LIVER & GALL

BLADDER.

DR.AB RAHMAN (BIJOY)

MBBS(SSMC),BCS (Health)
FCPS (Medicine)final part
MD (Nephrology)course.
 LIVER – PHYSIOLOGICAL
ANATOMY.
 Largest gland
 Wt – 1500 gm
 Anatomically – lobes – 2
 Right & left
 Each part has blood
supply from hepatic
artery, portal vein & own
venous & biliary
drainage.
 STRUCTURAL
CHARACTERISTICS
 Structural & functional
units – hepatic lobules –
about 1 lac
 Each lobules has hepatocytes
in columns
 Between columns present
bile canaliculi
 Hapatocytes tunneled by
blood sinusoids which drains
into central vein.
 STRUCTURAL
CHARACTERISTICS
 Sinusoids lined by
endothelial cells, along with
Kupffer cells in between.
 At periphery of each lobule
present portal triad.
 Contains – portal vein,
hepatic artery & bile duct.
 Acinus – is structural unit of
liver.
 ZONES OF ACINUS
 Zone 1 – central portion
of acinus immediately
surrounding terminal
hepatic arteriole & portal
venule
 Zone 2 – between zone 1
&3
 Zone 3 – most peripheral
part, most susceptible to
anoxic injury.
 HEPATIC CIRCULATION
 Hepatic artery – branch of ciliac trunk (20-
25%)
 Portal vein – collects from mesenteric &
splenic vascular bed ( 75-80%)
 Hepatic vein – sinusoids drain into central
vein, all central veins joins to form right &
left hepatic veins which drains into inferior
venacava.
 HEPATIC BILIARY SYSTEM
 Intra hepatic Biliary
system – bile secreted by
hepatic cells into canaliculi
which form hexagonal
network around liver cells
 At periphery canaliculi
becomes continuous with
intralobular ductules –
joins together to form
hepatic duct
 EXTRA HEPATIC BILIARY
APPARATUS
 Gall Bladder – pear
shaped sac beneath
liver, 30-50 ml
capacity, stores bile
 Extra hepatic ducts.
 Hepatic duct
 Cystic duct
 Common bile duct.
 EXTRA HEPATIC DUCTS.
 Hepatic duct – right &
left hepatic ducts from
2 sides joins to bile
common hepatic duct
(4 cm)
 Cystic duct (4cm) –
connects neck of gall
bladder to common
hepatic duct to form
CBD
 EXTRA HEPATIC DUCTS.
 Common bile duct (8
cm)
 Joins pancreatic duct to
form common
hepatopancreatic duct
(Ampulla of Vater)
 Opens into 2ndpart of
duodenum at major
duodenal papilla.
 Surrounded by sphincter
of Oddi.
 FUNCTIONS OF LIVER
 Secretory function
 Metabolic function
 Carbohydreate
 Fat
 Protein
 Detoxicating and protective function.
 Storage function
 Excretory function
 Synthesis function
 Miscellaneous function.
 SECRETORY FUNCTION

 Liver – exocrine gland

 Secrete bile for digestion and absorption of

fats.
 METABOLIC FUNCTION
 Carbohydrate –
 Glycogenesis
 Glycogenolysis

 Gluconeogenesis.

 Alcohol metabolism

 Fats – degradation & synthesis of fats

 Proteins – Deamination, urea formation.

Tuesday, September 18, 2018

 DETOXICATING AND
PROTECTIVE FUNCTION.
 Kupffer cells –
removes bacteria &
cleansing action
 Detoxify drugs by
oxidation, hydrolysis,
reduction &
conjugation.
 STORAGE FUNCTION

 Glucose ( in the form of Glycogen), Vit B12, Vit A

 Blood iron buffer & iron storage medium in the

form of ferritin & hemosiderin.

 EXCRETORY FUNCTION

 Exogenous dyes like bromsulpthalein & rose

Bengal dye are excreted.

