Liver Theory Flashcards
Amoebic liver abscess commonly affects
Right lobe
Posterosuperior aspect
Anchovy pus sauce
Amoebic liver abscess Liquefaction necrosis thrombosis of blood vessels broken rbcs No wbc unless secondarily infected Choc brown color Odourless Usually sterile
Life cycle of entameoba histolytica
Mature cyst in faeces-food n water-stomach pass undamaged-in alkaline medium cyst wall lysis by trypsin-excystation-quadrinucleate amoebae-metacyst trophozoites-crypts of caecum-
Acute liver abscess presentation
Toxicity
Rt sided abdominal pain tenderness
Fever loss of weight chills rigor non productive cough shoulder pain
Intercostal tenderness rt sided pleural effu
Mild jaundice rigidity skin edema
Features-systemic abdominal thoracic
Complications of amoebic liver abscess
Rupture(lung pleura abdomen pericardium intestine biliary system skin)
Infection septicemia liver failure
Hepatic encephalopathy.
Buddchiari
Most dangerous complication of ala
Cardiac tamponade
Mostly in left lobe abscess
Ddx for acute ala
Acute cholecystitis
Hcc
Subphrenic abscess
Pyogenic liver abscess
Ddx for chronic amebic liver abscess
Hepatoma
Inv ala
Tc hb esr crp Lft pt Us abdomen Cxr? Ct Sigmoidoscopy colonoscopy Technetium 99 scanning Iha -most sensitive
Medical Treatment ala
Metro 800mg tds or inj 500mg iv tds 10-40days
Tinidazole 600mg bd 5days
Luminal : duodohydroxyquin diloxanide furoate paromomycin
Tissue : emetine dehydroemetine
Mixed: nitroimidazole derivatives
Others-chloroquine tetracycline
Indications for aspiration in ala
>10cm Sec infection Drug therapy failure Large left lobe abscess Seronegative abscess Pregnancy
Amoebicidal drug c/i in pregnancy
Metronidazole c/i in frst trimester
Widened prothrombin time rx
Inj vit k 10mg im or iv 5days
Still wide-ffp
Aspiration ala position
Rt 6th ics midaxillary line
Us guided now
Percutaneous drainage
Pigtail catheter
7-20days
Mainstay of treatment?
Indications for surgery in ala
Recurrence Thick pus Multiloculated abscess Left lobe abscess Ruptured abscess Caudate lobe abscess Multiple abcess
Ala surgery
Malecots catheter
Transperitoneal approach
Avoid alcohol chloroquine 250mg bd 10days nd diloxanide furoate 500mg tds 10-14 days
Apple core sign
Barium enema
Hepatocellular carcinoma
Def host echinococcus granulosus
Dog
Most commonly involved segment hydatid disease
7
Right lobe
Layers of hydatid. Cysts
Adventitia host derived
Laminated membrane or ectocyst
Germinal epithelium (only living part)
Features of hydtid fluid
Clear
High specific gravity
Shows hooklets and scolices
Sites for hydatid cyst
Liver lungs muscles bones
Rarely kidney brain spleen
Water lily sign
Hydatid cyst
Separated laminTed membrane
More often seen in lung hydatid
Possible courses of hydatid disease
Calcified Enlarged nd palpable Jaundice due to pressure over biliary tree Rupture into peritoneal cavity anaphylactic reaction Rupture into biliary channels(commonest) Rupture into bowel pleura Sec inf Sec cysts Hepatic dysfn Disseminated abdominal hydatidosis
Cf hydatid disease
Hydatid thrill
Jaundice n pain
Anaphylaxis
Discomfort in rt upper quadrant
Dyspepsia hydatid cachexia wt loss fatigue vomiting
Splenomegaly cholangitis pleural eff allergic asthma fever
Camellotte sign
Camellote sign
Hydatid
Same as water lily sign?
Following intrabiliary rupture gas enters into the cyst causing partial collapse of cyst wall
Ddx for hydatid
Hepatoma
Ala
Cystic disease of liver
Complications of hydatid
Anaphylaxis rupture
Obst jaundice
Infection calci liver failure
Inv hydatid
Us (diagnostic) Xray Ct Serology elisa iha lat etc Sec laboratory tests(arc 5 immuno electrophoresis? Lft casonis Mri Pair
Hassen gharbis ultrasound based classification
Liver hydatid
5 types?
