DIG Exam 2 Sos and Lopez

Frequency of liver metastasis

Colorectal 70%

Pancreatic 50-60%

Breast 30-50%

Lung cancer 20-30%

Liver border vertically

5th intercostal to costal margin

1: falciform ligament

2: round ligament of liver

5 Left triangular ligament

4: coronary ligament

3: Right triangular ligament

1: Falciform ligament

2: Round ligament

3: Left anatomical lobe

4: Right anatomical lobe

5: Quadrate lobe

6: Caudate lobe

7: Porta Hepatis

1: Hepatic artery proper

2: Bile duct

3: Portal vein

4: IVC

The hepatic portal system is a vital component of the circulatory system that directs blood from part of the ______ and _____ to the liver

GI tract

Spleen

Blood from the hepatic portal system delivers _____, ______. and other substances to the liver for _____, _______, ______, and other processing before it enters systemic circulation

nutrients, toxins

metabolism, detoxification, storage

IMV, SMV, Splenic vein, gastric veins

Main tributaries of hepatic portal system

Important portal-caval shunts

periumbilical, distal esophagus, hemorrhoids?

Each segment of the liver has its own vascular _____, _____, and ______ drainage

inflow, outflow, and biliary

Each segment has its own portal vein branch, hepatic artery branch, bile duct branch, and hepatic vein drainage

of the liver

____ vein: Divides the liver into upper and lower segments

Portal

____ ______ vein: Divides the liver into right and left lobes functionally (not the same as anatomic lobes).

Middle Hepatic

_____ and ___ _____veins: Further divide the lobes into sectors.

Right and left hepatic

_____ _______vein → separates segments V&VIII (anterior) from VI&VII (posterior).

Right hepatic

_____ ______ vein → separates right from left functional lobes

Middle hepatic

_____ ______ vein → separates segments II–III (lateral) from IV (medial).

Left Hepatic

Normal liver

Hepatic Lobule

1: Portal Vein

2: hepatic artery

3: bile duct

2: Sinusoid

Hepatocyte stains _____ and has a ______ places _____ nuclei

eosinophilic; centrally; round

Hepatocytes make up __% of the liver’s mass

80%

Is it normally for some hepatocytes to by binucleate?

Yes

Some functions of hepatocytes include

Protein synthesis

Protein storage

Transformation of carbohydrates

Synthesis of cholesterol, bile salts and phospholipids

Detoxification, modification, and excretion of exogenous and endogenous substances

Initiation of formation and secretion of bile

Contains the blood plasma and microvilli of hepatocytes

Contains hepatic stellate cells (also known as Ito cells) [store fat or fat soluble vitamins]

Space of Disse

Specialized macrophages located in the sinusoids of the liver, derived from monocytes.

Kupffer cells

1: Portal lobule

2: Classic lobule

3: Liver acinus

Zone 1: Closest to the portal triads, this zone receives the most __________ blood and is most active in _________ metabolism

Zone 2: intermediate levels of oxygenation and metabolic activity

Zone 3: Farthest from the blood supply, this zone receives the least _______ blood. More susceptible to _______ injury and toxins

oxygenated; oxidative

oxygenated; ischemic

Comprises all hepatocytes that drain into a SINGLE bile duct bound peripherally by the ventral veins

Portal lobule

C. zone 3

Central vein - _____ veins - _______ - IVC

interlobar veins; hepatic veins

A 50-year-old man presents with a dull, aching pain in the epigastric region that radiates to the back. The pain has been persistent for the past several weeks and is associated with nausea. Physical examination reveals tenderness over the epigastric region, and imaging shows a mass in the right lobe of the liver. The visceral somatic innervation responsible for transmitting the pain from the liver to the spinal cord is most likely mediated by which of the following nerves?

Greater splanchnic nerve (T5-T9)

Difficulty breathing

Tachypnea

Tachycardia

Bowel sounds in the chest

symptoms of

diaphragmatic hernia

Diaphragmatic hernia: congenital defect

Acceleration/deceleration and crush injuries

Tears along the falciform and round ligament and triangular ligament

Liver trauma

What maneuver do you use to control liver hemorrhage?

Pringle

Liver trauma is the ______ most common abdominal injury

second, spleen is number 1

Space between the right lobe of the liver, right kidney, and right colic flexure?

