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Surgical aspects of liverSurgical aspects of liver
diseasesdiseases
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Liver anatomyLiver anatomy
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INFECTIOUS DISEASESINFECTIOUS DISEASES
Pyogenic AbscessPyogenic Abscess
Amoebic liver abscessAmoebic liver abscessHydatid diseaseHydatid disease
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Pyogenic liver abscessesPyogenic liver abscesses
AetiologyAetiology
Most pyogenic liver abscesses areMost pyogenic liver abscesses aresecondary to infection originating in thesecondary to infection originating in theabdomen.abdomen. CholangitisCholangitis due to stones ordue to stones orstrictures is the commonest cause,strictures is the commonest cause,followed by abdominal infection due tofollowed by abdominal infection due to
diverticulitis or appendicitisdiverticulitis or appendicitis. In. In 1515% of% ofcases no cause can be found (cryptogeniccases no cause can be found (cryptogenicabscesses)abscesses)
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Origins and causes of pyogenic liverOrigins and causes of pyogenic liver
abscessabscessxx BiliarytractBiliarytract
Gall stonesGall stones
CholangiocarcinomaCholangiocarcinoma
StricturesStricturesxx Portal veinPortal vein
AppendicitisAppendicitis
DiverticulitisDiverticulitis
Crohn's diseaseCrohn's diseasexx HepaticarteryHepaticartery
Dental infectionDental infection
Bacterial endocarditisBacterial endocarditis
xx DirectextensionDirectextension of:of:
Gall bladder empyemaGall bladder empyema
Perforated peptic ulcerPerforated peptic ulcer
Subphrenic abscessSubphrenic abscessxx TraumaTrauma
xx IatrogenicIatrogenic
Liver biopsyLiver biopsy
Blocked biliary stentBlocked biliary stentxx CryptogenicCryptogenic
xx SecondaryinfectionofSecondaryinfectionoflivercystlivercyst
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MicrobiologyMicrobiology
Most patients presenting with pyogenic liverMost patients presenting with pyogenic liverabscesses have a polymicrobial infection usuallyabscesses have a polymicrobial infection usuallywithwith Gram egative aerobic and anaerobicGram egative aerobic and anaerobicorganismsorganisms. Most organisms are of bowel origin,. Most organisms are of bowel origin,withwith Escherichia coli, Klebsiella pneumoniae,Escherichia coli, Klebsiella pneumoniae,bacteroides, enterococci, anaerobicbacteroides, enterococci, anaerobicstreptococci, and microaerophilic streptococcistreptococci, and microaerophilic streptococci
being most commonbeing most common. Staphylococci, haemolytic. Staphylococci, haemolyticstreptococci, andstreptococci, and Streptococcus milleriStreptococcus milleriareareusually present if the primary infection isusually present if the primary infection isbacterial endocarditis or dental sepsisbacterial endocarditis or dental sepsis
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ClinicalfeaturesClinicalfeatures
x Right upper quadrant pain and tendernessx Right upper quadrant pain and tenderness
x Nocturnal fevers and sweatsx Nocturnal fevers and sweatsx Anorexia and weight lossx Anorexia and weight loss
x Raised right hemidiaphragm in chestx Raised right hemidiaphragm in chest
radiographradiographx Raised white cell count and erythrocytex Raised white cell count and erythrocyte
sedimentation rate with mild anaemiasedimentation rate with mild anaemia
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TreatmentTreatment
Antibiotics should includeAntibiotics should include penicillin, an aminoglycoside,penicillin, an aminoglycoside,and metronidazoleand metronidazole. In elderly people and those with. In elderly people and those withimpaired renal function aimpaired renal function a third generation cephalosporinthird generation cephalosporin
should be used instead of an aminoglycoside. Theshould be used instead of an aminoglycoside. Theregimen should be modified after culture has identifiedregimen should be modified after culture has identifiedthe infective organism.the infective organism.
Treatment is continued for two to four weeksTreatment is continued for two to four weeks
Antibiotics alone are effective in only a few patients, andAntibiotics alone are effective in only a few patients, andmost patients will requiremost patients will require percutaneous aspiration orpercutaneous aspiration orcatheter drainagecatheter drainage guided by ultrasonography orguided by ultrasonography orcomputed tomographycomputed tomography..
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Amoebic liver abscessAmoebic liver abscess
Entamoeba histolyticaEntamoeba histolytica
The abscess isThe abscess is usually solitary and affectsusually solitary and affects
the right lobe inthe right lobe in 8080% of cases% of cases. The. Theabscess contains sterile pus andabscess contains sterile pus and
reddish-brown (anchovy paste) liquefiedreddish-brown (anchovy paste) liquefied
necrotic liver tissue. Amoebae arenecrotic liver tissue. Amoebae are
occasionally present at the periphery ofoccasionally present at the periphery ofthe abscess.the abscess.
