NMS. Casos Clínicos

211

Chapter 7 ♦ Pancreatic and Hepatic Disorders

Right lobe posterior section

Right lobe anterior section

Left lobe medial section

Left lobe lateral section

Inferior vena cava

Middle hepatic vein

Right hepatic vein

Left hepatic vein

2

4A

7

8

1

3

4B

6

5

Portal vein

Common bile duct

Proper hepatic artery

Q: How would you work up this patient? A: Findings of RUQ tenderness and fever with leukocytosis point to a hepatobiliary condi- tion. This could include complications of gallstones or infectious processes such as chol- angitis or liver abscess. Appropriate tests include ultrasound or spiral CT. An ultrasound demonstrates many hepatobiliary processes, including liver abscesses and biliary obstruc- tion or stones, whereas CT may be better at identifying hepatic abscesses near the dome of the liver and visualizing other lesions such as intra-abdominal abscesses or diverticulitis (Fig. 7-33). A CT scan reveals multiple low-density lesions within both lobes of the liver with peripheral rim enhancement indicative of liver abscesses. Q: What treatment is appropriate? A: Liver abscesses can be either pyogenic (caused by bacterial spread) or amebic (caused by Entamoeba histolytica ) . Typically, liver abscesses result from a partial or complete obstruction of the biliary system with spread of bacteria up the biliary tree. Bacterial trans- Figure 7-32: Hepatic sectional and segmental anatomy. Under the Anglo-Saxon system, the liver is divided into four sections by the three hepatic veins (anterior and posterior sections of the right lobe and medial and lateral sections of the left lobe). Under the Couinaud system, the liver is divided into eight segments based on vascular and biliary boundaries. Under this system, the portal vein divides the liver in the horizontal plane and the three hepatic veins divide the liver in the vertical plane. (From Lee EY. Pediatric Radiology: Practical Imaging Evaluation of Infants and Children . Wolters Kluwer Health; 2017, Fig. 14-2.) SAMPLE