Pathology and dysfunction

The previous paragraphs stressed the normal anatomy and function, and touched on the problems one might encounter with hepatobiliary disease. The systematic review of all liver diseases is beyond the scope of this chapter; however, our focus will be on surgical pathologic states and the most commonly encountered problems on clinical rotations. What soon will be apparent is that many diseases converge in common pathways. Infectious diseases such as hepatitis B and C lead to hepatocytes damage and subsequent destruction of the liver architecture. Cholestasis as a result of obstructing stone disease, but also secondary to tumors, autoimmune disease or cystic disease leads to destruction of hepatocytes and liver architecture as well. With the loss of normal hepatic architecture and function, characteristic signs of liver failure surface can easily be understood based on the anatomy and function as discussed previously. For the sake of this chapter, we will divide liver disease in four broad categories: infections, stones, tumors, and chronic liver disease.

The liver is a major filter of pathogens, mainly originating from the gut but any other connection to the liver may be a portal of entry as well, including the blood supply, biliary tree, and even direct-penetrating trauma. Hepatitis is the common liver disease worldwide. Hepatitis B is indigenous to many parts of the world and is a common risk factor for primary malignancies of the liver. Hepatitis C is the most common infectious hepatitis currently in the United States. It affects 1 percent of the total population in the United States (10 million persons) and is currently the most common cause of end-stage liver disease resulting in liver transplantation.9 Hepatitis A-, B-, or C-associated liver disease is a medical problem, until complications of the disease result in a complication such as hepatocellular carcinoma (HCC) that can be surgically addressed. Hepatitis B or C is common risk factor for primary hepatic neoplasm, as well as cirrhosis, portal hypertension, and its sequela. Surgical therapies exist for some hepatic neoplasms in the form of resection or transplantation as well as medical refractory complications from portal hypertension.

Another common infectious entity in the liver is hepatic abscess. Once the physiologic clearance of bacteria is outmatched by the influx, localized liver infection can ensue. Commonly, when stasis of fluids occurs, an abscess is formed. Abscesses can result from biliary obstruction, trauma, or secondary to intraperitoneal processes such as diverticulitis or appendicitis. Probably because of the constant assault from the gut with bacteria, the microbial flora found in hepatic abscesses is often mixed with a predominance of gramnegative rods and anaerobic organisms. Escherichia coli and Klebsiella pneumoniae are common, but Staphylococcus aureus and enterococcus species are often found as well. Broad-spectrum antibiotic coverage is required. Prolonged treatment with antibiotics alone does not absolve the problem, and percutaneous drainage is the therapy of choice. Failure of percutaneous drainage is an indication for open surgical drainage and this should be pursued aggressively if percutaneous drainage fails to resolve the processes. Amebic abscesses are the exception to this rule. They usually respond to antibiotic treatment and percutaneous drainage is contraindicated. Amebic abscesses, however, are not very common in the United States and a simple blood test for antiamebic antibodies will be positive in 95 percent of patients with this condition.10

One of the more common causes of stasis and thus infection in the United States is gallstone disease. Bile salts, cholesterol, and calcium salts usually are found in perfect solution in bile; however, when an imbalance occurs, the bile salts come out of solution and precipitate into sludge or stones. Hemolytic states, such as due to sickle cell disease, results in the formation of pigmented stones, whereas high cholesterol states result in cholesterol stones, the most common form of gallstones. Mostly, these stones are formed where natural stasis of bile occurs in the gallbladder. Stones are, however, rarely formed in the bile ducts or intrahepatically. Stones are generally asymptomatic until they cause obstruction. Biliary pain can be caused by contraction of the gallbladder, but severe disease typically does not appear until a stone occludes the bladder or a duct. A gallbladder with stones is called cholelithiasis. Obstruction of the outflow of the gallbladder by a stone, results in cholecystitis inflammation of the gallbladder. When a stone has passed into the common bile duct, choledocholithiasis, it can result in stasis of bile inside the liver and result in a condition called cholangitis. Cholangitis can lead to sepsis and death if left untreated. If the stone obstructs the biliary tree at the site of the ampulla of Vater, this can result in stasis of pancreatic secretions and lead to pancreatitis.

For symptomatic cholecystitis and asymptomatic cholecystolithiasis in high-risk patient populations (i.e., diabetics), surgical removal of the gallbladder is indicated, which is one of the most commonly performed surgical procedures. A rare, but important complication of stone disease in elderly patients is gallstone ileus—a bowel obstruction secondary to the passing of a stone into the small bowel through a biliary-enteric fistula. This disease requires open surgical removal of the stone and cholecystectomy with repair of the fistula.

Likewise, neoplasms are commonly found in the liver. It is key to make the distinction between benign and malignant disease as well as true primary hepatic malignancies and metastatic disease from tumors of extrahepatic origin. The three most common benign primary liver tumors are hepatic adenomas

(HA), focal nodular hyperplasia (FNH), and hemangiomas. These tumors generally are asymptomatic, but diagnostic uncertainty may warrant resection in selected cases.11 HAs are more common in women and are thought to be associated with hormonal stimulation, most commonly oral contraceptives. These lesions mandate resection due to the risk of spontaneous rupture and hemorrhage as well as the very small risk of malignant transformation. While the size of the lesion may decrease with hormonal withdrawal, the risk of malignant transformation does not and resection is still warranted. Diagnosis of this lesion during pregnancy is problematic as the hormonal stimulation will not cease until delivery and risk of rupture is high. When possible, they should be resected at the safest time for both mother and fetus. FNH on the other hand, if asymptomatic, can be followed with sequential imaging (CT scan, MRI, and US). If the patient becomes symptomatic or the tumor enlarges, local ablation or resection is warranted. The key is the difference between the adenoma and FNH (Table 11-1). Each tumor has distinct characteristics on various forms of imaging that help in the diagnostic dilemma.

HCC or hepatoma is the most common primary hepatic malignancy.12 HCC is a cancer that is primarily found with chronic liver injury secondary to viral disease (hepatitis B and C), alcohol abuse, or other causes of cirrhosis.

Get Rid of Gallstones Naturally

Get Rid of Gallstones Naturally

One of the main home remedies that you need to follow to prevent gallstones is a healthy lifestyle. You need to maintain a healthy body weight to prevent gallstones. The following are the best home remedies that will help you to treat and prevent gallstones.

Get My Free Ebook


Post a comment