Liver

The liver is a major metabolic organ exclusively found in vertebrates which performs many essential biological functions, such as detoxification of the organism and the synthesis of various proteins and other biochemicals necessary for digestion and growth. In humans, it is located in the right upper quadrant of the abdomen, below the diaphragm and mostly shielded by the lower right rib cage. Its other metabolic roles include carbohydrate metabolism, the production of a number of hormones, conversion and storage of nutrients such as glucose and glycogen, and the decomposition of red blood cells. Anatomical and medical terminology often use the prefix hepat- from ἡπατο-, from the Greek word for liver, such as hepatology, and hepatitis.

The liver is also an accessory digestive organ that produces bile, an alkaline fluid containing cholesterol and bile acids, which emulsifies and aids the break up of dietary fat. The gallbladder, a small hollow pouch that sits just under the right lobe of liver, stores and concentrates the bile produced by the liver, which is later excreted to the duodenum to help with digestion. The liver's highly specialized tissue, consisting mostly of hepatocytes, regulates a wide variety of high-volume biochemical reactions, including the synthesis and breakdown of small and complex organic molecules, many of which are necessary for normal vital functions. Estimates regarding the organ's total number of functions vary, but are generally cited as being around 500. For this reason, the liver has sometimes been described as the body's chemical factory.

It is not known how to compensate for the absence of liver function in the long term, although liver dialysis techniques can be used in the short term. Artificial livers have not been developed to promote long-term replacement in the absence of the liver. As of 2018, liver transplantation is the only option for complete liver failure.

The liver is the largest internal organ in vertebrates and its structure is similar in all other vertebrates. It is mostly divided into right and left lobes.

Structure

The liver is a dark reddish brown, wedge-shaped organ with two lobes of unequal size and shape. A human liver normally weighs approximately 1.5 kilograms (3.3 pounds) and has a width of about 15 centimetres (6 inches). There is considerable size variation between individuals, with the standard reference range for men being 970–1,860 grams (2.14–4.10 lb) and for women 600–1,770 g (1.32–3.90 lb). It is both the heaviest internal organ and the largest gland in the human body. It is located in the right upper quadrant of the abdominal cavity, resting just below the diaphragm, to the right of the stomach, and overlying the gallbladder.

The liver is connected to two large blood vessels: the hepatic artery and the portal vein. The hepatic artery carries oxygen-rich blood from the aorta via the celiac trunk, whereas the portal vein carries blood rich in digested nutrients from the entire gastrointestinal tract and also from the spleen and pancreas. These blood vessels subdivide into small capillaries known as liver sinusoids, which then lead to hepatic lobules.

Hepatic lobules are the functional units of the liver. Each lobule is made up of millions of hepatocytes, which are the basic metabolic cells. The lobules are held together by a fine, dense, irregular, fibroelastic connective tissue layer extending from the fibrous capsule covering the entire liver known as Glisson's capsule after British doctor Francis Glisson. This tissue extends into the structure of the liver by accompanying the blood vessels, ducts, and nerves at the hepatic hilum. The whole surface of the liver, except for the bare area, is covered in a serous coat derived from the peritoneum, and this firmly adheres to the inner Glisson's capsule.

Development

Organogenesis, the development of the organs, takes place from the third to the eighth week during embryonic development. The origins of the liver lie in both the ventral portion of the foregut endoderm (endoderm being one of the three embryonic germ layers) and the constituents of the adjacent septum transversum mesenchyme. In the human embryo, the hepatic diverticulum is the tube of endoderm that extends out from the foregut into the surrounding mesenchyme. The mesenchyme of septum transversum induces this endoderm to proliferate, to branch, and to form the glandular epithelium of the liver. A portion of the hepatic diverticulum (that region closest to the digestive tube) continues to function as the drainage duct of the liver, and a branch from this duct produces the gallbladder. Besides signals from the septum transversum mesenchyme, fibroblast growth factor from the developing heart also contributes to hepatic competence, along with retinoic acid emanating from the lateral plate mesoderm. The hepatic endodermal cells undergo a morphological transition from columnar to pseudostratified resulting in thickening into the early liver bud. Their expansion forms a population of the bipotential hepatoblasts. Hepatic stellate cells are derived from mesenchyme.

