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Liver

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Liver 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. Anterior view of the position of the liver (red) in the human abdomen. Latin jecur, iecer

Structural overview

The liver is the largest glandular organ with a weight of about 1.5 kg (3.3 lb). It is a reddish brown organ with four lobes of unequal size and shape. The liver is on the right side of the abdominal cavity just below the diaphragm and is connected to two large blood vessels, one called the hepatic artery and one called the portal vein. The hepatic artery carries blood from the aorta whereas the portal vein carries blood containing digested food from the small intestine and the descending colon. These blood vessels subdivide into capillaries which then lead to a lobule. Each lobule is made up of thousands of hepatic cells which are the basic metabolic cells.

Anatomy

An adult human liver normally weighs between 1.4–1.6 kg (3.1–3.5 lb),[4] and is a soft, pinkish-brown, triangular organ. It is both the largest internal organ (the skin being the largest organ overall) and the largest gland in the human body.

It is located in the right upper quadrant of the abdominal cavity, resting just below the diaphragm. The liver lies to the right of the stomach and overlies the gallbladder.

Blood flow

The liver receives a dual blood supply from the hepatic portal vein and hepatic arteries. Supplying approximately 75% of the liver's blood supply, the hepatic portal vein carries venous blood drained from the spleen, gastrointestinal tract, and its associated organs. The hepatic arteries supply arterial blood to the liver, accounting for the remainder of its blood flow. Oxygen is provided from both sources; approximately half of the liver's oxygen demand is met by the hepatic portal vein, and half is met by the hepatic arteries.[5] Blood flows through the sinusoids and empties into the central vein of each lobule. The central veins coalesce into hepatic veins, which leave the liver and empty into the inferior vena cava.

Biliary flow

The term biliary tree is derived from the arboreal branches of the bile ducts. The bile produced in the liver is collected in bile canaliculi, which merge to form bile ducts. Within the liver, these ducts are called intrahepatic (within the liver) bile ducts, and once they exit the liver they are considered extrahepatic (outside the liver). The intrahepatic ducts eventually drain into the right and left hepatic ducts, which 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 second part of the duodenum together at the ampulla of Vater.

The biliary tree

Surface anatomy

Peritoneal ligaments

Apart from a patch where it connects to the diaphragm (the so-called ``bare area``), 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. An exception to this is the falciform ligament, which attaches the liver to the posterior portion of the anterior body wall.

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.

Functional anatomy

Correspondence between anatomic lobes and Couinaud segments Segment* Couinaud segments Caudate 1 Lateral 2, 3 Medial 4a, 4b Right 5, 6, 7, 8

* or lobe in the case of the caudate lobe. Each number in the list corresponds to one in the table.

Caudate Superior subsegment of the lateral segment Inferior subsegment of the lateral segment Superior subsegment of the medial segment Inferior subsegment of the medial segment Inferior subsegment of the anterior segment Inferior subsegment of the posterior segment Superior subsegment of the posterior segment Superior subsegment of the anterior segment

The central area where the common bile duct, hepatic portal vein, and hepatic artery proper enter 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 an imaginary plane joining the gallbladder fossa to the inferior vena cava. The plane 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 also separates the medial and lateral segments. The medial segment is also 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.[6][7]

In other animals

The liver is found in all vertebrates, and is typically the largest visceral organ. Its form varies considerably in different species, and is largely determined by the shape and arrangement of the surrounding organs. Nonetheless, in most species it is divided into right and left lobes; exceptions to this general rule include snakes, where the shape of the body necessitates a simple cigar-like form. The internal structure of the liver is broadly similar in all vertebrates.[8]

An organ sometimes referred to as a liver is found associated with the digestive tract of the primitive chordate Amphioxus. However, this is an enzyme secreting gland, not a metabolic organ, and it is unclear how truly homologous it is to the vertebrate liver.[8]

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.

