Hepatobiliary System Anatomy and Physiology PDF

Hepatobilliary System Anatomi dan Fisiologi Dr. Elton Fredy Kalvari.,Sp.PK ANATOMI HEPAR 2  The largest gland in Live the body. r Weighs approximately 1500 g. (2.5% of adult body weight). Lies mainly in: Epigastric Right...

Hepatobilliary System Anatomi dan Fisiologi Dr. Elton Fredy Kalvari.,Sp.PK ANATOMI HEPAR 2  The largest gland in Live the body. r Weighs approximately 1500 g. (2.5% of adult body weight). Lies mainly in: Epigastric Right hypochondrium, Epigastrium and Left hypochondrium. Protected by the thoracic cage and diaphragm, lies deep to Hypogastric ribs 7-11 on the right side and crosses the midline toward the left nipple. 3  Anterior: 1. Diaphragm, Relations of 2. Right and left costal Liver margins, 3. Right and left pleura, 4. Right and left lungs, 5. Xiphoid process, 6. Anterior abdominal wall. Posterior: 1. Diaphragm, 2. Right kidney, 3. Right suprarenal land, 4. Right colic (hepatic ) flexure, 5. Duodenum, 6. Gallbladder, 7. Inferior vena cava, 8. Esophagus and 4  Peritoneal  The liver is completely Reflection Superior Diaphragm surrounded by a fibrous layer of capsule. coronar Peritoneum y  It is partially covered by ligament peritoneum. Inferior Anterior layer of abdominal  The bare area of the liver coronar wall y is an area lying on the ligament diaphragmatic surface Posterior abdominal (on posterior surface of right lobe) where wall there is no peritoneum between the liver and the diaphragm.  Boundaries of Bare area:  Anterior: Superior layer of coronary ligament.  Posterior: Other bare areas Inferior of the layer liverof coronary ligament. include:  Right: 1. Porta hepatis, Right triangular 2. ligaments. Gall bladder fossa.& 5  The liver has two surfaces: Surfaces A convex diaphragmatic surface, of Liver (superior, anterior and right lateral surface). A relatively flat or even concave visceral surface. (posteroinferior). 6  Diaphragmat ic Surface The convex upper, anterior and right lateral surface is smooth and molded to the undersurface of the domes of the diaphragm. The diaphragm separates the liver from pleurae, base of both lungs, pericardium, and heart. It is covered with visceral peritoneum, except posteriorly in the bare area of the liver, where it 7 lies in direct contact with  Visceral The visceral or the Surface posteroinferior surface, is related to the abdominal viscera. It is covered with peritoneum, except 3 areas: Gallbladder fossa, Porta hepatis. I.V.C groove. It bears multiple 8  Two sagittally oriented Fiss fissures, linked centrally by transverse porta ures hepatis, form the letter H on the visceral surface. Ligamentum Inferior The left fissure is the venosum vena cava continuous Anteriorly groove by theformed: fissure for the round ligament , (teres). Posteriorly by the fissure for the ligamentum venosum. The right fissure is the continuous groove Anteriorly by formed: gallbladder fossa. Round Porta Gall Posteriorly by the ligament hepatis bladder groove for the inferior vena cava. 9  Relations of Visceral Surface of the Liver The visceral surface is related 1. to: Stomach. 2. Esophagus. 7 1 3. Lesser 2 omentum. 6 4. Gallbladder. 3 5. Right 4 colic flexure 5 6. Right kidney. 7. Right 1 0  Porta Hepatis (Hilum of A transverse fissure on the the Liver) Structures passing through the visceral surface which lies porta hepatis include: between caudate and quadrate Right and left hepatic lobes. ducts. Its margins is attached to the Right and left branches of upper part of lesser omentum the hepatic artery. Right and left branches of the C portal vein. Sympathetic and parasympathetic fibers. A few hepatic lymph nodes Q lie here; they drain the liver and gallbladder and send groovetheir for efferent 1 vessels IVC. to the celiac 1 Ligaments of the Liver Falciform ligament It is a two-layered fold of the peritoneum, connects the liver to the diaphragm; anterior abdominal wall & umbilicus. Its sickle-shaped free margin contains the ligamentum teres (round Ligament) of liver. It is obliterated umbilical vein, which carried oxygenated blood from the placenta to the fetus. Ligamentum venosum Ligamentum venosum IVC It is the fibrous remnant of fetal