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The Liver

The Liver . Overview. Anatomy Function Investigations Symptoms and signs Jaundice Encephalopathy Hepatorenal Cirrhosis Portal vein thrombosis/ GIT complications Drugs Metastasis Effect of CPB ITU management. Anatomy. Largest organ in body RUQ Anatomical and functional differences

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The Liver

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  1. The Liver

  2. Overview • Anatomy • Function • Investigations • Symptoms and signs • Jaundice • Encephalopathy • Hepatorenal • Cirrhosis • Portal vein thrombosis/ GIT complications • Drugs • Metastasis • Effect of CPB • ITU management

  3. Anatomy • Largest organ in body • RUQ • Anatomical and functional differences • Dual blood supply • Microstructure • Biliary system

  4. Function • Metabolism • Protein • Carbohydrate • Lipids • Lactate • Bile acids • Bilirubin metabolism • Hormone and drug inactivation • Immunological

  5. Metabolism - Protein • Synthesis • All major proteins except IgGs • Albumin and clotting factors except VIII • Degradation • Amino acids • ammonia to urea to kidneys

  6. Function albumin • Osmotic • Carrier for H2O insoluble substances

  7. Metabolism - carbohydrate • Glucose • Sources • Sugars • Glycogen (glycogenolysis) • Lactate/Protein/amino acids (gluconeogenesis)

  8. Metabolism - Lipids • Fat / cholesterol • Insoluble, transport proteins – lipoproteins • Hypercholesterolaemia • HMGCoA reductase inhibitors • LDL receptor

  9. Metabolism - Lactate Glucose No oxygen Lactic acid Pyruvate TCA cycle Oxygen ATP Energy

  10. Bile acids • Formed from cholesterol • Cholic and chenodeoxycholic acid • Conjugated with lycine or taurine • GIT absorption of lipids • Cholestyramine sequesters

  11. Bilirubin metabolism • Formed from RBC breakdown • Myoglobin, cytochromes, catalases • Hb • Biliverdin • Bilirubin • Glucuronic acid • Bacteria form bilirubin • Urobilinogen (enterohepatic circulation) • stool stercobilinigen • Urine urobilinogen

  12. Hormone and drug inactivation • Insulin • Glucagon • Oestrogen • Growth hormone • Parathormone • Drug solubilisation

  13. Immunological • Reticuloendothelial • Phagocytic Kupffer’s cells • Sieve for portal vein • Tuftsin synthesis

  14. Investigations • Routine biochemistry • Additional blood tests • Imaging

  15. Routine biochemistry • Normal values do not exclude severe disease • Bilirubin conjugated or unconjugated • Aminotransferases • AST/SGOT • ALT/SGPT • Alk Phos • Liver • Bile duct • Gamma GT • Serum proteins • Albumin • hyperglobulinaemia

  16. Additional blood tests • FBC • HB • WCC • Plt • Splenomegally / hypersplenism • Alpha fetoprotein • Autoantibodies

  17. Imaging • AXR/CXR • Stones • Size • Free air ? “Perf” • USS • Intrahepatic / extrahepatic • CT

  18. Symptoms and signs • Acute verses chronic • Acute • Yellow, pale stool dark urine • Chronic • Every organ affected

  19. Jaundice • Gilberts syndrome • 2 – 5 % population • Raised unconjugated • Haemolytic • Acholuric jaundice • Cholestatic • Intrahepatic • Extrahepatic • Raised conjugated • Choluric jaundice

  20. The Brain / Encephalopathy / Alcohol • Wernickes encephalopathy • Acute or chronic • Ammonia and potassium • Korsakoff psychosis/syndrome • Alcohol withdrawal • Ataxia, nystagmus, confusion, heart failure in an alcoholic give Vitamin B1 (thiamine)

  21. Hepatorenal syndrome • Renal failure in setting of deep jaundice • Kidneys normal (can be used for transplantation) • ? Circulating factor ? NSAID • Keep well hydrated • ? Use mannitol

  22. Cirrhosis • Degeneration / regeneration / fibrosis • Multiple causes (alcohol most common) • Think of all the livers functions • Think stomach ulcers • Think oesophageal varices

  23. Portal vein thrombosis/ GIT complications • Always think about in a • hypotensive, • hypoglycaemic, • acidotic, • ? Not really bleeding but given clotting factors • Especially if deteriorates over a few hours or quicker

  24. Metastasis • Think about in all patients who have cancer • Anatomical verses functional significance

  25. Effect of CPB (peri and post op) • Hypoperfusion particularly in cirrhosis • Reduced function • Clotting • Glucose • Acid-base

  26. Picking up liver disease • Suspicion • History eg alcohol • LFTs • Hypoglycaemia / severe acidosis • GIT bleeds • Clotting abnormality • Fuscidic acid / paracetamol

  27. ITU management - 1 • THINK • Glucose • Acid-base balance Lactate • Clotting (Vitamin K) • Albumin • Sepsis • Alcohol withdrawal • Varices / stomach ulcers • Drugs

  28. ITU management - 2 • Gastric protection • Thiamine • Type of feed • DVT prophylaxis • Renal function • Pressure sores / oedema • N acetyl cysteine • ALL TREATMENTS ARE SUPPORTIVE

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