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LIVER DISEASESLIVER DISEASES
Shanghai Jiaotong University Medical SchoolRenji Hospital Luo meng
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ANATOMYANATOMYANATOMYANATOMY
Four channels within liver:� Four channels within liver:�
Inflow: HA PVInflow: HA PV
Outflow: HV Biliary ductOutflow: HV Biliary duct
Lobes & segments of the Liver� Lobes & segments of the Liver�
(Couinaud’s system of segments)(Couinaud’s system of segments)
Four channels within liver:� Four channels within liver:�
Inflow: HA PVInflow: HA PV
Outflow: HV Biliary ductOutflow: HV Biliary duct
Lobes & segments of the Liver� Lobes & segments of the Liver�
(Couinaud’s system of segments)(Couinaud’s system of segments)
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Three major hepatic veins drain the liverThree major hepatic veins drain the liver
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Intrahepatic divisions of the portal veinIntrahepatic divisions of the portal vein
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Liver � Liver � Functions: Functions:
Formation of bileFormation of bile
Regulation of material metabolismRegulation of material metabolism
energy, carbohydrate, fat, proteins,energy, carbohydrate, fat, proteins,
vitamins, hormones, and formation of vitamins, hormones, and formation of
coagulant factors etc.coagulant factors etc.
Mechanism of defense and detoxification Mechanism of defense and detoxification
Capacity of regeneration after massive Capacity of regeneration after massive
resection.resection.
Liver � Liver � Functions: Functions:
Formation of bileFormation of bile
Regulation of material metabolismRegulation of material metabolism
energy, carbohydrate, fat, proteins,energy, carbohydrate, fat, proteins,
vitamins, hormones, and formation of vitamins, hormones, and formation of
coagulant factors etc.coagulant factors etc.
Mechanism of defense and detoxification Mechanism of defense and detoxification
Capacity of regeneration after massive Capacity of regeneration after massive
resection.resection.
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LIVER ABSCESSMany kinds of LA:
Pyogenic AmebicVirus & Fungi
PATHOGENESIS� The micro-organisms through follows to hepatic parenchyma portal venous stream ascension from biliary tract hepatic artery direct penetrating trauma Amount and ability of invasion of micro-organisms vs defense mechanism of the body.
LIVER ABSCESSMany kinds of LA:
Pyogenic AmebicVirus & Fungi
PATHOGENESIS� The micro-organisms through follows to hepatic parenchyma portal venous stream ascension from biliary tract hepatic artery direct penetrating trauma Amount and ability of invasion of micro-organisms vs defense mechanism of the body.
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Etiology Etiology of pyogeof pyogenic abscenic abscessss
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DIAGNOSIS� DIAGNOSIS� Clinical manifestations: Fever pain at R.U.Q. enlargement of liver Others: nausea jaundice Antecedent diarrhea in amebic liver abscess LABS: WBC↑ RBC↓ Albumin↓ blood culture for bacteria positive in 40%EXAMS: X’ray film:
Elevated diaphragm and pleural effusion
BUS and CT: guiding to aspiration of abscess
DIAGNOSIS� DIAGNOSIS� Clinical manifestations: Fever pain at R.U.Q. enlargement of liver Others: nausea jaundice Antecedent diarrhea in amebic liver abscess LABS: WBC↑ RBC↓ Albumin↓ blood culture for bacteria positive in 40%EXAMS: X’ray film:
Elevated diaphragm and pleural effusion
BUS and CT: guiding to aspiration of abscess
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CT scan of a pyogenic hepatic abscessCT scan of a pyogenic hepatic abscess
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COMPLICATIONS� Generalized sepsis, emphysema
Ruptured abscess into pleural cavity, peri - cardiaum and intra-abdominal cavity
TREATMENT� Medical therapy:
General support therapy
Antibiotics, metronidazole
Drainage-lavage by catheter
Surgical therapy: drainage resection or of liver
COMPLICATIONS� Generalized sepsis, emphysema
Ruptured abscess into pleural cavity, peri - cardiaum and intra-abdominal cavity
TREATMENT� Medical therapy:
General support therapy
Antibiotics, metronidazole
Drainage-lavage by catheter
Surgical therapy: drainage resection or of liver
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PRIMARY LIVER CARCINOMA
•Hepatocellular carcinoma (HCC) occupied th
e third place of malignancy in China.
•Recent two decades, the higher recurrence rat
e has remained as a rather difficult problem in
spite of the improvement in the diagnosis and t
reatment.
PRIMARY LIVER CARCINOMA
•Hepatocellular carcinoma (HCC) occupied th
e third place of malignancy in China.
•Recent two decades, the higher recurrence rat
e has remained as a rather difficult problem in
spite of the improvement in the diagnosis and t
reatment.
