MS RLE
Liver The liver synthesizes most plasma proteins,
Largest gland of the body and a major organ including albumin, globulins, clotting factors,
Receives nutrient-rich blood directly from the GI tract and transport proteins.
Stores or transforms nutrients into chemical It requires Vitamin K for the synthesis of
substances clotting factors, such as prothrombin.
Manufactures and secretes bile Amino acids are used for protein synthesis in
Removes waste products from the bloodstream and the liver.
secretes them into the bile
Fat Metabolism
Bile produced by the liver is stored temporarily in the
The liver breaks down fatty acids for energy
gallbladder
and produces ketone bodies (acetoacetic acid,
When needed for digestion, the gallbladder empties
beta-hydroxybutyric acid, acetone) during
and bile enters the intestine
times of limited glucose (e.g., starvation or
Important in the regulation of glucose and protein diabetes).
Fatty acids also help in synthesizing
cholesterol, lecithin, lipoproteins, and other
lipids.
Vitamin and Iron Storage
The liver stores vitamins A, B, D, and B-
complex vitamins, as well as iron and copper.
Bile Formation
Bile is continuously produced by hepatocytes
and stored in the gallbladder for digestion.
Bile aids in fat emulsification and the excretion
of waste products like bilirubin.
Anatomy of the Liver
The liver is a large, vascular organ located behind the Bilirubin Excretion
ribs in the upper right abdomen, weighing 1200- Bilirubin, from the breakdown of hemoglobin, is
1500 g and divided into four lobes. processed in the liver and excreted in bile.
Each lobe is divided into functional units called In the intestine, bilirubin is converted to
lobules, surrounded by connective tissue. urobilinogen, partially excreted in feces, and
Blood enters the liver from two sources: 80% from the reabsorbed into portal blood for reuse or
nutrient-rich but oxygen-poor portal vein, and the excretion through the kidneys.
rest from the oxygen-rich hepatic artery. Drug Metabolism
These blood vessels form sinusoids, which bathe The liver metabolizes many drugs (e.g.,
liver cells (hepatocytes) in a mixture of venous and barbiturates, opioids, sedatives) by
arterial blood. conjugating them with compounds for
The sinusoids drain into central veins, which join to excretion.
form the hepatic vein, draining into the inferior vena First-pass metabolism reduces the
cava near the diaphragm. bioavailability of some oral drugs, meaning
Kupffer cells, a type of phagocyte, engulf bacteria larger doses may be needed to achieve the
and other particles from portal blood. desired effect compared to parenteral routes.
The smallest bile ducts, called canaliculi, carry
secretions from hepatocytes to larger bile ducts, Assessment of Liver
forming the hepatic duct. Health History
The hepatic duct and cystic duct from the gallbladder Past Medical History: Check for liver diseases
merge to form the common bile duct, which or past issues (e.g., hepatitis, cirrhosis).
empties into the small intestine. Lifestyle: Look at alcohol use, diet, exercise,
-The sphincter of Oddi controls bile flow from the and toxin exposure.
common bile duct into the duodenum. Medications: Review drugs that may affect
liver health.
Functions of the Liver Family History: Ask about liver problems or
Glucose Metabolism genetic liver conditions.
The liver regulates blood glucose levels by
converting glucose into glycogen (stored in Physical Assessment
hepatocytes) after meals. Skin: Look for jaundice (yellow skin/eyes),
When needed, glycogen is converted back to swelling (edema), or spider veins.
glucose (glycogenolysis) and released into the Tremor and Asterixis: Check for hand tremors
bloodstream. or involuntary hand flapping (signs of liver
When glycogen stores are insufficient, the liver issues).
produces glucose via gluconeogenesis, using Abdominal Assessment
amino acids or lactate, especially during Fluid Wave: Check for fluid buildup in the
hypoglycemia. abdomen (ascites).
Ammonia Conversion Palpation:
Ammonia, a by-product of amino acid Liver Size: Feel for the liver in the right
breakdown, is converted into urea by the liver. upper abdomen.
Ammonia from intestinal bacteria is also Tenderness: Look for pain when touching
removed from portal blood and converted into the liver.
