LIVER

SCHWARTZ CHAPTER 31

LIGAMENTS OF LIVER = Can be divided in bloodless plane to mobilize the liver

1. Round ligament =Remnant of obliterated umbilical vein. Enters L liver hilum at front edge of falciform
ligament
2. Falciform ligament = Separates L lateral & L medial segments. Anchors liver to anterior abdominal wall
3. Triangular ligament = Secure the 2 sides of the liver to the diaphragm
4. Coronary ligament

COUINAUD SEGMENTS
From French surgeon & anatomist Claude Couinaud (1922-2008) Divides liver
into 8 segments, numbered in clockwise direction
- Caudate Lobe = Segment I
- SEGMENT II + III = Left lateral segment
- SEGMENT IV = Left Medial Segment / Quadrate Lobe
- Segment IVA = cephalad, just below the diaphragm
- SEGMENT IVB =Quadrate, adjacent to GB fossa RIGHT LOBE
- Segments V, VI, VII, & VIII
- SEGMENT V + VIII = Right anterior lobe
- SEGMENT VI+ VII = Right posterior lobe

Anatomy: BLOOD SUPLY / ARTERIAL SUPPLY

- Dual Blood Supply: Hepatic Artery (25%) & Portal Vein ( 75 %)
-
Liver Function Measure cell damage
- AST (aspartate transaminase)
- ALT (alanine transaminase)
- ALP (alkaline phosphatase)
- GGTP (gamma-glutamyltranspeptidase)
Measure liver function
- Serum albumin = Not an acute marker, has long t1/2 = 15-20 days
- Prothrombin time

BENIGN LIVER TUMORS

Work-Up of Incidental Liver Mass
Increased with use of Oral contraceptives Cyst
- Simple / Congenital Cysts
- Biliary Cystadenoma
- Hemangioma
- Hepatocellular adenoma
- Focal Nodular Hyperplasia
- Biliary Hamartoma

HEPATIC CYSTS
- Majority are asymptomatic
- Incidental finding, can occur throughout lifetime
- Most common = Congenital / Simple CYSTS: Congenital
Cysts
- (5-14%), 4x more common in females
- From excluded hyperplastic bile duct rests
- Thin-walled, homogenous, fluid filled structures, no / few septations, contain serous fluid
- Usually asymptomatic
- If Large: (+) abdominal pain, epigastric fullness, early satiety Treatment:
- CT / UTZ guided percutaneous cyst Sclerotherapy
- Laparoscopic / Open Surgical fenestration
- If cyst wall has signs of malignancy do complete resection by enucleation / formal hepatic resection
CYSTS: Secondary Cysts
- Trauma (Seroma / biloma)
- Infection (pyogenic / parasitic)
- Neoplastic
CYSTS: Biliary Cystadenoma
- Slow growing, unusual, large lesions in right lobe
- Usually benign
- Can undergo malignant transformation Presentation: Abdominal
pain, abdominal mass on PE
- CT Scan: Thick walls with soft tissue nodules, cyst’s septations enhance Treatment:
Surgical resection
- Biopsy to r/o occult Cystadenocarcinoma

HEPATIC TUMORS HEMANGIOMA

- Most common solid benign liver mass, usually asymptomatic
- Congenital vascular lesions containing fibrous tissue & small blood vessels
- Large endothelial-lined vascular spaces
- More common in women, 2-20% of population
- Small ( < 1 cm) Giant Cavernous Hemangiomas (10-25 cm) Clinical
Presentation:
- PAIN – in tumors 5-6 cm, main indication for resection
- By stretching Glisson’s capsule or compressing adjacent structures
- SPONTANEOUS RUPTURE bleeding Diagnostics:
 - Biphasic CT + Contrast = asymmetrical nodular peripheral enhancement isodense with large vessels, progressive
centripetal enhancement
- MRI = Hypointense T1 weighted images, hyperintense T2 weighted images
- Gadolinium = (+) peripheral nodular enhancement Treatment:
only if symptomatic
- Enucleation
- Formal hepatic resection

