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1 & (,( 1.Timothy D, Curley S. Liver in Charles Brunicardi.Schwartzhs Principles of surgery 8th ed. New York: McGraw-Hill Company 2005:1139-1186. 2.Oddsdottir M, HunterJ. Gallbladder and the extrabiliary system in Charles Brunicardi.Schwartzhs Principles of surgery 8th ed. New York: McGraw-Hill Company 2005:1187-1220. 3.DhAngelica M, Fong Y.The liver in Townsend Sabiston Textbook of Surgery 17th ed.2004:1513-1574. 4.Ahrendt S, Pitt H. Biliary tract in Townsend Sabiston Textbook of Surgery 17th ed.2004:1597-1642. 5.( u
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"+ &/, 2549:6-35. 14.Bruix J, Sherman M. Management of Hepatocellular Carcinoma. HEPATOLOGY 2005;42(5):1208-1236. 15. Heilpern K, Quest T.Jaundice in Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.2008:243-246.

2

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hepatic artery 72 blood flow 25% &,/72 oxygenation !/  50% -
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3

Infectious diseases *,$ #!+!,)))/!0$2&/ pyogenic liver abscess, amebic liver abscess &  hydatid cyst (echinococcal cyst) 7

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# )0$2)/!/ amebic liver abscess )7
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(3) Hepatic artery ) #!*- systemic infection 0$2&/ endocarditis, pneumonia, osteomyelitis 1
,2
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#
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single organism & "/
7_/ 70% 1
gram negative bacilli 0$2&/ E.coli , K.pneumonia, Enterococcus faecalis, Enterococcus faecium &,/|"') #!
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7_/ 1
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single abscess

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/!2! ,-/) fever, RUQ tenderness ]% 1
most common findings, jaundice )0$2 25% "G) laboratory investigation ) leucocytosis 70-90%, LFT ) mildly elevated ALP 80%, elevated bilirubin 20-50% & mildly transminitis 60%  - "" pyogenic liver abscess -z ,-,/‚ +
# ,/!01 1


$G imaging study ]% initial test *! ultrasonography 7
w""/ intraabdominal pathology !- 1
" ,+! abscess *"/ CT scan abdomen "/
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!/ CT scan

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2 "/
 *!   abscess &  "  ,+! abscess /
associated intraabdominal pathology (1)   abscess 1!)01$272 appropriate antibiotics & )
!]%/!
72†/ #!,2!G hemoculture /!
& *"/ abscess fluid gram stain &  culture

4

- 72 broad spectrum antibiotics &

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1w 10-14 
-
#
72
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z/,$  acute appendicitis  1
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" , $- acute appendicitis ,2!G appendectomy, " ,- acute cholangitis

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alcohol G72,$ !#
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unilocular abscess )/!/

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delay onset & sepsis
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/
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 metronidazole "G)7
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1. Cavernous hemagioma 1
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 |

6

Treatment 7
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) "G)z/,$,#&,/ enucleation, liver resection ! liver transplantation  !(z/,$+%#
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multiple hemangiomas, extensive hilar involvement ! ! $ " !$/z/,$

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benign tumor like lesion ))/! 1
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neoplastic process 0/* ",/! 1
 | & 0/&]2!


Treatment w0/!|0/,2!G 7$‚ +2!)/#7
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G72G surgical resection with clear margin/ enucleation

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.$,2!$3/ content $3$!!0/7/ !$ ! bile

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cystic biliary epithelium z

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Malignant liver tumor  |))/!7
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1.Hepatocellular carcinoma (HCC) 1
 |))/! 1
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aflatoxin !alcohol, *
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z312 {! 50-60 16+
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1
decompensated cirrhosis - tumor invade portal vein ! IVC 3.0/!7$‚ &,/)- imaging study

