Deseases of the liver

Balaka Sviatoslav Nikolaevich

Kharkov National Medical University

Department of surgery №2

Anatomy

3

5

1

2

4

1 - falciform ligament

2 - round ligament

3 - coronary ligament

4 - triangular ligament

5 - diaphragm

3

4

2

Liver location types (by Didanski)

Segments of liver (by Couinaud)

Venous inflow and outflow

1

1 – The Rex-Kantli line

2 – Fissure line

2

I

II

III

IVV

VI

VII

VIII

Blood

supply of the liver

Portacaval shunts

1.cardiac region

2.umbilical region

3. rectal region

4. renal region

Lymphatic system

1) l.n. of posterior mediastinum

2) l.n. of anterior mediastinum

3) portal l.n.

4) suprapancreatic l.n.

Functions of the liverSynthesis

Further information: Proteins produced and secreted by the liver

A CT scan in which the liver and portal vein are shown.

A large part of amino acid synthesis

The liver performs several roles in carbohydrate metabolism:

Gluconeogenesis (the synthesis of glucose from certain amino acids, lactate or glycerol)

Glycogenolysis (the breakdown of glycogen into glucose)

Glycogenesis (the formation of glycogen from glucose)(muscle tissues can also do this)

The liver is responsible for the mainstay of protein metabolism, synthesis as well as degradation

The liver also performs several roles in lipid metabolism:

Cholesterol synthesis

Lipogenesis, the production of triglycerides (fats).

A bulk of the lipoproteins are synthesized in the liver.

The liver produces coagulation factors I (fibrinogen), II (prothrombin), V, VII, IX, X and XI, as well as protein C, protein S and antithrombin.

In the first trimester fetus, the liver is the main site of red blood cell production. By the 32nd week of gestation, the bone marrow has almost completely taken over that task.

The liver produces and excretes bile (a yellowish liquid) required for emulsifying fats. Some of the bile drains directly into the duodenum, and some is stored in the gallbladder.

The liver also produces insulin-like growth factor 1 (IGF-1), a polypeptide protein hormone that plays an important role in childhood growth and continues to have anabolic

effects in adults.

The liver is a major site of thrombopoietin production. Thrombopoietin is a glycoprotein hormone that regulates the production of platelets by the bone marrow.

Breakdown

The breakdown of insulin and other hormones

The liver glucoronidates bilirubin, facilitating its excretion into bile.

The liver breaks down or modifies toxic substances (e.g., methylation) and most medicinal products in a process called drug metabolism. This sometimes results in toxication,

when the metabolite is more toxic than its precursor. Preferably, the toxins are conjugated to avail excretion in bile or urine.

The liver converts ammonia to urea (urea cycle)

Other functions

The liver stores a multitude of substances, including glucose (in the form of glycogen), vitamin A (1–2 years' supply), vitamin D (1–4 months' supply), vitamin B12 (1–3 years'

supply), iron, and copper.

The liver is responsible for immunological effects—the reticuloendothelial system of the liver contains many immunologically active cells, acting as a 'sieve' for antigens carried

to it via the portal system.

The liver produces albumin, the major osmolar component of blood serum.

The liver synthesizes angiotensinogen, a hormone that is responsible for raising the blood pressure when activated by renin, an enzyme that is released when the kidney

senses low blood pressure.

Diagnostic imaging

ultrasonography

scintigraphy

CT

MRI

laparoscopy

arteriography

portografphy

Ultrasonography

Computed tomography

Nuclear magnetic resonance diagnostics

Percutaneous transhepaticportography

Cut-down

approaches

Sutures of liver

Liver trauma

Liver trauma

Liver trauma

Liver trauma

Liver trauma

Liver trauma

Liver trauma

Liver trauma

Liver trauma

Liver trauma

Liver trauma

Cirrhosis

Picture of Cirrhosis

• Ascites

• Asterixis

• Spider angiomas

• Palmer erythema

• Gynecomastia

• Caput medusa

• Splenomegaly

Child-Pugh ClassificationPoints

1 2 3

Bilirubin (mg/dL) < 2 2 – 3 > 3

Albumin (g/dL) > 3.5 2.8 – 3.5 < 2.8

Prothrombin time

(seconds ↑)

1 – 3 4 – 6 > 6

Ascites None Slight Moderate

Encephalopathy None Minimal Advanced

•Grade A – 5-6 points.

