Liver and Spleen Diseases

Bernard S. Victorio, M.D., FPCS, FPSGS, FACS

at the end of the session

 imaging modalities use in diagnosis of hepatobiliary,

extrabiliary and spleen diseases

 diagnosis and management of benign and malignt

diseases

 diagnosis and management of hepato-biliary and

splenic diseases

 management of liver and splenic injuries

 Imaging Studies
ADVANTAGE DISADVANTAGE
ULTRASOUND • Initial imaging • Incomplete imaging
• Biliary and liver • Obesity/bowel

Intraoperative UTZ
CT SCAN • Contrast medium
• Arterial/venous phase
MRI T1/T2
PET SCAN Metastatic tumors Lack of exact localization
60 F year female was referred to you due to severe
abdominal pain.

Afebrile, (-) jaundice

UTZ = multiple stone, thickened wall, CBD not dilated

SGPT > 2500, alk phos = 243

Plan: Lap Chole, IOC CBDE/ post op ERCP

3 days after, repeat SGPT= 23, alk phos = 250

PLAN
 Infection of the liver
PYOGENIC
ETIOLOGY • Acute appendicitis
• Impaired biliary drainage
• Hematogenous
• endocarditis
LOCATION • Single
• Multiple- honeycomb
• Right lobe of liver
SYMPTOMS • RUQ pain, fever
• Jaundice- 1/3
• Leukocytosis
• Increase ESR and alk phos
• Elevated transaminase
AMOEBIC
entamoeba
• Single/ Multiple
• Superior, anterior near
diaphragm
• Necrotic central portion
• Anchovy paste or
chocolate sauce
• RUQ pain, fever
• Jaundice, unusual
• Hepatomegaly
• Leukocytosis
• Mildly increase AP
 Infection of the liver
IMAGING PYOGENIC AMOEBIC
UTZ Hypoechoic lesions with Non specific
well defined borders,
internal echoes For follow up
CT Hypodense, air fluid level Non specific
Extrahepatic involvement
Well defined low density
round lesion with wall
enhancement
Central cavity with
sepatations/air fluid level

For follow up
MRI High level of sensitivity
*Guided biopsy
 Infection of the liver

MANAGEMENT PYOGENIC AMOEBIC

CULTURE 50% of cases Flourescent antibody
ANTIBIOTIC Gram (-) (+) Metronidazole 750 mg TID
anaerobic for 7 to 10 days
DRAINAGE • Laparoscopic/open Aspiration rarely needed
• Anatomic resection • Large abscess
• Necrotic hepatic • Not responding to
malignancy medical therapy
• Superinfected
• Left lobe
Liver Lesions

Benign Malignant
Cyst Hepatocellular CA
Hemangioma cholangiocarcinoma
Focal Nodular Hyperplasia Gallbladder CA
Adenoma Metastatic colorectal CA
Biliary hamartoma Metastatic neuroendocrine
(carcinoid)
abscess Metastatic cancers
 Benign Liver Lesions

cyst Most frequently encountered

• Congenital cyst
• Biliary cystadenoma
• Polycystic liver disease
• Caroli’s disease
Bile duct hamartoma • Small liver lesion (2 to 4 mm) surface of liver
• Firm, yellow, smooth in appearance
• Excisional biopsy
 manifestations

Hemangioma adenoma Focal nodular

hyperplasia
• Most common • Young women (20 to • Childbearing
• Pain (larger than 5-6 40) • Oral conceptive use
cm) • pain • Do not rupture
• Spontaneous • Solitary, sometimes • No significant risk of
rupture is rare multiple malignant
• Malignant • Prior or current use of transformation
transformation (?) oral contraceptive
• Spontaneous rupture
(10-25%)
• Malignant
transformation to HCC
 CT scan

