Category Archives: Hepatobiliary Surgery

Main Clinical Manifestations of Hepatic Abscess

Hepatic abscess is a focal collection of pus within the liver parenchyma, most frequently bacterial (pyogenic) or amoebic in origin. Clinical expression reflects the host response, abscess size, number, and the presence of systemic dissemination. Recognition of the evolving pattern is essential for early drainage and antimicrobial therapy.

  1. High-grade fever with rigors
    Spiking temperature > 38.5 °C, often accompanied by chills and profuse sweating, is the hallmark of intrahepatic infection and may precede localising symptoms by several days.
  2. Right-upper-quadrain pain
    A constant dull ache or pleuritic pain under the costal margin is typical; larger abscesses produce a boring sensation that radiates to the right shoulder tip (diaphragmatic irritation).
  3. Tender hepatomegaly
    The liver edge is smooth, hot and exquisitely tender to percussion and palpation; a localised soft bulge may be ballotable if the abscess is superficial.
  4. Pleuro-pulmonary manifestations
    Reactive pleural effusion, basal atelectasis or diaphragmatic elevation give rise to dry cough, dyspnoea and pleuritic chest pain; hiccough suggests phrenic nerve irritation.
  5. Gastro-intestinal upset
    Anorexia, nausea and intermittent vomiting are common; large abscesses compress the stomach, producing early satiety and eructation.
  6. Jaundice
    Modest elevation of conjugated bilirubin occurs when multiple abscesses impinge on intrahepatic bile radicals or when sepsis precipitates cholestasis; frank jaundice suggests concurrent biliary obstruction.
  7. Systemic toxicity
    Tachycardia, hypotension, prolonged capillary refill and confusion indicate impending septic shock; leucocytosis with left shift and elevated C-reactive protein are uniformly present.
  8. Amoebic colitis association
    Amoebic liver abscess may be preceded by loose stools with blood and mucus; sterile dysentery can, however, be inapparent.
  9. Complication warnings
    Persistent hiccoughs, uncontrolled fever despite antibiotics, or sudden shoulder pain may herald rupture into the pleural or peritoneal cavity, requiring urgent intervention.
Symptom / SignTypical Presentation
High fever & rigors> 38.5 °C, chills, profuse sweating
RUQ painDull ache, pleuritic, radiates to shoulder
Tender hepatomegalyHot, exquisitely tender edge
Pleuro-pulmonaryDry cough, dyspnoea, pleuritic chest pain
GI upsetAnorexia, nausea, early satiety
JaundiceModest conjugated hyper-bilirubinaemia
Systemic toxicityTachycardia, hypotension, confusion
Amoebic colitisBloody mucoid diarrhoea (may be absent)
Alarm signsHiccoughs, uncontrolled fever → rupture

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  1. Main Clinical Manifestations of Hepatic Hydatid Disease
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  3. Main Clinical Manifestations of Hepatic Rupture
  4. Main Clinical Manifestations of Extrahepatic Bile-Duct Stones
  5. Main Clinical Manifestations of Acute Cholecystitis
  6. What Are the Symptoms of Psoas Abscess

Main Clinical Manifestations of Hepatic Rupture

Hepatic rupture is an acute disruption of liver parenchyma that may follow blunt trauma, penetrating injury, spontaneous bleeding from tumours, or iatrogenic insults during percutaneous procedures. Clinical expression ranges from contained subcapsular haematoma to massive intraperitoneal haemorrhage and haemodynamic collapse. Recognition of the constellation below is essential for rapid intervention.

