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Surgical Gastroenterology

Overview

Gall Bladder Stone Disease

Gallstones are small, pebble-like substances that develop in the gallbladder. The gallbladder is a small, pear-shaped organ located below liver in the right upper abdomen. Gallstones form when bile stored in the gallbladder hardens into pieces of stone-like material. Bile which is produced in liver and stored in gallbladder helps the body to digest fats. When needed for purpose of digestion gallbladder contracts and pushes the bile into a tubular structure called the common bile duct that carries it to the small intestine, where it helps with digestion. Gallstones can sometime block the normal flow of bile if they move from the gallbladder and lodge in any of the ducts that carry bile from the liver to the small intestine like the Common Bile duct & the Hepatic ducts. Sometimes gallstones passing through the common bile duct provoke inflammation in the pancreas - called gallstone pancreatitis - an extremely painful and potentially dangerous and life-threatening condition. If any of the bile ducts remain blocked for a significant period of time, severe damage or infection can occur in the gallbladder, liver, or pancreas. Left untreated, the condition can be fatal. Symptoms As gallstones move into the bile ducts and create blockage, pressure increases in the gallbladder and one or more symptoms may occur. Many times, gall bladder is filled with multiple stones, and it stretches gall bladder wall due to distension. Steady pain in the right upper abdomen that increases rapidly and lasts from 30 minutes to several hours or pain in between the shoulder blades or near the right shoulder. Diagnosis Diagnosis is usually confirmed on Sonography & MRCP Additional blood test is performed to access the Liver function. Surgery Laparoscopic (keyhole) removal of the Gallbladder is now the gold standard in these patients. Nowadays it can also be performed with single incision too. Conversion to an open procedure may be required in extremely difficult cases in the patient’s best interest. Recovery after laparoscopic surgery usually involves 24-48 Hrs hours stay in the hospital, and normal activity can be resumed after a few days at home. If gallstones are present in the bile ducts it may require clearing of stone with endoscopic procedure with or without stenting prior to gall bladder surgery.

Gall Bladder Cancer

Cancer of gall bladder is a disease which commonly affects elderly (>50 years) with higher incidence in patients with gallstone disease, porcelain gallbladder and large polyps. Incidence higher in North and NE India especially along the Gangetic basin (industrial toxins). Majority of Gallbladder cancers are associated with gallstones (80%). Symptoms may be similar to gallstone disease. And for this particular reason all gall bladder specimens removed after surgery should undergo pathological evaluation to look for gall bladder cancer.Main presenting symptom of Gall bladder cancer is upper abdominal pain, Loss of weight and appetite, Jaundice and vomiting. Jaundice in patients usually indicates an advanced disease and very often a guarded prognosis. Outcome is best for early GBC, and those with limited invasion in the surrounding organs like the liver & duodenum. Diagnosis Usually, Suspicion of Gall bladder cancer is made up on USG upper abdomen. Triple phase CT scan with or without PET scan should be done to confirm diagnosis and asses for extent of disease. Biopsy is only needed in cases where definitive surgery is not an option. Surgery Aim of gall bladder surgery is to remove all of the tumour in total. Hence surgery varies from a radial cholecystectomy. (GB + lymphadenectomy + liver tissue from GB base) to segmental hepatectomy (4a +5) to extended hepatectomy. (Right trisegmentectomy) for advanced disease.

Bile Duct Diseases

Benign biliary stricture (BBS) BBSs most often arise from postoperative or inflammatory aetiologies. Surgery-related BBS most frequently results from LC, bile-duct surgery, and Post liver transplantation. The incidence of Lap Cholecystectomy -related BS i?0.5%, usually caused by direct surgical bile-duct injury, including thermal injury, scissors, ligatures, or clips. Biliary Strictures that form following liver transplantation occur in ~10%–25% of cases, and most commonly occur at the anastomotic site. Bile duct strictures may be asymptomatic but, if ignored, can cause life-threatening complications, such as ascending cholangitis, liver abscess, and secondary biliary cirrhosis. Symptoms In the absence of symptoms of the primary disease, most patients with bile duct strictures remain asymptomatic until the lumen of the bile duct is sufficiently narrowed to cause resistance to the flow of bile. Occasionally, patients may have intermittent episodes of right upper quadrant , with or without laboratory features of biliary obstruction. Patients most often present with features of obstructive jaundice. On occasion, a patient may present dramatically with sepsis and hypotension due to ascending cholangitis. Diagnosis USG Abdomen is first investigation done to confirm for diagnosis of biliary stricture. MRCP is the investigation of choice for confirmation and assessing for the extent of disease. In some specific cases triple phase CT Abdomen may be required. Treatment Treatment of BBS depend upon site of stricture and its extent. Most of them can be managed with Endoscopic stenting (ERCP). However certain complicated stricture require surgical intervention (biliary diversion) in form of Hepatico Jejunostomy with or without Hepatectomy.

