Liver Dr. Ashok Jaisingani

Liver is largest organ in the body weighting 1.5 kg in average 70 kg man.

The liver parenchyma is entirely covered by thin capsule and by visceral peritoneum on all but the posterior surface of the liver termed as “bare area”

The liver is divided in to ‘right large lobe’ which is constitute three quarters of liver and ‘smaller left lobe.

Surgical resection of these lobes would be termed as right or left lobectomy.

Introduction

The liver has ability to regenerate after the partial resection.

There are two anatomical lobes with separate blood supply, bile duct and venous drainage.

Liver has dual blood supply with 20% from the hepatic artery and 80% from portal vein.

Liver Anatomy

Maintaining core body temperature pH balance and correction of lactic acidosis Synthesis of the clotting factors Glucose metabolism, glycolysis and

gluconeogenesis. Urea formation from protein catabolism Bilirubin formation from haemoglobin

degradation Drug and hormone metabolism Removal of gut endotoxins and foreign

antigens

Main Function Of Liver

Viral hepatitis (hepatitis A, B, C, D, E) Drugs reaction [halothane, isoniazid,

rifampicin, antidepressant, NSAIDs and valproic acid]

Paracetamole overdose Mushroom poisoning Shock and multiorgan failure Acute Budd – Chiari syndrome Wilson’s Disease Fatty liver disease

Causes Of Acute Liver Failure

Test Normal Range

Bilirubin 5 – 17 µmol/liter

Alkaline phosphatase (ALP) 35 – 130 IU/liter

Aspartate Transaminase (AST) 5 – 40 IU/liter

Alanine Transaminase (ALT) 5 – 40 IU/liter

Gama – glutamyl transpeptidase (GGT)

10 – 48 IU/liter

Albumin 35 – 50 g/liter

Prothrombin time (PT) 12 – 16 sec

Routinely Available Tests For Liver Function

Fluid balance and electrolytes Acid – base balance and blood glucose

monitoring Nutrition Renal Function (Haemofiltration) Respiratory Support (Ventilation) Monitoring and treatment of cerebral edema Treat bacterial and fungal infection

Supportive Therapy For Acute Liver Failure

Lethargy Fever Jaundice Protein Catabolism (wasting) Coagulopathy (bruising) Cardiac (Hyperdynamic circulation) Neurological (Hepatic Encephalopathy) Portal hypertension [Ascites, esophageal

varices and splenomegaly] Cutaneous [Spider naevi, palmer erythema]

Features Of Chronic Liver Disease

Imaging Modality Principle 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 anticipitated (ductal stones)

PTC Biliary tract imaging when ERCP is failed or impossible

Angiography To detect vascular involvement by tumour

Nuclear medicine To quantify biliary excretion and tumour spread

Laparoscopy/laparoscopic ultrasound

To detect peritoneal tumour spread and superficial liver metastasis

Imaging The Liver

Liver injuries are fortunately uncommon because of the position of the liver under the diaphragm where it is protected by the chest wall.

When liver injury occurs it is serious and associated with significant morbidity and mortality

Liver trauma can be divided into blunt and penetrating liver trauma.

Blunt injuries produce contusion, laceration and avulsion injury to the liver, often in association with splenic, mesenteric and renal injury.

Penetrating injury such as stab and gunshot wound are often associated with chest or pericardial involvement.

Liver Trauma

Remember the associated injuries and at risk group such as

1- Stabbing/gunshot in lower chest or upper abdomen 2- Crush injury with multiple rib fracture

Resuscitate the patient (airway, breathing & circulation) Assessment of injury by 1- Spiral CT with contrast 2- Laparotomy if haemodynamically unstable

Treatment consist of the 1- Correction of coagulopathy, 2- Suture laceration 3- Resect if vascular Injury 4- Packing if diffuse parenchymal injury

Management Of Liver Trauma

Intrahepatic haematoma Liver Abscess Bile Collection Biliary Fistulae Hepatic Artery aneurysm Arteriovenous Fistulae Arteriobiliary fistulae Liver Failure

Other Complication Of Liver Trauma