LIVER

ANATOMY OF LIVER

• 4 LOBES- Right lobe, Left lobe,

Quadrate lobe, Caudate lobe.

• Supporting Structures- Right

triangular ligament, Left
triangular ligament and
Falciform ligament
 Hepatic Artery (20%)
Dual Blood supply
Portal Vein (80%)

Coeliac Axis Hepatic Artery

(Hepatic artery ligation is used as a palliative therapy in advanced HCC)
Liver parenchyma is covered by a thin capsule (GLISSONS CAPSULE) and by
visceral peritoneum all over but posterior surface (BARE AREA)
• COUNIAUDS Segments
Liver is divided into functional
segments by CANTLIE’S LINE
( Line passing from the left of the
gall bladder fossa to the left of the
IVC).

• BISMUTH Classification-
Seperation of sectors by
HEPATIC VEIN

• FUNCTIONAL UNIT- Called a

Hepatic Lobule- Hepatic Vein
and Portal Triad ( Hepatic
Arteriole, Portal Venule, Bile
ductile)
 FUNCTIONS OF LIVER
• FIRST FILTER- Removal of Gut endotoxins and Foreign Antigens
• First pass Metabolism- Drugs and Hormones
• Formation of Bilirubin and its metabolism
• Protein Catabolism
• Glucose Metabolism- Gycolysis, Gluconeogenesis
• Clotting Factors synthesis
• Storage of Vitamin B12, Copper, Iron.
LIVER FUNCTION TEST
• SYNTHETIC Function- PT-INR, Factor V, VII, Albumin, Bilirubin

• Biliary Canalicular function- ALP, 5’nucleotide, Gamma Glutamyl transferase

(GGT), Bilirubin

• S. Bilirubin (van den Bergh test)- Both direct and indirect Bilirubin are measure

• SGOT/AST and SGPT/ALT are the enzymes of the liver

• ALK- Is indicative of the functioning of the bile ducts

• Serum Albumin- Indicator of chronic liver disease

BILIRUBIN METABOLISM:

Bilirubin is taken into hepatocytes by

Passive diffusion or Receptor mediated
endocytosis.

The liver removes unconjugated

bilirubin ( with the help of Glutathione
s- Transferace).

Uridine diphosphate glucuronyl

transferace conjugates bilirubin with
glucoronic acid to form water solvable
forms.

This is then excreted into bile (RATE

LIMITING STEP)
 ENTEROHEPATIC CIRCULATION

Movement of Bile acid from the liver to the small intestine and back to the
liver.
95% Bile salts are recycled by ENTEROHEPATIC circulation.
 AMOEBIC LIVER ABSCESS
(Tropical Abscess)

• Cause- Entamoeba histolytica

• More common in alcoholics and cirrhosis patients.

• Occurs from caecum after an attack of amoebic typhlitis through SMA and Portal
Vein.

• Right Lobe is usually involved over posterosuperior surface ( Due to Larger size
of right lobe and streamline effect)

• Trophozoites destroy hypatocytes by releasing HISTIOLYSIN.

Cyst pass through the
stomach undamaged.

Cell wall lysis is caused by

trypsin.

Habitat- Crypts of caecum,

Sigmoid colon and form
trophozoites.
Pus is typically ANCHOVY SAUSE colour.

Clinical Features:-

-Usually history of dysentery is present.

-Fever, Loss of weight, Chills, Rigor, Non Productive cough, Shoulder pain.

-Soft, Tender, smooth liver with increased liver span.

-Intercoastal Tenderness.

Investigations :-

Increased Total Counts, Increased Prothromin time, Altered Liver enzymes

USG- Altered echogenicity

CXR- Raised Diaphragm- Tenting of Diaphragm

TECHNETIUM 99 scan- COLD LESION WITH A HOT RIM (Pyogenic abscess is entirely hot) - Due to absence of leukocytes in
amoebic liver abscess.
 Treatment of Amoebic liver Abscess
Tab Metronidazole 800mg P/O 1-1-1 for 10-14 days ( NOT GIVEN IN 1st TRIMESTER)

Oral/IV antibiotics to control secondary infections ( Cefotaxime, Ciplox, Amoxicillin)