BILE DUCT CANCER (CHOLANGIOCARCINOMA)

Cholangiocarcinoma’s are malignancies of the biliary duct system that may originate in the liver and extrahepatic bile ducts, which terminate at the ampulla of Vater where bile duct enters small intestine. Cholangiocarcinoma’s are encountered in three anatomic regions: intrahepatic, extrahepatic (i.e., perihilar), and distal extrahepatic. Perihilar region is most common site for cholangiocarcinoma’s. Cholangiocarcinoma’s arise from the intrahepatic or extrahepatic biliary epithelium. Most cholangiocarcinoma’s are adenocarcinoma and rest are squamous cell carcinoma. The etiology of most bile duct cancers remains undetermined. Long-standing inflammation, as with primary sclerosing cholangitis (PSC) or chronic parasitic infection, has been suggested to play a role by inducing hyperplasia, cellular proliferation, and, ultimately, malignant transformation. Cholangiocarcinoma’s tend to grow slowly and to infiltrate the walls of the ducts, dissecting along tissue planes. Local extension occurs into the liver, porta hepatis, and regional lymph nodes of the celiac and pancreaticoduodenal chains. Symptoms Cholangiocarcinoma mainly manifests as Jaundice Clay-coloured stools Bilirubinuria (dark urine),Pruritus (Itching) ,Weight loss & Abdominal pain. Life-threatening infection (cholangitis) may occur that requires immediate antibiotic intervention and aggressive biliary drainage. Diagnosis Liver Function profile in patient with cholangiocarcinoma shows deranged pattern based on stage and extent of disease. Most commonly seen derangement is rise in bilirubin level (Direct Bilirubin) with elevated Alkaline Phosphatase (SAP) and Gamma Glutaryl Transferase (GGT). In few patients mainly with associated cholangitis AST &ALT levels may also be raised. Carbohydrate antigen 19(CA 19) is tumour marker found elevated in patient with cholangiocarcinoma. Carcinoembryonic Antigen (CEA) levels are also found to be elevated in bile duct cancer patients. Ultrasound may demonstrate biliary duct dilatation and larger hilar lesions. Small lesions and distal cholangiocarcinoma’s are difficult to visualize. Patients with underlying primary sclerosing cholangitis (PSC) may have limited ductal dilatation secondary to ductal fibrosis. Doppler ultrasound may show vascular encasement or thrombosis. Triple phase Abdominal CT resembles ultrasound in that it may demonstrate ductal dilatation and large mass lesions. CT also has the capability to evaluate for pathologic intra-abdominal lymphadenopathy. CT scans are accurate in diagnosing the level of biliary obstruction. Magnetic resonance imaging (MRI) demonstrates hepatic parenchyma. MR cholangiography enables imaging of bile ducts and, in combination with MR angiography, permits staging (excluding vascular involvement). Hepatic involvement can also be detected. PET imaging can be added to conventional CT and MRI Scan to identify any smaller lesion and metastases. Treatment Complete surgical resection is the only therapy to afford a chance of cure for cholangiocarcinoma. And surgery depends upon level of tutor, extent of disease and associated vessel involvement. In patient with Intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma mostly major hepatectomy (Right, Left Or Extended) along with Common Bile duct resection is required. For Distal Cholangiocarcinoma Pancreaticoduodenectomy is needed for complete surgical resection of tumour. Unfortunately, many patients present with unresectable disease and they require palliative treatment with CBD or Intrahepatic duct stenting via Endoscopic procedure (ERCP) or Percutaneous procedure (PTBD).These patient are started on chemotherapy after palliation of presenting symptoms.

CHOLEDOCHAL CYST

Choledochal cysts are congenital bile duct anomalies with cystic dilatations of the biliary tree can involve the extrahepatic biliary radicles, the intrahepatic biliary radicles, or both. Signs and Symptoms Infants with choledochal cyst can present with Jaundice with acholic stools and Palpable abdominal lump in right upper abdomen with hepatomegaly. In older children and adult’s manifestation of choledochal cyst is variable. Classic triad of abdominal pain, Jaundice and right upper abdominal mass is not very common. Many patients might present with complication associated symptoms such as fever, vomiting and upper GI bleed. Diagnosis Based on extent of dilated diseased bile duct choledochal cyst are classified into five different types. USG Abdomen is first screening investigation to detect cystic dilatation of bile duct whether extra or intra hepatic. MRCP is investigation of choice to diagnose disease and to evaluate extent for planning of surgery. In few complicated cases (with associated cholangitis, hepatic abscesses or portal hypertension) Triple phase Abdominal CT scan might be needed. Treatment Removal of dilated and diseased bile duct with surgery is treatment of choice in patient with choledochal cyst. Surgery needed depends upon type of choledochal cyst and it varies from Endoscopic procedure , CBD Resection with Roux En Y Hepatico-Jejunostomy with or without Hepatectomy and Liver Transplantation. PANCREAS The pancreas is a gland organ that is located in the abdomen, behind the stomach and below the ribcage. It specialises in producing important enzymes and hormones that help break down and digest foods. It also makes insulin to moderate the levels of sugar in the blood.

