Anatomy of the liver Anatomy of the liver

Anatomy of the liver

Anatomy of the liver

Resections of the liver Right extended hemihepatectomy Left hemihepatectomy Right hemihepatectomy Left lobectomy Left extended hemihepatectomy Atypical resection

SYMPTOMS OF LIVER DISEASES

General symptoms n n n ASYMPTOTIC FORM Discomfort, heaviness in right upper quadrant Right hypochondriac pains Hepatomegaly Elevated transaminase levels (AST, ALT) Liver insufficiency

Hollow structures compression n Biliar hypertension (mechanical jaundice) Yellowish colour of skin and sclerae n Dark urine n High levels of alkaline phosphatase and γ-GTP n Enlargement of biliar ducts n Non-drained segment syndrome n n n Portal hypertension Duodenal stenosis

Instrumental diagnostic of liver lesions n. Ultrasound n. CT scan n. MRI

Liver ultrasound

CT scan

SOLID LESIONS OF THE LIVER

What can it be? n Benign diseases: Hemangioma n Focal nodular hyperplasia n Adenoma n n Malignant diseases: Metastases n Hepatocellular carcinoma n Cholagiocellular carcinoma n

Hemangioma

Hemangioma - treatment n n Generally requires NO TREATMENT Biopsy is contraindicated Dynamic observation (ultrasound 1 per year) Resection: by compression of nearby structures or rupture

Liver adenoma

Liver adenoma n n Risk factors: peroral contraceptives, steroids If lesser than 5 cm – dynamic observation If larger than 5 cm – can be ruptured or turn malignant Treatment – resection or embolization

Hepatocellular carcinoma

Hepatocellular carcinoma n n n Elevated levels of CEA and α-fetoprotein Confirmation by biopsy Radical treatment: Resection n Liver transplantation n Radioablation n n Non-radical treatment: Embolization n Chemoembolization n Chemotherapy n

Metastatic liver disease

CYSTIC LESIONS OF THE LIVER

What can it be? n n n n Simple cyst Polycystic liver disease Liver abscess Amebic liver abscess Cystadenocarcinoma Echinococcosis Alveococcosis

Liver cysts n n Mostly asymptotic Symptoms of compression by large diameter Diagnosed by ultrasound Additional methods: CT, MRI, biopsy – if thick wall, internal septs or calcificates were found

Liver cysts (simple)

Treatment of simple cysts Asymptotic – dynamic observation n Method of choice for surgery – laparoscopic fenestration n Alternative method – puncture, aspiration and sclerosant injection n

Laparoscopic fenestration

Polycystic liver disease n n n Method of choice – puncture and aspiration of large cysts Laparoscopic fenestration in separate cases Transplantation of liver (and kidneys)

LIVER ABSCESS

Liver abscess etiology n Enterogenic (through v. portae) n Cholangiogenic n Hematogenic n Posttraumatic (also iatrogenic) n Contact

Bacterial abscesses 1. 2. 3. 4. Intoxication Liver affection symptoms Other organs involvement Complications

Intoxication symptoms n Hectic fever n Shivering n Sweating n Left shift, leukocytosis

Local liver symptoms n Pain in right hypochondrium n Hepatomegaly n Jaundice n High levels of AST, ALT n Ascites

Nearby organs reaction n High position of diaphragm n Reactive pleuritis n Cholecystitis n Duodenal compression n Kidney reaction

Complications of abscesses n Toxic shock n Septic metastases n Liver insufficiency n Bleeding n Fistula formation n Rupture of abscess

Abscess rupture

Diagnostic of abscess n Ultrasound n CT scan n Chest X-ray n ERCPG or TTCG by biliar abscess n Serologic test for Entamoeba histolytica

Liver abscess - Ultrasound

Liver abscess – CT scan

Liver abscess – cholangiography Transcutaneous Fistulography

Surgical tactic by liver abscess n n Antibioticotherapy – cephalosporin III generation + metronidazole / piperacillin for 2 weeks Transcutaneous puncture and drainage Biliar abscesses – biliar drainage Open surgical drainage - if no effect from puncture

