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1. WelcomeTo The Functions of the Liver and Liver Cancer Tutorial Alverno College 2008 Sarah Arvelo Directions andObjectives

2. The Functions of the Liver and Liver Cancer Directions Next Page Please click the buttons that contain black text and are outlined in black to move through the tutorial. Information will be provided on the functions of the liver, normal lab values, as well as signs and symptoms caused by a dysfunctional liver. The learner will be able to test their new knowledge through questions given throughout this exercise. When a question appears click on the correct answer. To get started click the button on the right.

3. The Functions of the Liver and Liver Cancer Objectives Main Menu Learn and apply knowledge about the functions of the liver, i.e., labs, signs, symptoms and nursing assessment. Learn and apply knowledge about the symptoms produced by liver cancer and what labs may be affected. Learner will be able to verbalize a few treatments for liver cancer and how the TP53 gene plays a role in its effectiveness.

4. Liver Functions and Pathology Anatomyand Physiology Menu Pathology Menu You will find information about the function of the liver in this section. You will find information about abnormals and information on liver cancer in this section. Case Study DirectionsPage Image from Microsoft clip art References

5. Anatomy and Physiology Anatomy Physiology Labs NursingAssessment of the Liver Image from Microsoft clip art End Show Liver Functions and Pathology Menu

6. Anatomy In this section you will find information on the basic anatomy of the liver. Click below to start. Anatomy and Physiology Menu Next Anatomy Page

7. Anatomy of the Liver The liver is covered in the Gilsson’s capsule made of a fibroelastic material. Diaphragm Gallbladder Hepatic Duct Cystic Duct Common Bile Duct Duodenum Next Anatomy Page Lopez, E.B., 2008. Used with Permission.

8. Anatomy Bile is produced by the hepatocytes and is where 75% of LDL is found. Bile moves through the liver into the duodenum of the intestine. Next Anatomy Page Hepatobiliary Tree - intrahepatic and extrahepatic duct. Common Bile Duct - formed by the cystic and hepatic ducts. Both ducts lead to the duodenum. Bile Canalculi - lie between hepatocytes. Sphincter of Oddi - tissue that regulates the flow of bile.

9. Anatomy The liver is 3 lbs. and the largest visceral organ in the body. Click here for the answer. The large right lobe and small left lobe. Click here for the answer. The caudate and quadrate lobes. Click here for the answer. Next Anatomy Page The hepatic artery and portal vein. Click here for the answer. How big is the liver? The liver has two lobes. The visceral surface also has two lobes. The liver has a dual blood supply.

10. Anatomy Due to this structure, hepatic cells are exposed to blood that travels through the sinusoid. Next AnatomyPage Lobules - there are 50,000 - 100,000 lobules in the liver. Lobules empty into a central vein that connects to the hepatic vein. Sinusoids - are hepatic cells that form a plate like structure that branch off the central vein and extend to the lobule.

11. Anatomy What do these cells do? Image from Microsoft Clip art They remove defective blood cells, bacteria, and foreign material from portal blood. They also remove enteric bacilli from blood in from the intestine. They filter blood. Next Anatomy Page Kupffer’s cells line the venous sinusoids.

12. Anatomy Bile empties into the bile canaliculi. The hepatocytes produce bile. The Sphincter of Oddi opens. Bile enters the hepatobiliary tree. STEP1 STEP 2 STEP 3 STEP 4 STEP5 STEP 6 STEP 7 Bile flows through the common bile duct. Bile empties into the duodenum. If the sphincter is closed the bile moves back into the common bile duct and the gallbladder. Click on each step to organize the flow of bile. Next Page

13. The Flow of Bile 1. Hepatocytes produce bile. 2. Bile empties into the bile canaliculi. 3. Bile enters the hepatobiliary tree. 6. If the sphincter is closed the bile moves back into the common bile duct and the gallbladder. 4. The Sphincter of Oddi opens. 5. Bile flows through the common bile duct. 7. Bile empties into the duodenum. Anatomy and Physiology Menu

14. Physiology In the following section you will find information on the different functions of the liver. Physiology Menu

15. Physiology Bilirubin Elimination Bile Production Carbohydrate Fat/Lipids Hormones/Drugs Protein Synthesisof Clotting Factors Anatomy and Physiology Menu End Show

16. Nursing Assessment of the Liver LiverSpan FluidWave TestYourKnowledge ScratchTest PalpatingtheLiver Anatomy and Physiology Menu The nursing assessment of the liver includes the entire abdominal assessment. This tutorial will only focus on the specific assessment of the liver. CLICK ON THE ASSESSMENT TO FIND OUT MORE.

