Liver and Intrahepatic Bile Duct Diseases / Liver Cancer

Serous liver cysts, also called simple liver cysts or essential liver cysts, are small bubbles formed in the liver, filled with clear fluid. This category also includes gallstones. The walls of the channels through which the ball is removed form swellings from place to place, in which the ball eventually collects.

Uncomplicated cysts may be asymptomatic or with non-specific symptoms, namely, discomfort in the upper abdomen and right (right hypochondrium).

Acute cholecystitis

Inflammation of the wall of the gallbladder, the most common complication of vesicular lithiasis, manifested by intense, violent pain in the upper and right abdominal floor (right hypochondrium), local pus, subicterus (yellowing of the tegument and sclera), dynamic occlusion phenomena (lack of bowel movement), peritonitis, which is most often localized, febrile/cold syndrome.

Chronic cholecystitis

Assumes the existence of a recurrent inflammatory process (incomplete and intermittent obstruction of the cystic duct) of the gallbladder with biliary lithiasis. Clinically it is manifested by pain in the right hypochondrium and the presence of a variable degree of dyspeptic syndrome (nausea, vomiting, meteorism, bitter mouth).

– Abdominal ultrasound – non-invasive and atraumatic imaging method based on ultrasound is the method of choice, which reveals cystic (anechogenic) formation
– Computed Tomography (CT) – it takes a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region the contrast substance is used; it is indicated when the diagnosis is not clear or it is considered necessary to evaluate the anatomical ratios and liver volumetry (in case of giant cystic fibrosis, polycystic disease)
– Blood tests that may show abnormal liver function (coagulogram – prothrombin time, platelet count, liver samples – transaminases, bilirubin, alkaline phosphatase, gamma glutamyltransferase- GGT, total protein, albumin)

Surgical treatment

If the size does not increase over time and compress neighbouring organs, essential/serous cysts can remain untreated for the rest of your life. If they are large, symptomatic (cause pain etc), compress the bile ducts or surrounding organs, if they rupture, they can be resolved by surgical treatment (by laparoscopic, or classic/open approach – especially in the case of cysts located behind the posterior liver, where the laparoscopic approach
is more difficult).

Liver transplantation

In severe forms of polycystic liver disease, the entire liver fills up
cysts, resembling a sponge full of holes, the only treatment in these extreme forms being liver transplantation.

Hydatid cyst

Hydatid cysts are parasitic liver cysts caused by a liver fluke. of herbivores (Echinococcus granulosus), transmitted to humans by dogs. Hydatid cysts appear as a cavity filled with clear fluid, lined by a whitish membrane. In cysts old but still active hydatid membrane, the membrane inside proliferates, filling the cavity with smaller vesicles, called daughter vesicles. The outer wall of the hydatid cyst is thick and, if located at the periphery of the liver, causes an inflammatory reaction around it that over time attracts and attaches the surrounding organs to the cyst.

Uncomplicated cysts may be asymptomatic or with non-specific symptoms, namely, discomfort in the upper abdomen and right (right hypochondrium).

– Abdominal ultrasound – non-invasive and atraumatic imaging method based on ultrasound is the method of choice, which can specify the number of cysts, location, size, relationship to vascular structures; ultrasound appearance is thickened cystic walls, unilocular/multilocular cyst, intracystic/pericytic calcifications, presence of daughter vesicles
– Computed tomography (CT) takes a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region the contrast substance is used; it is indicated in case of complex cysts, with suspicion of fistulas, in case of suspicion of -extrahepatic- localizations
– Nuclear magnetic resonance (NMR) – imaging method using a magnetic field and radiofrequency pulses to visualise the image of various organs and tissues of the human body; for better visualisation, contrast dye may also be used; indicated for complex cysts with suspected fistulae, suspected extrahepatic locations
– Blood tests – haemoleukogram (increased eosinophils, low haemoglobin in case of intracystic haemorrhage)

Drug treatment

– represented by benzimidazole derivatives, especially albendazole (10-15 mg/kg/day in one or two doses) – in the case of univisicular hydatid cyst

Surgical treatment

– which involves removing the cyst to prevent secondary complications, eradicating the parasite and preventing recurrence. The most common technique is laparoscopic perichystectomy, both by the classical and laparoscopic approach.

Liver abscess

A liver abscess is a localized infection of the liver, a collection of pus, following a bacterial, fungal or parasitic infection.