After migration of hepatoblasts into the septum transversum mesenchyme, the hepatic architecture begins to be established, with liver sinusoids and bile canaliculi appearing. The liver bud separates into the lobes. The left umbilical vein becomes the ductus venosus and the right vitelline vein becomes the portal vein. The expanding liver bud is colonized by hematopoietic cells. The bipotential hepatoblasts begin differentiating into biliary epithelial cells and hepatocytes. The biliary epithelial cells differentiate from hepatoblasts around portal veins, first producing a monolayer, and then a bilayer of cuboidal cells. In ductal plate, focal dilations emerge at points in the bilayer, become surrounded by portal mesenchyme, and undergo tubulogenesis into intrahepatic bile ducts. Hepatoblasts not adjacent to portal veins instead differentiate into hepatocytes and arrange into cords lined by sinusoidal epithelial cells and bile canaliculi. Once hepatoblasts are specified into hepatocytes and undergo further expansion, they begin acquiring the functions of a mature hepatocyte, and eventually mature hepatocytes appear as highly polarized epithelial cells with abundant glycogen accumulation. In the adult liver, hepatocytes are not equivalent, with position along the portocentrovenular axis within a liver lobule dictating expression of metabolic genes involved in drug metabolism, carbohydrate metabolism, ammonia detoxification, and bile production and secretion. WNT/β-catenin has been identified as playing a key role in this phenomenon.

At birth, the liver comprises roughly 4% of body weight and weighs on average about 120 g (4 oz). Over the course of further development, it will increase to 1.4–1.6 kg (3.1–3.5 lb) but will only take up 2.5–3.5% of body weight.

Hepatosomatic index (HSI) is the ratio of liver weight to body weight.

Fetal blood supply

In the growing fetus, a major source of blood to the liver is the umbilical vein, which supplies nutrients to the growing fetus. The umbilical vein enters the abdomen at the umbilicus and passes upward along the free margin of the falciform ligament of the liver to the inferior surface of the liver. There, it joins with the left branch of the portal vein. The ductus venosus carries blood from the left portal vein to the left hepatic vein and then to the inferior vena cava, allowing placental blood to bypass the liver. In the fetus, the liver does not perform the normal digestive processes and filtration of the infant liver because nutrients are received directly from the mother via the placenta. The fetal liver releases some blood stem cells that migrate to the fetal thymus, creating the T cells (or T lymphocytes). After birth, the formation of blood stem cells shifts to the red bone marrow. After 2–5 days, the umbilical vein and ductus venosus are obliterated; the former becomes the round ligament of liver and the latter becomes the ligamentum venosum. In the disorders of cirrhosis and portal hypertension, the umbilical vein can open up again.

Unlike eutherian mammals, in marsupials the liver remains haematopoietic well after birth.

Disease

The liver is a vital organ and supports almost every other organ in the body. Severe or end-stage liver failure has dire consequences for the body's overall health and quality of life. Visible signs of liver disease include jaundice and ascites. Hepatomegaly refers to an enlarged liver and may be caused by several underlying diseases. It can be palpated in an abdominal exam.

Scarring (fibrosis) of the liver from any cause can lead to cirrhosis. Cirrhosis increases the resistance to blood flow in the liver, and can result in portal hypertension. Congested anastomoses between the portal venous system and the systemic circulation, can be a subsequent condition.

The most common chronic liver disease is nonalcoholic fatty liver disease, which affects an estimated one-third of the world population.

