Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M A N I P A L U N I V E R S I LIVER- Abscesses & Tumors Dr.B.SELVARAJ MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Malaysia
1. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y LIVER- Abscesses & Tumors
Dr.B.SELVARAJ MS;Mch;FICS; Professor of Surgery Melaka Manipal
Medical College Malaysia
2. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y LIVER- Anatomy-Lobes Cantlies
LineAnatomical Lobes
3. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y LIVER- Anatomy-Segments Couinauds
Segments
4. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y LIVER- Abscesses & Tumors
Pyogenic Abscess Amebic Abscess Hydatid Cyst Hepatic adenoma Focal
nodular hyperplasia Hepatic hemangioma Hepatocellular carcinoma
Secondary in liver
5. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Pyogenic Abscess-Etiology Potential
routes of hepatic exposure to bacteria as follows: Biliary tree
(most common route) Portal vein (pyelophlebitis due to
diverticulitis, appendicitis, PID, IBD, perforation, etc.) Hepatic
artery (systemic bacteremia-associated with multiple microabscess)
Direct extension & Trauma
6. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Pyogenic Abscess-Etiology Pyogenic
abscesses with no identifiable primary infection are called
cryptogenic hepatic abscesses Organisms cultured include
gram-negative aerobes E coli, Klebsiella and Proteus species are
most commonly isolated Aerobic Streptococcus and Staphylococcus are
also seen Increased use of indwelling biliary stents and
broad-spectrum antibiotics has led to an increased prevalence of
Pseudomonas and fungi.
7. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Pyogenic Abscess-Clinical Features
Most common in right lobe Most common organisms isolated E. coli,
Klebseilla and Proteus Most common presenting symptomsfever,
chills, abdominal pain and jaundice A rare complication of
Klebseilla abscess is endogenous endophthalmitis (3%), common in
diabetics
8. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Pyogenic Abscess-Investigations
X-ray chest shows elevated right hemidiaphragm, pleural effusion
and atelectasis. USG abdomen unilocular or multilocular cyst CT
abdomen- Rim enhancement in CECT
9. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Pyogenic Abscess-Treatment
Percutaneous catheter drainage along with broad spectrum
antibiotics Surgery is reserved for those who fail percutaneous
technique and for those whom surgery is required for some other
pathology or rupture of abscess A falling serum albumin level and
presence of jaundice are bad prognostic signs.
10. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Amebic Abscess-Etiology The
causative organism is Entamoeba histolytica It is almost and always
secondary to amebic ulcers on the colonic wall. The organisms
ultimately reach the liver via the inferior mesenteric vein and
then portal vein. Due to liquefaction necrosis of liver, the
abscess results anchovy sauce colored and odorless
11. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Amebic Abscess-Clinical Features
Residence or travel to endemic areas H/o Amebic dysentery RUQ pain
Fever- moderate Tender hepatomegaly
12. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Amebic Abscess-Complications
13. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Amebic Abscess-Investigations
Diagnosis is by isolation of the parasite from the liver lesion or
the stool and confirming its nature by microscopy. Enzyme immuno
assays (EIA) have sensitivity 99%and specificity > 90% in
patients with amebic abscess USG- Hypoechoic and non homogenous
rounded lesion abutting liver capsule without significant rim
echoes
14. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Amebic Abscess-Investigations CT
scan: More sensitive in differentiating pyogenic from amebic
because there will be rim enhancement in pyogenic abscess on
contrast study. Nuclear scan (Gallium ): Helps in differentiating
because amebic abscess does not contain leukocytes and hence does
not light up on these scans
15. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Amebic Abscess-Treatment Oral
metronidazole750 mg three times/10 days is the drug of choice.
Emetine im injections is very effective for invasive amoebiasis
Therapeutic aspiration is usually avoided. Metrogyl is the
treatment of choice and about 90% cases respond well.
16. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Amebic Abscess-Treatment
Indications for aspiration: abscess wall diameter larger than 5 cm
(abscess with high risk of rupture) abscess in the left lobe of
liver for diagnostic uncertainty failure to respond in 3-5
days
17. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Amebic & Pyogenic Liver
Abscesses
18. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hydatid cyst- Etiology Echinococcus
granulosus is M/c. others E. multilocularis, E. oligartus. Dogs are
definitive hosts in which adult worms develop Sheeps are
intermediate hosts that consume the ova passed by the feces of dog
over grasses Humans are accidental hosts consuming these eggs that
converts to embryo in duodenum and releases an oncosphere
containing hooklets
19. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hydatid cyst- Etiology The
oncosphere reaches the liver or lungs, where the parasite develops
into larval stage called as hydatid cyst Remember humans are
end-stage host.
20. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hydatid cyst- Pathogenesis 3 weeks
after ingestion, a pericyst derived from host tissue wall develops
surrounding the hydatid cyst. The cyst itself has two walls:
ectocyst (outer gelatinous) and endocyst (inner germinal) layers.
In definitive host, they develop into adult tapeworm, but in
intermediate host they develop only into new hydatid cyst Daughter
cysts are true replicae of the mother cyst.
21. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hydatid cyst- Clinical features
Most common in right lobe of liver Most frequent signhepatomegaly
Most common symptomsabdominal pain, dyspepsia and vomiting.
