENIC LIVER ABSCESSAetiology

1. Bile Ducts Causing Ascending Cholangitis

2. Portal Vein Pylephlebitis From Appendicitis Or Diverticulitis

3. Direct Extension From The Contagious Disease

4. Trauma Due To The Blunt Or Penetrating Injuries

5. Hepatic Artery Due To Septicaemia

6. Cryptogenic

PREDISPOSING FACTORS

• Adult

• Diabetus mellitus

• Cirrhosis

• Chronic pancreatitis

• Peptic ulcer disease

• Inflamatory bowel disease

• Jaundice

• Pyelonephritis

• Malignany

• Children

• Cronic granulomatous disease

• Compliment deficiencies

• Leukemia

• Malignancy

• Sickel cell anemia

• Polycystic liver disease

PATHOLOGY

• SOURCE NUMBER SIZE LOCATION

PORTAL SINGLE LARGE RIGHT LOBE

TRAUMATIC USUALLY SINGLE LARGE PREFERENTIAL

CRYPTOGENIC SINGLE LARGE PREFERENTIAL

BILIARY MULTIPLE SMALL BILATERAL

ARTERIAL MULTIPLE SMALL BILATERAL

FUNGAL MULTIPLE MILLIARY BILATERAL

CATEGORY OF ORGANISMS % OF PATIENTS GRAM NEGATIVE AEROBES (BILIARY TREE) 50-70%ESCHERICHIA COLI 35-45%KLEBSIELLA KLEBSIELLA PNEUMONIA

18%K1 Serotype 60% IN TAIWAN AND KOREAS

PROTEUS 10%ENTEROBACTER 15%GRAM-POSITIVE AEROBES 55%STAPHYLOCOCCAL SPECIES 20%ANAEROBES (INTESTINAL,CRYPTOGENIC) 40-50%BACTEROIDES SPECIES 24%BACTEROIDES FRAGILIS 15%FUSOBACTERIUM 10%PEPTOSTREPTOCOCCUS 10%FUNGAL 26%ENTEROCOCCUS FAECALIS 10%BETA-STREPTOCOCCI 5%ALPHA-STREPTOCOCCI 5%STERILE (AMEBIC,PARASITIC) 7%

CLINICAL PRESENTATIONSYMPTOMS PERCENTAGE FEVER 83

WEIGHT LOSS 60

PAIN 55

NAUSEA AND VOMITING 50

MALISE 50

CHILLS 37

ANOREXIA 34

COUGH AND PLEURISY 30

PRURITIS 17

DIARRHOEA 12

SIGNS PERCENTAGE

RIGHT UPPER QUADRENT TENDERNESS 52

HEPATOMEGALY 40

JAUNDICE 31

RIGHT UPPER QUADRENT MASS 25

ASCITIS 25

PLEURAL EFFUSION OR RUB 20

LABORATORY DATA PERCENTAGE

INCREASED ALKALINE PHOSPHATASE 87

WBC COUNT >10,000 71

ALBUMIN <3g/dl 55

HEMATOCRIT <36% 53

BILIRUBIN >2mg/dl 24

RADIOLOGY

PLAIN CHEST X RAYS • Abnormal In 50% Of Patients.

• Elevated Right Hemidiaphragm,

• Right Pleural Effusion,

• Right Lower Lobe Atelectasis)

ABDOMINAL FILMS • Hepatomegaly

• Air-fluid Levels In The Presence Of Gas-forming Organisms

• Portal Venous Gas If Pylephlebitis Is The Source

ULTRASOUND

ADVANTAGES• Distinguish Solid From Cystic Lesions • Cost Effective • Portable. • 80–95% Sensitive LIMITATIONS• Morbidly Obese • Lesions That Are Located Under The Ribs • Homogeneous Liver.