Depending on the causative agent (bacteria, parasites, fungi), the liver abscess may manifest itself:

If you have the above symptoms, it is necessary to perform the following tests and procedures to establish the diagnosis of liver abscess:
– Blood tests – leukocytosis with predominance of neutrophils, increased C-reactive protein, increased procalcitonin, tests that may show abnormal liver function (coagulogram – prothrombin time, platelet count, liver samples – transaminases, bilirubin, alkaline phosphatase, gamma glutamyltransferase- GGT); positive blood cultures if collected in febrile episode;
-Imaging tests – Abdominal ultrasound – non-invasive and atraumatic ultrasound-based imaging method that involves visualization of organs
intra-abdominal, which may highlight the presence of abscess;
– Computed tomography (CT) takes a series of detailed images of certain regions of the body, these images are taken from different planes; for a more detailed
better view of the explored region, the contrast substance is used: it allows the exact location of the abscess, with the presence of air inside, and allows the description of the relationship with the surrounding structures,
– Nuclear magnetic resonance (NMR) – an imaging method that uses a magnetic field and radiofrequency pulses to visualise images of various organs and tissues of the human body; for better visualisation, contrast material may also be used; it is more sensitive in identifying smaller abscesses.

Treatment depends on the type of liver abscess, its location and extent.
Abscesses require targeted antibiotic therapy for the pathogen involved.

In most cases, percutaneous drainage of the abscess under ultrasound guidance (percutaneous ultrasound drainage) is required. In the case of multiple abscesses, the largest abscess should be drained, while antibiotic treatment is indicated for the others.

In patients in whom drainage is ineffective, symptoms persist or in those with complicated abscesses (multilocular, ruptured), surgical treatment is indicated either by laparoscopic or classical approach, which may involve drainage or resection of a portion of the liver.

Liver cancer is cancer that develops in the liver. The most common type of liver cancer is hepatocellular carcinoma/hepatocarcinoma.

There are several factors that increase a person’s risk of developing liver cancer, such as:

– Cirrhosis – a chronic liver disease in which fibrosis develops in liver tissue, replacing healthy liver tissue and preventing it from functioning normally. The most important causes of cirrhosis are chronic alcohol abuse, infection with hepatotropic viruses (mainly hepatitis C virus and hepatitis B virus);
– Viral hepatitis B – an infectious disease of the liver caused by the liver B virus;
– Viral hepatitis C – infectious disease of the liver caused by liver virus C;
– Alcohol consumption;
– Smoking;
– Obesity and diabetes;
– Aflatoxins – toxic substances, considered liver carcinogens that occur through food contamination with certain fungi;
– Haemochromatosis – hereditary disease in which iron is absorbed in very high amounts in the body;
– Hepatic steatosis – is the accumulation of fat in the liver;
– Alpha 1 antitrypsin deficiency – an inherited condition caused by a lack of a liver protein – alpha 1 antitrypsin which blocks the destructive function of some enzymes, and can lead to lung or liver damage;
– Cutaneous porphyria – a hereditary condition caused by a disorder of haem synthesis (the non-protein fraction of haemoglobin), characterised by the accumulation in the tissues of intermediate substances of this synthesis, porphyrins;
– Diet – high fat foods and red meat;
– Chemicals: arsenic, pesticides, herbicides, vinyl chloride, tobacco and cigarette combustion products, etc.

Liver cancer can give you the following symptoms and signs:

If you have the above symptoms, the following tests and procedures should be performed to determine the diagnosis of liver cancer:
– Blood tests – which may show abnormal liver function (coagulogram – prothrombin time, platelet count, liver samples – transaminases, bilirubin, alkaline phosphatase, gamma glutamyltransferase- GGT, total protein, albumin);
– Tumor marker alpha feto-protein assay;
– Imaging tests – Abdominal ultrasound – non-invasive, atraumatic ultrasound-based imaging method that involves visualization of intra-abdominal organs;
– Computed tomography (CT) – takes a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region, contrast substance is used;
– Radiotherapy – anti-tumour treatment using high intensity X-rays or
other types of radiation that are capable of destroying malignant cells; it can be as in the case of chemotherapy of two types: neoadjuvant or adjuvant;
– Liver biopsy – a manoeuvre that involves harvesting a fragment of liver tissue by inserting a fine needle through the skin into the liver under ultrasound guidance (percutaneous ultrasound puncture), which is then analysed under a microscope.

