Appetite

Give a general overview of liver?

The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions.
- The liver is necessary for survival.
- This organ plays a major role in metabolism.
- It lies below the diaphragm in the abdominal-pelvic region of the abdomen.
- It produces bile, an alkaline compound which aids in digestion.
- It does so via the emulsification of lipids.
- The liver’s highly specialized tissues regulate a wide variety of high-volume biochemical reactions.
- The reactions include the synthesis and breakdown of small and complex molecules that are necessary for normal vital functions.
- Medical terms related to the liver often start in hepato- or hepatic.
- This comes from the Greek word for liver, hēpar.

Functions of Liver
More than 500 vital functions have been identified with the liver. The functions include:
- Detoxification.
- Protein synthesis.
- Production of biochemicals that are necessary for digestion.
- Glycogen storage.
- Decomposition of red blood cells.
- Plasma protein synthesis.
- Hormone production.
- Production of bile for digestion.
- Production of certain proteins for blood plasma.
- Production of cholesterol and special proteins that help to carry fats through the body.
- Conversion of excess glucose into glycogen for storage.
- Regulation of blood levels of amino acids.
- These amino acids form the building blocks of proteins.
- Processing of hemoglobin – the liver stores iron.
- Conversion of poisonous ammonia to urea.
- Clearing the blood of drugs and other poisonous substances.
- Regulating blood clotting.
- Resisting infections by producing immune factors.
- Removing bacteria from the bloodstream.
- Liver breaks down harmful substances which are excreted into the bile or blood.
- Bile by-products enter the intestine and ultimately leave the body in the feces.

Liver Location
- The liver is located in the upper right-hand portion of abdominal cavity.
- This is beneath the diaphragm.
- And on top of her stomach, right kidney and intestines.
- Weight: The liver weighs about 2 pounds.

Regulation Process of the Liver
- The liver regulates most chemical levels in the blood.
- It excretes a product called bile.
- This helps to break down fats.
- It also prepares them for further digestion and absorption.

Lobes of the liver
- The liver consists of two main lobes.
- Both of these lobes are made up of thousands of lobules.
- These lobules are connected to small ducts.
- These connect with larger ducts to ultimately form the hepatic duct.

Blood flow and liver
- All of the blood leaving the stomach and intestines pass through the liver.
- The liver processes this blood.
- It breaks down the nutrients.
- The drugs present in the blood are broken into forms that are easier to use for the rest of the body.

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What are symptoms of primary sclerosing cholangitis?

Primary sclerosing cholangitis (PSC) is a chronic (lasting years and decades), progressive (worsening over time) disease of the bile ducts.
- This disease channelizes bile from the liver into the intestines.
- Bile is a watery liquid made by the cells of the liver that is important for digesting food in the intestine, particularly fat.
- This liquid also helps to get rid of the body of toxins.
- Liver cells secrete the bile they make into small canals within the liver.
- The bile flows through the canals and into larger collecting canals (ducts).
- The bile then flows within the intrahepatic bile ducts out of the liver and into the extrahepatic bile ducts.
- From the extrahepatic bile ducts, the bile flows into the intestine where the bile mixes with food.

In primary sclerosing cholangitis :
- The intrahepatic and extrahepatic bile ducts become inflamed,
- scarred and thickened (sclerotic),
- narrowed,
- finally obstructed.

Obstruction of the ducts can lead to:
- abdominal pain,
- itching,
- jaundice,
- infection in the bile ducts (cholangitis),
- liver scarring that leads to liver cirrhosis,
- liver failure.

Symptoms of primary sclerosing cholangitis:
- Most patients with early primary sclerosing cholangitis have no symptoms.
- The presence of primary sclerosing cholangitis is recognized only because of abnormally elevated blood levels of liver enzymes (particularly alkaline phosphatase levels).
- This is often recognized along with a routine physical examination.
Early symptoms of primary sclerosing cholangitis include
- Fatigue
- bodily itching (pruritus)

With the progress of the disease:
- Patients may develop jaundice (yellowing of skin and darkening of urine).
- Jaundice is due to the accumulation of bilirubin in the body.
- The bilirubin accumulates because it is not able to be eliminated in the bile.
- This is due to prolonged obstruction of the bile ducts.
- The accumulation of bilirubin turns the skin and whites of the eye (sclera) yellow.
- It may be due to accumulation of bile salts in the body.
- It is as a result of obstruction of the bile ducts.

