Describe the storage, synthetic, metabolic and excretory functions of the liver and to identify the physiological consequences

of hepatic disease
Liver is the biggest gland of the body, with most diverse functions. It is essential for life as total hepatectomy is always fatal within 24 hrs due to severe hypoglycaemia. Functions of the liver Metabolic, involving: Carbohydrate metabolism Glycogen metabolism Gluconeogenesis Glucolysis Protein and lipoprotein metabolism Aminoacid metabolism Turnover of proteins Protein synthesis (esp albumin, coagulation protein, carrier protein, lipoproteins) Lipid metabolism: Fatty acid oxidation Synthesis of cholesterol and phospholipids Production of ketoacids Biotransformation of drugs (eg cytochrome p450 oxidase system) Production and Excretion of bile Production of urea (krebs-henseleit cycle) Storage of vitamins A, D, Eand K, iron, copper and glycogen Endocrine functions: Synthesis of 25 hydroxycholecalciferol Inactivation of some hormones Synthesis of hormone pre-cursors Metabolism of steroid hormones Production of somatomedins Synthesis of erythropoietin (esp fetal liver but still 10% in adult liver) Immunological functions: phagocytic action of Kupffer cells Filtration of bacteria and the degradation of endotoxins Haematological functions associated with haemopoiesis in the fetus Blood reservoir Carbohydrate metabolism: Liver is important for the mentainance of blood glucose within narrow limits The uptake of glucose is energy independent. Glucokinase in the hepatocyte converts glucose to glucose 6 phosphate so that a low intracellular glucose is maintained allowing for continued diffusion. Outline of glucose utilization in liver:

Glycogen formation: Liver contains about 100g of glycogen Glycogen formation from glucose-6-phosphate proceeds via glucose-1-phosphate and uridine diphosphate glucose (UDPglucose). Two enzymes controlling glycogen in the liver: an anabolic enzyme, glycogen synthetase; and a catabolic enzyme, glycogen phosphorylase. Sources of Glycogen: mainly from lactate and to a lesser extent from pyruvate, glycerol and gluconeogenic amino acids, dietary glucose (~10% converted) Gluconeogenesis Hormones affecting gluconeogenesis: Facilitated by glucagon, which enhances the transport of alanine across the hepatocyte membrane and pyruvate across the mitochondrial membrane. Cortisol increases both peripheral tissue proteolysis and plasma conc. of amino acids, thus promoting gluconeogenesis. Insulin enhances glucose phosphorylation, activates glycogen synthetase, increases glycolysis, stimulates pyruvate dehydrogenase activity with increased acetyl coenzyme A (CoA) formation and inhibits glycogenolysis and gluconeogenesis. Perivenous hepatocytes are primarily responsible for glycolysis and the periportal cells for gluconeogenesis. Glycolysis: The breakdown of glucose to CO2 and water with the production of energy is called glycolysis.

Two pathways of glucose catabolism: Embden-Meyerhorf pathway: cleavage to trioses producing pyruvic acid and lactic acid Hexose monophosphate shunt: oxidation and decarboxylation to pentose The net energy gain from glycolysis is three molecules of ATP. Pyruvic acid enters the citric acid cycle by conversion to acetic acid with the loss of one molecule of CO2, The citric acid cycle generates 12 molecules of ATP for every molecule of acetic acid. In total, 38 molecules of ATP are produced by the aerobic breakdown of glucose to pyruvate and its incorporation into the citric acid cycle. Glycolysis produces acetyl CoA, which is used as a substrate for lipogenesis and subsequently the production of triglycerides. Also production of reduced nicotinamide adenine dinucleotide phosphate (NADPH) via the pentose phosphate pathway is required for microsomal hydroxylation of steroid hormones and biotransformation of drugs

Lipid metabolism: The liver has two main roles in lipid metabolism: (1) synthesis of fatty acids which are converted to triacylglycerol and very low-density lipoprotein (VLDL) (2) partial oxidation of fatty acids to ketone bodies

Figure: outline of pathway of fat utilization in the liver Lipoprotein lipases hydrolyse the chylomicrons producing free fatty acids that may be taken up by adipocytes for storage or metabolized within body tissues as an energy source. -0xidation of fats to acetyl coenzyme A occurs rapidly in the liver. Excess acetyl CoA is converted to acetoacetic acid, a highly soluble molecule that can be transported to other tissues where it can be reconverted to acetyl CoA and used for energy. The liver is also important for cholesterol metabolism, which is controlled by the enzyme hydroxymethylglutaryl CoA (HMG-CoA). About 80 % of the cholesterol

synthesized in the liver is converted to bile and the remainder is transported in the blood by lipoproteins. Bile production the liver produces about 1L of bile/day which passess into gall bladder where it is concentrated to about 1/5th of its volume Constituents of bile: protein, lipids, electrolytes, bile salts, bile pigment Pathway of bile metabolism:

