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The liver Dr,Dler Omer 4th year-2016 The liver is the largest organ in the body, weighing 1.5 kg in the average 70-kg man. The liver parenchyma is entirely covered by a thin capsule and by visceral peritoneum on all but the posterior surface of the liver, termed the ‘bare area’. The liver is divided into a large right lobe, which constitutes three-quarters of the liver parenchyma, and a smaller left lobe. Surgical resection of these lobes would be termed a right or left lobectomy. The liver divided into (anatomical): right & left lobes by the falciform ligament. divided into right & left surgical (functional) lobes along gall-bladder fossa and MHV Liver segments (v – viii) to the right of this line are supplied by the right hepatic artery, right branch of portal vein, and drain bile via Rt hepatic duct. To the left of this line (segments i – iv), functionally is the left liver. Ligaments & peritoneal reflections: • The liver is fixed in the RUQ by peritoneal reflections that form ligaments: 1. LT triangular ligament: left lobe to diaphragm 2. RT triangular ligament: fixes Rt lobe to Rt hemidiaphragm. 3. falciform ligament (remnant of umbilical vein): runs from umbilicus to the liver , attaching it to posterior aspect of ant. Abd. Wall. 4. lesser omentum: betw stomach & liver, contains hilar structures in its free edge Blood supply 80% from portal vein & 20% from hepatic artery. The venous drainage is via the hepatic veins into the IVC. Structures in the hilum of the liver: The hepatic artery, portal vein, & bile duct ((are present in the free edge of the lesser omentum or (hepatoduodenal ligament)). At the hilum the major structures divide into right & left branches. Main functions of the liver: 1. 2. 3. 4. 5. 6. 7. 8. maintaining core body temperature pH balance & correction of lactic acidosis synthesis of clotting factors glucose metabolisim, glycolysis and gluconeogenesis urea formation from protein catabolism bilirubin formation from haemoglobin degradation drug & hormone metabolism removal of gut endotoxins and foreign antigens. Tests of liver function 1. Bilirubin: 5-17 umol/l (direct <5) increase in haemolytic, hepatocellular dysfunction (defect in transport & excretion), biliary obst 2. Alk. Pho ALP: 35-130 iu/l 3. Aspartate transaminase AST: 5-40 4. Alanine transaminase ALT: 5-40 5. Gamma-glutamyl transpeptidase GGT: 10-48 6. ALBUMIN : 35-50 gm/l 7. PT: 12-16 seconds Acute liver failure: causes 1. Viral hepatitis (ABCDE) 2. Drug reactions (halothane, antidepressants, NSAIDS, 3. Paracetol oversose 4. Mushroom poisoning 5. Shock & MOF syndrome 6. Acute Budd-chiari syndrome 7. wilson’s disease 8. Fatty liver of pregnancy INH-rifampicine, C/F of ALF • Early stages: mb no signs • Severe cases: jaundice, neurological signs of liver failure (liver flap, drowsiness, confusion, coma) • MR 50% • Liver transplant: some pts – poor results Supportive Rx of ALF 1. Fluid & electrolyte balance 2. Acid-base balance & bd glucose 3. Nutrition & renal function 4. Respiratory support 5. Monitoring & treatment of cerebral edema 6. Treat bacterial & fungal infection Chronic liver disease Lethargy weakness ------- jaundice Fever: cytokine release from diseased liver, bacterial infection Muscle wasting, Coagulopathy: skin bruising Hepatic encephalopathy: memory impairment, confusion, slow slurred speech, flapping tremor Portal hypertension, ascites, oesophageal varices, splenomegaly Endocrine: hypogonadism & gynaecomastia Skin changes: spider naevi, palmar erythema, cutaneous nodules, white nails (leuconychia) Child’s classification of hepatocellular function in cirrhosis (severity of CLD) Group designation Bilirubin (mg dl–1) Albumin (g dl–1) Ascites Neurological disorder Nutrition A < 2.0 > 3.5 None None Excellent B 2.0–3.0 3.0–3.5 Easily controlled Minimal Good C > 3.0 < 3.0 Poorly controlled Advanced Wasting Imaging the liver Imaging modality Principal indication ------------------------- ------------------------------ Ultrasound Standard first-line investigation Spiral CT Anatomical planning for liver surgery MRI Alternative to spiral CT MRCP First-line, non-invasive cholangiography ERCP Imaging the biliary tract when endoscopic intervention is anticipated (e.g. ductal stones) PTC Biliary tract imaging when ERCP impossible or failed Angiography Nuclear medicine To detect vascular involvement by tumor To quantify biliary excretion and tumor spread Laparoscopy/ To detect peritoneal tumor spread and laparoscopic superficial liver metastases