ACUTE NECROTIZING PANCREATITIS

Necrotizing pancreatitis occurs when pancreatic tissue dies due to inflammation. When a person has necrotizing pancreatitis, bacteria may spread into the dead tissue and cause an infection. The pancreas is an organ behind the stomach that makes enzymes to help digest food. When the pancreas is healthy, these enzymes pass through a duct into the small intestine. If the pancreas becomes inflamed, these enzymes may leak into the pancreas and damage the tissues. This is called pancreatitis. If the damage is severe, blood and oxygen may not be able to reach some parts of the pancreas, leading to tissue death. Alcohol intake and gall stones are most common causes of Acute Pancreatitis. Other causes include hypertriglyceridemia, hypercalcemia, pancreatic trauma, Pancreatic cancer, autoimmune disorder and congenital causes such as cystic fibrosis. Symptoms Primary symptom of necrotizing pancreatitis is abdominal pain. A person may feel abdominal pain in front of the abdomen, near the stomach and around to the back. Pain may be severe and can last for several days. Other symptoms that may accompany pain include abdominal distension, nausea, fever and vomiting Necrotizing pancreatitis may lead to a bacterial infection and sepsis if left untreated. Sepsis is a condition where a person’s body reacts adversely to bacteria in their bloodstream, possibly causing the body to go into shock. Shock may be life-threatening, as it reduces the blood flow to major organs. This may damage them temporarily or permanently. Without treatment, a person may die from sepsis. Necrotizing pancreatitis may also cause a pancreatic abscess. Diagnosis Diagnosis of acute pancreatitis can be suspected based on clinical examination. To confirm diagnosis blood investigations and radiological imaging is required. Serum amylase and lipase level are raised out of proportion in patient with acute pancreatitis. Patient of acute pancreatitis may show derangement in blood investigation profile (CBC,LFT,KFT,Blood sugar level) depending upon cause of pancreatitis or associated complication. CRP or Serum Procalcitonin level should also be done on index presentation to assess for follow up complication or recovery. USG Abdomen is the first screening investigation to confirm diagnosis to assess for the disease and possible cause, But many a times due to inappropriate window or bowel gases USG scan is suboptimal. Triple phase CT or MRI scan might be needed to confirm diagnosis, assess for dead pancreatic tissue or associated complication. Treatment Treatment of necrotizing pancreatitis is in two stages. Firstly, aim is to treat the pancreatitis then treat the part of the pancreas that has died separately. Initial therapy of resuscitation & conservative management of SIRS needs to be done in an ICU to tide over the first couple of weeks. Intervention (Radiological or Surgical) is required to tackle infected Acute Necrotic Collection (ANC) or Walled of Necrosis (WON). Surgical intervention is generally delayed to at least 4 weeks if possible so that the necrotic elements separate from the viable pancreas. At times a second or third debridement may also be required albeit rarely. Earlier mortality rate for patient with acute necrotizing pancreatitis used to be high (35-40%) but now days with progress in intensive care and defined treatment protocol it has improved drastically (<10%).

CHRONIC PANCREATITIS

Chronic pancreatitis is a long-term progressive inflammatory disease of the pancreas that leads to permanent breakdown of the structure and function of the pancreas. The most common cause is long-term alcohol abuse and it affects men more in comparison to women. Symptoms For most patients with chronic pancreatitis, abdominal pain is the presenting symptom. The patient experiences intermittent attacks of severe pain, often in the mid-abdomen or left upper abdomen and occasionally radiating in a band like fashion or localized to the midback. The pain may occur either after meals or independently of meals, but it is not fleeting or transient and tends to last at least several hours. Other symptoms associated with chronic pancreatitis include diarrhoea and weight loss. Diagnosis Diagnosis is based on tests of pancreatic structure and function. Imaging studies such as abdominal radiography and CT scanning can show inflammation or calcium deposits in the pancreas or changes in the pancreatic ducts. Pancreatic calcifications, often considered pathognomonic of chronic pancreatitis, are observed in approximately 30% of cases. Magnetic Resonance cholangiopancreatography (MRCP) test provides the most accurate visualization of the pancreatic ductal system and has been regarded as the criterion standard for diagnosing chronic pancreatitis. In certain cases with associated complication such as portal vein thrombosis Triple phase CT scan might be needed. Due to association of cancer (10-15%) one should rule out underlying malignancy with radiological imaging. Treatment Treatment is typically directed at the underlying cause of the pancreatitis and to relieve pain and malabsorption. Pain relief Pancreatic enzyme supplementation may be helpful in reducing pain. The hypothesis is that stimulation of the pancreas by food causes pain. Cholecystokinin (CCK) is one of the possible mediators of this response. When exogenous pancreatic enzymes are taken with a meal, CCK-releasing factors are degraded and CCK release in response to a meal is reduced. This decreases pancreatic stimulation and pain. Endoscopic therapy aimed at decompressing an obstructed pancreatic duct can be associated with pain relief in some patients. The rationale for this approach is based on the hypothesis that ductal hypertension due to strictures of the main pancreatic duct leads to pain Surgery Surgery tackles pain & surrounding organ complications like duodenal and biliary obstruction secondary to a pancreatic head mass. Surgery varies from a simple pancreaticojejunostomy for Pancreatic duct drainage to the more complex head coring procedures (Frey’s and Beger’s procedure). The radical Whipple’s procedure is done when cancer cannot be ruled out. Surgical results for pain relief varies between 75% to 90% at 5 years. Choice of operation depends on the clinical problem and the preoperative assessment of the abnormality. In general, the approach aims either to improve pancreatic duct drainage or to resect the diseased organ. Data suggest that surgical drainage of the pancreatic duct is more effective than endoscopic drainage in patients with obstruction of the pancreatic duct due to chronic pancreatitis. In patients with a dilated pancreatic duct, a Roux-en-Y side-to-side pancreaticojejunostomy is indicated. If the disease is limited to the head of the pancreas, a Whipple operation (pancreaticoduodenectomy) can produce good results. If conventional medical therapy is unsuccessful and the patient has severe, intractable pain, celiac ganglion blockade can be considered. [1] This approach tries to alleviate pain by modifying the afferent sensory nerves in the celiac plexus, using agents that anesthetize, reduce inflammation, or destroy the nerve fibers.

