A lecture for undergraduate students

1. Amr Badawy
Assistant lecturer

2.  Benign liver tumors are extremely frequent
and mostly asymptomatic.
 Each cellular component of the liver ( e.g.
hepatocyte, biliary endothelium, or other
mesenchymal cells) can undergo benign
proliferation, but only three lesions have
common clinical relevance:
◦ Hemangioma
◦ Focal nodular hyperplasia
◦ Hepatocellular adenoma

3.  Most common benign solid
tumors of the liver.
 They are usually single and
less than 5 cm in diameter,
Lesions greater than 5 cm
are arbitrarily called giant
hemangiomas.
 F:M of 5:1
 Occur more commonly in
adults than in children

4.  Clinical Manifestations :
 Most of patients with hemangioma
are asymptomatic
 But few of them may present with
chronic mild right upper quadrant
abdominal pain, increasing
abdominal girth, early satiety, nausea,
vomiting, and/or prolonged fever.
 Rare presentations have been
reported, including
1. Obstructive jaundice
2. Torsion of a pedunculated lesion
3. Spontaneous rupture with
intraperitoneal hemorrhage

5.  Diagnosis :
 U/S : hyperechoic masses
clearly demarcated from the
surrounding liver; the addition of
duplex US can provide further
information on peripheral blood
flow and central pooling of
venous blood.

6.  CT: peripheral enhancement
after the initial injection of
contrast material. Delayed
CT scanning demonstrates
central filling of the
hypodense lesion.
(Progressive centripetal
filling)

7.  MRI is considered to be
the most sensitive and the
most specific diagnostic
study.
 It appears as a
hypointense lesion on
T1-weighted sequences
and strongly
hyperintense lesion on
T2-weighted sequences
with a “light bulb”
pattern.

8.  Treatment :
◦ In nearly all cases of
asymptomatic
hemangiomas,
observation is the most
appropriate treatment.
◦ If symptomatic , they
can be treated by
enucleation or a formal
segmental or lobar
resection

9.  Hepatic hemangiomas of infancy and childhood are different
from those seen in adults.
 The lesion is typically large, and symptoms are rarely subtle.
 The vast venous lakes within the lesion can function as
tremendous siphons for a large proportion of the total cardiac
output, leading to congestive heart failure and death.

10.  The risk of spontaneous rupture of a hepatic hemangioma in infancy
is much greater than that of such tumors in Adults.
 Kasabach-Merritt syndrome, associated with life-threatening
thrombocytopenia and afibrinogenemia, occurs much more
frequently in infants than in adults.

11.  The initial treatment usually consists of digitalis,
diuretics, oxygen, corticosteroids, and ligation of the
hepatic artery.
 Life-saving resection or enucleation of the lesion should
be done

12.  The second most common
benign tumor of the liver.
 Predominantly discovered
in young women
 Usually a small (<5 cm)
nodular mass arising in a
normal liver.

13.  Pathology :
 Grossly: well circumscribed,
unencapsulated, usually
solitary mass with a central
fibrous scar that radiates into
the liver parenchyma.
 Microscopically: hepatocytes
arranged in nodules delineated
by fibrous septa originating
from the central scar.

14.  The etiology of FNH is not known. but the most common theory is
that FNH is related to a developmental vascular malformation.
 Not related to female hormones or OCPs

15.  Clinical Presentation :
 In most patients, FNH presents as an incidental finding at
laparotomy or more commonly on imaging studies.
 If symptoms are noted, they are most often vague abdominal
pain.
 Rupture, bleeding, and infarction are exceedingly rare, and
malignant degeneration of FNH has never been reported

16.  Diagnosis :
 Contrast-enhanced CT and MRI
have become accurate methods of
diagnosing FNH.
 Demonstrate a homogeneous
mass with a central scar that
rapidly enhances during the
arterial phase of contrast
administration.
 Technetium-99m-labeled sulfur
colloid scintigraphy may be
helpful in demonstrating the
presence of Kuppfer’s cells.

17.  Management :
 Asymptomatic patients with typical radiologic features do not
require treatment.
 If diagnostic uncertainty exists, resection may be necessary for
histologic confirmation.
 Patients with persistent symptomatic FNH or an enlarging mass
need to be considered for resection

18.  Occur in reproductive-aged
women.
 small (< 5 cm), soft, solitary
lesions, but may be multiple
in up to 30% of cases.
 There is an etiologic link
between OCP usage and the
development of a hepatic
adenoma.

