Liver and Hpt

LIVER, GALLBLADDER, AND THE HEPATOBILIARY TREE

  • Instructor: Rannie Rabe-Baquiran, MD, MHPED, FPCS, FPSGS

  • Date: September 13, 2024

OBJECTIVES

  • Students will be able to:

    • Diagnose common diseases of the liver, gallbladder, and hepatobiliary tree (HBT) through clinical presentation and physical exam findings.

    • Identify diagnostic tests that facilitate diagnoses.

    • Explain surgical management options for liver, gallbladder, and HBT diseases.

OUTLINE

  1. Surgical Anatomy and Physiology

  2. Diseases of the Liver

    • Benign Conditions

      • Liver cirrhosis and portal hypertension

      • Hepatic cysts

    • Malignant Conditions

      • Hepatocellular carcinoma

      • Cholangiocarcinoma

  3. Diseases of the Gallbladder (GB) and Hepatobiliary Tree (HBT)

    • Benign Conditions

      • Gallstone diseases

      • Choledochal cysts

    • Malignant Conditions

      • Gallbladder cancer

LIVER ANATOMY

Ligaments

  • Falciform ligament

  • Left and right triangular ligaments

Lobes

  • Right Lobe: Segments VII, VIII

  • Left Lobe: Segments II, III, IVa, IVb

  • Caudate Lobe: Segment I

Vascular Supply

  • Hepatic Arteries: Common hepatic artery, right and left hepatic arteries

  • Veins: Main portal vein, superior mesenteric vein, inferior mesenteric vein, splenic vein

LIVER PHYSIOLOGY

  • Functions: Bile formation, metabolism ( bilirubin, drugs), synthesis of proteins and clotting factors.

LIVER CIRRHOSIS AND PORTAL HYPERTENSION

Etiology

  • Viral hepatitis (B, C)

  • Alcohol abuse

  • Metabolic disorders (e.g., hemochromatosis, Wilson's disease)

  • Non-alcoholic fatty liver disease (NAFLD)

Clinical Presentation

  • Symptoms: Fatigue, anorexia, jaundice, abdominal pain, ascites, hepatic encephalopathy.

  • Signs: Spider angiomata, palmar erythema, hepatic enlargement, splenomegaly.

Diagnostic Tests

  • Child-Turcotte-Pugh (CTP) Score: Determines severity of cirrhosis based on bilirubin, albumin, prothrombin time, etc.

  • MELD Score: Scores for liver transplant eligibility.

Management

  • Cirrhosis: Liver transplantation.

  • Portal Hypertension: Surgical shunt procedures (portocaval, TIPS).

HEPATIC CYSTS

Epidemiology

  • Prevalence of 5-14%, more common in females.

Clinical Presentation

  • Most are asymptomatic; larger cysts may cause abdominal pain.

Types

  • Congenital/Simple cysts

  • Biliary cystadenoma

  • Polycystic liver disease

  • Management: Aspiration, excision, liver transplantation for complex cases.

BENIGN HEPATIC TUMORS

Types and Management

  • Hemangioma: Most common, usually asymptomatic.

  • Adenomas: Surgical resection recommended if symptomatic or >5 cm.

  • Focal Nodular Hyperplasia: Generally requires observation; risk of rupture is low.

MALIGNANT LIVER TUMORS

Hepatocellular Carcinoma (HCC)

Risk Factors

  • Viral hepatitis, alcoholic cirrhosis, metabolic disorders.

Clinical Presentation

  • RUQ pain, weight loss, jaundice.

Diagnostics

  • Imaging: Triphasic CT or MRI, Alpha-fetoprotein (AFP) levels.

Management

  • Resection, liver transplantation, palliative care.

Cholangiocarcinoma

  • Risk Factors: Choledochal cysts, UC, infectious agents.

  • Clinical Presentation: Asymptomatic early, later RUQ pain, jaundice.

  • Diagnostics: Imaging and tumor markers.

  • Management: Surgical resection dependent on tumor location.

GALLSTONE DISEASE

Risk Factors

  • Age, gender, diet, obesity, pregnancy, rapid weight loss.

Clinical Presentation

  • Biliary colic, RUQ pain, may be asymptomatic.

Diagnostic Tests

  • Ultrasound, CT, MRCP.

Management

  • Surgical intervention (open vs laparoscopic), ERCP for complications.

BILE DUCT STRICTURES

Causes and Management

  • Causes include operative injuries, TB, sclerosing cholangitis.

  • Management focuses on restoring biliary continuity and controlling inflammation.