Synthesis

Further information: Proteins produced and secreted by the liver A large part of amino acid synthesis The liver performs several roles in carbohydrate metabolism: Gluconeogenesis (the synthesis of glucose from certain amino acids, lactate or glycerol) Glycogenolysis (the breakdown of glycogen into glucose) Glycogenesis (the formation of glycogen from glucose)(muscle tissues can also do this) The liver is responsible for the mainstay of protein metabolism, synthesis as well as degradation The liver also performs several roles in lipid metabolism: Cholesterol synthesis Lipogenesis, the production of triglycerides (fats). The liver produces coagulation factors I (fibrinogen), II (prothrombin), V, VII, IX, X and XI, as well as protein C, protein S and antithrombin. In the first trimester fetus, the liver is the main site of red blood cell production. By the 32nd week of gestation, the bone marrow has almost completely taken over that task. The liver produces and excretes bile (a greenish liquid) required for emulsifying fats. Some of the bile drains directly into the duodenum, and some is stored in the gallbladder. The liver also produces insulin-like growth factor 1 (IGF-1), a polypeptide protein hormone that plays an important role in childhood growth and continues to have anabolic effects in adults. The liver is a major site of thrombopoietin production. Thrombopoietin is a glycoprotein hormone that regulates the production of platelets by the bone marrow.

Breakdown

The breakdown of insulin and other hormones The liver breaks down hemoglobin, creating metabolites that are added to bile as pigment (bilirubin and biliverdin). The liver breaks down or modifies toxic substances (e.g., methylation) and most medicinal products in a process called drug metabolism. This sometimes results in toxication, when the metabolite is more toxic than its precursor. Preferably, the toxins are conjugated to avail excretion in bile or urine. The liver converts ammonia to urea.

Other functions

The liver stores a multitude of substances, including glucose (in the form of glycogen), vitamin A (1–2 years' supply), vitamin D (1–4 months' supply), vitamin B12, iron, and copper. The liver is responsible for immunological effects- the reticuloendothelial system of the liver contains many immunologically active cells, acting as a 'sieve' for antigens carried to it via the portal system. The liver produces albumin, the major osmolar component of blood serum. The liver synthesizes angiotensinogen, a hormone that is responsible for raising the blood pressure when activated by renin, an enzyme that is released when the kidney senses low blood pressure.

Diseases of the liver

Main article: Liver disease Left lobe liver tumor

The liver supports almost every organ in the body and is vital for survival. Because of its strategic location and multidimensional functions, the liver is also prone to many diseases. [9]

The most common include : Infections such as hepatitis A,B, C, E, Alcohol damage, fatty liver, cirrhosis, cancer, drug damage (especially acetaminophen, cancer drugs)

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 haemoglobin of dead red blood cells; normally, the liver removes bilirubin from the blood and excretes it through bile.

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

Diseases that interfere with liver function will lead to derangement of these processes. However, the liver has a great capacity to regenerate and has a large reserve capacity. In most cases, the liver only produces symptoms after extensive damage. [10]

Liver diseases may be diagnosed by liver function tests, for example, by production of acute phase proteins.

Disease Signs

The classic signs of liver damage include the following:

Pale stools occur when the bilirubin mixes with stools, it cause a whitish discoloration. Dark urine occurs when bilirubin mixes with urine Bilirubin when it deposits in skin, causes an intense itch. Itching is the most common complaint by people who have liver failure. Often this itch cannot be relieved by drugs. Swelling of the abdomen, ankles and feet occurs because the liver fails to make albumin. Excessive fatigue occurs from a generalized loss of nutrients, minerals and vitamins. Bruising and easy bleeding are other features of liver disease. The liver makes substances which help prevent bleeding. When liver damage occurs, these substances are no longer present and severe bleeding can occur. [11]

Diagnosis

The diagnosis of liver function is made by blood tests. Liver function tests can readily pinpoint the extent of liver damage. If infection is suspected, then other serological tests are done. Sometimes one may require an ultrasound or a CT scan to image the liver.