HEPATIC ADENOMA
- Solitary tumors
- Young women (20-40 years), associated with oral contraceptives / androgenic steroids
- (+) malignant transformation into Hepatocellular CA Clinical
Presentation:
- Asymptomatic
- Palpable abdominal mass / abdominal pan (25%)
- Spontaneous Rupture & intraperitoneal hemorrhage (10-25%)
- Mortality rate = 9% Pathology:
- Soft tan/light brown tumors with sharply circumscribed edges, no true capsule.
- Contain normal hepatocytes, no Kupffer cells / bile duct cells HEPATIC
ADENOMA
Diagnosis:
- Suspected when mass seen on UTZ or other scan of liver
- CT Scan - sharply defined borders, confused with metastatic tumors
- Hypodense / isodense compared with background liver
- MRI + Gadolinium – diagnostic procedure of choice
- Hyperintense on T1 weighted images, enhance after gadolinium injection
- Can differentiate adenoma from FNH
- Hepatobiliary Scanning – shows “cold” lesions
- Biopsy – done to r/o malignancy Treatment
- Stop intake of OCP, Anabolic steroids
- Avoid pregnancy (will increase size of tumor)
- Risk of spontaneous rupture & hemorrhage
Observation Resection

• Small size • Large

• Intrahepatic • Superficial
• Associated with OCP use • Exophytic on a narrow pedicle
• Woman anticipates pregnancy

ADENOMA: Spontaneous Rupture

- Resuscitation
- If stable Angiography to visualize vessel embolization with thrombus
- If unstable / angiography not available / suspect CA OR
- HEPATIC ARTERY LIGATION – control bleeding, only minor aberrance in liver function if liver is not cirrhotic
- Do elective hepatic resection at a later date
 - HEPATIC RESECTION – has high mortality rate in presence of acute rupture
- OPEN PACKING / Angiographic Embolization of Hepatic Artery – if patient is very unstable

FOCAL NODULAR HYPERPLASIA

- Women of childbearing age, weak association with OCP Clinical
Presentation:
- Asymptomatic / Incidental finding
- Similar to hepatic adenoma Pathology:
- Single / multiple lesions with nodular appearance
- Hyperplastic hepatocytes with inflammatory (KupfFer) Cells + bile duct epithelium
- Resemble regenerating nodules of cirrhosis Diagnosis:
- CT Scan - well-circumscribed lesions with central scar
- MRI - Fibrous septa extending from central scar
- Sulfur-colloid imaging: selective uptake by Kupfer cells
- (-) significant risk of malignant transformation Treatment:
- Stop oral contraceptive use
- Surgical resection BILE DUCT
HAMARTOMA
- Small liver lesions 2-4 mm in size, on surface of liver
- Firm, smooth, whitish yellow
- Difficult to distinguish from metastatic lesions Diagnosis:
- Excisional biopsy

LIVER INFECTIONS
- Abscesses
- Pyogenic / bacterial abscesses
- Amebic abscesses
- Hydatid cysts
- Ascariasis
- Schistosomiasis

Pyogenic Abscess
- Most common hepatic abscess in Western World
- Most common in Right Lobe
- If multiple abscesses coalesce Honeycomb Appearance Etiology:
- Secondary to intraabdominal infection (cholangitis, appendicitis, diverticulitis, Crohn’s disease)
- Gram (-) rods (E. coli), Anaerobes (Bacteroides), Anaerobic streptococci (Enterococci)
- Seeding from a distant infectious source (endocarditis, infected catheters)
- Gram (+) organisms
- No source identified (10-50%)
- 40% = monomicrobial
- 40% = polymicrobial
- 20% = Culture (-)
Clinical Presentation:
- Fever, sepsis, chills, WBC, anemia, jaundice (30%)
ALP, ESR
- RUQ, enlarged / tender liver
- Hemobilia – from erosion of abscess into the biliary tree Diagnosis:
- Ultrasound – round / oval hypoechoic lesions, well-defined borders & variable internal echoes
- CT Scan – highly sensitive for localization, hypodense, peripherally enhancing with air-fluid levels (gas forming
organisms)
Treatment:
- Correct underlying cause
- Percutaneous aspiration
- IV antibiotics
- Gram (-) & anaerobic coverage
- At least 8 weeks
- Laparoscopic / open drainage – if medical therapy fails
- Anatomical surgical resection – in patients with recalcitrant abscesses

