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Variceal Bleeding

Esophageal and gastric variceal bleeding represents a common and potentially life-threatening complication of cirrhosis, and occurs as a consequence of progressive portal hypertension. Patients with cirrhosis are initially categorized as having either compensated or decompensated cirrhosis, the latter defined by the development of overt hepatic decompensation events such as ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatic hydrothorax, or variceal hemorrhage. These complications arise predominantly from the…

Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a common and debilitating complication of cirrhosis, and is characterized by cognitive impairment which occurs as the consequence of a complex series of alterations in brain functioning due to impaired liver function and portosystemic shunting. Although the pathophysiology of HE remains incompletely understood, there are several prevailing hypotheses to explain the biological origins for the distinct behavioral, cognitive, and motor changes seen…

Ascites

Ascites is one of the most common and serious complications of cirrhosis and has significant prognostic importance as a marker of hepatic decompensation and liver failure. The development of ascites is associated with a decrease in overall and liver-related survival and may be associated with related complications such as spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). The development of SBP is associated with a 2-year…

Liver Function Tests

Liver function tests (LFTs), also known as liver enzymes or liver chemistries, generally refer to a panel of serum biochemical studies used to screen for and monitor liver disease. This panel evaluates hepatic components ranging from hepatocellular necrosis and damaged hepatic synthetic capacity to the liver's ability to excrete breakdown products. LFTs also describe a battery of dynamic tests that provide real-time evaluation of liver function,…

Anatomy of the Liver

Topography of the Liver The liver (Greek hepar ) is located in the upper part of the abdomen, where it occupies the right hypochondrium and the greater part of the epigastric regions ( Fig. 143.1 ). The left lobe of the liver extends into the left hypochondrium. The liver is the largest organ of the body and weighs an average of 1300 g (800–2400 g) in women and…

Gallbladder Cancer

Although highly lethal, gallbladder cancer is extremely rare. The annual incidence in the United States is less than 7000 cases, and it is the fifth most common malignancy of the gastrointestinal (GI) tract. When the diagnosis of carcinoma of the gallbladder is incidental on routine cholecystectomy for gallstone disease, the prognosis is excellent. Incidental carcinoma of the gallbladder is noted in 1% to 3% of cholecystectomy…

Periampullary Cancer

Periampullary cancers are defined as cancers arising within 2 cm of the papilla of Vater. The term “periampullary” includes a heterogenous group of neoplasms arising from the pancreas, duodenum, distal common bile duct, or structures of the ampullary complex ( Fig. 140.1 ). On initial presentation, all these tumors have similar clinical presentation resulting in difficulty in defining the primary site of origin. However, there are fundamental…

Sphincter of Oddi Dysfunction

The sphincter of Oddi (SO) is a smooth muscular structure usually 7 to 13 mm in length encircling the distal common bile duct (CBD) and the pancreatic duct (a common channel opening into the ampulla of Vater). The three functions of the SO are control of the flow of bile and pancreatic secretions into the duodenum, prevention of reflux of duodenal juice into the pancreaticobiliary system, and…

Choledocholithiasis and Cholangitis

Stones in the common bile duct (CBD) are either primary or secondary. Primary stones are formed de novo in the CBD as a result of bacterial action on phospholipid and bilirubin (see Chapter 134 ). Secondary stones, including cholesterol and pigment stones, are formed in the gallbladder and are passed into the CBD. Choledocholithiasis The prevalence of CBD stones varies depending on several factors. Along with…

Chronic Cholecystitis

Cholelithiasis and cholecystitis are classified into three types based on presentation: (1) silent gallstones, in which gallstones are detected accidentally and are truly asymptomatic; (2) symptomatic gallstone disease; and (3) abdominal symptoms mimicking cholelithiasis but caused by a comorbid condition such as peptic ulcer or irritable bowel syndrome. Asymptomatic Gallstone Disease Approximately 15% of the adults in the United States are estimated to have gallstones. Almost…

Acute Cholecystitis

Acute cholecystitis is inflammation of the gallbladder after persistent obstruction of the gallbladder outlet from an impacted stone, resulting in increased gallbladder pressure, rapid distention, decreased blood supply, and gallbladder ischemia, with subsequent bacterial invasion, inflammation, and possible perforation ( Fig. 135.1 ). Approximately 10% to 20% of patients with symptomatic gallstones develop acute cholecystitis. Open full size image Fig. 135.1 Acute Calculous Cholecystitis. Clinical Picture…