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BENIGN PATHOLOGIES OF THE LIVER

DR. A . PERVEZ (PG, DEPT OF GENERAL SURGERY). BENIGN PATHOLOGIES OF THE LIVER. INTRODUCTION. *Benign liver pathologies are broadly divided into two categories *Firstly, infectious diseases such as 1.Pyogenic abscess 2.Amoebic abscess 3.Hydatid cysts

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BENIGN PATHOLOGIES OF THE LIVER

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  1. DR. A .PERVEZ (PG, DEPT OF GENERAL SURGERY) BENIGN PATHOLOGIES OF THE LIVER

  2. INTRODUCTION *Benign liver pathologies are broadly divided into two categories *Firstly, infectious diseases such as 1.Pyogenic abscess 2.Amoebic abscess 3.Hydatid cysts 4.Simple cysts, polycystic liver disease *And then, non malignant tumors

  3. PYOGENIC ABSCESS • Hepatic abscess’s occur when inoculum of bacteria exceeds liver’s ability to clear it which results in tissue invasion,neutrophil infiltration and abscess formation • Routes & Causes : 1.biliary causes (biliarystones,RPC,caroli’sdisease,biliaryascariasis,ERCP) 2.Portal vein (ascending pyelophlebitis,untreatedappendicitis,pancreatitis,perforatedviscus)

  4. 3.Hepatic artery (systemic infection) 4.Direct extension of a nearby focus of infection 5.Trauma (infection of an intrahepatic hematoma due to blunt/penetrating trauma) - Mostly involving right lobe of liver(probably due to preferential laminar blood flow) - Mostly solitary

  5. 40% are polymicrobial but most common causative organisms are E.Coli & K.Pneumoniae • C/F – fever,jaundice,right upper quadrant pain and tenderness are common modes of presentation • Rare complication – endogenous endophthalmitis ( typical of klebsiella) • O/E – fever,RT.hypochondrialpain,hepatomegaly,chest findings are usual.ascitis & splenomegaly are rare presentations

  6. Laboratory findings : leukocytosis,anemia, elevated ALP, grossly elevated total bilirubin.sometimeshypoalbuminemia &elevated PT can occur. • Imaging : CECT(95-100% sensitive) , USG, CXR(elevated RT hemidiaphragm/pleural effusion/atelectasis) • C/S of USG guided aspirate

  7. Treatment : 1.Broad spectrum IV antibiotics 2.Percutaneous catheter drainage (<5cm) 3.Laparotomy & open drainage (>5cm) 4.Rarely liver resection if recurrent abscesses occur due to infected hepatic malignancy or intrahepaticbiliary strictures

  8. AMOEBIC ABSCESS • Disease of tropical & developing countries • Causative agents – E.Histolytica & E.Dispar • Male preponderance • Poverty ,lower socio economic status with low hygiene standards,chronicalcoholism,malnutrition,chronic steroid usage and immunocompromised status are well known associated factors • Feco-oral transmission with humans being principal hosts

  9. Pathogenesis – enzymatic cellular hydrolysis resulting in localised hepatic liquefaction necrosis • Mainly in right lobe of liver • C/F – fever,chills,anorexia,right upper quadrant pain&tenderness,jaundice(when a large abscess compresses the biliary tree),referred pain to the shoulder can occur due to diaphragmatic irritation

  10. Complications : 1.Amoebic hepatitis 2.Hepatopleurobronchial fistula (pt coughs the classical ‘anchovy sauce’ pus) 3.Rupture into the peritoneum with resultant peritonitis Laboratory findings : Leucocytosis,eosinophilia,anemia, LFT abnormalities( commonly elevated PT)

  11. Imaging – CXR(elevated hemidiaphragm/pleural effusion/atelectais), USG(hypoechoic rounded lesion abutting liver capsule without significant rim echoes) CT (investigation of choice) , Gallium/ Tc99 liver scans( if facility present) • Other diagnostic modalities – EIA , diagnostic aspiration

  12. Management – • Conservative (nitroimidazoles,luminalamoebicides, quinine in refractory cases) • Invasive 1.Therapeutic needle aspiration(percutaneous) 2.Laparotomy and drainage in complicated cases

  13. HYDATID CYSTS • Zoonotic caused by echinococcus in sheep rearing regions • E.Granulosus, E.Multilocularis, E.Oligartus • Dog is definitive host, humans are accidental intermediate hosts • Pathogenesis – parasitic embryo releases an oncosphere in human duodenum which reaches liver to form hydatid cysts

