7.02 - HPB Liver

Question 1

What are simple liver cysts?

Answer 1

Fluid filled epithelial lined sacs within the liver, most commonly occurring in the right lobe.

They are thought to be due to a congenitally malformed bile duct, failing to connect to the extrahepatic ducts, leading to local dilatation filled with bile-like fluid.

Question 2

What are the clinical features of simple liver cysts?

Answer 2

Usually asymptomatic and detected incidentally on imaging.

Around 10% of patients are symptomatic:
- abdominal pain
- nausea
- early satiety

Question 3

How are liver cysts investigated?

Answer 3

LFTs (usually normal, although GGT may be raised)

Tumour markers CEA and CA19-9 can be elevated

Ultrasound is imaging modality of choice, showing well-defined lesions.

Question 4

How are simple liver cysts managed?

Answer 4

Most do not require intervention.

If >4cm in side, follow-up ultrasound is recommended.

If patient is symptomatic, can do ultrasound-guided aspiration or laparoscopic de-roofing

Question 5

What is polycystic liver disease?

Answer 5

The presence of ≥20 cysts within the liver parenchyma, caused by one of the two following autosomal dominant conditions:

• autosomal dominant polycystic kidney disease (ADPKD)
• autosomal dominant polycystic liver disease (ADPLD)

Polycystic structures are not connected to intrahepatic bile ducts and so do not drain, leading to dilatation.

Question 6

What are the clinical features of polycystic liver disease?

Answer 6

Majority of patients are asymptomatic, however symptoms can occur due to localised compression.

Common symptoms include abdominal pain, hepatomegaly, and urinary tract symptoms.

Significant disease can eventually cause liver cirrhosis and portal hypertension.

Question 7

How is polycystic liver disease investigated?

Answer 7

LFTs (normal, though ALP may be raised)

U&Es to examine renal function (ADPLD)

Definitive diagnosis via ultrasound imaging, demonstrating multiple cysts.

Question 8

How is polycystic liver disease managed?

Answer 8

Asymptomatic disease left alone.

US-guided aspiration or laparoscopic de-roofing of cysts if:
- intractable symptoms
- inability to rule out malignancy
- prevention of malignancy

Question 9

What are cystic neoplasms?

Answer 9

Make up around 5% of liver cysts, most commonly cystadenomas.

They are premalignant developing as a result of abdominal proliferation of biliary epithelium.

Question 10

What are the clinical features of cystic neoplasms?

Answer 10

Most commonly asymptomatic

Abdominal pain, anorexia, nausea, fullness and bloating if symptomatic due to compression of local structures.

Question 11

How are cystic neoplasms investigated?

Answer 11

LFTs normal

ALP, CEA and CA19-9 elevated

CT with contract performed

Question 12

How are cystic neoplasms managed?

Answer 12

Liver lobe resection, with samples sent for subsequent biopsy.

Question 13

What are hydatid cysts?

Answer 13

Tapeform Echinococcus granulosus passes via the hepatic portal system into the liver, where they continue to grow and form cysts.

Question 14

What are the clinical features of hydatid cysts?

Answer 14

Cysts grow very slowly so can remain asymptomatic for many years.

Common presenting symptom is vague abdominal pain, caused by mass effect on surrounding structures or due to rupture.

OE jaundice or cholangitis, vomiting, dyspepsia, early satiety.

Question 15

How are hydatid cysts investigated?

Answer 15

LFTs normal (unless cholangitis)

FBC shows eosinophilia

Ultrasound scan first line, with further imaging via CT imaging with contract

Question 16

How are hydatid cysts managed?

Answer 16

Primary treatment is cystic deroofing with radiological drainage.

Medical management used in adjunct, for example metronidazole.

Question 17

Are primary or malignant lesions of the liver most common?

Answer 17

Malignant lesions of the liver most common, representing 90% of cases.

Question 18

What is the most common primary liver cancer?

Answer 18

Hepatocellular carcinoma most common

Question 19

What are the risk factors for hepatocellular carcinoma (HCC)?

Answer 19

• liver cirrhosis (hepatitis B / hepatitis C; alcohol excess; NAFLD)
• aflatoxin exposure (HBV infection)
• hepatocellular adenoma
• smoking
• advanced age
• positive family history

Question 20

What are the clinical features of HCC?

Answer 20

• fatigue
• weight loss
• irregular enlarged liver
• ascites
• jaundice
• confusion

Question 21

How is HCC investigated?

Answer 21

• FBC
• LFTs
• clotting profile
• AFP measured to monitor disease response or surveillance

Question 22

What imaging is used to screen for HCC in high risk individuals?

Answer 22

Ultrasound screening

MRI imaging or CT imaging can be used if HCC suspected from ultrasound

Question 23

What staging system is used for HCC?

Answer 23

Barcelona Clinic Liver Cancer staging (BCLC) accounts for tumour stage, based on tumour size, number of tumours and liver function.

0 - very early
A - early
B - intermediate
C - advanced
D - terminal

Question 24

How is HCC managed?

Answer 24

Curative options include liver transplantation or liver resection in those with no or mild liver cirrhosis.

In metastatic disease, anti-angiogenic agents such as Atezolizumab is used.

Question 25

What is the most common primary site for secondary liver cancer to have metastasised from?

Answer 25

Colorectal tumour via the portal circulation

Can also spread from pancreas, breast and lung.

Question 26

What is the most common cause of liver abscess?

Answer 26

Results from polymicrobial bacterial infection spreading from the biliary or gastrointestinal tract.

Common caused include cholecystitis, cholangitis, diverticulitis, appendicitis or septicaemia.

Most commonly isolated organisms are E. coli and K. pneumoniae

Question 27

What are the clinical features of liver abscesses?

Answer 27

• fever
• rigors
• abdominal pain*
• bloating
• nausea
• anorexia
• weight loss
• fatigue
• jaundice

OE RUQ tenderness and hepatomegaly. If abscess ruptures may be signs of shock and peritonism.

*Pyogenic abscess should be considered in all patients presenting with pyrexia of unknown origin associated with abdominal pain or bloating.

Question 28

How are liver abscesses investigated?

Answer 28

• FBC showing leucocytosis
• LFTs with raised ALP, ALT and bilirubin
• peripheral blood and fluid cultures sent for microscopy

US imaging and CT imaging with contrast for definitive diagnosis.

Question 29

How are liver abscesses managed?

Answer 29

• fluid resuscitation
• appropriate abx therapy as per sensitivities and local policies
• drainage via USS-guided aspiration