as presented by Dr. Gilligan

1. Hígado

2. Anatomy
• Cantlie’s line: separates the lobes. Line
between GB fossa and IVC
• Ligamentum Teres: carries obliterated
umbilical vein
• Foramen of Winslow:
– Anterior: portal triad
– Posterior: IVC
– Inferior: duodenum
– Superior: Liver

6. Anatomy
• Replaced right hepatic artery arises from the
SMA, travels posterolateral to CBD in Porta
Hepatis. Important in Whipples
• Replaced left hepatic artery arises from the
left gastric artery, travels through the
gastrohepatic ligament into the falciform
ligament. Important in Nissens

7. Blood Supply
• Portal vein 75% blood flow, 50% of O2
• Portal vein formed by confluence of SMV and
splenic
• Hepatic artery 25% blood flow, 50% O2
• Left HV segments II, III, IVa; right HV segments
VI, VII, VIII; middle HV segments IV and V;
caudate drains into IVC

8. Pyogenic liver abscess
• MCC biliary instrumentation, can also be from
strictures, stones or Portal venous spread via GI
infections (diverticulitis, appendicitis, perf ulcer)
• MC in right lobe, can be multiple
• MC organism: E. Coli
• Present: fever, chills, RUQ pain
• Elevated wbc, elevated t bili, elevated alk phos
• Dx via CTCT-contrast enhancing, well defined
masses with low density, US-hypoechoic lesions
• Tx: perc drainage and broad spectrum abx

12. Amebic Abscess
• Amebic: tropical travel, complication of
intestinal amebiasis (E. Histolytica), spread to
liver via portal vein, usually solitary
• Fever, RUQ pain, hepatomegaly
• Imaging: often solitary right lobe, CT: low
density with peripheral rim of edema,
• Serology: indirect hemagglutination
• Treatment: Metronidazole aka Flagyl

14. Echinococcal Cyst
• Caused by tapeworm
• Mediterranean/Middle East
• sheep→dogs→humans
• Fever, abdominal pain, jaundice, weight loss
• Serology: indirect hemagglutination, also if
they mention positive Casoni test
(intradermal injection of sterilized fluid from
hydatid cyst that results in a wheal response)
• Imaging: unilocular or complex lesion with
daughter cysts

15. • Rupture or leak from PC aspiration 
anaphylactic shock
• Tx: Albendazole
• PAIR (Puncture, Aspiration, Injection, Re-
Aspiration) for unilocular
• Surgical excision or deroofing and evacuation
for complicated cysts (ruptured cyst, biliary
fistula, multiseptated)

18. Simple Liver Cyst
• Thin walled cyst with water dense content
• True cyst, no malignant potential
• If symptomatic can do laparoscopic
marsupialization
• Ovarian stroma – cystadenoma and needs
resection

20. Benign Liver Lesions
• Hemangioma
• FNH
• Adenoma

21. Hemangioma
• Most common benign solid tumor
• Congenital
• Asymptomatic
• Women of childbearing age
• Kasabach-Merritt syndrome (consumptive
coagulopathy, CHF, DIC) in infants

22. Hemangioma
• Imaging:
– US: Hyperechoic, well-demarcated, increased
vascular flow
– CT: rim enhancing with central filling on delayed
imaging on arterial phase
– MRI: isodense on T1, Hyperdense on T2,
peripheral enhancement to central enhancement
– TC99 RBC study: highly specific/sensitive
– hypervascular

23. Hemangioma
• Avoid biopsy  bleed
• Conservative treatment

25. Focal nodular hyperplasia (FNH)
• Second MC liver tumor
• Due to polyclonal proliferation within liver
• No risk of malignant transformation and low
rupture risk
• Imaging:
– US: non-specific
– CT: central stellate scar on portal venous phase
– MRI: T1 and T2, early hyperdensity with gadolinium
– Tc 99 sulfur colloid scan: Enhancement due to bile
proliferation (FNH has Kupffer cells)
• Conservative treatment

28. Adenoma
• Oral Contraceptives, Anabolic Steroids
• Rupture risk: >5cm
• Risk of malignant transformation 5%
• Imaging:
– MRI/CT scan: hypodense
– Sulfur Colloid scan: cold, no uptake, because no
Kupffer cells in adenomas

31. Adenoma
• Treatment:
• Asymptomatic + <4cm
– Stop OCPs, repeat imaging, if regression then you are done
– Resection if no regression
• Symptomatic or >4cm
– Resect for malignancy and rupture risk
• Ruptured  angioembolization

