Assessment and Management of Patients with Hepatobiliary Disorders
HEPATOBILIARY SYSTEM
Liver
➢ One of the largest organs of the body located in the r... [Show More] ight upper abdominal quadrant
➢ The lobes are further subdivided into smaller units known as lobules (functional unit of the liver). It is
composed of central vein, hepatic plates, bile canaliculi, and sinusoids that are lined with Kupffer’s
cells (phagocytic cells).
➢ Blood supply to the liver is from the portal vein (80%), which drains the gastrointestinal (GI) tract and
is rich in nutrients but lacks oxygen; and from the hepatic artery (20 %) and is rich in oxygen.
➢ The liver contains various cell types, including hepatocytes (liver cells) and Kupffer cells (phagocytic
cells that engulf bacteria).
Biliary system
➢ Canaliculi, the smallest bile ducts located between
liver lobules, receives bile from hepatocytes.
➢ The canaliculi form larger bile ducts, which leads to
the hepatic duct
➢ The hepatic duct from the liver joins the cystic duct
from the gallbladder to form the common bile duct,
which empties into the duodenum
➢ The flow of bile into the intestine is controlled by the
sphincter of Oddi.
➢ The gallbladder is a hollow, pear-shaped organ, 3”
to 4” long, attached to the liver under the right lobe.
➢ The gallbladder normally holds 30 to 50 ml of bile
and can hold up to 70 ml when fully distended.
Pancreas
➢ A slender, fish-shaped organ, the pancreas lies horizontally in the abdomen behind the stomach and
extends roughly from the duodenum to the spleen.
➢ The functional pancreatic exocrine unit is the secreting acinus
➢ Pancreatic acini are arranged in lobules with channels that extend to the main lobular duct
➢ The acini normally produce between 1200 and 3000 ml of pancreatic juice daily
The Function of the Hepatobiliary System
1. Liver functions include
➢ Regulating blood glucose level; making glycogen when blood glucose is high, which is stored in the
hepatocytes.
➢ Synthesizing glucose from amino acids through gluconeogenesis by deamination in response to
hypoglycemia.
➢ Converting ammonia produced from gluconeogenetic by-products and bacteria to urea.
➢ Synthesizing plasma proteins such as albumin, globulins, clotting factors, and lipoproteins. Vitamin K
is required by the liver for the synthesis of prothrombin and some of the other clotting factors. Amino
acids are used by the liver for protein synthesis
➢ Breaking down fatty acids into ketone bodies (acetoacetic acid, beta-hydroxybutyric acid, and acetone)
as a source of energy.
➢ Storing vitamins and minerals such as vitamin A, D, E, K, B12 & iron
➢ Bile formation and secretion. The functions of bile are excretory; it also serves as an aid to digestion.
➢ Drug metabolism, such as barbiturates, opioids, sedatives, anesthetics, and amphetamines.
➢ Excretion of adrenal cortex hormones (glucocorticoids, mineralocorticoids, sex hormones)
➢ Phagocytosis by Kupffer cells
2. Continuously formed by hepatocytes (about 1 L/day), bile (greenish liquid) comprises:
➢ Water and electrolytes such as sodium, potassium, calcium, chloride, and bicarbonate, and also
contain significant amounts of lecithin, fatty acids, cholesterol, bilirubin, and bile salts.
➢ Bilirubin: pigment derived from the breakdown of hemoglobin; conjugated with glucuronic by
hepatocytes, producing direct or conjugated bilirubin that is secreted into the bile
➢ Bile salts: emulsify fat, reabsorbed in the distal ileum, and returned to the liver via the portal vein
➢ The presence of fat in the acidic chyme into the duodenum causes the secretion of cholecystokinin
that causes gallbladder contraction and relaxation of the sphincter of Oddi, releasing bile into the
CBD to the duodenum.
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NCM-116
3. Metabolic functions of the biliary system include:
➢ Draining bile from the hepatocytes to the gallbladder by way of the biliary tree
➢ Storing bile in the gallbladder and releasing it to the duodenum
4. The pancreas has both endocrine and exocrine functions. Exocrine functions include:
➢ Producing pancreatin juice, which contains 3 types of digestive enzymes: amylase, lipase, and trypsin.
➢ Secreting water and bicarbonate to neutralize the gastric juice.
Assessment
1. Assess liver size by percussing the upper and lower liver borders
2. Record the level at which the lower borders descend below the right costal margin
3. Palpate the liver, if possible, to assess consistency and firmness, pain, shape, and nodules
Laboratory studies and Diagnostic Test
1. Liver function tests
a. Serum Alkaline phosphatase
➢ Slight to moderate elevation in hepatocellular disease because the bile disposes of this
enzyme, so any impairment of liver cell excretory function will cause an elevation.
➢ Severe elevation in obstructive biliary disease.
b. AST (Aspartate aminotransferase) and ALT (Alanine aminotransferase): a most specific indicator
of liver function. These enzymes are found in high concentrations in the liver. Liver injury results
in enzyme release into the blood. Normal: AST (10-40 U/mL) and ALT (8-40 U/mL)
c. Lactic dehydrogenase (LDH)
d. Serum proteins (decrease in hepatocellular disease because the liver is unable to metabolize
protein. Low serum protein causes decrease colloid osmotic pressure that leads to edema including
ascites.
e. Serum bilirubin
➢ Total serum bilirubin: increase in hepatocellular damage because the liver is unable to
metabolized bilirubin. Normal: 0.1 – 1 mg/dl
➢ Conjugated/ Direct bilirubin: increase in biliary obstruction
➢ Unconjugated/Indirect bilirubin: Increase in hemolysis of RBC and hepatocellular damage
because the liver is unable to conjugate bilirubin
f. Serum Ammonia Level: increase in severe hepatocellular damage because the liver is unable to
convert ammonia into urea → hepatic encephalopathy). Normal: 75 ug/dl
g. Clotting factors: PT, PTT, and aPTT (increase in hepatocellular disease because the liver is unable
to metabolize protein that is required to synthesize clotting factors → bleeding)
h. Serum lipids /cholesterol (increase in biliary obstruction while a decrease in hepatocellular damage
because the liver is unable to metabolize fats. Normal: 140-200mg/dl
2. Ultrasound or Ultrasonography: A noninvasive test that focuses high-frequency sound waves over an
area in the abdomen to generate an image of the structure. Ultrasound of the abdomen can detect
gallstones, dilated bile ducts, fluid-filled cysts, ascites, and small abdominal masses.
Preparation
➢ NPO 4-8 hours before the exam and a fat-free meal is preferred the evening before the test, to
minimize air in the stomach and bowel, which would obscure images of the gallbladder, liver,
pancreas, and spleen
➢ Laxative the night before the procedure
➢ Adequate hydration
3. Liver biopsy: a sampling of the liver tissue by needle aspiration for histologic analysis to establish a
diagnosis of specific liver disease
Preparation
➢ Secure written consent
➢ NPO 2-4 hours
➢ Vitamin K injection before the procedure if PT is prolonged
➢ Monitor coagulation time; initial vital signs
➢ Position: left lateral
➢ Instruct the patient to exhale deeply; hold the breath for 5-10 seconds during needle insertion to
prevent trauma to the [Show Less]