As primary sclerosing cholangitis progresses, patients typically develop:
- Right upper abdominal pain,
- Fever,
- Fatigue,
- Pruritus
- Jaundice
- These patients also are at risk of developing primary sclerosing cholangitis complications.
- The patients with the autoimmune form of primary sclerosing cholangitis have more rapid symptoms of abdominal pain, jaundice and fever.

How is primary sclerosing cholangitis treated?

Primary sclerosing cholangitis (PSC) is a chronic (lasting years and decades), progressive (worsening over time) disease of the bile ducts.
- This disease channelizes bile from the liver into the intestines.
- Bile is a watery liquid made by the cells of the liver that is important for digesting food in the intestine, particularly fat.
- This liquid also helps to get rid of the body of toxins.
- Liver cells secrete the bile they make into small canals within the liver.
- The bile flows through the canals and into larger collecting canals (ducts).
- The bile then flows within the intrahepatic bile ducts out of the liver and into the extrahepatic bile ducts.
- From the extrahepatic bile ducts, the bile flows into the intestine where the bile mixes with food.

In primary sclerosing cholangitis :
- The intrahepatic and extrahepatic bile ducts become inflamed,
- scarred and thickened (sclerotic),
- narrowed,
- finally obstructed.

Obstruction of the ducts can lead to:
- abdominal pain,
- itching,
- jaundice,
- infection in the bile ducts (cholangitis),
- liver scarring that leads to liver cirrhosis,
- liver failure.

Diagnosis of primary sclerosing cholangitis includes:
- Blood tests
- Radiologic tests
- Colonoscopy

The treatment of primary sclerosing cholangitis includes:
- Cholestyramine (Questran) or rifampin(Rifadin) to diminish itching.
- Antibiotics for infection, specifically cholangitis.
- Vitamin D and calcium to prevent bone loss (osteoporosis).
- Medications such as ursodiol (UDCA) to retard the progression of primary sclerosing cholangitis.
- ERCP with balloon dilatation.
- Stenting (a procedure in which the bile ducts are stretched open) for primary sclerosing cholangitis patients with dominant extra-hepatic duct strictures.
- Liver transplantation for patients with advanced cirrhosis.

Medications
- Ursodiol (UDCA),
- Prednisone,
- Methotrexate(Rheumatrex, Trexall),
- Colchicine,
- 6-mercaptopurine,
- Tacrolimus (Prograf),
- Cyclosporine (Neoral, Gengraf)

UDCA
- Ursodiol (UDCA) is a bile acid.
- This is given orally and replaces other bile acids in the body.
- UDCA is believed to protect against damaging effects of other bile acids on the liver cells.
- It also can induce formation of antioxidants.
- UDCA is the most extensively studied medication for primary sclerosing cholangitis.
- Its standard doses are15 mg/kg/day.
- It has been shown to improve fatigue, and improve blood levels of liver enzymes in these patients.
- Higher doses (20-30 mg/kg/day) UDCA has been shown to improve blood liver enzymes.
- It also decreases bile duct inflammation, and decrease liver scarring.
- UDCA is safe and well tolerated.
- It may improve bile duct disease and retard the development of liver cirrhosis.
- UDCA may decrease colon cancer risk in patients with both primary sclerosing cholangitis and chronic ulcerative colitis.

Treatment of dominant strictures
- Dominant strictures are major narrowing in the extrahepatic bile ducts.
- Dominant strictures of the extrahepatic bile ducts occur in 7%-20% of primary sclerosing cholangitis patients.
- ERCP and balloon dilatation (stretching) of the stricture can improve symptoms and abnormal blood levels of liver enzymes and bilirubin.
- Successful dilatation of dominant strictures decreases the risk of developing cholangitis.
- ERCP and dilatation of dominant strictures should be done in centers with highly experienced physicians.
- In ERCP, doctors often also perform brush cytology of the dominant strictures to exclude cholangiocarcinoma.
- Surgery is another treatment for dominant extrahepatic strictures.
- Surgical resection of the stricture followed by creation of a choledocho-jejunostomy which is an artificial passage for bile formed by attaching the bile duct from above the stricture directly into the small intestine.
- This can improve symptoms, delay liver transplantation, and lower the risk of cholangiocarcinoma.

Liver transplantation
The reasons for liver transplant in primary sclerosing cholangitis patients are similar to those in other forms of end-stage liver disease. They are:
- Internal bleeding due to rupture of esophageal varices.
- Severe ascites that are refractory to medical treatment.
- Frequent episodes of bacterial cholangitis.
- Hepatic encephalopathy.