DISEASES OF THE LIVER

Viral HEPATITIS
• Hepatitis A
• Single strand RNA
• Transmitted by fecal-oral
• (contaminated food or water)
• Incubation period 2-4w
• Never lead to chronic liver disease
• Detected by serum IgM antibodies
• Hepatitis B
• Double strand DNA
• Transmitted by parenteral, sexual contact,
perinatal
• Incubation period 1-4months
• 10% lead to chronic liver disease
• Detection of HBsAg or antibody to HBcAg
• Hepatitis c
• Single strand RNA
• Transmitted by parenteral, Intranasal cocaine
use
• Incubation period 7-8 weeks
• 80% leads to chronic liver disease
• Detection of HCV RNA Antibody detection
• Hepatitis D
• Circular defective single strand RNA
• Transmit parentally
• Incubation period 2-4w
• 5% leads to chronic liver disease
• Detection of IgM and IgG antibodies,
HDV In serum, HDAg in liver
• Hepatitis E
• Single strand RNA
• Transmit by fecal –oral
• Incubation period 4-5 w
• Never leads to chronic liver disease
• PCR for HEV ,detection of serum IgM
and IgG antibodies
 Outcomes
• ASYMPTOMATIC
Incidental ( B,C,D)
↑ Serum Transaminases
Antiviral antibodies

• SYMPTOMATIC ( PRE- ICTERIC)

Non specific
Serum sickness-like ( HBV )
↑ Serum Transaminases
• CONVALESCENCE
Recovery
• PROGRESSION

Fulminant hepatitis
Chronic hepatitis
Carrier state
 Diagnosis of Acute Hepatitis
• To diagnose hepatitis
– Biochemistry
• Serum Bilirubin (Total & Conjugated)
• AST / ALT / ALP

• To determine etiology
– Serology (Initial testing)
• HBsAg, IgM Anti-HBc , Anti-HCV Ab, Anti-HAV Ab
• HBeAg, Anti-HEV Ab
– Molecular biology (Usually not required)
• HCV RNA
• HBV DNA
 Diagnosis of Chronic Hepatitis
• To diagnose chronic hepatitis
– Biochemistry
• AST / ALT (persistent elevation 6 months )
• To determine etiology
– Serology
• HBsAg, HBeAg, Anti-HCV Ab
– Molecular biology (for quantification, guided by
serology)
• HBV DNA
• HCV RNA
 Acute / Chronic Hepatitis
co-infections

• HDV occurs only along with HBV infection

• Co-infection of HBV and HCV may occur

• HBV or HCV may coexist with HIV infection

LIVER ABSCESS
— Pyogenic abscess, which is most often
polymicrobial, accounts for 80% of hepatic
abscess cases in the United States.
— Gram +ve , gram –ve,Anerob
— Amebic abscess due to Entamoeba histolytica
accounts for 10% of cases.
— Fungal abscess, most often due to Candida
species, accounts for less than 10% of cases
 AMOEBIC LIVER ABSCESS
• Protozoan parasite: Entamoeba histolytica
• Exposure via fecal-oral route Humans are the
principal host
• Source of infection is the cyst-passing
chronic patient or asymptomatic carrier
• It results from spread of the organisms from
the intestinal submucosa to the liver via the
portal system
 Clinical Features
— History
The most frequent symptoms of hepatic abscess include the
following:
a) Fever (either continuous or spiking)
b) Chills
c) Right upper quadrant pain
d) Anorexia
e) Malaise

- Referred pain to the right shoulder may be present.

- Fever of unknown origin (FUO) frequently can be an initial
diagnosis in indolent cases. Multiple abscesses usually result in
more acute presentations, with symptoms and signs of systemic
toxicity.
- Afebrile presentations have been documented!
— Physical Findings