Palpable Liver: If the liver is enlarged, it
, MS RLE
Liver function tests may not show abnormal Bilirubin and Urobilinogen: Serum bilirubin and
results until more than 70% of liver tissue is urine urobilinogen levels may be elevated.
damaged. Liver Enzymes: AST and ALT levels increase,
Tests measure enzyme activity and serum indicating liver cell damage.
levels of proteins, bilirubin, ammonia, clotting Other Symptoms: Headache, chills, and fever,
factors, and lipids. particularly if the cause is infectious.
Prognosis: Hepatocellular jaundice may be
ALT (Alanine Aminotransferase): Increased in liver
reversible depending on the cause and extent
disorders, used to monitor conditions like hepatitis,
of liver damage.
cirrhosis, or liver damage from medications.
AST (Aspartate Aminotransferase): Elevated levels Obstructive Jaundice
can indicate damage to organs like the heart, liver, Cause:
muscles, or kidneys. Not specific to liver disease Extrahepatic Obstruction: Blockage
but may increase in cirrhosis, hepatitis, or liver outside the liver (e.g., gallstones,
cancer. inflammation, tumors, or pressure from an
GGT (Gamma Glutamyl Transferase): High levels enlarged organ).
are linked to cholestasis and alcoholic liver Intrahepatic Obstruction: Blockage inside
disease. the liver’s small bile ducts (e.g.,
inflammation or certain medications like
Liver Biopsy
some antibiotics and hormones).
A liver biopsy involves removing a small
Effects:
sample of liver tissue for examination.
Bile backs up into the liver and enters the
It helps diagnose liver conditions when clinical
bloodstream, causing jaundice (yellowing
findings and lab tests aren’t enough.
of skin, mucous membranes, and eyes).
Often used to evaluate liver disorders or detect
Urine turns deep orange and foamy due to
lesions
bilirubin.
.
Stools become light or clay-colored
Other Diagnostic test
because of a lack of bile in the intestine.
Ultrasonography, CT Scans, and MRI: Used to
Symptoms:
identify normal liver structures and abnormalities in
Itching from bile buildup in the skin.
the liver and biliary tree.
Fatty food intolerance and indigestion due
Radioisotope Liver Scan: Assesses liver size, blood
to impaired fat digestion.
flow, and possible obstructions.
Lab Results:
Laparoscopy: A fiberoptic endoscope is inserted
Moderate increase in AST, ALT, and
through a small abdominal incision to:
GGT.
Jaundice High bilirubin and alkaline phosphatase
Occurs when bilirubin concentration in the blood levels.
increases due to liver disease, bile flow obstruction Hyperbilirubinemia (high bilirubin levels) can be
(e.g., gallstones), or excessive red blood cell caused by inherited disorders, leading to jaundice.
destruction. Gilbert Syndrome:
With bile duct obstruction, bilirubin cannot enter the Increased unconjugated bilirubin causes
intestine, leading to a decrease in urobilinogen in jaundice.
the stool and absence in the urine. Liver function and histology are normal, with
Jaundice becomes visible when serum bilirubin no hemolysis.
exceeds 2.0 mg/dL, resulting in a yellow or Affects 3-8% of the population, mostly males.
greenish-yellow tint to the skin and sclerae (the
Other Inherited Conditions:
white part of the eyes).
Dubin-Johnson Syndrome: Chronic jaundice with liver
Types of Jaundice pigment.
Hemolytic Jaundice Rotor Syndrome: Chronic conjugated
Cause: Increased red blood cell destruction, hyperbilirubinemia, no liver pigment.
leading to excess bilirubin in the blood. Benign Cholestatic Jaundice of Pregnancy: Due to
Bilirubin: Predominantly unconjugated (free) sensitivity to pregnancy hormones.
bilirubin. Benign Recurrent Intrahepatic Cholestasis: A genetic
Fecal and Urine Urobilinogen: Increased, but condition affecting bile flow.
urine is free of bilirubin.
Portal Hypertension
Symptoms: Mild jaundice, unless bilirubin
increased pressure in the portal venous system due
levels are extremely high (over 20-25 mg/dL),
to liver damage, commonly caused by cirrhosis but
which can lead to central nervous system
can occur in non-cirrhotic liver disease.
effects.
Complications: Long-term mild jaundice can Key Features:
lead to pigment stones in the gallbladder. Splenomegaly (enlarged spleen) with possible
hypersplenism (overactive spleen).