Depending on the stage of the disease, the location of the tumour formation, there are several treatment options:
– Surgical treatment – which involves removing the affected part of the liver;
– Liver transplant – which involves removing the diseased liver and replacing it with a healthy liver from another person;
– Ablative therapy – the procedure by which cancer cells can be killed – there are several types of ablation: using heat, laser, radiation (radiotherapy) or by injecting a special type of alcohol directly into the tumour formation;
– Chemotherapy – anti-tumour treatment, which uses certain drugs to destroy cancer cells; it may be given before surgical treatment (neoadjuvant chemotherapy) to reduce the size of the tumour formation so that it can be removed by surgery, or it may be given after surgical treatment (adjuvant chemotherapy) to destroy cancer cells that may have already spread in the body;
– Radiotherapy – anti-tumour treatment using high-intensity X-rays or other types of radiation that are capable of destroying malignant cells; it can be, as with chemotherapy, of two types: neoadjuvant or adjuvant;
– Radiochemotherapy – involves combining chemotherapy with radiotherapy to increase their effectiveness;
– Biological therapy/immunotherapy – uses substances produced by the body or synthesised in the laboratory to strengthen the immune system in its fight against cancer.
– Embolisation – a procedure to block blood vessels reaching the tumour; this method can sometimes be combined with chemotherapy (chemoembolisation) or radiotherapy (re-embolisation).

Intrahepatic cholangiocarcinoma is a malignant tumour that develops in the bile ducts inside the liver.
There are several factors that can increase a person’s risk of developing intrahepatic bile duct cancer, such as:
– Genetic mutations/abnormal changes in the AND of cells;
– Bile duct malformations present at birth;
– Primary sclerosing cholangitis – a chronic progressive disease of unknown cause characterized by inflammatory, fibrosing and stenotic lesions of the bile ducts;
– Alcohol consumption;
– Liver parasites;
– Chronic liver disease;
– Exposure to toxic substances.

If you experience symptoms, they may be:
– Weight loss with no apparent cause;
– Yellowing of the skin and whites of the eyes (sclerosing jaundice);
– Itchy skin (generalised itching);
– Lack of appetite;
– Abdominal pain below the ribs on the right side;
– Fatigue and weakness;
– Light-coloured, white (watery) chair.

In order to accurately establish the diagnosis of intrahepatic cholangiocarcinoma, it is necessary to perform certain investigations:
– Blood tests – which may show abnormal liver function (liver samples – transaminases, bilirubin, alkaline phosphatase, gamma fightsyltransferase – GGT);
– Serological tumor marker assay – CA19-9;
– Imaging tests: abdominal ultrasound – non-invasive imaging method and
atraumatic, ultrasound-based, which can detect bile duct dilatation, loculobstruction and exclude the presence of gallstones (gallstones);
– Computed tomography (CT) – takes a series of detailed images of a number of regions of the body, these images are taken from different planes; contrast material is used to better highlight the region being explored;
– Nuclear Magnetic Resonance Imaging (MRI) – an imaging method that uses a magnetic field and radiofrequency pulses to visualize images of various organs and tissues of the human body; contrast material may also be used for better visualization;
– Cholangio-MRI – imaging method imaging method that uses a magnetic field and radiofrequency pulses to visualize the image of various organs and tissues of the human body; for better visualization, contrast material can also be used with the possibility of 3D reconstruction of the biliary tree
– Biopsy puncture – hepatic – a manoeuvre to confirm the diagnosis by which a fine needle is inserted under ultrasound guidance and the doctor harvests a fragment of tissue from a suspicious-looking area, which is then analysed under a microscope.

Depending on the stage of the disease, the location of the tumour formation, there are several treatment options:
– Surgical treatment – which involves removing the affected part of the liver (liver resection);
– Liver transplant – which involves removing the diseased liver and replacing it with a healthy liver from another person;
– Chemotherapy – anti-tumour treatment, which uses certain drugs to destroy cancer cells; it may be given before surgical treatment (neoadjuvant chemotherapy) to reduce the size of the tumour formation so that it can be removed by surgery, or it may be given after surgical treatment (adjuvant chemotherapy) to destroy cancer cells that may have already spread in the body;
– Ablative therapy – the procedure by which cancer cells can be killed – there are several types of ablation: using heat, laser, radiation (radiotherapy) or by injecting a special type of alcohol directly into the tumour formation;
– Chemoembolisation – a procedure that involves the introduction of cytostatics and embolic material into the tumour formation after catheterisation of the segmental branches that supply the tumour formation;
– Radiotherapy – anti-tumour treatment using high-intensity X-rays or other types of radiation that are capable of destroying malignant cells; it can be, as with chemotherapy, of two types: neoadjuvant or adjuvant;
– Radiochemotherapy – involves combining chemotherapy with radiotherapy to increase their effectiveness;