  14. Parts of cyst – pericyst(fibrous capsule around the cyst derived from host tissue),ectocyst(outer gelatin membrane),endocyst(inner germinal membrane) • Occur more in the right lobe of liver • Presentations – asymptomatic,abdominalpain,dyspepsia,vomiting, in 8% jaundice and fever. Most frequent sign is hepatomegaly. Free rupture can result in disseminated echinococcosis which can cause a fatal anaphylaxis

  15. Diagnosis – serology,casoni’sintradermal test, imaging( USG/MRI/CT), in case of biliary tree involvement ERCP or PTC • Treatment – 1.medical ( albendazole/mebendazole) 2.Percutaneous aspiration(PAIR technique) 3.Laparotomy ( pericystectomy,marsupialization,partialhepatectomy)

  16. POLYCYSTIC LIVER DISEASE • Autosomal dominant • Combination of both macro and micro cysts • Usually hepatic parenchyma and liver function is preserved • Generally aymptomatic but can present with abdominal pain & distention • Associated with PCKD • LFT is usually normal • Rare complications – infection,bleeding

  17. Diagnosis – USG/CT • Treatment 1.Percutaneous aspiration with or without sclerotherapy 2.Fenestration(laparotomy/laparoscopy 3.Hepatic resection 4.Orthotopic liver transplant

  18. SIMPLE CYSTS • Contain serous fluid • No communication with biliary tree • Aseptate • Spherical or ovoid (around 15-20cm diameter) • Regarded as uncomplicated congenital malformations • Large cysts can compress liver inducing regional atrophy sometimes compensatory hypertrophy

  19. Common complication : intracystic bleeding • Diagnosis – USG/CT • Management 1.Sclerotherapy 2.Fenestration (laparotomy/laparoscopy)

  20. BENIGN TUMORS • Hemangioma (most common) • Liver cell adenoma • Focal nodular hyperplasia • Cystadenoma • Miscellaneous & Rare tumors

  21. HEMANGIOMA • Most common benign tumor of the liver • Female preponderance • Considered as congenital malformation • Usually single and <5cm • >5cm are considered as giant hemangiomas • Microscopically : endothelium lined blood filled spaces separated by thin septae • Usually asymptomatic ,can cause symptoms secondary to compression

  22. Rare complication – rapid expansion,sudden acute thrombosis, sudden spontaneous rupture • Can occur as Kasabach-Merritt syndrome (thrombocytopenia,coagulopathy,hemangioma’s) • Diagnosis – CT/MRI • Management – resection (enucleation with inflow control)

  23. ADENOMA • Rare • Female preponderance • Associated with OCP usage • >10 in number is termed as adenomatosis • Most commonly present as upper abdominal pain • Complications – rupture with fatal intraperitoneal hemorrhage and malignant transformation

  24. Diagnosis – CT(well circumscribed heterogenous mass showing enhancement in arterial phase) , MRI • Management : 1.In near fatal hemorrhage hepatic artery embolization followed by laparotomy and resection 2.In adenomatosis, orthotopic liver transplant is recommended

  25. FOCAL NODULAR HYPERPLASIA • Second most common benign liver tumor • Female preponderance • Usually <5cm involving both lobes of liver • Characterised by central fibrous scar with radiating septa • Considered as developmental vascular malformation • Broadly classified under 2 types classical & non classical(telangiectic,hyperplastic,adenomatous,mixed) • Usually asymptomatic and is a by chance finding on laparotomy

  26. Rare complications – rupture,bleeding,infarction • Diagnosis – CECT/MRI • Management – reassurance but may require resection should symptoms and complications arise

  27. CYSTADENOMA • Rare • Presents as large cystic mass (10-20 cm) • Has globular external surface with multiple protruding cysts & locules • Women > 40years • Can present with abdominal pain,abdomendistention,anorexia and nausea • Can turn into cystadenocarcinoma (rare) • Diagnosis : USG ,CECT/MRI

  28. USG – cystic structure with varying wall thickness,nodularity,septations & fluid filled vacuoles • CECT – enhancement of cyst wall & septae • Management : complete excision must be done as recurrence rate is high (40%)

  29. RARE HEPATIC PATHOLOGIES • Macroregenerative nodules – cirrhotic patients,malignancy potential+ • Nodular regenerative hyperplasia - <2cm,not malignant • Mesenchymalhamartomas – childhood tumor,abdomen mass+, need resection • Fatty tumors of liver – primary lipoma,myelolipoma,angiolipoma,angiomyolipoma

  30. Leiomyoma,myxoma,schwannoma,lymphangioma,teratoma • Benign fibrous tumor of liver • Pseudotumor of liver • Intrahepaticbiliarycystadenoma • Bile duct adenoma • Biliaryhamartoma

  31. THANK YOU -REFERENCES : BAILEY & LOVE(25TH) , SABISTON(18th) -PUBMED CENTRAL (PICTORIAL REFERENCES)

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