Advisor : dr.

Sjaiful Bachri, SpB

Melissa L. Thenata
Fakultas Kedokteran Universitas Tarumanagara

Liver Structure
Largest gland in the body

(1.5 Kg)
Under the diaphragm, within

the rib cage in the upper

right quadrant of the

abdomen

Liver Structure
4 lobes: major (left and right),

minor (caudate and quadrate)

Ducts: common hepatic, cystic

from gall bladder, common bile

choledochus (join pancreatic
duct at hepatopancreatic
ampulla)

Liver Structure
Liver lobules hexagonal structures consisting of hepatocytes

Hepatocytes radiate outward from a central vein

At each of the six corners of a lobule is a portal triad
Liver sinusoids

Liver Structure
Hepatocytes produce bile

Bile flows through canals

called bile canaliculi to a

bile duct
Bile ducts leave the liver

via the common hepatic

duct

Liver Function
Regulating homeostasis of carbohydrate, lipid and amino

acid metabolism.
Storing nutrients such as glycogen, fats and vitamin B12, A

and K.
Producing and secreting plasma proteins and lipoproteins,

including clotting factors and acute phase proteins.

Liver Function
Synthesizing and secreting bile salts for lipid digestion.

Detoxifying and excreting bilirubin, other endogenous waste

products and exogenous metal ions, drugs and toxins

(xenobiotics).
Clearing toxins and infective agents from the portal venous

blood whilst maintain systemic immune tolerance to antigens

in the portal circulation.

Gall Bladder Structure

Thin-walled green muscular sac

On the inferior surface of the liver

Stores bile that is not immediately needed for digestion
When the muscular wall of the gallbladder contracts bile is

expelled into the bile duct

Gall Bladder Structure

Gall Bladder Function

Stores 60 mL of bile, released when food containing fat

enters the digestive tract.

The bile, produced in the liver, emulsifies (breaks down) fats

and neutralizes acids in partly digested food.

Biliary Atresia
Obliteration or discontinuity of the extrahepatic biliary system,

resulting in obstruction to bile flow, in the first few weeks of life.

Inflammatory process from an unknown cause affects the bile duct

in the newborn infant.

Destruction of the extrahepatic bile ducts, causing obstructive

jaundice and liver failure.

Kasai procedure, surgical correction of this abnormality before 8

weeks of age produces the best outcome.

Choledochal Cyst
Cystic dilatation of the intra- or extrahepatic ducts is a rare

condition, usually presenting before the age of 16 years.

Symptoms : cholangitis, pancreatitis, stone formation and jaundice.

Infants may occasionally present with an abdominal mass.

The cause of this condition is debated.

Choledochal Cyst
Cysts are classified according

to their site and shape,

although 80% are fusiform
abnormalities of the

extrahepatic bile duct. Type

II cysts are extremely rare.

Choledochal Cyst
Treated by surgical excision

of the cyst with the

formation of a roux-en-Y
anastomosis to the biliary

duct.

Hepatobiliary Trauma
The liver is the most commonly injured solid abdominal organ,

despite its relative protected location.

Treatment of traumatic liver injuries is based on patient

physiology, mechanism and degree of injury, associated

abdominal and extra-abdominal injuries and local expertise.

Hepatobiliary Trauma
Liver Organ Injury Scale
Grade
I

II

III

Description
Hematoma

Subcapsular, <10% surface area

Laceration

Capsular tear, <1 cm parenchymal depth

Hematoma

Subcapsular, <10% - 50% surface area;

intraparenchymali, <10 cm in length

Laceration

1-3 cm parenchymal depth, <10 cm in length

Hematoma

Subcapsular, >50% surface area or expanding;

