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51 Cards in this Set

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  • Back
Explain how the Liver is attached to the GI tract
-Liver is connected to the Duodenum by the extrahepatic bile ducts
-Hepatic ducts drain the bile from the liver, forming the Common Bile Duct
-Common Bile Duct is laterally attached to the Gall Bladder by the Cystic Duct
-terminal portion of the Common Bile Duct passes thru the head of the pancreas & prior to entering the duodenum is confluent with the Main Pancreatic Duct at the Papilla of Vater
Describe the blood supply of the Liver
Liver had DUAL blood supply
-2/3 arrives from the Portal Vein
-1/3 arrives from the Hepatic Artery
Describe how blood flows through the liver
1. Portal Vein and Hepatic Artery form several branches which terminate in the Portal Tracts
2. Portal Vein & Hepatic Artery empty blood into Sinusoids of the Hepatic Acinus
3. Sinusoidal blood drains into the Terminal Hepatic Venule
4. Terminal Hepatic Venule -> Hepatic Vein -> IVC
What comprises the Portal Tract?
1. Bile Ducts

2. Portal Vein

3. Hepatic Artery
Describe the Sinusoids of the Liver
-Modified capillaries that form the vascular spaces of the Acinus
-Fenestrated Endothelial Cells = lined with a discontinuous basement membrane that separates the lumen from the perisinusoidal Space of Disse
Describe Kupffer Cells
-fixed Macrophages located in the spaces of Disse
-phagocytic & participate in the uptake of particulate material from circulation (ie - take up fragments of destroyed RBC's in hemolytic anemia)
Describe liver Stellate Cells (Ito cells or Lipocytes)
Fat-storing mesenchymal cells known to be an important storage site for Vitamin A
-in Cirrhosis they transform into collagen-producing myofibroblasts
Left = Portal Tract

Right = Terminal Hepatic Venule (Central Vein)
What is shown at the left?

What is the "Limiting Plate"?
Interface between the connective tissue of the Portal Tracts and the periportal Hepatocytes
Describe Bile Canaliculi
Bile-filled narrow spaces formed between adjacent hepatocytes
Fill in the blanks
What % of Cardiac Output does the Liver receive?

*Hepatic Artery brings in 30-40% of blood
*Portal Vein brings in 60-70%
Describe the "Hepatic Lobule"
Liver cells are arranged around the Terminal Hepatic Venule (Central Vein)
Describe the "Hepatic Acinus"
Portal Tracts are the centers of the functional hepatic units
-blood enters into the center of the unit & flows toward the periphery to finally reach the THV
Describe what happens in Cholestasis
Bile Canaliculi become dilated
Discuss the Metabolic functions of the Liver
Hepatocytes process almost all nutrients entering the body thru the GI tract
-Carbohydrate, Amino acid, & fat metabolism
Discuss the Secretory function of the Liver
Synthesizes almost all blood plasma proteins, lipoproteins, and glycoproteins
Discuss the Storage function of the Liver
-Store energy and metabolites, predominately in the form of lipids and carbohydrates
-Store Vitamins (folic acid, B12, vitamin A), Oligominerals (Copper & Iron)
Discuss the Excretory function of the Liver
Excretes Bile, Bilirubin, & lipids (cholesterol) into the GI tract
Which LFT's are used to assess the Hepatic Secretory function?
1. Serum Albumin = synthesized constantly & has half-life of ~ 3 wks = takes time to develop Hypoalbuminemia

2. Coagulation proteins = use Prothrombin Time (PT) to assess liver fxn loss
Which LFT's are used to assess the Excretory functions of the Liver?
1. Bilirubin = conjugated bilirubin that cannot be excreted into the Intestine accumulates in the blood and can be measured as Direct Bilirubin

2. Alkaline Phosphatase = found along the liver cell membrane lining the intercellular canaliculi

3. Gamma-glutamyl transpeptidase = primarily a hepatic enzyme (vs. Alk Phos) = marker of liver cell injury (esp. alcohol-induced injury)
What are elevated levels of Alkaline Phosphatase typical of?
Obstructive Jaundice

*Alk Phos is found along the liver cell membrane lining the Intercellular Canaliculi
What lab tests are used to assess Liver Cell injury?
1. Aspartate Amino-transferase (AST)

2. Alanine Amino-transferase (ALT)

**cytoplasmic enzymes released into circulation upon liver cell injury
**not liver specific but liver is major source of these plasma enzymes
What are the 3 most common causes of Fatty Liver?
1. Obesity
2. Diabetes
3. Alcohol
List some reversible changes that occur in Liver injury
1. Hydropic change
2. Ballooning & feathery degeneration
What is glycogen accumulation in the Liver most commonly due to?
What would cause Hemosiderin accumulation in the Liver?