•Grade B – 7-9 points.

•Grade C – 10-15 points.

Portal hypertension

Portal

hypertension

- a complex of

changes arising at

difficulty of a blood

flow in portal

system, caused by

various diseases.

Portal hypertension syndrome

1. High portal pressure

2. Decrease of portal blood flow

3. Enlargement of the spleen

4. Esophageal and stomach varicose

veins dilatation with a bleeding

5. Ascites

6. Hemorrhoids.

CLASSIFICATION

Mortality from the first

esophago-gastric bleeding

Esophageal and stomach varicose veins

dilatation

Frequency of relapses bleedings within

the first year

90 %

50 %

60 %

30 %Mortality from relapse bleedings within

the first year

GIT bleeding 25-35 %

90 %

The reasons of portal hypertension

Extrahepatic

portal

hypertensia

Cirrhosis of

liver

The reasons of a portal hypertension

Extrahepatic portal hypertension

In children In adults

- Congenital defect

(anomaly) of portal

vein

- Thrombosis after

umbilical sepsis

-Myeloproliferation diseases

-Thrombophilia

-Traumas

-Inflammatory diseases of

abdominal cavity

Segmental portal

hipertension

Total portal hypertension Segmental portal hypertension

Portal Hypertension and Varices

• major cause of

morbidity and mortality

• 50% of cirrhosis

develops varices

• 15-20% of varices

bleed

• 1/3 of deaths from

bleeds

Hemorrhage

Mortality (bleeding from esophageal varices)

– 23% one year

– 34% two year

– 58% three years

Most bleeding within 1-2 y.

30% rebleed within 6 weeks

60- 70% rebleeding rate

within 1 year

42

The stage of varicose

1st

The stage of varicose

2nd

The stage of varicose

3d

VARICOSE VEINS OF STOMACH

The stage of varicose

Sengstaken-

Blakemor Tube

Treatment

drugs

Endoscopic treatment

Sclerotherapy

T I P S

Surgical treatment

Treatment

1.Vasopressin

2.Terlipressin

3.Somatostatin

4.Sandostatin

Treatment– 5-7 days

drugsSengstaken-

Blakemor Tube

Endoscopic treatment

Sclerotherapy

T I P S

Surgical

treatment

Sengstaken-Blakemor Tubedrugs

Sengstaken-

Blakemor Tube

Endoscopic treatment

Sclerotherapy

T I P S

Surgical

treatment

Endoscopic

Banding

drugsSengstaken-

Blakemor Tube

Endoscopic treatment

Sclerotherapy

T I P S

Surgical

treatment

perivascular

Endoscopic variceal ligation

drugsSengstaken-

Blakemor Tube

Endoscopic treatment

Sclerotherapy

T I P S

Surgical

treatment

intravascular

Отделение экстренной хирургии и

портальной гипертензии 51

Endoscopic variceal ligation

Transjugular

Inrahepatic

Portasystemic Shuntdrugs

Sengstaken-

Blakemor Tube

Endoscopic treatment

Sclerotherapy

T I P S

Surgical

treatment

drugsSengstaken-

Blakemor Tube

Endoscopic treatment

Sclerotherapy

T I P S

Transjugular

Inrahepatic

Portasystemic Shunt

54

Patsiora's operation

TIPS

Surgical

treatment

drugsSengstaken-

Blakemor Tube

Endoscopic treatment

Sclerotherapy

Patsiora's operation

Surgical treatment

Отделение экстренной хирургии и

портальной гипертензии 57

Surgical treatment

Surgical

treatment

drugsSengstaken-

Blakemor Tube

Endoscopic treatment

Sclerotherapy

TIPS

Surgical treatment

T I P S

Surgical

treatment

drugsSengstaken-

Blakemor Tube

Endoscopic treatment

Sclerotherapy

проксимальный спленоренальный

анастомоз с удалением селезенки

дистальный спленоренальный

анастомоз

Main types of portocaval

anastomosis

кавамезентериальный анастомоз

мезентерикокавальный анастомоз спленоренальный анастомоз

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Thanks for your attention!