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home - Liver - Liver Masses - Granulomas Written by Dr Sebastian Zeki
Knowledge


Knows the epidemiology pathology clinical presentation and natural
history of benign tumours of the liver

Can define a programme of investigation and characterisation of
benign liver lesions including haemangioma focal modular
hyperplasia and adenoma

Skills
Demonstrates ability to make an appropriate differential diagnosis
Formulates appropriate plan of management
Behaviours
Recognises importance of the role of multidisciplinary team in
diagnosis and management

Also...

Knowledge


Understands the epidemiology risk factors pathology prevalence
and range of presentations of HCC

Knows the appropriate investigation and staging of the disease
Aware of treatment options including trans-arterial
chemoembolisation (TACE) radiofrequency ablation (RFA) local
ethanol injection

Appreciates the indications and contraindications of each and how
the most appropriate is selected Aware of surgical treatment options

Aware of role of surveillance and referral for specialist multidisciplinary management including liaison with oncology

Skills
Appreciates the indications and contraindications of each modality of
treatment and how the most appropriate is selected

Understands the process of selection of patients for liver resection or
transplantation

Behaviours
Appreciates Involvement of multi-disciplinary team in management
decisions close liaison with surgical radiology oncology and
pathology colleagues

Granulomas

Infections —AIDS related causes —Mycobacteria, Cryptococcus neoformans, CMV, histoplasmosis, and toxoplasmosis.Medication also causes it eg. include sulfonamides and isoniazid.Fungal diseases —The Most common histoplasmosis, coccidioidomyco-sis, cryptococcosis, candidiasis, and blastomycosisQ fever (Coxiella burnetii)-fibrin-ring granulomasBrucellosis —esp B. abortus and B. melitensis.Malignancy —Hodgkin and non-Hodgkin lymphoma and renal cell carcinoma.Drugs — ManagementFor idiopathic granulomatous hepatitis immunosuppression is appropriate.If concerns re TB can give anti-TB treatment, and if no response, then give steroids.Corticosteroids give a biochemical response in months and may need repeated course.Methotrexate - can be uses if there is no steroid response. Types of granulomas:Noncaseating eg. sarcoidosis.Caseating-characterized by central necrosis- eg TB.Fibrin-ring —Epithelioid cells surround a vacuole circled by fibrin ring eg Hodgkin lymphoma,CMV, leishmaniasis, hep A, toxoplasmosis, giant cell arteritis, Boutonneuse fever, Q fever, allopurinol.Lipogranulomas-central lipid vacuole ( in patients mineral oil ingestion). Hepatic granulomas Inc ALP/ GGT The granulo-mas are often located in the portal tract. Steroids not recommended for hepatic sarcoidosis alone Intrahepatic duct Stric-tures similar to PSC- respond to steroids IVC Hepatic artery Portal vein Hepatic veins Hepatic vein throm-bosis due to narrow-ing of the hepatic veins from involve-ment with sarcoid granulomas. Portal hypertension (presumably presi-nusoidal due to the presence of peripor-tal granulomas). PBC like cholestatic jaundice with pruritus and hypercholes-terolemia (Bx shows vanishing bile ducts.Most such patients were black males presenting with fever, hepatosplenomegaly, jaun-dice, and pruritus in whom liver biopsy showed ductope-nia.Ursodeoxycholic acid has been used in such patients. Complications Sl. inc ALT Hepatic granulomas in 90 % with miliary TB, 70 % with extrapulmonary TB25 % with isolated pulmonary TB Granulomas are portal areas;may or may not caseate.Acid-fast bacilli occasionally seen within the granulomas. Sarcoidosis Most common causes are:SarcoidosisTuberculosisPBCDrug reactions Autoimmune disorders —Sarcoidosis and PBC most commonAlso Wegener's granulomato-sis and with polymyalgia rheumatica. Idiopathic —10 to 36 %.The term "granulomatous hepatitis" refers to a syndrome charac-terized by a prolonged febrile illness, myalgias, hepatospleno-megaly, and arthralgias of unclear etiology.Labs nonspecific; ESR often elevated Causes Tuberculosis Can be throughout the hepatic lobule.Occasionally site specific eg sarcoid granulomas are periportal ,PBC is portal Written by Dr Sebastian Zeki

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