Hepatitis is a common condition of inflammation of the liver. The cause is usually viral, and the most common of these infections are hepatitis A, B, C, D, and E. Some of these infections are transmitted sexually or through non-sterile needles. Inflammation can also be caused by other viruses in the family Herpesviridae such as the herpes simplex virus. Chronic (rather than acute) infection with hepatitis B virus or hepatitis C virus is the main cause of liver cancer. Globally, about 248 million individuals are chronically infected with hepatitis B (with 843,724 in the U.S.), and 142 million are chronically infected with hepatitis C (with 2.7 million in the U.S.). Globally there are about 114 million and 20 million cases of hepatitis A and hepatitis E respectively, but these generally resolve and do not become chronic. Hepatitis D virus is a "satellite" of hepatitis B virus (it can only infect in the presence of hepatitis B), and co-infects nearly 20 million people with hepatitis B, globally.

Hepatic encephalopathy is caused by an accumulation of toxins in the bloodstream that are normally removed by the liver. This condition can result in coma or death if not treated.

Budd–Chiari syndrome is a condition caused by blockage of the hepatic veins (including thrombosis) that drain the liver. It presents with the classical triad of abdominal pain, ascites and liver enlargement.

Many diseases of the liver are accompanied by jaundice caused by increased levels of bilirubin in the system. The bilirubin results from the breakup of the hemoglobin of dead red blood cells; normally, the liver removes bilirubin from the blood and excretes it through bile.

Other disorders caused by excessive alcohol consumption are grouped under alcoholic liver diseases and these include alcoholic hepatitis, fatty liver, and cirrhosis. Factors contributing to the development of alcoholic liver diseases are not only the quantity and frequency of alcohol consumption, but can also include gender, genetics, and liver insult.

Liver damage can also be caused by drugs, particularly paracetamol and drugs used to treat cancer.

A rupture of the liver can be caused by a liver shot used in combat sports.

Primary biliary cholangitis is an autoimmune disease of the liver. It is marked by slow progressive destruction of the small bile ducts of the liver, with the intralobular ducts (Canals of Hering) affected early in the disease. When these ducts are damaged, bile and other toxins build up in the liver (cholestasis) and over time damages the liver tissue in combination with ongoing immune related damage.

There are also many pediatric liver diseases, including biliary atresia, alpha-1 antitrypsin deficiency, alagille syndrome, progressive familial intrahepatic cholestasis, Langerhans cell histiocytosis and hepatic hemangioma, a benign tumour. It is the most common type of liver tumour, thought to be congenital. A genetic disorder causing multiple cysts to form in the liver tissue, usually in later life, and usually asymptomatic, is polycystic liver disease. Diseases that interfere with liver function will lead to derangement of these processes. However, the liver has a great capacity to regenerate and has a large reserve capacity. In most cases, the liver only produces symptoms after extensive damage.

The bare area of the liver is a site that is vulnerable to the passing of infection from the abdominal cavity to the thoracic cavity.

Consuming caffeine regularly may help safeguard individuals from liver cirrhosis. Additionally, it has been shown to slow the advancement of liver disease in those already affected, lower the risk of liver fibrosis, and provide a protective benefit against liver cancer for moderate coffee drinkers. A 2017 study revealed that the positive effects of caffeine on the liver were evident regardless of the coffee preparation method.

Symptoms

The classic symptoms of liver damage include the following:

Pale stools occur when stercobilin, a brown pigment, is absent from the stool. Stercobilin is derived from bilirubin metabolites produced in the liver.

Dark urine occurs when bilirubin mixes with urine

Jaundice (yellow skin and/or whites of the eyes) This is where bilirubin deposits in skin, causing an intense itch. Itching is the most common complaint by people who have liver failure. Often this itch cannot be relieved by drugs.

Fluid accumulating in the abdomen, and swelling of the ankles and feet occurs because the liver fails to make albumin.

Excessive fatigue occurs from a generalized loss of nutrients, minerals and vitamins.

Bruising and easy bleeding are other features of liver disease. The liver makes clotting factors, substances which help prevent bleeding. When liver damage occurs, these factors are no longer present and severe bleeding can occur.

Pain in the upper right quadrant can result from the stretching of Glisson's capsule in conditions of hepatitis and pre-eclampsia.

