Liver
The liver is the largest solid organ located in the right upper region of the abdomen, just below the diaphragm. It plays many critical roles, including metabolism, detoxification, production of bile juices, storage of various nutrients, including proteins, and production of clotting factors.
The liver consists of two lobes: the right lobe, which is larger than the left lobe. It has a dual blood supply—one from the intestine and another from the heart.
The liver produces between 700 to 1000 ml of bile juice every day. This bile is emptied into the duodenum through bile ducts or tubes.
Considering its size and location, the liver is affected by a wide range of diseases. Commonly encountered diseases include:
- Infections – Viral, bacterial, and parasitic.
- Trauma.
- Cystic diseases of the liver.
- Benign diseases like hepatic adenomas and hyperplasia.
- Cancers.
1. Drainage of Liver Abscesses
The liver, being the largest solid organ in the body, may develop abscesses or collections of pus within its tissue, leading to various symptoms. These abscesses can be caused by bacterial infections, amoebic infections, or parasitic infections and may be either single or multiple.
Symptoms:
- Abdominal pain.
- Right lower chest pain with pain on deep inspiration.
- High-grade fevers with chills.
- Abdominal bloating.
- Nausea and vomiting.
- Jaundice.
- Occasional history of loose stools a few weeks back.
Diagnosis:
- Clinical examination.
- Blood investigations.
- Ultrasound abdomen and pelvis.
- CT abdomen and pelvis with oral and intravenous contrast.
- MRI.
Treatment:
- Conservative management – Antibiotics and analgesics.
- Percutaneous drainage – Ultrasound or CT guided.
- Surgical management – Laparoscopic / Open drainage.
Laparoscopic Drainage of Abscess:
Surgical drainage may be required for patients who have not improved with conservative treatment or in cases where the abscess bursts, causing pus to disperse throughout the abdomen. In such cases, using small keyholes, the abscess is punctured, pus is drained, and a drain tube is placed for any residual pus to exit.
2. Hydatid Cyst Excision
A hydatid cyst is a zoonotic infection that most commonly occurs in the liver, caused by a parasite, and is commonly seen in people living in proximity to cattle and pets.
Symptoms:
- Abdominal pain.
- Right lower chest pain with pain on deep inspiration.
- Occasional fevers.
- Abdominal bloating.
- Nausea and vomiting.
- Jaundice.
Diagnosis:
- Clinical examination.
- Blood investigations.
- Ultrasound abdomen and pelvis.
- CT abdomen and pelvis with oral and intravenous contrast.
- MRI.
Treatment:
- Percutaneous drainage – Ultrasound or CT guided - PAIR.
- Surgical management – Laparoscopic / Open excision of hydatid cyst / pericystectomy.
Laparoscopic Excision of Hydatid Cyst / Pericystectomy:
Surgical excision will be required in most cases. Surgery is performed after a course of medications (Tab. Albendazole), which is restarted after surgery for a duration of 3-4 weeks. The surgery is conducted using small keyholes, taking adequate precautions to avoid spillage of the cyst contents.
3. Excision of Cystic Tumours / Haemangioma
Cysts, or fluid-filled swellings, and haemangiomas, or tumours arising from blood vessels, are common in the liver. Most of these are detected incidentally during routine health checks or on scans performed for other reasons. Cysts can be congenital and may be multiple. The majority are benign or non-cancerous. Smaller cysts and haemangiomas are usually asymptomatic, while larger ones can cause varied symptoms.
Symptoms:
- Abdominal pain.
- Abdominal fullness / bloating.
- Nausea.
- Vomiting.
- Jaundice.
Diagnosis:
- Clinical examination.
- Blood investigations.
- Ultrasound abdomen and pelvis.
- CT abdomen and pelvis with oral and intravenous contrast (Triple phase).
- MRI.
Treatment:
- Observation and reassurance.
- Embolization in selected cases of haemangioma.
- Surgical management – Laparoscopic / Open deroofing of cysts / excision of haemangiomas.
- Liver transplant in rare cases like polycystic diseases.
Laparoscopic / Open Deroofing of Cysts / Excision of Haemangiomas:
Using small keyholes, large or symptomatic cysts are deroofed, and their contents are suctioned out. In situations where there is communication with the biliary system, additional procedures might be required. Large haemangiomas not amenable to embolization may need excision, which can be performed laparoscopically or, occasionally, via an open technique.
4. Liver Resections: Major / Minor for Cancers and Tumours
Tumours of the liver can be cancerous or non-cancerous. The majority of them are non-cancerous and are incidentally detected on scans. Commonly seen non-cancerous tumours include hepatic adenomas and focal nodular hyperplasia. Treatment of these depends on the symptoms, size, number, and location. Cancerous tumours can arise primarily in the liver (hepatocellular carcinoma) or can be metastatic, having spread from another organ.
Symptoms:
- Abdominal pain.
- Jaundice.
- Fevers.
- Nausea.
- Abdominal fullness.
- Swelling of feet and abdomen.
- Tiredness.
- Loss of weight and appetite.
- Gastrointestinal bleed.
Diagnosis:
- Ultrasound abdomen and pelvis.
- CT scan abdomen and pelvis with intravenous contrast – Triple phase.
- MRI.
- Ultrasound or CT guided biopsy.
- Special blood investigations – CEA, CA-125, CA 19-9, AFP, LDH.
Treatment:
- Observation and reassurance.
- Angio-embolization.
- Trans-arterial chemo-embolization (TACE).
- Trans-arterial radioembolization.
- Radiofrequency ablation.
- Surgery – Laparoscopic / Open liver resection, liver transplant.
Laparoscopic / Open Liver Resection:
In this procedure, a portion of the liver containing the tumour is removed along with an adequate margin. Liver resections can be performed both by laparoscopy and by the regular open technique. The size and location of these tumours aid in choosing the modality of surgery.
