1. 1. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y LIVER- Abscesses & Tumors Dr.B.SELVARAJ MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Malaysia
2. 2. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y LIVER- Anatomy-Lobes Cantlies LineAnatomical Lobes
3. 3. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y LIVER- Anatomy-Segments Couinauds Segments
4. 4. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y LIVER- Abscesses & Tumors Pyogenic Abscess Amebic Abscess Hydatid Cyst Hepatic adenoma Focal nodular hyperplasia Hepatic hemangioma Hepatocellular carcinoma Secondary in liver
5. 5. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Pyogenic Abscess-Etiology Potential routes of hepatic exposure to bacteria as follows: Biliary tree (most common route) Portal vein (pyelophlebitis due to diverticulitis, appendicitis, PID, IBD, perforation, etc.) Hepatic artery (systemic bacteremia-associated with multiple microabscess) Direct extension & Trauma
6. 6. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Pyogenic Abscess-Etiology Pyogenic abscesses with no identifiable primary infection are called cryptogenic hepatic abscesses Organisms cultured include gram-negative aerobes E coli, Klebsiella and Proteus species are most commonly isolated Aerobic Streptococcus and Staphylococcus are also seen Increased use of indwelling biliary stents and broad-spectrum antibiotics has led to an increased prevalence of Pseudomonas and fungi.
7. 7. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Pyogenic Abscess-Clinical Features Most common in right lobe Most common organisms isolated E. coli, Klebseilla and Proteus Most common presenting symptomsfever, chills, abdominal pain and jaundice A rare complication of Klebseilla abscess is endogenous endophthalmitis (3%), common in diabetics
8. 8. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Pyogenic Abscess-Investigations X-ray chest shows elevated right hemidiaphragm, pleural effusion and atelectasis. USG abdomen unilocular or multilocular cyst CT abdomen- Rim enhancement in CECT
9. 9. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Pyogenic Abscess-Treatment Percutaneous catheter drainage along with broad spectrum antibiotics Surgery is reserved for those who fail percutaneous technique and for those whom surgery is required for some other pathology or rupture of abscess A falling serum albumin level and presence of jaundice are bad prognostic signs.
10. 10. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Amebic Abscess-Etiology The causative organism is Entamoeba histolytica It is almost and always secondary to amebic ulcers on the colonic wall. The organisms ultimately reach the liver via the inferior mesenteric vein and then portal vein. Due to liquefaction necrosis of liver, the abscess results anchovy sauce colored and odorless
11. 11. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Amebic Abscess-Clinical Features Residence or travel to endemic areas H/o Amebic dysentery RUQ pain Fever- moderate Tender hepatomegaly
12. 12. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Amebic Abscess-Complications
13. 13. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Amebic Abscess-Investigations Diagnosis is by isolation of the parasite from the liver lesion or the stool and confirming its nature by microscopy. Enzyme immuno assays (EIA) have sensitivity 99%and specificity > 90% in patients with amebic abscess USG- Hypoechoic and non homogenous rounded lesion abutting liver capsule without significant rim echoes
14. 14. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Amebic Abscess-Investigations CT scan: More sensitive in differentiating pyogenic from amebic because there will be rim enhancement in pyogenic abscess on contrast study. Nuclear scan (Gallium ): Helps in differentiating because amebic abscess does not contain leukocytes and hence does not light up on these scans
15. 15. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Amebic Abscess-Treatment Oral metronidazole750 mg three times/10 days is the drug of choice. Emetine im injections is very effective for invasive amoebiasis Therapeutic aspiration is usually avoided. Metrogyl is the treatment of choice and about 90% cases respond well.
16. 16. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Amebic Abscess-Treatment Indications for aspiration: abscess wall diameter larger than 5 cm (abscess with high risk of rupture) abscess in the left lobe of liver for diagnostic uncertainty failure to respond in 3-5 days
17. 17. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Amebic & Pyogenic Liver Abscesses
18. 18. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hydatid cyst- Etiology Echinococcus granulosus is M/c. others E. multilocularis, E. oligartus. Dogs are definitive hosts in which adult worms develop Sheeps are intermediate hosts that consume the ova passed by the feces of dog over grasses Humans are accidental hosts consuming these eggs that converts to embryo in duodenum and releases an oncosphere containing hooklets
19. 19. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hydatid cyst- Etiology The oncosphere reaches the liver or lungs, where the parasite develops into larval stage called as hydatid cyst Remember humans are end-stage host.
20. 20. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hydatid cyst- Pathogenesis 3 weeks after ingestion, a pericyst derived from host tissue wall develops surrounding the hydatid cyst. The cyst itself has two walls: ectocyst (outer gelatinous) and endocyst (inner germinal) layers. In definitive host, they develop into adult tapeworm, but in intermediate host they develop only into new hydatid cyst Daughter cysts are true replicae of the mother cyst.
