Diseases of the Liver
Anatomy
Anatomy and Physiology
1. size: 25156cm
weight: 2% of the body weight, male 1342g, female 1234g
2. ligaments:
triangular, coronary, falciform, teres, gastrohepatic, hepatoduodenal
3. Hilus of the liver
first hilus, second hilus, third hilus
4. Segmentations:
liver fissures system
fiver lobes and four segments
Souoault and Couinaud’ system:
eight segments
5. Intrahepatic system:
portal vein: 70-80% liver supplied blood
hepatic artery: 20-30% liver supplied blood
bile ducts:
hepatic veins: right, midddle, left, short
Physiology
1. Bile secretion: 600-1000ml
2. Participate in metabolism of protein, lipid, carbohydrate, vitamin and
exterminate thehormones
3. Coagulation, hematopoiesis, regulation of blood circulation
4. Detoxication of drugs and toxins
5. Phagocytosis and immunization: Kupffer’ cells
• bacterial abscess
• amebic abscess
• mycotic abscess
• tuberculous abscess
hepatic abscess
bacterial liver abscess
1. Pathogenesis
pyogenic abscess
E. Coli, staphylococcus
2. Infective routes
◆ biliary tract infections: the most common sources
◆ blood:
hepatic artery: secondary to any parts of systemic pyogenic infection
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portal vein:
intraperitoneal infection, intestinal infection
◆ lymph: subdiaphragmentic infection
◆ direct extension: blunt and penetrating injuries
3. Clinical presentation
symptoms:
◆ general symptoms: chills and fever, anergy, loss of appetite,
neusea, vomiting, jaundice
◆ local symptoms: abdominal pain in right upper quadrant, radiation
of the pain
signs:
◆ right upper quadrant tenderness
◆ hepatomegaly,
◆ hepatic percussion pain
assistant examinations:
◆ blood routine examination: leukocytosis, anemia
◆ liver function tests: GPT↑, AKP↑ bilirubin ↑
◆ positive blood cultures:
50%
◆ X-ray, BUS, CT
◆ percutaneous aspiration
4. Diagnosis and Differential diagnosis
◆ infective history
◆ symptoms and signs
◆ assistant examinations
Differential diagnosis
◆ subphrenic and subhepatic abscess
◆ amebic abscess
◆ liver tumors
◆ biliary infection
5. Treatment
◆ supporting treatment:
2
◆ antibiotics:
◆ percutaneous drainage: under BUS or CT:
◆ operation: surgical drainage
intraperitoneal route
amebic liver abscess
1. Etiology and pathology
etiology
amebic liver abscess is complication of intestinal amebic infections
pathology
amebas invade the colonic mucosa and be carried to the liver via
portal vein. Within the liver these organisms multiply and produce a
proteolytic enzyme, cause the liver cells necrosis and abscess formation
complications:
◆ secondary bacterial infections
◆ discharge into subphrenic, pleural, lung, pericardial spaces,
intraperitoneal and intestinal cavity
2. Clinical presentation and diagnosis
◆ lower fever, right upper quadrant abdominal
pain; hepatomegaly with tenderness, hepatic
percussion pain
◆ fecal examinations: amebic trophozoite
◆ colonoscopy: ulcers, amebas
◆ percutaneous needle aspiration: brown fluid
◆ respond to antiamebic therapy:
3. Treatment
◆ medicine treatments with antiamebic therapy
◆ percutaneous drainage under BUS or CT
◆ operation:
indications:
huge abscess with diameter>10cm
complicated with bacterial infection
rupture into adjoining structures
no respond to antiamebic therapy
no respond to percutaneous drainage
3
operative method: open drainage
hydatid disease of liver
1. Pathogenesis and pathology
Hydatid cyst is a hepatic cystic lesion that the liver is invaded by
the larvae of ehinococcus granulosus.
