5 The Liver
Anatomy
General Facts
Macroscopic subdivision of the liver is into:
left and right lobe
caudate lobe
quadrate lobe
The liver is covered by peritoneum, except for the “bare area,” which is directly connected to the diaphragm. It weighs about 1.5–2.5 kg, although the effective weight is only about 400 g because the gravitational force of the thoracic organs (vacuum in the thorax), on the one hand, and the abdominal organ pressure, on the other, reduce it.
Blood flow through the liver is about 1.5 L/min.
Location
The liver is located in the right upper abdomen below the diaphragm.
Cranial Boundary
anterior: fifth intercostal space (ICS) on the right to the sixth ICS on the left
on the left side; extending roughly to a vertical line through the body via the center of the left inguinal ligament
posterior: T8-T9
Caudal Boundary
anterior: lower costal arch ascending from right to left past the center line
posterior: T11-T12
Topographic Relationships
dorsolateral and anterior on the right: abdominal wall and ribs 8–11
diaphragm
gallbladder
hepatic/cystic/common bile duct
inferior vena cava
portal vein
proper hepatic artery
esophagus
stomach
right adrenal gland
right kidney
duodenum: superior and descending part
right colic flexure
indirect contact to pleura, lung, pericardium, and heart
Attachments/Suspensions
pressure in the abdominal cavity
turgor
coronary ligament
left and right triangular ligament
falciform ligament
round ligament of the liver
lesser omentum (hepatoduodenal and hepatogastric ligaments)
hepatorenal ligament
inferior vena cava
Circulation
Arterial
Hepatic artery proper from the celiac trunk.
Venous
portal vein (collects blood from the spleen, distal esophagus, stomach, small intestine, colon, upper rectum, pancreas, and gallbladder)
inferior vena cava
Lymph Drainage
The lymphatic vessels run parallel to the blood vessels.
Innervation
sympathetic nervous system from T7 to T10 via the greater and lesser splanchnic nerve
switchover in the celiac plexus
vagus nerve
The liver capsule is innervated via the phrenic nerve (C3–C5).
Organ Clock
Maximal time: 1–3a.m.
Minimal time: 1–3p.m.
Organ-Tooth Interrelationship
Organs and teeth have a relationship to each other that is comparable to the system of connective tissue zones on the back or the foot reflex zones. Disorders or even just functional disturbances of an organ are reflected in the weakening of a tooth, the adjoining gum, or the nearby mucous membranes. The tooth can hurt without a corresponding lesion being present. Likewise, it is possible that the tooth, gums, or mucous membranes are inflamed.
Similarly, a damaged tooth also affects the corresponding organ. This can reach the point where an organic disturbance can be cured only after the tooth or gums have healed up.
For osteopaths, it is therefore important to know the interrelationships of each organ and tooth, and to take countermeasures against misdiagnoses and mistreatments early on. For this reason, the tooth associated with the organ is identified here. In this context, always remember that the adjoining gum and mucous membranes are part of this relationship as well.
Canine tooth in the upper jaw on both sides
Movement Physiology according to Barral
Mobility
The liver displays mobility in three planes, as follows.
Frontal Plane
During inhalation, the diaphragm leads the lateral parts of the liver inferiorly to medially. Looked at from the front, the liver rotates in a counterclockwise direction.
The axis of movement is a sagittotransverse axis through the left triangular ligament.
Sagittal Plane
In this plane, the liver tilts with the cranial parts anteriorly while at the same time shifting the caudal edge posteriorly. The frontotransverse axis of movement runs approximately through the coronary ligament.
Transverse Plane
The liver carries out a leftward rotation along a frontosagittal axis through the inferior vena cava as an approximate anatomic landmark. Looked at from above, this is a counterclockwise rotation.
Motility
The motions of motility correspond in direction and axis to those of mobility.
Physiology
Metabolic Functions of the Liver
lipolysis (metabolism of fatty acids up to coenzyme A)
production of ketone bodies from fat, e.g., in hunger periods or in badly adjusted diabetes mellitus with bad breath smelling of acetone
lipogenesis (production of triglycerides)
glycogenesis and glycogenolysis
gluconeogenesis (synthesis of glucose from lactate or amino acids)
formation of proteins from amino acids (e.g., albumin, globulin, fibrinogen, prothrombin, vitamin K-dependent coagulation factors)
breakdown of proteins, e.g., estrogen
production of urea from brain—toxic ammonia, the product of protein breakdown
breakdown and excretion of exogenous toxins, e.g., medications
storage organ, e.g., for glycogen, or vitamin A or B12
production and excretion of bile
synthesis and processing of cholesterol
location of blood production up to the sixth fetal month
The liver metabolizes all three basic elements of food (carbohydrates, fats, and proteins) in different ways, therefore playing a dominant role in intermediary metabolism.
Pathologies
Symptoms that Require Medical Clarification
Icterus
Recurrent upper abdominal complaints
Fever of uncertain origin
Acute inflammation
Cachexia
Icterus
Definition. The deposition of bilirubin causes a yellow coloration in blood plasma and connective tissue. With regard to connective tissue, the sclerae turn yellow first, followed by the skin. This phenomenon occurs when the concentration of bilirubin in the plasma exceeds 0.30.5 mmol/L.
Types
Prehepatic icterus: the rate of erythrocyte breakdown is increased. With the liver functioning normally, the amount of accumulating hemoglobin is greater than the liver’s capacity to process it. A possible cause is a congenital hemolytic anemia, e.g., thalassemia.
Intrahepatic icterus: the liver cells are damaged and lose their ability to break down hemoglobin. A possible cause is acute hepatitis.
