The document discusses the anatomy, blood supply, drainage, and ligaments of the liver. It describes the internal segmentation of the liver into right and left lobes and lists the main functions of the liver, including metabolism, protein synthesis, and detoxification. Common liver diseases mentioned include liver failure, trauma, esophageal varices, hydatid cysts, and tumors such as hepatocellular carcinoma. Imaging modalities and treatments for various liver conditions are also summarized.

1. liver

2. Anatomy— ligaments and peritoneal reflection
1- lf triangular lig. fixed lf lobe of liver to the diaphragm ---division
ant. and post. Leaf allow to mobilize lf lobe of liver from lf lat.
wall of ivc
2- RT triangular ligament. fixed RTlobe of liver to the RT
Hemidiaghragm
3- falciform ligament which it’s a remnant of umbilical vein runs
from umbilicus to the liver
4- lesser omentum connect liver to the stomach
Blood supply of liver
80% from portal vein ,20% from hepatic artery which branch from
caelic trunk which come from aorta. Hepatic artery dividing to
RT and LF hepatic artery to supply the RTand lLFlobe of

3. Structure in hilum of liver
Hepatic artery (above and medial),portal vein
(posterior)and cbd(above and lat.),presents with free
aged of lesser omintum ,
Venous drainage of the liver
Via hepatic veins in to the inferior vena cava
Anatomy of liver ( internl); liver divided to rt and lf lobe
.rt lobe has segment from V to VIII SUPPLY by rt
hepatic artery and rt branch of portal vein and drain
via rt hepatic duct.
Lf lobe of liver contain from 1 to 1v segments supply by lf
hepatic artery and lf branch of portal vein and drain
via lf hepatic duct.

4. Main function of liver
1- maintain core body temperature
2- PH balance and correction of lactic acidosis
3-SYNTHESIS OF CLOTTING FACTOR
4- glucose metabolism glycolysis and gluconeogensis
5- urea formation from protein catabolism
6- bilirobin formation from hg segregation
7-drug and hormone metabolism
8- removal of gut endotoxin and foreign antigen.

5. 
Liver function test
1-TSB DIRECT AND INDIRECT 2- ALP(alkalin
phosphatase) 35-130 IU 3- AST(ASPERTATE
TRANSAMINASE) 4-40 IU 4- ALT(ALANIN
TRANSAMINASE) 5-40
5-GAMMA GLUTAMYL TRANSPEPTUDASE (GGT)10-
48IU
6- SERIEM ALBUMIN 35-50 GM 7- PROTHROMPIN
TIMIME 12-16 SECOND

6. 
Liver failure
Either acute or chronic
Main feature of chronic liver failure are
Lethargy ,fever, jaundice, wasting(protein
catabolism), coagulopathy ,hyper dynamic
circulation, hepatic encephalopathy , portal
hypertension ,ascitis , esophageal varecies ,
splenomegaly , coetaneous --( spider naive ,
palmer erythema)

7. 
Imaging study of the liver
U/S , SPIRAL CT SCAN (give information for lesion
down to less than 1 cm in diameter and give
information on there nature) ,MRI , ERCP (very
useful in obstructive cause of liver failure but
most check coagulation) , PTC ,ANGIOGRAPHY
,NUCLEAR MEDICIN SCANING radioisotope
scanning ,
LAPARASCOPY AND LAPARASCOPIC U/S (is useful
in staging of hepatopancreatobiliary cancer

8. Liver trauma
Liver injury serious and associated with significant morbidity and
mortality even with prompt and appropriate management. Because its
highly vascular. Liver trauma divided to blunt(avulsion , laceration,
contusion) and penetrating trauma9 stab wound or gun shoot).
Diagnosis of liver injury;
All lower rt chest and upper abdominal stab wound should be suspect liver
injury and may be associated with other intra abdominal organ injury
especially if there is sign and symptoms of blood loss.
If pt haemodianamicly unstable because of blood loss or pt with
penetrating trauma needs urgent laparotomy ,if pt stable can do ct scan
with contrast enhanced.---- peritoneal lavage if haemopertoneal----
laparoscopy by which can see if there is diaphragmatic rapture.

9. 
Managements ;
First manage any pt with trauma as abcde . in case of pt
with abnormal circulation ; 2 large bore canulae send
blood for blood group and cross match 10 pints
.sample for full blood count ,urea and electrolyte liver
function test clotting screening ,glucose and amylase .
Then start with fluid replacement start with colloid or o
negative blood (what the difference between colloid
and crystalloid??)
Arterial blood gas should obtain and the pt intubate
and ventilate if gas exchange in adequate.
Chest tube if there is haemo or pnemothorax .

10. Surgical approach to the liver;
Rooftop incision provide excellent visualization of
the liver and spleen.
(What is Pringle maneuver ) a traumatic clump
across foramen of Winslow to control on bleeding
from liver.
Packing of liver may be essential if there is diffuse
bleeding from parenchyma of liver .pressure
from below usually packs for 48 hours in most of
pts no further treatment need.

