THE LIVER Fourth Year Medical college Nov 2013

THE LIVER Fourth Year Medical college Nov. 2013 Hawler Medical University College of Medicine Department of Surgery 1 2/10/2018 12: 22 PM Dr. Husen Ibrahim Taha, MSc. , MRCS

List if Contents l l l 2 Objectives Introduction Anatomy Acute and Chromic Liver Diseases Investigations of Liver Management of Liver Infections, Cirrhosis, and Tumors. 2/10/2018 12: 22 PM

Objectives l l l 3 To Understand Anatomy of liver Signs of Chronic and Acute liver diseases Investigations of Liver Management of Liver trauma and Diseases 2/10/2018 12: 22 PM

ANATOMY l l l 4 The Liver is the largest solid organ, 1. 5 kg in adults Has a thin capsule Covered by visceral peritoneum only in bare area Has two triangular Lig, and falciform lig. And lesser omentum It has a dual blood supply: 80% Portal, 20% hepatic artery Arterial anatomical variations may present. 2/10/2018 12: 22 PM

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Structures in the Hilum and Venus Drainage l l l 6 Portal vein, common bile duct and hepatic artery with lymphatics run into hilum in the free edge of lesser omentum (hepatoduodenal Lig). Lowest and anterior is the bile duct, and above is artery with portal vein behind them. There is 3 hepatic veins drain liver into IVC, with many small veins drain directly from liver parenchyma into IVC. 2/10/2018 12: 22 PM

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THE INTERNAL ANATOMY OF LIVER l l 8 The liver has 8 segments Each segment can be viewed as a functional unit with its own blood supply and bile duct. The understanding of these divisions facilitate surgical resection of liver for tumors, trauma and infection. The hepatic Lobule is the functional unit within the liver segment. 2/10/2018 12: 22 PM

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Embryology l l 10 The liver is a foregut structure Develops from an endodermal bud from 2 nd part of duodenum making liver cells and bile ducts Liver endothelium develops from the vitelline duct and umbilical vein Supporting connective tissue, hemopoetic cells and Kupfer cells from mesnchyla cells of septum traversum 2/10/2018 12: 22 PM

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FUNCTIONS OF LIVER l l l l 12 Maintain core body tept. p. H balance and correction of lactic acidosis Synthesis of clotting factors Glucose metabolism Urea formation and protein catabolism Bilirubin formation from heam. Drug and hormone metabolism Removal of gut endotoxins and foreign antigens 2/10/2018 12: 22 PM

LIVER FUNCTION TESTS l l l l 13 Bilirubin 5 -17 umol/L Alkaline Phosphatase ALP 35 -130 IU/L Aspartate transaminase AST (s. GOT) 5 -40 IU/L Alanine transaminate ALT (s. GPT) 5 -40 IU/L Gamma-glutamyl transpeptidase GGT 10 -48 IU/L Albumen Prothrombine time II, VII, IX and X 35 -50 gm/L 12 -16 s 2/10/2018 12: 22 PM

IMAGING THE LIVER l l l l l 14 Ultrasound and Doppler US CT Scan MRI MRCP ERCP PTC Angiography Nuclear medicine Laparoscopy and Laparoscopic US 2/10/2018 12: 22 PM

US AND CTS 15 2/10/2018 12: 22 PM

MRI AND MRCP 16 2/10/2018 12: 22 PM

ERCP AND PTC 17 2/10/2018 12: 22 PM

ANGIOGRAPHY, NUCLEAR AND LAP US 18 2/10/2018 12: 22 PM

ACUE LIVER FAILURE l l l 19 Early stage-No signs When sever damage-jaundice, neurological signs Liver flap. Confusion. Coma 2/10/2018 12: 22 PM

Causes of Acute Liver Failure l l l l 20 Viral hepatitis Drugs: halothabe, INH, NSAD, antidepressant Paracetamole Mushroom poisoning Shock and Multiorgan Failure Acute Budd-Chiari Syndrome Wilson disease Faty liver of Pregnancy 2/10/2018 12: 22 PM

Management of Acute Liver Failure l l l l 21 Mortality >50% Well balanced fluid therapy Acid base and blood glucose monitoring Dialysis if renal failure Ventilation Treatment of cerebral edema Vigorous treatment of infections Liver transplantation 2/10/2018 12: 22 PM

