In this presentation, I discussed the various liver swellings- both cystic and solid swellings. Cystic lumps are Pyogenic liver abscess, Amebic liver abscess and hydatid cyst. Benign solid swellings are Hepatic adenoma, Focal nodular hyperplasia and Hemangioma. The malignant solid swelings are secondary carcinoma of the liver, primary Hepatocellular carcinoma and Hepatoblastoma.

1. LIVER LUMPS
RUQ LUMPS/Abdominal Lumps
AN OVRVIEW
Dr.B.Selvaraj MS;Mch;FICS;
“Surgical Educator”
Malaysia

2. RT UPPER QUADRANT LUMPS
CAUSES
TENDER NON-TENDER
 Pyogenic liver abscess
 Liver in hepatitis
 Liver in Congestive heart
failure
 Subphrenic abscess
 Gall bladder in Acute
Cholecystitis
 Empyema Gall bladder
 Perinephric abscess
 Abdominal wall hematoma
 Hepatocellular carcinoma-
Primary
 Secondary metastatic carcinoma
liver
 Hepatic adenoma
 Focal nodular hyperplasia
 Hepatic hemangioma
 Courvoisier’s gall bladder
 Rt renal tumor
 Rt adrenal tumor

3. RT UPPER QUADRANT LUMPS
ANATOMY

4. RT UPPER QUADRANT LUMPS
ANATOMY

5. PYOGENIC ABSCESS
 Potential routes of hepatic exposure to
bacteria as follows:
 Biliary tree (most common route)
 Portal vein (pyelophlebitis due to
diverticulitis, appendicitis, PID, IBD,
perforation, etc.)
 Hepatic artery (systemic bacteremia-
associated with multiple microabscess)
 Direct extension & Trauma
ETIOLOGY
 Pyogenic abscesses with no identifiable primary
infection are called cryptogenic hepatic
abscesses
 Organisms cultured include gram-negative
aerobes E coli, Klebsiella and Proteus species
 Aerobic Streptococcus and Staphylococcus are
also seen
 Increased use of indwelling biliary stents and
broad-spectrum antibiotics has led to an
increased prevalence of Pseudomonas and
fungi.

6. PYOGENIC ABSCESS
 Most common in right lobe
 Most common organisms isolated –E. coli,
Klebseilla and Proteus
 Most common presenting symptoms—
fever, chills, abdominal pain and jaundice
 A rare complication of Klebseilla abscess
is endogenous endophthalmitis (3%),
common in diabetics
Clinical
Features

7. PYOGENIC ABSCESS
 X-ray chest shows elevated right
hemidiaphragm, pleural effusion
and atelectasis.
 USG abdomen unilocular or
multilocular cyst
INVESTIGATION
S
 CT abdomen- Rim enhancement in
CECT

8. PYOGENIC ABSCESS
 Percutaneous catheter drainage along with broad
spectrum antibiotics
 Surgery is reserved for those who fail
percutaneous technique and for those whom
surgery is required for some other pathology or
rupture of abscess
 A falling serum albumin level and presence of
jaundice are bad prognostic signs.
TREATMENT

9. AMEBIC ABSCESS
 The causative organism is Entamoeba histolytica
 It is almost and always secondary to amebic
ulcers on the colonic wall.
 The organisms ultimately reach the liver via the
inferior mesenteric vein and then portal vein.
 Due to liquefaction necrosis of liver, the abscess
results is anchovy sauce colored and odorless
ETIOLOGY

10. AMEBIC ABSCESS
 Residence or travel to endemic areas
 H/O Amebic dysentery
 RUQ pain
 Fever- moderate
 Tender hepatomegaly
Clinical Features

11. AMEBIC ABSCESS
COMPLICATIO
NS

12. AMEBIC ABSCESS
INVESTIGATION
S
 Diagnosis is by isolation of the parasite from
the liver lesion or the stool and confirming its
nature by microscopy.
 Enzyme immuno assays (EIA) have
sensitivity 99%and specificity > 90% in
patients with amebic abscess
 USG- Hypoechoic and non homogenous
rounded lesion abutting liver capsule without
significant rim echoes
 CT scan: More sensitive in differentiating
pyogenic from amebic because there will be
rim enhancement in pyogenic abscess on
contrast study.
 Nuclear scan (Gallium ): Helps in
differentiating because amebic abscess does
not contain leukocytes and hence does not
light up on these scans

13. AMEBIC ABSCESS
TREATMENT
 Oral metronidazole—750 mg three times/10
days is the drug of choice.
 Emetine im injections is very effective for
invasive amoebiasis
 Therapeutic aspiration is usually avoided.
Metrogyl is the treatment of choice and about
90% cases respond well.
 Indications for aspiration:
 Abscess wall diameter larger than 5 cm
(abscess with high risk of rupture)
 Abscess in the left lobe of liver
for diagnostic uncertainty
 Failure to respond in 3-5 days

14. PYOGENIC ABSCESS Vs
AMEBIC ABSCESS

15. HYDATID CYST
ETIOLOGY
 Echinococcus granulosus is M/C. others E.
multilocularis, E. oligartus.
 Dogs are definitive hosts in which adult
worms develop
 Sheeps are intermediate hosts that consume
the ova passed by the feces of dog over
grasses
 Humans are accidental hosts consuming
these eggs that converts to embryo in
duodenum and releases an oncosphere
containing hooklets
 The oncosphere reaches the liver or lungs,
where the parasite develops into larval
stage called as hydatid cyst
 Remember humans are end-stage host.

