The document discusses the anatomy, physiology, and common diseases of the liver. It begins with a brief history of liver surgery and anatomy including liver innervation and lymph drainage. It then covers liver physiology including metabolism of nutrients, proteins, and drugs. Common liver diseases are summarized such as viral hepatitis, alcohol-related disease, cirrhosis, portal hypertension, and liver cancer. Specific conditions like fatty liver disease, jaundice, acute liver failure, and infections are also reviewed. Imaging findings and treatments for various benign and malignant liver lesions are mentioned.

1. The liver

2. History of liver surgery
Ancient Greek , hepar, derives from the verb hepaomai, which
means “mend” or “repair.”
The ancient Greek myth of Prometheus reminds us that the liver
is the only organ that regenerates.
principles are correct that after hepatic resection, the remnant
liver will hypertrophy over weeks to months to regain most of its
original liver mass.
what is the maximum amount of liver that can be resected while
retaining adequate liver function ?

3. • Liver before and after auto repair

11. Liver Innervation
* Parasympathetic :
- Anterior liver  Lt Vagal Branch
- Posterior Liver  Rt Vagal Branch
* Sympathetic :
- Greater Thoracic splanchnic & celiac branches.

13. Lymph Drainage
• Lymph is produced within the liver  perisinusoidal space of
Disse  hilar cystic duct lymph node (Calot’s triangle node),
common bile duct, hepatic artery, and retropancreatic and
celiac lymph nodes.

15. Calot’s node - “hilar node”

16. Calot’s triangle

17. Liver Physiology
• These include processes such as storage, metabolism, production, and secretion.
• One crucial role is the processing of absorbed nutrients through the metabolism of glucose,
lipids, and proteins.
• The liver maintains glucose concentrations in a normal range over both short and long
periods and in the fasting state. by performing several important roles in carbohydrate
metabolism. (Glycogenolysis ,gluconeogenesis ,glycogen synthesis or glycolysis and
lipogenesis.)
• The liver also plays a central role in lipid metabolism through the formation of bile and the
production of cholesterol and fatty acids.
• Protein metabolism occurs in the liver through amino acid deamination, resulting in the
production of ammonia as well as the production of a variety of amino acids.
• the liver also is responsible for the synthesis of most circulating plasma proteins. (albumin,
factors of the coagulation and fibrinolytic systems, and compounds of 2 the complement
cascade.
• the detoxification of many substances through drug metabolism occurs in the

18. Bilirubin Metabolism

19. Bile Synthesis

20. Drug Metabolism

21. Liver Function Test
*Hepatic Cell Injury:
• Aspartate transaminase (AST)
• Alanine transaminase (ALT)
• Alkaline phosphatase (AP)
• γ-glutamyltranspeptidase (GGT)
• Bilirubin
* Liver Function:
• Serum albumin levels
• Prothrombin time (PT).

22. Abnormal synthetic function
• Liver synthetic function is best assessed by:
-Albumin level
-INR ( PT )
• liver produces approximately 10 g of albumin per day.
However, albumin levels are dependent on a number of factors
such as nutritional status, renal dysfunction, protein-losing
enteropathies, and hormonal disturbances.

23. Cholestasis
• Cholestasis is a condition in which bile flow from the liver to
the duodenum is impaired, due to intrahepatic causes
(hepatocellular dysfunction) or extrahepatic causes (biliary
tree obstruction).
• detected by measuring the serum levels of bilirubin, AP, and
GGT.
• elevated indirect bilirubin level suggests  intrahepatic
cholestasis.
• elevated direct bilirubin level suggests  extrahepatic
obstruction.

24. Jaundice
• Yellowish discoloration of skin , sclera and mucus membrane
with the pigment bilirubin.
1) Prehepatic : ( Excessive Hemolysis – insufficient gluco)
A- genetic ( spherocytosis , leptocytosis , G6PD deficency)
B- Acquired ( coomp’s test)
2) Intrahepatic (involve the intracellular mechanisms for
conjugation and excretion of bile from the hepatocyte).
3) Extrahepatic ( extrinsic or intrinsic biliary obstruction )

25. Detectable when Bilirubin > ?? mg/dl.

26. Acute Liver Failure
• Rate of extent of hepatocytes damage exceed the
regenerative ability of the liver.
• Around 2000 patient annually in U.S .
• Development of Hepatic Encephalopathy within 26 weeks
of severe liver injury with no previous history of liver
diseases or portal HTN.
• Before the introduction of orthotopic liver transplantation
(OLT), the chance for survival was <20%. Currently, most
series report 5-year survival rates of >70% for affected
patients.2

