CITY OF MANILA

UNIVERSIDAD DE MANILA
(Formerly City College of Manila)
Mehan Gardens, Manila
College of Health Sciences
Department of Nursing

A Case Study of

Liver Cirrhosis

In Partial Fulfillment for the requirements on related learning experience

Submitted by:

Patricio, Rothchelle

Soriano, Marielle

Tabora, Liezel

NR-42 Group 2

Submitted to:

Marilou C. Pacheco RN, MAN

 Table of contents

Acknowledgement
Chapter I – Introduction
1. Background of study
2. Significance of the Study
3. Objective of the case study
4. Scope and Limitation
Chapter II - Nursing Summary
A. Nursing health history
a. Biographical Data
b. Admission Data
c. Chief Complaint
d. History of Present Illness
e. Past Medical History
f. Family history
B. Physical Assessment
C. Laboratory and Diagnostic Exam
D. Course in the Ward
Chapter III – Clinical Discussion and description of disease
A. Definition and description of disease
B. Anatomy and Physiology / Pathophysiology / Schematic Diagram of disease
C. Drug Study
Chapter IV
A. Nursing Care Plan
ACKNOWLEDGEMENT

The group would like to express their heartfelt gratitude, sincere appreciation and

profound regards to the following people who, in one way or another, gave guidance, strength,

and encouragement in making this case presentation possible.

First of all, to Almighty God the Father, who granted us the knowledge and skills, Who

send forth the gift of Holy spirit that aided them in completing this study. Without Him, none of

these things would be possible.

To our family, friends, and classmates, for their consideration and unending support,

emotionally, spiritually and financially.

To our clinical instructor, Mrs. Marilou C. Pacheco, RN, MAN for guiding us in the

course of making this case presentation and giving them tips on how to have a good presentation.

To all medical personnel and staff members of Sta. Ana Hospital, Intensive Care Unit for

the warm accommodation during our clinical exposure and for giving us inspiration to keep the

spirit of caring burning.

To the members of the group, for sharing ideas, cooperating and giving full effort in

making the case presentation successful.

Lastly, to our client and his family for their acceptance and willingness to share time,

effort and giving us the essential information needed for this case presentation.
INTRODUCTION

The liver is one of the largest and most complex organs in the body. It stores vital energy

and nutrients, manufactures proteins and enzymes necessary for good health, protects the body

from disease, and breaks down (or metabolizes) and helps remove harmful toxins, like alcohol,

from the body. It is one of the most important organs in the body since it has many significant

functions. A lack or failure to provide proper care of it may lead to an abnormality or disorder.

One of the severe forms that may happen is Liver Cirrhosis.

Liver Cirrhosis is derived from Greek word kirrhos, meaning "tawny" (the orange-yellow

colour of the diseased liver).It is a chronic disease that causes cell destruction and fibrosis

(scarring) of hepatic tissue. Fibrosis alters normal liver structure and vasculature, impairing

blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein.

Cirrhosis is most commonly caused by alcoholism, hepatitis B and C and fatty liver disease but

has many other possible causes. Some cases are idiopathic, i.e., of unknown cause. It may be

classified by the structural changes that take place or by the cause of the disorder.
Background of the study

Internationally, liver cirrhosis is the 8thth most common cause of death. It is most

common among people ages 45 – 75, killing more than 25,000 people each year, 50% of which

are alcohol related. In the Philippines and other underdeveloped countries, however, the

incidence of liver cancer is rather high. Liver cancer is relatively common in our country

primarily because many Filipinos suffer from cirrhosis of the liver, a major risk factor for liver

cancer. Cirrhosis of the liver precedes 80 percent of all liver cancers; thus, any condition that

predisposes to cirrhosis indirectly causes liver cancer. The usual cause of liver cirrhosis among

Filipinos is chronic hepatitis B, a major public health problem in the country. Chronic hepatitis B

afflicts between 10 and 12 percent of all Filipinos (i.e., more than 8 million Filipinos). Other less

significant causes of cirrhosis are hepatitis C infection and alcoholism. The latest DOH advisory

shows that liver cancer is the third most common form of cancer among Filipinos—in men, it is

the second most common, while in women, it is the ninth most common. Locally, liver cirrhosis

is the 17th leading cause of death here in Davao.

In connection with it, last December 9 2013, the Group 5 of NR-42 was assigned on duty

at Sta. Ana Hospital – ICU . where they met their patient F.N who was diagnosed of having

Liver Cirrhosis. They were motivated to learn more and study the disorder since it was their first

time to encounter such case. Also, the group was more encouraged to choose the patient for their

case presentation in order to acquire better understanding and to gain more knowledge and use it

for the future.

Significance of the Case study

To client and the relatives

-To help them to understand the present condition and its complication.

To Student Nurse

-To help to understand the disease process of the patient and help those identifying the

primary needs of patient by recognizing such needs and health problems arise that the group can

now formulate an individualize care plan for the patient that would address these needs and

problems, effectively.

-To enhance the level of knowledge, skills and attitude on how to manage future patient

with same or similar disease.

To Reader

- Acquire more understanding about the present condition and its complication and to

increase their awareness.

College/ University

-To have reference to the certain disease.