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SymptomsofamoebicliverabscessSymptomsofamoebicliverabscess
x Painx Pain
x Enlarged liver with maximal tenderness over abscessx Enlarged liver with maximal tenderness over abscess
x Intermittent fever (x Intermittent fever (3838--3939C)C)x Night sweatsx Night sweats
x Weight lossx Weight loss
x Nauseax Nausea
x Vomitingx Vomiting
x Coughx Cough
x Dyspnoeax Dyspnoea
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TreatmentTreatment
Ninety five per cent of uncomplicatedNinety five per cent of uncomplicatedamoebic abscesses resolve withamoebic abscesses resolve withmetronidazolemetronidazole alone (alone (800800 mg, three timesmg, three timesa day for five days).a day for five days).
After the amoebic abscess has beenAfter the amoebic abscess has been
treated, patients are prescribedtreated, patients are prescribed diloxanidediloxanidefuroatefuroate 500500 mg, eight hourly for sevenmg, eight hourly for sevendays, to eliminate intestinal amoebae.days, to eliminate intestinal amoebae.
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Hydatid disease of the liverHydatid disease of the liver
Echinococcus granulosusEchinococcus granulosus
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PresentationPresentation
Liver enlargement and right upper quadrant painLiver enlargement and right upper quadrant painComplications include rupture of the cyst into theComplications include rupture of the cyst into theperitoneal cavity, which results in urticaria,peritoneal cavity, which results in urticaria,anaphylactic shock, eosinophilia, andanaphylactic shock, eosinophilia, andimplantation into the omentum and otherimplantation into the omentum and otherviscera.viscera.
Cysts may compress or erode into a bile ductCysts may compress or erode into a bile duct
causing pain, jaundice, or cholangitis,causing pain, jaundice, or cholangitis,or the cyst may become infected secondary to aor the cyst may become infected secondary to abile leak.bile leak.
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DiagnsosisandtreatmentDiagnsosisandtreatment
Ultrasonography and computed tomographyUltrasonography and computed tomography
Eosinophilia is present inEosinophilia is present in 4040% of patients% of patients
The diagnosis is confirmed by haemagglutinationThe diagnosis is confirmed by haemagglutination
and complement fixation testsand complement fixation tests
ERCP in jaundiced patientsERCP in jaundiced patients
All symptomatic cysts require surgical removal toAll symptomatic cysts require surgical removal to
prevent complicationsprevent complications
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Liver tumorsLiver tumors
Incidentalsolidlivertumors: DiagnosticfrequencyforvariousIncidentalsolidlivertumors: Diagnosticfrequencyforvarious
histologieshistologies
TumorRelative frequencyTumorRelative frequency
HemangiomaHemangioma 5252%%
Focal nodular hyperplasiaFocal nodular hyperplasia 1111%%
Metastatic tumor (TxNxMMetastatic tumor (TxNxM11)) 1111%%
Hepatocellular adenomaHepatocellular adenoma 88%%
Focal fatty infiltrationFocal fatty infiltration 88%%
Hepatocellular carcinomaHepatocellular carcinoma 66%%
Extrahepatic processExtrahepatic process 33%%
(e.g., abscess, adrenal tumor)(e.g., abscess, adrenal tumor)Other benign hepatic processOther benign hepatic process 11%%
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Benign tumoursBenign tumours
Usually asymptomatic. Although most needUsually asymptomatic. Although most need
no treatment, it is important to be able tono treatment, it is important to be able to
differentiate them from malignant lesions.differentiate them from malignant lesions.
HaemangiomasHaemangiomas
The commonest benign solid tumours ofThe commonest benign solid tumours ofthe liverthe liver
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LivercelladenomaLivercelladenomaLiver cell adenoma became more prevalent with theLiver cell adenoma became more prevalent with the
widespread use ofwidespread use oforal contraceptivesoral contraceptives in thein the 19601960s, buts, but
the reduced oestrogen content of modern contraceptivesthe reduced oestrogen content of modern contraceptiveshas made it less common.has made it less common.
The risk of rupture isThe risk of rupture is 1010%, and malignant transformation is%, and malignant transformation is
found infound in 1010% of resected specimens. Patients should% of resected specimens. Patients should
have liver resection to prevent these eventshave liver resection to prevent these events..
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FocalnodularhyperplasiaFocalnodularhyperplasia
not related to use of oral contraceptivesnot related to use of oral contraceptives
usually asymptomaticusually asymptomatic
Not premalignantNot premalignant
Mass lesions usually contain a central stellate scarMass lesions usually contain a central stellate scar
on computed tomography and magnetic resonanceon computed tomography and magnetic resonance
imaging.imaging.It does not require treatment unless symptomaticIt does not require treatment unless symptomatic
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Malignant tumorsMalignant tumors
PrimaryPrimary
Hepatocellular carcinomaHepatocellular carcinoma
Intrahepatic CholangiocarcinomaIntrahepatic Cholangiocarcinoma
HepatoblastomaHepatoblastoma
MetastaticMetastatic
ColorectalColorectalNeuroendocrineNeuroendocrine
Noncolorectal, NonNoncolorectal, Non--neuroendocrineneuroendocrine
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Thank youThank you
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