LIVER & BILIARY TRACT 7 Liver abscess

. HEPATIC ABSCESSES

Pyogenic   bacteria  and  Entamoeba  histolytica  are  the   main

causative agents.  The amebic liver abscess has been discussed in

the chapter on Tropical Diseases.

7.1 PYOGENIC ABSCESSES

Results  from a secondary biliary infection; haematogenic  spread

from portal system or result from septicaemia

Diagnosis is by:

*  Clinical examination aided by the findings of local pain and

   tenderness

*  Fever with chills and rigor

*  Ultrasound and

*  CT scans

Treatment is with antibiotics and drainage.  The initial  attempt

is at aspiration repeated if required.  A laparotomy and drainage

is required if aspiration

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LIVER & BILIARY TRACT 6 Hepatic Trauma

. HEPATIC TRAUMA

INCIDENCE

The liver is at greater risk of injury in motor traffic accidents

and penetrating wounds.  This is also true of all blunt traumatic

injuries of the abdomen.

PATHOLOGY

When  the  Glisson's capsule ruptures the liver  blood  and  bile

enter the peritoneal cavity.

*  Patient with injury at the hilus, however, do not survive long

   enough for a surgical exploration.

CLINICAL MANIFESTATIONS

In a case of rupture through the Glisson's capsule, the signs and

symptoms  are  due to shock and peritoneal irritation.   This  is

usually a severe surgical emergency there is:

*  Abdominal pain;

*  Spasm and rigidity are prominent findings

TREATMENT

The  shock  is corrected first of all and surgical  procedure  is

directed  at  control of bleeding by ligating  bleeders  and  the

removal of necrotic devitalized tissue

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LIVER & BILIARY TRACT 5 Synthesis protiens carbohydrates lipids

5.1 PROTEINS SYNTHESIS

As the hepatic cell is responsible of synthesis of

   -  albumin,alfa feta protein, cereloplasmin, ferritin and

      Transfenin

   -  fibrinogen

   -  prothrombin and other factors involved in blood clotting I,

      II, V, VII, IX, X, XI, XII, XIII

Estimation  of serum albumin is the most accurate  relfection  of

liver function.

*  Half life of albumin is more than 10 days

*  Flocculation and Turbidity Tests are dependant on albumin  and

   thus;

   - Cephalin flocculation

   - Thymol turbidity

   - Zinc   sulfate  turbidity  tests  are  reflections  of   the

     alteration in the albumin globulin ration in the serum

5.2 CARBOHYDRATES AND LIPIDS SYNTHESIS

Syntehsis of both phospholipid and cholesterol takes place in the

liver  and  the  latter  serves as an  indicator  for  the  lipid

metabolism

*  Biliary obstruction results in a rise in cholesterol

*  The other common effects of hepatic disease is a deficiency of

   glycogenesis with resultant hyperglycemia

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Liver Biliary Tract 4 Bile production Lver functions

COMPOSITION OF BILE

Main constitutents of the bile are:

*  Electrolytes

*  Sodium  potassium  calcium  and  chloride  are  in  the   same

   concentration as in  plasma. 

The ether constituents are:

*  Bile salts

*  Protein

*  Cholestrol

*  Fats

*  Bile pigments

The pH of liver bile ranges between 5.7 and 8.6

5. LIVER FUNCTION

The  functioning  liver  cells are capable  of  wide  variety  of

activities.   The metabolic pool in the liver is a reservoir  for

the entire body.

*  Storage  function - Stores glycogen, fat, protein, Vit. A  and

   B12

*  Production  and  secretion  of materials by  the  liver  cells

   including bilirubin and cholesterol

*  Detoxification function (metabolism of drugs and toxins)

*  Metabolism of carbohydrates, fats and proteins

*  Synthesis of plasma proteins, fibrinogens and prothrombin

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LIVER BILIARY TRACT 3 Hepato cytes lobules

BILE SECRETION

Normal adult produces 250 to 1100 ml. bile per day.

*  Vagal stimulation increase secretion

*  Stimulation of splanchnic nerves results in decreased bile

   flow

*  Bile  salts  are   very   effective   choleretics   (stimulate

   secretion).

Biliary Secretion

Lobules of the hepatocytes are the source of hepatic bile secretion. Blood flow to the hepatocytes comes from brahches of both the portal vein and the hepatic artery. Blood from the portal vein flows through sinusoids past the hepatocyte to the central vein where it drains into the hepatic veins and inferior vena cava. Only one layer of hepatocutes separates the sinusoids.

Bile is a solution of both organic and inorganic compounds.

The hepatocyte secretes two primary bile acids, cholic acid and chenodeoxycholic acid. These are synthesized in the hepatocyte from cholesterol and recycled through the enterohepatic circulation to conserve bile salts. Primary bile acids, are converted to secondary bile acid (deoxycholic acid and lithocholic acid) when in contact with bacteria in the GIT

Purpose of secretion of bile acids is to allow for the formation of micelles. Micelles are formed and the, bile acid form the outer layer with the fats in the centre so that they will be more soluble in the aqueous medium. The emulsion then move down the gastrointestinal tract and allow lipids that are ingested to freely move in and out of the micelles so that they can be presented to the enterocytes for absorption.

The pigment of bile give it its color, is bilirubin. Bilirubin is derived from the degradation of hemoglobin in the reticuloendothelial system. Because bilirubin itself is not soluble. It is conjugated primarily with glucuronide and occasionally with sulfate. Circulating bilirubin is bound to albumen from which it dissociates at the hepatocyte on the portal venous membrane. It enters the bile canaliculus as bilirubin diglucuronide.

The bile acids, are synthesized or reused by the hepatocutes as they are presented as conjugated and unconjugated bile acids from the portal circulation. The liver produces approximately 500 to 1000 ml of bile per day.

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