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Liver Diseases
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Liver Diseases ANAHAT DHILLON, MD n RANDOLPH H. STEADMAN, MD n
Normal Hepatic Anatomy Hepatic Function in Health Carbohydrate Metabolism Lipid Metabolism and Transport Protein Synthesis Detoxification and Transformation Bilirubin Metabolism
The Injured Liver Cellular Responses Laboratory Manifestations of Hepatobiliary Dysfunction
Etiology of Liver Dysfunction Viral Hepatitis Hydatid Cyst Disease Nonalcoholic Steatohepatitis Genetic Causes of Liver Disease Drug-Associated and Other Toxic Liver Disease Ischemic Liver Injury Liver Function in the Geriatric Patient Biliary Cirrhosis Pregnancy-Associated Liver Disease
Systemic Effects of Liver Disease Cardiovascular Effects Portal Hypertension and Ascites Renal Effects Pulmonary Effects Hepatic Encephalopathy
Assessment of Perioperative Risk Anesthetic Management Abnormal Laboratory Values in Asymptomatic Patients Acute Hepatitis Cirrhosis Acute Liver Failure Transjugular Intrahepatic Portosystemic Shunt Biliary Tract Procedures Hepatic Resection Liver Transplantation Postoperative Liver Dysfunction
Conclusion 162
KEY POINTS n The liver receives a dual afferent blood supply; the portal
vein provides 75% and the hepatic artery 25% of hepatic inflow. With differences in oxygen content, each source contributes about 50% of the liver's oxygen supply. n Hepatocytes make up 80% of the liver. Nonparenchymal cells include Kupffer cells, members of the monocytephagocyte system that play a key role in immunity. Stellate cells undergo transformation to fibroblasts and produce collagen in response to injury, fundamental to fibrosis and cirrhosis. n Hepatic dysfunction affects most organ systems because of the liver's extensive metabolic, detoxification, and digestive functions; alterations cause encephalopathy, coagulopathy, and muscle wasting. n Liver injury leads to fibrosis and portal hypertension, which is responsible for ascites, gastrointestinal bleeding, and renal dysfunction, the characteristic manifestations of cirrhosis. n The major causes of liver disease include noncholestatic cirrhosis, cholestatic cirrhosis, acute hepatic necrosis, biliary atresia, metabolic diseases, malignant neoplasms, and drug-induced injury. Noncholestatic cirrhosis includes hepatitis; hepatitis C is the most common diagnosis in U.S. liver transplant recipients. n Nonalcoholic steatohepatitis is increasing in incidence in the United States, possibly secondary to the obesity epidemic. n Alagille's syndrome is the most common form of familial intrahepatic cholestasis; 90% of patients have associated congenital heart disease, most often pulmonic stenosis. n Alpha-1-antitrypsin deficiency, the most common metabolic disorder of the liver, is associated with decreasing FEV1 and exacerbated by smoking. n Hemochromatosis first affects the liver, then the pancreas with diabetes mellitus, the skin with bronze pigmentation, and iron deposition in the heart with restrictive cardiomyopathy and arrhythmias.
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A
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Liver Diseases ANAHAT DHILLON, MD n RANDOLPH H. STEADMAN, MD n
Normal Hepatic Anatomy Hepatic Function in Health Carbohydrate Metabolism Lipid Metabolism and Transport Protein Synthesis Detoxification and Transformation Bilirubin Metabolism
The Injured Liver Cellular Responses Laboratory Manifestations of Hepatobiliary Dysfunction
Etiology of Liver Dysfunction Viral Hepatitis Hydatid Cyst Disease Nonalcoholic Steatohepatitis Genetic Causes of Liver Disease Drug-Associated and Other Toxic Liver Disease Ischemic Liver Injury Liver Function in the Geriatric Patient Biliary Cirrhosis Pregnancy-Associated Liver Disease
Systemic Effects of Liver Disease Cardiovascular Effects Portal Hypertension and Ascites Renal Effects Pulmonary Effects Hepatic Encephalopathy
Assessment of Perioperative Risk Anesthetic Management Abnormal Laboratory Values in Asymptomatic Patients Acute Hepatitis Cirrhosis Acute Liver Failure Transjugular Intrahepatic Portosystemic Shunt Biliary Tract Procedures Hepatic Resection Liver Transplantation Postoperative Liver Dysfunction
Conclusion 162
KEY POINTS n The liver receives a dual afferent blood supply; the portal
vein provides 75% and the hepatic artery 25% of hepatic inflow. With differences in oxygen content, each source contributes about 50% of the liver's oxygen supply. n Hepatocytes make up 80% of the liver. Nonparenchymal cells include Kupffer cells, members of the monocytephagocyte system that play a key role in immunity. Stellate cells undergo transformation to fibroblasts and produce collagen in response to injury, fundamental to fibrosis and cirrhosis. n Hepatic dysfunction affects most organ systems because of the liver's extensive metabolic, detoxification, and digestive functions; alterations cause encephalopathy, coagulopathy, and muscle wasting. n Liver injury leads to fibrosis and portal hypertension, which is responsible for ascites, gastrointestinal bleeding, and renal dysfunction, the characteristic manifestations of cirrhosis. n The major causes of liver disease include noncholestatic cirrhosis, cholestatic cirrhosis, acute hepatic necrosis, biliary atresia, metabolic diseases, malignant neoplasms, and drug-induced injury. Noncholestatic cirrhosis includes hepatitis; hepatitis C is the most common diagnosis in U.S. liver transplant recipients. n Nonalcoholic steatohepatitis is increasing in incidence in the United States, possibly secondary to the obesity epidemic. n Alagille's syndrome is the most common form of familial intrahepatic cholestasis; 90% of patients have associated congenital heart disease, most often pulmonic stenosis. n Alpha-1-antitrypsin deficiency, the most common metabolic disorder of the liver, is associated with decreasing FEV1 and exacerbated by smoking. n Hemochromatosis first affects the liver, then the pancreas with diabetes mellitus, the skin with bronze pigmentation, and iron deposition in the heart with restrictive cardiomyopathy and arrhythmias.