Cirugía general R2 - Sesión 8 - Patología hepática y biliar qx - José Luis Paz - 2026-I

Introducción a la Patología Hepática y Vesicular

Generalidades del Hígado

• El Dr. José Luis Paz introduce el tema de la sesión, que se centra en la patología del hígado y vesícula biliar, incluyendo anatomía y fisiología del hígado.

• Se mencionan las enfermedades infecciosas más relevantes del hígado, así como tumores benignos y malignos, patologías quísticas, y generalidades sobre la vía biliar.

Anatomía Hepática

• La anatomía hepática es crucial para entender preguntas de examen; se presentan técnicas mnemotécnicas para recordar los segmentos hepáticos.

• Se explica cómo identificar los lóbulos hepáticos utilizando la mano como referencia: el pulgar representa el lóbulo caudado (segmento 1), mientras que otros dedos representan los segmentos restantes.

Irrigación Hepática

• El hígado recibe irrigación principalmente de la vena porta (75% de oxígeno) y de la arteria hepática común (25%). Cada segmento tiene su propia triada portal.

• La vena porta drena sangre desde todo el sistema digestivo, lo que es relevante para entender metástasis en el hígado, siendo esta una causa principal de cáncer hepático.

Enfermedades Infecciosas del Hígado

Absceso Piógeno

• Un absceso piógeno es una acumulación de pus en el hígado; puede ser criptógeno o derivar de infecciones biliares como colangitis supurativa ascendente.

• Los síntomas incluyen dolor en cuadrante superior derecho e ictericia; diagnóstico inicial con ecografía pero mejor confirmado por tomografía. Tratamiento incluye drenaje si mide más de 5 cm.

Absceso Amebiano

• Este tipo es endémico en América Latina; asociado a Entamoeba histolytica, presenta síntomas como diarrea e ictericia tras un viaje a zonas endémicas. Puede causar necrosis hasta la cápsula del hígado.

• Diagnóstico mediante ecografía o tomografía; tratamiento incluye drenaje si mide más de 10 cm y medicación específica post-drenaje con paramomicina y yodoquinol.

Quiste Hidatídico

Características Generales

• Causado por Echinococcus granulosus, este parásito tiene al perro como huésped definitivo; los humanos son huéspedes incidentales sin síntomas hasta que ocurre ruptura del quiste causando anafilaxia.

• Diagnóstico se realiza mediante ecografía o pruebas serológicas específicas; tratamiento depende del tamaño: menos de 5 cm requiere tratamiento médico mientras que mayores requieren cirugía.

Tumores Benignos del Hígado

Hemangioma Cavernoso

• El hemangioma cavernoso es un tumor benigno vascularizado que afecta mayormente a mujeres jóvenes; su identificación es importante debido a su relación con anticonceptivos orales aunque no siempre está presente esta asociación.

Radiology and Ectasia Management

Understanding Ectasia in Radiology

• Ectasia growth is not due to neoplasia but rather an expansion of existing tissue.

• Conservative management is recommended unless severe compression occurs, particularly if the ectasia exceeds 5 cm.

Casach-Merrich Syndrome

• The hemangioma is linked to Casach-Merrich syndrome, characterized by thrombocytopenia (low platelet count).

• This syndrome primarily affects pediatric patients, especially neonates with hemangiomas.

Surgical Indications for Hemangiomas

Surgical Considerations

• Surgery is indicated for large hemangiomas (>5 cm), those that rupture, or in cases of Casach-Merrich syndrome.

• The risk of malignancy exists in certain vascular malformations, particularly in young women.

Hepatic Adenoma Insights

Hepatic Adenoma Characteristics

• Hepatic adenomas are commonly associated with oral contraceptive use and can harbor mutations leading to a high risk of malignant transformation into hepatocellular carcinoma.

• Early surgical intervention is necessary regardless of size if there’s a desire for pregnancy or significant hemorrhage risk.

Cystic Pathologies Overview

Types of Cysts

• Simple cyst: Congenital, typically asymptomatic, requires observation unless large enough to warrant surgery.