Hepatocellular Jaundice
Major complications include ascites (fluid buildup in
Cause: Liver cell damage prevents proper
the abdomen) and varices (enlarged veins, often in
clearance of bilirubin from the blood. Common
the esophagus, which can bleed).
causes include hepatitis, viral infections,
alcohol abuse, and chemical toxins. Ascites
Associated with: Cirrhosis (often due to is the buildup of fluid in the abdomen, often due to
excessive alcohol intake or viral infections). liver problems.
, MS RLE
Widening blood vessels in the digestive system Sodium intake may be further reduced to 500
adds to fluid buildup. mg/day
The liver’s inability to process aldosterone Rarely used (not well tolerated by most
causes the kidneys to keep too much water and patients)
salt. Diuretics may be prescribed
Low albumin levels from liver damage make fluid
Pharmacologic Therapy
leak into the abdomen.
Main Treatment
Effect: The body keeps retaining more fluid, making
Diuretics + low-sodium diet = works in 90% of
the problem worse.
patients
Other Causes: Conditions like cancer, kidney
First Choice Diuretic
disease, and heart failure can also cause ascites.
Spironolactone
Blocks aldosterone
Helps keep potassium levels normal
Best for ascites due to cirrhosis
Furosemide
May be added to spironolactone
Use carefully — can cause low sodium
(hyponatremia) if used long-term
Drugs to Avoid
Ammonium chloride
Acetazolamide
These can trigger hepatic encephalopathy
(brain dysfunction)
Safe Weight Loss (per day)
With edema: Max 1 kg (2.2 lbs)
Without edema: Max 0.5–0.75 kg(1.1–1.65 lbs)
Fluid Restriction - Only if sodium levels are very low
Possible Side Effects
Clinical Manifestations of Ascites
Fluid and electrolyte problems:
Increased abdominal size and rapid weight
gain.Shortness of breath and discomfort from the Dehydration (hypovolemia)
enlarged abdomen. Low potassium (hypokalemia)
Visible striae (stretch marks) and distended veins on
Low sodium (hyponatremia)
the abdomen. Alkalosis (↑ blood pH)
Umbilical hernias may occur, especially in patients
Encephalopathy
Caused by dehydration or low potassium
with cirrhosis.
Fluid and electrolyte imbalances are common.
Low potassium → ↑ ammonia in blood → brain
problems
Assessment and Diagnostic Findings
Physical Exam:
Paracentesis
Procedure to remove ascitic fluid from the peritoneal
Percussion of the abdomen is used to check
for fluid buildup. cavity
Done through a puncture or small surgical incision in
When the patient lies down, the flanks of the
abdomen may bulge, indicating fluid. the abdominal wall
Performed under sterile conditions
Shifting dullness or a fluid wave confirms the
Not a routine treatment for ascites anymore
presence of fluid (a large amount is needed for
Now mainly used for:
fluid wave).
Monitoring:
Diagnostic examination of ascitic fluid
Regular measurement of abdominal girth and Treatment of massive, resistant ascites causing
body weight helps track the progress of ascites serious problems
and response to treatment. Preparation for: Diagnostic imaging, Peritoneal
Medical Management Treatment Includes:
dialysis, Surgery
Paracentesis gives only temporary relief
Dietary changes.
Medications. Ultrasound Guidance
In patients at high risk for bleeding (abnormal
Bed rest.
Paracentesis (removal of fluid from the coagulation)
In patients with previous abdominal surgery (risk of
abdomen).
Shunts and other treatments as needed. adhesions)
Nutritional Therapy for Ascites Lab Tests on Ascitic Fluid
Cell count
Treatment Goal is to achieve negative sodium
Albumin level
balance to reduce fluid retention.
Total protein level
Foods to Avoid
Culture
Table salt
Other diagnostic tests as needed
Salty foods/snacks
Salted butter and margarine Large-Volume Paracentesis
Canned and frozen foods (unless low- Removal of 5–6 liters of fluid is considered safe
sodium/2g sodium labeled) Effective treatment for severe ascites
Adapting to Low-Sodium Diet, taste buds may take Should be considered early, not just for patients who
2–3 months to adjust. fail diuretic therapy
Liver The liver synthesizes most plasma proteins,
Largest gland of the body and a major organ including albumin, globulins, clotting factors,
Receives nutrient-rich blood directly from the GI tract and transport proteins.
