Chapter 6. SURGICAL PATHOLOGY OF THE LIVER

Desintoxication

Destruction and removal of allergens, poisons and toxins, excesses of hormones, mediators, vitamins, toxic products of metabolism - ammonia, phenol, acetone, etc.

Barrier-protective

Reticuloendotheliocytes of the liver (Kupffer cells) perform fixation of immune complexes and phagocytosis of bacteria, yeasts, viruses and parasites, destruct old erythrocytes, produce proteins of early phase of inflammation (C-reactive protein, gamma-globulin, etc.)

Energetic

Provision of energetic demands of the organism with glucose, conversion of fat and aminoacids, glycerin, lactic acid, etc. into glucose (gluconeogenesis)

Energetic

Participation in all types of metabolism: protein, lipid (including cholesterol), carbohydrate, pigment, mineral and other metabolisms

Secretory

Synthesis of bile acids and bilirubin, bile secretion and excretion

Hemostasis regulation

Formation of basic blood coagulation factors (of fibrinogen, prothrombin, etc.)

Depository (depotting)

Preserving supplies of blood, glycogen, vitamins, microelements

Hemopoietic

In fetus and in infants of the first year of life

Regenerative

Possibility to restore the initial mass after extensive (up to 75%) resections

The decrease or befalling of the liver's functions cause the development of hepatic insufficiency.

Clinical picture and diagnostics

Complaints

Abdominal pain. In intraabdominal hemorrhage - weakness, dizziness.

Anamnesis

The established fact of the trauma resulting from the wound by the gunshot or plain weapon, obtuse object, as well as by downfall from height, automobile incident, etc.

Physical data

A wound or traces of the blow in the liver's projection.

Signs of shock and bloodloss - pallor, cold perspiration, weak rapid pulse, decrease of AP.

Signs of intraabdominal hemorrhage and possible bile leakage - a dull percussion sound in deposed parts of the abdomen, Kulenkampff's symptom (analogous to Blumberg's sign in lack of abdominal wall tension), phrenicus-symptom.

Signs of hemobilia are also possible - vomiting with admixture of blood, melena.

Laboratory investigations

In bleeding - decrease of hemoglobin, erythrocyte number, hematocrit.

Instrumental investigations

Presence of free fluid at US, possibly - revelation of focal formation (hematoma) in the liver. Blood in the abdominal cavity at laparoscopy, presence of ruptures on the surface of the liver.

Hematomas of the liver may be formed as secondary pathology after suturing the wounds and ruptures of the liver. Primary and secondary hematomas have the tendency to suppuration and manifest themselves by local and general symptoms of inflammation during the remote periods.

Subcapsular hematomas may suppurate and empty into the abdominal cavity. Hemobilia developing in deep hematomas has a recurring character and manifests itself in intestinal hemorrhages. There is also a possible occurrence of mechanical jaundice due to biliary ducts' obturation with blood clots.

Clinical picture and diagnostics

Symptomatics

the 1^st period (asymptomatic)

the 2^nd period (with pronounced symptomatics)

Complaints

absent

Sense of heaviness, squeezing pain in the right hypochondrium, weakness, reduced appetite.

Anamnesis

Residence in the endemic region, contact with dogs, grass, water, food infected by the feces of the final host.

Physical examination

Moderate enlargement of the liver is possible.

Pronounced enlargement of the liver, protrusion of the abdominal wall is possible. In the projection of the liver there is a palpable painless formation with a smooth surface.

Laboratory investigations

Eosinophilia accelerated ESR, positive serological reactions (indirect hemagglutination, immunoenzymatic analysis).

Instrumental investigations

Roentgenological investigation - high position of the right diaphragmatic cupola, its limited mobility, possible presence of petrificates in the cyst membrane.

US, CT, NMRI make it possible to detect the presence of cysts in the liver, their sizes, localization, presence or lack of "daughter" and "granddaughter" vesicles, impairment of other organs and tissues.

Screening investigations (US, immunological investigations) among the residents of endemic regions are of great importance in early diagnostics.

Treatment of complications

Rupture of the cyst

Type of surgical intervention

into the abdominal cavity with the development of peritonitis

liquidation of the cyst, toilet and drainage of the abdominal cavity

into the pleural cavity with the development of pleural empyema

thoracolaparotomy, liquidation of the cyst, phrenoplasty, toilet and drainage of the pleural cavity

into the bronchus with the development of a fistula

thoracolaparotomy, liquidation of the cyst, phrenoplasty, suturing of the fistula or resection of the lung

into the biliary ducts with the development of mechanical jaundice, cholangitis

liquidation of the cyst, choledochotomy, sanation and external drainage of the biliary ducts

In constriction of the duodenum, choledochus, portal veins (v. portae) by echinococcus and development of intestinal obstruction, mechanical jaundice, portal hypertension it is sufficient to liquidate the cyst. Frequently these operations are emergency operations.