Hemangioma adenoma Focal nodular

hyperplasia
Large – asymmetrical Sharply defined border, • Biphasic, well
nodular peripheral confused with metastatic circumscribe with a
enhancement, tumors typical central scar
isodense • Venous phase – • intense homogenous
hypodense/isodense enhancement on
• Arterial phase – subtle arterial phase contrast
hypervascular images, often isodense
enhancement or invisible compared
hypodense with background liver
on venous phase
 MRI

Hemangioma adenoma Focal nodular

hyperplasia
Hypointense on T1 and Hyperintense on T1 and Hypointense on T1 and
hyperintense on T2 enhance early after isointense to
gadolinium hypointense on T2
Godolinium, become
hyperintense but
become hypointense on
delayed images
Nuclear imaging “cold” Radionuclide sulfur
colloid
 Management

Hemangioma adenoma Focal nodular

hyperplasia
• Liver biopsy – with • resection Main indication for
caution, increase risk surgery is abdominal
of bleeding pain
• Main indication for Oral contraceptive or
resection – pain estrogen should be
• Enucleation stopped
• formal hepatic
resection
Malignant Liver Tumor

Hepatocellular
Carcinoma
Risk factors Viral hepatitis
Alcoholic hepatitis
Hemochromatosis
Nonalcoholic steatohepatitis
CT scan Hypervascular in arterial phase and
hypodense during the delayed phase
MRI Variable T1 and hyperintense T2
Portal vein thrombosis Highly suggestive
Algorithm for HCC
Cholangiocarcinoma 2nd most common
Hilar (klatskin) Peripheral
Obstructive jaundice, painless Tumor mass
locoregional
• Surgical resection (absence of PSC) Poor survival
• chemoradiation • Vascular invasion
• Positive margins
• Multiple tumors
Improved outcome Prognostic factors affecting survival
• Histologic negative margin • Absence of mucobilia
• Concomitant hepatic resection • Nonpapillary tumor
• Well differentiated • Advance stage
• Nonhepatectomy
• Lack of pre-op chemo
3 to 5 year survival : 41.7% to 26.8% 3 year survival: 55
Gallbladder CA
• Rare, aggressive tumor Diagnosis
• Poor prognosis • Pre-op : 57%
• Associated with cholelithiasis • Intra-op: 11%
• Incidental: 32%
Surgical approach • Re-op for incidental gallbladder CA after
choleycstectomy
• Beyond stage 1 (T2 and T3)
• Central liver resection
• Hilar lymphadenopathy
• Evaluation of cystic duct stump
• Radical resection with advance disease
• Role of formal lobectomy/extended
lobectomy (?)
Metastatic colo-rectal CA
Resection on fewer than 4 10 year survival
• 4 or more : 29%
• Solitary: 33%
Resectability is no longer
defined on what actually is
removed but on what will
remain after resection
• Use of neoadjuvant
chemotherapy
• Portal vein embolization
• Simultaneous ablation
• Resection of extra-hepatic
tumor
Mets from Neuroendocrine Other metastatic tumor
tumor
Protacted natural history • Breast
Debilitating endocrinopathy • Renal
• Other Gi
2 stage procedure
Primary tumor is resected
• Resection with limited
resection of left hemiliver,
portal vein ligation
• 8 weeks, right or extended
right hepatectomy
• 2, 5, 8 overall survival rate:
94%, 94$, 79%
• Disease free survival rates:
85%, 50%, 26%
 treatment option
option
Hepatic resection Gold standard
HCC with cirrhosis (?)
Margin: 1cm
Liver transplantation HCC with cirrhosis
Recurrent rates (>50%)
Improved survival rate
• Early stage (stage 1 or 2)
• One tumor, 5cm
• Three tumor largest 3cm
• Absence of gross vascular
invasion or extrahepatic
spread
 option
Radiofrequency ablation • HCC of 3 to 7.5 cm
• Recurrence rate after
resection (44% vs 11%)
• Combination with TACE
Ethanol ablation, cryosurgery,
microwave ablation
chemoembolization
Yttrium 90 micropheres Inoperable primary or
metastatic liver tumor
Stereotactic radiosurgery
Systemic chemotherapy
Surgical techniques
 CIRRHOSIS