COMPUTED TOMOGRAPHY (CT)

• sensitive (95–100%) • Lesions are detectable to around 0.5 cm • not limited by shadowing from ribs or air. cholangiography, often via an indwelling biliary stent, may visualize the abscess

TREATMENT

1. ANTIBIOTIC ADMINISTRATION2. DRAINAGE 3. SURGERY

EXCEPTION

4. Multiple small abcesses

5. Milliary fungal abcesses

• I/V antibiotics • Antifungals• No drainage

ANTIBIOTICS

• AMINOGLYCOSIDES, CLINDAMYCIN, AMPICILLIN , VANCOMYCIN, FLUOROQUINOLONES AND METRONIDAZOLE

• Single-agent therapy with TICARCILLIN-CLAVULANATE, IMIPENEM-CILASTATIN OR PIPERACILLIN-TAZOBACTAM

• Treatment used to be given for 4–6 weeks

• multiple abscesses <1.5 cm in size and no concurrent surgical disease, patients may be treated with IV antibiotics alone.

• Candidial infections AMPHOTERICIN B (2-9g)

• FLUCONAZOLE in a dose of 6mg/kg/day is a suitable alternative .

ASPIRATION AND PERCUTANEOUS CATHETER DRAINAGE

• similar mortality rates

• Rate of recurrence

• Patients in whom percutaneous drainage is not appropriate include those patients with

(1) multiple large abscesses

(2) known intra-abdominal source that requires surgery

(3) an abscess of unknown etiology

(4) ascites

(5) abscesses that would require transpleural drainage.

SURGICAL DRAINAGE

• Traditional approach :

Extraperitoneally via a 12th-rib resection to avoid contamination of the peritoneal cavity.

• Newer concept

Transperitoneal surgical exploration

• Advantages

(1) treat the inciting pathology in the remainder of the abdomen/pelvis

(2) gain access and exposure of the entire liver for evaluation and treatment

(3) access the biliary tree for cholangiography and bile duct exploration

Surgical drainage is currently reserved for patients that have

• Failed Nonoperative Therapy,

• Those With Multiple Macroscopic Abscesses,

• Those On Steroids,

• Concomitant Ascites.

COMPLICATIONS• Up to 40% of patients develop complications from pyogenic liver abscesses

• Generalized Sepsis (Most Common)• Pleural Effusions• Empyema• Pneumonia • Perihepatic Abscess• Hemobilia • Hepatic Vein Thrombosis.

FACTORS ASSOCIATED WITH POOR OUTCOME

Failure To Establish A Diagnosis

Inability To Achieve Adequate Drainage

Diabetes mellitus

Associated malignancy

Multiple abscesses

Septicemia

AMEBIC LIVER ABSCESS

• Amebic liver abscess is caused by the parasitic protozoan Entamoeba histolytica.

• First described by Hippocrates and other associates in 5tH century BC

• Second only to malarial disease as a cause of protozoan-mediated death.

PATHOLOGY

• 90% of people are asymptomatically colonized, • Incubation takes 1–4 weeks. • invasive disease is colitis• Licqufied hepatic parenchyma with debris and blood – ANCHOVY SAUSE • 70–80% diarrhea, abdominal pain, weight loss, and stools consisting of blood and

mucus. • "buttonhole" ulcers with undermined edges. • The most common extraintestinal site of amebiasis is the liver, occurring in 1–7% of

children and 50% of adults

Symptom Percentage

Pain 90

Fever 87

Nausea and vomiting 85

Anorexia 50

Weight loss 45

Malaise 25

Diarrhoea 25

Cough and pleurisy 25

Pruritis <1

CLINICAL PRESENTATION

Sign Percentage

Hepatomegaly 85

Right upper quadrant tenderness

84

Pleural effusion or rub

40

Right upper quadrant mass

12

Ascitis 10

Jaundice 5

Laboratory Percentage

Increased alkaline phosphatase 80 in cronic cases

Wbc count >10000 70

Hamatocrit <36% 49

Albumin <3g/dl 44

Bilirubin >2mg/dl 10

Stool samples 40-50%

DIAGNOSIS

• The Definitive Diagnosis Of Amebic Liver Abscess Is By E. Histolytica Trophozoites In The Pus

• Detection Of Serum Antibodies To The Ameba.

