LIVER BILIARY TRACT 10 Atreasia

CONGENITAL BILIARY ATRESIA

Congenital  atresia  of the extrahepatic bile ducts is  the  most

common  cause of prolonged obstructive jaundice in  the  neonatal

period.

INCIDENCE

Biliary atresia occurs once in every 20,000 to 30,000 births.

PATHOLOGY

Failure  of  recanalization  of the ducts which  have  no  lumen.  

Coexistence of atresia of the extrahepatic and entrahepatic ducts

supports  the  belief  that a development anomaly  is  the  basic

defect.

The  procedure  is an attempt to reduce pressure  the  esophageal

veins by :

*   Devasularestion,  the  vessal  supplying  the  upper  greater

    curvature  (spleic bronchea) and the lesser  currature  (left

    gastric branches) are ligated

*   Shunt procedures like a spleno-renal anastamosis or an end to

    side porto-caval an mesenteric vein and canal anastomosis can

    also reduce pressure.

TREATMENT

Surgical  operation to expolore the fibrous tissues at the  Porta

Hepatis  and an anastomosis of bile channels with  an  intestinal

loop provides an outlet for the bile.

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LIVER & BILIARY TRACT 9 Portal hypertension treatment

PATHOLOGY

The collateral channesl that open up are:

*  The  coronary  veins that connect the  azygos  and  hemiazygos

   veins  (SV) with the oesophageal veins (PS) which are  dilated

   due to the increased pressure.

*  The  superior  hemorrhoidal veins (PS) that connect  with  the

   middle and inferior hemorrhoid veins (SV)

*  Umbilical (PS) and paraumbilical veins (SV) giving rise to the

   caput medusa.

*  Retroperitoneal veins.

OESOPHAGEO-GASTRIC VARICES

The  increase in pressure causes a dilatation of  the  submucosal

veins.

*  Later,  the mucosa atrophies and the wall of the  veins  forms

   the inner lining of the oesophagus.

*  The veins of the fundus of the stomach may also be involved.

*  Rupture  of these vessels can occur at any time  resulting  in

   serious manifestation of haematemesis.

TREATMENT

Treatment is directed at prompt control of the bleeding by :

*  Ballon tamponade with Sengstaken Blakmore tube Fig. above

*  Sclerotherapy of the bleeding veins

    5-6  cc  of  selorosant (Ethanomoline 5%) into  each  of  the

    venous  columns  a fibroptic gastoscope is required  and  the

    columns  are  injected above  the  gastroesophageal  junction

    other   sclerosants   used  are  absolute   alcohols   sodium

    morrhuate.

*  Surgical  treatment  attempts to reduce pressure by  a  porto-

   caval shunt operation or

   Splenic vein can be joined to the renal vein

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LIVER & BILIARY TRACT 8 Portal hypertension etioplogy pathopysiology

9. PORTAL HYPERTENSION

Portal hypertension may result from disease of the liver  leading

to  intrahepatic  obstruction or an obstruction to  the  flow  of

blood in the extrahepatic portal system

As  a  result,  abnormal channels of  communication  between  the

portal  system (PS) and systemic veins (SV) open up and a  common

site are the oesophageal veins Fig. above

ETIOLOGY

The majority of cases are due to intrahepatic obstructions  (90%)

and the disorders include:

*  Nutritional cirrhosis (commonest)

*  Postnecrotic cirrhosis and

*  Biliary cirrhosis

PATHOPHYSIOLOGY

The normal pressure is less than 300 mm of water and this can  be

measured by introduction of a cannula into portal tributaries and

shows  an  elevation.   There is in addition,  an  elevation  of

splenic pulp pressure.

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LIVER BILIARY TRACT 7 Tumours

8. LIVER TUMOUR

8.1 Benign

8.1.1 Adenoma

This  is a rare tumour usually seen as an incidental  finding  on

scan or laporatomy

TREATMENT

The  tumour should be removed if there is  uncertaininty  regards

diagnosis.

8.1.2 CAVERNOUS HAEMONGIOMA

This  is  the commonest tumour seen at autopsy as  an  incidental

finding.  They are silent, soft and spongy

TREATMENT

It is difficult

8.2 MALIGNANT HEPATOCELLULAR CARCINOMA

This  carcinoma  is  associated  with  cirrhosis  and  occurs  in

population where there is an association with large reservior  of

Hepatitis B carrier.

8.2.1 LIVER METASTASIS

These  are met with most often in cases where the primary  lesion

is in the gastro-intestinal tract, breast or lungs.

TREATMENT

Resection of single metastasis can be planned.

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