Diagnosis

The diagnosis of liver disease is made by liver function tests, groups of blood tests, that can readily show the extent of liver damage. If infection is suspected, then other serological tests will be carried out. A physical examination of the liver can only reveal its size and any tenderness, and some form of imaging such as an ultrasound or CT scan may also be needed.

Sometimes a liver biopsy will be necessary, and a tissue sample is taken through a needle inserted into the skin just below the rib cage. This procedure may be helped by a sonographer providing ultrasound guidance to an interventional radiologist.

Liver regeneration

The liver is the only human internal organ capable of natural regeneration of lost tissue; as little as 25% of a liver can regenerate into a whole liver. This is, however, not true regeneration but rather compensatory growth in mammals. The lobes that are removed do not regrow and the growth of the liver is a restoration of function, not the original form. This contrasts with true regeneration where both original function and form are restored. In some other species, such as zebrafish, the liver undergoes true regeneration by restoring both shape and size of the organ. In the liver, large areas of the tissues are formed but for the formation of new cells there must be sufficient amount of material so the circulation of the blood becomes more active.

This is predominantly due to the hepatocytes re-entering the cell cycle. That is, the hepatocytes go from the quiescent G0 phase to the G1 phase and undergo mitosis. This process is activated by the p75 receptors. There is also some evidence of bipotential stem cells, called hepatic oval cells or ovalocytes (not to be confused with oval red blood cells of ovalocytosis), which are thought to reside in the canals of Hering. These cells can differentiate into either hepatocytes or cholangiocytes. Cholangiocytes are the epithelial lining cells of the bile ducts. They are cuboidal epithelium in the small interlobular bile ducts, but become columnar and mucus secreting in larger bile ducts approaching the porta hepatis and the extrahepatic ducts. Research is being carried out on the use of stem cells for the generation of an artificial liver.

Scientific and medical works about liver regeneration often refer to the Greek Titan Prometheus who was chained to a rock in the Caucasus where, each day, his liver was devoured by an eagle, only to grow back each night. The myth suggests the ancient Greeks may have known about the liver's remarkable capacity for self-repair.

Liver transplantation

Human liver transplants were first performed by Thomas Starzl in the United States and Roy Calne in Cambridge, England in 1963 and 1967, respectively.

Liver transplantation is the only option for those with irreversible liver failure. Most transplants are done for chronic liver diseases leading to cirrhosis, such as chronic hepatitis C, alcoholism, and autoimmune hepatitis. Less commonly, liver transplantation is done for fulminant hepatic failure, in which liver failure occurs rapidly over a period of days or weeks.

Liver allografts for transplant usually come from donors who have died from fatal brain injury. Living donor liver transplantation is a technique in which a portion of a living person's liver is removed (hepatectomy) and used to replace the entire liver of the recipient. This was first performed in 1989 for pediatric liver transplantation. Only 20 percent of an adult's liver (Couinaud segments 2 and 3) is needed to serve as a liver allograft for an infant or small child.

More recently, adult-to-adult liver transplantation has been done using the donor's right hepatic lobe, which amounts to 60 percent of the liver. Due to the ability of the liver to regenerate, both the donor and recipient end up with normal liver function if all goes well. This procedure is more controversial, as it entails performing a much larger operation on the donor, and indeed there were at least two donor deaths out of the first several hundred cases. A 2006 publication addressed the problem of donor mortality and found at least fourteen cases. The risk of postoperative complications (and death) is far greater in right-sided operations than that in left-sided operations.

With the recent advances of noninvasive imaging, living liver donors usually have to undergo imaging examinations for liver anatomy to decide if the anatomy is feasible for donation. The evaluation is usually performed by multidetector row computed tomography (MDCT) and magnetic resonance imaging (MRI). MDCT is good in vascular anatomy and volumetry. MRI is used for biliary tree anatomy. Donors with very unusual vascular anatomy, which makes them unsuitable for donation, could be screened out to avoid unnecessary operations.

Source: Wikipedia, The Free Encyclopedia · CC BY-SA 4.0