Liver and Spleen Diseases

Bernard S. Victorio, M.D., FPCS, FPSGS

at the end of the session

imaging modalities use in diagnosis of hepatobiliary, extrabiliary and spleen diseases

diagnosis and management of benign and maligntdiseases

diagnosis and management ofhepatobiliary splenic diseases

management of liver and splenic injuries

RADIOLOGIC EVALUATION

ADVANTAGE DISADVANTAGE

ULTRASOUND • Initial imaging• Biliary and liver

Intraoperative UTZ

• Incomplete imaging• Obesity/bowel

RADIOLOGIC EVALUATION

ADVANTAGE DISADVANTAGE

CT SCAN • Contrast medium• Arterial/venous phase

MRI T1/T2

PET SCAN Metastatic tumors Lack of exact localization

Infection of the liverPYOGENIC AMOEBIC

ETIOLOGY • Acute appendicitis• Impaired biliary drainage• Hematogenous• endocarditis

entamoeba

LOCATION • Single• Multiple- honeycomb• Right lobe of liver

• Single/ Multiple• Superior, anterior near

diaphragm• Necrotic central portion• Anchovy paste or chocolate

sauce

SYMPTOMS • RUQ pain, fever• Jaundice- 1/3• Leukocytosis• Increase ESR and alk phos• Elevated transaminase

• RUQ pain, fever• Jaundice, unusual• Hepatomegaly• Leukocytosis• Mildly increase AP

Infection of the liverIMAGING PYOGENIC AMOEBIC

UTZ Hypoechoic lesions with well defined borders, internal echoes

Non specific

For follow up

CT Hypodense, air fluid level

Non specificExtrahepaticinvolvementWell defined low density round lesion with wallenhancementCentral cavity with sepatations/air fluid level

For follow up

MRI High level of sensitivity*Guided biopsy

Infection of the liver

MANAGEMENT PYOGENIC AMOEBIC

CULTURE 50% of cases Flourescent antibody

ANTIBIOTIC Gram (-) (+)anaerobic

Metronidazole 750 mg TID for 7 to 10 days

DRAINAGE • Laparoscopic/open• Anatomic resection• Necrotic hepatic

malignancy

Aspiration rarely needed• Large abscess• Not responding to medical

therapy• Superinfected• Left lobe

Incidental liver mass

Liver Lesions

Benign Malignant

Cyst Hepatocellular CA

Hemangioma cholangiocarcinoma

Focal Nodular Hyperplasia Gallbladder CA

Adenoma Metastatic colorectal CA

Biliary hamartoma Metastatic neuroendocrine (carcinoid)

abscess Metastatic cancers

Benign Liver Lesions

cyst Most frequently encountered• Congenital cyst• Biliary cystadenoma• Polycystic liver disease• Caroli’s disease

Bile duct hamartoma • Small liver lesion (2 to 4 mm) surface of liver• Firm, yellow, smooth in appearance• Excisional biopsy

manifestations

Hemangioma adenoma Focal nodular hyperplasia

• Most common• Pain (larger than 5-6 cm)• Spontaneous rupture is

rare• Malignant

transformation (?)

• Young women (20 to 40)• pain• Solitary, sometimes multiple• Prior or current use of oral

contraceptive• Spontaneous rupture (10-

25%)• Malignant transformation to

HCC

• Childbearing• Oral conceptive use • Do not rupture• No significant risk of

malignant transformation

CT scan Hemangioma adenoma Focal nodular hyperplasia

Large – asymmetrical nodular peripheral enhancement,isodense

Sharply defined border, confused with metastatic tumors• Venous phase –

hypodense/isodense• Arterial phase – subtle

hypervascular enhancementhypodense

• Biphasic, well circumscribe with a typical central scar

• intense homogenous enhancement on arterial phase contrast images, often isodense or invisible compared with background liver on venous phase

MRI

Hemangioma adenoma Focal nodular hyperplasia

Hypointense on T1 and hyperintense on T2

Hyperintense on T1 and enhance early after gadolinium

Hypointense on T1 and isointense to hypointense on T2Godolinium, become hyperintense but become hypointense on delayed images