Physical exam of the liver is not accurate in determining the extent of liver damage. Physical exam can only reveal presence of tenderness or size of liver but in all cases some type of radiological study is required to look at the liver [12]

Biopsy

The ideal way to look at damage to the liver is with a biopsy. A biopsy is not required in all cases but may be necessary when the cause is unknown. The procedure is done at the bedside and only requires local anesthetic. A small thin needle is inserted into the skin just below the rib cage and a biopsy is obtained. The tissue is sent to the laboratory where it is analyzed under a microscope. Sometimes the radiologist may perform a liver biopsy under ultrasound guidance if only a small area is involved. [13] The liver is the powerhouse of the body and vital for survival. The best way to be free of most liver disorders is to eat healthy, avoid alcohol and tobacco and exercise on a regular basis.

Regeneration

The liver is the only internal human organ capable of natural regeneration of lost tissue; as little as 25% of a liver can regenerate into a whole liver. A human liver is known to grow back in no less than 8 years, due to hyptochronatin cells in the remaining liver.[14]

This is predominantly due to the hepatocytes re-entering the cell cycle. That is, the hepatocytes go from the quiescent G0 phase to the G1 phase and undergo mitosis. This process is activated by the p75 receptors.[15] There is also some evidence of bipotential stem cells, called ovalocytes or hepatic oval cells, which are thought to reside in the canals of Hering. These cells can differentiate into either hepatocytes or cholangiocytes, the latter being the cells that line the bile ducts.

Liver transplantation

Main article: Liver transplantation

Human liver transplants were first performed by Thomas Starzl in the United States and Roy Calne in Cambridge, England in 1963 and 1965, respectively.

After resection of left lobe liver tumor

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.[16] The risk of postoperative complications (and death) is far greater in right-sided operations than that in 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 resonance 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 unsuitable for donation, could be screened out to avoid unnecessary operations.

MDCT image. Arterial anatomy contraindicated for liver donation.

MDCT image. Portal venous anatomy contraindicated for liver donation.

MDCT image. 3D image created by MDCT can clearly visualize the liver, measure the liver volume, and plan the dissection plane to facilitate the liver transplantation procedure.

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 in two to five days; 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.

As food

Main article: Liver (food)

Cultural allusions

“ The liver has always been an important symbol in occult physiology. As the largest organ, the one containing the most blood, it was regarded as the darkest, least penetrable part of man's innards. Thus it was considered to contain the secret of fate and was used for fortune-telling. In Plato, and in later physiology, the liver represented the darkest passions, particularly the bloody, smoky ones of wrath, jealousy, and greed which drive men to action. Thus the liver meant the impulsive attachment to life itself. ”

—James Hillman[17]

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. (The liver is the only human internal organ that actually can regenerate itself to a significant extent.)

Many ancient peoples of the Near East and Mediterranean areas practised a type of divination called haruspicy, whereby they tried to obtain information from examining the livers of sheep and other animals.

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

The Persian, Urdu, and Hindi languages (جگر or जिगर or jigar) refer to the liver in figurative speech to indicate courage and strong feelings, or ``their best``; e.g., ``This Mecca has thrown to you the pieces of its liver!`` [18]. The term jan e jigar, literally ``the strength (power) of my liver``, is a term of endearment in Urdu. In Persian slang, jigar is used as an adjective for any object which is desirable, especially women. In the Zulu language, the word for liver (isibindi) is the same as the word for courage.

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

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. Although there are narrations that suggest that Hind did ``taste``, rather than eat, the liver of Hamza, the authenticity of these narrations have to be questioned.