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ETIOLOGY� Risk factors: virus infection hepatitis type B.C.and D. various liver cirrhosis Some chemical carcinogenic material e.g. Aflatoxin� PATHOLOGY macroscopic classification:
massive, nodular or diffuse solitary or multiple growth pattern: infiltrative, expanded, mixed infiltrative and expanded,diffuse, small (less than 2cm in diameter) metastasis: through peri hepatic lymphatics or direct invasion particular ca thrombus in portal v. or ruptured ca into abdominal cavity
ETIOLOGY� Risk factors: virus infection hepatitis type B.C.and D. various liver cirrhosis Some chemical carcinogenic material e.g. Aflatoxin� PATHOLOGY macroscopic classification:
massive, nodular or diffuse solitary or multiple growth pattern: infiltrative, expanded, mixed infiltrative and expanded,diffuse, small (less than 2cm in diameter) metastasis: through peri hepatic lymphatics or direct invasion particular ca thrombus in portal v. or ruptured ca into abdominal cavity
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Ca With Complete CapsuleCa With Complete Capsule
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CLINICAL MANIFESTATIONCLINICAL MANIFESTATION
• No distinctive symptoms until late stageNo distinctive symptoms until late stage• Anorexia, fullness or pain in RUQ, and weight Anorexia, fullness or pain in RUQ, and weight
loss are commonloss are common• In addition, clinical presentation of liver In addition, clinical presentation of liver
cirrhosiscirrhosis
LAB STUDYLAB STUDY• AFP>400ng/ml in 70% of patients with HCCAFP>400ng/ml in 70% of patients with HCC• Pseudo-positive (AFPV)Pseudo-positive (AFPV)
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IMAGING EXAMSIMAGING EXAMS
• BUSBUS• CT and CT and
MRIMRI• Hepatic Hepatic
angiographyangiography
Hypo-echo area
IVC
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CTCT
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Hepatic angiographyHepatic angiography
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An Occupied Lesion on AngiogramAn Occupied Lesion on Angiogram
Hepatic angiographyHepatic angiography
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� HOW TO DETECT SUBCLINICAL CASES
It is important that the high-risk people who ar
e with chronic hepatitis or liver cirrhosis should be
closely followed up by AFP test and BUS. It is mos
t possible that newly identified tumors in the liver
are HCC or precancerous lesion.
� HOW TO DETECT SUBCLINICAL CASES
It is important that the high-risk people who ar
e with chronic hepatitis or liver cirrhosis should be
closely followed up by AFP test and BUS. It is mos
t possible that newly identified tumors in the liver
are HCC or precancerous lesion.
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� DIFFERENTIAL DIAGNOSIS
• Metastatic liver carcinoma
• Liver cirrhosis
• Focal nodular hyperplasia of liver
• Cavernous hematoangioma of liver
� DIFFERENTIAL DIAGNOSIS
• Metastatic liver carcinoma
• Liver cirrhosis
• Focal nodular hyperplasia of liver
• Cavernous hematoangioma of liver
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� TREATMENT
○ SURGICAL RESECTION
Indications:
Solitary, not too big multiple but collect an
area
Patient’s condition
Evaluation of liver function (Child A or B)
� TREATMENT
○ SURGICAL RESECTION
Indications:
Solitary, not too big multiple but collect an
area
Patient’s condition
Evaluation of liver function (Child A or B)
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� TREATMENT
○ SURGICAL RESECTION
Surgical procedure
•Hemihepatectomy, lobectomy, eg mentectomy
– In liver cirrhosis, limited resection with 1.5cm margin fr
om tumor
•Liver transplantation
–Only indicated for small HCC without outside liver spre
ad
Complication: bleeding, liver failure, sepsis
� TREATMENT
○ SURGICAL RESECTION
Surgical procedure
•Hemihepatectomy, lobectomy, eg mentectomy
– In liver cirrhosis, limited resection with 1.5cm margin fr
om tumor
•Liver transplantation
–Only indicated for small HCC without outside liver spre
ad
Complication: bleeding, liver failure, sepsis
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○Non-surgical treatment
• TACE under highly selective hepatic arteriocatheterization,
lipoidol, cytotoxic agents and embolized material to be injected. Mainly indicated for big HCC.
To make the tumor smaller in 15% patients with big HCC, the resection of tumor may be possible. •INJECTION OF ETHONAL
for small tumor in 2cm diameter or less•OTHERS
○Non-surgical treatment
• TACE under highly selective hepatic arteriocatheterization,
lipoidol, cytotoxic agents and embolized material to be injected. Mainly indicated for big HCC.
To make the tumor smaller in 15% patients with big HCC, the resection of tumor may be possible. •INJECTION OF ETHONAL
for small tumor in 2cm diameter or less•OTHERS
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Angiography---Chemo-Angiography---Chemo-embolizationembolization
The Lesion Getting Smaller 2 Months The Lesion Getting Smaller 2 Months Later Later
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Ca Showed by Hypo-echoCa Showed by Hypo-echo
After Chemo-embolizationAfter Chemo-embolization
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Chemo-embolizationChemo-embolization
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Multiple Liver Cysts (Congenital) Multiple Liver Cysts (Congenital)
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李 × 男性 62岁 ,17月前因肝癌行肝癌根治术 ,术后随访中发现α-FP呈进行性上升 ,B超及 CT均未发现明显病变 ,动脉造影证实肝内肝癌复发
李 × 男性 62岁 ,17月前因肝癌行肝癌根治术 ,术后随访中发现α-FP呈进行性上升 ,B超及 CT均未发现明显病变 ,动脉造影证实肝内肝癌复发
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Occupied Lesion on AngiogramOccupied Lesion on Angiogram
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Recurrent liver cancerRecurrent liver cancer