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Medical management of bleeding varices: Primary and secondary prophylaxis for variceal bleeding

Introduction The presence of portal hypertension is a prerequisite for the development of, and bleeding from, varices. Portal hypertension is defined by a portal venous pressure exceeding the inferior vena cava pressure by more than 5 mm Hg (see Chapters 74 , 76 , and 79 ). Measuring the free hepatic vein pressure and subtracting this from the wedged hepatic vein pressure, commonly known as the…

Management of ascites in cirrhosis and portal hypertension

A brief history of ascites and portal hypertension Ascites is the pathologic accumulation of fluid in the peritoneal cavity. It is both the most frequent and prominent clinical sign of liver disease. Notwithstanding the near reflexive association of ascites with liver disease, the formation of ascites is caused by a variety of conditions that range from benign to sinister. Descriptions of ascites exist in human history…

Support of the failing liver

Failing liver A failing liver is a serious condition that warrants a multimodal approach (see Chapter 77 ). The best treatment for a failing liver in the setting of acute liver failure (ALF; no history of liver disease) or acute-on-chronic liver failure (ACLF; history of chronic liver disease or cirrhosis) is liver transplantation (see Chapter 105 ). Supportive therapy, however, in ALF, ACLF, and posthepatectomy liver…

Management of liver failure

Acute liver failure (ALF), a term that is equivalent to the now archaic “fulminant hepatic failure,” evolves after a catastrophic insult to the liver and results in the development of the dual characteristics of coagulopathy and encephalopathy within a matter of days or weeks of the liver injury. The absence of a previous diagnosis of liver disease is another requirement, with the exception of severe reactivations…

Nonhepatic surgery in the cirrhotic patient

Overview Chronic liver disease and cirrhosis were the eleventh leading cause of death in the United States and resulted in more than 44,358 deaths in 2019. Chronic viral infection (see Chapter 68 ) and alcohol abuse account for the majority of the disease burden globally, but the incidence of obesity-associated nonalcoholic fatty liver disease (see Chapter 69 ) accounts for an ever-increasing proportion of cases, especially…

Cirrhosis and portal hypertension: Pathologic aspects

Overview Cirrhosis, the final stage of untreated chronic liver disease (see Chapter 7 ), is primarily attributable to alcohol abuse, viral hepatitis C (see Chapter 68 ), and, increasingly, nonalcoholic steatohepatitis (NASH; see Chapter 69 ) in the United States (US). The true prevalence of cirrhosis is unknown because in early, developing stages, the condition may be asymptomatic. Nevertheless, cirrhosis is the 11th most common cause…

Simple cysts and polycystic liver disease: Clinical and radiographic features and surgical and nonsurgical management

The entity common to simple cysts and polycystic liver disease (PCLD) is a malformation, lined by a nonatypical biliary-type epithelium that does not communicate with the biliary tree. This differentiates these diseases from hydatid cysts (see Chapter 72 ), cystic hepatobiliary neoplasms (see Chapter 88B ), and cystic dilation of the intrahepatic bile ducts (see Chapter 46 ). Simple cysts and PCLD do not simply differ…

Hydatid disease of the liver

Introduction Hydatid disease, or cystic echinococcosis (CE), is a worldwide parasitic zoonosis, caused by the larval stages of the metacestode Echinococcus granulosus . Three more species of Echinococcus of public health concern have been recognized: Echinococcus multilocularis, causing alveolar echinococcosis, which will be discussed in the next section of this chapter; and Echinococcus vogeli and Echinococcus oligarthus, both causing polycystic echinococcosis. Hydatid disease is the most…

Amebiasis and other parasitic infections

Amebic liver abscess History The earliest report of amebiasis is probably the Sanskrit document Brigu-samhita, written about 3000 bce , referring to bloody mucoid diarrhea. Assyrian and Babylonian texts refer to blood in the feces, suggesting the presence of amebiasis in the Tigris-Euphrates basin before the sixth century bce , and it is possible that hepatic and perianal abscesses described in both Epidemics and Aphorisms in…

Pyogenic liver abscess

Overview Pyogenic liver abscess (PLA) may be solitary or multiple collections of pus within the liver, the result of bacterial infection. PLA causes significant morbidity, mortality, and increased consumption of healthcare resources. PLA represents the most common visceral abscess, with an incidence of 5 to 20 in 100,000 hospitalizations in the Western population. In 1938 Ochsner et al. reported the first series of patients with hepatic…