Nuclear imaging “cold” Radionuclide sulfur colloid

Management

Hemangioma adenoma Focal nodular hyperplasia

• Liver biopsy – with caution, increase risk of bleeding

• Main indication for resection – pain

• Enucleation• formal hepatic resection

• resection Main indication for surgery is abdominal painOral contraceptive or estrogen should be stopped

Malignant Liver Tumor

Hepatocellular Carcinoma

Risk factors Viral hepatitisAlcoholic hepatitisHemochromatosisNonalcoholic steatohepatitis

CT scan Hypervascular in arterial phase and hypodenseduring the delayed phase

MRI Variable T1 and hyperintense T2

Portal vein thrombosis Highly suggestive

Algorithm for HCC

Cholangiocarcinoma 2nd most common

Hilar (klatskin) Peripheral

Obstructive jaundice, painless Tumor mass

locoregional

• Surgical resection (absence of PSC)• chemoradiation

Poor survival• Vascular invasion• Positive margins• Multiple tumors

Improved outcome• Histologic negative margin• Concomitant hepatic resection• Well differentiated

Prognostic factors affecting survival• Absence of mucobilia• Nonpapillary tumor• Advance stage• Nonhepatectomy• Lack of pre-op chemo

3 to 5 year survival : 41.7% to 26.8% 3 year survival: 55

Gallbladder CA

• Rare, aggressive tumor• Poor prognosis• Associated with cholelithiasis

Diagnosis• Pre-op : 57%• Intra-op: 11%• Incidental: 32%

Surgical approach • Re-op for incidental gallbladder CA after choleycstectomy

• Beyond stage 1 (T2 and T3)• Central liver resection• Hilar lymphadenopathy• Evaluation of cystic duct stump

• Radical resection with advance disease• Role of formal lobectomy/extended

lobectomy (?)

Metastatic colo-rectal CA

Resection on fewer than 4 10 year survival• 4 or more : 29%• Solitary: 33%

Resectability is no longer defined on what actually is removed but on what will remain after resection

• Use of neoadjuvant chemotherapy• Portal vein embolization• Simultaneous ablation• Resection of extra-hepatic tumor

Mets from Neuroendocrine tumor Other metastatic tumor

Protacted natural historyDebilitating endocrinopathy

• Breast• Renal• Other Gi

2 stage procedurePrimary tumor is resected• Resection with limited resection of

left hemiliver, portal vein ligation• 8 weeks, right or extended right

hepatectomy

• 2, 5, 8 overall survival rate:94%, 94$, 79%

• Disease free survival rates:85%, 50%, 26%

treatment option

option

Hepatic resection Gold standardHCC with cirrhosis (?)Margin: 1cm

Liver transplantation HCC with cirrhosisRecurrent rates (>50%)Improved survival rate• Early stage (stage 1 or 2)• One tumor, 5cm• Three tumor largest 3cm• Absence of gross vascular invasion

or extrahepatic spread

option

Radiofrequency ablation • HCC of 3 to 7.5 cm• Recurrence rate after resection

(44% vs 11%)• Combination with TACE

Ethanol ablation, cryosurgery,microwave ablation

chemoembolization

Yttrium 90 micropheres Inoperable primary or metastatic liver tumor

Stereotactic radiosurgery

Systemic chemotherapy

Surgical techniques

Acute Liver Failure

Etiology Viral infection (hepatis a, b, e)

Drug induce (acetaminophen)

Clinical PresentationJaundice and encephalopathy

Hepatic coma

Increase creatinine

Arterial ph <7.30

Culture proven infection

ALF

Liver biopsy

Rapid progression

Acetaminophen overdoseActivated charcoal

N-acetylcysteine

ICU

Prognosis

CIRRHOSIS

History and PE

Lab findings Mild normochromic anemiaLow WBC, platelet Bone marrow – macronormoblasticProlong PT, not responding to vitamin KBilirubin, transamines, alk phos -elevated

Liver biopsy UTZ or CT guided percutaneous biopsy

Assessment of surgical risk(Child-Turcotte-Pugh Score)

variable 1 point 2 points 3 points

bilirubin <2mg/dl 2-3mg/dl >3m/dl

albumin >3.5 g/dl 2.8-3.5 g/dl <2.8 g/dl

INR <1.7 1.7 -2.2 >2.2

encephalopathy none controlled uncontrollable

ascites none controlled uncontrollable

Class

A- 5-6 points

B- 7-9 points

C – 10-15 points

PORTAL HYPERTENSION

Gastroesophageal varices

Splenomegaly

Caput medusae (cruveilhier-baumgarten murmur)