Amebic Abscesses
- Most common liver abscesses worldwide
- Entamoeba histolytica trophozoites
- Multiply & block intrahepatic portal radicles focal infarction of hepatocytes
- Proteolytic enzyme destroys liver parenchyma
- Most common site = Superior-Anterior part of Right Lobe near the diaphragm Abscesses:
- Single or multiple
- Necrotic central portion with thick, reddish-brown, pus-like material (“Anchovy Paste”) Clinical
Presentation:
- RUQ pain, fever, hepatomegaly
- Mildly ALP Diagnosis:
- (+) Fluorescent antibody test for E. histolytica
- Ultrasound & CT : low-density round lesions with peripheral enhancement, “ragged” appearance with peripheral
edema
- Central cavity may have septations & air-fluid levels Treatment:
Medical Therapy
- Metronidazole 750 mg TID x 7-10 days (95% successful)
- Abscess resolves within 30-300 days

Aspiration
- large abscesses
- refractory to medical therapy
- superinfections
- abscesses of left lobe that may rupture into the pericardium
Hydatid Disease
- From larval / cyst stage of infection of dog tapeworm Echinococcus granulosus
- Cysts caught in hepatic sinusoids, 70% form in liver
- Right lobe of liver (antero-inferior or postero-inferior margins)
- Common in sheep-raising areas Clinical
presentation:
- Dull RUQ, abdominal distention
- Rupture Anaphylactic shock Diagnosis:
- ELISA for echinococcal antigens
- WBC: eosinophilia
- UTZ & CT scan: well-defined hypodense lesions with distinct wall & ring-like calcifications of pericysts
Treatment:
- Albendazole – initial treatment for small, asymptomatic cysts
- Surgical Resection – remove cyst, instill scolicidal agent
- Caution: do not rupture cyst will release protoscolices into peritoneal cavity acute anaphylaxis or
peritoneal implantation & recurrence
- Formal anatomic liver resection – if complete cystectomy is not possible ASCARIASIS
- Ova of the roundworm Ascaris lumbricoides
- Retrograde flow in the bile ducts
- Adult worm = 10 – 20 cm long, lodge in CBD bile obstruction & 2º cholangitic abscesses Clinical
Presentation:
- Biliary colic
- Acute cholecystitis
- Acute pancreatitis
- Hepatic abscesses Diagnosis:
- SFA / Ultrasound / ERCP –linear filling defects in the bile ducts
- Worms can be seen moving into & out of the biliary tree from the duodenum Treatment:
- Piperazine citrate / mebendazole / albendazole
- ERCP extraction of worm

MALIGNANT LIVER TUMORS

- Hepatocellular CA
- Cholangiocarcinoma
- Gallbladder CA
- Metastatic Colorectal CA
- Metastatic Neuroendocrine CA (Carcinoid)
- Other metastatic cancers PRIMARY:
- Primary (cancers that originate in the liver)
- Hepatocellular carcinomas (HCCs / hepatomas) – cancers arising from hepatocytes
- Cholangiocarcinomas – cancers arising from bile ducts METASTATIC:
- Cancers that spread to the liver from an extrahepatic primary site
HEPATOCELLULAR CA (Hepatoma) 5th most common CA worldwide Major risk
factors:
- Viral hepatitis (B or C)
- Chronic Hepatitis B = 80% of cases
- Cirrhosis (any cause) = 60-90%, macronodular
- Hemochromatosis
- Schistosomiasis & other parasitic infections
- Chemicals: biphenyls, hydrocarbon solvents, nitrosamines, vinyl chloride, organochloride pesticides
- Aflatoxins (Aspergillus flavus / Aspergillus fumigatus)
- Thorotrast (IV contrast agent)
- Men (2x increased incidence) , Average age = 50 y/o Clinical
Presentation:
- Small – asymptomatic
- Dull, aching RUQ pain, fever, malaise, jaundice
- Hepatomegaly (88%), weight loss, tender abdominal mass, cirrhosis
- Tumor rupture Acute hemorrhage into peritoneal cavity (10-15%)
- Paraneoplastic Syndromes (Cushing’s syndrome)