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-.72, American Association for the Surgery of Liver Disease 2005 (AASLD) +! $%$+
$+!2!
7
cirrhotic liver -G ultrasonography 1
 $
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$7_// 2 cm 72"/ dynamic imaging technique 1 
$$01
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hypervascular mass 7
arterial phase
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-.0$2  $0/,2!G biopsy !!-"/ AFP '2/ 200 ng/ml |
-.0$2  &,/'2 atypical vascular pattern 72 confirm $2G biopsy (2) 2!
+
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$ /
dynamic CT scan /) dynamic MRI ! dynamic ultrasonography -z 1
typical vascular pattern # 2 imaging study |
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(3)2!
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-
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1.Okuda classification $-w*/ albumin, bilirubin, ascites & +
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 $3 .,* HCC !/ $ $0/0$21 
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9

3.Barcelona clinic liver cancer (BCLC) staging system ]%1!)$21 
liver function status (, Child-Puge classification), tumor stage (, Okuda classification) &  physical status (, WHO performance status) +!z321{/
# 3 parameter

" & (O3( Child-Pugh classification Clinical or laboratory feature

1 point

2 points

3 points

Encephalopathy (grade) 0 (absent) 1Œ2 Ascites Absent Slight Bilirubin (mg/dl) < 2.0 2.0 Œ 3.0 Albumin (g/dl) > 3.5 2.8 Œ 3.5 INR < 1.7 1.7 Œ 2.2 * 5-6 points = Class A, 7-9 points= Class B, 10-15 points= Class C

3Œ4 Poorly > 3.0 < 2.8 > 2.3

" & (O3( Okuda classification

Stage

Tumor Size > 50 % (+)

I

< 50% (-) (-)

Ascites (+)

Albumin (-)

< 3 g/dl (+)

> 3 g/dl (-)

(-)

II

1 or 2 ( + )

III

3 or 4 ( + )

(-)

Bilirubin > 3 mg/dl < 3 mg/dl (+) (-) (-)

" & (O3( World Health Organization Performance Status grades World Health Organization Performance Status grades Stage 0 Stage 1 Stage 2 Stage 3 Stage 4

Fully active, normal life, no symptoms Minor symptoms, able to do light activity Capable of self-care but unable to carry out work activities Up for more than 50% waking hours Limited self care capacity Confined to bed or chair > 50% waking hours Completely disabled Confined to bed or chair 10

]% staging system ))
-# "
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 $2]%- /7
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Treatment -w, BCLC staging system $,

-, |
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4 &
 *! (1) Radical curative treatment 0$2&/G hepatic resection, liver transplantation &  PEI/RF (percutaneous ethanol injection/radiofrequenct ablation) ]% curative treatment 720$27
w stage 0 &  A /
#
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w* 1
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Clinical manifestation "/
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72"/ CT scan ! MRI !
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Algolithm O3(1 & approach ICC

Treatment  0$2z $"$*!z/,$$) & 1^--)
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!-z312 {) +w!37/
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Gallbladder O' biliary tract Anatomy '
#G$ (gallbladder) 1
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0$2&/ fundus, body, infundibulum & neck  histology )/'
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1
common hepatic duct -
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common bile duct & -01"#
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complicated gallstone disease 1w 3-5% ,/!16
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13

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wG splenectomy 7
z321{  hemolytic anemia |G cholecystectomy 012!
5. bariatric surgery (  ! $*!2
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0"2! -
,-/-) focal tenderness &  guarding ) w
22!7,2*+ & ,-) Murphy's sign ( inspiratory arrest with deep palpation in the right subcostal area)  - !$,-) mild-moderate leucocytosis (WBC 12,00015,000 cells/mm3) '2 WBC / 20,000 cells/mm3 ,2! complicated cholecystitis $01 LFT "3+%#
0$2 &,/0/ $  !0/ 
4 mg/dl

Diagnosis Ultrasonography 1
imaging of choice $ sensitivity & specificity 1w 95% "G) CT scan |"'