History and PE Portal Hypertension

Ascites
Hepatic encephalopathy
Lab findings Mild normochromic anemia
Low WBC, platelet
Bone marrow – macronormoblastic
Prolong PT, not responding to vitamin
K
Bilirubin, transamines, alk phos -
elevated
Liver biopsy UTZ or CT guided percutaneous biopsy
 Assessment of surgical risk
(Child-Turcotte-Pugh Score)

variable 1 point 2 points 3 points

bilirubin <2mg/dl 2-3mg/dl >3m/dl
albumin >3.5 g/dl 2.8-3.5 g/dl <2.8 g/dl
INR <1.7 1.7 -2.2 >2.2
encephalopathy none controlled uncontrollable
ascites none controlled uncontrollable

Class
A- 5-6 points
B- 7-9 points
C – 10-15 points
 PORTAL HYPERTENSION
 Gastroesophageal varices

 Splenomegaly

 Caput medusae (cruveilhier-

baumgarten murmur)

 Ascitis

 Anorectal varices
 Management, portal hpn
Prevention of Variceal bleeding
Acute Variceal Bleeding
(5 day hemostasis rate)
Abstinence from alcohol
Avoidance of aspirin and NSAID
Adminstration of propranolol
Prophylactic endoscopic variceal ligation
(EVL)
• Blood resuscitation
• Fresh-frozen plasma and platelet
• Prophylactic antibiotics
• Vasopressin (0.2 to 0.8 units/min) or in
combination with nitroglyerin
• Somatostin (initial bolus 50μ/IV)
• Balloon tamponade (<24 hours)
• Surgical shunt/TIPs (refractory variceal
bleeding)
 Rebleeding prophylaxis
• Median rebleeding risk of 70% within 2 years
• Mortality rate of 33%
• Secondary prophylaxis should begin once acute bleeding is
controlled
• Pharmacologic prophylaxis
• EVL
• TIPS/shunt is warranted
 shunts
Shunts
Aim
Portosystemic shunt
Warren shunt (distal splenorenal)
Transjugular Intrahepatic
Portosystemic Shunt (TIPS)
Reduce portal venous pressure
Maintain total hepatic and portal blood
flow
Avoid a high incidence of complicating
hepatic encephalopathy
Higher incidence of shunt thrombosis and
rebleeding
High incidence of encephalopathy
Mesocaval shunt- for transplant
Lower rate of hepatic encephalopathy
and decompensation
>90% of cases refractory to medical
treatment
 Non shunt
procedure
Suguira
Extrahepatic portal vein thrombosis and • Extensive devascularization of the
refractory bleeding stomach and distal esophagus
• Transection of the esophagus
• Splenectomy
• Truncal vagotomy
• pyloroplasty
Hepatic transplant Promising role
Patients only chance of definitive Not affected by previous EVL, TIPS,
therapy and long term survival splenorenal, mesocaval shunts
Patient with variceal bleeding
refractory to all forms of management
Reverses most of the hemodynamic
and humoral changes associated with
cirrhosis
Management of refractory ascites
 Nonpharmacologic
o Sodium restriction, 1.5 to 2 g
o Fluid restriction, 1 to 1.5/l per day (profound hyponatremia)

 Pharmacologic
o Diuretics
• Loop diuretic (furosemide)
• Potassium sparing Aldosterone antagonist
(spirinolactone)

 Albumin

 Vasoncontrictors- octreotide
 Interventional therapy
o Large volume paracentesis (4-5 liters)
o TIPS
o Peritoneovenous shunt
• Higher rate of complication
Management of hepatic
encephalopathy

 Overt hepatic encephalopathy

o Oral disaccharide – gold standard
o Dietary protein restriction
o Low absorbable antibiotic