The main functions of the bile salts: Emulsification of dietary fat, this being essential for fat absorption. Absorption of the fat-soluble vitamins, especially vitamins A, D, E and K. At the terminal ileum bile salts are reabsorbed by the apical sodium-dependent bile transporter. The reabsorbed bile salts are carried to the liver in the portal circulation, mostly bound to plasma proteins. (enterohepatic circulation) Bilirubin metabolism Haemoglobin is broken down in the retiruloendothelial system, particularly in the spleen. Haem is broken down by haem-oxygenase and NADPH-cytochrome P-450 to biliverdin. Biliverdin is then converted to bilirubin by a biliverdin reductase.

About 85 % of bilirubin is derived from the haem moiety of the red-cell haemoglobin. Bilirubin is bound to serum albumin and is transported to the liver. In the liver, the unbound bilirubin enters the hepatocyte where rapid uptake occurs with two binding proteins being involved. The bilirubin is conjugated with glucuronides by UDP glucuronyl transferase, rendering it water soluble, and the conjugate is then secreted in the bile. In the gut, conjugated bilirubin is broken down by bacteria to form urobilinogen, which then undergoes enterohepatic circulation and is excreted in the urine.

PROTEIN METABOLISM Role of liver: Removing amino acids from the blood for gluconeogenesis and protein synthesis. releases amino acids into blood for utilization by the peripheral tissues Breakdown of amino acids, removing the nitrogen as urea. Anabolic processes Albumin is synthesized in the liver at a rate of 120-300 mg/kg body weight per day. plasma albumin has a long half-life (20 days) it is a poor marker of acute liver damage. The liver also synthesizes 1, 2, globulins, all of which are important transport or binding proteins and also form the complement proteins Important site for the synthesis of haptoglobin (which binds to free haemoglobin), 1 anti-trypsin, 2 macroglobulin, antithrombin Ill, 1 acid glycoprotein and C-reactive protein. Vitamin K-dependent clotting factors (II, VII, IX, X) and some vitamin Kindependent factors (V, VIII, XI, XII and XIII) are synthesized in the liver.

Protein catabolism The rate of protein turnover in the liver is 10 days, which contrasts sharply with the rate of 180 days for muscle proteins. Amino acid degradation is by transamination, deamination and decarboxylation. Oxidative deamination breaks down surplus amino acids and releases energy. These reactions produce acetyl CoA, oxoglutarate, succinyl CoA etc which enter the citric acid cycle. Amino acids such as arginine, histidine, lysine, methionine, threonine, phenylalanine and tryptophan are degraded mainly in the liver

UREA SYNTHESIS The nitrogenous end product of amino acid degradation is ammonia

ammonia is toxic in concentrations greater 1ug/ml, and it is converted to urea by ornithine cycle in liver for excretion by the kidneys. Ornithine cycle, utilizes three ATP molecules per molecule of urea synthesized. About 30 g of urea is produced daily from 100 g of protein contained in the diet. As two hydrogen ions are produced for each molecule of urea synthesized, about 1000mmol of hydrogen ions are formed.

Creatine synthesis: Creatine is synthesized in liver from methionine, glycine and arginine In muscle, creatine is phosphorylated to form phosphocreatine, which forms a backup energy store for ATP production

Creatinine is formed from phosphocreatine and is excreted at a relatively constant rate in the urine

PHAGOCYTIC FUNCTIONS

Substances phagocytosed by Kupffer cells include bacteria, viruses, endotoxins, immune complexes, denatured albumin, thrombin, fibrinrinogen complexes and even tumour cells. The phagocytosed materials are then degraded by lysosomal enzymes. Endo-toxins derived from enteric bacteria are usually phagocytosed by the kupffer cells STORAGE FUNCTIONS The liver stores glycogen, triglycerides, vitamins (A, D, E, K, riboflavin, nicotinamide, pyridoxine, folic acid, B12) iron and copper. 4 months store of vitamin D 10 months store of vitamin A 12 months store of vitamin B12 Excess iron is taken up by liver cells where it combines with apoferritin to from ferritin. DRUG METABOLISM Biotransformation in the liver converts compounds to hydrophilic substances that may be readily eliminated either by the kidneys, or in bile. The biotransformation reactions are divided into two distinct phases: Phase I reactions (oxidation, reduction, hydrolysis): oxidative reactions catalysed by cytochrome P-450 (11types) located in the smooth endoplasmic reticulum. Reductase and hydrolase enzymes are mainly located in the cytoplasm Phase II reactions (glucuronidation, sulphation, acetylation): Conjugation reactions that occur primarily in the cytoplasm and produce more polar compounds. The clearance of a drug by the liver is influenced by a number of factors, including hepatic blood flow, plasma protein binding of the drug and hepatic enzyme activity.
Describe the laboratory assessment of liver function and hepatic failure