  1. Acute abdominal pain
    Sudden, severe right-upper-quadrain pain often radiates to the shoulder tip (phrenic nerve irritation) and is exacerbated by movement, coughing, or deep inspiration.
  2. Peritoneal irritation
    Blood and bile extravasate onto the peritoneal surface, producing guarding, rebound tenderness and board-like rigidity. Shoulder-tip pain may dominate when the patient is supine.
  3. Hypovolaemic shock
    Tachycardia > 120 beats min⁻¹, hypotension, narrowed pulse pressure, cool clammy extremities, and altered sensorium indicate > 30 % circulating volume loss. Paradoxical bradycardia can transiently occur with high spinal reflexes.
  4. Abdominal distension and shifting dullness
    Rapid accumulation of blood creates a tensely distended abdomen with positive fluid thrill and dullness that shifts to the flanks.
  5. Falling haematocrit and haemoglobin
    Serial measurements show a progressive drop within 30–60 min despite crystalloid resuscitation; base deficit and lactate rise in parallel.
  6. Nausea, vomiting and vasovagal response
    Vagal stimulation from peritoneal irritation or hypotension leads to repeated retching, sweating and transient hypotension.
  7. Associated thoracic signs
    Right-sided pleural rub or basal crackles suggest concomitant diaphragmatic injury or pleural effusion from peritoneal blood tracking.
  8. Localised swelling and ecchymosis
    Subcapsular haematoma may present as a tender, palpable hepatic mass without free intraperitoneal blood; overlying bruising or seat-belt imprint implies deceleration injury.
  9. Coagulopathy and haemobilia
    Massive transfusion or underlying cirrhosis can precipitate diffuse oozing; communication with bile ducts produces intermittent haematemesis and melaena (haemobilia).
Symptom / SignTypical Presentation
Acute RUQ painSudden, severe, radiates to shoulder
Peritoneal signsGuarding, rebound, board-like rigidity
Hypovolaemic shockTachycardia, hypotension, cool skin
Abdominal distensionPositive shifting dullness, fluid thrill
Falling Hb/HctProgressive despite resuscitation
Nausea/vomitingVagal response to irritation
Pleural signsRub, crackles, effusion
Localised massTender hepatomegaly (subcapsular)
HaemobiliaIntermittent GI bleeding, melaena

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  1. Main Clinical Manifestations of Hepatic Hydatid Disease
  2. Main Clinical Manifestations of Hepatic Abscess
  3. Main Clinical Manifestations of Hepatic Ascites
  4. Main Clinical Manifestations of Congenital Biliary Malformations
  5. Main Clinical Manifestations of Biliary Tract Tumours
  6. Main Clinical Manifestations of Portal Vein Thrombosis

Main Clinical Manifestations of Extrahepatic Bile-Duct Stones

Extrahepatic bile-duct stones (choledocholithiasis) are most frequently cholesterol calculi that have migrated from the gallbladder, or primary pigment stones that form de novo within the common bile duct. Symptoms depend on the degree of obstruction, the presence of infection, and the duration of bile stasis.

  1. Biliary colic
    Epigastric or right-upper-quadrain pain begins 30–60 min after a fatty meal, builds steadily for ≥30 min, may last several hours, and radiates to the right scapula or inter-scapular region. Movement does not relieve the discomfort, and antacids are ineffective.
  2. Nausea and vomiting
    Gastric stasis and vagal reflexes produce repeated retching that may transiently lessen pain.
  3. Fluctuating jaundice
    Intermittent occlusion of the common bile duct elevates conjugated bilirubin, producing scleral icterus, dark urine, and clay-coloured stools that wax and wane as stones impinge or disimpact.
  4. Cholangitis
    Complete obstruction plus bacterial contamination produces Charcot triad: spiking fever with rigors, persistent RUQ pain, and deepening jaundice. Suppurative forms add hypotension and mental confusion (Reynolds pentad), indicating pus under pressure within an obstructed ductal system.
  5. Acute pancreatitis
    Impaction at the ampulla obstructs both bile and pancreatic flow, leading to mid-epigastric pain radiating to the back, intractable vomiting, and elevated serum amylase/lipase.
  6. Abdominal tenderness and guarding
    Deep palpation elicits localized guarding; inspiratory arrest during RUQ palpation (Murphy sign) may be positive if concomitant acute cholecystitis is present.
  7. Systemic response
    Tachycardia, low-grade pyrexia, and elevated C-reactive protein accompany active obstruction; leukocytosis is common during infective episodes.
Symptom / SignTypical Presentation
Biliary colicPost-prandial RUQ/epigastric pain ≥30 min, radiates to scapula
Nausea/vomitingRepeated, may transiently relieve pain
JaundiceFluctuating, dark urine, pale stools
CholangitisFever + RUQ pain + jaundice (Charcot triad)
Acute pancreatitisEpigastric pain to back, intractable vomiting
Tenderness/guardingLocalized RUQ, positive Murphy sign possible
SystemicTachycardia, low-grade fever, leukocytosis