 Associated acute liver failure

o Increase intracranial pressure
• Hypotonic solution should be avoided
• Mannitol

 Minimal Hepatic Encephalopathy

Splenic Diseases
 Radiologic Evaluation
ADVANTAGE DISADVANTAGE
ULTRASOUND • First imaging modality Risk of hemorrhage
• Pre-op planning during percutaneous
ultrasound guided
procedures
CT SCAN • High degree of
resolution
• Invaluable tool in
evaluation and
management of
splenic trauma
• Splenomegay,
solid/cystic
• Percutaneous
procedures
Plain radiography Outline of spleen
 ADVANTAGE DISADVANTAGE
MRI Excellent detail and versatility No obvious advantage
More expensive
Angiography Therapeutic splenic arterial Pancreatitis
embolization (SLE) Risk of invasive procedure
• Localization and treatment
of hemorrhage in trauma pt
• Delivery of therapy in
patients with
cirrhosis/portal/transplant pt
• Adjunt to splenectomy
Nuclear imaging Locating accessory spleen
Splenic index 120 ml to 480 ml
Indications for splenectomy

 Splenic rupture

 RBC disorder and hemoglobinopathies

 WBC disorder

 Platelet disorder

 Bone marrow disorder

 Cyst/tumors

 Infections and abscess

 Infiltrative disorder
 Pre-op consideration

vaccination Overwelming Postsplenectomy

infection
Encapsulated bacteria, 2 weeks
elective surgery
• Streptococcus pneumoniae
• H. Influenza
• Meningococcus
Splenic artery embolization Reduce spleen size
Deep vein thrombosis prophylaxis Portal vein thrombosis
• Anorexia
• Abdominal pain
• Leukocytosis
• Thrombocytosis
Sequential compression device
Heparin (5000 I.U)
 post splenectomy outcomes
Complications
 Left lower lobe atelectasis, most common
 Subphrenic hematoma
 Subphrenic abscess
 Pancreatitis, psedocyst, pancreatic fistula
 Thromboembolic

Hematologic
 Initial response – rise in platelet count
 Increase in hemoglobin to 10g/dl
OPSI

 Medical emergency
 Progress to bacteric septic shock, with hypotension, anuria,
DIC

 More common in hematologic diseases

 <5 years of age and >50 years of age

 Pathogenesis
 Loss of splenic macrophages
 Diminish tuftsin prodcution
 Loss of spleen reticuloendothelial function
vaccination

 Pneumococcus and other encapsulated

 2 weeks before planned surgery

 With 7 to 10 days of emergent splenectomy

 OPSI cases
 Pneumococcus
 Meningococcus
 H. influenza type B
 group A Streptococci
Trauma
Thank you
Gallbladder and extrahepatic biliary
system

Bernard S. Victorio, M.D., FPSGS, FPCS,

Anomalies
 Classic description – 1/3 of patients

 Gallbladder:
abnormal portions, intrahepatic, rudimentary, duplicatiion

 Bile Ducts: ducts of Lushka, accessory right hepatic duct

 Artery:
50% of population
Right hepatic artery from SMA (20%)
2 right hepatic arteries (5%)
Cystic artery arising from left hepatic, common hepatic,
gastroduodenal or SMA (10%)
Imaging Studies

sensitivity specificity
Ultrasound >90% >90%
CT scan
MRI
MRCP 95% 89%
ERCP
HIDA scan 95% 95%
PTC
Oral cholecystography
Endoscopic UTZ
Ultrasound

 Operator dependent

 Stones (>90% S and S) – acoustic shadow

 Thickened wall

 Evaluate
• extrahepatic biliary tree
• tumor invasion and flow in portal vein
CT scan

 Define biliary tree and nearby structures

 Test of choice for malignancy

 HIDA scan

 IV injection of radionuclide

 Detected in the liver within 10 min, GB, ducts and

duodenum are visualized within 60 mins

 Acute cholecysttis- non visualized galbladder (95% S and S)