2. Clinical presentations and diagnosis
(1)asymptomatic in early and small or light pain in right upper
quadrant, a mass can be occasionally found
(2)compressive symptoms:
gastrointestinal: neusea, vomiting
biliary: objective jaundice
portal vein: hepatomegaly ,splenomegaly, ascites
(3)anaphylactic reaction:
skin itching and rash, dyspnea
(4)physical examination:
mass in right upperquadrant, hydatid thrill, hepatomegaly
(5)complications:
infection: bacterial liver abscess
rupture:
biliary tract: colic and jaundice
peritoneal cavity: anaphylactic shock
(6)laboratory tests:
peripheral esinophilia↑
Casoni’s skin test: 85% sensitive
complement fixation test:
(7)BUS, CT
2. Treatment
operation:
◆ extirpation of inner capsule
◆ hepatolobectomy
Liver Tumors
primary liver cancer
1. Etiology and Pathology
etiology: unclear, but relations with viral hepatitis, cirrhosis,
aflatoxin and nitrosamine
pathology:
gross classification:
nodular, massive, and diffuse types
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microscopic classification: hepatocellular, cholangiocellular
and mixed types
metastases:
intrahepatic
blood and lymph
direct invasion
intraperitoneal seed-breeding
2. Clinical Presentations
■symptoms:
♥ local symptoms: abdominal pain
♠ gastrointestinal symptoms: anorexia, abdominal swelling, neusea,
vomiting
♦ general symptoms: weight loss, fever, jaundice, ascites
♣ paracarcinoma manifestations:
hypoglycemia, erythremia, hypercalcemia, hypercholesterinemia
■ signs: hepatomegaly with tenderness, mass
■ complications:
hepatic coma
gastrointestinal bleeding
tumor rupture and infection
3. Diagnosis
■ history
■ symptoms and signs
■ assistant examinations:
Laboratory Examinations:
● α-fetoprotein (AFP):≥400ng/ml★
● serum enzymology: AKP, γ-GPT, LDH
● liver function tests
● hepatitis B or C antigen and antibody
Imaging Diagnosis:
■ BUS
■ CT
■ MRI
■ hepatic angiography
■ nuclear scans
■ positron emission tomography (PET)
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■ needle biopsy
■ laparoscopy
■ laparotomy
Differential diagnosis:
secondary (metastatic) liver cancer
hepatic abscess
hepatic hemangioma
4. Treatment
● operative resection
● transarterial embolization (TAE)
● percutaneous ethanol injection (PEI)
● biological and gene therapy
● chemotheraphy
● radiotherapy
● Chinese medicine
(1)operative resection
Indications:
● localized lesions without exceeding half of the liver;
● no vascular invasion of main portal trunks and main hepatic vein
Contraindications:
● serious jaundice, ascites;
● critical liver function damage;
● extrahepatic widespread tumor;
● not enduring for the operation with dysfunction of organs
resection principles:
regular resection:
● lobe resection if the tumor located in a segment
● half liver resection as the tumor limited in a lobe or invasion
of near lobes
● three lobes resection when the tumor crosses a lobe or gets to
half of the liver, but no obvious cirrhosis
“radical local resection”:
a resection to achieve 2cm margin of normal tissue
unresectable tumors during operation:
● hepatic artery ligation
● catheterization
● alcohol injection
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● liquid nitrogen freeze
● microwave diathermy
rupture and bleeding:
● conservative therapy
● hepatic artery ligation, plugging
● hepatolobectomy
two-stage resection:
recurrent re-resection:
liver transplantation:
(2)transarterial embolization (TAE)
indications:
● unresectable big tumor;
● diffuse multiple tumors;
● recurrences and unsuitable for re-operation;
● postoperation
contraindications:
● the tumor volume >70% of liver volume;
● serious jaundice, ascites;
● critical liver function damage;
● serious varices of esophagus and fundus of stomach;
● very poor general condition;
● dysfunction ofcoagulation;
● hypersensitive test to iodine
(3)percutaneous ethanol injection (PEI)
indications:
● tumor size < 3cm and in deep;
● tumor number <3
contraindications:
● tumor in the surface of liver (relatively);
● critical liver function damage, especially with ascites
(4)biological and gene therapy:
(5)chemotheraphy:
(6)radiotherapy:
(7)Chinese medicines:
cavernous hemangioma of liver
1. Clinical presentations and diagnosis
● no symptoms in early stage and small size
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● abdominal pain in right upper quadrant
● gastrointestinal symptoms: anorexia, abdominal swelling,
neusea, vomiting
● hepatomegaly and liver mass
● ultrasound, CT, M RI, angiography
2.Treatment
● observation and follow up: small and asymptomatic
● operation: >8cm
Surgical resection
hepatic artery ligation
suture and ligation
embolization
freeze, microwave and sclerosis
cyst of liver
1. Classification
parapsitic cysts: hydatid disease of liver
nonparapsitic cysts:
congenital cysts: true cyst (single cyst and polycystic liver disease)
traumatic cysts:
inflammatory cysts: retention cysts
neoplasm cysts: teratoma, cystic lymphangioma, cystadenoma
2. Clinical presentation and Diagnosis
· small cysts: asymptomatic
· large cysts: abdominal swelling and pain, compression of adjacent
structures
· hepatomegaly, mass
· BUS, CT
3. Treatment
· asymptomatic cysts require no treatment
· large, asymptomatic, infected and with objective jaundice can be
operated by either an open approach or laparoscopy
fenestration (unroofed) operation
drainage operation: internal and external
cyst resection
hepatolobectomy
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