Liver

Revision as of 16:54, 27 August 2008 by Apalmer (Talk | contribs)

Jump to: navigation, search

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Please Join in Editing This Page and Apply to be an Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [2] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.

Overview

Liver
Leber Schaf.jpg
Liver of a sheep: (1) right lobe, (2) left lobe, (3) caudate lobe, (4) quadrate lobe, (5) hepatic artery and portal vein, (6) hepatic lymph nodes, (7) gall bladder.
Gray1224.png
Anterior view of the position of the liver (red) in the human abdomen.
Artery hepatic artery
Vein hepatic vein, hepatic portal vein
Nerve celiac ganglia, vagus[1]
Precursor foregut
MeSH Liver

WikiDoc Resources for

Liver

Articles

Most recent articles on Liver

Most cited articles on Liver

Review articles on Liver

Articles on Liver in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Liver

Images of Liver

Photos of Liver

Podcasts & MP3s on Liver

Videos on Liver

Evidence Based Medicine

Cochrane Collaboration on Liver

Bandolier on Liver

TRIP on Liver

Clinical Trials

Ongoing Trials on Liver at Clinical Trials.gov

Trial results on Liver

Clinical Trials on Liver at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Liver

NICE Guidance on Liver

NHS PRODIGY Guidance

FDA on Liver

CDC on Liver

Books

Books on Liver

News

Liver in the news

Be alerted to news on Liver

News trends on Liver

Commentary

Blogs on Liver

Definitions

Definitions of Liver

Patient Resources / Community

Patient resources on Liver

Discussion groups on Liver

Patient Handouts on Liver

Directions to Hospitals Treating Liver

Risk calculators and risk factors for Liver

Healthcare Provider Resources

Symptoms of Liver

Causes & Risk Factors for Liver

Diagnostic studies for Liver

Treatment of Liver

Continuing Medical Education (CME)

CME Programs on Liver

International

Liver en Espanol

Liver en Francais

Business

Liver in the Marketplace

Patents on Liver

Experimental / Informatics

List of terms related to Liver

The liver is an organ present in vertebrates and some other animals. It plays a major role in metabolism and has a number of functions in the body, including glycogen storage, decomposition of red blood cells, plasma protein synthesis, and detoxification. This organ also is the largest gland in the human body. It lies below the diaphragm in the thoracic region of the abdomen.[2] It produces bile, an alkaline compound which aids in digestion, via the emulsification of lipids. It also performs and regulates a wide variety of high-volume biochemical reactions requiring very specialized tissues.

Medical terms related to the liver often start in hepato- or hepatic from the Greek word for liver, hēpar (ήπαρ).[3]

Anatomy

The adult human liver normally weighs between 1.4 - 1.6 kilograms (3.1 - 3.5 pounds),[4] and it is a soft, pinkish-brown "boomerang shaped" organ. It is the second largest organ (the largest organ being the skin) and the largest gland within the human body. It is located on the right side of the upper abdomen below the diaphragm. The liver lies to the right of the stomach and overlies the gallbladder (which stores bile).

Flow of blood

The splenic vein joins the inferior mesenteric vein, which then together join with the superior mesenteric vein to form the hepatic portal vein, bringing veneous blood from the spleen, pancreas, stomach, small intestine, and large intestine, so that the liver can process the nutrients and byproducts of food digestion.

The hepatic veins of the blood can be from other branches such as the superior mesenteric artery.

Both the portal venules & the hepatic arterioles enter approximately one million identical lobules acini, likened to and changes in the size of chylomicrons lipoproteins of dietary origin brought about by the quantity & types of food fats.

Approximately 60% to 80% of the blood flow to the liver is from the portal venous system, and 1/4 is from the hepatic artery.

Flow of bile

The Biliary Tree.

The bile produced in the liver is collected in bile canaliculi, which merge to form bile ducts.

These eventually drain into the right and left hepatic ducts, which in turn merge to form the common hepatic duct. The cystic duct (from the gallbladder) joins with the common hepatic duct to form the common bile duct.

