Liver 2022-2023

The normal liver in the adult is impalpable. In contrast, an infant’s liver is normally palpable two
finger breadths below the right costal margin. The enlarged liver extends downwards below the
right costal margin and may fill the subcostal angle or even extend beneath the left costal margin
in gross hepatomegaly. The liver moves with respiration, is dull to percussion and the liver
dullness may extend above the normal upper level of the fifth right interspace.

Liver function tests:

Bilirubin: Serum bilirubin is measured in direct (conjugated) and indirect (unconjugated)
fractions. The normal serum bilirubin is 1 mg/dL. Excess bilirubin becomes clinically detectable
when the serum level rises to over 2-3 mg/dL.

Aminotransferases (ALT, AST): Aminotransferases (also referred to as transaminases) are

enzymes markers reflect acute hepatocellular disease or damage, as does the gamma-glutamyl
transpeptidase (GGT) level

Alkaline phosphatase; representative of bile duct obstruction or inflammation rather than

hepatocyte injury.

Prothrombin time and albumin: Prothrombin time (measured as international normalized ratio,
INR) and serum albumin are markers of the synthetic function of the liver and are probably the
best overall markers of severity of liver disease.

IMAGING THE LIVER

Ultrasound: is usually the first line modality in imaging the liver and biliary tract for detection
of focal liver lesions and assessment of biliary tract dilatation.
Computed tomography: with or without contrast used in diagnosis and staging of liver lesions.
Magnetic resonance imaging (MR) of the liver is superior to CT in characterizing liver lesions
and detecting small liver metastases.
Magnetic resonance cholangiopancreatography (MRCP) provides excellent quality non-
invasive imaging of the biliary tract.
Endoscopic retrograde cholangiopancreatography (ERCP); is performed in patients with
obstructive jaundice, (endoscopic removal of CBD stones, biliary drainage in septic patient or
insertion of a biliary tract stent).
Direct endoscopic cholangioscopy; Cholangioscopy enables direct visualization of the bile
ducts, either operatively or endoscopically.
Endoscopic ultrasound (EUS); EUS evaluates the extrahepatic biliary tree. EUS provides
detailed views of the bile ducts, ampulla, pancreas and liver hilum, but does not carry the
associated risks of ERCP.
Percutaneous transhepatic cholangiography (PTC) is indicated where endoscopic
cholangiography has failed or is impossible. It is often required in external drainage of the
obstructed bile ducts to relieve jaundice and stent insertion.
Angiography; employed only for Occlusion of arteriovenous malformations, the embolisation of
tumours or hemorrhagic sites in the liver.

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Positron emission tomography (PET): PET can be useful in staging hepatobiliary and
pancreatic (HBP) malignancy.

Hepatic infections and infestations

Amebic Liver Abscess

The causative organism is Entamoeba histolytica. Risk factors include low socioeconomic status,
overcrowded, unsanitary conditions, malnutrition, and depressed immunity
Pathology; It is almost and always secondary to amebic ulcers on the colonic wall. The
organisms reach the liver via the inferior mesenteric vein and then portal vein. The abscess is
large and thin-walled, is usually solitary and in the right lobe, and contains brown sterile pus
resembling anchovy sauce.
Clinical Features
• Pain over the right hypochondrium, worsened by movements and coughing.
• Anorexia, nausea, weight loss and night sweats
• History of colitis that presents with gradually worsening diarrhea.
• Anemia, low grade fever, tenderness and rigidity over the right hypochondrium area and
enlarged liver.
• Jaundice is uncommon.

Investigations
1. Blood—leucocytosis with eosinophilia is found. Anemia may be present.
2. Stool—for detection of amoebae. Usually positive
3. Amoebic serology usually positive.
4. X-ray abdomen shows tenting (i.e. fixed and elevated) right dome of diaphragm.
4. Ultrasound—demonstrates the site, size of the abscess and aspiration of the liver abscess.

Complications; The common complications of amebic liver abscess include secondary infection,
rupture, basal pneumonia and pleural effusion.
Treatment;-
• Drugs: Metronidazole—is the treatment of choice. Dose: Orally 750 mg thrice daily or 400 IV
thrice daily × 10 days.
• Drainage; when abscess does not resolve on medical treatment: Percutaneous under ultrasound
guidance or Open Drainage; when US guided aspiration fails.

Pyogenic Liver Abscess

may arise by several mechanisms including: (1) More cases are related to surgical or invasive
non-surgical treatment of hepatobiliary disease, (2) via the portal vein when Portal pyaemia may
follow pelvic or gastrointestinal infection as in appendicitis ,diverticulitis or infected
hemorrhoids , (3) as the result of penetrating wounds or blunt trauma, or (4) without an obvious
cause, cryptogenic.

Risk factors: It has an increased incidence in the elderly, diabetics and the immunosuppressed.
Pathology: bacteria are mixed growths. The most common organisms are Escherichia coli and
Streptococcus faecalis, anaerobic organisms like Bacteroids.

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Clinical Features
The onset of symptoms is often insidious and the patient may present with pyrexia of unknown
origin.
• Pain in the right upper quadrant
• High grade swinging fever often accompanied by chills and rigor.
• nocturnal sweating, vomiting, anorexia, malaise
• Jaundice—May be present in patients with large abscess
• a tender palpable liver
Investigations
• Blood— leucocytosis 15000 to 30000 /cmm.
• Chest X-ray show elevated right dome of diaphragm with basal atelectasis or pleural effusion
• Ultrasound and CT scan—indicate the presence, size, number and location of the abscesses.
Treatment
1. Antibiotics; Intravenous antibiotics are given immediately and should include
coverage for gram negative and anaerobic organisms such as cefotaxime with
metronidazole.
2. Drainage; Percutaneous; The solitary or macro abscess may be drained
percutaneously under ultrasound or CT guidance. Open Drainage; It is indicated
with failure of percutaneous drainage or in patients with rupture of the abscess
into the peritoneal cavity.
3. A source for the liver abscess should be sought and treated.