 To evaluate biliary leak

MRI

 MRCP
to delineate anatomy of the bile duct and pancreatic duct
ERCP

 Direct visualization of ampullary region and direct access

to distal CBD

 Theapeutic and diagnostic

 Evalaute complicated duct stones

 Complications – pancreatitis and cholangitis

Gallstone
 Most patient are asymptomatic

 1-3% become symptomatic per year

 3-5% developed complications

Prophylactic Incidental
Cholecystectomy cholecystectomy
• Elderly patients with DM • Polyps
• isolated from medical • Greater than 10mm, sessile,
care adenomatous, rapid growth
• Population with
increased risk for cancer • Porcelain GB

• During hepatic metastatectomy

(colrectal/neuroendocrine)
 Special populations

• DM
• prophylactic cholecystectomy not indicated

• Hemoglobinopathy
• Hereditary spherocytosis and thalasemia not recommended

• Transplant

• Gallbladder cancer

• Spinal cord injury (once symptomatic)

• TPN

• Morbid obesity
Acute Chronic Acalculous Cholecystits
Cholecystitis Cholecystitis

same same Critically ill, ICU

Same with acute
Fever, WBC, bili ALP

Ultrasound Ultrasound Ultrasound

HIDA scan HIDA scan
CT scan CT scan

hydrops

Aschoff-Rokitansky sinus
management

 IV fluid

 Antibiotics (gram negative and anaerobes

 Analgesic

 Cholecystectomy- early vs delayed

 Unfit for surgery – cholecystostomy

Biliary cyst
 Congenital cystic dilatation of extrahepatic/intrahepatic

 Types
• Type I, fusiform
• Type II, saccular diverticulum
• Type III, bile duct dilatations within duodenal wall
• Type IVA and IVB, multiple cyst
• Type V, intrahepatic biliary cyst

 US, CT, ERCP, MRC

 I, II, IV
• excision of extrahepatic biliary tree (including
cholecystectomy, roux-en-y hepaticojejunostomy
choledocholithiasis
 Clinical manifestation
• Silent
• Cholangitis
• Gallstone pancreatitis
• Obstructive jaundice

 Diagnosis: US, MRC, ERCP

 Treatment
• ERCP followed by lap cholecytectomy
• IOC and lap CBD
• Open CBD with t tube placement
cholangitis
 Ascending bacterial infection
(E coli, Klebsiella pneumonia, Streptococcus fecalis, bacteriodes
fragilis)

 Clinical presentation: charcot’s triad/reynold pentad

 Diagnosis
• Leukocytosis, hyperbilirubinemia, increase alk phos and
transamines
• US, ERCP, PTC, CT, MRI

 Treatment
• IV antibiotic and fluid resusciatation
• Drainage of obstructive CBD as soon patient has been stabilized
 Morbidity and mortality of the disease are directly related to the number o

the mortality is generally zero; with three to five positive signs, mortality

there are more than seven positive Ranson signs. Although prognostic sig

limitations to the value of these signs. One has to measure all 11 signs to

Biliary pancreatitis to complete the profile. A delay of 48 hours after admission merely for as

during this time. It is important to realize that Ranson's prognostic signs a

been validated for later time intervals. Although several investigators (Imr

to simplify these prognostic criteria throughout the years since their incept

Table 33-4 Ranson's Prognostic Signs of Pancreatitis

 Common channel theory Criteria for acute pancreatitis not due to gallstones

At admission During the initial 48 h

 Diagnosis Age >55 y Hematocrit fall >10 points

WBC >16,000/mm 3 BUN elevation >5 mg/dL

• Ranson’s criteria
Blood glucose >200 mg/dL Serum calcium <8 mg/dL
• Amylase, lipase, urinary Serum LDH >350 IU/L Arterial P O2 <60 mm Hg

amylase
Serum AST >250 U/dL Base deficit >4 mEq/L
• US – ductal dilatations, Estimated fluid sequestration >6 L