Casoni’s test
Intradermal test
Hydatid
Not used nowadays
Who classification of liver hydatid
Cl Ce1 Ce2 Ce3-water lily Ce4 Ce5-calcified
Contraindications for drug therapy in hydatid
Large cysts Honeycomb (withsepta) Infected cyst Calcified cyst Pregnancy
Drugs hydatid cyst
Albendazole 4 week cycle with 2wk drug free interval
3 such cycles400mgbd or 10mg/day/kg
Praziquantel 60mg/kg
Mebendazole
Side effects of albendazole
Altered lft
Fever
Alopecia
Leucopenia
PAIR
Liver hydatid
Puncture aspiration injection reaspiration
Under us or ct
Procedure
Contraindications for pair
Inaccessible cysts hyperechogenic cyst Honeycomb cyst Cystobiliary communication Calcified cyst Lung cysts
Complications of PAIR
Fever anaphylaxis infection recurrence
Gold standard therPy for hydatid disease
Surgery
Scoliocidal agents
Cetrimide Alcohol 80% Hypertonic saline 15% Sod hypochlorite Hydrogen peroxide
Which scolicidal agent is. Used in. Case of cystobiliary communication
Hypertonic saline(15%-20%)
Types of surgeries used for hydatid disease
Conservative- Lap-asp-eva-scoli- Partial pericystectomy Laporoscopic approach using perforator grinder aspi Radical- Pericystectomy lobectomy hepatectomy Communication
Cystpbiliary communicationcorrection
Suturing t tube drainage
Pericystectomy marsupialization
Capitonnage introflexion omentoplasty
Etc
Malignant hydatid
Echinococcus multilocularis(alveolaris) Liver failure
Risk factors for hepatoma
Aflatoxin Hep b and c chronic carriers Alcoholic cirrhosis Clonarchis sinensis Smoking Hemochromatosis @1antitrypsin deficiency Hepatic adenoma Env Chemicals Tannins griseofulvin etc Anabolic steroids pvc Nafld obesity diabetes Pbc wilsons disease
Types of hcc
Hanging type of tumour
Pushingtype
Infiltrative
Okuda classification of hcc
Multifocal
Indeterminate
Spreading
Expanding
Variants of hcc
Fibrolamellar Mixed hepatocellu,ar cholangiocellular Clear cell variant Giant cell variant Sarcomatoid
Fibrolamellar variant hcc
Younger Equal inc in m nd f No elevated afp Elevated vit b12 binding protein n neurotensin level Unrelated to viral hep or cirrhosis Left lobe common Fibrous stroma with thin hyaline bands
Child pugh scoring
….
Cf hepatoma
Painless mass in rt hypochondriac with loss of apetiten weight Jaundice Ascitis Splenomegaly Hep thrill bruit Fever Hemoperitoneun features of chronic liver disease Liver failure gi bleed Paraneoplastic
Types of presentation of hcc
Asymptomatic Symptomatic Symptoms due to complications Symptoms due to metastasis Paraneoplastic syndrome
Ddx hcc
Secondaries Cholangiocarcinoma Liver abscess Polycystic liver disease hydatid cyst Benign tumours hepatosteatosis
Investigations hcc
US-hyperechoic mosaic with thin halo Ct scan abdomen Tumour markers Celiac or ct angiography Lft Li rads ceus Contrast mri or ct Ascitic tap Lapascopic evaluation Hrct Fdg pet Surveillance scanning
Tumour markers for hcc
Afp>100iu (usually more than 400iu even upto 1000iu)
Pivka ii
Dcp
Glypican 3
Definitive treatment for hcc
If limited to 1 lobe hemihepatectomy
Total hepatectomy with orthotopic liver transplantation
Indications for transplantation
Resection c/i as in cirrhotics portal htn varices ascitis
C/i to liver resection in hcc
Extrahepatic tissues or node inv
Portal vein thrombus
Distant spread
Cirrhotics portal htn???
Palliative treatment for hcc
Rfa
Percutaneous ethanol or acetic acid injection
Tac adriomycin/cisplatin/mitomycin thru gastroduodenal artery
Tae tace
Microwave or cryoablations
Hepatic artery ligation
Targeted iodine 131 with lipiodol injection
Hcc ideL for rfa
<3cm
Deep in parenchyma
Away drom hilum
A lesion >1cm in US with afp>20ng/ml is almost diagnostic of
Hcc
Chemotherapy for hcc
Sorafenib Levatinib Regorafenib carbozantinib Iiv adriamycin(doxorubicin) cisplatin carboplatin mitomycin c 5 fu Octreotide Neoadjuvant chemotherapy