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  1. Main Clinical Manifestations of Bile-Duct Stones
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  4. Main Clinical Manifestations of Hepatic Hydatid Disease
  5. Main Clinical Manifestations of Hepatic Abscess
  6. Main Clinical Manifestations of Hepatic Ascites

Main Clinical Manifestations of Hepatic Hydatid Disease

Hepatic hydatid disease (hepatic echinococcosis) is a zoonotic infection caused by the larval stage of Echinococcus granulosus or E. multilocularis. Its presentation is dictated by cyst number, size, location, integrity, and associated complications. Many patients remain asymptomatic for years; symptoms emerge only when growing cysts exert a mass effect, rupture, or become secondarily infected.

  1. Pain and right-upper-quadrant discomfort
    A constant dull ache or sensation of fullness develops beneath the costal margin as the cyst expands or stretches Glisson’s capsule; sudden sharp pain heralds cyst rupture or intracystic haemorrhage.
  2. Palpable hepatic mass
    Inspection reveals asymmetric abdominal bulging; palpation detects a smooth, resilient, ballotable mass that moves with respiration and is dull to percussion.
  3. Dyspeptic complaints
    Early satiety, eructation, nausea and occasional vomiting occur when a large cyst compresses the stomach or duodenum.
  4. Jaundice and cholestasis
    Obstruction of segmental bile ducts by daughter cysts or external compression of the common hepatic duct produces fluctuating conjugated hyper-bilirubinaemia, dark urine and pale stools.
  5. Acute hypersensitivity phenomena
    Leakage or spontaneous rupture releases antigen-rich cyst fluid, provoking urticaria, pruritus, eosinophilia, or life-threatening anaphylaxis with hypotension and bronchospasm.
  6. Secondary infection and suppuration
    Fever, rigors and right-upper-quadrant tenderness appear when bacteria colonise the cyst, converting it into an abscess; laboratory studies show leucocytosis and raised C-reactive protein.
  7. Vascular and biliary fistulae
    Rupture into the biliary tree causes cholangitis, recurrent pyrexia and Charcot triad; communication with the portal vein or hepatic artery may lead to acute haemobilia with melena and anaemia.
  8. Systemic features
    Chronic weight loss, fatigue and low-grade fever reflect long-standing inflammation and diminished oral intake.
  9. Parasitic dissemination
    Implantation of protoscolices along the peritoneal or pleural surfaces produces secondary cysts, presenting months or years later as abdominal masses or pleural nodules.
Symptom / SignTypical Presentation
RUQ painDull ache; sudden if rupture/haemorrhage
Palpable massSmooth, ballotable, moves with respiration
DyspepsiaEarly satiety, nausea, eructation
JaundiceFluctuating; daughter-cyst obstruction
HypersensitivityUrticaria, pruritus, eosinophilia, anaphylaxis
Secondary infectionFever, rigors, tenderness, leucocytosis
Biliary fistulaCholangitis, Charcot triad, haemobilia
SystemicWeight loss, fatigue, low-grade fever
DisseminationSecondary peritoneal or pleural cysts

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  1. Main Clinical Manifestations of Hepatic Abscess
  2. Main Clinical Manifestations of Hepatic Ascites
  3. Main Clinical Manifestations of Hepatic Rupture
  4. Main Clinical Manifestations of Hilar Cholangiocarcinoma
  5. Main Clinical Manifestations of Congenital Biliary Malformations
  6. Main Clinical Manifestations of Acute Cholecystitis

What Are the Symptoms of Intrahepatic Biliary Calculi?