Bile can either drain directly into the duodenum via the common bile duct or be temporarily stored in the gallbladder via the cystic duct. The common bile duct and the pancreatic duct enter the duodenum together at the ampulla of Vater.

The branchings of the bile ducts resemble those of a tree, and indeed the term "biliary tree" is commonly used in this setting.

Regeneration

The liver is among the few internal human organs capable of natural regeneration of lost tissue; as little as 25% of remaining liver can regenerate into a whole liver again.

This is predominantly due to the hepatocytes acting as unipotential stem cells (i.e. a single hepatocyte can divide into two hepatocyte daughter cells). There is also some evidence of bipotential stem cells, called ovalocyte(o´və-lo-sīt), which exist in the Canals of Hering. These cells can differentiate into either hepatocytes or cholangiocytes (cells that line the bile ducts).

Traditional (Surface) anatomy

Peritoneal ligaments

Apart from a patch where it connects to the diaphragm, the liver is covered entirely by visceral peritoneum, a thin, double-layered membrane that reduces friction against other organs. The peritoneum folds back on itself to form the falciform ligament and the right and left triangular ligaments.

These "ligaments" are in no way related to the true anatomic ligaments in joints, and have essentially no functional importance, but they are easily recognizable surface landmarks.

Lobes

Traditional gross anatomy divided the liver into four lobes based on surface features.

The falciform ligament is visible on the front (anterior side) of the liver. This divides the liver into a left anatomical lobe, and a right anatomical lobe.

If the liver flipped over, to look at it from behind (the visceral surface), there are two additional lobes between the right and left. These are the caudate lobe (the more superior), and below this the quadrate lobe.

From behind, the lobes are divided up by the ligamentum venosum and ligamentum teres (anything left of these is the left lobe), the transverse fissure (or porta hepatis) divides the caudate from the quadrate lobe, and the right sagittal fossa, which the inferior vena cava runs over, separates these two lobes from the right lobe.

Each of the lobes is made up of lobules, a vein goes from the centre of each lobule which then joins to the hepatic vein to carry blood out from the liver.

On the surface of the lobules there are ducts, veins and arteries that carry fluids to and from them.

Modern (Functional) anatomy

The central area where the common bile duct, hepatic portal vein, and hepatic artery enter the liver is the hilum or "porta hepatis". The duct, vein, and artery divide into left and right branches, and the portions of the liver supplied by these branches constitute the functional left and right lobes.

The functional lobes are separated by a plane joining the gallbladder fossa to the inferior vena cava. This separates the liver into the true right and left lobes. The middle hepatic vein also demarcates the true right and left lobes. The right lobe is further divided into an anterior and posterior segment by the right hepatic vein. The left lobe is divided into the medial and lateral segments by the left hepatic vein. The fissure for the ligamentum teres (the ligamentum teres becomes the falciform ligament) also separates the medial and lateral segments. The medial segment is what used to be called the quadrate lobe. In the widely used Couinaud or "French" system, the functional lobes are further divided into a total of eight subsegments based on a transverse plane through the bifurcation of the main portal vein. The caudate lobe is a separate structure which receives blood flow from both the right- and left-sided vascular branches.[5][6] The subsegments corresponding to the anatomical lobes are as follows:


Segment* Couinaud segments
Caudate 1
Lateral 2, 3
Medial 4a, 4b
Right 5, 6, 7, 8
  • or lobe in the Caudate's case.

Each number in the list corresponds to one in the table.

  1. Caudate
  2. Superior subsegment of the lateral segment
  3. Inferior subsegment of the lateral segment
    1. Superior subsegment of the medial segment
    2. Inferior subsegment of the medial segment
  4. Inferior subsegment of the anterior segment
  5. Inferior subsegment of the posterior segment
  6. Superior subsegment of the posterior segment
  7. Superior subsegment of the anterior segment

Physiology

The various functions of the liver are carried out by the liver cells or hepatocytes.

Currently, there is no artificial organ or device capable of emulating all the functions of the liver. Some functions can be emulated by liver dialysis, an experimental treatment for liver failure.