Definition and statistical data

It is a pathological process caused by the impairment of blood outflow in the portal vein, hepatic vein and inferior vena cava due to the occurrence of obstacles at various levels, which is characterized by significant (more than 12 mm/Hg) increase of portal pressure and specific critical syndrome.

It occurs in 1% of the population. In 80-90% of patients portal hypertension is conditioned by cirrhosis of the liver.

In males it occurs in 2-2.5 times more frequently than in females.

Annually 300000 people in the world die from the diseases leading to this syndrome.

Clinical picture and diagnostics

Stage I - preclinical

Stage II - pronounced clinical manifestations

Stage III - complications

Complaints

a non-persistent sense of heaviness in the right hypochondrium, lack of appetite, malaise

adding of pains in the hypochondria, fatigue, nausea, abdominal extension, sometimes jaundice

pressing pains in the abdomen, its sharp enlargement, vomiting with blood, rectal bleeding, weakening of memory and attention, jaundice, pronounced fatigue, loss of weight

Anamnesis

In the congenital form - most frequent occurrence in childhood.

In the acquired form - endured hepatitis, alcohol abuse, acute and chronic intoxications.

For the acute form of Budd-Chiari syndrome a hectic development of the disease is

typical.

Physical examination

moderate meteorism

enlargement of the liver and spleen, vascular «asterisks», «jellyfish head» - dilatation of anterior abdominal wall subcutaneous veins, ascites, possible ictericity of the skin and sclerae, hemorrhoids, manifestations of encepha-lopathy

adding of the signs of esophagogastric or rectal hemorrhage, hypodynamia, cachexia, oliguria

Laboratory investigations

possible presence of antibodies to the viruses of chronic hepatitis, moderate elevation of ALT and AST level, moderate hypoproteinemia, accelerated ESR

pronounced anemia, accelerated ESR, thrombocytopenia, hypoproteinemia, impairments of hemostasis system, possible variably directed change of ALT and AST transaminases level, raised content of urea, creatinine in the blood and urine, «cytopenic» syndrome (thrombocytopenia, leukopenia and anemia) in hypersplenism

Instrumental investigations

Esophagogastroduodenoscopy (EGD) allows diagnosing varicose esophageal veins, the degree of their changes, signs of hemorrhage. Rectoscopy makes it possible to reveal the signs of hemorrhoids, bleeding. Abdominal US with Dopplerography allows determining the changes in the size and structure of the liver, spleen, presence of ascites, the diameter of the portal veins, hepatic veins and the inferior vena cava; to detect the level of the obstacle in the portocaval system, change of blood flow direction. CT and NMRI allow assessing the size and shape of the vessels, density of hepatic and splenic parenchyma. Angiography (celiacography, splenoportography, cavagraphy, mesentericoportography) help to determine the level of the blood flow disturbance. Splenoportomanometry is helpful in assessing the pressure in the portal system. Laparoscopy helps to establish the character of hepatic damage. Biopsy is performed during laparoscopy or under US-control.

Differential diagnostics is carried out in order to detect the causes of hypertension (cirrhosis, thrombosis, neoplasm, cardiac insufficiency) as well as the obstacle level (suprahepatic, intrahepatic, infrahepatic blockage).

Evaluation of compensatory capacities of the liver according to Child-Pugh

Criteria

Number of points

1

2

3

Ascites

absent

minor

major

Degree of encephalopathy

no

1-2

3-4

Bilirubin (mmol/l)

<34

34-51

>51

Albumin (g/l)

>35

28-35

<28

Prothrombin index (%)

>70

50-70

<50

The sum of the points helps to determine the functional class of cirrhosis of the liver.

Class

Sum of the points

«А» - the stage of functional compensation

5-7

«В» - the stage of subcompensation

8-10

«С» - the stage of decompensation

>10

Therapeutical agents are aimed to decrease portal pressure and arrest the hemorrhage (non-selective β-adrenoblockers, nitrates, hemostatics) are used to prepare a patient for a surgical treatment, as well as an independent method of treatment in inoperable cases.

