Liver Lesions Flashcards
What are the types of benign hepatic tumours?
Haemangioma
Focal nodular hyplasia
Adenoma
Liver cysts
What is the most common liver tumour?
Haemangioma
What is a haemangioma?
Hypervascular tumour (blood filled) Small mass contained within capsule with clear borders
How does haemangioma present?
Asymptomatic and incidental finding
How does haemangioma present on imaging?
US - echogenic spot that is well demarcated
CT - venous enhancement from periphery to centre
MRI - high intensity area
What is the management for haemangiomas?
None
What is focal nodular hyperplasia?
Benign nodule on liver
Congenital vascular abnormality causes hyperplasia because of abnormal arterial flow
What is the classical description of focal nodular hyperplasia?
Central scar containing a large artery radiating branches to the periphery
How does focal nodular hyperplasia present?
Usually asymptomatic but may cause pain if compressing on structures
Who is focal nodular hyperplasia most common in?
Middle aged women
What is seen on histology in focal nodular hyperplasia?
Kupffer cells, bile ductules, all the liver’s ultra-structure
How does focal nodular hyperplasia present on imaging?
US - nodule with varying echogenity
CT - hypervascular mass with a central scar
MRI - iso/hypo intense
FNA - normal hepatocytes and Kupffer cells
What is the management for focal nodular hyperplasia?
None as no malignant potential
What is a hepatic adenoma?
Benign neoplasm composed of normal hepatocytes
No portal tract, central vein or bile duct involvement
Who is hepatic adenoma more common in?
Women
Associated with contraceptive pill use and anabolic steroids
How does hepatic adenoma present?
Usually asymptomatic but can be RUQ pain
What complications can occur in hepatic adenomas?
Rupture causing haemorrhage
Malignant transformation
How does hepatic adenoma present on imaging?
US - filling defect
CT - dissuse arterial enhancement
MRI - hypo-hyper intense lesion
FNA may be required
What is the management for hepatic adenoma?
Stop taking oral contraceptives/hormones/anabolic steroids
In males surgical excision irrespective of size
In females annual MRI if <5cm or reducing in size or surgical excision if >5cm or increasing in size
Which are more common in the liver, primary or secondary tumours?
Secondary
What is the most common primary liver tumour?
Hepatocellular carcinoma
What are the risk factors for hepatocellular carcinoma?
Cirrhosis
HBV, HCV
Male sex
What is the pathology of hepatocellular carcinomas?
Usually single nodule
Consists of cells resembling hepatocytes
Metastasis can be to bones, lungs, lymph nodes
What are the clinical features of hepatocellular carcinomas?
Weight loss, malaise, fever, anorexia Ache in RUQ Worsening of pre-existing chronic liver disease Ascites Rapid progression of these
What are examination findings that are suggestive of hepatocellular carcinoma?
Signs of cirrhosis
Hard enlarged RUQ mass
Liver bruit
What investigations can be done for hepatocellular carcinoma?
Serum alpha-fetoprotein is HCC marker but is normal in 1/3 of cases
US
CT (MRI needed if <1cm)
Tumour biopsies are less frequent
What is the characteristic appearance of a hepatocellular carcinoma?
Hypervascularity of the nodule and a lack of portal vein washout
What scoring system is used to determine prognosis of hepatocellular carcinoma?
Child-Pugh score
What is the first choice treatment for hepatocellular carcinomas, and when can this be done?
Resection
Small lesions with preserved liver function
No jaundice or pulmonary hypertension
What is the second choice treatment for hepatocellular carcinomas, and when can this be done?
Liver transplantation
If there is one nodule <5cm or up to three, all <3cm
What treatment is done if you can’t get liver transplant?
Local ablation - temporary measure
What is TACE?
Transarterial chemoembolisation
Chemotherapy is selectively injected into the hepatic artery
Then an embolic agent is injected
Given to patients with early cirrhosis
What is sorafenib?
Used in hepatocellular carcinoma if there are no other options
Kinase inhibitor
Gives a few extra months
Who is fibre-lamellar carcinoma more common in?
Younger patients
Which primary liver cancer is not associated with cirrhosis?
Fibro-lamellar carcinoma
What investigations are done for fibre-lamellar carcinoma, and what does it show?