Multiple blood transfusions
What is Centrolobular Necrosis?
necrosis in Zone 3 = part furthest away from Portal Tract but close to the Terminal Hepatic Venule = last part to receive blood
Macrovesicular Fatty Liver
-Fatty change due to Chronic Alcoholism
-Mallory Hyaline is also present
What is seen here?
Alcohol-induced hepatitis
-fatty change
-focal liver cell necrosis
-infiltrates of neutrophils
-Mallory Hyaline
What is seen here?
Viral Hepatitis
-Apoptotic cells = Councilman bodies
-Lymphocyte infiltration
What is seen here?
Viral Hepatitis
-Vacuolar degeneration
-Councilman body
-inflammatory lymphocytes
What is seen here?
List the signs & symptoms of Liver Disease
Constitutional (nonspecific)
1. Anorexia
2. Nausea
3. Weight loss

-dark urine
-Acholic (pale) stools

-hematemesis (blood in vomit)
-Hematochezia (blood in stool)

Hormonal problems
-amenorrhea, gynecomastia, impotence, spider nevi, palmar erythema
What are the 3 possible signs of Portal HTN?
1. Esophageal varices

2. Hemorrhoids

3. Caput Medusa
What are the 3 consequences of Portal Hypertension
1. Ascites = accumulation of serous fluid in abdominal cavity

2. Generalized edema = Anasarca

3. Hemorrhoids, Caput Medusa, Esophageal Varices
Discuss the Pathogenesis of Ascites in Cirrhosis
1. Portal HTN = increased hydrostatic pressure leads to transudation of fluid into abdominal cavity

2. Hypoalbuminemia = liver cannot produce adequate albumin

3. Lymphatic Overflow

4. Hyperaldosteronism = aldosterone is released in response to volume regulatory sensors = conserves Na+ & H2O = water overflows into abdominal cavity
What are the signs & symptoms of Biliary disease?
1. Subcostal & RUQ pain

2. Biliary colic & fever

3. Jaundice

4. Murphy sign = tender gallbladder on taking deep breath

5. Courvoisier sign = palpable distended gallbladder
What are the 3 forms of Jaundice?
1. Hemolytic

2. Hepatocellular

3. Obstructive
Define Jaundice
yellow discoloration of the skin, sclera (icterus) & mucous membranes due to increased levels of BILIRUBIN in circulation
Describe how Bilirubin is formed
1. release of Heme from RBC
2. Heme -> Biliverdin -> Bilirubin (macrophage in spleen & liver)
3. Bilirubin is bound to Albumin = Unconjugated or Indirect Bilirubin
4. Conjugation of Bilirubin to Glucuronic Acid by UGT in Hepatocytes
5. Excretion of water-soluble Bilirubin Glucuronides = Conjugated or Direct Bilirubin
6. Deconjugation of some Direct Bilirubin by intestinal bacteria to Urobilinogen = 80% is excreted in feces together with Conjugated Bilirubin
7. Recirculation of Urobilinogen in Enterohepatic cycle; small amount is excreted in urine
What enzyme performs Bilirubin conjugation?
Uridine Diphosphate-Glucuronosyl Transferase (UGT1A1)
What 2 things would cause increased production of Bilirubin?
1. Hemolysis

2. Hematomas
What syndrome has reduced hepatic uptake of Bilirubin?
Gilbert Syndrome
What conditions have reduced conjugation of Bilirubin resulting in Jaundice?
1. Physiologic in Neonates
2. Gilbert Syndrome (some)
3. Crigler-Najjar Syndrome (deficiency of Glucuronosyl Transferase)
4. Hepatitis (viral or drug-induced)
What conditions have reduced excretion of Bilirubin leading to Jaundice?
1. Dubin-Johnson syndrome
2. Rotor syndrome
3. Hepatitis (viral or drug-induced)

**result in Conjugated Hyperbilirubinemia
List 6 causes of Extrahepatic Bile Duct Obstruction resulting in Jaundice
1. Gallstones
2. Tumors of the Common Bile Duct, Ampulla of Vater, Head of pancreas
3. Primary Sclerosing Cholangitis
4. Strictures due to Surgery
5. Congenital Atresia
5. Parasites = Liver flukes, Ascaris
Define Cholestasis
condition where Bile cannot flow from the Liver to the Duodenum
What are the signs & symptoms of Cholestasis?
1. Jaundice due to Conjugated Bilirubin
2. Pruritis = due to bile acids circulating in the blood
3. Xanthomas = due to cholesterol that is normally excreted in Bile, are taken up by Macrophages
4. Acholic stools (pale stools) = due to absence of bile excretion
5. Dark urine = due to Bilirubin
6. Malabsorption, steatorrhea, Vitamin deficiency (DAKE vitamins)
What lab findings are consistent with Cholestasis?
1. increased CONJUGATED Bilirutin

2. increased Alkaline PHosphatase

3. increased GGT
What are the liver biopsy findings consistent with Obstructive Jaundice?
1. Bile plugs in Intercellular Canaliculi
2. Bile accumulation in Liver cells -> feathery degenaration -> Bile lakes -> Bile infarcts
3. Uptake of bile by Kupffer cells
4. Bile duct proliferation
5. Portal fibrosis -> Portal-Portal bridging fibrosis -> biliary cirrhosis
Obstructive Jaundice
-bile is present in Intercellular Canaliculi
What is this showing?