See also

Look up liver in Wiktionary, the free dictionary. Artificial liver Bile Bile canaliculus Hepatocyte Liver function tests Liver shot (martial arts strike)

References

This article includes a list of references, related reading or external links, but its sources remain unclear because it lacks inline citations. Please improve this article by introducing more precise citations where appropriate. (June 2008) ^ Physiology at MCG 6/6ch2/s6ch2_30 ^ Maton, Anthea; Jean Hopkins, Charles William McLaughlin, Susan Johnson, Maryanna Quon Warner, David LaHart, Jill D. Wright (1993). Human Biology and Health. Englewood Cliffs, New Jersey, USA: Prentice Hall. ISBN 0-13-981176-1. OCLC 32308337.  ^ The Greek word ``ήπαρ`` was derived from hÄ“paomai (ηπάομαι): to mend, to repair, hence hÄ“par actually means ``repairable``, indicating that this organ can regenerate itself spontaneously in the case of lesion. ^ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease. St. Louis, MO: Elsevier Saunders. pp. 878. ISBN 0-7216-0187-1.  ^ Benjamin L. Shneider; Sherman, Philip M. (2008). Pediatric Gastrointestinal Disease. Connecticut: PMPH-USA. pp. 751. ISBN 1-55009-364-9.  ^ ``Three-dimensional Anatomy of the Couinaud Liver Segments``. http://dpi.radiology.uiowa.edu/nlm/app/livertoc/liver/liver.html. Retrieved 2009-02-17.  ^ ``Prof. Dr. Holger Strunk - Homepage``. http://www.uni-bonn.de/~umm705/quiz0403.htm. Retrieved 2009-02-17.  ^ a b Romer, Alfred Sherwood; Parsons, Thomas S. (1977). The Vertebrate Body. Philadelphia, PA: Holt-Saunders International. pp. 354-355. ISBN 0-03-910284-X.  ^ Cirrhosis Overview National Digestive Diseases Information Clearinghouse. Retrieved on 2010-01-22 ^ Liver Tissue Damage And Treatment Retrieved on 2010-01-22 ^ Extraintestinal Complications: Liver Disease Crohn's & Colitis Foundation of America. Retrieved on 2010-01-22 ^ Liver Information HealthLine. Retrieved on 2010-01-22 ^ [ http://www.medicinenet.com/script/main/art.asp?articlekey=191 Liver.. The largest gland in the body] MedicineNet. Retrieved on 2010-01-22 ^ Liver Regeneration May Simpler Than Previously Though, April 2007, http://www.medicalnewstoday.com/articles/67653.php  ^ Suzuki K, Tanaka M, Watanabe N, Saito S, Nonaka H, Miyajima A (July 2008). ``p75 Neurotrophin receptor is a marker for precursors of stellate cells and portal fibroblasts in mouse fetal liver``. Gastroenterology 135 (1): 270–281.e3. doi:10.1053/j.gastro.2008.03.075. PMID 18515089. http://linkinghub.elsevier.com/retrieve/pii/S0016-5085(08)00571-4.  ^ Bramstedt K (2006). ``Living liver donor mortality: where do we stand?``. Am. J. Gastrointestinal 101 (4): 755–9. doi:10.1111/j.1572-0241.2006.00421.x. PMID 16494593.  ^ Krishna, Gopi; Hillman, James (commentary) (1970). Kundalini – the evolutionary energy in man. London: Stuart & Watkins. pp. 77. SBN 7224 0115 9. http://www.scribd.com/doc/7577310/KUNDALINI-the-evolutionary-energy-in-man.  ^ THE GREAT BATTLE OF BADAR (Yaum-e-Furqan)

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: Sanjiv Chopra. The Liver Book: A Comprehensive Guide to Diagnosis, Treatment, and Recovery, Atria, 2002, ISBN 0-7434-0585-4 Melissa Palmer. Dr. Melissa Palmer's Guide to Hepatitis and Liver Disease: What You Need to Know, Avery Publishing Group; Revised edition May 24, 2004, ISBN 1-58333-188-3. her webpage. Howard J. Worman. The Liver Disorders Sourcebook, McGraw-Hill, 1999, ISBN 0-7373-0090-6. his Columbia University web site, ``Diseases of the liver``

External links

Wikimedia Commons has media related to: Liver Liver at the Open Directory Project. VIRTUAL Liver - online learning resource v â€¢ d â€¢ e Anatomy of torso, digestive system: accessory digestive glands (TA A05.8-9,