UG Class

1. LIVER

2. ANATOMY
 Glissons capsule
 Ligaments & peritoneal reflections
 Lobe Vs Segment

5. Arterial Supply

6. Segmental anatomy
 Couinard
 Sector
 Segment
 Goldsmith & Woodburne
 Segment
 Subsegment

12. Hepatic Lobules

13. Physiology
 Bile metabolism
 Protein synthesis and catabolism
 Glucose metabolism
 Removal of gut endotoxins
 Drug & hormone metabolism

14. Assesment
 Hematological (LFT)
 Imaging
– X-Ray
– USG
– CT
– MRI
– Nuclear medicine
– FDG – PET
– Laparoscope

15. Child`s classification
1 2 3
Bilirubin mgs% < 2 2 – 3 > 3
Albumin gm% > 3.5 3 - 3.5 < 3
Ascitis None Controlled Uncontrolled
Neurologic # None Minimal Advanced
Nutrition Excellent Good Wasted
A ≤ 6 B 7-9 C ≥ 10

16. PORTAL HYPERTENSION
 Anatomy

18. ↑ resistance to portal flow
↓
splanchnic hyperemia
↓
portosystemic shunting
↓
systemic changes
Pathophysiology

19. Etiology
 ↑ Resistance
– Pre-hepatic
– Hepatic
• Pre sinusoidal
• Sinusoidal
• Post sinusoidal
– Post-hepatic
 ↑ Flow

20. Patient evaluation

21. Patient evaluation
 Ascitis
 Caput medussae
 Splenomegaly
 Testicular atrophy
 Palmar erythema
 Asterixs
 Leuconychia
 Coma
 Alopecia
 Arcus
 Icterus
 Xanthelesma
 Parotid swelling
 Fetor hepaticus
 Gynaecomastia
 Spider naevi

22. Investigations
 ↓ Hb
 ↑ BT & CT
 LFT
Identify cause
 α1anti trypsin
 Ceruloplasmin
 Hepatitis B, C
 Biopsy

23. Hepatic hemodynamic assesment
 Hepatic vein wedge pressure
 Selective visceral angiography
– V. phase of SMA angio
• I - Normal perfusion
• II - Intra hepatic portal vein radicals
• III - Opacification of portal vein
• IV - Non visualisation of portal vein
 Duplex USG

25. Bleeding varices
 Resuscitation & Diagnosis
– ABC
– CVP measurement
– Pul A. catheter
– PT > 3sec → FFP
– Plt < 50000 → Platelet transfusion
– OGD

26.  Vasopressin/Terlipressin
– Splanchnic vasoconstriction
– Systemic vasoconstriction
 Somatostatin
 Octreotide
 Inderal/Nadolol (β antagonist)
Pharmacotherapy

27. Endoscopic therapy
 Mechanical
– Bands
– Clips
 Injection
– Sclero
– Adrenalin
– Gelfoam
– Glue
 Thermal
– Basic
– Cryo
– LASER
– BICAP

28. Endoscopic therapy
 Banding
 Sclerotherapy
– Agents
– Circular staircase / Capetowm technique
– Intravariceal / Paravariceal / Combined
– 3 - 5 ml; 3 sites @ 1 sitting
– Complications
• Ulcer / fever / retrosternal pain
• Perforation / aspiration / ↑ bleeding

31. Balloon tamponade
 Sengstaken – Blakemore / Minnesota
 Immediate but temporary
 Complications
– Rebleed
– Ischaemic necrosis
– Perforation
– Aspiration

32. Balloon tamponade

33. TIPSS
 Non selective shunt
 Only when pharmaco & endo fails
 Bridge for transplant
 Contraindications
 Complications

35. Emergency surgery
 Failure of conservative
 Bleed from gastric varices / PHG
 Devascularisation / Shunt

36. Suguiura

38. Warren

40. HEPATIC INFECTIONS
 Ascending cholangitis
– Biliary obstruction
– Charcot`s triad
– DHBR
– Medical emergency
– Biliay drainage

41. Pyogenic Liver Abscess
 Etiology
– Biliary
– Portal vein
– Hepatic artery
– Traumatic
– Direct

42. Clinical features
 Fever
 Chills
 Wt loss
 RH pain
 Anorexia
 N & V
 Diarrhoea
 Malaise
 Hepatomegaly
 RH tenderness
 Jaundice
 Ascitis

46.  Treatment
– Abscess
– Precipitating factors
 Antibiotics
– Broad spectrum until c/s
– Penicillin + Amino + Metro
– Antifungal only after confirmation
– 4 – 6 weeks