19.  the risk of developing a hepatic adenoma while taking OCP may
be related to the amount of estrogen in OCP preparation.
 In addition to estrogens, several other hormone therapies,
including androgens, clomiphene, danazol and human growth
hormone have been linked to the development of hepatic
adenomas

20.  Individuals affected with type I glycogen storage disease,
galactosemia, Klinefelter’s syndrome, and Turner’s syndrome may
also have an increased incidence of hepatic adenomas.
 There is no convincing evidence linking pregnancy to the
development of hepatic adenoma, but it may increase the incidence
of complications associated with hepatic adenomas like rupture

21.  Pathology :
 Grossly hepatic adenomas appear pale
yellow on cut surface, and may contain a
variegated appearance secondary to
internal hemorrhage .
 Microscopically, hepatic adenomas are
composed of monotonous sheets of
hepatocytes, often containing considerable
glycogen.
 Unlike FNH, portal triads and bile ducts
are absent and the existing blood vessels
are thin-walled

22.  Clinical Presentation:
◦ Small adenomas are asymptomatic.
◦ Large adenoma: Abdominal pain ,Fullness or discomfort.
 Complications:
1. an acute rupture and intraperitoneal bleeding(20-40%
more in women, during pregnancy, >5cm)).
2. Malignant transformation (10%, more in men with large
adenoma)

23.  Diagnosis :
◦ Ultrasonography:
 well delineated heterogenous
hepatic mass
◦ CT:
 hypervascular and heterogenous
on arterial phase
◦ MRI:
 Adenoma appears hyperintense
(due to fat content) on T1-
weighted images and mildly
hyperintense on T2 weighted
images

25. Small lesions (<4 cm): low risk of complications can be
observed after cessation of OCPs and avoidance of pregnancy
(may regress).
Adenomas >4 cm: Surgical resection is indicated to avoid
complications.
Management :

26. 1. Biliary Hamartomas
2. Solitary Fibrous
Tumor
3. Angiomyelipoma,
Lipoma
4. mesenchymal
hamartoma
5. Myxoma
6. Teratoma

28. 1. Parasitic Hydatid Liver Cyst
◦ Caused by the dog tapeworm, Echinococcus granulosus.
◦ Dogs are the definitive host
◦ Human infection follows accidental ingestion of ova passed in dog
faeces.
◦ The ova penetrate the intestinal wall and pass through the portal vein
to the liver, lung, and other tissues.

30. • Usually asymptomatic but may
present with abdominal pain,
dyspepsia, and vomiting.
• Physical findings: Hepatomegaly
may be present .

31. ◦ Complications include :
 Bacterial superinfection
 Rupture into the pleural, pericardial cavity or the bronchial tree
 Perforation into adjacent viscus (stomach, duodenum)
 Rupture into the biliary tree causing obstructive jaundice,
cholangitis
 Rupture into the peritoneal cavity result in disseminated
echinococcosis and a potentially fatal anaphylactic reaction

32.  Diagnosis :
◦ Lab.Ix : Indirect
hemagglutination test
(IHA) and ELISA test for
anti-Echinococcus
antibodies (IgG).
◦ Casoni skin test (+ve in
25% of patients)
◦ U/S
◦ CT Abdomen
 Around 10% of patients with a liver
cyst will also have a lung hydatid
on chest radiography

33.  Treatment :
◦ It is primarily surgical
◦ laparoscopic or open complete
cyst removal with instillation
of a scolicidal agent is curative.
◦ Scolicidal agents include
formalin, hydrogen perioxide,
hypertonic saline (15-20%)
chlorhexidine, alcohol (70-
95%) and cetrimide.
◦ Albendazole or
Mebendazole is given for
two weeks
postoperatively to prevent
recurrence.

34.  PAIR (puncture,
aspiration, injection
and reaspiration)
has become more
accepted in some
institutions
 Indications include:
◦ Inoperable cases
◦ refusing surgery
◦ relapse after surgery
or chemotherapy
◦ Multiple cysts in
Segment I, II, III

35.  Treatment :
◦ Medical treatment with
Albendazole or Mebendazole
can be used in patients unfit for
surgery and in those with
disseminated, recurrent, or
inoperable disease and as an
adjuvant in complex surgery.

36.  About 10% of the world's
population is chronically infected
with Entamoeba histolytica.
 Amoebiasis is the third
commonest parasitic cause of
death, surpassed only by malaria
and schistosomiasis

37.  Pathogenesis
◦ The parasite is transmitted through the faecooral route with the
ingestion of viable protozoal cysts.
◦ The cyst wall disintegrates in the small intestine, releasing motile
trophozoites. These migrate to the large bowel, where pathogenic
strains may cause invasive disease.
◦ Mucosal invasion results in the formation of flaskshaped ulcers
through which amoebae gain access to the portal venous system.
◦ The abscess is usually solitary and affects the right lobe in 80% of
cases. The abscess contains sterile pus and reddishbrown (“anchovy
paste”) liquefied necrotic liver tissue

38.  Clinical Presentation :
◦ Unlike pyogenic abscesses, amoebic abscesses are more subacute, and it
may take weeks for symptoms to appear.
◦ Usually Present with :
◦ Fever (38 – 39)
◦ localized epigastric abdominal and right upper quadrant pain .
◦ When the abscess lies adjacent to the diaphragm, there may be referred
shoulder pain, cough, or even pleurisy.
◦ Gastrointestinal symptoms may be present in about 25% of patients and
include nausea, vomiting, abdominal distension, and diarrhea
 Complications :
◦ Secondary infection
◦ Rupture into adjacent structures such as pleural, pericardial, or
peritoneal spaces.