Stores or transforms nutrients into chemical It requires Vitamin K for the synthesis of
substances clotting factors, such as prothrombin.
Manufactures and secretes bile Amino acids are used for protein synthesis in
Removes waste products from the bloodstream and the liver.
secretes them into the bile
Fat Metabolism
Bile produced by the liver is stored temporarily in the
The liver breaks down fatty acids for energy
gallbladder
and produces ketone bodies (acetoacetic acid,
When needed for digestion, the gallbladder empties
beta-hydroxybutyric acid, acetone) during
and bile enters the intestine
times of limited glucose (e.g., starvation or
Important in the regulation of glucose and protein diabetes).
Fatty acids also help in synthesizing
cholesterol, lecithin, lipoproteins, and other
lipids.
Vitamin and Iron Storage
The liver stores vitamins A, B, D, and B-
complex vitamins, as well as iron and copper.
Bile Formation
Bile is continuously produced by hepatocytes
and stored in the gallbladder for digestion.
Bile aids in fat emulsification and the excretion
of waste products like bilirubin.
Anatomy of the Liver
The liver is a large, vascular organ located behind the Bilirubin Excretion
ribs in the upper right abdomen, weighing 1200- Bilirubin, from the breakdown of hemoglobin, is
1500 g and divided into four lobes. processed in the liver and excreted in bile.
Each lobe is divided into functional units called In the intestine, bilirubin is converted to
lobules, surrounded by connective tissue. urobilinogen, partially excreted in feces, and
Blood enters the liver from two sources: 80% from the reabsorbed into portal blood for reuse or
nutrient-rich but oxygen-poor portal vein, and the excretion through the kidneys.
rest from the oxygen-rich hepatic artery. Drug Metabolism
These blood vessels form sinusoids, which bathe The liver metabolizes many drugs (e.g.,
liver cells (hepatocytes) in a mixture of venous and barbiturates, opioids, sedatives) by
arterial blood. conjugating them with compounds for
The sinusoids drain into central veins, which join to excretion.
form the hepatic vein, draining into the inferior vena First-pass metabolism reduces the
cava near the diaphragm. bioavailability of some oral drugs, meaning
Kupffer cells, a type of phagocyte, engulf bacteria larger doses may be needed to achieve the
and other particles from portal blood. desired effect compared to parenteral routes.
The smallest bile ducts, called canaliculi, carry
secretions from hepatocytes to larger bile ducts, Assessment of Liver
forming the hepatic duct. Health History
The hepatic duct and cystic duct from the gallbladder Past Medical History: Check for liver diseases
merge to form the common bile duct, which or past issues (e.g., hepatitis, cirrhosis).
empties into the small intestine. Lifestyle: Look at alcohol use, diet, exercise,
-The sphincter of Oddi controls bile flow from the and toxin exposure.
common bile duct into the duodenum. Medications: Review drugs that may affect
liver health.
Functions of the Liver Family History: Ask about liver problems or
Glucose Metabolism genetic liver conditions.
The liver regulates blood glucose levels by
converting glucose into glycogen (stored in Physical Assessment
hepatocytes) after meals. Skin: Look for jaundice (yellow skin/eyes),
When needed, glycogen is converted back to swelling (edema), or spider veins.
glucose (glycogenolysis) and released into the Tremor and Asterixis: Check for hand tremors
bloodstream. or involuntary hand flapping (signs of liver
When glycogen stores are insufficient, the liver issues).
produces glucose via gluconeogenesis, using Abdominal Assessment
amino acids or lactate, especially during Fluid Wave: Check for fluid buildup in the
hypoglycemia. abdomen (ascites).
Ammonia Conversion Palpation:
Ammonia, a by-product of amino acid Liver Size: Feel for the liver in the right
breakdown, is converted into urea by the liver. upper abdomen.
Ammonia from intestinal bacteria is also Tenderness: Look for pain when touching
removed from portal blood and converted into the liver.