• Cystadenoma: Has potential for malignancy; diagnosed via ultrasound showing mucinous fluid and multiple septations. Treatment involves complete excision.

Polycystic Disease Discussion

Polycystic Kidney Disease (PKD)

• Autosomal dominant inheritance pattern; often presents after age 60 with renal involvement preceding hepatic manifestations. Genes PKD1 and PKD2 are implicated.

• Diagnosis primarily through tomography as it reveals more cystic structures than ultrasound alone; treatment may involve transplantation if organ failure occurs.

Biliary Dilation Issues

Biliary Dilatation Consequences

• Various types of biliary dilatations can lead to recurrent cholangitis due to bile stasis caused by obstruction within the biliary tree. Potential malignancy exists depending on the type of dilation observed on imaging studies like CT or MRI.

Cholangiocarcinoma Risk Factors

Cholangiocarcinoma Insights

• Primary sclerosing cholangitis is a major risk factor for cholangiocarcinoma, especially among Asian populations; other risks include choledocholithiasis and chronic infections from parasites like Clonorchis sinensis.

• Diagnosis relies on tumor markers such as CA19–9 and imaging techniques including MRCP (Magnetic Resonance Cholangiopancreatography).

Hepatocellular Carcinoma Overview

Key Features

• Hepatitis B virus infection stands out as the primary risk factor for hepatocellular carcinoma development alongside cirrhosis.

• Alpha-fetoprotein serves as a crucial marker in monitoring disease progression but has limitations based on tumor subtype characteristics.

• Biopsy remains essential for definitive diagnosis despite challenges posed by certain cancers like gallbladder cancer where biopsy risks dissemination.

Treatment Options

Therapeutic Approaches

• Various treatments exist beyond surgery including ethanol injection therapy, radiofrequency ablation, and transarterial chemoembolization tailored according to individual patient needs.

• The Child-Pugh score assists in assessing liver function prior to interventions while considering factors such as portal vein thrombosis and tumor morphology.

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Understanding Biliary Conditions: Risk Factors, Diagnosis, and Treatment

Risk Factors for Biliary Issues

• The presence of "arenilla" or bile sludge can lead to the formation of gallstones; it is a result of bile condensation.

• Key risk factors are summarized as the four Fs: female, fat, forty (age), and fertility (pregnancy).

• Pregnancy increases cholesterol levels, contributing to the risk of biliary issues.

Diagnosis and Initial Management

• Diagnosis primarily involves ultrasound imaging to identify biliary conditions.

• Expectant management may be appropriate if symptoms are minimal and there’s no recurrent biliary colic; dietary changes can aid recovery.

Differentiating Between Biliary Conditions

• Distinction between gallstones (colelitiasis) and other conditions like choledocholithiasis is crucial; not all stones cause symptoms.

• Gallstones can lead to complications such as cholecystitis or cholangitis but do not always present with acute abdominal pain.

Types of Gallstones

• Three main types of gallstones include:

• Cholesterol stones: primarily composed of cholesterol and calcium, found in the gallbladder due to supersaturation.

• Black pigment stones: formed from concentrated bilirubin in chronic hemolytic states or cirrhosis.

• Brown pigment stones: consist of pigments and cholesterol, typically located in intrahepatic or extrahepatic bile ducts due to bacterial infections.

Long-term Management Strategies

• Patients with confirmed cholelithiasis without symptoms have a high chance (70%-80%) of remaining asymptomatic over 20 years.

• Prophylactic cholecystectomy is generally discouraged unless specific high-risk factors are present (e.g., large stones, porcelain gallbladder).

Symptoms and Acute Management

• Symptomatic patients may experience biliary colic characterized by temporary obstruction of the cystic duct lasting less than four hours.

• Diagnosis includes transabdominal ultrasound which reveals key features like acoustic shadowing indicative of gallstones.

Treatment Options for Gallstones

• Medical treatment options exist but often have low efficacy rates; only about 50% success in preventing recurrence after using ursodeoxycholic acid.

• Surgical intervention remains the definitive treatment for symptomatic cases or when complications arise.