 SYNTHESIS FUNCTION
 Plasma proteins – albumin & α & β globulin

 Coagulation factors I,V, VII, IX & X

 Enzymes – alkaline phosphatase. SGPT, SGOT

 Removes ammonia to synthesize urea

 Cholesterol.
Tuesday, September 18, 2018
 MISCELLANEOUS FUNCTION.
 Reservoir of blood – about 650 ml
 Erythropioiesis
 Hormone metabolism
 Inactivation of insulin, glucagon, vasopressin
 Reduction & conjugation of oestrogen,
testosterone, cortisol, aldosterone.
 Destruction of RBC
 Thermal regulation.
 BILE
 Digestive juice formed
in liver.
 Hepatocytes to bile
canaliculi
 Common hepatic duct
 Cystic duct
 Common bile duct
FORMATION OF BILE
 COMPOSITION OF BILE
 Bile formed in hepatocytes & released into canaliculi.
 Its an alkaline juice comprised of

 Water & solids (organic/inorganic)

 Organic – bile salts, pigments, cholesterol, lecithin, FA, alkaline
phosphatase

 Inorganic – Na+, K+, Ca+, HCO3- & Cl-

 COMPOSITION OF BILE
 Bile salts
 Bile pigments
 Phospholipids
 Cholesterol
 Electrolytes.
 FORMATION OF BILE SALTS
 Bile salts
 Formation
 FUNCTIONS OF BILE SALTS
 Emulsification of fats
 Acceleration of action of pancreatic lipase
 Micelle formation
 Absorption of fat soluble vitamins
 Cholerectic action- formation of bile
 Cholesterol kept in soluble form in gall
bladder
 Intestinal motility.
 ENTEROHEPATIC
CIRCULATION OF BILE SALTS
 BILE PIGMENTS

 Mainly Bilirubin & Biliverdin

 From metabolite of hemoglobin.

 OTHER CONTENTS
 Phospholipids – Primarily Lecithins.

 Cholesterol – by product of bile salts synthesis.

 Normal level in bile – 60-170 mg/dl

 Electrolytes
 Cl- & HCO3- mainly.
FUNCTIONS OF GALL BLADDER
(RECSS)
 Regulates equalization of pressure in biliary
system
 Effect on pH of bile
 Concentration of bile – becomes thicker,
viscous & darker
 Storage of bile – 30-50 ml
 Secretion of mucous

Tuesday, September 18, 2018

 FUNCTIONS OF BILE
MADE-(LPC)2
 Digestive function - FATS
 Absorptive function – fats & Vit
 Excretory function – heavy metals, toxins , bacteria, lecithin
 Laxative action – GIT motility
 Protective action – Natural detergent.
 Cholerectic action – secretion of bile.
 Maintenance of pH of gastrointestinal tract.
 Prevention of gall stone formation
 Lubricating function.
 Cholegogue function – Increases release of bile from gall bladder.
 REGULATION OF BILE
 Regulation of biliary
secretion
 Regulation of release
of bile from gall
bladder.
 REGULATION OF BILIARY
SECRETION

 Regulation of bile Indepedent fraction of biliary

secretion

 Regulation of bile depedentr fraction of biliary

secretion
 REGULATION OF BILE INDEPEDENT
FRACTION OF BILIARY SECRETION
 Its amount of fluid containing water &
electrolytes.
 Controlled by secretin & vagal stimulation.
 Secretin – produces watery secretion rich in
HCO3 – via cAMP.
 Vagovagal reflex – initiated during intestinal
phase of digestion through Ach.
 REGULATION OF BILE DEPEDENT
FRACTION OF BILIARY SECRETION

 Quantity of bile salts by liver.

 Directly proportional amount of bile salts
reabsorbed from portal circulation.