PANCREATIC AND PERI-AMPULLARY CANCER

Pancreatic cancer develops when uncontrolled cell growth begins in a part of the pancreas. Some genetic factors are associated with increased risk of this cancer running in families. Smoking and alcohol intake is also associated risk factor for development of pancreatic cancer. Pancreatic cancer is most common after fifth decade of life and commonly occurs in male as compared to female. Approximately 75% of all pancreatic carcinomas occur within the head or neck of the pancreas, 15-20% occur in the body of the pancreas, and 5-10% occur in the tail. Symptoms The initial symptoms of pancreatic cancer are often quite nonspecific and subtle in onset. Patients typically report the gradual onset of nonspecific symptoms such as anorexia, malaise, nausea, fatigue, and midepigastric or back pain. Jaundice and abdominal pain , but these might not appear until the later stages. Loss of weight and appetite, recent onset diabetes, nausea and vomiting, altered bowel habits, & itching are other infrequent symptoms. Diagnosis: The laboratory findings in patients with pancreatic cancer are usually nonspecific. Patients with advanced pancreatic cancers and weight loss may have general laboratory evidence of malnutrition (eg, low serum albumin or cholesterol level). Potentially useful tests in patients with suspected pancreatic cancer include the following: CBC count, Hepatobiliary tests: Patients with obstructive jaundice show significant elevations in bilirubin (conjugated and total), ALP, GGT, and, to a lesser extent, AST and ALT. Serum amylase and/or lipase levels may be elevated in few patients. Tumor markers such as CA 19-9 antigen and CEA: 75-85% have elevated CA 19-9 levels; 40-45% have elevated CEA levels. USG abdomen is initial screening method to diagnose the disease. However, Triple phase CT Abdomen or MRI Abdomen is investigation of choice to diagnose the disease, its extent, involvement of vessels, and rule out metastases. PET scan can be done along with CT Scan/MR Scan to rule out any metastatic spread. Treatment The treatment options for pancreatic cancer will depend on the type of pancreatic cancer a person has, its stage the person’s age, overall health, and other characteristics, their personal choices. Treatment aims to remove the cancer, delay or stop its progress & relieve the symptoms Surgery If the cancer is localized at the time of diagnosis, it may be possible to eliminate the cancer cells by removing all or part of the pancreas. The three main surgical procedures for pancreatic cancer are: Whipple procedure It essentially involves removal of pancreas head and sometimes the whole pancreas, along with a portion of the stomach, duodenum, lymph nodes, and other tissue. Sometimes when adjacent vessels (venous ) involvement is there then involved vessel segment is removed along with tumour and reconstruction is done. Whipple surgery complications include leaking, infections, bleeding, and stomach problems. Distal pancreatectomy In distal pancreatectomy, the surgeon removes distal part of the pancreas with or without spleen. The spleen supports the immune system, so there may be a higher risk of infection after its removal. Total pancreatectomy In total pancreatectomy, the surgeon removes the entire pancreas and spleen. A person can live without a pancreas, but diabetes may develop because the body no longer produces insulin cells. Palliative surgery Palliative surgery can help relieve symptoms such as obstructions in the bile duct or duodenum. A surgeon can create a bypass so that bile can continue to flow from the liver. This can minimize pain and digestive problems. Another option is to insert a small stent in the bile duct to keep it open. This is a less invasive procedure using an endoscope.

CYSTIC TUMOUR OF PANCREAS

These are not so unusual and many a times mistaken for pseudocysts. In fact 30% of treated pseudocysts are actually tumors. Tumors vary from the benign serous cystadenomas to locally aggressive and potentially malignant mucinous and solid pseudopapillary tumors. Surgical resection of the tumor is necessary as these can undergo a malignant change. Not all cystic lesions require surgery, infact a fair of them can be observed for their progression. Surgery may be necessary in large tumors which cause symptoms such as pain, jaundice and at times pancreatitis due to ductal obstruction. Conservative surgery when possible is the norm. Saving the parenchyma as in Central pancreatectomy or vessel & spleen preserving pancreatic resections are the norm now for low grade/borderline lesions.

LIVER

LIVER (HEPATIC) CYSTS

Liver cysts are abnormal sacs in the liver that may contain fluid or a solid mass of cells. Cysts that grow in the liver are often congenital. This term means that the cysts formed before birth, while a person was developing in the womb. Liver cysts can also occur at any point during a person’s life and women are more likely to develop liver cysts than men. Infection with an Echinococcus tapeworm can also lead to liver cysts. These parasites are often present in farm animals or animals that live on farms, which can include dogs, wolves, and coyotes. A person can become infected with Echinococcus through exposure to the feces of these animals. Infection with Echinococcus is known as hydatid disease, cystic hydatid disease, or echinococcosis. This condition can also cause cysts in the lungs, kidneys, brain, and other organs around the body. Polycystic liver disease (PLD) is another condition that can cause liver cysts. PLD is a rare genetic condition, which means that it runs in families. People with PLD develop multiple cysts throughout their lives, but the condition often causes no symptoms. Many individuals with PLD also have polycystic kidney disease. Other causes of liver cysts include liver cancer and injury to the liver. Symptoms Usually, liver cysts do not cause symptoms or require any treatment. Sometimes, however, if the cyst becomes large, a person may experience pain or other symptoms that require treatment. Diagnosis Because liver cysts often cause no symptoms, people usually only discover they have them while undergoing an imaging test for something else. If a person does have symptoms that may indicate a liver cyst, a doctor may order an imaging test, such as an USG abdomen or CT Scan or MRI Scan.. If there is a doubt of hydatid cyst then patient should also undergo specific blood test for it along with routine blood test. Treatment Most people with liver cysts do not require treatment unless they are experiencing symptoms. If liver cysts are causing problems, a doctor may drain the cyst by inserting a fine needle through the abdomen. However, this is usually only a temporary treatment as the fluid can return over time. The most effective treatment for liver cysts is surgical removal. Surgeons can usually remove the cyst using a laparoscopic approach, which involves making only 2-3 small keyhole incisions into the abdomen. After removal, cysts are unlikely to return. For Hydatid cysts surgery is the gold standard & ranges from opening the cyst under sterile scolicidal precautions & removal of the germinating membrane, packing the cavity with omentum & under-running bile leaks if any, to cysto-pericystectomy to hepatectomy. A course of albendazole is given for atleast 6 weeks. In rare instances, a person with PLD or polycystic kidney disease may require a liver or kidney transplant if their condition is causing life-threatening symptoms. There is also role of medications such as somatostatin analogs in treatment of cystic lesions of liver.