32. Budd-Chiari Syndrome
• Occlusion of hepatic veins
• Women with hypercoagulable disorders
• Acute onset of ascites
• abdominal pain, ascites, hepatosplenomegaly
• Caudate lobe hypertrophy
• Best diagnostic test: Ultrasound
• Treatment: anticoagulation; surgical
portosystemic shunt
– Remember any shunt that uses the IVC or portal
vein makes transplant much more difficult

34. HCC
• Most common primary hepatic tumor
• Chronic Liver disease - hep B and Hep C; Can also
be alpha-1 antitrypsin, NAFLD, glycogen storage,
aflatoxin rash
• Clinical deterioration, painful hepatomegaly,
weight loss, anorexia
• AFP >400 diagnostic
• Cirrhotics need periodic imaging (US) and AFP
• No biopsy
• Fibromellar variant younger patients w/o
cirrhosis – best prognosis

35. HCC
• Surgical resection – 1 cm margins, need at least
25% healthy liver remnant
• Transplant (best results) – Milan criteria – one
tumor <5cm, 3 or fewer each less than 3cm, no
PV or IVC involvement; best option for Childs B+C
• Tumor ablation– ethanol, RFA, small tumors or as
bridge to transplant
• Embolization: transarterial chemoembolization
(TACE) – palliative or bridge to transplant, also for
large unresectable tumors

37. Intrahepatic Cholangiocarcinoma
• Related to PSC, clonorchis (flukes), cirrhosis
• Elevated alk phos, bili, GGT; normal ast/alt
• Many present painless jaundice
• Surgical resection only potential for cure
• Start with diagnostic laparoscopy since large
percentage have peritoneal mets
• Palliative if mets

38. Hepatic Angiosarcoma
• PVC, arsenic exposure
• Often unresectable, poor prognosis

39. Liver mets
• Mets to Primary ratio 20:1
• Intraop US = most sensitive for identifying mets in liver
• MCC colorectal mets
• Need to achieve r0 resection
• When combined chemotherapy 5yr survival 30-50%
• RFA in unresectable
• Contraindications for hepatic resection: celiac or
periarotic LN, carcinomatosis, unresectable
extrahepatic disease
• Monitor CEA levels

40. Acute Liver Failure
• Most common with hepatitis, liver toxins, drug toxicity
• Rapid hepatocellular decline, jaundice, coagulopathy,
encephalopathy
• High likelihood of infections
• Cerebral edema  uncal herniation
• Kings College Criteria for transplant: PT >100 seconds
or 3 of following: <10 or >40, non-A/non-B hepatitis,
jaundice >7days prior to encephalopathy, PT >50, bili
>17
• Supportive tx: prophy GI bleed, correct hypoglycemia,
ICP monitoring with interventions, urgent transplant

41. Chronic Liver Failure
• Hep B, Hep C, EtOH, NAFLD
• MELD score (t bili, INR, cr)
• Childs (Ascites, Bili, INR, albumin, encephalopathy)
• Variceal bleed- egd and banding, octreotide, B Blockers
(prophylactic)
• Lasix, spironolactone, pericentesis manage ascites
• TIPS –makes encephalopathy worse
• Abx to prevent SBP
• Lactulose, rifaximin if encephalopathy
• Hepatorenal syndrome – albumin, octreotide,
midodrine

42. Hepatic Encephalopathy
• Development of asterixis = sign of progression
• Tx: Lactulose acidifies colon, preventing
uptake of ammonia – titrate 2-3 stools/day
–Neomycin: gets rid of ammonia producing
bacteria
–Limit protein intake (<70g/day)
–Feed with branch chain Amino Acids (VIL-
valine, isoleucine, leucine)
• Metabolized by skeletal muscle

43. Hep B
• Serology Test for: HBsAg, HBeAg, Anti-HBs,
Anti-HBc
• 1st Ab to appear is IgM (anti-HBc)
• HBcAg is never found in serum
• HBeAG is a marker for active viral replication
• HBsAB is a marker for immunity or recovered
past infections

44. Portal HTN
• Hepatic venous pressure gradient >12
• Varices – esophagus, hemorrhoids,
periumbilical, veins of Retzius
• If esophageal bleed- abx, vasopressin,
octreotide, egd with banding; propranolol,
TIPS