Pathology:
- Solitary / multiple masses
- May have local invasion into diaphragm
- Distant metastasis in 45%
- Most common = lung Diagnosis:
- Liver Function tests – usually abnormal but non-specific
- Alpha feto-protein – from embryonal hepatocytes, in 70%
- Hepatic UTZ – cannot assess lesions < 2 cm
- CT Scan, MRI - most reliable
- Determines presence & operability of lesions
 Treatment
Resection & transplantation
- Milan Criteria:
o One nodule < 5 cm
o 2 or 3 nodules all < 3 cm
o No gross vascular invasion / extrahepatic spread Chemotherapy
Chemoembolization
Embolizing arterial supply of tumor with chemotherapuetic agents + thrombus

CHOLANGIOCARCINOMA
- Bile duct adenoCA in biliary epithelial cells
- 2nd most common primary liver malignancy
- Subclassifications:
o PERIPHERAL / INTRAHEPATIC – presents as tumor mass within a hepatic lobe or at the periphery of
the liver
o CENTRAL / EXTRAHEPATIC
o PROXIMAL = Hilar CholangioCA / Klatskin’s Tumor
 Originates in wall of bile duct at hepatic duct confluence
 Presents with obstructive jaundice
o DISTAL
Clinical presentation:
- RUQ pain, jaundice, hepatomegaly, palpable mass
- Patients = 60-70 years old Pathology:
- Hard grayish mass
- Metastasis liver / regional LN
Associations:
- Clonorchis sinensis
- Primary sclerosing cholangitis (PSC) – 10%
- Thorotrast exposure

HEPATOBLASTOMA
- Most common primary malignant liver CA in children
- Solitary liver masses with nests & cords of primitive cells Presentation:
- Abdominal distention
- Failure to thrive
- (+) AFP
- Treatment:
- Surgical excision
- Liver transplantation
ANGIOSARCOMA / MALIGNANT HEMANGIOENDOTHELIOMA
- Highly malignant liver tumor composed of irregular spindle cells lining the lumina of hepatic vascular spaces
- 85% occur in males Metastasis:
- Spleen (80%)
 - Lungs (60%)
- High association with chemical agents:
- Vinyl chloride, thorotrast, arsenicals, organochloride pesticides
- Poor prognosis HEPATIC
METASTASIS
- More common than primary tumors (20:1)
- Liver is 2nd most common site of metastasis for all CA of the abdominal viscera
- 1/3 of all CA spread to the liver
- Most common site of hematogenous spread Negative
Prognostic Factors for Liver Metastasis:
- Non-breast origin
- Age > 60 years
- Disease-free interval < 12 months
- (+) need for major hepatectomy
- (+) R2 resection
- (+) Extrahepatic metastasis

TREATMENT OPTIONS
- Hepatic resection
- Liver transplant
- Ablation Techniques
- Radiofrequency ablation
- Ethanol ablation
- Cryoablation
- Microwave ablation
- Regional Liver Therapies
- Chemoembolization / embolization

TUMOR MARKERS:

CEA – can be used to monitor treatment. Not specific to the liver (can also be used in colon-rectal and other CAs)

AFP – elevated in HCC

CA19-9 – more of sa pancreatic CA, but may be elevated pag may biliary tract obstruction, cholangitis, liver cirrhosis.