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Michael Brillantes, MD, FPCS, FPSGS

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1 Michael Brillantes, MD, FPCS, FPSGS
LIVER By Michael Brillantes, MD, FPCS, FPSGS

2 Anatomy -1/50 of total body weight Surgically divided into the right and left lobe by a line through the IVC and gallbladder (Cantlie’s line)

3 -left lobe divided into medial and lateral
segments by falciform ligament -blood supply  hepatic a. - 25% portal v – 75%

4 II. Liver function Circulatory function- material absorbed from the GI tract are brought to the liver through the dual blood supply to be used in the metabolic pool

5 B. Biliary passages- channel of exit for
materials secreted by the liver through the dual blood supply to be used in the metabolic pool

6 C. Reticuloendohelial system- contains
phagocytic Kupffer cells and endothelial cells D. Metabolic Activity- anabolic and catabolic activities

7 III. Function Tests a. Albumin – half- life is 21 days; decrease means a chronic liver disease (more than 3 wks)

8 B. Carbohydrates and Lipids- hepatic
disease causes decrease in glycogenesis with resultant hyperglycemia

9 C. Enzymes Alkaline phospatase- increase indicates an obstructive pathology

10 2. SGOT and SGPT- increase indicates liver
cellular damage; SGPT more applicable for hepatic disease 3. Dye excretion

11 4. Coagulation factors a. Vit. K dependent clotting factors II, VII, IX, and X b. Inability to synthesize prothrombin

12 IV. Special Studies A. Needle Biopsy- provides pathologic diagnosis B. Ultrasound, CT scan, MRI C. Angiography

13 V. Pathology Trauma- 2nd most commonly injured organ 1. Clinical manifestation- shock, abdominal pain, spasm, and rigidity

14 2. Diagnostic- CT scan is the most useful
- may also use ultrasound, paracentesis or peritoneal lavage

15 3. Treatment Correct shock- IVF and blood Surgery Control bleeders- perihepatic packaging, ligation of bleeders, Pringle maneuver Debridement External drainage

16 4. Complications Recurrent bleeding- inadequate homostasis or loss of coagulation factors secondary to massive transfusions Intraabdominal sepsis

17 C. Hematobilia- free communication between blood vessel and biliary tree
- triad of abdominal pain, GI bleeding, and previous trauma - jaundice may be present

18 B. Hepatic Absdess 1. Pyogenic- most commonly due to cholangitis secondary to CBD obstruction; septicemia second most common etiology

19 - Fever with “picket fence” pattern, hepatomegally and tenderness
-organism- usually e. coli -usually found in the right lobe, solitary or multiple

20 Presents with hepatic tenderness and fever
Diagnostic i. CBC- leukocytosis, with count up to 18-20,000

21 ii. Radiograph- immobility or elevation of right hemidiaphragm
iii. Ultrasound or CT scan

22 b. Treatment I .Antibiotics- IV for 2 wks, followed by 1 month oral form II. Drainage- percutaneous under ultrasound or CT guidance, or open

23 2. Amebic- reaches the liver via the portal vein from an ulceration in the bowel wall
-organism- e. histolytica -occurs in the right lobe, usually solitary, with characteristic “anchovy paste”

24 Fever and liver pain, assoc. woth tender hepatomegally
33% with antecedent diarrhea

25 Diagnostic i. CBC- leukocytosis ii. Indirect heme agglutinstion test iii. Ultrasound iv. Aspiration of trophozoites

26 b. Complications i. Secondary bacterial infection ii. rupture

27 c. Treatment i. Amebicidal drugs- Metronidazole 500 mg TID ii. Surgery – indicated for persistence of abscess, secondary infection

28 C. Cysts 1. Non- parasitic – usually solitary, found in the right lobe, watery content, with low internal pressure

29 -polycystic liver assoc. with polycystic kiny in 51.6% of cases
-usually presents as a RUQ mass

30 Classification Blood or degenerative Dermoid Lymphatic Endothelial Retention – polycystic liver Proliferative cysts- cystadenomas

31 b. Diagnostic – ultrasound, CT scan, arteriography, scintillography, peritoneoscopy
c. Asymptomatic- no treatment Symptomatic- drainage with unroofing or sclerotherapy

32 2. Hydatid cysts- caused by Echinococcus granulosus
- with high internal pressure, causing rupture and anaphylactic reaction

33 Asymptomatic unless there are pressure symptoms on adjacent organs
Diagnostic- radiograph, ultrasound and CT scan -Casoni’s skin test

34 b. Treatment i. small calcified cyst- no treatment ii. Sterilizationof cyst prior to surgery with hypertonic saline or alcohol followed by surgical removal

35 D. Benign Tumors 1. Classification a. Hamartomas- tissues normally found in the organ but arranged in a disorderly manner

36 b. Adenoma- associated with contraceptive
use; may transform into hepatocellular carcinoma; high rate of bleeding

37 c. Focal nodular hyperplasia- reaction to
injury or a response to a preexisting vascular malformation d. Hemangioma- most common nodule in the liver

38 2. Diagnostic- ultrasound, CT scan, angiography
3. Treatment- excision if symptomatic

39 E. Malignant lesions 1. Primary carcinoma- from Aspergillus flavus, kwashiorkor

40 Classification hepatoblastoma- usually affects children less than 2 years old.

41 ii. Fibrolamellar carcinoma- adolescent and young adults; large solitary lesion
iii. Hepatocellular carcinoma- most common primary malignancy, usually follows postnecrotic cirrhosis (hepatitis B)

42 Manifested by mass, weight loss, abdominal pain, or intraperitoneal hemorrhage

43 b. Diagnostic i. Liver function test- alkaline phosphatase ii. Alpha Feto Protein

44 iii. Angiography iv. Ultrasound, intraoperative ultrasound, CT scan, MRI

45 c. Treatment- curative resection, chemotherapy with direct arterial infusion

46 2. Other Primary Neoplasms
Sacroma- angiosacroma most common Mesenchymoma Infantile hemangioendothelioma

47 3. Metastatic neoplasms - most common malignant tumor of the liver - reach the liver by portal vein, hepatic artery, lymphatics, direct extension

48 Symptoms are usually referable to the liver (i. e
Symptoms are usually referable to the liver (i.e. pain, ascites, weight loss, anorexia and jaundice

49 Diagnostic i. alkaline phosphatase ii. Serum marker referable to the primary carcinoma iii. SGOT iv. CT scan, MRI

50 b. Treatment Control primary tumor Check for other systemic metastases Patient should be able to tolerate a major resection Resection of metastasis should be feasible

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