Chapter 21 The Liver and Biliary System Structure and Function of the Liver IMPO T!"T F#!

T$ #S Complex metabolic functions. Double blood supply from hepatic artery and portal vein. Liver lobule is basic structural unit. Branches of hepatic artery, portal vein, and bile duct travel in portal tracts. Blood flow in lobule is from portal tract to central vein. Bile flow in canaliculi is from central vein toward portal tract. Bile FO M!TIO" !"% #&C #TIO" OF BILI $BI" Bile pigment derived from breakdown of red blood cells in reticuloendothelial system. Conjugation and excretion by liver. COMPOSITIO" !"% P OP# TI#S Contains bile pigment, cholesterol, bile salts, lecithin, and other materials. unctions as biologic detergent! no digestive en"ymes. Causes and #ffects of Liver In'ury M!"IF#ST!TIO"S Cell necrosis. atty change. #ixed necrosis and fatty change. CLI"IC!L #FF#CTS #ild injury with complete recovery. $evere injury with hepatic failure. Chronic or progressive injury causes scarring with impaired liver function. COMMO" T(P#S OF LI)# I"*$ ( %iral hepatitis. atty liver. &lcoholic liver disease. Cirrhosis. )iral +epatitis CLI"IC!L M!"IF#ST!TIO"S !"% CO$ S# 'ne third become sick and jaundiced. 'ne third become sick but not jaundiced. 'ne third asymptomatic but liver function abnormal. +#P!TITIS ! ()& virus. $hort incubation period. %irus in secretions and stools during early phases. *ransmitted by direct contact or contaminated food or water. $elf+limited, low mortality, no carriers. ,amma globulin provides protection. -mmuni"ation available. +#P!TITIS B

D)& virus. Long incubation. Large amount of surface antigen produced by virus can be detected in blood of carriers and infected persons. *en percent of infected persons become chronic carriers of virus. .igh carrier rate in some populations. *ransmitted by blood or secretions of infected persons. ,amma globulin provides some protection. -mmuni"ing vaccine provides protection against infection. +#P!TITIS C *ransmitted like hepatitis B. -ncubation period intermediate between .&% and .B%. #any persons become chronic carriers. )o immuni"ation available. ,amma globulin does not provide protection. +#P!TITIS % ,%#LT! +#P!TITIS%irus only infects persons with acute or chronic .B% infection. Delta virus unable to produce own virus coat and uses .Bs&g produced by .B%. OT+# +#P!TITIS )I $S#S /pstein+Barr 0/B1 virus. Cytomegalovirus. +#P!TITIS !MO". M!L# +OMOS#&$!LS $pread by sexual practices. !LCO+OLIC LI)# %IS#!S# atty Liver P!T+O.#"#SIS at accumulates in liver cells owing to liver injury. Common in heavy drinkers and alcoholics. $ometimes caused by other chemicals and solvents. -mpaired liver function but injury reversible. !lcoholic Liver %isease M!"IF#ST!TIO"S *hree stages of progressively increasing severity. (elated to amount and duration of alcohol consumption. atty liver! cells accumulate fat. &lcoholic hepatitis! cell necrosis with #allory bodies and inflammation. Cirrhosis! diffuse scarring throughout liver. Cirrhosis %#FI"ITIO" $carring in liver from any cause. Repeated bouts of alcoholic hepatitis. Massive liver necrosis. Repeated episodes of liver injury. &ssociated derangements of liver cell regeneration and liver function. M!"IF#ST!TIO"S

-mpaired liver function. 2ortal hypertension. Bypass routes connect systemic+portal venous systems. (isk of fatal hemorrhage from esophageal varices. S$ .IC!L P OC#%$ #S TO T #!T CI +OSIS 2ortal+systemic anastomoses to control varices. Splenorenal shunt. Portacaval shunt. Intrahepatic portosystemic shunt. BILI! ( CI +OSIS 2rimary An autoimmune disease attacking small intrahepatic bile ducts. No specific treatment. May lead to liver failure and re uire liver transplant. $econdary !bstruction of large e"trahepatic bile ducts. #reated by relieving duct obstruction or bypassing obstruction. eye/s Syndrome P!T+O.#"#SIS 2robably related to combined effect of viral illness and aspirin. &cetaminophen recommended rather than aspirin to reduce risk. C+! !CT# ISTICS &ffects primarily infants and children. atty liver with liver dysfunction. Cerebral edema with neurologic dysfunction. )o specific treatment available. Cholelithiasis and Cholecystitis F!CTO S I"FL$#"CI". SOL$BILIT( OF C+OL#ST# OL I" BIL# Cholesterol insoluble in a3ueous solution. Dissolved in micelles composed of bile salts and lecithin. $olubility of cholesterol depends on ratio of cholesterol to bile salts and lecithin. $upersaturated bile promotes calculi. COMPLIC!TIO"S OF .!LLSTO"#S &symptomatic in gallbladder. Biliary colic results if stone extruded into ducts. $ommon duct obstruction% obstructive jaundice. $ystic duct obstruction% no jaundice& but acute cholecystitis may occur if pree"isting infection of gallbladder. T #!TM#"T OF .!LLSTO"#S Cholecystectomy. Chenodeoxycholic acid dissolves gallstones. C+OL#C(STITIS Chronic infection common. ,allstones may predispose to infection. -mpaction of stone in neck of gallbladder may precipitate acute cholecystitis.

Tumors of the Liver and .all0ladder I"CI%#"C# Benign adenomas uncommon! occur in women taking oral contraceptives. 2rimary carcinoma uncommon! occurs in patients with cirrhosis. #etastatic carcinoma common. Spread from gastrointestinal tract& breast& lung& or other sites. $# scan aids in recognition. *aundice CL!SSIFIC!TIO" .emolytic! excessive red cell breakdown. .epatocellular! liver cell injury. 'bstructive! common duct obstruction by tumor or stone. Biopsy of the Liver I"%IC!TIO"S !"% M#T+O% -ndicated when cause of liver disease undetermined after clinical and laboratory evaluation. )eedle inserted through skin directly into liver. Biopsy specimen examined histologically by pathologist.