Intrahepatic biliary calculi (hepatolithiasis) are stones that form within the liver’s intrahepatic bile ducts. Most small or segmental stones are silent; symptoms appear when stones obstruct flow, provoke cholangitis, or lead to secondary biliary cirrhosis.

  1. Right-upper-quadrant pain
    Dull or colicky ache under the ribs, often recurrent and triggered by fatty meals; may radiate to the back or right shoulder.
  2. Cholangitis attacks
    Intermittent fever with chills, shaking rigors, and raised right-sided tenderness (Charcot triad) when stones block a segmental duct and become infected.
  3. Jaundice
    Fluctuating yellowing of sclera and skin, dark urine, and pale stools occur as stones impact major intra-hepatic radicals or cause stricture.
  4. Pruritus
    Intense itching accompanies fluctuating hyper-bilirubinaemia, even if jaundice is not overt.
  5. Hepatomegaly & palpable mass
    Chronic obstruction produces lobar hypertrophy; the liver edge feels firm and nodular, sometimes with an audible bruit over dilated ducts.
  6. Systemic features
    Low-grade fever, night sweats, fatigue and weight loss reflect recurrent infection and biliary cirrhosis.
  7. Complication warnings
    Persistent high fever, hypotension, confusion (Reynold pentad) or upper-GI bleeding from portal hypertension signal acute suppurative cholangitis or advanced secondary cirrhosis.

Because findings overlap with gallbladder stones or tumours, any combination of recurrent RUQ pain, fluctuating jaundice and fever warrants imaging to map stones and strictures.

Symptom / SignTypical Features
RUQ painRecurrent, colicky, post-prandial
CholangitisFever + chills + RUQ tenderness
JaundiceFluctuating, dark urine, pale stools
PruritusIntense, bile-salt related
HepatomegalyFirm, nodular liver edge
SystemicNight sweats, fatigue, weight loss
Alarm signsHigh fever, hypotension, GI bleeding

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What Are the Symptoms of Intrahepatic Cholangiocarcinoma?

Intrahepatic cholangiocarcinoma (ICC) arises from bile ducts within the liver parenchyma. Early lesions are usually asymptomatic; as the tumor enlarges or metastasizes, the following complaints typically appear:

  1. Right-upper-quadrant pain
    A dull, continuous ache or vague fullness beneath the ribs is the most frequent early symptom; it may radiate to the back or shoulder.
  2. Palpable mass or hepatomegaly
    Patients or clinicians can feel a firm, nodular liver edge or localized lump that moves with respiration.
  3. Unintended weight loss & anorexia
    Rapid loss of >5 % body weight within weeks, early satiety and loss of interest in food are common systemic effects.
  4. Fatigue and night sweats
    Persistent tiredness, low-grade fever and drenching night sweats reflect cytokine release and tumor cachexia.
  5. Jaundice (less common than in hilar tumors)
    Yellow sclera/skin, dark urine and pale stools occur only when large tumors compress intra-hepatic bile radicals or invade the hepatic hilum.
  6. Pruritus
    Deposition of bile salts can produce intense, often intractable itching even before visible jaundice.
  7. Paraneoplastic signs
    Hypercalcaemia, hypoglycaemia or dermatomyositis occasionally precede other manifestations.

Because findings overlap with benign liver disease, any new combination of RUQ pain, weight loss and fatigue—especially in patients with cirrhosis, hepatitis or primary sclerosing cholangitis—should prompt urgent imaging and tumour-marker assessment.

Symptom / SignTypical Features
RUQ pain/heavinessDull ache, may radiate to shoulder
Palpable massFirm, nodular, moves with breathing
Weight loss>5 % in weeks, anorexia
Fatigue/night sweatsPersistent, low-grade fever
JaundiceLate, if bile radicals compressed
PruritusIntense, may precede icterus
ParaneoplasticHypercalcaemia, skin rash

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What Are the Symptoms of Budd-Chiari Syndrome?