DISTINGUISHING CLINICAL CHARECTERISTICS

AMEBIC PYOGENIC

Age <50yrs Age >50yrs

M:F 10:1 M:F 1.5:1

PAIN FEVER

DIARROHEA JAUNDICE,PRURITIS

ABDOMINAL TENDERNESS PALPABLE MASS

RECENT H/O TRAVEL TO ENDEMIC AREA NO HISTORY

PULMONARY COMPLICATIONS MALIGNANCY

RADIOLOGY

• Chest radiographs pleural effusion infiltrates elevated hemidiaphragm.

• Ultrasound, CT, and magnetic resonance imaging (MRI) Excellent but are nonspecific.19

In 75–80% of cases, only a single abscess is present and in the right lobe 10% are in the left lobe The mean resolution time is 7 months, and 70% have findings that persist for more than 6 months.

TREATMENT

• Since the introduction of metronidazole in the 1960s, surgical drainage of amebic liver abscesses has become virtually unnecessary

ANTIBIOTICS• Noninvasive infections can be treated with paromomycin.

• Nitroimidazoles, especially metronidazole, are the mainstays of treatment for invasive amebiasis.

• This antibiotic crosses the placenta and blood-brain barrier and is contraindicated in the first trimester of pregnancy.

• Positive responses to metronidazole should be seen by the third day of treatment.

• nitroimidazole treatment should be followed with paromomycin or diloxanide furoate to cure luminal infection

THERAPEUTIC ASPIRATION

• Drainage should be considered in patients that have no clinical response to drug therapy within 5–7 days

• those with a high risk of abscess rupture defined as having a cavity >5 cm in diameter

• by the presence of lesions in the left lobe.

• Bacterial coinfection of amebic liver abscess has been observed

PERCUTANEOUS DRAINAGE

• Most useful for treating pulmonary, peritoneal, and pericardial complications.

• The high viscosity of amebic abscess fluid, requires a large diameter catheter for adequate drainage.

SURGICAL

• Failed To Respond To Conservative Therapy (Most Common Indication).

• Laparotomy Is Indicated For Life-threatening Hemorrhage

• When The Amebic Abscess Erodes Into A Neighboring Viscus

• Sepsis Due To A Secondarily Infected Amebic Abscess

COMPLICATIONS

• Complications from amebic abscesses occur secondary to rupture of the abscess into the peritoneum, pleural cavity, or pericardium (Fig 28–7). incidence 2–17% ,mortality rates between 12% and 50%.23

SEQUELAE

• Thoracic amebiasis (empyema, bronchohepatic fistulas, and pleuropulmonary abscess) is the most common complication,

• Pericardial amebiasis (acute pericarditis with tamponade).

• Pleural cavity drainage of the pleural cavity with tube thoracostomy.

• Bronchi, Surgical intervention is not required,

• Cerebral amebiasis - seizures.

OUTCOME

Increased age

Increased bilirubin level >3.5mg/dl

Pulmonary involvement

Rupture or extension

Late presentation

HYDATID LIVER CYST

• E. granulosus and • E. multilocularis• Zoonosis• Humans are accidental intermediate hosts, whereas animals can be both

intermediate hosts and definitive hosts.• In humans, 50–75% of the cysts occur in the liver,• 25% are located in the lungs, and• 5–10% distribute along the arterial system

LIFE CYCLE OF ECHINOCOCCUS GRANULOSUS.• parasite lives in the proximal small bowel

• Eggs are released into the host's intestine

• excreted in the feces

• humans are the intermediate host

• ingest the ovum

• The ovum loses the protective chitinous layer and is digested in the duodenum

• The released hexacanth embryo (oncosphere) passes through the intestinal wall into the portal circulation and develops into cysts within the liver