 Cholerectics enhances bile salts secretion by

hepatocytes.
 REGULATION OF RELEASE OF
BILE FROM GALL BLADDER.
 Filling of gall bladder – controlled by
pressure gradient.
 During interdigestive period as sphincter of oddi
closed bile goes to gall bladder & pressure rises to
7 cm of H2O
 Emptying of gall bladder – during digestive
period as sphincter of oddi relaxed pressure
in gall bladder rises to 20 cm of H2O bile
enters to duodenum.
 RELEASE OF BILE
CONTROLLED BY
 Hormones – CCK
 Fats & protein digestion products stimulate
secretion of CCK which causes contraction of gall
bladder & relxation of sphincter of oddi.
 Neural
 Vagal stimulation during gastric phase of digestion
causes contraction of gall bladder.
 Cholegogue – Substances causing
contraction of gall bladder.
 APPLIED ASPECTS
 Disorders of liver and
gall bladder
 Jaundice or icterus.
 Cirrhosis of liver
 Viral hepatitis
 Cholecystitis – Gall
bladder inflammation.
 JAUNDICE OR ICTERUS
 Yellowish
discolouration of skin
& mucous membrane
due to raised bilirubin
in blood.
 Normal value – 0.3-1
mg/dl
 Jaundice > 2 mg/dl
 TYPES OF JAUNDICE
 Haemolytic – prehepatic
 Hepatocellular – Hepatic
 Obstructive – post hepatic
 CIRRHOSIS OF LIVER
 Irreversible chronic
damage to liver with
extensive fibrosis &
regenerative nodule
formation.
 VIRAL HEPATITIS
 Cause – hepatitis virus – A,B,C,D,E,F & G
 Hepatitis B hepatitis Most common
 Clinical features
 Odema
 Haemorrhagic disorders
 Muscle weakness, tremors, convulsions
 Hepatomegaly, ascites
 Steatorrhoea
 Anaemia, jaundice

Raised SGPT, SGOT, Blood urea
 GALL STONE
 Cholelithiasis – gall stone
formation.
 Types
 Cholesterol stone – 80-85%
 Due to precipitation of
cholesterol
 Radioluscent – cannot seen.
 Pigment stones – Ca
bilirubinate stones
 15-20 %, Radiopoaque.

Tuesday, September 18, 2018

 LIVER FUNCTION TESTS
 Tests to assess Secretory functions of liver
 Tests to assess Metabolic functions of liver.
 Tests to assess Synthesis of function of liver.
 Tests to assess Detoxication function of liver.
 Tests to assess Hepatic cellular integrity.
 Miscellaneous tests
 TESTS TO ASSESS SECRETORY
FUNCTIONS OF LIVER
 Serum bilirubin –
 Total serum bilirubin – 0.3-1 mg/dl
 Conjugated bilirubin – 0.1-0.3 mg/dl
 Unconjugated bilirubin – 0.2-0.7 mg/dl
 Urine bilirubin & bile salts
 Urine urobilinogen > 4mg/dl
 Faecal stercobilinogen - > 20-25 mg/dl
 Faecal fat level - > 5-6 %
 TESTS TO ASSESS METABOLIC
FUNCTIONS OF LIVER.
 Galactose tolerance tests
 Blood glucose level < 70-90 mg/dl
 Blood & urine amino acid levels > 30-65
mg/dl
 Lipid Profile
 Increase – plasma NEFA & FFA & Ketone bodies
 Decrease – serum cholesterol, serum TG, Serum
PL, total lipids.
 TESTS TO ASSESS SYNTHESIS
OF FUNCTION OF LIVER.
 Estimation of plasma proteins –
Hypoalbuminemia & reversal of A:G ratio
 Serum liver enzymes level – raised
Transaminase & alkaline phosphatase
 Blood urea - < 20-40 mg/dl
 Blood ammonia - > 20-80 mg/dl
 Coagulation factors – II,V, VII, IX & X
decreases.
TESTS TO ASSESS DETOXICATION
FUNCTION OF LIVER.
 Bromsulphthalein excretion test.
 Rate of removal of BSP from blood depends on
functional efficiency of liver & rate of hepatic blood
flow.
 TESTS TO ASSESS HEPATIC
CELLULAR INTEGRITY.
 USG – to detect
cirrhosis of liver, fatty
liver, abcesses, cysts,
tumours, gall stones &
dilatation of biliary
system.
 CT scan
 TESTS TO ASSESS HEPATIC
CELLULAR INTEGRITY.
 Radionucleotide imaging –
Technetium (99mTc)
 Liver biopsy
 FNAC
 Cholecystography
 Other tests –
 Percutaneous choleangiography
 Portal venography
 Endoscopic retrograde cholagiography
THANK YOU