Fever and tender hepatomegaly are the most common

signs.
Mid epigastric tenderness, with or without a palpable mass,
is suggestive of left hepatic lobe involvement.
Decreased breath sounds in the right basilar lung zones, with
signs of atelectasis and effusion on examination or
radiologically, may be present.
A pleural or hepatic friction rub can be associated with
diaphragmatic irritation or inflammation of Glisson capsule.
Jaundice may be present in as many as 25% of cases and
usually is associated with biliary tract disease or the
presence of multiple abscesses.
 Current indications for the surgical treatment
of amoebic liver abscess
Surgical intervention :-
– perforated amebic colitis, massive GI bleeding, or
toxic megacolon.
– Amebic liver abscess generally responds to medical
therapy alone and drainage is seldom necessary.
– When necessary, imaging-guided percutaneous
treatment (needle aspiration or catheter drainage)
has replaced surgical intervention as the procedure of
choice for reducing the size of an abscess.
Indications for drainage : -
– Presence of left-lobe abscess (>10 cm in diameter)
– Rupture and
– abscess that does not respond to medical therapy
within 3-5 days
 Complications
— metastatic complications e.g., CNS infection or
endophthalmitis ( usually with K pneumoniae infection.
— sepsis
— abscess rupture – presents as peritonitis or pneumoperitoneum.
— subphrenic abscess - Patients may have symptoms of diaphragmatic
irritation.
— pleuropulmonary or hepatobronchial fistula - Patients may present
with a cough, productive of purulent sputum. Metallic-
tasting sputum has been reported
— abdominal or hepatic venous thrombosis
— liver failure - More common in people with pre-existing liver
disease, or large abscesses
— acute pancreatitis - rare complication. Presents with acute
epigastric pain and vomiting.
— fistula to adjacent organs - such as to the stomach, colon, small
bowel, or kidney
HYDATID CYST
Life cycle of [Link]
• The right lobe is the most frequently
involved portion of the liver.
• Once in the human liver, cysts grow to 1
cm during the first 6 months and 2–3 cm
annually thereafter, depending on host
tissue resistance.
 Surgical Management
• Indications:
1-Large liver cysts with multiple daughter cysts;
superficially located single liver cysts that may
rupture (traumatically or spontaneously).
2-liver cysts with biliary tree communication or
pressure effects on vital organs or structures.
3-infected cysts .
4-cysts in lungs, brain, kidneys, eyes, bones .
 Medical therapy
• Indications:
• primary liver or lung cysts that are inoperable
(because of location or medical condition), patients
with cysts in 2 or more organs, and peritoneal cysts.
• Chemotherapeutic agents:
• (albendazole and mebendazole).
• Albendazole is administered in several 1-month oral
doses (10-15 mg/kg/d) separated by 14-day intervals.
for 3-6 months,
• Mebendazole is also administered for 3-6 months
orally in dosages of 40-50 mg/kg/d.
 PAIR ( puncture ,Aspiration ,Instillation
,Re-aspiration)
• This technique, performed using either ultrasound or
CT guidance, involves aspiration of the contents via a
special cannula, followed by injection of a scolicidal
agent for at least 15 minutes, and then reaspiration
of the cystic contents. The cyst is then filled with
isotonic sodium chloride solution. Perioperative
treatment with a benzimidazole is mandatory (4 d prior
to the procedure and 1-3 mo after).
• The cysts should be larger than 5 cm in diameter and
type I or II according to the Gharbi ultrasound
classification of liver cysts
CIRRHOSIS
 Cirrhosis
Definition : It is an end stage of chronic liver
disease characterized by :
[Link] fibrous septae : Scars extending
between portal tracts; portal tract and
central vein
[Link] nodules : Proliferating
hepatocytes encircled by fibrosis
[Link] of the architecture of the entire
liver
Gross -Normal
Cirrhosis
 Classification
Based on the size of the nodules
• Micronodular : ( < 3 mm size) : Alcoholic liver
disease, hemochromatosis, Biliary cirrhosis.
• Macronodular : ( > 3 mm size) : Viral hepatitis,
Wilson disease, Indian childhood cirrhosis
• Micro-macro nodular (Mixed) : alcoholic, drug
induced
PORTAL HYPERTENSION
• Elevation of portal venous pressure >5mm Hg
• Clinically significant - >10mm Hg
• Risk of variceal bleeding - >12mm Hg
 Pathogenesis

• Increased resistance to the portal blood flow

• Causes :
[Link] : Obstructive thrombosis, narrowing
of portal vein
[Link] hepatic: right heart failure, constructive
pericarditis, hepatic vein outflow obstruction
[Link] : Cirrhosis, schistosomiasis,
massive fatty change, diffuse granulomatous
disease (sarcoidosis, miliary TB)
 Portosystemic Venous Shunts

Sites : -
Rectum – hemorrhoids.
Cardioesophageal junction – Esophagogastric
varices- in 65% of pts with advanced cirrhosis –
life threatening hemetemesis.
–Periumbilical & abdominal wall collaterals –
caput medusae ; important clinical hall mark
of portal hypertension
LIVER TUMOURS
• Benign
• Malignant
• Metastatic: colon, lung, and breast
• Tumour like conditions
Cavernous hemangioma