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LIVER DISEASEDr.Mohmmadzadeh
Anatomy •Largest solid organ of body•Weight : 1.5 kg•From the nipple line in 4th intercostal
down to the costal margin•Falciform ligament & ligamentum teres
hepaticus
Portal vein
•A valveless vein•Confluence of the smv & splenic vein•75% of total liver blood•Normal pressure 3-5 mmHg
Hepatic veins
•Three hepatic veins•Right H.V drains segments V,VI,VII,VIII•Middle H.V drains segments
IVA,IVB,V,VIII•Left H.V drains segments II,III
Hepatic artery
•From celiac trunk & give off gastroduodenal & right gastric artery
•Cystic artery from right hepatic artery
Biliary system
•Canaliculi canal of Hering small duct R & L hepatic ducts common hepatic duct common bile duct
•Normal CBD is less than 10 mm
Synthetic functions
•Coagulation factors•Albumin a variety of acute-phase proteins
& cytokines
Carbohydrate metabolism
•Critical storage site of glycogen•Metabolization of lactate % Cori cycle
Lipid metabolism
•Synthesis of lipoproteins, triglycerides,•Gluconeogenesis from fatty acics•Cholestrol metabolism
Bilirubin metabolism
•A product of heme metabolism•Glucuronidated in liver & actively
secreted in bile•One liver sector is adequate for bilirubin
secretion•Electrolyte composition of bile is similar
to plasma
Radiologic evaluation of liver
•Ultrasound : cirrhosis or fatty liver cystic or solid nature of
tumors for screening in high-risk
population of HCC IOUS•CT-scan : smallest detectable lesion 1 cm cystic or solid nature•MRI : more sensitive for early HCC
•PET scan : hepatic metastsis of colorectal cancer
less useful for HCC•Angiogeraphy•Percutaneous biopsy•Diagnostic laparascopy
Cystic diseases of the liver
•Congenital cysts
•Polycystic liver disease
Congenital cyst
•Most common benign lesion•Dose not contain bile•Recurrence of simple aspiration is high•PAIR •Wide cyst fenestration
Polycystic liver disease
•An autosomal dominant presenting in adulthood
•Three general anatomic presentation•PAIR•Fenestration•Resection of cyst•Formal lobectomy•Transverse hepatectomy
Benign solid liver tumors
•Hepatic adenoma•Focal nodular hyperplasia
•Hemangioma •Hamartoma
Hepatic adenoma
•In reproductive –aged women•In women who used OCPs•Pathology : sheets of hepatocytes ith no
nonparanchymal cells or bile ducts•75% symptomatic•They can rupture•Radiographycally difficult to distinguish
from FNH•Management : cessation of OCPs -
surgery-RFA
FNH
•Asymptomatic ,does not rupture ,no malignant
•Two third of lesions have central scar•Resection in symptomatic lesions
Hemangioma •A common benign lesion discovered
incidentally•Chronic low-intestity RUQ pain•US , CT-scan , MRI•Atypical hemangioma : Tc99 -labeled red
cell•Resection in symptomatic lesions
Hamartoma •Most common liver lesion in laparotomy•Peripheral ,firm & smooth•Usually less than 1-3 mm
Pyogenic liver abscesses
•In past : appendicitis & pylephlebitis•Currently : biliary tract manipulation ,
diverticular disease ,IBD ,systemic infections , ERCP, cryptogenic (one third )
•RUQ pain, fever, jaundice•US ,CT•Percutaneous aspiration•Laparoscopy
Amebic abscess
•A recent history of diarrhea is uncommon•Sweating & chills for one week ,RUQ pain
& tenderness•Positive fluorescent antibody test •Mild liver enzymes abnormality•Metronidazole at least for one week•Aspiration
Computed tomographic scan finding for an adenoma.
Classic appearance of hemangioma on magnetic resonance imaging.
Appearance of a giant adenoma on computed tomography.
Computed tomographic appearance of fibronodular hyperplasia lesion.
Magnetic resonance imaging appearance of a fibronodular hyperplasia lesion in the
right liver, seen on T1-weighted (A) and T2-weighted (B) images.
Hepatocellular carcinoma• Hepatocellular carcinoma (HCC) is the most
common primary malignancy of the liver and one of the most common malignancies worldwide, accounting for more than 1 million death annually
• The geographic distribution of HCC is clearly related to the incidence of hepatitis B virus (HBV) infection.
• HCC is two to eight times more common in males than in females in low and high incidence areas
• In general, the incidence of HCC increases with age, but a tendency to develop HCC earlier in high incidence areas has been noted.
Ethiology •Hepatic viral infections•Environmental exposure•Alcohol use ,smoking•Genetic & metabolic diseases•Cirrhosis •OCPs
Clinical Presentation• Most commonly, patients presenting with HCC are
men 50 to 60 years of age who complain of right upper quadrant abdominal pain and weight loss and have a palpable mass.
• Nonspecific symptoms of advanced malignancy such as anorexia, nausea, lethargy, and weight loss are common. .
• Another common presentation of HCC is hepatic decompensation in a patient with known mild cirrhosis or even in patients without previously recognized cirrhosis
Diagnosis• Radiologic investigation is a critical part of
the diagnosis of HCC
• ultrasound, CT, and MRI
• Ultrasound plays a significant role in screening and early detection of HCC
• definitive diagnosis and treatment planning rely on CT and MRI.
AFP measurements • AFP measurements can be very helpful in
the diagnosis of HCC.
• An AFP level greater than 20ng/mL is noted in about three fourths of documented cases of HCC.
• False-positive elevations of serum AFP can be seen in inflammatory disorders of the liver, such as chronic active viral hepatitis
Treatment Options for Hepatocellular Carcinoma•Surgical Resection
Orthotopic liver transplantation•Ablative EtOH injection
Acetic acid injection Thermal ablation (cryotherapy, radiofrequency ablation, microwave)