SURGICAL

DISEASES OF LIVER
 ANATOMY
• The liver is the largest organ in the body : 1200-1600 g
• Regarded as a paired organ which is fused along a line which
can be drawn between the gallbladder fossa and IVC.
• Each lobe receives a full branch of the portal vein, hepatic
artery and bile duct.
• By further division of the vascular supply- each lobe is
composed of 4 segments which are numbered 1 to 4 for the
left and 5 to 8 for the right liver.
Segmental anatomy
Clockwise numbering of the segments
On a frontal view of the liver the posteriorly
located segments 6 and 7 are not visible.
 ANATOMY
• Hepatic veins of surgical importance are three:
– the right hepatic vein which drains segments 6-8 by a
short vessel directly into the suprahepatic vena cava,
– the middle hepatic vein which drains from both
hepatic lobes and empties directly into the vena cava
or the left hepatic vein
– the left hepatic vein which drains segment 2, 3, 4.
• Segment 1 or caudate lobe drains by several small
hepatic veins directly into the infrahepatic vena
cava.
 PORTAL VEIN, CBD, CHA
• In the portal hilum the portal vein which has formed
behind the head of the pancreas by the junction of
splenic and mesenteric veins, passes along the edge
of the lesser omentum.
• In front of and to the right, common bile duct drains
both liver lobes and receives the cystic duct at a
variable point of its course and on either side.
• To the left of the common bile duct runs the
common hepatic artery giving off the main cystic
artery and branches to the common bile duct prior to
division into right and left branches.
PORTAL SYSTEM
 LIVER FUNCTION
1. Bile formation and excretion
• About 500-1000 ml. of bile are secreted each day.
• The liver synthesizes bile acids from cholesterol. Almost all of
the bile acids are reabsorbed by the terminal ileum and enter
the enterohepatic circulation.
• Bile pigments are derived from the breakdown of hemoglobin
to biliverdin then bilirubin. In the liver unconjugated bilirubin
is conjugated and then secreted into the bile canaliculi and
transported to the gastrointestinal tract.
• Bile contains cholesterol in micellar form, bile acids,
phospholipids, electrolytes, mucin and water.
JAUNDICE
INVESTIGATIONS
 Ultrasonography

• In patients with cholestasis, dilated IH-BD clearly pinpoint the

presence of duct obstruction.
• Gallstones may be diagnosed with an accuracy of 95% in the
best hands.
• Well shown are liver cysts and abscesses
• Primary liver tumours and multifocal MTS are readily seen.
• Intraoperative US of the liver can demonstrate precisely the
anatomy of vascular structures, the boundaries of palpable
liver tumours and the presence of impalpable foci enabling a
more appropriate resection line.
 CT scanning of the liver

• Normally the procedure is combined with contrast meal to

define the stomach and duodenum and iv contrast to outline
the vessels and focal lesions within the liver.

• The procedure is expensive and time-consuming but it is

consistent and leads to relatively easy interpretation.

• Furthermore surrounding structures are also well shown,

particularly the diaphragm, lung bases and suprahepatic vena
cava.
Big liver abscess and other three small liver
abscesses
Chest X-ray with free air between diaphragm and liver
The use of 99mTc labelled red blood cells (RBC) for the diagnosis
of suspected cavernous haemangioma in the liver.
Note the discordant accumulation indicated by the arrow.
 Needle biopsy of the liver
Indications:
- alcoholic liver disease
- unexplained hepatomegaly-
- space-occupying lesions of the liver
- drug-related liver disease
It is contraindicated in patients with:
- coagulopathies,
- tense ascites and
- suspected hemangiomas.
 Pyogenic abscesses

Pathogenesis
• The main etiological factor is bile-duct infection with ascending cholangitis
commonly due to E. Coli and anaerobic organisms.
• Other sourses of infection include an ascending pylephlebitis- it arises
particularly with complicated diverticulitis.
• Some hepatic abscesses of staphylococcal and streptococcal origin arise as
a complication of generalized septicemia
• Others arise by direct extension from suppurative cholecystitis and
subphrenic collections.
• Obviously trauma to the liver tissue and subsequent infection produces an
abscess.