17. Abnormal Assessent Portal Obstruction, Cirrhosis, High Obstruction of Inferior Vena Cava and Lymphocytic Leukemia Enlarged liver noted with palpation. Possible Abnormal Assessment signs that need further investigation. Click to find out the possible cause Bulging flanks when supine. Taut skin. Ascites Hepatitis PainintheRUQ. Cirrhosis, Metastatic Cancer, Syphilis Enlarged nodular liver noted with palpation. Peritoneal friction rub over lower right rib cage. Tumor Localized distention. Abscess or Metastatic Tumor Pathology of the Liver Menu

18. Liver Span STEP 1 PERCUSSION: Start at the area of lung resonance until a dull sound is heard (mark this spot). STEP 2 Start at abdominal tympany up until dull sounds are heard (mark this spot). NEXT NursingAssessment Menu Back to Pictures

19. Liver Span Finding the upper border of the liver. 2 1 Images from Sarah Arvelo Next Page Liver Span 3

20. Liver Span 5 4 Images from Sarah Arvelo Measure between your marks, to find the border of the liver. Next Page Liver Span 6

21. Liver Span Images from Sarah Arvelo Use a tape measure to compare. 9-12CM (Normal Liver Span) Next Page Liver Span The bottom border can extend slightly past the costal margin.

22. Palpating the Liver Step 2 Place right hand in the RUQ. Fingers should be pointed toward patient's head. Step 1 Place left hand under patient’s back. Step 3 Push deeply down and under the right costal margin. Step 4 Have the patient take a deep breath. Back to Pictures Nursing Assessment Menu

23. Palpating The Liver Images from Sarah Arvelo Next Page Palpating the Liver 1 2 4 3

24. The Scratch Test STEP 2 Start RLQ scratch. Make short strokes over abdomen toward liver. Back to Pictures STEP 1 Place stethoscope over the liver. Next Nursing Assessment Menu THE BORDER IS FOUND WHEN THE SCRATCHING IS MAGNIFIED. When the abdomen is distended or the muscles are tense the examiner can perform the scratch test to determine borders.

25. Scratch Test 1 2 Images from Sarah Arvelo Next Page Scratch Test 3

26. Fluid Wave STEP 3 Place left hand on the person’s right flank while the right hand strikes the left flank. Nursing Assessment Menu STEP 2 Have patient place hand, fingers down and ulnar side down, on the middle of the abdomen. STEP 1 Stand on the right side of the patient . Back to Pictures A fluid wave indicates ascites. This test is done when the examiner suspects fluid in the peritoneal cavity (ascites).

27. Fluid Wave 1 2 Images from Sarah Arvelo Next Page Fluid Wave 3 4

28. Test Your Knowledge When palpating the liver what is normal? Close A. Nothing is felt Almost B. The edge of the liver is felt Yes C. All of the above NursingAssessment Menu Next Question

29. Test Your Knowledge Liver span can be determine through percussion. What is the normal size of the liver Correct, for and adult A. 6-12 CM Abnormal B. 14-20CM Incorrect C. The span of the rib cage Next Question Nursing Assessment Menu

30. Test Your Knowledge Obesity and gas would produce no change. TRUE Obesity produces a fluid wave. Correct FALSE Nursing Assessment Menu

31. Metabolism of Hormones and Drugs Phase I Reactions Phase ii reactions Chemical modification or inactivation of a substance. Conversion of lipid-soluble substances to water-soluble. Water-soluble substances can be excreted unchanged in the urine or bile. Lipid-soluble substances can accumulate in the body until they are converted by this process. Next Page Hormones and Drugs Images from Microsoft Clip art

32. Metabolism of Hormones and Drugs Image from Microsoft Clip art PHASE I PHASE II • Drug metabolism occurs in the lipophilic membrane of the smooth endoplasmic reticulum of the liver cells. • Microsomal enzymes, located in the lipophilic membrane, are responsible for oxidation of the drug. • Conjugation occurs and is the process that breaks down the drug to make in more water soluble. Next Page Hormones and Drugs

33. Hormones Metabolized by the Liver Next Page Glucocorticoids Aldosterone Sex Hormones Cortisol is released by the adrenal gland during the stress response. The liver helps maintain blood glucose during the time when mechanisms of the body are hypoactive.

34. Bile Production Physiology Menu • Bile contains water, bile salts, bilirubin, and cholesterol. The liver produces 600 - 1200 ml of bile, that is yellow-green in color, a day. • Bile salts assist with digestion and absorption of fats. • 94% of bile salts are reabsorbed into portal circulation and go through the system at least 18 times before being excreted in the feces.