Pathology PERICYST,

ECTOCYST

ENDOCYST IS THE GERMINAL MEMBRANE

BROOD CAPSULES

PROTOSCOLECES

A PROTOSCOLEX. ADULT TAPE WORM DAUGHTER CYST

endogenic vesiculation.Ectogenic vesiculation

CLINICAL PRESENTATIONSymptoms Percentage

Asymptomatic 75

Abdominal pain 20

Dyspepsia 13

Fever and chills 8

Jaundice 6

signs percentage

Right upper quadrent mass 70

Right upper quadrent tenderness 20

Laboratory data percentageEosnophilia 35

Bilirubin > 2mg/dl 20

Wbc count<10,000 10

Elisa 90

Arc 5 91

RADIOLOGY

CHEST X RAYS • Elevated diaphragm • concentric calcifications in the cyst wall

• ULTRASOUND

• Specificity- approx 90%

• hydatid sand,daughter cyst,unilocular & calcified cyst wall

• Internal structure,number,and location of the cysts and the presence of complication

Type I has a pure fluid collection

Type II has a fluid collection with a split wall (floating membrane)

Type III reveals a fluid collection with septa (honeycomb image)

Type IV has heterogenous echographic patterns

Type V has reflecting thick walls(dead calcified wall)

GHARBI’S CLASSIFICATION

COMPUTED TOMOGRAPHY

• specific information about the location

• depth of the cyst within the liver

MRI

• structural details of the hydatid cyst

Endoscopic retrograde cholangiopancreatography (ERCP)

• communication between the cysts and bile ducts

DIFFERENTIAL IMAGING AND CHARACTER OF HEPATIC CYSTS

Pyogenic Amoebic Hydatid Number Single or

multiple One or few Usually single

Wall character Uniform or multiloculated

Usually uniform

Uniform, daughter cysts; 50% calcified

Cyst contents Usually pus Red-brown; like anchovy paste

Clear or bilious; gelatinous

TREATMENT

PRINCIPLES

(1) Eradication Of The Parasite Within The Cyst

(2) Protection Of The Host Against Spillage Of Scoleces,

(3) Management Of Complications.

METHODS

• Medical

• Percutaneous

• surgical

Medical treatment

Success rate of 30%

-Albendazole (10-15mg/kg/day) is drug of choice - decreases the size of cyst - decreases intracystic pressure - decreases risk of rupture Mebendazole (50mg /kg)& Praziquantel ( 50mg/kg)

Indications

Small cysts (<4 cm) located deep in the parenchyma of the liver

TREATMENT

PERCUTANEOUS ASPIRATION AND DRAINAGE• Surgical dictum

• “ PERCUTANEOUS PUNCTURE OF A HYDATID CYST IS A DANGEROUS AND CONTRAINDICATED “

• 1983, Fornage challenged this axiom

• FREQUENTLY USED PROTOSCOLICIDAL AGENTS

• 15–20% Saline

• 95% Ethanol

• A Combination Of 30% Saline And 95% Ethanol,

• Mebendazole Solution.

The PAIR technique (percutaneous aspiration, injection and re-aspiration) has also been combined with albendazole therapy with 70% success rate

SURGERY

• OBJECTIVES

• (1) Inactivate The Scoleces• (2) Prevent Spillage Of Cyst Contents• (3) Eliminate All Viable Elements Of The Cyst• (4) Manage The Residual Cavity Of The Cyst.

• Preparation

• Give 4-6 week of albendazole tablet before surgery (800mg/day in divided doses) in adult

• Pre operative visualization of biliary tract by ERCP.

• Anaesthesist warned of sudden anaphylactic shock in case of spillage.

SURGERY

Open surgery

partial pericystectomy+ omentopexy

partial pericystectomy+ capittonage

Laparoscopic surgery

partial pericystectomy + omentopexy

TREATMENT OPTIONS FOR HYDATID CYSTS Uncomplicated cystsPercutaneous or laparoscopyGharbi type I or II Anterior cystsPeripheral cystSmall cyst No or minimal calcification

Open surgeryGharbi type IV or V Posterior cystCentral cystLarge cystHeavy calcification

Complicated cystsOpen surgeryBiliary communicationPleural communicationPeritoneal ruptureInfected hydatid cyst

• Rupture into CBD causing obstructive jaundice

• Anaphylactic shock

• Rupture into peritoneal cavity

• Rupture into lung

COMPLICATIONS OF HYDATID CYST

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