27. • ETIOLOGY :
- East  Viral hepatitis A,B,E.
- West  Drug & Toxins .
ALF need to be monitored in the intensive care unit (ICU) setting,
and specific attention needs to be given to fluid management,
ulcer prophylaxis, hemodynamic monitoring, electrolyte
management, and treatment of infection.
- Hypophosphatemia, a sign of hepatic regeneration, may
indicate a higher likelihood of spontaneous recovery and needs
to be corrected via intravenous (IV) administration of
phosphate.

28. How to treat Acetaminophen overdose
?

29. • Few Hours of presentation ?  Charcoal reduces the
amount of acetaminophen in the GI tract.
• N-acetylcysteine (NAC) 
1.orally (140 mg/kg initial dose, followed by 70 mg/kg every
4 hours × 17 doses)
2. intravenous route (loading dose of 150 mg/kg, followed
by a maintenance dose of 50 mg/kg every 4 hours × 12
doses).

30. Liver cirrhosis

31. Cirrhosis & portal HTN
• Sustained wound healing in response to chronic liver injury
 presence of fibrous septa subdividing the parenchyma
into hepatocellular nodules.
• 40% of cirrhotic patients are asymptomatic.
• ESLD – end stage liver disease is an indication for liver
transplant with 5 year mortality of 50% of patient.
• Liver cirrhosis is the most common nonneoplastic cause of
death among patients with hepatobiliary and GI diseases.
• Morphology : micronodular , macronodular ,mixed.

32. Macronodular cirrhosis

33. Micronodular cirrhosis

34. • Causes of portal HTN are:
Prehepatic  portal vein thrombosis.
Hepatic  cirrhosis , HCC , fibrosis.
Posthepatic  Budd-chiari syndrome.
• Cirrhosis induced Portal HTN accounts for 90% of all Portal
HTN cases.
• Rule of 23 of portal HTN:
23 of cirrhotic patient develop Portal HTN
23 of portal HTN patient develop Esophageal varices.
23 of esophageal varices are ruptured.

35. * Clinical presentation of liver cirrhosis :
• fatigue, anorexia, weight loss, jaundice, abdominal pain,
peripheral edema, ascites, GI bleeding, and hepatic
encephalopathy.
*On physical examination
Spider angiomata and palmar erythema (alterations in sex
hormone metabolism), Finger clubbing , leukonychia
duputyren’s contracture.
* Clinical presentation of cirrhosis with portal HTN :
• Esophageal varices , splenomegaly , caput medusa ,
hemorrhoids.

38. • Ruptured Esophageal varcies is the most dangerous
complication of Portal HTN.
• Ruptured esophageal acounts for 50% of upper GI bleeding in
patients known to have esophageal varcies.
Diagnostic test  EGD “ upper GI endoscopy” .
* Treatment of ruptured Esophageal Varices :
• Large bore IV’s x 2
• Iv fluids , Foleys catheter , cross blood send labs.
• Intubation to protect from aspiration.

39. Caput Medusa – Portal HTN

41. Example of palmar erythema- cirrhosis

42. Spider angioma

43. leukonychia - cirrhosis

44. Infections of the liver
• liver contains the largest portion of the reticuloendothelial
system in the human body and is therefore able to handle the
continuous low-level exposure to enteric bacteria that it
receives through the portal venous system , nonviral infections
are unusual.

45. Pyogenic Abscess
• Most common abscess seen in the U.S .
• 40%  Monomicrobial.
• 40%  Polymicrobial.
• 20%  Negative Culture.
• Commenst are Gram negative : E.coli (70%) , klibseila
proteus.
• Most common liver abscess in the U.S .
• In patients with endocarditis and infected indwelling
catheters, Staphylococcus and Streptococcus species are
more commonly found.
• Treatment include correction of the underlying cause and
IV antibiotic therapy (8 weeks ).