35. Bilirubin Elimination Direct bILIRUBIN (conjugated) INDIRECT BILIRUBIN (free bilirubin) • Is a part of the contents of bile and passes through bile ducts into the small intestine. • ½ of bilirubin is converted into urobilinogen by the flora of the intestine. • Urobilinogen is absorbed into portal circulation or excreted in the feces. • 1) Travels through blood attached to albumin. • 2) Travels through the liver, releases from albumin, and moves into the hepatocytes. • 3) Inside hepatocytes it is converted into conjugated bilirubin. Physiology Menu

36. Carbohydrate Metabolism PhysiologyMenu Image from Microsoft Clip art The liver stores excess glucose (glycogen) and releases it into circulation when glucose levels fall. Converts excess carbohydrates into triglycerides and stores them in adipose tissue.

37. Protein Metbolism Next Slide Protein Fibrinogen and C-reactive protein increase in production in the acute-phase response of inflammation. The increased presence of these proteins increases the ESR (an important indicator of inflammation). Deamination is the conversion of proteins, amino acids, and nucleic acids into urea. Transamination is the conversion of an amino group to an acceptor substance, allowing amino acids to be involved in the metabolism of carbohydrates.

38. Protein Metabolism Plasma proteins, albumin, globulins, and fibrinogen. Examples Next Page Plasma proteins allow for fluid to stay in the capillary and not move into the tissue spaces.

39. Lipid Metabolism Next Lipid Page Oxidation of fatty acids supply energy for other body functions. Synthesis of cholesterol, phospholipids, and lipoproteins. Glycerol and fatty acids split by beta oxidation into two-carbon acetyl-coenzyme A. Acetyl-coenzyme is converted by the citric acid cycle to produce adenosine triphosphate (ATP).

40. Lipid Metabolism NextLipid Page FAT Fat is spit and converted. Glycerol Fatty Acids BETA OXIDATION Acetoacetic Acid (Highly Soluble Ketoacid) Acetyl- CoA Acetyl- CoA Liver cannot not use all Acetyl-CoA formed. Citric Acid Cycle ATP

41. Lipid Metabolism PhysiologyMenu Ketoacids are used to deliver energy into other tissues in the body. Extra Acetl-CoA is used for synthesis of cholesterol and bile acids.

42. Lipid Metabolism Triglyceride removed Fat cells VLDL triglyceride IDL Transport Muscle cells VLDL or LDL HDL Good cholesterol Cholesterol and Triglycerides must attach to lipoproteins to transport in the blood LDL is the main transporter of Cholesterol Known as the (bad cholesterol) Physiology Menu

43. Clotting Factors Image from Microsoft Clip art Next Slide The liver produces procoagulants vitamin K, factor VII, IX, X, prothrombin and protein C as well as plasma proteins that are involved in the process. Blood clotting decreases blood loss when injury occurs.

44. Clotting Factors Factor X Activated Prothrombin Fibrinogen Thrombin Antithrombin III converts… Acts as an enzyme to convert … Physiology Menu Fibrin (Stabilizes the Clot) Intrinsic and extrinsic pathways are activated by the coagulation process. This is the 3rd step in the hemostatic process.

45. Liver Function Tests Prealbumin/ Albumin ALT/AST The purpose of these tests is to evaluate the extent of damage as well as identify different dysfunctions of the liver. Image from Microsoft Clip art PT GGT SerumBilirubin ALP AFP Anatomy and Physiology Menu

46. PT (Prothrombin Time) Image from Microsoft Clip art Liver Function Test Menu Used to evaluate clotting ability. PT measures Factor I (fibrinogen), II (prothrombin), V, VII, and X. Normal PT 11-12.5 seconds 85 - 100% PT is prolonged when clotting factors are lacking.

47. Serum Bilirubin Image from Microsoft Clip art Liver Function Tests Menu Levels greater than 2.5 mg/dl produce jaundice. Levels can increase due to the liver’s inability to excrete bilirubin or with a defect in metabolism. Adults normal total bilirubin is 0.1 - 1.0 mg/dl, indirect 0.2 mg/dl, direct .1 - 0.3 mg/dl.

48. GGT y-glutamyltransferase Image from Microsoft Clip art Liver Function Test Menu Measures hepatic excretory function. GGT assists in the transport of amino acids and peptides into liver cells. May indicate alcohol abuse.

49. Alkaline Phosphatase (ALP) Image from Microsoft Clip art Liver Function Tests Menu Used to monitor diseases of the liver. ALP is excreted in bile and found in the bile duct epithelium and canalicular membrane of the hepatocytes. Normal levels are 30 - 85 IU/ml. Elderly levels are slightly higher.

50. ASTAspartateAminotransferase Liver Function Test Main Menu AST (Adult 5 - 40 IU/L) AST is an enzyme found in tissue of the heart muscle, liver cells and skeletal muscle cells and is released when cells become injured. This test is used to evaluate patients with possible coronary occlusive heart disease or suspected hepatocellular diseases.