All types of abscesses are found more commonly in the right lobe.
 LIVER ABSCESS
• Diagnosis: pain RH, fever,
chills, increased WBC,
secondary anemia.

• Treatment is usually a
combination of drainage
and prolonged iv antibiotic
therapy .
 Clinical features of hepatic abscesses
• The clinical picture may be dominated by the primary disorder
(ascending cholangitis, diverticulitis, suppurative cholecystitis).
• Characteristically there is a high fever, rigors, profuse sweating,
anorexia and vomiting with pain as a relatively late symptom.
• An abscess may reach a very large size before causing pain if it is
directed through the bare area of the liver.
• Hepatomegaly is common.
• On investigation an anemia and leucocytosis may be found. ESR is
elevated.
• Blood cultures are usually positive with pyogenic abscesses when
taken during the height of pyrexia and anaerobic infection should be
considered.
 Imaging investigations

• Clinical suspicion of hepatic abscess may be confirmed by a

ultrasonic or CT scanning of the liver which may also
demonstrate the presence of pus.

• A plain film of the abdomen and chest may rarely show an

air/fluid level within the liver substance and usually an
elevated immobile diaphragm with loss of the anterior
costophrenic angle is found.
 Liver abscess
• CT demonstrates a heterogeneous
lesion with irregular margins and
possibly peripheral contrast
enhancement. Internal septations are
common.
• The radiologic differential diagnosis
includes cystic or necrotic metastases
and hydatid cysts.
• Often the diagnosis of a bacterial
abscess is suggested clinically.
• Treatment consists of percutaneous or
surgical drainage and antibiotics.
• The mortality rate is almost 100% if
the abscess remains untreated.
Amebic liver abscess is a collection of pus in the
liver brought on by an intestinal parasite
Causes
• Amebic liver abscess is caused by Entamoeba histolytica, the same
organism that causes amebiasis, an intestinal infection also called amebic
dysentery. The organism is carried by the blood from the intestines to the
liver.
• The disease spreads through ingestion of amebic cysts in food or water
contaminated with feces
• The infection occurs worldwide, but is most common in tropical areas
where crowded living conditions and poor sanitation exist.
Risk factors for amebic liver abscess include: Alcoholism , Cancer ,
Homosexual activity, particularly in men, Immunosuppression,
Malnutrition, Old age, Recent travel to a tropical region, Steroid use.
 Symptoms

Symptoms may include:

• Abdominal pain
– Particularly in the right, upper part of the abdomen
– Intense, continuous, or stabbing pain
• Chills
• Diarrhea
• Fever
• General discomfort or ill feeling (malaise)
• Jaundice
• Joint pain
• Loss of appetite
• Sweating
• Weight loss
 Exams and Tests

Tests that may be done include:

• Abdominal ultrasound
• Abdominal CT scan or MRI
• Complete blood count
• Liver function tests
• Serology for amebiasis
• Stool testing for amebiasis
 Treatment
• An antibiotic medicine called metronidazole (Flagyl)
is the usual treatment for liver abscess.
• A medication such as iodoquinol must also be taken
to get rid of all the amebas in the intestine.
• This can usually be delayed until after the abscess
has been treated.
• The abscess may need to be drained to help relieve
some of the abdominal pain.
 Complications of the liver abscess

• recurrent septicemia
• extension and rupture of the abscess may occur
in any direction:
- peritoneal rupture results in peritonitis or
subphrenic collection
- extension through the diaphragm may lead to
thoracic empyema or to a rupture into the
bronchus with expectoration of large volumes of
pus.
- rarely, the abscess ruptures into the pericardium
with high mortality.
 Treatment
- Antibiotics according to bacterial sensitivity;
- Precise microbiological identification may result from
aspiration of the abscess with ultrasonic control.
- Drainage of the abscess cavity by repeated needle
aspiration or fine-bore catheter directed under ultrasonic
control.
- Antibiotics may be instilled into the cavity.
- Progress is monitored by repeated ultrasound scan
examinations.
- Surgical drainage if: - deterioration in the general
condition of the patient
- repeated episodes of septicemia
- failure of the abscess to decrease in size.
 Liver cysts