ASPIRATION: Large abscess (>10cm), Infected abscess, Failure of drug therapy, large left lobe
abscess, sero negative abscess, abscess in pregnancy

PERCUTANEOUS DRAINAGE (Failure if thick pus, multiloculated, multiple abscess)

Surgery: Transperitoneal approach, abscess in drained, Mallecots catheter is placed and removed
when drainage stops completely. Discharged with T Chloroquine 250mg BD x 10 days and T.
Diloxanide furoate 500mg TDS x 10-14 days.
 PYOGENIC LIVER ABSCESS
ETIOLOGY:

-Biliary sepsis (35%)

- Portal vein sepsis (20%)

- Distant infections- via hepatic artery
(15%)

- Super added infections (5%)

- Cryptogenic Liver abscess (20%)-
Chronic presentation

- Trauma
- Direct Extension (5%)
Right lobe (75%)- Due to laminar blood flow, Left lobe (20%), Caudate Lobe (5%)

Usually solitary (60%)

Contains pus with virulent organisms.

M/C in Diabetics

Blood culture is usually positive for bacteria.

Clinical Presentation :-

-Pain in RHC

-Fever with rigours

-Jaundice

- Intercoastal tenderness, features of toxicity

- Constitutional Symptoms

Diagnosis :-

USG (90% sensitivity), CT (97% sensitive for contrast study)

Blood cultures

Technetium 99 scan- Entire abscess will be HOT.

 Treatment
• IV Antibiotics- THIRD GENERATION CEPHALOSPORINS AND
METRONIDAZOLE

• PERCUTANEOUS DRAINAGE- Treatment of choice

• TREAT THE PRIMARY CAUSE.

• Klebsiella abscess can cause dangerous endogenous endophthalmitis ( commonly

in diabetics) imparting vision.
 HYDATIC CYST OF LIVER

Cause: Echinococcus granulosus

(Dog Tape worm)

Most common segment involved-

Segment VII.

Commonly right lobe (66%), Both

lobes in 16%.
CYST : 3 Layers

- Adventitia/Pseudocyst :
Inseperable fibrous tissue due to
REACTION OF LIVER TO
PARASITE

- Laminated membrane/Ectocyst :
Formed by the parasite, Contains
hydatid fluid.

- Germinal Epithelium : Only living

part, Secretes hydatid fluid, brood
capsules with scolioses ( Head of
future worms)
Brood capsules disintegrate to form
daughter cysts.
Clinical Features :
- Hydatid Thrill/ Classical Thrill (Elicited by 3 finger test)

-Jaundice and Pain

Discomfort in RHC. Hydatid Cachexia in children.

CAMELLOTTE Sign- Folowing intrabiliary rupture, gas enters into cyst causing partial collapse of cyst wall

Investigations:
USG- Rosette of daughter cysts, doubled contoured membrane of cyst, Calcification of cyst wall.

CT abdomen

Serological tests- ELISA, IHA

CASONI’s TEST- Intradermal complement fixation test

Detection of precipitation line-arc 5 in immunoelectrophorosis

TREATMENT :

ALBENDAZOLE (Ovicidal, Larvicidal, Vermicidal)- 4 week cycles with 2 weeks drug free interval.
3 cycles are used. 400mg p/o BD

PRAZIQUANTEL- 60mg/kg for 2 weeks.

PAIR (PUNCTURE-ASPIRATION-INJECTION-REASPIRATION). Scolicidal agents- 15-20%

hypertonic saline followed by sclerosant.

SURGERY: GOLD STANDARD

Scolicidal agents- Cetrimide, 80% alcohol, Hypertonic saline ( Used if biliary communication is
present), Sodium Hypochlorite, Hydrogen peroxide.
 ACTINOMYCOSIS OF LIVER
Cause: ACTINOMYCOSIS Israeli

Reached liver via portal vein from caecum,

or hepatic artery from distant foci
(Faciocervical).

Progresses slowly causing multiple abscess-

HONEYCOMB LIVER

INV: USG Guided aspiration of pus shows

Sun ray appearance.

Rx: PENICILLIN for 3-6 weeks.