11. Complication of liver trauma
1- profuse bleeding 2-liver abscess due to infection
of liver hematoma
3- bile collection and sometime biliary fistula
Late complication 1- hepatic artery aneurysm 2- a.v
fistula or a. biliary fistula 3- rarly biliary tract
stricture

12. Esophageal varices;
Dilated tortuous veins of lower part of esophagus ,it’s a complication of
portal hypertension (what other site of potocystemic connection).
USUALLY present with acute onset of a large amount of haematamesis
Diagnosis usually from history of pt with liver cirrhosis ,
Liver function test ,coagulating factor assessment
Management mainly blood replacement ,frb to correct caogulopathy,
vitamin k im. Platelet replacement if count less than 50x109/l-1
Sengstaken tube may be inserted if there is a profuse bleeding to provide
temporally homeostasis in tube (gastric balloon inflated 250 ml of air --
esophageal balloon inflated at 40 mmgh pressure .there is a 2
remaining channel for gastric and esophageal aspiration.
The balloon should temporally deflated after 12 hours to prevent pressure
necrosis of esophagus.

13. Drugs treatment –vasopressin most widly used for initial
control of variceal hemorrhage (20 unit in 10 ml of g/w iv in
10 mints)
Octreotide long acting somatostatin may equally effective.
Endoscopiclly treatment
By endoscopic a- seclerotherapy using ethanolamine oleate
b- panding
other treatments of oesophageal vareces are
TIPSS(transjugular intrahepatic portocystemic stent shunt)
Surgical procedure *portcystemic shunt *esophageal
transaction *splenactomy and gastric devascolrization

14. Hydatid cyst ;
Causative agent is , echinoccous granulosus .
Humans become infected by ingested egg of the adult tapeworm which
have been pass from the doge .the egg penetrate small bowel mucosa
and enter blood stream from which distribute to various part of the body
,
( why more common in the liver??)
c.f
many cyst are asymptomatic and become discover incidentally .if become
large it cause swelling in rt hypoch. Area. Some time pain because of
pressure or infection of cyst. FEVER DUE TO INFACTION.
Sequel of the cyst
*enlarge in size producing pressure effect on surrounding structure
*rapture producing anaphylactic shock
*rapture to lung cause dyspnea and cough or to biliary passage producing
obstructive jaundice

15. 
Investigation
1- plain x ray of abdomen may show calcification or clear
zone producing by the cyst
2- u/s and c.t scan 3- serological test use to detect
antibodies in the serum as ELISA TEST
&COMPLEMENT FIXATION ,
Cyst containing 3 layer outer layer due to reaction of
host tissue to the parasite ,ectocyst & endocyst
(containing germinal layers which containing scoleses
and hydatid fluid)

16. Treatment
Medical treatment albendazole 10 -15 mg /kg ( about
400 mg twice dialy) or mebandezol 40-50 mg /kg
continue for 3 months without interruption the
reassess the patient and decide whether continue on
medical treatment or go to syrgical procedure ,also
can use praziquantel 40 mg /kg/day.
Post operatively 2 wks albendazol + praziquantel
should be given .why??
Surgical treatment indication in infected cyst ,or in
rapture to biliary tract

17. 
Types of surgery 1- ct scan or u/s guidance PAIR 2-
marciplaization and tube drainage or
omentoplasty 3- radical surgical resection 4-
partial bepatactomy
Scolesydal agents used 1- 20 % hyper tonic slain 2-
0.5 silver nitrate 3- 95 % sterile ethanol (pair) 4-
absolute alcohol (pair) .
Whate are the indication ,contraindication and
complication of pair.?

18. Indication for hepatic surgery;
1- large cyst with suspected multiple doughter cyst
2- super facial cyst with risk of rapture
3- 2nd bacterial infection of the cyst
4- cystobiliary complication
5- pressure effect on adjacent organs

19. 

Liver tumour

Benign ; haemangiomas most common lesions it contain abnormal
plexus of vessels and there nature ,diagnosed by u/s or c.t scan ,by ct
scan with delayed contrast enhancement show the characteristic
appearance of slow contrast enhancement due to small vessels uptake in
the haemangioma. they varies in size.

Hepatic adenoma ;rare, treatment is by surgical resection
because they have potential malignant risk and there is no test by which
can differentiate it from malignant tumor. it have major correlation with
contraceptive piles.

Focal nodular hyperplasia ;unknown etiology ,there is a focal over
growth of functioning liver tissue supported by fibrous stroma ,contrast
c.t scan may show central scaring and evidence of awell vasulirized
lesion (not specific). Fnh contain both hepatocyte and kupffer cells
.kupffer cells take up the colloid by which differentiated from either
benign adenoma and 1 * or metastatic cancer ,non of which not
containing significant number of kupffer cells.

20. Hepatocellular carcinoma
It’s the most common primary malignant tumor of liver
account more than 75 % of primary malignant tumor .
Associated risk factor ;1-cirrhosis (chronic liver disease) 2-
hepatitis b&c virus 3- alcohol abuse 4- hemochromatosis ,
schestomiasis 5- aflatoxin (fungi)
Any patient presented with with chronic liver disease must
be secreaning for hcc by 1- us 2- c.t scan 3- measuring alfa
feto protein ( afp)
Signs and symptoms as patients with chronic liver disease or
pt complaining from anorexia, loss of wt mass in rt
hypochondriam

21. Staging of disease
Depend on 1- general condition of the pt 2- child classification
3- size and site of tumor
4- chest c.t scan and bone scaning why??
Surgical treatment
Based on resection of tumor with 1 -2 cm of normal edge and we
minimize tissue resection in pt with liver cirrhosis to decrease
incidence of post operative liver failure .
Large tumor or multi focal treated by liver transplant
Fallow up and adjuvant therapy
There is a little evidence that adjuvant chemotherapy will improve
the prognosis of the patients fallowing resection of hcc and it
may damage the function of liver in those underlying chronic
liver disease .
Alfa feto protein is clinically useful tumor marker.