46. Multiple hepatic Abscess. “ honeycomb appearance”

47. Amebic Abscess
• Entamoeba histolytica is a parasite that is endemic
worldwide, infecting approximately 10% of the world’s
population.( areas with poor sanitaion).
• Most commonly involve Rt superior anterior liver lobe.
• Most common type of liver abscess worldwide.
• Amebiasis should be considered in patients who have traveled
to an endemic area and present with right upper quadrant pain,
fever, hepatomegaly, and hepatic abscess.
• Leukocytosis is common, whereas elevated transaminase
levels and jaundice are unusual

49. “Amebic - Anchovy paste abscess”

50. • Ultrasound and CT scanning of the abdomen are both very
sensitive but nonspecific for the detection of amebic
abscesses.
• Metronidazole 750 mg three times a day for 7 to 10 days is
the treatment of choice and is successful in 95% of cases.
• Aspiration of the abscess if :
- large abscesses
- not respond to medical therapy
- superinfected.
- abscesses of the left lobe of the liver at risk for rupture into
the pericardium.

51. Hydatid Cyst
• Hydatid disease is due to infection by the tapeworm
Echinococcus granulosus in its larval or cyst stage.
• 70 % of hydatid cysts found in the liver , others found in lung ,
brain or bone.
• Hydatid cysts commonly involve the right lobe of the liver,
usually the anterior-inferior or posterior-inferior segments .
Eosinophilia is seen in approximately 30% of infected patients.
Ultrasonography and CT scanning of the abdomen are both quite
sensitive for detecting hydatid cysts.

53. Ring like calcifications - Hydatid cyst

54. • Unless the cysts are small or the patient is not a suitable
candidate for surgical resection, the treatment of hydatid
disease is surgically based because of the high risk of
secondary infection and rupture.
• Medical treatment with albendazole relies on drug
diffusion through the cyst membrane(albendazole
preferred over mebendazole )
• surgical resection involving laparoscopic or open complete
cyst removal with instillation of a scolicidal agent is
preferred and usually is curative.
• If complete cystectomy is not possible, then formal
anatomic liver resection can be undertaken.

55. Benign Liver Lesions
• Hepatic Cyst
• Adenoma
• Hemangioma
• Focal nodular hyperplasia
• Bile duct Hamartoma

56. cyst
• 1. primary (congenital )
• 2. secondary to trauma
• 3. infection ( pyogenic/ parasitic)
• 4. neoplastic disease.
• In most cases, congenital cysts are differentiated from
secondary cysts (infectious or neoplastic origin) in that they
have :
well-defined thin wall , no solid component and are filled with
homogeneous, clear fluid.

57. Simple hepatic cyst Vs Infectious hydatid cyst

58. Hemangioma
• Hemangiomas are the most common solid benign masses that
occur in the liver.
• They consist of large endothelial-lined vascular spaces
• represent congenital vascular lesions that contain fibrous
tissue and small blood vessels that eventually grow.
• surgical resection can be considered if the patient is
symptomatic.
• Caution should be exercised in ordering a liver biopsy if the
suspected diagnosis is hemangioma because of the risk of
bleeding from the biopsy site..

59. Liver Hemangioma on CT

60. Adenoma
• Hepatic adenomas are benign solid neoplasms of the liver.
They are most commonly seen in premenopausal women older
than 30 years of age and are typically solitary.
• Use of Estrogen Contraceptives are clear risk factors.
• Histologically : Adenoma lacks bile duct glands , kupffer cells ,
have no lobules and contain hepatocytes that are congested.
• Hepatic adenomas also have a risk of malignant transformation
to a well-differentiated HCC. Therefore, it usually is
recommended that a hepatic adenoma (once diagnosed) be
surgically resected.

61. Hepatic adenoma

62. Focal Nodular Hyperplasia
• FNH is a solid, benign lesion of the liver believed to be a
hyperplastic response to an anomalous artery. Similar to
adenomas, they are more common in women of childbearing
age.
• Biphasic CT  well circumiscribed lesion with central scar.
• MRI  The lesion appear black on both T1 & T2
• FNH lesions usually do not rupture spontaneously and have no
significant risk of malignant transformation. Therefore, the
management of FNH is usually reassurance and prospective
observation irrespective of size.
• Oral contraceptive or estrogen use should be stopped when
either FNH or adenoma is diagnosed. ( stop it )

63. Malignant liver tumor
• A – primary ( HCC , Cholangiocarcinoma)
• B – Metastasis ( colorectal CA )
• Most common liver tumor is Metastasis colorectal cancer.
• Around 150000 new cases of colorectal CA are diagnosed
every year with 60% of them will have hepatic metastasis.
• TO be continued .