16. HYDATID CYST
PATHOGENESI
S
 3 weeks after ingestion, a pericyst derived from host
tissue wall develops surrounding the hydatid cyst.
 The cyst itself has two walls: ectocyst (outer
gelatinous) and endocyst (inner germinal) layers.
 In definitive host, they develop into adult tapeworm,
but in intermediate host they develop only into new
hydatid cyst
 Daughter cysts are true replicae of the mother cyst

17. HYDATID CYST
Clinical
Features
 Most common in right lobe of liver
 Most frequent sign—hepatomegaly
 Most common symptoms—abdominal pain, dyspepsia
and vomiting.
 Complications: Rupture into biliary tree, bronchial
tree, pleural, peritoneal and pericardial cavity

18. HYDATID CYST
INVESTIGATIO
NS
 USG: Rosette like appearance or water lilley
appearance is seen when daughter cysts are
present. Calcifications in the wall are highly
diagnostic
 Serological tests: ELISA, arc 5 test, IHA test,
immunoblast test, where available is the test of
choice
 Casoni test: Intradermal injection of sterile hydatid
fluid produces a wheal of 5 cm in half hour

19. HYDATID CYST
INVESTIGATIO
NS
CECT
CYSTS INSIDE
A CYST

20. HYDATID CYST
TREATMENT
 Primarily surgical, but introduction of PAIR
has totally replaced it.
 During surgery, packing off the abdomen from
the cyst is very important because of the
anaphylactic reaction that may occur if cyst
ruptures into peritoneal cavity
 Remember surgery is now preferred, where
PAIR is not possible or when it does not
respond to PAIR or when there is any
communication to biliary tree
 Surgical procedures:
 Pericystectomy & Marsupialization
 Omentoplasty
 Total cystectomy
 Partial hepatectomy
 Percutaneous aspiration, infusion of scolicidal
agents and reaspiraion (PAIR).
 Given with prophylactic cover of albendazole.
 Scolicidal agents—20% hypertonic saline, 0.5%
silver nitrate, 95% ethanol, absolute alcohol,
mebendazole 2.4 microgram/ml
 Contraindications for PAIR:
 Superficially located cyst (chance of rupture)
 Honey combing of cysts (multiple thick
internal septae)
 Communication with biliary tree
 Dead or inactive cysts

21. CYSTIC SWELLINGS OF LIVER
RECAP

22. LIVER TUMORS-
BENIGN
 Hepatocellular adenoma
 Focal Nodular Hyperplasia
 Hepatic Hemangioma

23. LIVER TUMORS-
BENIGN

24. HEPATIC ADENOMA
CECT
Three-phase CT scan of a hepatic adenoma.
Left: arterial phase; center: portal phase;
right: venous phase.

25. FOCAL NODULAR
HYPERPLASIA
CECT

26. FOCAL NODULAR
HYPERPLASIA
Sulphur Colloid Scan

27. LIVER HEMANGIOMA
CECT

28. LIVER TUMORS-
BENIGN
RECAP

29. HEPATOCELLULAR CARCINOMA
Risk Factors
 Infections: Hepatitis B virus, hepatitis C virus
 Cirrhosis: Alcohol induced, autoimmune hepatitis, primary
biliary cirrhosis
 Environmental: Aflatoxins, pyrrolizidine alkaloids Thorotrast
N-nitrosylated compounds
 Metabolic diseases: Hemochromatosis, alpha1-antitrypsin
deficiency,Wilson disease, porphyria cutanea tarda, Type 1 and
3 glycogen storage disease, galactosemia,
citrullinemia,hereditary tyrosinemia, familial cholestatic
cirrhosis

30. HEPATOCELLULAR CARCINOMA
Clinical Features
 Most common in males; 50-60 year
 Presentation:
1. Right upper quadrant pain
2. Weight loss
3. Palpable mass
4. In known cirrhotics—sudden decompensation of liver
think of HCC.
5. Rupture
6. Less than 1% cases present with paraneoplastic syndrome
most commonly hypercalcemia, hypoglycemia,
Erythrocytosis
7.Hepatocellular carcinoma has the tendency to invade the
portal vein

31. HEPATOCELLULAR CARCINOMA
INVESTIGATIONS
 USG—plays significant role in screening and
early detection of HCC
 CT and MRI—are definitely needed for
planning surgeries
 Serum AFP—used in diagnosing HCC
-Value > 400 mg/dl is highly suggestive
-AFP is mainly used to monitor
recurrences in treated patients
-AFP levels are elevated in about 70%–
80% cases
 Biopsy is contraindicated in suspected
cases Biopsy is done only in inoperable
cases which are tried for non-operative
therapies
 Percutaneous biopsy carries the risk of
tumor spillage, rupture and bleeding

32. HEPATOCELLULAR CARCINOMA
TREATMENT
 Complete excision of HCC by partial
hepatectomy or by total hepatectomy
with liver transplantation
 Percutaneous ethanol & acetic acid
injection
 Thermal ablative techniques
Cryotherapy, Radiofrequency ablation
(RFA), microwave
 RFA and cryotherapy can be done
percutaneously.
 Main disadvantage is heat sink effect,
limiting the use near major blood vessels
 Based on the fact that most of the tumor
blood supply is from the hepatic artery
 HAI (hepatic arterial infusion)
chemotherapy using 5 flouorouracil,
cisplatin, doxorubicin; Sorafenib
 Chemoembolization: Embolization particles
and lipoidal oils added with chemotherapy
agents selectively taken up by HCC

33. OTHER LIVER
MALIGNANCIES

34. LIVER METASTASIS
Colorectal liver metastases on computed tomography (CT) scan: (a) after
oral contrast CT; (b) after intravenous contrast. The colorectal liver
metastasis occupying the entire right lobe of the liver is difficult to visualise
on oral contrast CT. The addition of intravenous contrast shows its lack of
enhancement and its relationship to the hepatic veins.

35. LIVER MALIGNANCIES

36. Peripheral Arterial Diseases(PAD)