LIVER

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LIVER
By Michael Brillantes, MD, FPCS, FPSGS
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• Anatomy
• -1/50 of total body weight

• Surgically divided into the right and
• left lobe by a line through the IVC and
• gallbladder (Cantlies line)

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-left lobe divided into medial and lateral
segments by falciform ligament
-blood supply ? hepatic a. - 25 ?portal v
75
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II. Liver function

1. 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

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B. Biliary passages- channel of exit for
materials secreted by the liver through the
dual blood supply to be used in the metabolic
pool
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C. Reticuloendohelial system- contains
phagocytic Kupffer cells and endothelial cells
D. Metabolic Activity- anabolic and catabolic
activities
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III. Function Tests
a. Albumin half- life is 21 days decrease
means a chronic liver disease (more than 3 wks)
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B. Carbohydrates and Lipids- hepatic disease
causes decrease in glycogenesis with resultant
hyperglycemia
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• C. Enzymes
• Alkaline phospatase- increase indicates
• an obstructive pathology

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2. SGOT and SGPT- increase indicates liver
cellular damage SGPT more applicable for
hepatic disease
3. Dye excretion
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4. Coagulation factors a. Vit. K dependent
clotting factors II, VII, IX, and X b.
Inability to synthesize prothrombin
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IV. Special Studies A. Needle Biopsy- provides
pathologic diagnosis B. Ultrasound, CT scan,
MRI C. Angiography
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• V. Pathology
• Trauma- 2nd most commonly injured organ
• 1. Clinical manifestation- shock, abdominal
  pain, spasm, and rigidity

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2. Diagnostic- CT scan is the most useful -
may also use ultrasound, paracentesis or
peritoneal lavage
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• 3. Treatment
• Correct shock- IVF and blood
• Surgery
• Control bleeders- perihepatic packaging, ligation
  of bleeders, Pringle maneuver
• Debridement
• External drainage

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

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C. Hematobilia- free communication between blood
vessel and biliary tree - triad of
abdominal pain, GI bleeding, and previous
trauma - jaundice may be present
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B. Hepatic Absdess 1. Pyogenic- most commonly
due to cholangitis secondary to CBD obstruction
septicemia second most common etiology
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- Fever with picket fence pattern,
hepatomegally and tenderness
-organism- usually e. coli
-usually found in the right lobe, solitary or
multiple
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• Presents with hepatic tenderness and fever
• Diagnostic
• i. CBC- leukocytosis, with count up to 18-20,000

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ii. Radiograph- immobility or elevation of right
hemidiaphragm iii. Ultrasound or CT scan
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b. Treatment I .Antibiotics- IV for 2 wks,
followed by 1 month oral form II. Drainage-
percutaneous under ultrasound or CT guidance, or
open
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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
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• Fever and liver pain, assoc. woth tender
  hepatomegally
• 33 with antecedent diarrhea

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

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b. Complications i. Secondary bacterial
infection ii. rupture
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c. Treatment i. Amebicidal drugs- Metronidazole
500 mg TID ii. Surgery indicated for
persistence of abscess, secondary infection
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C. Cysts 1. Non- parasitic usually solitary,
found in the right lobe, watery content, with
low internal pressure
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-polycystic liver assoc. with polycystic kiny in
51.6 of cases -usually presents as a RUQ mass
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• Classification
• Blood or degenerative
• Dermoid
• Lymphatic
• Endothelial
• Retention polycystic liver
• Proliferative cysts- cystadenomas

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b. Diagnostic ultrasound, CT scan,
arteriography, scintillography,
peritoneoscopy c. Asymptomatic- no treatment
Symptomatic- drainage with unroofing or
sclerotherapy
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2. Hydatid cysts- caused by Echinococcus
granulosus - with high internal pressure,
causing rupture and anaphylactic reaction
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• Asymptomatic unless there are pressure symptoms
  on adjacent organs
• Diagnostic- radiograph, ultrasound and CT scan
• -Casonis skin test

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b. Treatment i. small calcified cyst- no
treatment ii. Sterilizationof cyst prior to
surgery with hypertonic saline or alcohol
followed by surgical removal
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D. Benign Tumors 1. Classification a.
Hamartomas- tissues normally found in the organ
but arranged in a disorderly manner
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b. Adenoma- associated with contraceptive use
may transform into hepatocellular carcinoma
high rate of bleeding
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c. Focal nodular hyperplasia- reaction to injury
or a response to a preexisting vascular
malformation
d. Hemangioma- most common nodule in the liver
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2. Diagnostic- ultrasound, CT scan,
angiography 3. Treatment- excision if symptomatic
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E. Malignant lesions 1. Primary carcinoma- from
Aspergillus flavus, kwashiorkor
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• Classification
• hepatoblastoma- usually affects children less
  than 2 years old.

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ii. Fibrolamellar carcinoma- adolescent and young
adults large solitary lesion iii.
Hepatocellular carcinoma- most common primary
malignancy, usually follows postnecrotic
cirrhosis (hepatitis B)
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• Manifested by mass, weight loss, abdominal pain,
  or intraperitoneal hemorrhage

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b. Diagnostic i. Liver function test- alkaline
phosphatase ii. Alpha Feto Protein
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iii. Angiography iv. Ultrasound, intraoperative
ultrasound, CT scan, MRI
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c. Treatment- curative resection, chemotherapy
with direct arterial infusion
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• 2. Other Primary Neoplasms
• Sacroma- angiosacroma most common
• Mesenchymoma
• Infantile hemangioendothelioma

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3. Metastatic neoplasms - most common malignant
tumor of the liver - reach the liver by
portal vein, hepatic artery, lymphatics, direct
extension
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• Symptoms are usually referable to the liver (i.e.
  pain, ascites, weight loss, anorexia and jaundice

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

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• 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