Hepatorenal recess or Morison’s pouch

Fluid around the spleen

Peri splenic space

Fluid between uterus and rectum

Rectouterine pouch or pouch of Douglas

Left -back Morison’s pouch and right peri splenic space

Cuboidal epithelial parenchymal cell of the liver main functions metabolism, storage, digestion, coagulation factors, and bile production

Hepatocytes

Hepatocytes. Large active nucleolus. Glycogen granules

___% of blood is recieved from the portal vein

75

__% of blood is received from the hepatic artery

25

Hepatocytes are arranged in single rows or ____ with ____ surface facing bile canaliculi and ______ surfaces facing sinusoids.

cords, apical, basolateral

Perisinusoidal space between basal surface of hepatocytes and the endothelial cells of the sinusoids.

Space of Disse

Liver histology

Liver cell injury, inflammation, and fibrosis starts in ___________?

space of Disse

____ is the most common drug-induced liver injury in the US, zone __ necrosis

Acetaminophen; 3

Zone 3 necrosis, could be from acetominophen

Rare but serious acute illness that causes liver and brain damage, a rapidly progressive encephalopathy.

Affects children and teens recovering from a viral infection most commonly the flu or chickenpox

Symptoms: Diarrhea, rapid breathing, confusion, seizures and loss of consciousness

Aspirin used for relief of fever or pain

Reye’s syndrome

Liver microvesicular steatosis and hepatitis

Reye’s syndrome

Mitochondrial swelling

Reye’s syndrome

Fat stained with Oil red O or PAS

Reye’s syndrome

The liver stores vitamin ___ , ____ , ___ , ___ and B12

ADEK

Bile secretion and dietary fat breakdown is essential for absorbing ______ vitamins

ADEK

Occurs in animal products and mostly stored in the liver (stellate cells) an important in eye health, skin, intestines, lungs and immune system

Vitamin A (retinal)

Produced by the skin during exposure to the sun and the primary role is calcium absorption and bone health

Vitamin D

Primary role is as an antioxidant

Vitamin E

A group of vitamins required to make prothrombin involved in blood clotting “blood-clotting vitamin”

Vitamin K

Water soluble as all B vitamins. Naturally found in meats and important in brain functions and red blood cell synthesis. B12 deficiency involved in pernicious anemia, Crohn’s disease, gastritis, celiac disease and chronic alcoholism. B12 deficiency can cause permanent nerve and brain damage

Vitamin B12 Cobalamin

Alcohol consumption is the ____ leading risk factor for both death and burden of disease and injury

7th

_____ is a major cause of preventable liver disease worldwide

Alcohol

At least 20 year history of regular consumption of alcohol above threshold

Alcohol-related liver disease

AST > ALT (2:1)

think Alcohol-related liver disease

_____ consumed with food takes a priority to metabolize

Ethanol

The metabolic by-product of alcohol is ______ which is toxic to the body and increases ______

Acetaldehyde; inflammation

Final product of ethanol metabolism is?

Acetyl-CoA which is converted to fats and cholesterol

steatosis

steatohepatitis

liver fibrosis

Hepatocyte changes include Mallory bodies, cellular inclusions consisting of damaged cytokeratin filaments

Also has steatosis

Alcohol abuse and other disease

Liver parenchyma is replaced with scar tissue, an end stage organ damage state

Fatigue, loss of appetite and weight loss, jaundice and itchy skin, bruises and bleeding, edema, brown to orange urine, pale stool, disorientation

20% of chronic alcoholics

Alcohol-induced cirrhosis

Cirrhotic liver

Micronodular cirrhosis

Alcohol

Macronodular cirrhosis

Viral

Portal-systemic (cava) collaterals

Where fluid builds up when liver is backed up

Esophageal, periumbilical, rectal, retroperitoneal (gutters of large intestine)

Study

Esophageal varices

Edema secondary to obstruction of vascular flow

Ascites

Ascites

Caput medusae

Ascites and cirrhosis

Infection of ascitic fluid without apparent source

Fever and malaise worsen with increased hepatic failure

Spontaneous bacterial peritonitis

Hepatocellular carcinoma lives in a _____ liver

SICK

Hepatocellular carcinoma

could also be metastatic liver cancer

Hepatocellular carcinoma

Hepatocellular carcinoma

Normal liver- steatosis - alcoholic steatohepatitis - fibrosis - Cirrhosis - HCC

Alcohol liver disease

____ used for screening, diagnosis, prognosis, and monitoring but not specific for HCC. Used after HCC is removed.

Alpha-fetoprotein

Summary fpr alcohol liver disease

Steatosis is _______

reversible

Chronic inflammation involving portal triads, leading to bridging inflammation to additional triads

Inflammation is replaced with portal triad fibrosis and then bridging fibrosis

Cirrhosis is end result

Viral hepatitis

Autoimmune hepatitis

Hepatitis chronic inflammation, portal tracts

Cirrhosis

most common benign liver tumor

typically, does not need to be resected

Liver hemangioma