Disorders of the Liver

In the elderly, the most common hepatic lesion requiring surgery is metastatic cancer. (Cirrhosis and its complications are more common in younger persons; primary biliary cirrhosis is discussed in Ch. 108.) Because hepatic surgery is not well tolerated in the elderly, heroic measures that might enable long-term survival but that carry a high mortality rate, such as liver transplantation, are not attempted often. Liver tumors are discussed in Ch. 113.

Hepatic Cysts

Hepatic cysts may be congenital or acquired. Often, multiple congenital cysts are associated with polycystic disease of the kidney and pancreas. Usually, they are insignificant, and if found during surgery, they can merely be unroofed and left in place. Rarely, a cyst enlarges during periodic follow-up because it is a cystadenocarcinoma; excision is necessary.

Hydatid cysts, the single most important acquired type, are caused by the tapeworm Echinococcus granulosus and are common in many parts of the world. Because these cysts develop slowly, symptoms (eg, epigastric pain, liver enlargement, jaundice, anaphylactic reactions) may not be noted for many years. These cysts may be huge and multilocular and are diagnosed by CT or ultrasound. Aspiration should be avoided. Treatment is excision of the entire cyst; care must be taken to avoid spilling daughter cysts or scoleces into the abdomen, and the patient must be treated perioperatively with albendazole. Medical therapy alone and medical therapy plus percutaneous drainage have been studied; in patients who can tolerate laparotomy, surgical excision is the best treatment.

Hepatic Abscesses

Pyogenic abscesses and amebic abscesses of the liver must be differentiated because the treatment differs: pyogenic abscesses must be drained, whereas 75% of amebic abscesses can be treated by medical therapy alone.

Almost 40% of pyogenic hepatic abscesses result from biliary tract obstruction; in another 40% the exact etiology is not discernible. Because of the widespread use of antibiotics, pylephlebitis and secondary abscesses from appendicitis are rare. Diverticulitis and sepsis after hemorrhoidal banding are other known causes of pyogenic abscesses. Aerobic and anaerobic gram-negative bacteria predominate.

Symptoms of hepatic abscesses include upper abdominal pain, chills and fever, and, in many cases, right upper quadrant tenderness and mild jaundice. Such symptoms and signs should prompt an abdominal CT, although ultrasound and a radionuclide scan may be helpful. In nearly half the cases, multiple abscesses occur. Aspiration helps establish the bacteria involved.

Treatment of pyogenic abscesses consists of vigorous antibiotic therapy and percutaneous CT-guided drainage. Surgical drainage is now performed only on those that cannot be adequately drained percutaneously or for the patient who needs a laparotomy for other reasons. The cause should be identified and, if possible, treated. For example, cholangitis, a common finding, requires transperitoneal exploration of the biliary tree, cholecystectomy, and T-tube drainage of the common duct.

Amebic abscesses usually respond to metronidazole 500 to 750 mg po tid; metronidazole may also be given IV (500 mg q 6 h). Treatment usually lasts for 5 to 10 days, and an intestinal amebicide is generally given after the metronidazole course. Abscesses that are symptomatic (pain, mass effect) and do not respond to metronidazole, become secondarily infected, or are so large that rupture seems imminent should be aspirated percutaneously. Rupture of the abscess into the peritoneal cavity requires surgery.