pancreatic edema, PFC Criteria for acute gallstone pancreatitis

At admission During the initial 48 h

• CT Age >70 y Hematocrit fall >10 points

WBC >18,000/mm 3 BUN elevation >2 mg/dL

Blood glucose >220 mg/dL Serum calcium <8 mg/dL

Serum LDH >400 IU/L Base deficit >5 mEq/L

Serum AST >250 U/dL Estimated fluid sequestration >4 L

AST = aspartate transaminase; BUN = blood urea nitrogen; LDH = lactate

treatment
 Intensive care with food and fluid restrction, replacement
of fluids, electrolytes, control of pain

 Broad antibiotic

 Surveilance for complications

 Mild : cholecystecotomy with IOC or preoperative ERC

 Severe:
ERCP with sphincterotomy and stone extraction
cholecystectomy
Bile duct strictures
 Cause: operative injury, fibrosis (chronic pancreatitis),
CBD stones, cholangitis, Mirizzii’s syndrome, strictures in
biliary-enteric anastomosis

 Presents as cholangitis or jaundice

 US, CT, MRC, PTC, ERCP

 Endoscopic dilatation/stent placement, roux-en-y

choledochojejunostomy, hepaticojejunostomy or
cholechoduodenostomy
Injury to biliary tract
 Gallbladder
• Uncommon
• Penetrating or nonpenetrating
• Cholecystectomy

 Extrahepatic bile ducts

• Majority is iatrogenic
• Lap cholecystectomy: acute or chronic inflammation, anatomic
variations, inadequate exposure or failure to identify structures
• 25% recognized at time of operation
• 50% in the first post op month with elevated LFT or biloma
• US, CT, HIDA
• Recurrent cholangitis or cirrhosis
management
 Depends on the type, extent, level of injury and time of
diagnosis
• <3 mm or those draining a single hepatic segment can be safely
ligated
• >4 mm or larger need to be reimplanted
• Lateral injury to CBD or common hepatic duct is managed by t-
tube placement
• Major bile duct injury – bilairy enteric anastomosis
• Cystic duct leaks can usually be managed with percutaneous
drainage of intra-abdominal fluid collections followed by
endoscopic biliary stenting
• Major injuries diagnosed post-op require transhepatic catheter
placement for biliary decompression and percutaneous
drainage
• After acute inflammation has resolved, operative repair is
performed
 tumors
 Carcinoma of the gallbladder
• Rare, aggressive and poor prognosis
• High risk: porcelain gallbladder (20%) chronic inflammation,
stones >3cm, symptomatic gallstones, polypoid lesions,
choledochal cyst, sclerosisng cholangistis, anomalous
pancreatico-biliary junction, exposure to azotoluene,
nitrosamines
• Pathology: adenocarcinoma, squamous cell, adenosquamous
• Lymphatic, venous, direct invasion
• Clinical featue: indistinguisable from cholecystitis and
cholelithiasis
• US, CT
• treatment
 Bile duct carcinoma
• Rare, 2/3 = hepatic duct bifurcation
• Risk factors: primary sclerosing cholangitis, choledochal cyst,
ulcerative colitis, hepatolithiasis, biliary enteic anastomosis,
biliary tract infection with clonorchis chronic typoid carrieres
• 95% adenocarcinoma
• Anatomical division
• Intrahepatic, treated like HCC
• Perihilar (klatskin tumor
• Proximal
• distal
Thank you
Acute Liver Failure

 Etiology
 Viral infection (hepatis a, b, e)
 Drug induce (acetaminophen)

 Clinical Presentation
 Jaundice and encephalopathy
 Hepatic coma
 Increase creatinine
 Arterial ph <7.30
 Culture proven infection
ALF

 Liver biopsy

 Rapid progression

 Acetaminophen overdose
 Activated charcoal
 N-acetylcysteine

 ICU

 Prognosis