ductus venosus, which Porta Hepatis shunted blood from the Round ligament of liver umbilical vein to the IVC in intrauterine fetal life. GB 1 2  Lobes of The Liver The liver is divided into a large right lobe and a small left lobe by the attachment of the falciform ligament. The right lobe is further divided into a quadrate lobe and a caudate lobe by : Gallbladder, Fissure for the ligamentum teres, Groove for inferior vena cava, Caudate Fissure for ligamentum venosum. process The caudate lobe is connected to the right lobe by the caudate Caudate lobe process. Left lobe The quadrate and caudate lobes R are a functional part of the left i g lobe of the liver. (because of its h t supplying with left branches of C.H.Duct; Portal v.& Hepatic Ar.). l o b Sirkulasi pendarahan hepar 14  Blood Circulation through the Liver The blood vessels conveying blood to the liver are: Hepatic artery (30%) Portal vein (70%). The hepatic artery brings oxygenated blood to the liver. The portal vein brings venous blood rich in the end products of digestion, which have The venous blood is been absorbed from the drained by gastrointestinal tract. 2 hepatic veins which drain into the inferior  Blood Circulation through the Liver At or close to the porta The hepatic veins, are hepatis, the hepatic artery intersegmental in their and portal vein terminate distribution and function, by dividing into right and draining parts of adjacent left primary branches to segments. the corresponding lobe of The attachment of these veins the liver. to the IVC helps to hold the Within the liver, the primary liver in position. (The peritoneal branches divide to give ligaments and the tone of the secondary and tertiary abdominal muscles play a branches to supply the minor role in liver support. 1 hepatic segments  Lymph Drainage The liver produces a large amount of lymph—about one third to one half of all body lymph. The lymph vessels leave the liver to enter several lymph nodes in the porta hepatis. The efferent vessels pass to the celiac lymph nodes. A few vessels pass from the bare area of the liver through the diaphragm to the posterior mediastinal lymph nodes. Nerve Supply Sympathetic and parasympathetic nerves from : The celiac plexus and The anterior vagal trunk gives rise to a large hepatic branch, which passes directly to the liver.  Portal-Systemic (Portocaval) ItAnastomosis is a specific type of anastomosis that occurs between the veins of portal circulation and those of systemic circulation. In portal hypertension, these anastomosis open and form venous dilatation called varices. Sites: A. Esophagus (lower end). B. Anal canal (upper end). C. Paraumbilical  Sple Largest single mass en of lymphoid tissue. Located in the left It is separated hypochondrium, deepfrom the ribs by the diaphragm and th to the ribs 9, 10 & 11. costodiaphragmatic pleural recess (space in pleural cavity). Long Itaxis lies along ovoid the shaft of thein is 10shape th with a notched anterior border. Lower pole extends forward as far as the midaxillary rib. line. Normal size spleen can not be palpated on clinical examination. 1 8  Surfaces: Diaphragmatic surface: It is convexly curved to fit the concavity of the diaphragm and curved bodies of the adjacent ribs. Visceral surface: Related to viscera. Borders: The anterior and superior borders are sharp. Anterior border is notched. 1 9  Peritoneal Reflections/Ligaments Spleen is completely surrounded by peritoneum which passes from its hilus as: Gastrosplenic ligament to the greater curvature of stomach, carrying: Short gastric vessels, Left gastroepiploic vessels. Lienorenal ligament 2 to the front of left 0  Relatio ns Anteriorly: (visceral surface ): Stomach, Tail of pancreas, Left colic flexure & Left kidney. Posteriorly: Diaphragm, that separates it from, Left pleura (left costo- diaphragmatic recess) Left lung & 9, 10 & 11 ribs. Inferiorly: 2 1  Arterial Splenic artery Supply Largest branch of the celiac artery. Runs a tortuous course along the upper border of the pancreas. Passes within the lienorenal ligament. Divides into 4-5 branches, which 2 enter the spleen 2  Venous Drainage Splenic vein Leaves the hilus. Runs behind the tail & body of