No one test enables the clinician to accurately assess the livers total functional capacity and hence battery is required. Liver function tests can be classified as follows: Tests based on detoxification and excretory functions Serum bilirubin Urine bilirubin Blood ammonia Serum enzymes Enzymes that reflect damage to hepatocytes: (aminotransferases) AST ALT

Enzymes that reflect cholestasis: Alkaline phosphatise 5-nucleotidase Gamma Glutamyl Transpeptidase (GGT)

Tests that measure biosynthetic function of the liver Serum albumin Serum globulins Coagulation factors

Serum bilirubin exists in two states: Unconjugated bilirubin indirect bilirubin insoluble in water and bound to albumin Conjugated bilirubin direct bilirubin water soluble and easily excreted in urine Normal value: normal total serum bilirubin conc. is 17 mol/L (1 mg/dL). Up to 30%, or 5.1 mol/L (0.3 mg/dL), of the total is direct-reacting (or conjugated) bilirubin. Isolated elevation of unconjugated bilirubin hemolytic disorders and in a number of genetic conditions such as Crigler-Najjar and Gilberts syndromes Conjugated hyperbilirubinemia implies liver or biliary tract disease. Since transport of conjugated bilirubin into bile canaliculli is the rate-limiting step in bilirubin metabolism, elevation of the conjugated fraction may be seen in any type of liver disease. Urine Bilirubin

Since unconjugated bilirubin is always bound to the albumin, any bilirubin found in the urine is conjugated bilirubin Presence of bilirubinuria implies the presence of liver disease.

Blood Ammonia Ammonia is produced in the body during normal protein metabolism and by intestinal bacteria, primarily those in the colon. The liver plays a role in the detoxification of ammonia by converting it to urea, which is excreted by the kidneys. Striated muscle also plays a role in detoxification of ammonia, which is combined with glutamic acid to form glutamine. Patients with advanced liver disease typically have significant muscle wasting, which likely contributes to hyperammonemia in these patients. Problems with the use of blood ammonia for detecting encephalopathy or for monitoring hepatic synthetic function: There is very poor correlation between either the presence or the degree of acute encephalopathy and elevation of blood ammonia Also a poor correlation of the blood serum ammonia and hepatic function. Enzymes that reflect damage to hepatocytes The aminotransferases (transaminases) are sensitive indicators of liver cell injury Most helpful in recognizing acute hepatocellular diseases such as hepatitis. Include the aspartate aminotransferase (AST) and the alanine aminotransferase (ALT). AST is found in the liver, cardiac muscle, skeletal muscle, kidneys, brain, pancreas, lungs, leukocytes, and erythrocytes in decreasing order of concentration. ALT is found primarily in the liver. These enzymes are released into the blood in greater amounts when there is damage to the liver cell membrane resulting in increased permeability.

Poor correlation between the degree of liver cell damage and the level of the aminotransferases. Thus, the absolute elevation of the aminotransferases is of no prognostic significance in acute hepatocellular disorders. Striking elevationsi.e., aminotransferases >1000 U/L occur almost exclusively in disorders associated with extensive hepatocellular injury such as (1) viral hepatitis, (2) ischemic liver injury (prolonged hypotension or acute heart failure), or (3) toxin or drug-induced liver injury. The pattern of the aminotransferase elevation can be helpful diagnostically: In most acute hepatocellular disorders, the ALT is higher than or equal to the AST. An AST:ALT ratio >2:1 is suggestive, while a ratio > 3:1 is highly suggestive of alcoholic liver disease. The AST in alcoholic liver disease is rarely > 300 U/L and the ALT is often normal. A low level of ALT in the serum is due to an alcohol-induced deficiency of pyridoxal phosphate. The aminotransferases are usually not greatly elevated in obstructive jaundice.