Hepatic steatosis, steatohepatitis, and chemotherapy-related liver injury

Fatty liver disease (FLD), comprising hepatic steatosis or steatohepatitis with or without associated fibrosis, and hepatic sinusoidal injury (SI) are emerging challenges at the forefront of hepatobiliary surgery. Because of the high prevalence of metabolic syndrome elements (hypertension, diabetes mellitus, obesity, and dyslipidemia), many patients considered for hepatic resection for benign or malignant indications will have nonalcoholic fatty liver disease (NAFLD). In parallel with the metabolic…

Chronic hepatitis: Epidemiology, clinical features, and management

Surgery in the patient with chronic hepatitis can create multiple dilemmas in the preoperative, perioperative, and postoperative phases. Preoperatively, assessment of the stability of the patient’s liver disease can be crucial in decisions regarding a surgical procedure (see Chapter 4 ). Intraoperatively, both technical and anesthesiology considerations will potentially affect the outcome (see Chapters 26 and 101 ). Postoperative care involves strategies to prevent or treat…

Palliative treatment of pancreatic and periampullary tumors

Introduction Pancreatic and periampullary tumors are a common cause of cancer death, with rising incidence in the Western world. In 2018 the incidence of pancreatic cancer in the United States (US) was 13.7 per 100,000 persons, compared with 11.6 per 100,000 persons in 2000. Pancreatic cancer is the fourth most common cause of cancer death in men and women in the US (see Chapters 61 and…

Chemotherapy and radiotherapy for pancreatic cancer: Adjuvant, neoadjuvant, and palliative

Adjuvant chemoradiotherapy Early studies examining the role of external beam radiotherapy (EBRT) combined with 5-fluorouracil (5-FU) as a radio-sensitizing agent in advanced, unresectable, pancreatic adenocarcinoma identified increased median survival over radiotherapy alone. , One study published in 1979 by the Gastrointestinal Tumour Study Group (GITSG) demonstrated a survival benefit with radiotherapy and concurrent chemotherapy. In this trial, 43 patients were randomized, following potentially curative pancreatic resection,…

Pancreatic neuroendocrine tumors: Classification, clinical picture, diagnosis, and therapy

Introduction Neuroendocrine tumors (NETs) represent a group of heterogenous neoplasms that originate from the diffuse neuroendocrine cell system, most commonly arising in the lung or gastrointestinal (GI) tract. Although NETs represent a rarer group of neoplasms, NET incidence and prevalence continues to increase and NETs are now the second most prevalent GI cancer. Well-differentiated NETs can be subdivided largely based on their tissue of origin, with…

Pancreas as a site of metastatic cancer

Introduction The pancreas is a rare site of distant metastasis. In 1950 in an autopsy study, Abrams et al. were one of the first to highlight the pancreas as a potential site for metastatic spread. Overall, these metastatic lesions constitute only a minor portion (approximately 2%–5%) of all pancreatic neoplasms. , The most common sites of primary carcinoma for metastatic spread to the pancreas are renal…

Duodenal adenocarcinoma

Overview Duodenal adenocarcinoma (DA) is a rare malignancy that accounts for less than 1% of all gastrointestinal (GI) cancers and occurs at a rate of less than 6 cases per million person years. In 2018 it was estimated that within the United States there were 10,470 cases of small bowel cancer with 1450 deaths. Even though the duodenum comprises a relatively small portion of the small…

Pancreatic cancer: Clinical aspects, assessment, and management

Clinical presentation Pancreatic adenocarcinoma, or pancreas cancer, is one of the most lethal malignancies. While a relatively uncommon cancer, ranking 8th among cancer types in women and 10th in men, it is among the most common causes of cancer death in the United States. Pancreas cancer currently ranks third behind lung and colorectal cancer as a cause of cancer death, and is expected to become the…

Pancreatic cancer: Epidemiology

Overview The pancreas, an organ located in the retroperitoneum, has both exocrine and endocrine functions. The exocrine pancreas is composed of duct cells and acinar cells that produce enzymes needed to break down carbohydrates, proteins, and lipids, thus promoting digestion. The majority of malignant pancreatic neoplasms are presumed to arise from the exocrine component. Pancreatic ductal adenocarcinoma (PDAC) is the most common type of pancreatic cancer…