LIVER DISEASESLIVER DISEASES

Shanghai Jiaotong University Medical SchoolRenji Hospital Luo meng

ANATOMYANATOMYANATOMYANATOMY

Four channels within liver:� Four channels within liver:�

Inflow: HA PVInflow: HA PV

Outflow: HV Biliary ductOutflow: HV Biliary duct

Lobes & segments of the Liver� Lobes & segments of the Liver�

(Couinaud’s system of segments)(Couinaud’s system of segments)

Four channels within liver:� Four channels within liver:�

Inflow: HA PVInflow: HA PV

Outflow: HV Biliary ductOutflow: HV Biliary duct

Lobes & segments of the Liver� Lobes & segments of the Liver�

(Couinaud’s system of segments)(Couinaud’s system of segments)

Three major hepatic veins drain the liverThree major hepatic veins drain the liver

Intrahepatic divisions of the portal veinIntrahepatic divisions of the portal vein

Liver � Liver � Functions: Functions:

Formation of bileFormation of bile

Regulation of material metabolismRegulation of material metabolism

energy, carbohydrate, fat, proteins,energy, carbohydrate, fat, proteins,

vitamins, hormones, and formation of vitamins, hormones, and formation of

coagulant factors etc.coagulant factors etc.

Mechanism of defense and detoxification Mechanism of defense and detoxification

Capacity of regeneration after massive Capacity of regeneration after massive

resection.resection.

Liver � Liver � Functions: Functions:

Formation of bileFormation of bile

Regulation of material metabolismRegulation of material metabolism

energy, carbohydrate, fat, proteins,energy, carbohydrate, fat, proteins,

vitamins, hormones, and formation of vitamins, hormones, and formation of

coagulant factors etc.coagulant factors etc.

Mechanism of defense and detoxification Mechanism of defense and detoxification

Capacity of regeneration after massive Capacity of regeneration after massive

resection.resection.

LIVER ABSCESSMany kinds of LA:

Pyogenic AmebicVirus & Fungi

PATHOGENESIS� The micro-organisms through follows to hepatic parenchyma portal venous stream ascension from biliary tract hepatic artery direct penetrating trauma Amount and ability of invasion of micro-organisms vs defense mechanism of the body.

LIVER ABSCESSMany kinds of LA:

Pyogenic AmebicVirus & Fungi

PATHOGENESIS� The micro-organisms through follows to hepatic parenchyma portal venous stream ascension from biliary tract hepatic artery direct penetrating trauma Amount and ability of invasion of micro-organisms vs defense mechanism of the body.

Etiology Etiology of pyogeof pyogenic abscenic abscessss

DIAGNOSIS� DIAGNOSIS� Clinical manifestations: Fever pain at R.U.Q. enlargement of liver Others: nausea jaundice Antecedent diarrhea in amebic liver abscess LABS: WBC↑ RBC↓ Albumin↓ blood culture for bacteria positive in 40%EXAMS: X’ray film:

Elevated diaphragm and pleural effusion

BUS and CT: guiding to aspiration of abscess

DIAGNOSIS� DIAGNOSIS� Clinical manifestations: Fever pain at R.U.Q. enlargement of liver Others: nausea jaundice Antecedent diarrhea in amebic liver abscess LABS: WBC↑ RBC↓ Albumin↓ blood culture for bacteria positive in 40%EXAMS: X’ray film:

Elevated diaphragm and pleural effusion

BUS and CT: guiding to aspiration of abscess

CT scan of a pyogenic hepatic abscessCT scan of a pyogenic hepatic abscess

COMPLICATIONS� Generalized sepsis, emphysema

Ruptured abscess into pleural cavity, peri - cardiaum and intra-abdominal cavity

TREATMENT� Medical therapy:

General support therapy

Antibiotics, metronidazole

Drainage-lavage by catheter

Surgical therapy: drainage resection or of liver

COMPLICATIONS� Generalized sepsis, emphysema

Ruptured abscess into pleural cavity, peri - cardiaum and intra-abdominal cavity

TREATMENT� Medical therapy:

General support therapy

Antibiotics, metronidazole

Drainage-lavage by catheter

Surgical therapy: drainage resection or of liver

PRIMARY LIVER CARCINOMA

•Hepatocellular carcinoma (HCC) occupied th

e third place of malignancy in China.

•Recent two decades, the higher recurrence rat

e has remained as a rather difficult problem in

spite of the improvement in the diagnosis and t

reatment.

PRIMARY LIVER CARCINOMA

•Hepatocellular carcinoma (HCC) occupied th

e third place of malignancy in China.

•Recent two decades, the higher recurrence rat

e has remained as a rather difficult problem in

spite of the improvement in the diagnosis and t

reatment.