39.  Diagnosis :
◦ Lab.Ix : -
A. Serological tests provide a rapid means of confirming the diagnosis
including:
 E.histolytica antibodies detection using EIA (enzyme immunoassay)
 E.histolytica antigen detection using ELISA
B. Stool studies:
 Stool antigen detection using EIA or PCR.
 Microscopic examination for cysts ( of little value).

40.  Diagnosis :
◦ U/S
◦ CT Abdomen

41.  Treatment :
◦ Medical Rx :
 metronidazole alone (800 mg, three times a day for five days)
 Supportive measures such as adequate nutrition and pain relief
 diloxanide furoate 500 mg, eight hourly for seven days, to eliminate intestinal amoebae.
◦ U/S guided aspiration ( rarely need therapeutic drainage)
 if serology gives negative results
 the abscess is large ( > 10 cm)
 if they do not respond to treatment
 if there is impending peritoneal, pleural, or pericardial rupture
◦ Surgical drainage :
 if the abscess has ruptured causing amoebic peritonitis
 if the patient has not responded to drugs despite aspiration.

42.  Aetiology
◦ Most pyogenic liver abscesses are secondary to infection originating in
the abdomen.
◦ In 15% of cases no cause can be found (cryptogenic abscesses)
◦ Diabetes mellitus has been noted in 15% of adults with liver abscesses.

43. Origins and causes of pyogenic liver abscess
1. Biliary tract
•Gall stones
•Cholangiocarcinoma
•Strictures
5. Trauma
2. Portal vein
•Appendicitis
•Diverticulitis
•Crohn's disease
6. Iatrogenic
•Liver biopsy
•Blocked biliary stent
3. Hepatic artery
•Dental infection
•Bacterial endocarditis
7. Cryptogenic
4. Direct extension of:
•Gall bladder empyema
•Perforated peptic ulcer
•Subphrenic abscess
8. Secondary infection of liver cyst

44.  Microbiology :
◦ Most patients presenting with
pyogenic liver abscesses have a
polymicrobial infection usually
with Gram negative aerobic
and anaerobic organismsn
including Escherichia coli,
Klebsiella pneumoniae,
bacteroides, enterococci

45.  Clinical Presentation :
◦ swinging Fever
◦ abdominal pain (RUQ)
◦ nocturnal sweating, vomiting, anorexia, malaise, and weight loss.
 Physical findings
◦ right upper quadrant tenderness (50%)
◦ hepatomegaly (40%)
◦ jaundice (30%).

46.  Diagnosis :
◦ Lab.Ix : -
 Leukocytosis
 Raised erythrocyte sedimentation rate
 Abnormal liver function tests
 Hypoalbuminemia
 Anemia
 Blood culture and culture from the abscess

47.  Diagnosis :
1. Chest and
Abdomen x-ray
 an air fluid level in the abscess
cavity.
 The right diaphragm is often
raised, with a pleural reaction

48.  Diagnosis :
2. U/S and CT
abdomen

49.  Management :
1. Antibiotic therapy
 empiric treatment with parenteral,
broadspectrum antibiotics should be
initiated until the result of culture
2. U/S or CT guided aspiration
or catheter drainage
3. Operative drainage
 Failure of antibiotic
therapy and aspiration
 Complications secondary
to catheter placement
(abscess rupture,
intracystic bleeding,
peritonitis)

51.  A 42-year-old woman presented with right upper quadrant
pain for 4 months. There were no associated systemic
symptoms. She was afebrile and not jaundiced on general
examination. Hepatomegaly with a smooth edge was
detected on palpation of the abdomen. Laboratory
investigations revealed normal liver function and the alpha
fetal protein (AFP) level was within normal limits. Viral
hepatitis serology was negative. A CT of the abdomen was
performed for further evaluation
A. What abnormality is demonstrated on this four-
phase dynamic contrast enhanced CT ?
B. What is the most likely diagnosis ?
C. What is the treatment

53.  64-year-old woman, with a known history of insulin
dependent diabetes mellitus, complained of right upper
quadrant pain, fever, chills and rigor for 2 days. On general
examination, she was febrile and looked ill. Abdominal
examination showed hepatomegaly with local tenderness
Laboratory investigations revealed raised white cell count
and normal bilirubin and alkaline phosphatase level. The
alpha fetal protein level was within normal limits.
A. What abnormalities can you see on the CECT ?
B. What is the most likely diagnosis ?
C. What is the most common cause ?
D. What is the treatment?

55.  A 50-year-old male patient, a native of
Cyprus, presents with a painful mass in the
right upper quadrant. The pain is a
continuous dull ache and has the features of
a mass arising from the right lobe of the liver.
The blood count shows raised eosinophils.
The CT scan shows a smooth space-
occupying lesion with multiple septa within it.
A. What is the diagnosis?
B. What is the treatment?