9%20ECOGRAFIA%20ABDOMINAL%20COMO%20CUANDO%20DONDE

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ABDOMINAL ULTRASOUND
Table 4.7
Indications for liver transplantation
Chronic cholestatic disease
—PBC, PSC
Cirrhosis
—from hepatitis, alcoholic liver disease or other causes
(without malignancy)
Biliary atresia
—usually in children who have developed SBC
Malignancy
—patients with HCC associated with cirrhosis, provided
the lesion is small (< 3 cm) and solitary
Budd–Chiari syndrome
—non-malignant occlusion of the hepatic veins,
especially total venous occlusion and/or patients with
cirrhosis resulting from BCS
Fulminant hepatic failure
—due to drug (usually paracetamol) overdose, acute
hepatitis, BCS, Wilson’s disease or massive hepatic
trauma (an acute situation requiring immediate
transplant if a suitable donor is found)
Others
—rarely, transplant is undertaken for benign lesions
such as PCD, adenoma or large haemangiomas
PBC = primary biliary cirrhosis, PSC = primary sclerosing cholangitis,
SBC = secondary biliary cirrhosis, BCS = Budd–Chiari syndrome,
PCD = polycystic disease
Table 4.8
Contraindications to liver transplant
Absolute
—extrahepatic malignancy
—active extrahepatic sepsis
—severe cardiopulmonary disease
—AIDS
—inability to comply with regular postoperative drug
treatment
Relative
—age > 65, particularly if related to poor general
health
—moderate cardiopulmonary disease
—PV thrombosis
—active alcoholism or drug abuse
—previous complex hepatic surgery
—multiple or large focal hepatic malignancies (e.g.
cholangiocarcinomas associated with PSC)
AIDS = aquired immunodeficiency syndrome, PV = portal vein
or unable to be effectively bypassed by the
surgeon.
● Any of the features of portal hypertension
associated with chronic liver disease (see
above).
● Focal liver lesions which may represent
malignancy. These may require the
administration of ultrasound contrast agents, or
further imaging to characterize, such as MRI.
An HCC greater than 3 cm in diameter has an
80% chance of recurrence post-transplant. If
under 2 cm and solitary, this is likely to be
cured. Check the size, number and local spread
of disease.
● It is useful to document the spleen size as a
baseline for postoperative comparisons.
● Extrahepatic malignancy, in cases with an initial
diagnosis of carcinoma.
● Degree and scope of vascular thrombosis in
cases of BCS.
● Any incidental pathology which may alter the
management plan.
Doppler ultrasound is, of course, essential in
assessing the patency and direction of blood flow
of the portal venous system, the hepatic veins, IVC
and main hepatic artery. It may occasionally be
possible to demonstrate arterial anomalies. While
large numbers of patients are considered for transplant
and undergo ultrasound assessment, the
majority of these will never actually be transplanted.
This factor has numerous implications for
resources when setting up a transplant ultrasound
service.
Operative procedure
Most transplants are orthotopic, that is the diseased
liver is removed and replaced by the donor organ,
as opposed to heterotopic, in which the donor
organ is grafted in addition to the native organ
(like most kidney transplants).
If the patient suffers from extensive varices,
which may bleed, the removal of the diseased
organ prior to transplant is particularly hazardous.