ETIOLOGY� Risk factors: virus infection hepatitis type B.C.and D. various liver cirrhosis Some chemical carcinogenic material e.g. Aflatoxin� PATHOLOGY macroscopic classification:

massive, nodular or diffuse solitary or multiple growth pattern: infiltrative, expanded, mixed infiltrative and expanded,diffuse, small (less than 2cm in diameter) metastasis: through peri hepatic lymphatics or direct invasion particular ca thrombus in portal v. or ruptured ca into abdominal cavity

ETIOLOGY� Risk factors: virus infection hepatitis type B.C.and D. various liver cirrhosis Some chemical carcinogenic material e.g. Aflatoxin� PATHOLOGY macroscopic classification:

massive, nodular or diffuse solitary or multiple growth pattern: infiltrative, expanded, mixed infiltrative and expanded,diffuse, small (less than 2cm in diameter) metastasis: through peri hepatic lymphatics or direct invasion particular ca thrombus in portal v. or ruptured ca into abdominal cavity

Ca With Complete CapsuleCa With Complete Capsule

CLINICAL MANIFESTATIONCLINICAL MANIFESTATION

• No distinctive symptoms until late stageNo distinctive symptoms until late stage• Anorexia, fullness or pain in RUQ, and weight Anorexia, fullness or pain in RUQ, and weight

loss are commonloss are common• In addition, clinical presentation of liver In addition, clinical presentation of liver

cirrhosiscirrhosis

LAB STUDYLAB STUDY• AFP>400ng/ml in 70% of patients with HCCAFP>400ng/ml in 70% of patients with HCC• Pseudo-positive (AFPV)Pseudo-positive (AFPV)

IMAGING EXAMSIMAGING EXAMS

• BUSBUS• CT and CT and

MRIMRI• Hepatic Hepatic

angiographyangiography

Hypo-echo area

IVC

CTCT

Hepatic angiographyHepatic angiography

An Occupied Lesion on AngiogramAn Occupied Lesion on Angiogram

Hepatic angiographyHepatic angiography

� HOW TO DETECT SUBCLINICAL CASES

It is important that the high-risk people who ar

e with chronic hepatitis or liver cirrhosis should be

closely followed up by AFP test and BUS. It is mos

t possible that newly identified tumors in the liver

are HCC or precancerous lesion.

� HOW TO DETECT SUBCLINICAL CASES

It is important that the high-risk people who ar

e with chronic hepatitis or liver cirrhosis should be

closely followed up by AFP test and BUS. It is mos

t possible that newly identified tumors in the liver

are HCC or precancerous lesion.

� DIFFERENTIAL DIAGNOSIS

• Metastatic liver carcinoma

• Liver cirrhosis

• Focal nodular hyperplasia of liver

• Cavernous hematoangioma of liver

� DIFFERENTIAL DIAGNOSIS

• Metastatic liver carcinoma

• Liver cirrhosis

• Focal nodular hyperplasia of liver

• Cavernous hematoangioma of liver

� TREATMENT

○ SURGICAL RESECTION

Indications:

Solitary, not too big multiple but collect an

area

Patient’s condition

Evaluation of liver function (Child A or B)

� TREATMENT

○ SURGICAL RESECTION

Indications:

Solitary, not too big multiple but collect an

area

Patient’s condition

Evaluation of liver function (Child A or B)

� TREATMENT

○ SURGICAL RESECTION

Surgical procedure

•Hemihepatectomy, lobectomy, eg mentectomy

– In liver cirrhosis, limited resection with 1.5cm margin fr

om tumor

•Liver transplantation

–Only indicated for small HCC without outside liver spre

ad

Complication: bleeding, liver failure, sepsis

� TREATMENT

○ SURGICAL RESECTION

Surgical procedure

•Hemihepatectomy, lobectomy, eg mentectomy

– In liver cirrhosis, limited resection with 1.5cm margin fr

om tumor

•Liver transplantation

–Only indicated for small HCC without outside liver spre

ad

Complication: bleeding, liver failure, sepsis

○Non-surgical treatment

• TACE under highly selective hepatic arteriocatheterization,

lipoidol, cytotoxic agents and embolized material to be injected. Mainly indicated for big HCC.

To make the tumor smaller in 15% patients with big HCC, the resection of tumor may be possible. •INJECTION OF ETHONAL

for small tumor in 2cm diameter or less•OTHERS

○Non-surgical treatment

• TACE under highly selective hepatic arteriocatheterization,

lipoidol, cytotoxic agents and embolized material to be injected. Mainly indicated for big HCC.

To make the tumor smaller in 15% patients with big HCC, the resection of tumor may be possible. •INJECTION OF ETHONAL

for small tumor in 2cm diameter or less•OTHERS

Angiography---Chemo-Angiography---Chemo-embolizationembolization

The Lesion Getting Smaller 2 Months The Lesion Getting Smaller 2 Months Later Later

Ca Showed by Hypo-echoCa Showed by Hypo-echo

After Chemo-embolizationAfter Chemo-embolization

Chemo-embolizationChemo-embolization

Multiple Liver Cysts (Congenital) Multiple Liver Cysts (Congenital)

李 × 男性 62岁 ,17月前因肝癌行肝癌根治术 ,术后随访中发现α-FP呈进行性上升 ,B超及 CT均未发现明显病变 ,动脉造影证实肝内肝癌复发

李 × 男性 62岁 ,17月前因肝癌行肝癌根治术 ,术后随访中发现α-FP呈进行性上升 ,B超及 CT均未发现明显病变 ,动脉造影证实肝内肝癌复发

Occupied Lesion on AngiogramOccupied Lesion on Angiogram

Recurrent liver cancerRecurrent liver cancer