the pancreas. Reaches behind the neck of pancreas, where it joins the superior mesenteric S.M.V vein to form the portal vein. Tributaries: Short gastric vein. left gastroepiploic vein. 2 Pancreatic 3  Lymph Drainage Lymphatics emerge from the hilus and drain into several nodes lying at the hilum. Efferents from the hilar nodes pass along the course of splenic artery, and drain into the celiac lymph nodes. Nerve Supply Derived from the celiac plexus. Are distributed mainly along branches of splenic artery, and are vasomotor in function. Mikroskopis Hepar (HISTOLOGI) 26 Hepatosit Hepatosit  Sel poligonal ukuran 20-30 µmeter Celah di antara lempeng ini mengandung kapiler yaitu sinusoid hati Cairan darah dengan mudah akan menerobos dinding endotel dan berkontak dengan dinding sel, sehingga memudahkan pertukaran makromolekul dari lumen sinusoid ke hepatosit dan sebaliknya. Selain sel-sel endotel, sinusoid 27 FISIOLOGI HEPAR 28 FISIOLOGIS HEPAR 1.Metabolisme Karbohidrat, protein, lemak 2.Menghasilkan enzim hepar 3.Pemecahan eritrosit dan konjugasi bilirubin 4.Detoksifikasi 5.Filtrasi dan penyimpanan darah 6.Regenerasi 7.Produksi garam empedu 29 30 31 32 33 Klinis Pemeriksaan SGPT > spesifik dibandingkan SGOT. Contoh : 1. SGOT > SGPT  kerusakan otot/organ lain (jantung dll) 2. SGPT > SGOT  kelainan Hepar (hepatitis, abses hepar) 34 Metabolisme Karbohidrat 35 Metabolisme protein 36 Metabolisme lipid 37 Metabolisme Bilirubin Bilirubin: 1. Bilirubin direct/ terkonjugasi 2. Bilirubin indirect/ tidak terkonjugasi 3. Bilirubin total Urine  Urobilinogen Feses  stercobilinogen 38 39 Ikterik Ikterik 1.Ikterik pre hepatik (Indirek > Direk) 2.Ikterik hepatik (Direk = Indirek) 3.Ikterik post hepatik (Direk > Indirek) 40 Nilai Normal Hipoalbuminem ia Hiperbilir ubinemia 41 Nilai Normal 42 Soal Kasus Neonatus usia 8 hari, keluhan Kuning seluruh 1 badan sejak usia 2 hari. Orang tua mengaku 1 bayi jarang mau minum ASI. Laboratorium : DR (N), Bil total 18,5 mg/dL, Bil Direk 4,3 mg/dL, Bil Indirek 14,2 mg/dL Ekspertise Laboratorium : Hiperbilirubinemia pre hepatal Seorang wanita usia 45 tahun datang dengan keluhan demam, kulit pasien juga kuning sejak 1 minggu yll. Pasien mengeluhkan mual dan muntah, BAK warna kuning teh, BAB warna normal. 2 Pasien memiliki riwayat sering jajan makanan diluar Laboratorium : DR (N), SGOT : 1483; SGPT : 1582; Bil total 0,8 mg/dL, Bil Direk 0,5 mg/dL, Bil Indirek 0,4 mg/dL, anti HAV (+), Hbsag (-) Total/direk/indirek : 9,3/ 4,3 / 5,0 Ekspertise Laboratorium : Hiperbilirubinemia hepatal Stuktur Vesica Fellea  ALKALI FOSFATASE (ALP) Ditemukan di liver (terutama di traktus bilier), tulang, usus dan plasenta Konsentrasinya naik pada kasus-kasus obstruksi dan penyakit infiltrative (mis; batu atau tumor)  ALP normal ditemukan pada anak2 fase pertumbuhan.  kecurigaan keadaan tdk normal (mis. Rickets) tanpa  GGT Zinc adalah koenzyme dari AP-catalyzed reactions  kronis dari AP, kemungkinan dpt disebabkan krn  kadar zinc GAMMA GLUTAMYL TRANSFERASE (GGT) GGT didapatkan terutama di small bile ductule epithelium of the liver dan hepatocytes. Namun juga ditemukan di pancreas, lien, otak, mammae, usus halus, prostat dan ginjal  GGT tidak spesifik menunjukkan adanya liver disease.  GGT dan ALP mengetahui penyebab kenaikan ALP Aktivitas GGT berubah sejalan dengan pertambahan usia pada neonates nilainya 8x dewasa  GGT respon terapi anti kejang perlu  ALBUMI N Disintesis di endoplasmic reticulum kasar di hepatosit  kadar albumin  produksi liver pada penyakit hati stadium akhir (kronik)  kadar albumin malnutrisi, penyakit ginjal (mekanisme yang berbeda)  AMONIA Produksi ammonia berasal dari pemecahan protein oleh bakteri di usus Liver memegang peran untuk membersihkan ammonia  fungsi hati  klirens ammonia  kadar dalam darah encephalopathy Ada hubungan antara kadar ammonia dengan derajat encephalopathy Pemeriksaan lab sulit karena ammonia mudah menguap harus segera dikirim ke lab dalam es (suhu 40C) LACTATE DEHYDROGENASE LD1 & LD2 terutama di otot jantung, ginjal dan eritrosit LD4 & LD5 terutama di hati dan otot skelet 5-NUCLEOTIDASE/ 5-NT Terdapat di selaput sinusoid dan saluran bilier Menguatkan peningkatan ALP karena gangguan hati TERIMA KASIH