HEPATIC HAEMANGIOMA

A liver hemangioma, also known as a hepatic hemangioma, is a benign (non-cancerous) tumor in the liver that is made up of clusters of blood-filled cavities fed by the hepatic (liver) artery. Usually, a patient has only one hemangioma, but in some cases there may be more than one. Hemangiomas do not develop into cancer and do not spread to other areas of the body. Liver hemangioma is the most common benign (non-cancerous) liver tumor, affecting up to 5% of adults. Symptoms Most liver hemangiomas do not cause symptoms and are only discovered when the patient is being seen for another, unrelated health condition. Small (a few millimetres to 2 centimetres in diameter) and medium (2 to 5 centimetres) hemangiomas usually do not cause symptoms but should be followed regularly by a doctor. Such monitoring is needed because about 10% of hemangiomas increase in size over time, for unknown reasons. Giant liver hemangiomas (more than 10 centimetres) usually develop symptoms and complications that require treatment. Symptoms most often include upper abdominal pain, as the large mass presses against surrounding the liver tissue and capsule. Other symptoms are poor appetite, early satiety, nausea and vomiting. Diagnosis A liver hemangioma is not usually discovered during a routine physical exam or laboratory testing. Diagnosis usually results from imaging studies that are being done for a different condition. USG Abdomen, CT scan and MRI scan are radiological imaging used to confirm diagnosis of Treatment Some hemangiomas are diagnosed at birth or early childhood (in up to 5-10% of one-year-olds). The hemangioma will usually get smaller over the course of time, and might disappear in some cases. If a liver hemangioma is small, stable and causes no symptoms, it can be monitored with imaging studies every six to 12 months. There are no drug treatments for a liver hemangioma. Surgery may be needed to remove the hemangioma if it grows rapidly or causes significant discomfort or pain. A technique called embolization, in which the blood vessels that feed the hemangioma are obstructed, can slow or reverse its growth. Complications Mechanical complications such as rupture, compression may occur in giant hemangiomas. Bleeding complication may occur in giant hemangioma or which are sub capsular in location. Certain degenerative complications such as blood clotting, calcification or scarring may occur in long standing hemangiomas.

HEPATIC (HEPATOCELLULAR )ADENOMA

Hepatic adenoma is an uncommon benign solid liver tumor. Its phenotype is changing from single lesions to multiple lesions owing to the reduction in estrogen exposure and increasing incidence of obesity and metabolic syndrome as driving factors in the formation of hepatic adenoma. Symptoms Clinical presentation of hepatocellular adenoma (HCA) varies widely. Pain may be present in the right upper quadrant or epigastric region. Patients may notice a palpable mass. Lesions may also be discovered incidentally during an abdominal imaging study for an unrelated reason. History of birth control or anabolic steroid use should be elicited in patients with suspected HCAs.? Patients may also present with severe, acute abdominal pain with bleeding into the abdomen, which results in signs of shock (eg, hypotension, tachycardia, diaphoresis). Hemoperitoneum occurs more frequently if the patient is taking a high-dose oral contraceptive pill (OCP), is actively menstruating or pregnant, or is within 6 weeks postpartum. Location of the lesion also is important, with those near the surface of the liver more prone to causing hemoperitoneum. Diagnosis Blood profile is essentially normal, there could be slight derangement in liver profile secondarily to pressure effect caused by adenoma. Diagnosis is mainly made on radiological imaging. USG Abdomen finding are mainly uncharacteristic. MRI Abdomen is investigation of choice to diagnose hepatic adenoma. Triple phase CT scan also helps in characterising lesion and differentiating from liver cancer. Treatment Treatment of hepatic adenoma depends upon type, size, patient profile and symptoms. In females with lesion less than 5 cm in size and no associated symptoms, regular follow up can be advised. In males , lesion of size more than 5 cm , inflammatory or B- catenin variant surgery should be done. Surgery depends upon location , size and presence of other lesion. Parenchyma preserving liver resection to complex extensive hepatectomy may need to be done.