ruptured subcapsular or parenchymal hematoma

Laceration

<3 cm parenchymal depth

Hepatobiliary Trauma
Liver Organ Injury Scale
Grade

Description

IV

Hematoma

Parenchymal disruption involving 25% - 75% of

hepatic lobe or 1-3 Couinaud segments within a
single lobe

Laceration

Parenchymal disruption involving >75% of hepatic

lobe >3 Couinaud segments within a single lobe

Vascular

Juxtahepatic venous injuries; ie. Retrohepatic

vena cava/central major hepatic vein

VI

Hepatic avulsion

Management of Hepatic Trauma

Gall Bladder Cancer

Highly aggressive malignancy, usually presents at an advanced,

incurable stage, 5th most common gastrointestinal tumor

The median survival is less than 6 months after diagnosis
Women : Men = 2 6 : 1

The incidence steadily increases with age

Risk factor : obesity, a high-carbohydrate diet, smoking, and

alcohol use

Gall Bladder Cancer

Gall bladder cancer arises in the setting of chronic

inflammation. In the vast majority of patients (>75%), the

source of this chronic inflammation is cholesterol gallstones.
10-25% is caused by calcification of the gallbladder (porcelain

gallbladder)
Most common type of gallbladder cancer is adenocarcinoma.
Gallbladder cancer can spread by direct invasion through the

gallbladder wall into the liver or peritoneal cavity.

Gall Bladder Cancer

The symptoms of gallbladder cancer overlap with the

symptoms of gallstones and biliary colic. Abdominal pain may

be of a more diffuse and persistent nature than the classic
right upper quadrant pain of gallstone disease.
Jaundice, anorexia, and weight loss often indicate more

advanced disease.

Gall Bladder Cancer

Table 2. Summary of the Tumor-Node-Metastasis (TNM) Staging System*
Stage

Description

Mucosal or muscular invasion (T1N0M0)

Perimuscular-tissue invasion (T2N0M0)

Transmural invasion, liver invasion < 2 cm; lymph node metastasis to

hepatoduodenal ligament (T3N0M0, T13 N1M0)

4A

Liver invasion > 2 cm (T4N0M0, T4N1M0)

4B

Distant nodal (outside porta hepatis) or hematogenous metastasis

(TxN2M0, TxNxM1)

Gall Bladder Cancer

The work-up for right-upper-quadrant pain or biliary colic

generally starts with an ultrasound examination of the

gallbladder.
Laboratory tests should include liver function tests and

hematocrit. Advanced cases may demonstrate anemia and

elevated alkaline phosphatase and bilirubin.
Tumor markers, CEA and CA 19-9, may be of help and should

be considered if gallbladder cancer is suspected.

Gall Bladder Cancer

Further radiologic work-up such as CT-scan, MRI, or needle

biopsy are indicated if gallbladder cancer is suspected.

The most common and most effective treatment is surgical

removal of the gallbladder (cholecystectomy) with part of liver

and lymph node dissection.
Chemotherapy has not shown significant activity in gallbladder

carcinoma. Typically, 5-fluorouracil (5-FU) has been used with

response rates of 10-24% in advanced disease.

Gall Bladder Cancer

Gemcitabine has shown activity in gallbladder cancer. There is

an increased response rate with gemcitabine combination with

cisplatinum and capecitabine.
Currently, no clearly defined standard exists for chemotherapy

in gallbladder cancer. Patients should be encouraged to

participate in clinical trials.

Cholangiocarcinoma
Cholangiocarcinomas are malignancies of the biliary duct system

that may originate in the liver and extrahepatic bile ducts, which
terminate at the ampulla of Vater.
The etiology of most bile duct cancers remains undetermined.

However, one of the most commonly recognized risk factors is

primary sclerosing cholangitis.
Cholangiocarcinoma arises from the intrahepatic or extrahepatic

biliary epithelium. More than 90% are adenocarcinomas.

Cholangiocarcinoma
Cholangiocarcinomas tend to grow slowly and to infiltrate the

walls of the ducts, dissecting along tissue planes.

Local extension occurs into the liver, porta hepatis, and regional

lymph nodes of the celiac and pancreaticoduodenal chains.

Symptoms of cholangiocarcinoma include jaundice, clay-colored

stools, bilirubinuria (dark urine), pruritus, weight loss, and

abdominal pain.

Cholangiocarcinoma
The diagnosis and staging of cholangiocarcinoma require a

multimodality approach involving laboratory, radiologic,

endoscopic, and pathologic analysis.
The most studied serum tumor markers are the CA 19-9, is

currently the most commonly used tumor marker for

cholangiocarcinoma.
Surgical resection with curative intent is the treatment of

choice for extrahepatic cholangiocarcinoma.