-.*0$2$ &,/ sensitivity ,G/ ultrasonography

14

Treatment  1!)$2$
#G& !, fluid resuscitation, 72 antibiotic * !)*  gram negative aerobe &  anaerobe /
third generation cephalosporins with good anaerobic coverage ! second generation cephalosporins /) metronidazole z321{*0$2)z/,$'
#G$!!  2
7
+2!27
z/,$ /
"/ &  *1-G,0/ z/,$ (medically unfit patient) 1^--)
 G laparoscopic cholecystectomy 1
operation of choice /  7
z/,$ 2 &))*! early cholecystectomy *!z/,$7
3 
  $* & delay cholecystectomy *!z/*$ / 6-10 "1$  -'
#G$! ") $1^--)
&

2G early cholecystectomy 7
z312 {) 7
3 
+! $* &  "'
) *2! &,/'2z321{)   3 
+! $**z/,$ 1
delayed cholecystectomy
!-z/,$G0$2+%#

!-
#)w7 2& 2!&/  ! 1
complicated cholecystitis |-G 1
,2! z/,$. .
"G) medically unfit patient -wG cholecystostomy )
#G$&
"+!z312 {$+
%# !-*/!z/,$ !'
#G$!!7
 |0$2 3.Chronic cholecystitis 1
" ,+!1$2!))/! $1w 2 7
3 +!z312 {  gallstone disease - 1
chronic cholecystitis z321{-!1$2! 1
‚‚ (recurrent attack of pain) - recurrent cystic duct obstruction Clinical manifestation

z321{!1$2!2!) w #
16‰ & 7,2*+&)) biliary colic ( 1
misnomer $-‚& 21$ &)) constant pain 1
 1w 1-5 . & 2-% ) 1$ 
!0+
& 1$/  /
!
 )
!-/
!

"'!$) w cystic duct 0$2/+%#
!-1$201/") !")$2
+ ,-// !-) right upper quadrant tenderness &,/7
/0/!,-/ & z LFT -1,

Diagnosis $72 ultrasonography )
7
'
#G$/)!$ /"'72
-.0$2  &,/'20/)
)&*/  bile sludge  recurrent pain attack /) ultrasonography ) bile sludge ,#&,/ 2 *#+%#
01|"'72
-. & "'G cholecystectomy 0$2 

Treatment   *!z/,$ $G 1
elective laparoscopic cholecystectomy (LC)

4.Choledocholithiasis (common bile duct stone, CBD stone) !
7
/!
#G$ )0$21w 6-12% +!z321{*
7
'
#G$ $"'&)/ CBD stone !! 1
primary &  secondary CBD stone (1) Primary CBD stone *!
/!
#G$ $/!
#G$ ! ))/!7
 !  ) 1
brown pigmented stone ]%"
(

) bile stasis &  bacterial infection , 0 $
 /+2,2
(2) Secondary CBD stone $-
7
'
#G$  /
"3/ common bile duct )7
,
,0$2)/!/ 15

Clinical manifestation z321{ $2!1$2!&)) biliary colic, * 
0"2 ! -
,  !,  ! )*#0+2 $ cholangitis 0$2 ! $ 1
gallstone pancreatitis !!- 1
&)) intermittent
!-
"' * !
010$2 &,/)*#'2
 impact  ampulla of vater |G72 $ progressive jaundice 0$2 /



Diagnosis 7
z312 {"" CBD stone -,- LFT -) direct hyperbilirubinemia, elevated ALP / 2 / -
#
G ultrasonography "') intrahepatic bile duct dilatation, CBD dilatation (> 6 mm) & )
 0$2 &,/ sensitivity 2080% &  specificity 95% - |
/*/sensitivity range */!
+22-*/,G01"3 $
#
7
 "" CBD stone !3/ |,2!G investigation ,/!01 ]%,- (0$2&/ magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS) &  intraoperative cholangiogram (IOC) ]% 4 (
# sensitivity 7 2 *
1w 80-95% &  specificity 90-100%  !/-"/ investigation $2(7$+%#
)/z321{ !" CBD stone 
2! 7$ w!") CBD stone |- ! ERCP
!-"'G therapeutic intervention *! !
!! !7"/ stent ,/!0$2  &,/'2!")
0/
|- !( noninvasive //!