Criteria for Liver Transplantation l Paracetamole induced: l l p. H<7. 3 irrespective of encephalopathy, or PT>100 s+serum creatinine>100 umole/L+grade 3 -4 encephalopathy l Non-paracetamole induced: l PT>100 s or any of the following 3: 1. Age<10>40, 2. aetilogy Non-A, Non-B, halotahne or idiosyncratic drug reaction, 3. . 7 days jaundice before encephalopathy, 4. PT>50 s, 5. Milirubin>100 umol/L l 22 2/10/2018 12: 22 PM

Chronic Liver disease-Features l l l l l 23 Lethargy and weakness-early Fever might be due to liver infl or infection Jaundice later and indicate severity Waisting Hyperdynamic circulation Encephalopathy-imapired memmory, flapping tremor Portal hypertension: ascitis, esophageal varices, splen Skin: spider nevi, palmar erythema, easy bruising Coagulopathy-easy bruising 2/10/2018 12: 22 PM

Severity of Chronic Liver disease Child’s Classification Feature Child B Child C Bilirubin <2 mg/dl 2 -3 mg/dl >3 mg/dl Albumin >3, 5 gm/dl 3 -3. 5 gm/dl <3 gm/dl Ascites None Easily control Poorly control Encephalopathy None Minimal Advanced Nutrition 24 Child A Excellent Good Wasting 2/10/2018 12: 22 PM

Hydatid Disease of Liver l l 25 Cause: Echinococcus Granulosus This parasite present in dog intestine Eggs ingested-larva through portal vein to liver or any other organ making Cysts The cysts contains active daughter cysts if rupture each make a new cyst 2/10/2018 12: 22 PM

Presentation of Hydatid of Liver l l l 26 Abdominal mass, or discomfort Acute abdomen after rupture from trivial trauma or spontaneous Rupture into biliary tree –obstructive jaundice 2/10/2018 12: 22 PM

Diagnosis l l l 27 History Physical examination Ultrasound: Multiloculted cyst CT scan Serology: antibody to hydatid by ELISA 2/10/2018 12: 22 PM

Complications of untreated l l l 28 Rupture and anaphylactic shock and dissemination Jaundice Pressure symptoms Rupture into the chest Infection: usually leads to dead daughter cysts 2/10/2018 12: 22 PM

Treatment l l l 29 Medical: Albendazoel, and Mebendazole Surgery: Removal of Cyst The cysts is injected by hypertonic saline to kill daughter cysts prior to removal to prevent possibility of dissemination if ruptured. Rupture into biliary tract treated endoscopically prior to cyst removal Calcified cysts are usually dead and can be followed by U/S 2/10/2018 12: 22 PM

Ascending Cholangitis l l l 30 Duct stones are the commonest cause Fever, rigor, jaundice, tender hepatomegally Diagnosed: U/S: dilated ducts, abnomal LFT, and positive blood cultures It is a medical emergency: rehydration+broad spectrum antibiotics (cephalosporins) Endoscopic or percutaneus drainage Sphinterotomy and stone removal 2/10/2018 12: 22 PM

Pyogenic Liver Abscess l l l 31 Idiopathic, diabetes, immunocompressed Anerexia, malaise, fever, abd. Pain U/S and CT: multiloculated cystic mass, confirmed by aspiration for culture. A source for infection especially in colon should be sought. Broad spectrum antibiotic +metronidazole Percutaneus aspiration under U/S guide. . 2/10/2018 12: 22 PM

Amoebic Liver Abscess l l l 32 l Caused by Entameba Histolytica, spread by feco-oral The parasite reaches liver via portal vein. Presents with fever and riger. Diagnosed by finding the parasite from stool and liver lesion U/S: is important to detect liver abscess Treatment metronidazole 750 mg three times If not responded further assessment needed PM 2/10/2018 12: 22

Liver Tumors l l l 33 l Hemangiomas: Commonest Hepatic Adenoma: Rare Focal Nodular Hyperplasia: sulfur colloid scan needed to distinguish from malignant and adenoma Hepatoceluar carcinoma: U/S, AFP Cholangiocarcinoma- primary sclerosing choangitis, calrolis disease…gall stones Klatskin tumors: 2/10/2018 12: 22 PM

l 34 Thank you 2/10/2018 12: 22 PM