Gallstones
Two major types of gallstones: cholesterol and

pigment stones. Cholesterol gallstones contain50%

cholesterol monohydrate. Pigment stones have 20%
cholesterol and are composed primarily of calcium

bilirubinate.
Predisposing factors include demographic/genetics,

obesity, weight loss, female sex hormones, age, ileal

disease, pregnancy, type IV hyperlipidemia, and
cirrhosis.

Gallstones
Many gallstones are

silent. Symptoms occur

when stones produce
inflammation or

obstruction of the cystic

or common bile ducts.

Gallstones
Major symptoms: (1) biliary colica severe steady ache in the

RUQ or epigastrium that begins suddenly; often occurs 3090

min after meals, lasts for several hours, and occasionally
radiates to the right scapula or back; (2) nausea, vomiting.

Physical exam may be normal or show epigastric or RUQ

tenderness.
Mild and transient elevations in bilirubin [85 mol/L (5 mg/dL)]

accompany biliary colic.

Gallstones
Only 10% of cholesterol gallstones are

radiopaque. USG is best diagnostic test.

Elective cholecystectomy should be

reserved for: (1) symptomatic patients;

(2) persons with previous complications

of cholelithiasis; and (3) presence of an
underlying condition predisposing to an

increased risk of complications (calcified

or porcelain gallbladder).

Gallstones
Patients with gallstones 3 cm or with an anomalous gallbladder

containing stones should be considered for surgery.

Laparoscopic cholecystectomy is minimally invasive and is the

procedure of choice for most patients undergoing elective

cholecystectomy.
Oral dissolution agents (ursodeoxycholic acid) partially or

completely dissolve small radiolucent stones in 50% of selected

pts within 624 months.

Gallstones
Extracorporeal shockwave lithotripsy followed by medical

litholytic therapy is effective in selected patients with solitary

radiolucent gallstones. Because of the frequency of stone
recurrence and the effectiveness of laparoscopic surgery, the

role of oral dissolution therapy and lithotripsy has been

reduced to selected patients who are not candidates for
elective cholecystectomy.

Acute Cholecystitis
Acute inflammation of the gallbladder usually caused by cystic

duct obstruction by an impacted stone.

90% calculous; 10% acalculous.
Acalculous cholecystitis associated with higher complication rate

and associated with acute illness (i.e., burns, trauma, major

surgery), fasting, hyperalimentation leading to gallbladder stasis,
vasculitis, carcinoma of gallbladder or common bile duct, some

gallbladder infections but in > 50% of cases an underlying

explanation is not found.

Acute Cholecystitis
Signs and symptoms :
Attack of bilary colic (RUQ or epigastric pain), progressively worsens
Nausea, vomiting, anorexia
Fever

Examination typically reveals RUQ tenderness

Palpable RUQ mass found in 20% of patients
Murphys sign is present when deep inspiration or cough during

palpation of the RUQ produces increased pain or inspiratory arrest.

Acute Cholecystitis
Laboratory : Mild leukocytosis; serum bilirubin, alkaline

phosphatase, and AST may be mildly elevated.

Imaging : Ultrasonography is useful for demonstrating

gallstones and occasionally a phlegmonous mass surrounding

the gallbladder. Radionuclide scans may identify cystic duct
obstruction.

Acute Cholecystitis
No oral intake, nasogastric suction, IV fluids and electrolytes,

analgesia (meperidine or NSAIDS), and antibiotics

(ureidopenicillins, ampicillin sulbactam, third-generation
cephalosporins; anaerobic coverage should be added if

gangrenous or emphysematous cholecystitis is suspected;

consider combination with aminoglycosides in diabetic patient
or others with signs of gram-negative sepsis).

Acute Cholecystitis
Acute symptoms will resolve in 70% of patient.

Optimal timing of surgery depends on patient stabilization and

should be performed as soon as feasible.

Urgent cholecystectomy is appropriate in most patients with a

suspected or confirmed complication.

Delayed surgery is reserved for patients with high risk of

emergent surgery and where the diagnosis is in doubt.