Enzymes that reflect cholestasis GGT elevation in serum is less specific for cholestasis than are elevations of alkaline phosphatase or 5-nucleotidase. The normal serum alkaline phosphatase consists of many distinct isoenzymes found in the liver, bone, placenta, and, less commonly, small intestine. Elevation of liver-derived alkaline phosphatase is not totally specific for cholestasis, and a less than threefold elevation can be seen in almost any type of liver disease. Alkaline phosphatase elevations greater than four times normal occur primarily in patients with cholestatic liver disorders, infiltrative liver diseases such as cancer, and bone conditions characterized by rapid bone turnover (e.g., Pagets disease). In the absence of jaundice or elevated aminotransferases, an elevated alkaline phosphatase of liver origin often, but

not always, suggests early cholestasis and, less often, hepatic infiltration by tumor or granulomata. Other conditions that cause isolated elevations of the alkaline phosphatase include Hodgkins disease, diabetes, hyperthyroidism, congestive heart failure, and inflammatory bowel disease Serum Albumin Synthesized exclusively by hepatocytes. Long half-life: 15 to 20 days, with approximately 4% degraded per day Not a good indicator of acute or mild hepatic dysfunction In hepatitis, albumin levels <3 g/dL should raise the possibility of chronic liver disease. Not specific for liver disease and may occur in protein malnutrition of any cause, as well as protein losing enteropathies, nephrotic syndrome, and chronic infections Serum Globulins alpha and beta globulins produced primarily in hepatocytes. Gamma globulins are increased in chronic liver disease, such as chronic hepatitis and cirrhosis. Cirrhotic liver fails to clear bacterial antigens that normally reach the liver through the hepatic circulation. Diffuse polyclonal increases in IgG levels are common in autoimmune hepatitis; increases >100% should alert the clinician to this possibility. Increases in the IgM levels are common in primary biliary cirrhosis, while increases in the IgA levels occur in alcoholic liver disease. Coagulation factors With the exception of factor VIII, the blood clotting factors are made exclusively in hepatocytes.

Because of their rapid turnover, measurement of the clotting factors is the single best acute measure of hepatic synthetic function and helpful in both the diagnosis and

assessing the prognosis of acute parenchymal liver disease.

Useful for this purpose is the serum prothrombin time, which collectively measures factors II, V, VII, and X. Biosynthesis of factors II, VII, IX, and X depends on vitamin K. The prothrombin time may be elevated in hepatitis and cirrhosis as well as in disorders that lead to vitamin K deficiency such as obstructive jaundice or fat malabsorption of any kind.

Describe the formation, composition of bile and the handling of bilirubin in the body

Describe the anatomical and physiological considerations in hepatic blood flow

See CVS notes Important add on points: Liver is susceptible to hypoxic injury because: 1. In zone 3, minimal vasodilatation or increase in extraction in response to decrease in flow

2. Portal vein flow is not regulated to liver needs 3. Pressure gradient for portal vein and IVC is very low Describe the portal circulation and its significance Anatomy: Measuring approximately 8 cm in adults, the hepatic portal vein is located in the right upper quadrant of the abdomen, originating behind the neck of the pancreas. In most individuals, the hepatic portal vein is formed by the union of the superior mesenteric vein and the splenic vein. Occasionally, the hepatic portal vein also directly communicates with the inferior mesenteric vein, although this is highly variable. Other tributaries of the hepatic portal vein include the cystic and gastric veins. Immediately before reaching the liver, the portal vein divides into right and left. It ramifies further, forming smaller venous branches and ultimately portal venules. Each portal venule courses alongside a hepatic arteriole and the two vessels form the vascular components of the portal triad. These vessels ultimately empty into the hepatic sinusoids to supply blood to the liver. Portacaval anastomoses The portal venous system has several anastomoses with the systemic venous system. In cases of portal hypertension these anastamoses may become engorged, dilated, or varicosed and subsequently rupture. Physiology The hepatic portal vein and hepatic arteries form the liver's dual blood supply. Approximately 75% of hepatic blood flow is derived from the hepatic portal vein, while the remainder is from the hepatic arteries. Unlike most veins, the hepatic portal vein does not drain into the heart. Rather, it is part of a portal venous system that delivers venous blood into another capillary system, namely the hepatic sinusoids of the liver. In carrying venous blood from the gastrointestinal tract to the liver, the hepatic portal vein accomplishes two tasks; namely, it supplies the liver with metabolic substrates and it ensures that substances ingested are first processed by the liver before reaching the systemic

circulation. After draining into the liver sinusoids, blood from the liver is drained by the hepatic vein. Role in disease Portal hypertension Increased blood pressure in the portal vein, called portal hypertension, is a major complication of liver disease, most commonly cirrhosis. Stigmata of portal hypertension include those of chronic liver disease: ascites, esophageal varices, spider nevi, caput medusae, and palmar erythema. Chances of bleeding increases when the portal pressure > 20 mmHg