Primary sclerosing cholangitis (PSC)

The disease results in progressive fibrous stricturing and obliteration of both the intrahepatic and
the extrahepatic bile ducts. This condition often presents in young adults. A genetic
predisposition is likely, due to its association with inflammatory bowel disease (especially
ulcerative colitis).
The majority of patients are diagnosed while asymptomatic, during the evaluation of an
abnormal liver function, particularly with elevated alkaline phosphatase.
In symptomatic patients, pruritus, abdominal pain, diarrhea, jaundice, fatigue, and fever are
common.
Cholangiography with endoscopic retrograde cholangiopancreatography (ERCP) and liver
biopsy has been considered the gold standard for diagnosing.
PSC is a major risk factor for the development of Cholangiocarcinoma (CCa).
Treatment: There is no specific treatment that can reverse the ductal changes.
Immunosuppressant such as corticosteroids, azathioprine, cyclosporine, and methotrexate may
offer symptomatic improvement.
The only useful treatment modality is liver transplantation, which is associated with excellent
results if carried out before bile duct cancer has developed.
Temporary relief of obstructive jaundice can be achieved by biliary stenting.

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 LIVER NEOPLASMS

Benign
Benign liver tumours are common and are usually asymptomatic. Although most need no
treatment, it is important to be able to differentiate them from malignant lesions.

• Haemangioma
Haemangioma is the most common benign liver tumor; occur predominately in women aged 20
to 50 years. The tumors may be related to the oral contraceptive pill and may regress when the
pill is stopped. They may also enlarge during pregnancy.
Most are asymptomatic found incidentally during examinations for unrelated reasons and have
no major clinical implications but they can present as a mass lesion or rarely with spontaneous
hemorrhage.
Ultrasound, Contrast CT is diagnostic. Magnetic resonance imaging (MRI) is more sensitive.
Biopsy can precipitate catastrophic bleeding and is strongly contraindicated.
Most haemangiomas require no treatment. Malignant transformation does not occur.

• Adenoma
Adenoma is benign tumors, they are frequently found in young women in association with oral
contraceptive pills.
Most adenomas are asymptomatic and discovered incidentally
The patient may present with a right upper quadrant mass. Abdominal pain; as result of
hemorrhage into the tumour or infarction.
Rupture is associated with the symptoms and signs of acute intra-peritoneal bleeding.
The main risks of adenoma are bleeding and malignant transformation.
Adenomas may be detected by ultrasonography or CT. LFTs and serum α-fetoprotein levels are
usually normal.
Treatment In the absence of complications, it is safe to observe the patient with 6-monthly
ultrasounds for 2 years. Or consists of proper hepatic resection

Malignant
• Primary Hepatoma /(Hepatocellular Carcinoma—Hcc )

Etiology; Risk factors include cirrhosis of any cause: including hepatitis B, hepatitis C, primary
biliary cirrhosis, Primary sclerosing cholangitis, autoimmune hepatitis, alcohol liver disease,
nonalcoholic steatohepatitis, Food contamination by aflatoxin and hereditary disorders such as
hemochromatosis.

Clinical Features; HCC is more common in males between 20 to 40 years of age. Presenting
symptoms are vague usually include weight loss, malaise, weakness, jaundice, ascites, and
variceal bleeding due to portal hypertension, encephalopathy and upper abdominal lump.
Examination may reveal features of established liver disease and hepatomegaly.
Investigations:
Serum α-fetoprotein (AFP) may be significantly raised but not specific.
Ultrasound, CT scan, MRI, Radioisotope Scan and celiac axis angiography.

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Treatment;
In the absence of cirrhosis, may be treated by hepatic lobectomy. In the presence of cirrhosis,
Hepatic transplantation is occasionally carried out if there is no extra hepatic spread.
Chemotherapy and radiotherapy may have palliative value, although response rates is poor.

• Secondaries in Liver

The liver is a common site for metastatic disease. Almost 90% of patients with hepatic
metastases have tumour deposits in other sites.
Sources;
• Systemic blood spread from carcinoma of the breast, lung, testis and melanoma, etc.
• Portal venous spread occurs from carcinoma of the bowel, spleen and pancreas.
• Lymphatic spread occurs from the breasts and lungs.
• Direct spread from carcinoma of stomach, gallbladder and right colic flexure.
Clinical Features
a. Hepatomegaly and tenderness are distinctive features
b. Jaundice—Due to liver destruction and intrahepatic duct compression.
c. Ascites
d. Inferior vena cava obstruction producing leg edema.
e. Portal vein obstruction producing esophageal varices and ascites
f. Hepatic failure.
Investigations
• Liver function tests: The alkaline phosphatase and γ-glutamyl transpeptidase are often raised.
•Ultrasound and CT may demonstrate multiple filling defects.
•needle biopsy; the diagnosis can be confirmed by aspiration cytology or needle biopsy
undertaken under ultrasound control.
• Upper and lower GI endoscopy and contrast X-ray for identification of the primary lesion.