Not all cancers that affect the liver are considered liver cancers. Cancers that start elsewhere in the body – such as in the colon, lung or breast – and then spread to the liver are called metastatic cancers. From a medical point of view, metastasis is the last stage in the progression of a neoplastic disease towards death.

Depending on the timing of the onset of metastatic lesions in relation to the original tumour formation, there are two types of liver metastases: synchronous – which develop at the same time as the primary tumour formation or in the period of time following the surgical removal of the latter, or metachronous – which may occur over a much longer period of time after surgery (usually at least three years).

– The clinical manifestations of synchronous liver metastases are most often the expression of the primary tumour formation and less often the effects of tumour metastasis; enlargement of the liver (hepatomegaly) with a nodular surface;
– If metastatic tumour formations cause compression syndrome on the surrounding structures (i.e. bile ducts) there is tegumentary and scleral jaundice (yellow discolouration of the tegument and sclera), discolouration of the stool, steatosis (undigested fat present in the stool), hyperchromatic urine (dark urine), pruritus (itchy skin), repeated biliary infections;
– Weight loss, with no apparent cause;
– Profound influence on the general condition;
– Lack of appetite (lack of appetite);
– Fever, sweats;
– Nausea;
– Presence of an intraperitoneal fluid collection (ascites).

To accurately determine the diagnosis of liver metastases it is necessary to perform a number of investigations:
– Blood tests – which may show abnormal liver function (coagulogram – prothrombin time, platelet count, liver samples – transaminases, bilirubin, alkaline phosphatase, gamma glutamyltransferase- GGT, total protein, albumin);
– Tumor marker alpha feto-protein, CAE (carcinoembryonic antigen) assay ;
– Imaging tests – abdominal ultrasound – non-invasive and atraumatic ultrasound-based imaging method that involves visualization of organs
intra-abdominal; contrast material may also be used;
– Intraoperative ultrasound (US) of the liver which is the specific application of ultrasound technique during surgery; it may also include the use of contrast agents to better highlight liver nodules;
– Computed tomography (CT) – takes a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region, contrast substance is used;
– Nuclear Magnetic Resonance Imaging (MRI) – an imaging method that uses a magnetic field and radiofrequency pulses to visualise images of various organs and tissues of the human body; contrast material may also be used for better visualisation.

Depending on the number, size, location, relationship to vascular structures and clinical condition you have, there are several treatment options, such as surgical and/or oncological treatment
– Surgical treatment – liver resection/hepatectomy – which involves
removal of the part of the liver where the metastases are, being the only one with curative purpose;
– Ablative therapy – the procedure by which cancer cells can be killed – there are several types of ablation: using heat, laser, radiation (radiotherapy) or by injecting a special type of alcohol directly into the tumour formation;
– Chemotherapy – anti-tumour treatment, which uses certain drugs to destroy cancer cells; it may be given before surgical treatment (neoadjuvant chemotherapy) to reduce the size of the tumour formation so that it can be removed by surgery, or it may be given after surgical treatment (adjuvant chemotherapy) to destroy cancer cells that may already be spread in the body;
– Chemoembolisation – a procedure that involves the introduction of cytostatics and embolic material into the tumour formation after catheterisation of the segmental branches that supply the tumour formation;
– Radiotherapy – not commonly used in liver metastases because of the low resistance of liver tissue to the action of ionising radiation, prolonged irradiation can cause the development of radicular hepatitis;
– Biological therapy/immunotherapy – uses substances produced by the body or synthesised in the laboratory to strengthen the immune system in its fight against cancer.

Benign tumours are non-cancerous tumours that remain in one place and do not spread to other parts of the body. Also after they are removed they do not reappear. Even if they are not cancerous, they can cause symptoms by putting pressure on surrounding structures. Benign liver tumours are tumours located in the liver. The most common types of benign liver tumour are: haemangioma (consisting of a
a clot of dilated blood vessels), focal nodular hyperplasia (made up of normal liver cells, but growing chaotically) and hepatic adenoma.
Although the cause is unknown, there are some factors that may increase the risk of hemangiomas:
– gender – women have a higher incidence than men;
– age – is diagnosed at the age of 30 – 50;
– pregnancy – due to increased estrogen levels during pregnancy;
– hormone replacement therapy, administered during menopause.