Posthepatic icterus (obstructive icterus): in this form of icterus, the bile ducts are compromised. They can be blocked both within the liver, e.g., in a cirrhosis, and outside the liver by a tumor or gallstones in the common bile duct. Additional causes are:
– fatty liver
– hepatitis
– papillary stenosis
– cholangitis
– pancreatic head carcinoma
– pancreatitis
Acute Hepatitis
Definition. Infection of the body with a pathogenic virus that affects the liver cells.
Hepatitis A
Infection. The hepatitis A virus (HAV) is most often transmitted fecally or orally, although sexual or perinatal transmission is also possible. One risk factor is traveling to southern vacation areas: even in Europe, a clear north-south divide exists in the spread of hepatitis A infection.
Clinical. The period of incubation is 14–40 days. Most frequently, we see a prodromal stage with flulike and gastrointestinal symptoms (feeling of fullness, lack of appetite, nausea, diarrhea, fever, joint pain). This is followed by the organ manifestation with icterus, sensitivity to pressure in the liver, signs of liver cell degradation, and in a fifth of all cases splenomegaly.
The course of the disease is an average of 4–8 weeks; life-long immunity remains. This type has neither virus carriers nor chronification.
Hepatitis B
Infection. In the case of the hepatitis B virus (HBV), the path of transmission is parenteral (plus needle puncture wounds), sexual contact, or perinatal. Worldwide, about 200 million people are infected.
Clinical. The period of incubation is 60–120 days. A nonspecific preliminary stage can be missing; organ manifestation runs a much more serious and drawn-out course than in hepatitis A. Nevertheless, most hepatitis B infections are asymptomatic.
In 5–15% of infections, the acute form turns into the chronic form, which can lead to cirrhosis of the liver or a primary liver cell carcinoma. The disease takes a lethal course in 2–15% of all cases, but there are also healthy and infectious virus carriers.
Active immunization is advised.
Hepatitis D
Infection. The delta virus is attached to the B virus and utilizes parts of the HBV for its own reproduction. The path of infection is parenteral or by sexual contact. Endemic regions are southern Italy, the Balkans, the Near East, Africa, and South America.
Clinical. The period of incubation for simultaneous infection with HBV is 12–15 weeks. If a patient with persistent HBV is infected, the incubation period is clearly shorter, around 3 weeks.
The infection entails a serious negative effect on the liver, and not uncommonly also liver failure. Approximately 80% of hepatitis D virus (HDV) infections become chronic.
Protection against this infection is achieved by immunization against HBV.
Hepatitis C
Infection. The hepatitis C virus (HCV) is spread via injection or sexual transmission. It is found in 0.5–1.5% of all blood donors. Anti-HCV is clearly more common in people who have experienced an HBV infection.
Clinical. The period of incubation is 5–12 weeks. Asymptomatic courses are possible. Nevertheless, 50% of infections take a chronic course, and transition to cirrhosis or hepatocellular carcinoma is not uncommon.
There is no immunization.
Hepatitis E
Infection. The path of transmission for the hepatitis E virus (HEV) is fecal-oral. In developing countries, it is held responsible for epidemics of HEV infection.
Clinical. The course is identical to that of hepatitis A. There are no chronic courses or healthy virus carriers.
Women who become infected with HEV in the last trimester of pregnancy die in about 25% of cases.
Chronic Hepatitis
Definition
This condition refers to inflammatory liver disorders that persist for 6 months or longer without improvement.
Causes
HBV infection
HCV infection
HDV infection
autoimmune hepatitis
toxins (alcohol, medications)
Clinical. We distinguish between a persistent and an aggressive type. The persistent type is marked by nonspecific symptoms such as fatigue, weight loss, and diffuse upper abdominal complaints. The prognosis is favorable.
Aggressive chronic hepatitis manifests in a disease progression with not only nonspecific symptoms but also signs of liver cirrhosis, e.g., esophageal varices.
Fatty Liver
Definition. Fatty liver refers to an increase of fat deposits in the liver cells. If more than 50% of the cells are affected, we talk about a fatty liver. If less than 50% of cells are affected, we call the condition fatty degeneration of the liver.
Causes
alcohol abuse
adiposity
diabetes mellitus
pregnancy
toxins, e.g., poisonous mushrooms
Clinical. In most cases, hepatomegaly manifests with no complaints. The symptoms depend on the cause.
Liver Damage from Alcohol
Definition. Toxic effect on the liver as a result of excess alcohol or alcohol abuse.
Clinical
fatty liver
steatosis hepatitis or acute alcohol hepatitis with signs of liver insufficiency to the point of liver failure with:
– pressure pain in the liver
– nausea, and also weight loss
– fever
– icterus
– ascites
– hepatosplenomegaly
– encephalopathy
alcoholic liver cirrhosis
Cirrhosis of the Liver
Definition. Irreversible change in normal liver tissue with fibrosis and destruction of the physiologic microscopic lobe structure.
Causes
alcohol
HBV, HCV, HDV
medications
cystic fibrosis
chronic right cardiac insufficiency
Clinical. Liver insufficiency with:
structural tissue change: enlargement of the liver with hardening and bumpy surface (the liver shrinks terminally) and hypoperfusion of the liver
icterus
hepatic encephalopathy
ascites and ankle edema (albumin deficiency)
anemia
a bleeding tendency
Estrogen dominance with:
spider angioma
men with loss of chest hair, abdominal baldness, testicular atrophy
palmar erythema
gynecomastia
Portal hypertension with:
hypersplenism with bone marrow changes and pancytopenia and hemorrhagic diathesis
splenomegaly
esophageal varices
caput medusae
external hemorrhoids
ascites
General symptoms:
fatigue
reduced productivity
nonspecific upper abdominal complaints
cachexia
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