Complications: Rupture into biliary tree, bronchial tree, pleural,
peritoneal and pericardial cavity
22. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hydatid cyst- Investigations USG:
Rosette like appearance or water lilley appearance is seen when
daughter cysts are present. Calcifications in the wall are highly
diagnostic Serological tests: ELISA, arc 5 test, IHA test,
immunoblast test, where available is the test of choice Casoni
test: Intradermal injection of sterile hydatid fluid produces a
wheal of 5 cm in half hour
23. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hydatid cyst- Gross& CT
Abd
24. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hydatid cyst- Treatment Primarily
surgical, but introduction of PAIR has totally replaced it. During
surgery, packing off the abdomen from the cyst is very important
because of the anaphylactic reaction that may occur if cyst
ruptures into peritoneal cavity Remember surgery is now preferred,
where PAIR is not possible or when it does not respond to PAIR or
when there is any communication to biliary tree
25. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hydatid cyst- Treatment Surgical
procedures: Pericystectomy Marsupialization Omentoplasty Total
cystectomy Partial hepatectomy
26. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hydatid cyst- PAIR Percutaneous
aspiration, infusion of scolicidal agents and reaspiraion (PAIR).
Given with prophylactic cover of albendazole. Scolicidal agents20%
hypertonic saline, 0.5% silver nitrate, 95% ethanol, absolute
alcohol, mebendazole 2.4 microgram/ml
27. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hydatid cyst- PAIR- CI
Contraindications for PAIR: Superficially located cyst (chance of
rupture) Honey combing of cysts (multiple thick internal septae)
Communication with biliary tree Dead or inactive cysts
28. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Liver Abscesses- Recap
29. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Liver Tumors- Benign Hepatocellular
adenoma Focal Nodular Hyperplasia Hepatic Hemangioma
30. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Liver Tumors- Benign
31. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hepatic Adenoma- CT Abd Three-phase
CT scan of a hepatic adenoma. Left: arterial phase; center: portal
phase; right: venous phase.
32. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Focal nodular hyperplasia- CT Abd
Homogenous mass with central scar
33. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Focal nodular hyperplasia-sulphur
colloid scan
34. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Liver hemangioma- CT Abd
35. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Benign Liver tumors- Recap
36. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- risk
factors Infections: Hepatitis B virus, hepatitis C virus Cirrhosis:
Alcohol induced, autoimmune hepatitis, primary biliary cirrhosis
Environmental: Aflatoxins, pyrrolizidine alkaloids Thorotrast
N-nitrosylated compounds Metabolic diseases: Hemochromatosis,
alpha1- antitrypsin deficiency,Wilson disease, porphyria cutanea
tarda, Type 1 and 3 glycogen storage disease, galactosemia,
citrullinemia,hereditary tyrosinemia, familial cholestatic
cirrhosis
37. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- H & P
Most common in males; 50-60 year Presentation: 1. Right upper
quadrant pain 2. Weight loss 3. Palpable mass 4. In known
cirrhoticssudden decompensation of liver think of HCC. 5. Rupture
6. Less than 1% cases present with paraneoplastic syndrome most
commonly hypercalcemia, hypoglycemia, Erythrocytosis
7.Hepatocellular carcinoma has the tendency to invade the portal
vein
38. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hepatocellular carcinoma-
Investigations USGplays significant role in screening and early
detection of HCC CT and MRIare definitely needed for planning
surgeries Serum AFPused in diagnosing HCC Value > 400 mg/dl is
highly suggestive AFP is mainly used to monitor recurrences in
treated patients AFP levels are elevated in about 70%80% cases
39. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- CT
Abd
40. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- Biopsy
Biopsy is contraindicated in suspected cases Biopsy is done only in
inoperable cases which are tried for non-operative therapies
Percutaneous biopsy carries the risk of tumor spillage, rupture and
bleeding
41. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- Treatment
Complete excision of HCC by partial hepatectomy or by total
hepatectomy with liver transplantation Percutaneous ethanol &
acetic acid injection Thermal ablative techniquesCryotherapy,
Radiofrequency ablation (RFA), microwave RFA and cryotherapy can be
done percutaneously. Main disadvantage is heat sink effect,
limiting the use near major blood vessels
42. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hepatocellular carcinoma- Treatment
Based on the fact that most of the tumor blood supply is from the
hepatic artery HAI (hepatic arterial infusion) chemotherapy using 5
flouorouracil, cisplatin, doxorubicin; Sorafenib Chemoembolization:
Embolization particles and lipoidal oils added with chemotherapy
agents selectively taken up by HCC
43. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hepatocellular CA- D/D
44. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Liver metastasis Colorectal liver
metastases on computed tomography (CT) scan: (a) after oral
contrast CT; (b) after intravenous contrast. The colorectal liver
metastasis occupying the entire right lobe of the liver is
difficult to visualise on oral contrast CT. The addition of
intravenous contrast shows its lack of enhancement and its
relationship to the hepatic veins.
45. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Malignant Liver Tumors- Recap
46. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hepatocellular carcinoma-
videoclip
47. Melaka Manipal Medical College, Malaysia INSPIRED BY LIFE M
A N I P A L U N I V E R S I T Y Hepatocellular carcinoma-
videoclip