• Most cysts are asymptomatic

• When the cysts reach sufficient size to exert pressure
on adjacent viscera, produce non-specific symptoms
of vomiting, upper abdominal pain.
• Clinical examination reveals a non-tender liver
tumour.
• Plain film of the abdomen may show displacement of
the colon or stomach
• The lesion may be confirmed by ultrasonography and
scintiscanning.
 Liver cysts
• The main differential diagnosis is parasitic
cysts and solid tumours.
• With exception of the complications of
rupture and intracystic hemorrhage, the
operative treatment is confined to large
solitary cysts which are usually completely
extirpated or removed by limited hepatic
resection.
 Hydatid cysts of the liver
• This infestation is endemic in certain countries, particularly
the southern half of South America, Australia, New
Zeeland, France.

• Man is the secondary host and becomes infected by

ingesting vegetables and water fouled by dogs or more
directly by handling the parasite-infested dogs as pets.

• After ingestion the shell of the egg is destroyed by gastric

acid and hatched within the duodenum. The liberated
embryos migrate through the gut wall into the mesenteric
circulation and lodge within the liver.
 Hydatic cyst of the liver

• 80% of hydatic cysts are ultimatelly found in the liver parenchyma.

• The unilocular hydatic cyst is caused by Echinoccocus granulosus and

the alveolar type is caused by Echinococcus multilocularis.
 Clinical features

• Since the growth of the parasite is slow, many

years elapse before the cyst reaches
significant size.
• On physical examination an anteriorly located
cyst presents as a smooth rounded tense
mass.
• Secondary infection results in tender
hepatomegaly, rigors and pyrexia associated
with a deep-seated continuous pain.
 Further clinical features are the result
of cyst complications
• Intrabiliary rupture may give biliary colic and usually
causes jaundice and fever.
• Intraperitoneal rupture produces severe pain and
shock classically associated with pruritus and
urticaria.
• Intrathoracic rupture may be preceded by symptoms
of diaphragmatic irritation and rupture into bronchus
leads to a partly bloodstained sputum which
frequently becomes bile stained.
Hydatic allergy is manifested by urticaria or very rare
anaphylactic shock.
 Investigations

• The appearance of a painless liver swelling in a patient living

in an endemic area gives a high index of suspicion.
• An unruptured cyst may show on plain radiograph as a
calcified reticulated shadow if not calcified by displacement of
the diaphragm or a barium-filled stomach.
• Scintiscanning shows a large filling defect and ultrasonography
reveals an echogenic cyst.
• Although the cyst is isolated from the liver by an adventitial
layer, there is an absorption of parasitic products which acts
as an antigenic stimulus.
• This reflects in an eosinophilia in 25% of patients, a
complement-fixation test which is accurate in 93% of patients.
Multivesicular Hydatid Hepatic Cyst
Univesicular uncomplicated cyst
Multivesicular hydatid with multiple daughter cysts giving a
septated appearance to the cyst
 Old hypermature liver hydatid. Non-contrast CT shows
calcification in the cyst wall and matrix and fluid within the cyst
 Complications
Rupture. Three types of ruptures are possible:
contained, communicating and direct.

1. Contained rupture
• This occurs when the endocyst ruptures in the lesion and biliary ducts do
not penetrate the pericyst. This is asymptomatic and is diagnosed when
sectional imaging (USS, CT) shows floating membranes within the hydatic
lesion. Contained rupture does not predispose to secondary bacterial
infection.
2. Communicating rupture.
• This is possible when biliary ducts perforate the pericyst, allowing fluid
and formed elements to escape into the biliary tree. Sectional imaging of
liver cysts which have undergone communicating rupture demonstrates
detached endocyst floating in the remaining cyst fluid and there may be
evidence of downstream biliary obstruction. The bile that floods the
pericystic cavity probably always kills the parasite but secondary infection
is almost the rule.
 Surgical treatment

• Involves removing the cyst without contamining the patient.