Budd-Chiari syndrome (BCS) is a rare disorder caused by obstruction of hepatic venous outflow. Symptoms depend on the speed and extent of blockage; they range from none to fulminant hepatic failure. Three clinical patterns are recognised:

  1. Acute (days–weeks)
    Sudden, severe right-upper-quadrant pain, rapidly accumulating ascites, tender hepatomegaly, nausea and vomiting. Jaundice, high fever and early hepatic encephalopathy may appear if massive necrosis develops.
  2. Sub-acute (weeks–3 months)
    Moderate ascites, gradual abdominal distension, low-grade fever, fatigue and dull hepatic pain; collaterals begin to form so jaundice is often mild or absent.
  3. Chronic (>3 months)
    Persistent ascites, non-tender hepatomegaly, splenomegaly, lower-limb oedema and visible abdominal wall collaterals. Portal hypertension leads to oesophageal varices that can bleed massively. About half of patients develop renal impairment; 15–20 % are virtually asymptomatic owing to extensive venous collaterals.

Alarm features that suggest advanced disease or acute decompensation include confusion (hepatic encephalopathy), rapid liver enlargement with intractable ascites, haematemesis from variceal rupture, and oliguria indicating hepatorenal syndrome. Early recognition is essential because untreated BCS has a 3-year mortality >90 %.

Symptom / SignTypical Presentation
RUQ painSudden (acute) or dull chronic ache
AscitesRapid in acute; persistent in chronic
HepatomegalyTender in acute, firm in chronic
JaundiceCommon in acute, mild/absent in chronic
Lower-limb oedemaDue to IVC or portal hypertension
SplenomegalyChronic portal hypertension
EncephalopathyConfusion, drowsiness, coma
GI bleedingHaematemesis/melaena from varices

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What Are the Symptoms of Primary Liver Cancer?

Primary liver cancer (hepatocellular carcinoma, HCC) often begins silently; early-stage tumors rarely cause pain or obvious changes. As the lesion enlarges or invades adjacent structures, the following complaints typically appear:

  1. Right-upper-quadrant discomfort
    A dull, continuous ache or heaviness develops beneath the ribs and may radiate to the back or right shoulder.
  2. Palpable mass or abdominal swelling
    Patients or clinicians can feel a firm, nodular liver edge below the costal margin; progressive enlargement can produce visible asymmetry of the abdomen.
  3. Unintended weight loss & anorexia
    Rapid loss of >5 % body weight within weeks, early satiety and loss of interest in food are common systemic effects.
  4. Fatigue and weakness
    Persistent tiredness unrelated to exertion reflects both malignant cachexia and underlying chronic liver disease.
  5. Jaundice
    Yellow discoloration of sclerae and skin arises when tumour compression or portal vein invasion reduces bilirubin excretion.
  6. Ascites & peripheral oedema
    Fluid accumulates in the peritoneal cavity and ankles as portal hypertension and hypoalbuminaemia worsen.
  7. Pyrexia & night sweats
    Low-grade fever is present in ~30 % of cases, probably due to cytokine release or central tumour necrosis.
  8. GI bleeding
    Ruptured oesophageal or gastric varices may cause haematemesis or melaena when portal pressure rises.
  9. Paraneoplastic signs
    Hypercalcaemia, hypoglycaemia, erythrocytosis or cutaneous lesions (e.g., dermatomyositis) occasionally precede other manifestations.

Symptoms are often indistinguishable from decompensated cirrhosis; any new or worsening complaint in a cirrhotic patient warrants immediate imaging and tumour-marker assessment.

Symptom / SignTypical Features
RUQ pain/heavinessDull ache, may radiate to shoulder
Palpable massFirm, nodular, expands downwards
Weight loss>5 % in weeks, anorexia
FatiguePersistent, disproportionate
JaundiceYellow sclera, dark urine, pale stools
Ascites/oedemaBulging flanks, ankle swelling
FeverLow-grade, intermittent
GI bleedingHaematemesis, melaena
ParaneoplasticHypoglycaemia, skin rash

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What Are the Symptoms of Gallbladder Cancer?

