7.02 - HPB Liver Flashcards
What are simple liver cysts?
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.
What are the clinical features of simple liver cysts?
Usually asymptomatic and detected incidentally on imaging.
Around 10% of patients are symptomatic:
- abdominal pain
- nausea
- early satiety
How are liver cysts investigated?
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.
How are simple liver cysts managed?
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
What is polycystic liver disease?
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.
What are the clinical features of polycystic liver disease?
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.
How is polycystic liver disease investigated?
LFTs (normal, though ALP may be raised)
U&Es to examine renal function (ADPLD)
Definitive diagnosis via ultrasound imaging, demonstrating multiple cysts.
How is polycystic liver disease managed?
Asymptomatic disease left alone.
US-guided aspiration or laparoscopic de-roofing of cysts if:
- intractable symptoms
- inability to rule out malignancy
- prevention of malignancy
What are cystic neoplasms?
Make up around 5% of liver cysts, most commonly cystadenomas.
They are premalignant developing as a result of abdominal proliferation of biliary epithelium.
What are the clinical features of cystic neoplasms?
Most commonly asymptomatic
Abdominal pain, anorexia, nausea, fullness and bloating if symptomatic due to compression of local structures.
How are cystic neoplasms investigated?
LFTs normal
ALP, CEA and CA19-9 elevated
CT with contract performed
How are cystic neoplasms managed?
Liver lobe resection, with samples sent for subsequent biopsy.
What are hydatid cysts?
Tapeform Echinococcus granulosus passes via the hepatic portal system into the liver, where they continue to grow and form cysts.
What are the clinical features of hydatid cysts?
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.
How are hydatid cysts investigated?
LFTs normal (unless cholangitis)
FBC shows eosinophilia
Ultrasound scan first line, with further imaging via CT imaging with contract
How are hydatid cysts managed?
Primary treatment is cystic deroofing with radiological drainage.
Medical management used in adjunct, for example metronidazole.
Are primary or malignant lesions of the liver most common?
Malignant lesions of the liver most common, representing 90% of cases.
What is the most common primary liver cancer?
Hepatocellular carcinoma most common
What are the risk factors for hepatocellular carcinoma (HCC)?
- liver cirrhosis (hepatitis B / hepatitis C; alcohol excess; NAFLD)
- aflatoxin exposure (HBV infection)
- hepatocellular adenoma
- smoking
- advanced age
- positive family history
What are the clinical features of HCC?
- fatigue
- weight loss
- irregular enlarged liver
- ascites
- jaundice
- confusion
How is HCC investigated?
- FBC
- LFTs
- clotting profile
- AFP measured to monitor disease response or surveillance
What imaging is used to screen for HCC in high risk individuals?
Ultrasound screening
MRI imaging or CT imaging can be used if HCC suspected from ultrasound
What staging system is used for HCC?
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
How is HCC managed?
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.
What is the most common primary site for secondary liver cancer to have metastasised from?
Colorectal tumour via the portal circulation
Can also spread from pancreas, breast and lung.
What is the most common cause of liver abscess?
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
What are the clinical features of liver abscesses?
- 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.
How are liver abscesses investigated?
- 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.
How are liver abscesses managed?
- fluid resuscitation
- appropriate abx therapy as per sensitivities and local policies
- drainage via USS-guided aspiration
