Liver Atlas and Casebook

Was browsing through the book collection in the HDOK library and came across this book titled “Liver Atlas and Casebook” edited by our very Malaysian Director General of health, Dr Ismail Merican himself. I highly recommend this book for students like me out there as it highlights important concepts pertaining to the diagnosis and management of common diseases that affect one of the largest organs in our human body- the liver. On the other hand, this book compiles a number of complex cases, which were managed by the highly specialised team in our very own hepato-biliary excellence centre- Selayang hospital. Overall rating of 8/10 with high resolution pictures of specimens for an in depth understanding of the pathology of most liver diseases. Some of the important facts that I’ve gathered after finishing ¾ of the book.

• The text book triphasic CT characterisation of HCC

Arterial enhancement as HCC derives its blood supply from the hepatic arterial circulation

Complete venous washout

• HCC usually causes thrombosis of the portal vein and its branches. Jaundice is not a common presenting feature of HCC.
• Diagnosis of HCC rarely depends on liver biopsy due to potential tumour dissemination that may convert a resectable lesion into a non resectable disease.
• Among the common presentations of HCC is abdominal pain/discomfort usually felt as a dull sensation, awareness of abdominal mass/constitutional symptoms of appetite and weight loss. Jaundice and ascites develop in later stages of the disease, when present contraindicates surgery.
• Serum AFP may be normal in up to a third of patients with HCC
• Text book CT characterisation of FNH(Focal Nodular Hyperplasia)

Hyperdense vascular enhancement with central hypodensity (stellate scar)

• FNH usually does not require intervention unless patient is symptomatic/ uncertain and suspicious for malignancy
• The most common benign liver lesion-hepatic haemangioma that is usually picked up incidentally.
• Leptospirosis is caused by “Leptospira Icterohaemorrhagiae”. Rats are common source of human infection. It can also infect cattle shoes and swine. Incubation period takes about 10 days (average)
• Adolf Weil was the first person to document this disease and thus severe form of leptospirosis is also called Weil Syndrome.
• Jaundice and haemorrhagic manifestation are not uncommon, hence the name “Icterohaemorrhagiae”
• The leptospires, directly/through immune mechanism damage blood vessels, cause centrilobular necrosis of the liver, renal tubular dysfunction by causing interstitial nephritis and acute tubular necrosis. Diagnosis is based on serology with 1:800 being diagnostic.
• Liver abscess usually shows up as a hypoechoic area with some debris within it. ( On ultrasonography)
• K.Pneumonia has emerged as one of the most common pathogen responsible for liver absvess
• Metastatic infections are commonly seen in patients with K.Pneumoniae liver abscess. They are

Enopthalmitis

Septic Pulmonary embolism

Pulmonary abscesses

Cerebral abscesses

Purulent meningitis

Otitis media

Osteomyelitis

Prostate abscess

Psoas muscle abscess

• In a patient with abscesses in multiple sites, K.Pneumonia infection should always be considered as a possible cause
• Polycystic disease of the liver is a benign condition which usually presents as an incidental finding or abdominal discomfort/pain/mass
• Occasionally an infected cyst would present with pain and fever
• In a patient with abscesses in multiple sites, K.Pneumonia infection should always be considered as a possible cause
• Polycystic disease of the liver is a benign condition which usually presents as an incidental finding or abdominal discomfort/pain/mass
• Occasionally an infected cyst would present with pain and fever