Gallbladder cancer is an aggressive malignancy that usually produces no specific early warning signs. Symptoms appear only when the tumour obstructs bile flow, invades adjacent organs, or becomes advanced.

  1. Right-upper-quadrant pain
    A constant, dull ache or colicky pain under the ribs is the most common first complaint; it may radiate to the right shoulder or back and is often mistaken for uncomplicated gallstone disease.
  2. Palpable mass
    A firm, non-tender swelling is sometimes felt in the upper abdomen when the tumour has enlarged or the gall-bladder is distended by associated stones.
  3. Jaundice
    Yellow discoloration of skin and sclera, dark urine and pale stools develop if the tumour compresses or invades the common bile duct.
  4. Unintended weight loss & anorexia
    Rapid loss of >5 % body weight, early satiety and general fatigue reflect malignant cachexia and reduced oral intake.
  5. Nausea and intolerance to fatty foods
    Patients report recurrent queasiness, bloating and diarrhoea after meals rich in fat.
  6. Fever & night sweats
    Low-grade, intermittent pyrexia is common; high fever with chills suggests acute cholecystitis or super-infection of an obstructed system.
  7. Alarm features
    Severe, unrelenting pain, progressive jaundice, ascites, or left-supraclavicular lymph-node enlargement indicate advanced disease with distant spread.

Because findings overlap with benign biliary disorders, any new combination of RUQ pain, weight loss and jaundice—especially in older patients with long-standing gallstones—should prompt urgent imaging and tumour-marker assessment.

SymptomTypical Presentation
RUQ painConstant or colicky, may radiate to shoulder
Palpable massFirm, non-tender upper-abdominal swelling
JaundiceYellow skin/sclera, dark urine, pale stools
Weight loss>5 % in weeks, anorexia
Fat intoleranceNausea, bloating, post-prandial diarrhoea
FeverLow-grade; high with infection
Alarm signsAscites, severe pain, distant nodes

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What Are the Symptoms of Liver Cysts?

Liver cysts are fluid-filled sacs that usually remain asymptomatic and are found incidentally on imaging. When symptoms do occur, they are related to cyst size, number, or complications such as infection, rupture, or pressure on adjacent organs.

  1. Right-upper-quadrant discomfort
    A persistent dull ache or feeling of fullness under the ribs is the most common complaint, especially after meals or prolonged sitting.
  2. Abdominal bloating and early satiety
    Large cysts compress the stomach or intestines, producing visible distension and the sensation of being full after only a small amount of food.
  3. Nausea and occasional vomiting
    Pressure on the gastric wall can trigger queasiness, eructation, or post-prandial vomiting.
  4. Palpable mass
    Very large or superficial cysts may be felt as a smooth, non-tender swelling that moves with respiration.
  5. Acute pain
    Sudden, sharp pain indicates possible rupture, intracystic bleeding, or torsion; this is often accompanied by shoulder-tip pain if intraperitoneal bleeding occurs.
  6. Jaundice
    Obstruction of intra-hepatic bile ducts by centrally located cysts leads to scleral icterus, dark urine and pale stools.
  7. Fever and systemic signs
    Infected cysts produce high fever, chills, leukocytosis and localized tenderness resembling a liver abscess.

Most simple cysts never require treatment; however, any new or worsening symptom, especially acute pain or fever, warrants urgent imaging to exclude complications.

SymptomTypical Presentation
RUQ discomfortDull ache, fullness, post-prandial
Bloating & early satietyLarge cyst compresses stomach
Nausea/vomitingPressure-related, post-meal
Palpable massSmooth, non-tender, moves with breathing
Acute sharp painRupture, bleeding, torsion
JaundiceObstructive, dark urine, pale stools
Fever & chillsInfected cyst, leukocytosis

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