Palpable Liver: If the liver is enlarged, it
, MS RLE
Liver function tests may not show abnormal Bilirubin and Urobilinogen: Serum bilirubin and
results until more than 70% of liver tissue is urine urobilinogen levels may be elevated.
damaged. Liver Enzymes: AST and ALT levels increase,
Tests measure enzyme activity and serum indicating liver cell damage.
levels of proteins, bilirubin, ammonia, clotting Other Symptoms: Headache, chills, and fever,
factors, and lipids. particularly if the cause is infectious.
Prognosis: Hepatocellular jaundice may be
ALT (Alanine Aminotransferase): Increased in liver
reversible depending on the cause and extent
disorders, used to monitor conditions like hepatitis,
of liver damage.
cirrhosis, or liver damage from medications.
AST (Aspartate Aminotransferase): Elevated levels Obstructive Jaundice
can indicate damage to organs like the heart, liver, Cause:
muscles, or kidneys. Not specific to liver disease Extrahepatic Obstruction: Blockage
but may increase in cirrhosis, hepatitis, or liver outside the liver (e.g., gallstones,
cancer. inflammation, tumors, or pressure from an
GGT (Gamma Glutamyl Transferase): High levels enlarged organ).
are linked to cholestasis and alcoholic liver Intrahepatic Obstruction: Blockage inside
disease. the liver’s small bile ducts (e.g.,
inflammation or certain medications like
Liver Biopsy
some antibiotics and hormones).
A liver biopsy involves removing a small
Effects:
sample of liver tissue for examination.
Bile backs up into the liver and enters the
It helps diagnose liver conditions when clinical
bloodstream, causing jaundice (yellowing
findings and lab tests aren’t enough.
of skin, mucous membranes, and eyes).
Often used to evaluate liver disorders or detect
Urine turns deep orange and foamy due to
lesions
bilirubin.
.
Stools become light or clay-colored
Other Diagnostic test
because of a lack of bile in the intestine.
Ultrasonography, CT Scans, and MRI: Used to
Symptoms:
identify normal liver structures and abnormalities in
Itching from bile buildup in the skin.
the liver and biliary tree.
Fatty food intolerance and indigestion due
Radioisotope Liver Scan: Assesses liver size, blood
to impaired fat digestion.
flow, and possible obstructions.
Lab Results:
Laparoscopy: A fiberoptic endoscope is inserted
Moderate increase in AST, ALT, and
through a small abdominal incision to:
GGT.
Jaundice High bilirubin and alkaline phosphatase
Occurs when bilirubin concentration in the blood levels.
increases due to liver disease, bile flow obstruction Hyperbilirubinemia (high bilirubin levels) can be
(e.g., gallstones), or excessive red blood cell caused by inherited disorders, leading to jaundice.
destruction. Gilbert Syndrome:
With bile duct obstruction, bilirubin cannot enter the Increased unconjugated bilirubin causes
intestine, leading to a decrease in urobilinogen in jaundice.
the stool and absence in the urine. Liver function and histology are normal, with
Jaundice becomes visible when serum bilirubin no hemolysis.
exceeds 2.0 mg/dL, resulting in a yellow or Affects 3-8% of the population, mostly males.
greenish-yellow tint to the skin and sclerae (the
Other Inherited Conditions:
white part of the eyes).
Dubin-Johnson Syndrome: Chronic jaundice with liver
Types of Jaundice pigment.
Hemolytic Jaundice Rotor Syndrome: Chronic conjugated
Cause: Increased red blood cell destruction, hyperbilirubinemia, no liver pigment.
leading to excess bilirubin in the blood. Benign Cholestatic Jaundice of Pregnancy: Due to
Bilirubin: Predominantly unconjugated (free) sensitivity to pregnancy hormones.
bilirubin. Benign Recurrent Intrahepatic Cholestasis: A genetic
Fecal and Urine Urobilinogen: Increased, but condition affecting bile flow.
urine is free of bilirubin.
Portal Hypertension
Symptoms: Mild jaundice, unless bilirubin
increased pressure in the portal venous system due
levels are extremely high (over 20-25 mg/dL),
to liver damage, commonly caused by cirrhosis but
which can lead to central nervous system
can occur in non-cirrhotic liver disease.
effects.
Complications: Long-term mild jaundice can Key Features:
lead to pigment stones in the gallbladder. Splenomegaly (enlarged spleen) with possible
hypersplenism (overactive spleen).
