LIVER DISEASES Shanghai Jiaotong University Medical School Renji Hospital Luo meng

ANATOMYANATOMY Four channels within liver: Four channels within liver: Inflow: HA PV Inflow: HA PV Outflow: HV Biliary duct Outflow: HV Biliary duct Lobes & segments of the Liver Lobes & segments of the Liver (Couinaud’s system of segments) (Couinaud’s system of segments) Four channels within liver: Four channels within liver: Inflow: HA PV Inflow: HA PV Outflow: HV Biliary duct Outflow: HV Biliary duct Lobes & segments of the Liver Lobes & segments of the Liver (Couinaud’s system of segments) (Couinaud’s system of segments)

Three major hepatic veins drain the liver

Intrahepatic divisions of the portal vein

Liver Functions: Liver Functions: Formation of bile Formation of bile Regulation of material metabolism Regulation of material metabolism energy, carbohydrate, fat, proteins, energy, carbohydrate, fat, proteins, vitamins, hormones, and formation of vitamins, hormones, and formation of coagulant factors etc. coagulant factors etc. Mechanism of defense and detoxification Mechanism of defense and detoxification Capacity of regeneration after massive Capacity of regeneration after massive resection. resection. Liver Functions: Liver Functions: Formation of bile Formation of bile Regulation of material metabolism Regulation of material metabolism energy, carbohydrate, fat, proteins, energy, carbohydrate, fat, proteins, vitamins, hormones, and formation of vitamins, hormones, and formation of coagulant factors etc. coagulant factors etc. Mechanism of defense and detoxification Mechanism of defense and detoxification Capacity of regeneration after massive Capacity of regeneration after massive resection. resection.

LIVER ABSCESS Many kinds of LA: Pyogenic Amebic Virus & Fungi PATHOGENESIS The micro-organisms through follows to hepatic parenchyma portal venous stream ascension from biliary tract hepatic artery direct penetrating trauma Amount and ability of invasion of micro- organisms vs defense mechanism of the body. LIVER ABSCESS Many kinds of LA: Pyogenic Amebic Virus & Fungi PATHOGENESIS The micro-organisms through follows to hepatic parenchyma portal venous stream ascension from biliary tract hepatic artery direct penetrating trauma Amount and ability of invasion of micro- organisms vs defense mechanism of the body.

Etiology of pyogenic abscess

DIAGNOSIS DIAGNOSIS Clinical manifestations: Fever pain at R.U.Q. enlargement of liver Others: nausea jaundice Antecedent diarrhea in amebic liver abscess LABS: WBC↑ RBC↓ Albumin↓ blood culture for bacteria positive in 40% EXAMS: X’ray film: Elevated diaphragm and pleural effusion BUS and CT: guiding to aspiration of abscess DIAGNOSIS DIAGNOSIS Clinical manifestations: Fever pain at R.U.Q. enlargement of liver Others: nausea jaundice Antecedent diarrhea in amebic liver abscess LABS: WBC↑ RBC↓ Albumin↓ blood culture for bacteria positive in 40% EXAMS: X’ray film: Elevated diaphragm and pleural effusion BUS and CT: guiding to aspiration of abscess

CT scan of a pyogenic hepatic abscess

COMPLICATIONS Generalized sepsis, emphysema Ruptured abscess into pleural cavity, peri - cardiaum and intra-abdominal cavity TREATMENT Medical therapy: General support therapy Antibiotics, metronidazole Drainage-lavage by catheter Surgical therapy: drainage resection or of liver COMPLICATIONS Generalized sepsis, emphysema Ruptured abscess into pleural cavity, peri - cardiaum and intra-abdominal cavity TREATMENT Medical therapy: General support therapy Antibiotics, metronidazole Drainage-lavage by catheter Surgical therapy: drainage resection or of liver

PRIMARY LIVER CARCINOMA Hepatocellular carcinoma (HCC) occupied the third place of malignancy in China. Recent two decades, the higher recurrence rate has remained as a rather difficult problem in spite of the improvement in the diagnosis and treatment. PRIMARY LIVER CARCINOMA Hepatocellular carcinoma (HCC) occupied the third place of malignancy in China. Recent two decades, the higher recurrence rate has remained as a rather difficult problem in spite of the improvement in the diagnosis and treatment.