Ascitis

Anorectal varices

management

Esophageal Varices

Prevention of Variceal bleeding Abstinence from alcoholAvoidance of aspirin and NSAIDAdminstration of propranololProphylactic endoscopic variceal ligation (EVL)

Acute Variceal Bleeding(5 day hemostasis rate)

• Blood resuscitation• Fresh-frozen plasma and platelet• Prophylactic antibiotics• Vasopressin (0.2 to 0.8 units/min)• Somatostin (initial bolus 50μ/IV)• EVL• Surgical shunt/TIPs (refractory variceal bleeding)• Balloon tamponade (<24 hours)

shuntsShunts

Aim Reduce portal venous pressureMaintain total hepatic and portal blood flowAvoid a high incidence of complicating hepatic encephalopathy

Portocaval shunt Higher incidence of shunt thrombosis and rebleedingHigh incidence of encephalopathy

Warren shunt (distal splenorenal) Lower rate of hepatic encephalopathy and decompensation

Transjugular Intrahepatic PortosystemicShunt (TIPS)

>90% of cases refractory to medical treatment

Non shunt procedure

Suguira

Extrahepatic portal vein thrombosis and refractory bleeding

• Extensive devascularization of the stomachand distal esophagus

• Transection of the esophagus• Splenectomy• Truncal vagotomy• pyloroplasty

Hepatic transplant

Patients only chance of definitive therapy and long term survivalPatient with variceal bleeding refractory to all forms of managementReverses most of the hemodynamic and humoralchanges associated with cirrhosis

Not affected by previous EVL, TIPS, splenorenal, mesocaval shunts

Splenic Diseases

Radiologic Evaluation

ADVANTAGE DISADVANTAGE

ULTRASOUND • First imaging modality• Pre-op planning

Risk of hemorrhage during percutaneous ultrasound guided procedures

CT SCAN • High degree of resolution• Invaluable tool in

evaluation and management of splenic trauma

• Splenomegay, solid/cystic• Percutaneous procedures

Plain radiography Outline of spleen

ADVANTAGE DISADVANTAGE

MRI Excellent detail and versatility No obvious advantageMore expensive

Angiography Therapeutic splenic arterial embolization (SLE)• Localization and treatment of

hemorrhage in trauma pt• Delivery of therapy in patients

with cirrhosis/portal/transplant pt

• Adjunt to splenectomy

PancreatitisRisk of invasive procedure

Nuclear imaging Locating accessory spleen

Splenic index 120 ml to 480 ml

Indications for splenectomy

Splenic rupture

RBC disorder and hemoglobinopathies

WBC disorder

Platelet disorder

Bone marrow disorder

Cyst/tumors

Infections and abscess

Infiltrative disorder

Pre-op consideration

vaccination Overwelming Postsplenectomy infectionEncapsulated bacteria, 2 weeks elective surgery• Streptococcus pneumoniae• H. Influenza• Meningococcus

Splenic artery embolization Reduce spleen size

Deep vein thrombosis prophylaxis Portal vein thrombosis• Anorexia• Abdominal pain• Leukocytosis• ThrombocytosisSequential compression deviceHeparin (5000 I.U)

post splenectomy outcomesComplications

Left lower lobe atelectasis, most common

Subphrenic hematoma

Subphrenic abscess

Pancreatitis, psedocyst, pancreatic fistula

Thromboembolic

Hematologic

Initial response – rise in platelet count

Increase in hemoglobin to 10g/dl

OPSI

Medical emergencyProgress to bacteric septic shock, with hypotension, anuria, DIC

More common in hematologic diseases

<5 years of age and >50 years of age

PathogenesisLoss of splenic macrophagesDiminish tuftsin prodcutionLoss of spleen reticuloendothelial function

vaccination

Pneumococcus and other encapsulated

2 weeks before planned surgery

With 7 to 10 days of emergent splenectomy

OPSI casesPneumococcus

Meningococcus

H. influenza type B

group A Streptococci

Trauma

Thank you