CT - stellate scar with a radial spot showing persistent enhancement
What is the treatment for fibre-lamellar carcinoma?
Surgical resection or transplant if possible
TACE if not
What is a cyst?
A liquid collection lined by epithelium
What is a simple cyst?
A solitary cyst that doesn’t involve the biliary tree
How do simple cysts present?
Usually asymptomatic but may cause RUQ pain from compression or fever if infection or rupture
What investigation is used for simple cysts?
US
If any doubt follow up
What is the treatment for simple cysts?
If asymptomatic then none
If symptomatic/uncertain diagnosis then surgical removal
What is a hydatid cyst caused by?
The tape worm echinococcus granulosus
Who presents with hydatid cysts?
Faming communities as a result of contact with livestock
How do hydatid cysts present?
Often asymptomatic but can cause dull ache and swelling in right hypochondrium due to erosion into adjacent structures and vessels
What is the investigation for hydatid cysts?
AXR - cyst calcificatin
US/CT - diagnostic
Anti-echinococcus antibodies
What is a diagnostic sign of hydatid cysts?
The presence of daughter cysts
What is the treatment for hydatid cysts?
Surgery
Albendazole to reduce size
Can be drained using PAIR
What does PAIR stand for?
Puncture
Aspiration
Injection
Re-aspiration
What is polycystic liver disease caused by?
Embryonic ductal plate malformation
Causes malformed bile ducts
This leads to the formation of numerous cysts throughout the liver
What are the three types of polycystic liver disease?
Von Meyenburg complex
Polycystic liver disease
Autosomal dominant polycystic kidney disease
What is von meyenburg complex?
Benign cystic nodules throughout the liver
Originate in the peripheral biliary tree as a result of the ductal plate malformation
Incidental finding and asymptomatic
What is polycystic liver disease?
The presence of cysts in the liver
Liver function preserved and kidneys functioning normally
Symptoms depend on the size of the cyst and may cause RUQ pain and distension
What is autosomal dominant polycystic kidney
disease?
Polycystic disease in the kidneys which can cause hepatic manifestation
Reduction in kidney function but liver function should be preserved
Liver maybe massively enlarged
What is the clinical presentation of polycystic liver disease?
Abdominal pain
Abdominal distension
May be atypical symptoms due to many cysts compressing surrounding tissues
Liver failure if disease is very severe
What investigation is done for polycystic liver disease?
Gene studies
CT
Kidney function tests
What is the treatment for polycystic liver disease?
Surgery - aspiration and liver transplant only in severe disease
Somatostatin analogues to reduce liver volume and provide symptomatic relief
What is a clue for a patient having liver abscess?
Dental procedure followed by clinical presenation
What is the clinical presentation for liver abscess?
High fever Abdominal pain Nausea and vomiting Jaundice (+ maybe pleural rub in right lower chest) Malaise for several months
What is the investigation for liver abscess?
Check for leukocytosis CXR - raised right semi-diaphragm US - diagnosis CT - complex and multiple lesions Echocardiogram
What is the treatment for liver abscess?
Initial empiric broad spectrum antibiotics (amoxicillin, metronidazole, gentamycin) all IV
Aspiration/drainage
Operation if no improvement
Post-op 4 weeks of antibiotic therapy
What is haemochromatosis?
Autosomal recessive inherited disease characterised by excess iron deposition in the liver and other organs
What are the clinical features of haemochromatosis?
‘Bronzed diabetic’ (bronze or grey skin pigmentation, hepatomegaly, diabetes mellitus)
Cardiac arrhythmias and heart failure in younger patients
Signs of liver fibrosis or failure
Joint pain
Hypogonadism
What are the investigations for haemochromatosis?
Serum iron >30 in most cases
If normal do genetic testing
LFTs often normal
MRI
What is the management for haemochromatosis?
Venesecation
Avoid iron rich foods
What is Wilson’s disease?
Autosomal recessive disorder leading to reduced ceruloplasmin (the major copper transporter), causing a defect in copper transporting and excretion into bile
What are the symptoms of Wilson’s disease?
Kayser-Fleischer rings around eyes
Signs of liver disease
May show signs of CNS issue
What is the investigation for Wilson’s disease?
Urinary copper increased
Serum copper and ceruloplasmin usually reduced
What is the management for Wilson’s disease?
Penicillamine