47.  Aspiration
– Percutaneous needle
– Diagnostic & bacteriologic info
– Solitary abscess
 Percutaneous drainage
– Solitary uniseptate abscess
– 3 weeks catheter in situ
– Contraindications
– Complications

49.  Surgical drainage
– Loculated / multiple
– Inaccessible
– Entire hepatic lobe
– Co-existing biliary pathology
– Extraperitoneal / intraperitoneal

50. Complications
 Generalised sepsis
 Intraperitoneal rupture
 Controlled leak
 Hemobilia
 Pulmonary complications

51. Amoebic Liver Abscess
 Entamoeba histolytica
 Mature cyst is invasive
 Invasion of
– portal vein
– mesenteric lymphatic channels
– intra peritoneal spread

52. Cyst, trophozoite
in faeces Excystation in SI
Metacystic trophozoite
Mature trophozoite
in caecum
Ulceration
Amoeboma
Dissemination
Precyst in
Colon
Mature cyst

53.  Clinical features
 Lab investigation
– stool – cyst / trophozoite
 Imaging
 Serology
 Treatment
– Antibiotics
• Diloxanite 500mg oral x 10 days
• Paramomycin 25-30mg/kg/day oral x 10 days
 Complications

54. Hydatid Liver Cyst
 Echinococcus granulosus
 Pathology
– expand slowly, asymptomatic
– multilocular
– pericyst
• host reaction
• mechanical support
• metabolic interface
• calcification
– laminated membrane
– germinal epithelium
– hydatid sand & fluid

55. Clinical features
 Asymptomatic
 Pain
 Dyspepsia
 Fever & chills
 Jaundice
 Ascitis
 Mass

56. Diagnosis
 Imaging
– CT / USG
– calcification
– daughter cyst
– hydatid sand
 Serology
– Serum immuno electrophoresis
– ELISA
– Casoni

57. Treatment
 Medical
– germicidal: albendazole 10-15mg/kg/day
– scolicidal: praziquantel 40mg/kg/day
– both for 3 months
– reasses
– surgery / continue for 9 months
– post op for 2 weeks

58. PAIR
 Indications
– refusal
– comorbid
– ≥ 5 cm dia
– multiple segments
– relapse
– chemo failure
 Contraindications
– inaccessible
– multiple septations
– dead cysts
– communicating cysts

59. PAIR
 Scolicidal agents
– 20% NaCl
– 0.5% AgNO3
– absolute alcohol
– 95% ethanol
– mebendazole
 Complications
– urticaria
– anaphylaxis
– fever
– infection
– hematoma
– hypotension
– biliary fistula

60. HEPATIC TRAUMA
 Liver being the largest organ can easily be injured
in the abdominal trauma.
 Penetrating injuries > blunt injuries.
 Non operative management
 Most blunt lacerations occur along the segmental
fissures because vascular and biliary ductal
structures are moderately resistant.

61. Grade Injury type Injury description
I Hematoma
Laceration
Sub capsular <10% of the surface area
Capsular tear, <1cm of parenchymal depth
II Hematoma
Laceration
Subcapsular 10-15% of the surface area , intraparenchymal,
<5cm in dia.
Capsular tear, 1-3cm of parenchymal depth <10cm in length
III Hematoma
Laceration
Subcapsular >50% of the surface area, or expanding ruptured
subcapsular or parenchymal hematoma, intraparenchymal
hematoma >10cm or expanding.
>3cm of parenchymal depth
IV Laceration Parenchymal distruption involving 25-75% of hepatic lobe or
1-3 couinads segment within single lobe.
V Laceration
Vascular
Vascular
Parenchymal distruption involving >75% of the hepatic lobe
or >3 couinads segment within a single lobe.
Extrahepatic venous injuries is retrohepatic vena cava /
central major hepatic veins
Hepatic avulsion

62. Management
 Grade I - No specific treatment
 Grade II- Packing and manual
compression. If bleeding
recurs it can be
- Cauterized
- Local hemostatic packs
- Absorbable sutures
 Grade III – V - Operative

63. HEPATIC NEOPLASMS
 Benign
 Malignant
– Parenchymal
• Primary
• Secondary
– Cholangiocarcinoma

64. Etiology
 Congenital
 Infections
 Inflammation
 Toxins

65. Clinical features
 Constitutional symptoms
 Liver cell failure
 Jaundice
 Portal hypertention
 Paraneoplastic

66.  Diagnosis
 Treatment
– Curative
• Resection
• Hepatectomy + OLT
– Palliative
• Local
• Regional
• Systemic
• Supportive
Management