1. LIVER DISEASE Dr.Mohmmadzadeh

2. Anatomy Largest solid organ of body Weight : 1.5 kg From the nipple line in 4th intercostal down to the costal margin Falciform ligament & ligamentum teres hepaticus

3. Portal vein A valveless vein Confluence of the smv & splenic vein 75% of total liver blood Normal pressure 3-5 mmHg

4. Hepatic veins Three hepatic veins Right H.V drains segments V,VI,VII,VIII Middle H.V drains segments IVA,IVB,V,VIII Left H.V drains segments II,III

5. Hepatic artery From celiac trunk & give off gastroduodenal & right gastric artery Cystic artery from right hepatic artery

6. Biliary system Canaliculi canal of Hering small duct R & L hepatic ducts common hepatic duct common bile duct Normal CBD is less than 10 mm

7. Synthetic functions Coagulation factors Albumin a variety of acute-phase proteins & cytokines

8. Carbohydrate metabolism Critical storage site of glycogen Metabolization of lactate % Cori cycle

9. Lipid metabolism Synthesis of lipoproteins, triglycerides, Gluconeogenesis from fatty acics Cholestrol metabolism

10. Bilirubin metabolism A product of heme metabolism Glucuronidated in liver & actively secreted in bile One liver sector is adequate for bilirubin secretion Electrolyte composition of bile is similar to plasma

11. Radiologic evaluation of liver Ultrasound : cirrhosis or fatty liver cystic or solid nature of tumors for screening in high-risk population of HCC IOUS CT-scan : smallest detectable lesion 1 cm cystic or solid nature MRI : more sensitive for early HCC

12. PET scan : hepatic metastsis of colorectal cancer less useful for HCC Angiogeraphy Percutaneous biopsy Diagnostic laparascopy

13. Cystic diseases of the liver Congenital cysts Polycystic liver disease

14. Congenital cyst Most common benign lesion Dose not contain bile Recurrence of simple aspiration is high PAIR Wide cyst fenestration

15. Polycystic liver disease An autosomal dominant presenting in adulthood Three general anatomic presentation PAIR Fenestration Resection of cyst Formal lobectomy Transverse hepatectomy

16. Benign solid liver tumors Hepatic adenoma Focal nodular hyperplasia Hemangioma Hamartoma

17. Hepatic adenoma In reproductive –aged women In women who used OCPs Pathology : sheets of hepatocytes ith no nonparanchymal cells or bile ducts 75% symptomatic They can rupture Radiographycally difficult to distinguish from FNH Management : cessation of OCPs - surgery-RFA

18. FNH Asymptomatic,does not rupture,no malignant Two third of lesions have central scar Resection in symptomatic lesions

19. Hemangioma A common benign lesion discovered incidentally Chronic low-intestity RUQ pain US, CT-scan, MRI Atypical hemangioma : Tc 99 -labeled red cell Resection in symptomatic lesions

20. Hamartoma Most common liver lesion in laparotomy Peripheral,firm & smooth Usually less than 1-3 mm

21. Pyogenic liver abscesses In past : appendicitis & pylephlebitis Currently : biliary tract manipulation, diverticular disease,IBD,systemic infections, ERCP, cryptogenic (one third ) RUQ pain, fever, jaundice US,CT Percutaneous aspiration Laparoscopy

22. Amebic abscess A recent history of diarrhea is uncommon Sweating & chills for one week,RUQ pain & tenderness Positive fluorescent antibody test Mild liver enzymes abnormality Metronidazole at least for one week Aspiration

23. Computed tomographic scan finding for an adenoma.

24. Classic appearance of hemangioma on magnetic resonance imaging.

25. Appearance of a giant adenoma on computed tomography.

26. Computed tomographic appearance of fibronodular hyperplasia lesion.

27. Magnetic resonance imaging appearance of a fibronodular hyperplasia lesion in the right liver, seen on T1-weighted (A) and T2- weighted (B) images.

28. Hepatocellular carcinoma Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and one of the most common malignancies worldwide, accounting for more than 1 million death annually The geographic distribution of HCC is clearly related to the incidence of hepatitis B virus (HBV) infection.

29. HCC is two to eight times more common in males than in females in low and high incidence areas In general, the incidence of HCC increases with age, but a tendency to develop HCC earlier in high incidence areas has been noted.

30. Ethiology Hepatic viral infections Environmental exposure Alcohol use,smoking Genetic & metabolic diseases Cirrhosis OCPs

31. Clinical Presentation Most commonly, patients presenting with HCC are men 50 to 60 years of age who complain of right upper quadrant abdominal pain and weight loss and have a palpable mass. Nonspecific symptoms of advanced malignancy such as anorexia, nausea, lethargy, and weight loss are common.. Another common presentation of HCC is hepatic decompensation in a patient with known mild cirrhosis or even in patients without previously recognized cirrhosis

32. Diagnosis Radiologic investigation is a critical part of the diagnosis of HCC ultrasound, CT, and MRI Ultrasound plays a significant role in screening and early detection of HCC definitive diagnosis and treatment planning rely on CT and MRI.

33. AFP measurements AFP measurements can be very helpful in the diagnosis of HCC. An AFP level greater than 20ng/mL is noted in about three fourths of documented cases of HCC. False-positive elevations of serum AFP can be seen in inflammatory disorders of the liver, such as chronic active viral hepatitis

34. Treatment Options for Hepatocellular Carcinoma Surgical Resection Orthotopic liver transplantation Ablative EtOH injection Acetic acid injection Thermal ablation (cryotherapy, radiofrequency ablation, microwave)