Treatment of amebic abscesses n Monotherapy with metronidazole n Drainage by large abscesses or rupture risk n Concurrent treatment of amebic colitis (if found)

PARASITIC DISEASES OF THE LIVER

Liver parasites Entamoeba hystolitica n Ascaris lumbricoideus n Opisthorchis felineus n Fasciola hepatica n Clonorchis sinensis n Schistosoma haematobium n Echinococcus granulosus n Alveococcus multilocularis n Taenia solium n

Life cycle of E. granulosus

Echinococcal cyst structure n Fibrous capsule n Chitinous layer n Germinative layer n Secondary cysts (hydatids) n Hydatid liquid

Echinococcosis - symptoms n. I stage - asymptotic n II stage: n Heaviness, discomfort n Pains in right upper quadrant n Weakness n Allergic reactions - urticaria n Nausea

Ecinococcosis - symptoms n III stage – complications: n Suppuration n Perforation n Ascites n Jaundice n Anaphylaxis

Echinococcosis - diagnostic n Ultrasound n CT scan n Eosinophilia n Serologic reactions n Aspiration of hydatid liquid

US and CT scan

Hydatid types by WHO n n n I – singular cyst with double wall II – multicellular cyst IIIa – single cyst with separated internal capsule (”water lily sign”) IIIb – secondary cysts in dense matrix IV – heterogeneous structure with no apparent cysts V – solid formation with calcified wall

Treatment of echinococcosis n n Type I or 3 a, smaller than 5 cm – monotherapy with albendazole or mebendazole Type I or 3 a, larger than 5 cm – PAIR (puncture-aspiration-irrigation-reaspiration), then albendazole

Treatment of echinococcosis n Type II or 3 b – drainage or surgical excision, then albendazole

Treatment of echinococcosis n n Type IV and V – dynamic observation Surgical treatment by complications

Life cycle of alveococcus

Alveococcus

Treatment of alveococcosis n n n Method of choice – liver resection, parasite excision or liver transplantation After surgery – 2 year course of albendazole Palliative treatment – albendazole, miniinvasive surgery

Schistosomiasis n Caused by trematodes of Schistosoma genus: S. haematobium, S. mansoni, S. japonicum, S. guineensis, S. mekongi

Schistosomiasis n n n Occurs in Africa, Brazil, Cambodia, the Caribbean, China, Corsica, Indonesia, Laos, the Middle East, the Philippines, Suriname, and Venezuela Transmitted through water Affects liver, then blood vessels of the intestine, bladder, genitals

Schistosoma life cycle

Schistosomiasis – symptoms n Liver affection - portal hypertension: Ascites n Splenomegaly n n Urinary tract affection: Hematuria n Cystitis n Ureter obstruction n Pyelonephritis n

Schistosomiasis – symptoms n Genital organs affection: Prostatitis n Woman infertility n High risk of HIV and HPV n n Gastrointestinal tract affection: Appendicitis n Colitis n Perforation n Bleeding n Risk of bowel cancer n

Schistosomiasis – diagnostic n n Gold standard – detection of parasite’s eggs in stool and urine Serologic test

Schistosomiasis – treatment n n n Praziquantel 60 mg/kg per day Prophylaxis with single dose of praziquantel Surgery by complications: Treatment of bleedings n Treatment of portal hypertension n Resection of the intestines n

Liver trematodes n n Fasciola hepatica Opisthorchis felineus Clonorchis sinensis Dicrocoelium lanceatum

Fasciola life cycle

Opisthorchis and Clonorchis life cycle

Dicrocoelium life cycle

Symptoms of liver flukes n n n n Abdominal pain Fever Nausea, vomiting Diarrhea Urticaria Malaise, weakness Decreased appetite and weight loss

Diagnostic of liver flukes n n Stool analysis for parasites and their eggs Bile analysis Serologic tests Imaging methods (mostly for F. hepatica)

Treatment of liver flukes n n Fasciola hepatica – triclabendazole Praziquantel Albendazole Surgery for complications: Cholecystectomy n Biliar drainage n Liver resection n