!-G ERCP /!72 $&]2!
0$2 /

&,/#
#+%#
!3/) *2!+! *!! & &

z32 _7
&,/ "')


Treatment  +%#
) 1^-- /
*2!+!"'
) * _+!& /  
-.0$2 /!
z/,$ !/z/,$ 1
,2
$

#  !-0$2&/ ERCP with CBD stone removal & 2G LC   ! )
G LC+IOC & 2G post op ERCP ! LC/OC + common bile duct explorationation (CBDE) 1
,2


Algolithm 1 &,,2^!+O'&!1_ % `+a67(!+ CBD stone

16

5.Cholangitis 1
/!
#G$! ")$ $- ascending bacterial infection, *
#,2!1!)$2 2 !* 1!)"G*_7
 $**!  bacteria 7

#G$ & *$
7
/!
#G$"3+%#
1, bacteria "'z/
+2!! $

#G$0$2 1
*#* &,//  01‘!
0$2&/ sphincter of oddi 1‘!
0/72!- duodenum +27
/!
#G$, !,/!/ hepatocyte 1‘!
#!* +2"3,/ ) , Kupffer cell /7
 G-$ #!*,
#G$ antibacterial properties /
IgA, bile salt & 0 +!
#G$-)
 / &,/'2 $!$,
7
/!
#G$0// 1
-
 !
#!!G72
#G$0 2  bacteria - colonization & &)/, -G

/!72 $ ,$ !# 0$2 )/" ,))/!"$+! cholangitis *! gallstone
!-
#
/
benign/malignant stricture, parasite #! bacteria ))/!0$2&/ Escherichia coli, Klebsiella pneumoniae, Streptococcus faecalis &  Bacteroides fragilis

Clinical manifestation !
Gz321{) *!0+2
"
1$2!) w #
16‰!/!2!$2
+)
& ,  !,  ! # 3 !
# / Charcoths triad ]%)0$2 2 7
3 +!z321{  cholangitis z321{ cholangitis 1w 5% ! 
& / acute toxic cholangitis -! septic shock /) mental status change 01) Charcoths triad  1
Reynoldhs pentad (fever, jaundice, right upper quadrant pain, septic shock, and mental status changes) '! 1
 /$/
,2! )) $

#G$&)). .


Diagnosis z !$) leucocytosis, hyperbilirubinemia, and elevation of alkaline phosphatase and transaminases -
#
72"/ ultrasonography !1 
/!$,
 $

#G$ 1 
IHD (intrahepatic bile duct) dilatation &  definite diagnosis *! ERC (Endoscopic retrograde cholangiography) '2G ERC 0/0$2!-,2!G PTC (Percutaneous transhepatic cholangiography) 7
w""/" ,!- 1
-
#!!72"/ CT scan ! MRI $2

Treatment   &*!$
#G$! 72 fluid resuscitation & 72†/ #! /))
#G$$ ERCP ! PTBD (percutaneous transbiliary drainage)+%#
)/ 1
proximal &  distal obstruction 7
w 1
acute toxic cholangitis ,2!0$2))
#G$. .
!-G PTBD ! ERCP +%#
),G&
/ !$,
z/,$ !)
#G$G .w!3/7
"'
) 0/ PTBD/ERCP & 0/"'"/,/!z321{0$2 ! failed PTBD+ERCP -G 1
,2!)
#G$. .
7
 acute toxic cholangitis
!-*$
7
/!
#G$"3G72†/ #!0/"' +2017
/!
#G$0$2

6.Intrahepatic duct stone (IHD stone) 1
))/!7
&')1 ! $ .1 &') ! ,
!!0 /
0,2
’/! _1{
"/
7
1 0)0$20/)/!
 *
#0/0$2) $3&  !/'3,2!!-"/z 72 $,$ #! 1
,) &+|  | $

#G$7
,),/!010$2
+! intrahepatic duct stone ! hepatolithiasis *!
!3/7
/!
#G$+#,) 
! hepatic confluence "/
7_/) 7
left intrahepatic duct )/!/

17

Clinical manifestation )/ 60% +!z312 {! ! 40% 0/!-
 $!
#
,#&,/1$ #
16 !7,2*+  !/!
#G$! ") 567
,) ,)&+| ,)5{!  ! | $