Diseases of the liver

Many diseases of the liver are accompanied by jaundice caused by increased levels of bilirubin in the system. The bilirubin results from the breakup of the hemoglobin of dead red blood cells; normally, the liver removes bilirubin from the blood and excretes it through bile.

There are also many pediatric liver disease, including biliary atresia, alpha-1 antitrypsin deficiency, alagille syndrome, and progressive familial intrahepatic cholestasis, to name but a few.

A number of liver function tests are available to test the proper function of the liver. These test for the presence of enzymes in blood that are normally most abundant in liver tissue, metabolites or products.

Liver transplantation

Main article: Liver transplantation

Human liver transplant was first performed by Thomas Starzl in USA and Roy Calne in Cambridge, England in 1963 and 1965 respectively.

Liver transplantation is the only option for those with irreversible liver failure. Most transplants are done for chronic liver diseases leading to cirrhosis, such as chronic hepatitis C, alcoholism, autoimmune hepatitis, and many others. Less commonly, liver transplantation is done for fulminant hepatic failure, in which liver failure occurs over days to weeks.

Liver allografts for transplant usually come from non-living donors who have died from fatal brain injury. Living donor liver transplantation is a technique in which a portion of a living person's liver is removed and used to replace the entire liver of the recipient. This was first performed in 1989 for pediatric liver transplantation. Only 20% of an adult's liver (Couinaud segments 2 and 3) is needed to serve as a liver allograft for an infant or small child.

More recently, adult-to-adult liver transplantation has been done using the donor's right hepatic lobe which amounts to 60% of the liver. Due to the ability of the liver to regenerate, both the donor and recipient end up with normal liver function if all goes well. This procedure is more controversial as it entails performing a much larger operation on the donor, and indeed there have been at least 2 donor deaths out of the first several hundred cases. A recent publication has addressed the problem of donor mortality, and at least 14 cases have been found.[7] The risk of postoperative complications (and death) is far greater in right sided hepatectomy than left sided operations.

With the recent advances of non-invasive imaging, living liver donors usually have to undergo imaging examinations for liver anatomy to decide if the anatomy is feasible for donation. The evaluation is usually performed by multi-detector row computed tomography (MDCT) and magnetic resonence imaging (MRI). MDCT is good in vascular anatomy and volumetry. MRI is used for biliary tree anatomy. Donors with very unusual vascular anatomy, which makes them impossible for donation, could be screened out to avoid unnessary operation.

Development

Fetal blood supply

In the growing fetus, a major source of blood to the liver is the umbilical vein which supplies nutrients to the growing fetus. The umbilical vein enters the abdomen at the umbilicus, and passes upward along the free margin of the falciform ligament of the liver to the inferior surface of the liver. There it joins with the left branch of the portal vein. The ductus venosus carries blood from the left portal vein to the left hepatic vein and then to the inferior vena cava, allowing placental blood to bypass the liver.

In the fetus, the liver develops throughout normal gestation, and does not perform the normal filtration of the infant liver. The liver does not perform digestive processes because the fetus does not consume meals directly, but receives nourishment from the mother via the placenta. The fetal liver releases some blood stem cells that migrate to the fetal thymus, so initially the lymphocytes, called T-cells, are created from fetal liver stem cells. Once the fetus is delivered, the formation of blood stem cells in infants shifts to the red bone marrow.

After birth, the umbilical vein and ductus venosus are completely obliterated two to five days postpartum; the former becomes the ligamentum teres and the latter becomes the ligamentum venosum. In the disease state of cirrhosis and portal hypertension, the umbilical vein can open up again.

Liver as food

</tr>
Pork liver
Nutritional value per 100 g (3.5 oz)
Energy 130 kcal   560 kJ
Carbohydrates     2.5 g
Fat3.7 g
Protein 21 g
Vitamin A equiv.  6500 μg 722%
Riboflavin (Vit. B2)  3 mg  200%
Niacin (Vit. B3)  15 mg  100%
Vitamin B6  0.7 mg54%
Folate (Vit. B9)  212 μg 53%
Vitamin B12  26 μg  1083%
Iron  23 mg184%
Sodium  87 mg6%
Beef and chicken liver are comparable.
Percentages are relative to US
recommendations for adults.
Source: USDA Nutrient database</td></tr></table>

Mammal and bird livers are commonly eaten as food. Liver can be baked, broiled, or fried (often served as liver and onions) or eaten raw (liver sashimi), but is perhaps most commonly made into a spread (examples including liver pâté, foie gras, Braunschweiger, chopped liver, and leverpostej) or sausage (liverwurst).