21. 21. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hydatid cyst- Clinical features Most common in right lobe of liver Most frequent signhepatomegaly Most common symptomsabdominal pain, dyspepsia and vomiting. Complications: Rupture into biliary tree, bronchial tree, pleural, peritoneal and pericardial cavity
22. 22. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hydatid cyst- Investigations USG: Rosette like appearance or water lilley appearance is seen when daughter cysts are present. Calcifications in the wall are highly diagnostic Serological tests: ELISA, arc 5 test, IHA test, immunoblast test, where available is the test of choice Casoni test: Intradermal injection of sterile hydatid fluid produces a wheal of 5 cm in half hour
23. 23. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hydatid cyst- Gross& CT Abd
24. 24. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hydatid cyst- Treatment Primarily surgical, but introduction of PAIR has totally replaced it. During surgery, packing off the abdomen from the cyst is very important because of the anaphylactic reaction that may occur if cyst ruptures into peritoneal cavity Remember surgery is now preferred, where PAIR is not possible or when it does not respond to PAIR or when there is any communication to biliary tree
25. 25. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hydatid cyst- Treatment Surgical procedures: Pericystectomy Marsupialization Omentoplasty Total cystectomy Partial hepatectomy
26. 26. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hydatid cyst- PAIR Percutaneous aspiration, infusion of scolicidal agents and reaspiraion (PAIR). Given with prophylactic cover of albendazole. Scolicidal agents20% hypertonic saline, 0.5% silver nitrate, 95% ethanol, absolute alcohol, mebendazole 2.4 microgram/ml
27. 27. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hydatid cyst- PAIR- CI Contraindications for PAIR: Superficially located cyst (chance of rupture) Honey combing of cysts (multiple thick internal septae) Communication with biliary tree Dead or inactive cysts
28. 28. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Liver Abscesses- Recap
29. 29. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Liver Tumors- Benign Hepatocellular adenoma Focal Nodular Hyperplasia Hepatic Hemangioma
30. 30. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Liver Tumors- Benign
31. 31. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hepatic Adenoma- CT Abd Three-phase CT scan of a hepatic adenoma. Left: arterial phase; center: portal phase; right: venous phase.
32. 32. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Focal nodular hyperplasia- CT Abd Homogenous mass with central scar
33. 33. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Focal nodular hyperplasia-sulphur colloid scan
34. 34. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Liver hemangioma- CT Abd
35. 35. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Benign Liver tumors- Recap
36. 36. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- risk factors Infections: Hepatitis B virus, hepatitis C virus Cirrhosis: Alcohol induced, autoimmune hepatitis, primary biliary cirrhosis Environmental: Aflatoxins, pyrrolizidine alkaloids Thorotrast N-nitrosylated compounds Metabolic diseases: Hemochromatosis, alpha1- antitrypsin deficiency,Wilson disease, porphyria cutanea tarda, Type 1 and 3 glycogen storage disease, galactosemia, citrullinemia,hereditary tyrosinemia, familial cholestatic cirrhosis
37. 37. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- H & P Most common in males; 50-60 year Presentation: 1. Right upper quadrant pain 2. Weight loss 3. Palpable mass 4. In known cirrhoticssudden decompensation of liver think of HCC. 5. Rupture 6. Less than 1% cases present with paraneoplastic syndrome most commonly hypercalcemia, hypoglycemia, Erythrocytosis 7.Hepatocellular carcinoma has the tendency to invade the portal vein
38. 38. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- Investigations USGplays significant role in screening and early detection of HCC CT and MRIare definitely needed for planning surgeries Serum AFPused in diagnosing HCC Value > 400 mg/dl is highly suggestive AFP is mainly used to monitor recurrences in treated patients AFP levels are elevated in about 70%80% cases
39. 39. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- CT Abd
40. 40. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- Biopsy Biopsy is contraindicated in suspected cases Biopsy is done only in inoperable cases which are tried for non-operative therapies Percutaneous biopsy carries the risk of tumor spillage, rupture and bleeding
41. 41. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- Treatment Complete excision of HCC by partial hepatectomy or by total hepatectomy with liver transplantation Percutaneous ethanol & acetic acid injection Thermal ablative techniquesCryotherapy, Radiofrequency ablation (RFA), microwave RFA and cryotherapy can be done percutaneously. Main disadvantage is heat sink effect, limiting the use near major blood vessels
42. 42. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- Treatment Based on the fact that most of the tumor blood supply is from the hepatic artery HAI (hepatic arterial infusion) chemotherapy using 5 flouorouracil, cisplatin, doxorubicin; Sorafenib Chemoembolization: Embolization particles and lipoidal oils added with chemotherapy agents selectively taken up by HCC
43. 43. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hepatocellular CA- D/D
44. 44. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Liver metastasis Colorectal liver metastases on computed tomography (CT) scan: (a) after oral contrast CT; (b) after intravenous contrast. The colorectal liver metastasis occupying the entire right lobe of the liver is difficult to visualise on oral contrast CT. The addition of intravenous contrast shows its lack of enhancement and its relationship to the hepatic veins.
45. 45. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Malignant Liver Tumors- Recap
46. 46. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- videoclip
47. 47. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- videoclip