Chronic Cholecystitis
Chronic inflammation of the gallbladder; almost always

associated with gallstones. Results from repeated

acute/subacute cholecystitis or prolonged mechanical
irritation of gallbladder wall.
May be asymptomatic for years, may progress to symptomatic

gallbladder disease or to acute cholecystitis, or present with

complications.

Chronic Cholecystitis
Laboratory tests are usually normal.

Ultrasonography preferred; usually shows gallstones within a

contracted gallbladder.
Surgery indicated if patient is symptomatic.

Liver Infections Pyogenic Abscess

Pyogenic or bacterial abscess may be caused by several factors.

Infections may arise from the biliary tract, portal vein and hepatic
artery or by direct extension.
Symptoms : pyrexia and rigours associated with right upper

quadrant pain, general malaise and anorexia.

Examination may reveal tender hepatomegaly. A pleural effusion

may be present. Occasionally, hypotension and cardiovascular

collapse may be the presenting symptoms.

Liver Infections Pyogenic Abscess

Laboratory tests : hyperbilirubinemia, raised alkaline

phosphatase and transaminase levels, blood cultures are

frequently positive, leucocytosis.
USG / CT scan abdomen : to determine the size, characteristics,

number and anatomical location of the liver abscesses.

Chest X-ray : elevated hemidiaphragm or a pleural effusion.
ERCP or a colonoscopy : to determine the cause of pyogenic

liver abscesses.

Liver Infections Pyogenic Abscess

Treatment :
Analgesics and attention to adequate nutrition and hydration
Antimicrobial therapy
Drainage of the abscess
Frequent clinical, biochemical, microbial and radiological

follow-up is required to assess progress and detect relapses

Liver Infections Amoebic Liver Abscess

Amoebic infestation is caused by the organism Entamoeba

histolytica.
Transmission is by passage of cysts in the stool, the cysts then

being ingested orally as a result of poor hygienic practices.

Risk factors include malnutrition, depressed immunity and low

socioeconomic status.
Complications of amoebic abscess include rupture into the

peritoneal cavity or hollow viscus such as colon or stomach.

Liver Infections Amoebic Liver Abscess

The onset of the disease may be sudden or gradual.

The most common symptoms : right upper quadrant pain,

general malaise, weight loss, pyrexia and sweating.

Signs : tender hepatomegaly and, occasionally, jaundice.
Full blood examination : leukocytosis and eosinophilia.

Amoebic serology and stool cultures are usually positive.

The antibiotic of choice is metronidazole.

Benign Liver Tumors - Adenoma

Hepatocellular adenomas occur most commonly in women in

the third or fourth decades who take birth control pills.

The major concern is their tendency to rupture with massive

haemorrhage; therefore, this condition must be considered in

young women presenting with abdominal pain, signs of
hypovolaemic shock and features of haemoperitoneum.
After resuscitation, the treatment is resection of the affected

liver segment.

Benign Liver Tumors Focal Nodular Hyperplasia

Focal nodular hyperplasia (FNH) is not a true neoplasm but is

probably due to a fibrous reaction to vessel ingrowth.

It is most common in young women.
It appears as a nodular firm vascular mass.
There may be symptoms of right upper quadrant pain.

No specific treatment is required and the main purpose of

management is to distinguish the lesion from neoplasms.

Hepatocellular Cancer (Hepatoma)

Worldwides most common tumor.

Male : female = 4 : 1; tumor usually develops in cirrhotic liver

in persons in fifth or sixth decade.

High incidence in Asia and Africa is related to etiologic

relationship between this cancer and hepatitis B and C

infections.

Hepatocellular Cancer (Hepatoma)

Aflatoxin exposure contributes to etiology and leaves a molecular

signature, a mutation in codon 249 of the gene for p53.

Surgical resection or liver transplantation is therapeutic option but

rarely successful.
Hepatitis B vaccine prevents the disease. Interferon may prevent

liver cancer in persons with chronic active hepatitis C disease and

possibly in those with hepatitis B.
Ribivarin / interferon (IFN) is most effective treatment of chronic

hepatitis C.