#G$  /0/!)/,$,,/!7
 (

/ 10 16 ) )/-!  11%

Diagnosis - ultrasonography /

]%"' |
IHD stone, IHD dilatation -
#
&z
 -G 1
,2!32   !$,/‚0$2&/ ,G&
/+!
, !,), +,+!/!
#G$, G
+!,), ,)5{! , ,)&+|&  portal hypertension &  | $

#G$ $ MRCP 1
imaging of choice '20/72-w CT scan /) ERCP ! PTC

,2!,- tumor marker /
CA 19-9, CEA !" 1
 |0$2 & '2-G 1
,2!G,$,),2!1 
liver reserve function $2

Treatment '20/!0/,2!G  72,$,! 1
 -G ,/! !z321{! !,)5{! !  | $

#G$ 1
,2
(  3 ( 0$2&/ (1) surgery : bilioenteric bypass, liver resection, liver transplantation (2) endoscopic treatment (3) percutaneous removal

$ +%#
),G&
/
 & !,)  |!0/ ",) "*1-G,+!z312 {  /
'2,)0/$ 2G liver resection !'2*1-G,z312 { !-G open surgery 0/0$2

Malignant tumor of gallbladder and biliary tract 1.Gallbladder carcinoma  |'
#G$))/! 1
!
$)5 +! |7
)) $
! !1w 2-4% +! |)) $
! )7
_)/!/  2-3 / & )7
z321{ !/ 70 16 "G)1^-- "+! |'
#G$0$2&/
7
'
#G$+
$7_// 3 cm ( ",/! | 10 /+!*
1,), calcified gallbladder (porcelain gallbladder), choledochal cyst, chronic inflammation /
typhoid, gallbladder polyp +
$7_// 1 cm,  anomalous pancreaticobiliary duct junction (APBDJ), 0$2)"/! | /
nitrosamine, azotoluene )/1w 90% 1
adenocarcinoma

Clinical manifestation !&0$2) cholecystitis ! cholelithiasis /
!1$2!) w #
16‰ !7,2*+, * 
0"2 ! -
&,/!-)!,  !,  !0$21w 25-50%, "/,- !$2!1y),0/"' 
-.*0$2 &,/*z$1,+! LFT  1
 w biliary obstruction G72-G 1
,2!G")*2
,/! )// *%
% +!z312 {0/)/ 1
 |/!
Gz/,$

18

Diagnosis -"/ ultrasonography ]%"' gallbladder mass ! focal wall thickening -
#
-G 1
,2!"/ imaging study !
 ,
!-,2!1 
biliary, vascular, nodal, hepatic , adjacent organ involvement &  distant metastasis /!
z/,$ ]% 1^--)
 MRCP 1
single imaging study 1 
!/$ /0$2 &,/w0/ MRCP !-72 CT scan, ERCP ! PTC $&
0$2 "G) tumor marker 72 - CA 19-9 G biopsy /!
z/,$0/* -G 1

!-!-G72 ]

 |-017
/!2!
!- preoperative work up )/ 1
unresectable disease !--wG biopsy !


-./!
-w72 *)G)$

Treatment   *!z/,$ $ +%#
)+!*$'2 1
 T1 lesion (tumor invades mucosa, muscularis propria) 72Gz/,$  simple cholecystectomy (,$ .'
#G$!!!/ $) &,/'2 1
T2 lesion (tumor invades the perimuscular connective tissue without extension beyond the serosa or into the liver) 72G extended cholecystectomy *!,$'
#G$/),/!
#G  !+2 *& ,$,)) w segment IVB &  V, "G)  1
T stage "3/
#
*!   serosa ! invades ,)!!+2 * ,2!G extended right hepatectomy (,$,) segment IV,V,VI,VII &  VIII) w 1
metastatic disease !-01,/!
#G  !0 !!01-wG palliative treatment /
G)  $