Hepatocellular Jaundice
Major complications include ascites (fluid buildup in
Cause: Liver cell damage prevents proper
the abdomen) and varices (enlarged veins, often in
clearance of bilirubin from the blood. Common
the esophagus, which can bleed).
causes include hepatitis, viral infections,
alcohol abuse, and chemical toxins. Ascites
Associated with: Cirrhosis (often due to is the buildup of fluid in the abdomen, often due to
excessive alcohol intake or viral infections). liver problems.
, MS RLE
Widening blood vessels in the digestive system Sodium intake may be further reduced to 500
adds to fluid buildup. mg/day
The liver’s inability to process aldosterone Rarely used (not well tolerated by most
causes the kidneys to keep too much water and patients)
salt. Diuretics may be prescribed
Low albumin levels from liver damage make fluid
Pharmacologic Therapy
leak into the abdomen.
Main Treatment
Effect: The body keeps retaining more fluid, making
Diuretics + low-sodium diet = works in 90% of
the problem worse.
patients
Other Causes: Conditions like cancer, kidney
First Choice Diuretic
disease, and heart failure can also cause ascites.
Spironolactone
Blocks aldosterone
Helps keep potassium levels normal
Best for ascites due to cirrhosis
Furosemide
May be added to spironolactone
Use carefully — can cause low sodium
(hyponatremia) if used long-term
Drugs to Avoid
Ammonium chloride
Acetazolamide
These can trigger hepatic encephalopathy
(brain dysfunction)
Safe Weight Loss (per day)
With edema: Max 1 kg (2.2 lbs)
Without edema: Max 0.5–0.75 kg(1.1–1.65 lbs)
Fluid Restriction - Only if sodium levels are very low
Possible Side Effects
Clinical Manifestations of Ascites
Fluid and electrolyte problems:
Increased abdominal size and rapid weight
gain.Shortness of breath and discomfort from the Dehydration (hypovolemia)
enlarged abdomen. Low potassium (hypokalemia)
Visible striae (stretch marks) and distended veins on
Low sodium (hyponatremia)
the abdomen. Alkalosis (↑ blood pH)
Umbilical hernias may occur, especially in patients
Encephalopathy
Caused by dehydration or low potassium
with cirrhosis.
Fluid and electrolyte imbalances are common.
Low potassium → ↑ ammonia in blood → brain
problems
Assessment and Diagnostic Findings
Physical Exam:
Paracentesis
Procedure to remove ascitic fluid from the peritoneal
Percussion of the abdomen is used to check
for fluid buildup. cavity
Done through a puncture or small surgical incision in
When the patient lies down, the flanks of the
abdomen may bulge, indicating fluid. the abdominal wall
Performed under sterile conditions
Shifting dullness or a fluid wave confirms the
Not a routine treatment for ascites anymore
presence of fluid (a large amount is needed for
Now mainly used for:
fluid wave).
Monitoring:
Diagnostic examination of ascitic fluid
Regular measurement of abdominal girth and Treatment of massive, resistant ascites causing
body weight helps track the progress of ascites serious problems
and response to treatment. Preparation for: Diagnostic imaging, Peritoneal
Medical Management Treatment Includes:
dialysis, Surgery
Paracentesis gives only temporary relief
Dietary changes.
Medications. Ultrasound Guidance
In patients at high risk for bleeding (abnormal
Bed rest.
Paracentesis (removal of fluid from the coagulation)
In patients with previous abdominal surgery (risk of
abdomen).
Shunts and other treatments as needed. adhesions)
Nutritional Therapy for Ascites Lab Tests on Ascitic Fluid
Cell count
Treatment Goal is to achieve negative sodium
Albumin level
balance to reduce fluid retention.
Total protein level
Foods to Avoid
Culture
Table salt
Other diagnostic tests as needed
Salty foods/snacks
Salted butter and margarine Large-Volume Paracentesis
Canned and frozen foods (unless low- Removal of 5–6 liters of fluid is considered safe
sodium/2g sodium labeled) Effective treatment for severe ascites
Adapting to Low-Sodium Diet, taste buds may take Should be considered early, not just for patients who
2–3 months to adjust. fail diuretic therapy
