The Bottom Line: Liver transplant is recommended for patients with potentially resectable or transplantable disease according to performance status or lack of severe comorbidity, or in patients with unresectable disease who meet Milan or United Network for Organ Sharing (UNOS) criteria. Controversy exists over liver transplantation in patients with tumors marginally outside Milan or UNOS criteria, but some institutions may still consider it (DynaMed Plus, 2017).
- Milan criteria for liver transplantation for hepatocellular carcinoma includes either of:
- single lesion ≤ 5 cm in diameter
- 2-3 lesions all ≤ 3 cm in diameter
- UNOS criteria for liver transplantation for hepatocellular carcinoma includes both of:
- Milan criteria
- no evidence of macrovascular involvement or extrahepatic disease
Reference: DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 909499, Management of early hepatocellular carcinoma / Liver Transplant; [updated 2017 May 31, cited 2018 June 28]; [about 24 screens]. Emory login required.
- consider liver transplant for patients with tumor characteristics outside Milan criteria that are downstaged to within criteria
- refer patients potentially eligible for liver transplant to a liver transplant center (NCCN Category 2A)
- if the waiting time is expected to be long enough that there is a high risk of tumor progression and subsequent exclusion from the waiting list (for instance, > 6 months), consider
- class 3 obesity (body mass index [BMI] > 40 kg/m2) is a relative contraindication for liver transplant (AASLD Weak recommendation, Moderate-quality evidence)
- older age (> 70 years) is not a contraindication for liver transplant (AASLD Weak recommendation, Moderate-quality evidence)
- prompt or expedited evaluation for liver transplant suggested for potential liver transplant candidates if
- Model for End-Stage Liver Disease (MELD) score may be used to prioritize liver transplantation
- MELD score uses INR, bilirubin, creatinine, and history of dialysis to estimate relative disease severity and likelihood of survival after general surgery
- modifications include MELDNa (including serum sodium value) and Pediatric End-Stage Liver Disease (PELD) for patients < 12 years old
(DynaMed Plus, 2017)
The Bottom Line: Most cases of hepatic abscess present at advanced age. One study reported a mean age > 57 years.19 This finding suggests that older individuals are more susceptible to bacterial infection and thus abscess formation. Most of the symptoms of hepatic abscess are due to infection and are nonspecific and it can be quite difficult to diagnose in a timely manner. The most commonly reported signs and symptoms (Table 2. Page 162) include fever in most but not all cases, abdominal pain, and hypotension
Mavilia, M. G., Molina, M., & Wu, G. Y. (2016). The Evolving Nature of Hepatic Abscess: A Review. Journal of Clinical and Translational Hepatology, 4(2), 158–168.
Hepatic abscess remains a serious and often difficult to diagnose problem. HAs can be divided into three main categories based on the underlying conditions: infectious, malignant, and iatrogenic. Infectious abscesses include those secondary to direct extension from local infection, systemic bacteremia, and intra-abdominal infections that seed the portal system. Hepatic abscess can be defined as an encapsulated collection of suppurative material within the liver parenchyma, which may be infected by bacterial, fungal, and/or parasitic micro-organisms
The Bottom Line: Ischemic Hepatitis usually occurs in elderly individuals with right-side congestive heart failure and low cardiac output. It usually occurs after periods of haemodynamic instability or hypoxia such as haemorrhage, sepsis, pulmonary embolus, cardiac failure, arrhythmias, acute myocardial infarction and other causes of respiratory distress.
Khan, F., & Baagar, K. (2013). Ischaemic hepatitis precipitated by recurrent episodes of atrial fibrillation. Arab Journal of Gastroenterology., 14(4), 176-179.
Ischaemic hepatitis (IH), also called shock liver or hypoxic hepatitis, is defined as a diffuse hepatic injury that occurs as a result of acute hypoperfusion . It is characterised by a transient and often marked elevation of serum hepatic transaminase levels in association with centrilobular hepatic necrosis. Serum hepatic transaminases usually increase to 10–300 times the upper limit of normal and most often resolve over 5–25 days
Table 1. Demographic and Laboratory Characteristics of the Study Population
Patients with AHA (n=46) Patients with AHB (n=16) Healthy Controls (n=14)
Peak ALT (IU/L; median and IQR) 2828 (1351–4031) 2042 (1489–2919) n.d.
Peak AST (IU/L; median and IQR) 3255 (757–5325) 1010 (711–1502) n.d.
Shin, So Youn, Jeong, Sook-Hyang, Sung, Pil Soo, Lee, Jino, Kim, Hyung Joon, Lee, Hyun Woong, & Shin, Eui-Cheol. (n.d.). Comparative Analysis of Liver Injury-Associated Cytokines in Acute Hepatitis A and B. Yonsei Medical Journal., 57(3), 652-657.
In the present study, we found that the serum levels of IL-18, IL-8, CXCL9, and CXCL10 were elevated in AHA and AHB. In addition, the serum levels of IL-6, IL-22, granzyme B and sFasL were increased in AHA but not in AHB, indicating that AHA is accompanied by more vigorous immune responses compared to AHB. The levels of CXCR3 ligands, CXCL10 and CXCL9 correlated with peak ALT levels in AHA and AHB. Moreover, serum granzyme B levels correlated with peak ALT levels in AHA, and serum sFasL levels correlated with peak ALT levels in AHB. These findings together suggest that effector functions of T cells are elevated and contribute to liver injury in AHA and AHB.
In this study, all patients with cholecystitis (except two) had the final diagnosis confirmed at cholecystectomy. Of the patients with cholecystitis, four were acute and 14 were chronic. Among those in the group with hepatocellular disease 8 had alcoholic liver disease.
Rosenthall, L., Shaffer, E., Lisbona, R., & Pare, P. (n.d.). Diagnosis of hepatobiliary disease by 99mTc-HIDA cholescintigraphy. Radiology., 126(2), 467-474.
In cholestasis, often with just a modest hyperbilirubinemia, the impaired excretion of contrast material does not allow adequate visualization of the biliary tree and gallbladder. Several radiolabeled substances which were recently introduced for the clinical investigation of hepatobiliary disease appear to have overcome some of these problems. In animal and human studies they were shown to be nontoxic materials, rapidly cleared by the liver, and excreted into the bile duct in sufficient concentrations to render good identification of the gall bladder and bile ducts
Fig. 6. Cholestatic alcoholic hepatitis: a comparison between 131 I-rose bengal and 99mTc-HIDA. The Iiver-to background ratio is considerably higher with the former.