Both animal and fish livers are rich in iron and Vitamin A, and cod liver oil is commonly used as a dietary supplement. Very high doses of Vitamin A can be toxic; in 1913, Antarctic explorers Douglas Mawson and Xavier Mertz were both poisoned, the latter fatally, from eating husky liver. In the US, the USDA specifies 3000 μg per day as a tolerable upper limit, which amounts to about 50 g of raw pork liver or, as reported in a non scientific source, 3 g of polar-bear liver.[8] However, acute vitamin A poisoning is not likely to result from liver consumption, since it is present in a less toxic form than in many dietary supplements.[9]

Cultural allusions

In Greek mythology, Prometheus was punished by the gods for revealing fire to humans by being chained to a rock where a vulture (or an eagle) would peck out his liver, which would regenerate overnight. Curiously, the liver is the only human internal organ that actually can regenerate itself to a significant extent; this characteristic may have already been known to the Greeks due to survived injuries in battle.

The Talmud (tractate Berakhot 61b) refers to the liver as the seat of anger, with the gallbladder counteracting this.

In Arabic and Persian language, the liver is used in figurative speech to refer to courage and strong feelings, or "their best," e.g. "This Mecca has thrown to you the pieces of its liver!" [10]

The legend of Liver-Eating Johnson says that he would cut out and eat the liver of each man killed.

In the motion picture The Message, Hind bint Utbah is implied or portrayed eating the liver of Hamza ibn ‘Abd al-Muttalib during the Battle of Uhud.

Inuit will not eat the liver of polar bears (due to the fact a polar bear's liver contains so much Vitamin A as to be poisonous to humans) or seals [11]

Further reading

The following are standard medical textbooks:
  • Eugene R. Schiff, Michael F. Sorrell, Willis C. Maddrey, eds. Schiff's diseases of the liver, 9th ed. Philadelphia : Lippincott, Williams & Wilkins, 2003. ISBN 0-7817-3007-4
  • Sheila Sherlock, James Dooley. Diseases of the liver and biliary system, 11th ed. Oxford, UK ; Malden, MA : Blackwell Science. 2002. ISBN 0-632-05582-0
  • David Zakim, Thomas D. Boyer. eds. Hepatology: a textbook of liver disease, 4th ed. Philadelphia: Saunders. 2003. ISBN 0-7216-9051-3
These are for the lay reader or patient:

See also

References

  1. Physiology at MCG 6/6ch2/s6ch2_30
  2. KMLE Medical Dictionary. KMLE Medical Dictionary Definition of liver. Retrieved 2007-02-16
  3. The Greek word "ήπαρ" was derived from hēpaomai (ηπάομαι): to mend, to repair, hence hēpar actually means "repairable", indicating that this organ can regenerate itself spontaneously in the case of lesion.
  4. Robbins and Cotran Pathologic Basis of Disease, 7th Edition, p. 878
  5. Three-dimensional Anatomy of the Couinaud Liver Segments - University of Iowa
  6. Limitations and Pitfalls of Couinaud`s Segmentation of the Liver in Transaxial Imaging - Prof. Dr. Holger Strunk
  7. Bramstedt K (2006). "Living liver donor mortality: where do we stand?". Am J Gastroenterol 101 (4): 755-9. PMID 16494593.
  8. A. Aggrawal, Death by Vitamin A
  9. Myhre et al., "Water-miscible, emulsified, and solid forms of retinol supplements are more toxic than oil-based preparations", Am. J. Clinical Nutrition, 78, 1152 (2003)
  10. THE GREAT BATTLE OF BADAR (Yaum-e-Furqan)
  11. Man's best friend? - Student BMJ