In the case of focal nodular hyperplasia, there are certain risk factors that can increase the risk of developing it:
– women aged 30-40;
– contraceptive use.

Adenomas have a 5% risk of developing into a malignant (cancerous) tumour formation, with men having a higher risk than women.

Most haemangiomas are small in size (less than 5 cm) and do not cause symptoms and are most often discovered incidentally during imaging investigations. If you have symptoms, they are caused by large haemangiomas:
– Abdominal pain/abdominal discomfort, below the ribs on the right side (right hypochondrium);
– Yellowing of the skin and whites of the eyes (sclerosing jaundice) in case of compression of the main bile duct;
– Dyspeptic syndrome by compression of the stomach;
– Acute anaemia – in case of rupture of a haemangioma with consequent appearance of blood inside the abdominal cavity (haemoperitoneum)
– Presence of an abdominal tumour formation detected by palpation

In the case of focal nodular hyperplasia, patients often have no symptoms.
Abdominal pain or abdominal discomfort may occur (in the case of large tumours).
In the presence of an adenoma, most patients do not show symptoms. In the case of a ruptured adenoma, you may experience symptoms of bleeding inside the abdominal cavity (severe abdominal pain, abdominal discomfort, fever, vomiting).

In order to establish the exact diagnosis of hemangioma it is necessary to carry out certain investigations:
– Abdominal ultrasound – non-invasive, atraumatic ultrasound-based imaging method that involves visualization of the tumor that has a characteristic appearance for each type; contrast dye may also be used
– Computed Tomography (CT) – a series of detailed images of certain regions of the body are taken from different planes; contrast material is used to better highlight the region being explored; it is particularly necessary in patients with a large focal nodular hyperplasia/hemangioma/adenoma in order to make a differential diagnosis with malignant tumours or other benign tumour formations, and to establish relationships with biliary and vascular structures;
– Nuclear Magnetic Resonance Imaging (MRI) – an imaging method that uses a magnetic field and radiofrequency pulses to visualise images of various organs and tissues of the human body; contrast material may also be used for better visualisation;
– Blood tests – which may show abnormal liver function (coagulogram – prothrombin time, platelet count, liver samples – transaminases, bilirubin, alkaline phosphatase, gamma glutamyltransferase- GGT, total protein, albumin); haemoglobin (haemoglobin decrease in case of rupture of a haemangioma).

– Small benign liver tumours with no symptoms are not indicated for treatment or surgery.
– In men with adenoma, surgical resection is indicated due to the risk of malignancy
– Surgical treatment:
– involves excision of the focal hemangioma/hyperplasia nodule, removal of the
a portion of the liver (in case of complications – bleeding,
compression, if symptoms occur);
– In the case of women with adenoma, if they are over 5 cm in size they are indicated to be excised (if under 5 cm, they are clinically and imaging monitored).

Intrahepatic gallstones are stones in the bile ducts inside the liver.

In some situations patients may be asymptomatic. If you experience symptoms, they may be:
– Abdominal pain/abdominal discomfort located below the ribs on the right side
– Fever
– Vomiting
– Yellowing of the skin and whites of the eyes (sclerosing jaundice).

In order to establish the exact diagnosis of haemangioma, certain investigations need to be carried out:
– Abdominal ultrasound – a non-invasive, atraumatic, ultrasound-based imaging method to detect the presence of intrahepatic bile duct stones or liver abscesses;
– Cholangio-MRI – imaging method imaging method using a magnetic field and radiofrequency pulses to visualise the image of various organs and tissues of the human body; for better visualisation, contrast material can also be used with the possibility of 3D reconstruction of the biliary tree (of choice);
– Blood tests – which may show abnormal liver function (coagulogram – prothrombin time, platelet count, liver samples – transaminases, bilirubin, alkaline phosphatase, gamma glutamyltransferase- GGT, total protein, albumin;
haemolucogram – increased leukocyte count).

Surgical treatment – removal of a portion of the liver (hepatic resection) – in case of multiple intrahepatic bile duct strictures or peripheral dilatations of the intrahepatic bile ducts; associated or not, depending on the case, with a bilio-digestive shunt.