ETIOLOGY Risk factors: virus infection hepatitis type B.C.and D. various liver cirrhosis Some chemical carcinogenic material e.g. Aflatoxin PATHOLOGY macroscopic classification: massive, nodular or diffuse solitary or multiple growth pattern: infiltrative, expanded, mixed infiltrative and expanded,diffuse, small (less than 2cm in diameter) metastasis: through peri hepatic lymphatics or direct invasion particular ca thrombus in portal v. or ruptured ca into abdominal cavity ETIOLOGY Risk factors: virus infection hepatitis type B.C.and D. various liver cirrhosis Some chemical carcinogenic material e.g. Aflatoxin PATHOLOGY macroscopic classification: massive, nodular or diffuse solitary or multiple growth pattern: infiltrative, expanded, mixed infiltrative and expanded,diffuse, small (less than 2cm in diameter) metastasis: through peri hepatic lymphatics or direct invasion particular ca thrombus in portal v. or ruptured ca into abdominal cavity

Ca With Complete Capsule

CLINICAL MANIFESTATION No distinctive symptoms until late stageNo distinctive symptoms until late stage Anorexia, fullness or pain in RUQ, and weight loss are commonAnorexia, fullness or pain in RUQ, and weight loss are common In addition, clinical presentation of liver cirrhosisIn addition, clinical presentation of liver cirrhosis LAB STUDY AFP>400ng/ml in 70% of patients with HCCAFP>400ng/ml in 70% of patients with HCC Pseudo-positive (AFPV)Pseudo-positive (AFPV)

IMAGING EXAMS BUSBUS CT and MRICT and MRI Hepatic angiographyHepatic angiography Hypo-echo area IVC

CT

Hepatic angiography

An Occupied Lesion on Angiogram Hepatic angiography

HOW TO DETECT SUBCLINICAL CASES It is important that the high-risk people who are with chronic hepatitis or liver cirrhosis should be closely followed up by AFP test and BUS. It is most possible that newly identified tumors in the liver are HCC or precancerous lesion. HOW TO DETECT SUBCLINICAL CASES It is important that the high-risk people who are with chronic hepatitis or liver cirrhosis should be closely followed up by AFP test and BUS. It is most possible that newly identified tumors in the liver are HCC or precancerous lesion.

DIFFERENTIAL DIAGNOSIS Metastatic liver carcinoma Liver cirrhosis Focal nodular hyperplasia of liver Cavernous hematoangioma of liver DIFFERENTIAL DIAGNOSIS Metastatic liver carcinoma Liver cirrhosis Focal nodular hyperplasia of liver Cavernous hematoangioma of liver

TREATMENT ○ SURGICAL RESECTION Indications: Solitary, not too big multiple but collect an area Patient’s condition Evaluation of liver function (Child A or B) TREATMENT ○ SURGICAL RESECTION Indications: Solitary, not too big multiple but collect an area Patient’s condition Evaluation of liver function (Child A or B)

TREATMENT ○ SURGICAL RESECTION Surgical procedure Hemihepatectomy, lobectomy, eg mentectomy – In liver cirrhosis, limited resection with 1.5cm margin from tumor Liver transplantation –Only indicated for small HCC without outside liver spread Complication: bleeding, liver failure, sepsis TREATMENT ○ SURGICAL RESECTION Surgical procedure Hemihepatectomy, lobectomy, eg mentectomy – In liver cirrhosis, limited resection with 1.5cm margin from tumor Liver transplantation –Only indicated for small HCC without outside liver spread Complication: bleeding, liver failure, sepsis

○ Non-surgical treatment TACE under highly selective hepatic arteriocatheterization, lipoidol, cytotoxic agents and embolized material to be injected. Mainly indicated for big HCC. To make the tumor smaller in 15% patients with big HCC, the resection of tumor may be possible. INJECTION OF ETHONAL for small tumor in 2cm diameter or less OTHERS ○ Non-surgical treatment TACE under highly selective hepatic arteriocatheterization, lipoidol, cytotoxic agents and embolized material to be injected. Mainly indicated for big HCC. To make the tumor smaller in 15% patients with big HCC, the resection of tumor may be possible. INJECTION OF ETHONAL for small tumor in 2cm diameter or less OTHERS

Angiography---Chemo- embolization The Lesion Getting Smaller 2 Months Later

Ca Showed by Hypo-echo After Chemo-embolization

Chemo-embolization

Multiple Liver Cysts (Congenital)

李 × 男性 62 岁, 17 月前因肝癌行肝癌 根治术, 术后随访中发现 α -FP 呈进行 性上升, B 超及 CT 均未发现明显病变, 动脉造影证实肝内肝癌复发

Occupied Lesion on Angiogram

Recurrent liver cancer