Additional images

External links

Cost Effectiveness of Liver

| group5 = Clinical Trials Involving Liver | list5 = Ongoing Trials on Liver at Clinical Trials.govTrial results on LiverClinical Trials on Liver at Google


| group6 = Guidelines / Policies / Government Resources (FDA/CDC) Regarding Liver | list6 = US National Guidelines Clearinghouse on LiverNICE Guidance on LiverNHS PRODIGY GuidanceFDA on LiverCDC on Liver


| group7 = Textbook Information on Liver | list7 = Books and Textbook Information on Liver


| group8 = Pharmacology Resources on Liver | list8 = AND (Dose)}} Dosing of LiverAND (drug interactions)}} Drug interactions with LiverAND (side effects)}} Side effects of LiverAND (Allergy)}} Allergic reactions to LiverAND (overdose)}} Overdose information on LiverAND (carcinogenicity)}} Carcinogenicity information on LiverAND (pregnancy)}} Liver in pregnancyAND (pharmacokinetics)}} Pharmacokinetics of Liver


| group9 = Genetics, Pharmacogenomics, and Proteinomics of Liver | list9 = AND (pharmacogenomics)}} Genetics of LiverAND (pharmacogenomics)}} Pharmacogenomics of LiverAND (proteomics)}} Proteomics of Liver


| group10 = Newstories on Liver | list10 = Liver in the newsBe alerted to news on LiverNews trends on Liver


| group11 = Commentary on Liver | list11 = Blogs on Liver

| group12 = Patient Resources on Liver | list12 = Patient resources on LiverDiscussion groups on LiverPatient Handouts on LiverDirections to Hospitals Treating LiverRisk calculators and risk factors for Liver


| group13 = Healthcare Provider Resources on Liver | list13 = Symptoms of LiverCauses & Risk Factors for LiverDiagnostic studies for LiverTreatment of Liver

| group14 = Continuing Medical Education (CME) Programs on Liver | list14 = CME Programs on Liver

| group15 = International Resources on Liver | list15 = Liver en EspanolLiver en Francais

| group16 = Business Resources on Liver | list16 = Liver in the MarketplacePatents on Liver

| group17 = Informatics Resources on Liver | list17 = List of terms related to Liver


}}

ar:كبد

ay:K'iwcha zh-min-nan:Koaⁿ bs:Jetra bg:Черен дроб ca:Fetge cv:Пĕвер cs:Játra cy:Afu da:Lever de:Leber dv:ފުރަމޭ et:Maks el:Ήπαρeo:Hepato eu:Gibelga:Ae gd:Àdha gl:Fígado ko:간 hi:कलेजा hr:Jetra io:Hepato id:Hati is:Lifur it:Fegato he:כבד jv:Ati ka:ღვიძლი ku:Kezeb la:Iecur lt:Kepenys ln:Libale lmo:Fídech hu:Máj mk:Црн дроб ml:കരള്‍ mt:Fwied ms:Hati nah:Ēltapachtli nl:Leverno:Leveren nn:Lever oc:Fetge pag:Alteyqu:Kukupinsq:Mëlçia scn:Fìcatu simple:Liver sk:Pečeň sl:Jetra sr:Јетра sh:Jetra su:Ati fi:Maksa sv:Lever te:కాలేయం th:ตับtg:Ҷигарuk:Печінка yi:לעבער



Navigation WikiDoc | WikiPatient | Up To Date Pages | Recently Edited Pages | Recently Added Pictures

Table of Contents In Alphabetical Order | By Individual Diseases | Signs and Symptoms | Physical Examination | Lab Tests | Drugs

Editor Tools Become an Editor | Editors Help Menu | Create a Page | Edit a Page | Upload a Picture or File | Printable version | Permanent link | Maintain Pages | What Pages Link Here
There is no pharmaceutical or device industry support for this site and we need your viewer supported Donations | Editorial Board | Governance | Licensing | Disclaimers | Avoid Plagiarism | Policies
Linked-in.jpg