Hepatic

• Accessory organs to the digestive system


  Not part of the digestive tract, have other non-digestive functions
• Pancreas

  Produces enzymes and bicarbonate, connects to duodenum
• Liver


  Produces bile, connects to duodenum
• Gallbladder


  Stores bile from the liver, connects to duodenum
• Pancreas


  • Lies behind the stomach (retroperitoneal)
  • Exocrine function: secretes pancreatic lipase and trypsin, controlled by vagal stimulation and hormones
  • Endocrine function: islets of Langerhans secrete insulin and glucagon
• Liver


  • One of the largest organs, has 2 lobes (superior view) and 4 lobes (inferior view)
  • Hepatic lobule is the functional unit, composed of central vein, hepatic plates, bile canaliculi, venous sinusoids, Kupffer cells

  
• Major functions of the liver


  • Metabolism of carbohydrates, proteins, and fats
  • Production of bile salts
  • Bilirubin metabolism
  • Detoxification of endogenous and exogenous substances
  • Storage of minerals and vitamins
  • Blood reservoir
  • Excretion of adrenal cortex hormone
• Blood supply to the liver


  • 75% from nutrient rich, oxygen poor portal vein
  • 25% from nutrient poor, oxygen rich hepatic artery
  • Enterohepatic circulation gives liver first access to nutrients, toxins, medications from gut
• Gallbladder


  • Small, pear-shaped organ located beneath the liver, stores and concentrates bile produced by the liver
  • Muscular sac with inner mucosa and smooth muscle layer
  • Bile emulsifies and solubilizes fats

  
• You can donate up to 90% of your liver because it regenerates
• The falciform ligament divides the right and left lobe of the liver

  
• Pathway of blood flow in the liver


  1. Portal vein carries nutrient-rich but oxygen-depleted blood from GI tract, spleen, and pancreas to the liver

  2. Hepatic artery carries oxygen-rich blood from the heart to the liver

  3. Blood mixes in the sinusoids
• The common bile duct is part of the biliary tree
• Fat metabolism indicators


  • Serum total cholesterol and cholesterol esters
  • Serum phospholipids
• Protein metabolism indicators


  • Total serum protein
  • Immunoglobulins
  • Pro-time, PTT, APTT
  • Blood ammonia levels
• Bilirubin metabolism indicators


  • Total serum bilirubin
  • Conjugated/direct bilirubin
  • Unconjugated/indirect bilirubin
  • Urine bilirubin (foam test)
  • Urine urobilinogen
  • Fecal urobilinogen
• Unconjugated bilirubin passes through the liver to be conjugated
• Stercobilin is what makes your stool brown
• Blood ammonia levels


  Indicator of severe hepatocellular damage, may cause hepatic encephalopathy
• Normal value for blood ammonia

  40-80 mcg/dL
• Total serum bilirubin


  Indicator of hepatocellular damage, may cause hepatic encephalopathy
• Normal value for total serum bilirubin

  0.1-1 mg/dL
• Conjugated/direct bilirubin


  Indicator of biliary obstruction
• Normal value for conjugated/direct bilirubin

  0.1-0.2 mg/dL
• Unconjugated/indirect bilirubin


  Indicator of hemolysis of RBC and hepatocellular damage
• Normal value for unconjugated/indirect bilirubin

  0.1-1 mg/dL
• Urine bilirubin (foam test)


  Indicator of conjugated bilirubin in urine - hepatocellular or obstructive biliary disease
• Urine urobilinogen


  Byproduct of bilirubin, indicator of hepatocellular damage and obstructive biliary disease
• Normal value for urine urobilinogen

  Random urine = < 0.25 mg/dL, 24-hour urine = 4 mg/24 hrs
• Fecal urobilinogen (Stercobilin)


  Indicator of hemolysis of RBC, absent in obstructive biliary disease, causes acholic stool
• Liver function tests


  • Serum aminotransferase: AST, ALT, GGT, GGTP, LDH
  • Serum protein studies
  • Direct and indirect serum bilirubin, urine bilirubin, and urine bilirubin and urobilinogen
  • Clotting factors
  • Serum alkaline phosphatase
  • Serum ammonia
  • Lipids
• Additional diagnostic studies


  • Liver biopsy
  • Ultrasonography
  • CT
  • MRI
• Liver biopsy procedure


  1. Secure written consent

  2. NPO 2-4 hrs

  3. Vit K injection if prothrombin time is prolonged

  4. Monitor Pro time

  5. Place client in left lateral position

  6. Instruct client to exhale deeply and hold breath during needle insertion
• After liver biopsy procedure


  1. Turn to right side for 4 hrs to apply pressure

  2. Bedrest for 24 hrs

  3. Monitor V/S every hour for 24 hrs

  4. Observe for signs and symptoms of peritonitis
• Assessment of patient with alteration of liver


  • Health history: Previous exposure, travel, alcohol and drug use, lifestyle
  • Physical assessment: Skin, cognitive status, palpation, percussion

  
• Paracentesis (peritoneal tap) procedure

  1. Secure written consent

  2. Check initial V/S

  3. Ask to empty bladder

  4. Check serum protein studies

  5. Place in sitting upright position
• After paracentesis procedure


  1. Monitor V/S and urine output

  2. Monitor for abdominal rigidity

  3. Monitor for signs of hypovolemic shock
• Complications of paracentesis


  Bleeding, hypovolemic shock, peritonitis
• ERCP (Endoscopic Retrograde Cholangiopancreatography)


  Direct visualization with radiographic examination of the gallbladder, common bile duct, and the pancreas
• Before ERCP procedure


  1. Secure written consent

  2. NPO 10-12 hrs

  3. Check for iodine or seafood allergy

  4. Take initial V/S

  5. Administer atropine sulfate, valium, local anesthetic

  6. Place in left side lying position