FOCAL NODULAR HYPERPLASIA (FNH)

Focal nodular hyperplasia (FNH) is the second most common tumor of the liver, surpassed in prevalence only by hepatic hemangioma. The incidence of FNH is estimated to be 3-5%, and it occurs most often in women in the third through fifth decades of life. The liver is the only self-regenerative internal organ in the human body, and this regenerative ability puts the liver at risk for development of atypical masses. FNH is thought to be the result of increased hepatocytes caused by hypoperfusion or hyperperfusion from anomalous arteries in the hepatic lobule. Comorbid conditions can make diagnosis and management difficult. FNH is a hyperplastic process in which all the normal constituents of the liver are present but in an abnormally organized pattern. Symptoms In most patients, the clinical course is silent, and FNH is incidentally discovered during cross-sectional imaging, angiography, radionuclide liver scanning, or surgery. Although the use of contraceptive agents has not been implicated in the pathogenesis of FNH, their use is associated with an increase in the risk of complications for patients with FNH. In symptomatic females, hemorrhagic foci or infarctions may occur within the FNH; these are aggravated by administration of contraceptive agents. The rare complication of a spontaneous rupture into the peritoneum has also been associated with contraceptive useMalignant transformation of FNH has not been reported. FNH must be differentiated from a fibrolamellar variant of hepatocellular carcinoma, with which it shares imaging and gross features. Diagnosis Liver function test along with rest of blood parameters are mostly normal unless complicated.For imaging ultrasonography (US) is more widely used than other modalities; usually, US findings raise the possibility of FNH. Triple phase Abdominal CT Scan or MRI Abdomen is investigation of choice to confirm diagnosis of FNH. Central scar is mainly pathognomic feature of FNH on imaging. However in few cases it might be absent. Treatment Usually FNH does not require any treatment and are managed with closed follow up.Sometimes diagnosis need to be confirmed with biopsy in few cases.In case of complication or different differential it requires surgical removal.

HEPATOCELLULAR CARCINOMA (HCC)

Hepatocellular carcinoma (HCC) is a primary malignancy of the liver that occurs predominantly in patients with underlying chronic liver disease and cirrhosis However, up to 25% of patients have no history of cirrhosis or risk factors for it.The incidence of HCC has been rising worldwide over the last 20 years and is expected to increase until 2030 in some countries. The incidence of HCC is highest in Asia and Africa, where the endemic high prevalence of hepatitis B and hepatitis C strongly predisposes to the development of chronic liver disease and subsequent development of HCC.With current vaccination strategy it is estimated that in 20-30 years time incidence of HCC due to viral diseases will decrease.Meanwhile, however, there is a growing problem with cirrhosis due to nonalcoholic fatty liver disease (NAFLD), specifically nonalcoholic steatohepatitis (NASH). NASH, which typically develops in the setting of obesity, type 2 diabetes, dyslipidemia, and hypertension. Symptoms The presentation of HCC has evolved significantly over the past few decades. Whereas in the past, patients with HCC generally presented at an advanced stage, with right-upper-quadrant pain, weight loss, and signs of decompensated liver disease, HCC is now increasingly recognized at a much earlier stage as a consequence of the routine screening of patients with known cirrhosis, using ultrasonography with or without serum alpha-fetoprotein (AFP) measurements. Patients with hepatocellular carcinoma generally presents with signs and symptoms of advancing cirrhosis such as, Jaundice, Pruritus, splenomegaly, abdominal distension (Ascites), upper & lower GI bleed, cachexia , altered sensorium or upper abdominal pain. Diagnosis The diagnosis of hepatocellular carcinoma (HCC) can often be established on the basis of imaging, without biopsy confirmation. Even when biopsy is needed, imaging is usually required for guidance. Early diagnosis is crucial for patient with HCC as prognosis is generally dismal in late stage of disease. As HCC occurs most commonly in cirrhotic liver, screening protocol including USG Abdomen and Serum AFP level should be done in all of them on 6 monthly basis.AFP is elevated in 3/4th of cases. The level of elevation correlates inversely with prognosis. An elevation of greater than 400 ng/mL predicts for HCC with specificity greater than 95%. In the setting of a growing mass, cirrhosis, and the absence of acute hepatitis, many centers use a level greater than 1000 ng/mL as presumptive evidence of HCC (without biopsy). AFP alone is inadequate for screening purposes because of the high false positivity rate specially in acute hepatitis. USG Abdomen as a screening method is reported to have 60% sensitivity and 97% specificity in the cirrhotic population, and it is too, of choice for screening.Findings on US should then be confirmed with further imaging studies—multiphase computed tomography (CT) or magnetic resonance imaging (MRI)—and if required biopsy. On CT, HCC generally appears as a focal nodule with early enhancement on the arterial phase with rapid washout of contrast on the portal venous phase of a three-phase contrast scan. MRI of HCC generally demonstrates high signal intensity on T2 imaging. Biopsy is indicated in patients with HCCs that are larger than 2 cm with low AFP or in whom ablative treatment or transplant is contraindicated. In patients with elevated AFP and consistent imaging characteristics, patients can be treated presumptively for HCC without a biopsy. Patients should also undergo evaluation for extrahepatic disease (primarily pulmonary metastasis) with cross-sectional imaging, as the presence of extrahepatic disease would preclude curative treatment. Laboratory evaluation of patients with newly diagnosed HCC should include testing to determine the severity of the underlying liver disease, such as CBC,LFT, KFT,INR & Serum AFP. Treatment Management of hepatocellular carcinoma (HCC) is best performed in a multidisciplinary setting. Specifically, this is crucial to ensure that patients who are candidates for liver transplantation are referred in a timely manner, while their tumors are within defined criteria (Milan/UCSF).Treatment options for hepatocellular carcinoma depend on size, number and location of tutor;presence or absence of cirrhosis, operative risk based on extent of cirrhosis and comorbid disease; overall performance status, portal venous involvement or not ;and presence or absence of metastasis.

