LIVER & GALL

BLADDER.

DR NILESH KATE
MBBS,MD
ASSOCIATE PROF
ESIC MEDICAL COLLEGE, GULBARGA.
DEPT. OF PHYSIOLOGY
 OBJECTIVES.
 Liver
 Physiological anatomy
 Hepatic biliary system

 Functions of liver

 Bile

 Gall bladder
 Applied aspects.
 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.
Tuesday, September 18, 2018
 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.

Tuesday, September 18, 2018

 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.

Tuesday, September 18, 2018

 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.
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 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.

Tuesday, September 18, 2018

 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
Tuesday, September 18, 2018
 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.

Tuesday, September 18, 2018

 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
Tuesday, September 18, 2018
 EXTRA HEPATIC DUCTS.
 Common bile duct (8
cm)
 Joins pancreatic duct to
form common
hepatopancreatic duct
(Ampulla of Vater)
 Opens into 2nd part of
duodenum at major
duodenal papilla.
 Surrounded by sphincter
of Oddi.
Tuesday, September 18, 2018
 FUNCTIONS OF LIVER
 Secretory function
 Metabolic function
 Carbohydreate
 Fat
 Protein
 Detoxicating and protective function.
 Storage function
 Excretory function
 Synthesis function
 Miscellaneous function.

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 SECRETORY FUNCTION

 Liver – exocrine gland

 Secrete bile for digestion and absorption of

fats.

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 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.

Tuesday, September 18, 2018

 STORAGE FUNCTION

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

 Blood iron buffer & iron storage medium in the

form of ferritin & hemosiderin.

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 EXCRETORY FUNCTION

 Exogenous dyes like bromsulpthalein & rose

Bengal dye are excreted.

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 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.
Tuesday, September 18, 2018
 BILE
 Digestive juice formed
in liver.
 Hepatocytes to bile
canaliculi
 Common hepatic duct
 Cystic duct
 Common bile duct

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 FORMATION OF BILE

Tuesday, September 18, 2018

 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-

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 COMPOSITION OF BILE
 Bile salts
 Bile pigments
 Phospholipids
 Cholesterol
 Electrolytes.

Tuesday, September 18, 2018

 FORMATION OF BILE SALTS
 Bile salts
 Formation

Tuesday, September 18, 2018

 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.
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 ENTEROHEPATIC
CIRCULATION OF BILE SALTS

Tuesday, September 18, 2018

 BILE PIGMENTS

 Mainly Bilirubin & Biliverdin

 From metabolite of hemoglobin.

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 OTHER CONTENTS
 Phospholipids – Primarily Lecithins.
 Cholesterol – by product of bile salts synthesis.
 Normal level in bile – 60-170 mg/dl

 Electrolytes
 Cl- & HCO3- mainly.

Tuesday, September 18, 2018

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.

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 REGULATION OF BILE
 Regulation of biliary
secretion
 Regulation of release
of bile from gall
bladder.

Tuesday, September 18, 2018

 REGULATION OF BILIARY
SECRETION

 Regulation of bile Indepedent fraction of biliary

secretion

 Regulation of bile depedentr fraction of biliary

secretion

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 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.

Tuesday, September 18, 2018

 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.

Tuesday, September 18, 2018

 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.
Tuesday, September 18, 2018
 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.
Tuesday, September 18, 2018
 APPLIED ASPECTS
 Disorders of liver and
gall bladder
 Jaundice or icterus.
 Cirrhosis of liver
 Viral hepatitis
 Cholecystitis – Gall
bladder inflammation.

Tuesday, September 18, 2018

 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

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 TYPES OF JAUNDICE
 Haemolytic – prehepatic
 Hepatocellular – Hepatic
 Obstructive – post hepatic

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 CIRRHOSIS OF LIVER
 Irreversible chronic
damage to liver with
extensive fibrosis &
regenerative nodule
formation.

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 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

Tuesday, September 18, 2018

 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

Tuesday, September 18, 2018

 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 %
Tuesday, September 18, 2018
 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.

Tuesday, September 18, 2018

 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.
Tuesday, September 18, 2018
 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.

Tuesday, September 18, 2018

 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

Tuesday, September 18, 2018

 TESTS TO ASSESS HEPATIC
CELLULAR INTEGRITY.
 Radionucleotide imaging –
Technetium (99mTc)
 Liver biopsy
 FNAC
 Cholecystography
 Other tests –
 Percutaneous choleangiography
 Portal venography
 Endoscopic retrograde cholagiography

Tuesday, September 18, 2018

THANK YOU