• The initial stage involves protection of the operative field against live
cysts using multiple coloured towels soaked in hypertonic saline
which isolate the main cyst from the exposed peritoneal cavity.

• Since hydatid fluid is under high pressure the cyst is decompressed by

aspiration and injected with 20% saline and left 5 min. after which
the cyst is opened and all daughter cysts removed as well as the
germinal layer of the cyst.
 Surgical treatment
• Spillage of cyst content during surgery is a cause of
recurrence.

• The cavity is drained for a variable period of time

depending on the presence of fluid drainage.

• Jaundice after intrabiliary rupture requires

choledochotomy and clearance of cysts followed by
T-tube drainage
 Hemangiomas

• Hemangiomas are the commonest benign tumour but only

rarely produce symptoms.
• Histologically the lesion is composed of blood-filled
endothelial lined spaces separated by a varible degree of
fibrous tissue.
• These tumours, having grown to significant size will eventually
produce pain or dyspepsia and develop a palpable abdominal
mass.
• Rupture is rare but leads to a major intra-abdominal
hemorrhage with shock and collapse.
 Hemangiomas
• CT scann is usually quite diagnostic.
• Where the diagnosis remains doubtful, arteriography will
demonstrate the lesion.
• A biopsy is not indicated.
• The preferred treatment for clinically significant hemangiomas
is wedge excision where possible.
• Lobectomy is reserved for large lesions confined to one lobe.
• The residual liver may contain further hemangiomas.
• Scintiscanning and angiography will demonstrate the lesion
and if there appears to be a major feeding vessel from the
hepatic artery, it may be worthwhile ligating this vessel or the
main hepatic artery.
 USS-hemangiomas
• This is the commonest primary
tumour of the liver and is usually a
solitary lesion.

• This ultrasound image shows a

hyperechoic, homogenous, well-
circumscribed mass of the liver.
Primary malignant tumours of the liver

• Although primary malignant tumours of the liver are

uncommon in European and North American populations, the
condition is very common in African, Chinese and Indian
communities.
• The incidence of liver cancer in a community is directly
proportional to the incidence of viral hepatitis.
Risk factors:
• - alcohol intake, micronodular cirrhosis
• - chronic liver disease. The incidence of hepatoma in cirrhosis
may reach 25% but it is greatly elevated in patients with
antigen positive chronic active hepatitis (42%).
 Physical findings:

• - abdominal distension due to

hepatomegaly
• - ascites and sometimes is blood-stained.
• - hypoglycemia
• - hypercalcemia,
• - hyperlipidemia
• - hyperthyroidism
 Diagnosis
• Lab. studies: -abnormal liver function tests
- anemia due to intratumour hemorrhage
- polycytemia due to erythropoietin release.
- serum alphafetoprotein is a useful cancer marker
- HBS antigen should be looked for in all patients.

For patients undergoing surgery a study of the parameters of

coagulation is a sensible precaution.
Tumour localization and evaluation
• Lesions greater than 2 cm. in size can be detected as
a filling defect on a hepatic scintiscan but this mode
of investigation has little value.
• Ultrasound scanning demonstrates the size and
position.
• CXR for pulmonary metastases.
• CT scan demonstrates the lesion and its relatioship to
major structures.
• Needle biopsy under CT guidance.
• Arteriography is indicated for those patients in whom
liver resection is contempleted.
 Surgical treatment

• The object is to excise the lesion safely with a

margin of healthy liver tissue of 2 cm. or
more.
• Procedures:
• - wedge resection
• - segmentectomy
• - lobectomy
• - hepatic transplantation