Surgical Therapy

In view of the absence of effective chemotherapy and the insensitivity of HCC to radiotherapy, complete tumor extirpation represents the only opportunity for a long-term cure. Resection of the tumor by partial hepatectomy (right or left or segmental) can be performed in a limited number of patients due to underlying cirrhosis. However in patient with no underlying disease or early cirrhosis , it offers best curative option.Advances in the technique of liver resection, better patient selection, improved postoperative care, and expert anesthetic management have resulted in a dramatic reduction in perioperative morbidity and mortality. Liver resection is the operation of choice for patients with tumors limited to one portion of liver with absence of cirrhosis. These patients can often tolerate resection of up to 50% of the total liver volume. In these patients, an operative mortality of less than 2% can be expected in experienced centers. In patients with cirrhosis, the extent of liver resection that can be tolerated is significantly more limited. Clinically evident portal hypertension (defined as a hepatic vein–to–right atrial pressure gradient (HVPG)in excess of 10), esophageal varices, or splenomegaly with a platelet count lower than 100,000/μL predicts poor outcome with significant resection. In general, resection of more than two segments is contraindicated in patients with Child class B or C cirrhosis. However, among patients who do undergo successful resection, long-term survival is possible, with 5-year survival rates as high as 74% in patients without significant decompensation.

Liver Transplantation

In patients with decompensated liver disease, liver transplantation offers the potential for a long-term cure in patients with limited tumor burden.Compared with resection for HCC, orthotopic liver transplantation (OLT) offers several potential advantages. Complete hepatectomy eliminates the possibility of local recurrence at the resection margin and, moreover, removes the cirrhotic liver, which is clearly predisposed to tumor formation. Liver transplantation also eliminates concerns about the capacity of the post resection liver remnant to provide adequate liver volume. Earlier studies were suggestive of dismal results in patient with HCC post liver transplant. However since last 25 years as a result of various studies delineating specific criteria to identify patient who will achieve maximum benefit post transplant, results of liver transplant in HCC have improved with 5 year survival of more than 80%. Nonoperative Therapy In patients who are not candidates for liver transplantation or resection, tumor ablation can be offered to extend life and potentially to downstage the tumor so as to permit transplantation or resection. Alternatively, patients who have advanced disease may benefit from palliative care interventions rather than be subjected to often ineffective therapies. Transcatheter arterial chemoembolization (TACE) TACE is the most commonly offered therapy for hepatocellular carcinoma.It can be done as neoadjuvant treatment prior to surgical therapy.TACE is performed by an interventional radiologist who selectively cannulates the feeding artery to the tumor and delivers high local doses of chemotherapeutic agents, including doxorubicin, cisplatin, or mitomycin C. To prevent systemic toxicity, the feeding artery is occluded with gel foam or coils to prevent flow.A reduction in tumor burden can be achieved in 16-61% of treated patients. Because TACE is reasonably well tolerated and has minimal morbidity, it can be offered to well-compensated patients with cirrhosis as a method to reduce their disease burden and to potentially extend their life.The most common complication is postembolization syndrome, which is characterized by fever, elevated alanine aminotransferase (ALT), and abdominal pain; it occurs in 32-80% of treated patients. However, in patients with advanced cirrhosis and hepatic decompensation, TACE is contraindicated, because the ischemic damage associated with embolization can lead to a rapid decline in liver function with worsening encephalopathy, increased ascites, and, potentially, death. Radiofrequency Ablation (RFA) Curative treatment of patients with HCC who are not candidates for resection or OLT is limited. However, local ablative therapies can be used either as a bridge to transplant by reducing the risk of tumor progression or as a palliative procedure to extend disease-free survival. Ablative procedures, including ethanol injection, RFA, and cryotherapy, can be performed percutaneously, laparoscopically, or via an open surgical approach. In RFA, a conducting needle is placed within the tumor and current travels to a large dispersive electrode (grounding pad). The electric current leads to agitation of the ions in the tissue, heat generation, and desiccation of the tissues surrounding the probe. The coverage of the electric field can be extended with water cooling, multiple deployable tines within the needle, and other modified electrodes.When compared to other ablative procedures, RFA was associated with a trend toward improved 24-month patient survival rate.RFA success can be limited by the presence of large blood portal or hepatic vein branches adjacent to the tumor (Heat sink effect). RFA can also be used as an adjunctive therapy for patients waiting for transplantation. Systemic Chemotherapy Systemic chemotherapy remains the mainstay of therapy for patients with advanced HCC who are not candidates for surgical resection, liver transplantation, or localized tumor ablation. Unfortunately, HCC is minimally responsive to systemic chemotherapy.Chemotherapy is usually not well tolerated and seems to be less efficacious in patients with HCC who have underlying hepatic dysfunction. Sorafenib Sorafenib is an oral agent that has antiangiogenic, proapoptotic, and Raf-kinase inhibitory properties. In 2007, it was approved by the US Food and Drug Administration (FDA) for use in patients with unresectable HCC. Sorafenib is regarded as a standard medical treatment for advanced HCC. In addition, data from the few trial suggest that adding it to TACE may lead to improved survival as compared with TACE alone in patients with unresectable HCC. [56] The following additional systemic drug options exist for patients with HCC who have stopped responding to initial treatment with sorafenib such as regorafenib,nivolumab,lenvatinib,pembrolizumab,cabozantinib,ramucirumab and atezolizumabplez bevacizumab.