#G$!$,
$ PTBD ! ERCP "G)72  "$.&"!72 *)G)$z 0/*/!$


2.Extrahepatic cholangiocarcinoma 1
 |))/!7
*!"
& * 
!+!1 0 $1^-- " !
 /027
intrahepatic cholangiocarcinoma "'&)/ tumor 1
3 "/
,,G&
/0$2&/ hilar, middle &  distal location $,G&
/ hilar lesion 1
,G&
/))/!"$*!)1w 2 7
3 +! extrahepatic cholangiocarcinoma #$ &   |, G&
/
# / Klatskin tumor

Clinical manifestation O' Diagnosis !
Gz321{) )/!"$*! painless jaundice ]% 1
&)) cholestatic jaundice investigation & - ultrasonography - |
tumor &  bile duct proximal ,/! tumor dilatation -
#
72 investigation ,/! $ MRCP | 1
single useful imaging
!-"'1 
biliary anatomy, lymph nodes, vascular involvement &  tumor growth/invasion 0$2 &,/|!-72 CT /)ERCP ! PTC $&
0$2 /

"G) tissue diagnosisG0$2 &  sensitivity ,G -%&

G72G surgical exploration $! +2!3 - !"" &  imaging study |! &  /

-wG biopsy ! 1
preoperative staging )/ 1
unresecatble disease !-w72 &))!
,/! /
72 *)G)$

Treatment  +%#
),G&
/+!
#!! $
# (1) Hilar cholangiocarcinoma "'&)/
$$72 Bismuth-Corlette classification 1
4 type Type I : lesion of main hepatic duct, not involve main confluence Type II : lesion involving the confluence but clear of the right and left hepatic duct

19

Type IIIa : lesion involving the right hepatic duct Type IIIb : lesion involving the left hepatic duct Type IV : lesion involving the right and left hepatic duct

$ type I Gz/,$ hilar resection+lymphadenectomy+/- caudate lobe resection "/
type II G hilar resection+lymphadenectomy+caudate lobe resection , type IIIa G right hepatectomy, type IIIb G left hepatectomy "/
type IV '!/ 1
unresectable disease 72G palliative treatment !72
#G$)0$2 (2) Middle lesion 72G major common bile duct resection (3) Distal lesion 72G Whipple operation (pancreaticoduodenectomy)

Approach to jaundice z321{!,  !,  ! !$]/
" ,,/‚ ]%-G 1
,2!
-." ,72'3,2! .
#
G72 z$( /2 "/z "&/z321{0$2 "G) approach z321{$]/
 ( /
-G&
/ 1
prehepatic, hepatic !posthepatic jaundice, -G&
 1
unconjugated ! conjugated jyperbilirubinemia , -G&
/ 1
hemolytic, hepatocellular ! cholestatic jaundice &,/$01 -&z321{  ! 1
medical ! surgical jaundice ]% surgical jaundice (! obstructive jaundice ! cholestatic jaundice) $-!$,
+!/! $

#G $G72
#G$0/"'0 "3/ duodenum 0$2 !0

$2* G) G72 conjugated bilirubin reflux +2"3/&" !$ "/z 72 $!,  !,  ! &  0/ bile "3/ G0"2G72!--0/"' 1 
1
stercobilin "/z 72!- -"] $
!-
#1^""- +2 1
" bile - conjugated bilirubin ]%  
#G z/
010, & +)!!1^"" "/
!*
$- bile salt ]% 1
pruritogenic agent ,2
72*
!) \) endogenous opioid 7
&" !$+!z31 2 { & 72 opioid antagonist G72!$+%#
$"1 symptom/sign G72"" surgical jaundice 0$2&/ (1) 1,$]/
/)!--]$ 1^"" +2 & *
(2) !1$2! (3) ,-)2!
7
/!2! /
* G0$2'
#G$1{! -
#!!!$,
) w/!
#G$!3/,G/ cystic duct ]% / Courvoisierhs law

20

(4) LFT ) conjugated hyperbilirubinemia, elevated ALP !"" surgical jaundice 72"/ ultrasonography $3/  w!$,
/!
-

# -w"/ ERCP ! PTC , * ",/!01

Algolithm O3(1 & approach jaundice

21