The described methods of the surgical manual, except for transplantation of the liver, are palliative to this or that extent and they are aimed at the prophylaxis and arrest of hemorrhage, decrease of ascites. However these methods intensify the manifestations of encephalopathy and do not influence on the liver's function and prognosis of the disease.

Benign tumors

Benign tumor of the liver occurs in 7-12% of patients (according to the data of pathologo - anatomical investigations). In females it is found out in 5-7 times more frequently than in males. The ratio of its incidence occurrence in females and males is 5:1 correspondingly. Most frequently the disease occurs in patients of 44-55 years old.

Hemangioma accounts for up to 85% of benign neoplasms.

Malignant tumors of the liver occur in 0.15-1.4% of patients (according to the data of pathologo - anatomical investigations). Among all tumors in the world cancer of the liver accounts for 1.2%, in the countries of Asia and Africa this index is significantly higher - 50%.

Clinical picture and diagnostics

In tumors of minor sizes (up to 8 cm) symptomatics is lacking, and they are revealed accidentally at US. Clinical manifestations occur when the size of a tumor is more than 8 cm.

Complaints

unclear dull pains, sense of heaviness in the right hypochondrium, nausea, sometimes vomiting

Anamnesis

slow development of the disease

Physical examination

The liver may be enlarged, the tumor may be detected by palpation.

Laboratory investigations

There are no changes in uncomplicated course of the disease.

Instrumental investigations

US, CT, NMRI - heterogeneous formations with distinct contours. It is typical for hemangiomas to have multi-chamber formations containing fluid. Angiography - intraorganic vessels may be loosened, deformed. Laparoscopy allows determining the character of the tumor (in case of its appearance on the surface). Biopsy is performed at laparoscopy or under US-control. In case a hemangioma is suspected the procedure is not performed because of the risk of hemorrhage.

Complications may occur in tumors of major size and constriction of the adjacent formations: obturation jaundice, ascites, duodenal obstruction.

Hemangioma may be complicated by thrombosis of the vessels with subsequent necrosis, rupture and massive intraabdominal hemorrhage.

Treatment

Indications

Methods

- likelihood of adenomas' malignization;

- rapid tumor growth according to the data of US-monitoring;

- constriction of the adjacent organs;

- l arge hemangiomas (risk of intraabdominal hemorrhages);

- rupture of hemangioma.

Resection (of various volume) of the liver within the borders of the healthy tissues. Depending on the sizes of the lump there is performed atypical (marginal, wedge-shaped, plane) or anatomical (segmental, hemihepatectomy) resection.

Clinical picture and diagnostics

At early stages symptomatics is lacking and the tumor is accidentally revealed at US.

Complaints

They occur in neglected stages of the disease - sense of heaviness and pain in the right hypochondrium, loss of weight, reduced appetite, progressing general fatigue. In disintegration of the tumor - hyperthermia.

Anamnesis

Hepatitis B and C, abuse of alcohol, use of steroid hormones and contraceptives, occupational harms

Physical examination

Possible detection of dense enlarged liver or a tumor at palpation. In neglected cases of the disease - ascites, jaundice, cachexia, fever, enlargement of peripheral lymphatic nodes.

Laboratory investigations

In neglected stages of the disease - hypoproteinemia, anemia, accelerated ESR, increase of ALT, AST, bilirubin, alphafetoprotein. Leukocytosis, increased level of the markers of hepatic pathology - canceroembryonal antigen (CEA), carboanhydrate antigen (CA19-9).

Instrumental investigations

US, CT, NMRI - heterogeneous formations of a certain density with unclear contours. Angiography - revelation of pathological vessels in the tumor, uneven accumulation of the contrasting substance, unclear and irregular contours of the liver. Laparoscopy helps to determine the character of the tumor (in case of its entrance to the surface). Biopsy is performed at laparoscopy or under US-control

Complications may occur in large - sized tumors and in constriction of the adjacent formations: obturation jaundice, ascites, duodenal obstruction.

Differential diagnostics is carried out between benign and malignant formations, primary and secondary (metastatic) cancer. Biopsy of the formation at laparoscopy or under US-control plays the decisive role.

Methods of treatment

Transplantation of the liver. It is rarely used in case there are technical facilities. Anatomical resection of the liver. It is the main method of surgical treatment of cancer of the liver. It can be performed in 12-30% of cases.

Alternative methods of treatment. These include transarterial (TAC) and transportal (TPC) chemoembolization by microspheres with cytostatics, transcutaneous injection of ethanol (TIE) or radiofrequency ablation (RA).