GASTROINTESINAL LUMINAL CANCERS

CANCER STOMACH

Stomach cancer is an abnormal growth of cells that begins in the stomach. The stomach is a muscular sac located in the upper middle of your abdomen, just below your ribs. Stomach receives and holds the food you eat and then helps to break down and digest it. Stomach cancer, also known as gastric cancer, can affect any part of the stomach. In most of the world, stomach cancers form in the main part of the stomach (stomach body). Symptoms Signs and symptoms of stomach cancer may include: difficulty in swallowing, feeling boated after eating, heartburn, indigestion, nausea, stomach pain, unintentional weight loss. Diagnosis: Diagnosis of cancer stomach is confirmed by performing an endoscopy and taking biopsy from the suspected lesion (Ulcer/mass). After histopathological diagnoses Contrast CT scan with or without PET scan is performed to know about extent and stage of disease. Routine blood parameters (CBC.LFT,KFT,Blood sugar )level are also done to correct any associated abnormality. Treatment Surgery is mainstay of treatment for patient with cancer stomach. Surgery required depends upon location and extent of tutor spread. Patient with cancer stomach requires Partial gastrectomy, subtotal gastrectomy or total gastrectomy. In few patients with extensive spread may require removal of adjacent organ (colon.pancreas,spleen etc) to attain complete removal of tumour. Chemotherapy is needed in these patients depending upon stage of disease and is generally given prior or few weeks after surgery. COLON CANCER Colon cancer is a type of cancer that begins in the large intestine (colon). The colon is the final part of the digestive tract.Colon cancer typically affects older adults, though it can happen at any age. It usually begins as small, noncancerous (benign) clumps of cells called polyps that form on the inside of the colon. Over time some of these polyps can become colon cancers. Colon cancer is sometimes called colorectal cancer, which is a term that combines colon cancer and rectal cancer, which begins in the rectum. Symptoms Signs and symptoms of colon cancer include:change in bowel habit including diarrhoea or constipation, rectal bleeding or blood in stool, persistent abdominal discomfort, weakness or fatigue and unexplained weight loss.Many people with colon cancer experience no symptoms in the early stages of the disease. When symptoms appear, they'll likely vary, depending on the cancer's size and location in large intestine. Diagnosis Diagnosis of colorectal cancer is confirmed by performing colonoscopy or sigmoidoscopy to visualise the disease and take biopsy from lesion (ulcer/growth) for confirmation. Routine blood parameters and tutor marker assay CEA is done to correct ant anomaly and corroborate the diagnosis. Normal CEA level is less than 5 ng/ml. However its value is raised in patient with colorectal cancer with or without metastatic spread. Contrast CT scan with or without PET scan is needed to stage the disease and plan for surgical treatment. Treatment Surgical removal of tutor is treatment of choice in patient with colorectal cancer and surgery needed depends upon stage of disease, extent of disease and presence of metastasis or not.Depending upon location and extent patient may require Right or Left Hemicolectectomy, Extended right or left hemicolectomy, Radical hemicolectomy , Lower anterior resection or Abdomina-perineal resection. In patients with extensive or metastatic disease Neo adjuvant chemotherapy can be offered prior to surgery if patient is asymptomatic. In patients who undergo surgery prior , chemotherapy is offered based on stage of disease. Prognosis of colorectal cancer is good with 5 year survival more than 85% if complete tumour is achieved with surgery.

COLORECTAL LIVER METASTASIS

Hepatic metastatic disease from colorectal cancer (CRC) is a significant clinical problem. The liver is the dominant metastatic site for patients with CRC, and although two-thirds of affected patients have extrahepatic spread, some have disease that is isolated to the liver. For patients with isolated liver metastases, regional treatment approaches may be considered as an alternative to or in combination with systemic chemotherapy. The available regional treatments for hepatic metastases from CRC include surgical resection, thermal ablation, regional hepatic intraarterial chemotherapy, chemoembolization, radioembolization, and radiation therapy (RT), including stereotactic RT. Among these treatments, surgery remains the gold standard because it is associated with a long-term relapse-free survival plateau, although newer technologies, such as stereotactic RT, may theoretically confer similar long-term benefit to some patients. Although hepatic resection used to be reserved for patients with a maximum of three lesions in the same lobe, if it was possible to achieve 1 cm margins, and those without portal lymph node metastases, these "rules" have been changed in the modern era, particularly with advancements in both surgical technique and systemic therapy. Profound improvements in the outcomes of patients with metastatic CRC over the past 15 years have been attributed to increased use of hepatic resection in appropriately selected patients and more effective chemotherapy. As a result, the criteria for defining which patients are suited for surgical therapy have evolved, and many clinicians take an aggressive stance in the management of hepatic metastases.

Services

  • Splenectomy
  • Gastrointestinal cancer including,
  • Oesophageal cancer, gastric cancer, colorectal cancer, pancreatic cancer
  • Trauma and emergency surgery
  • Hepatocellular carcinoma or liver cancer
  • Hepatoblastoma
  • Hemangioma (non-cancerous lump on the liver, can cause pain)
  • Metastatic tumours
  • Benign liver tumours
  • Hydatid cysts (a complication of tapeworm infection, causing blister-like growth in the liver)
  • An amoebic liver abscess (a complication of amoebic dysentery infection, where the parasite infects the liver) 
  • Liver injury
  • Hepatolithiasis (gallstones in the biliary ducts of the liver)

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