Hospital/ Staff Nurse

-To enhance the appropriate nursing care to the future patient with the same disease
OBJECTIVES

To have a course of direction, organization and to recognize the essence of this study, we

have set the following objectives:

GENERAL OBJECTIVES

After rendering effective nursing care for three days at Sta. Ana Hospital -ICU, we aim:

 To provide an extensive study about Liver Cirrhosis for us to gain better understanding

about the disease and be equipped with competence in dealing with related situations in

the future;

 To improve our skills in doing relevant interventions which promote wellness to

persons having the disease;

 Not only to understand the situation of the client and their families who are

confronted with the disease but also to empathize with them.

SPECIFIC OBJECTIVES

Client- Centered Objectives:

 To establish rapport to the patient

 To increase awareness on the risk factors of the disease

 To develop family and support system and distinguish their respective roles in improving

patients health status

 To involve them in promoting the health care of the patient

Nurse-Centered Objectives:

 To present the physical assessment obtained from the patient

 To interpret the laboratory result of the patient

 To discuss the Anatomy and Physiology of the organ involved in the patient’s disease.

 To discuss the surgical procedure performed to the patient

 To present a specific, measurable, attainable, realistic, and time-bounded nursing care

plan for the client.

Scope and limitation of the case study:

This study covers and focuses on the following:

 The group is assigned at SAH-ICU

 The group handled the patient for 3 days

 The group is able to read the chart and gather the data about the patient’s laboratory exam

and medical management

Chapter II - Nursing Summary

A. Nursing health history

a. Biographical data

Name: F.N

Age: 55 y/o

Sex: Male

Date of birth: May 4, 1958

Place of birth: Camarines, Norte

Current address: San Andres Bukid, Manila

Occupation: Farmer

Nationality: Filipino

Religion: Roman Catholic

Civil Status: Single

b. Admission data

Date of admission: December 4, 2013

Time of admission: 11:30 AM

Mode of admission: Ambulatory

Chief complaint: ” Pedal edema and Jaundice for 1 month “

Final diagnosis: Liver Cirrhosis 20 to Alcoholic Liver disease to consider Obstructive Jaundice

Choledocholelithiasis

Source: Significant others and patient's chart

c. Chief Complaint

With a Chief complaint of “ Pedal edema and Jaundice for 1 month “

d. History of Present Illness

One month prior to admission, the patient experience gradual abdominal distention with

tolerable abdominal pain and yellowish color of the skin. Three weeks after prior to

admission, he noted an increase of abdominal distention associated with bipedal edema,

positive for anorexia, has a good bowel output, with mild weight loss for two to three times

per day,

e. Past Medical History

Patient was known to be alcoholic drinker since 25 years old. He drinks mixed hard and

alcohol beverages two to three times a day. He also smoke estimated 20 to 25 stick per day.

He claimed to have no allergies in medication, no previous hospitalization and negative

exposure to blood products and no current medication.

B. Physical Assessment

Date and Time Performed: December 9, 2013 at 8:00 AM

General Survey

Received patient lying on bed unconscious as evidenced by GCS of 11 E4V1M6. Patient

had an NGT intact, with oral airway, with endotracheal tube intact connected to the mechanical

ventilator; with ongoing IVF of D5NaCl at 80cc/hr at left hand metacarpal vein regulated and

infusing well, with Foley catheter connected to Urine bag draining 100 cc of dark yellow

colored urine. He was untidy as the patient was with dirty feet and untrimmed and dirty nails.

Vital Signs:

BP- 140/100mmhg Temperature- 38.0

PR- 96bpm RR- 24

Skin

The patient had jaundice with uniform skin color all throughout the body except under his

axillae, which is darker. His skin folds and axillae were moist. Skin temperature was uniform in

all extremities when touched. Warm to touch.. presence of skin rash and ecchymosis

Hair

Upon inspection, hair was short and dark in color. His hair was thin and evenly distributed as

evidenced by the absence of areas of alopecia along the scalp. No infection or infestations were

noted upon inspection and palpation of the patient’s hairline and scalp. No dandruff was noted on

patient’s scalp no lesions, lumps, or masses upon palpation.

Nails

Clubbing of nails was noted on patient. Upon palpation, nail base was firm and fingernails had a

rough texture. Epidermis surrounding the nails was intact and no lesions were noted. Nails were

long, dirty and untrimmed. Toenail surface was slightly curved and rough.

Skull and Face

Skull was rounded and normocephalic. Symmetry in anatomy of face was noted.

Eyes and Vision

Hair of eyebrows was evenly distributed and periorbital skin was intact without swelling or

inflammation. Eyebrows were symmetrically aligned. Upon inspection, skin of eyelids was

intact and no discharges and discolorations were present. Icteric sclera was noted. Iris were black

in color, and had a round, smooth border. Pupillary response to illumination was sluggish and

equal on both eyes as evidenced by constricting of both illuminated and non-illuminated pupils

upon illumination

Ears and Hearing

Upon inspection, auricles were of the same color with facial skin, were symmetrically aligned

with each other, and were aligned with the outer canthus of each eye. Cerumen was present but

was not impacted or excessive in amount. Upon palpation, auricles were firm, and not tender as

evidenced by the auricle being pulled upward, downward, and backward without resistance, and

the pinna being folded forward without resistance and recoiling after folding. Patient was

unresponsive since he is in unconscious.

Nose

Upon inspection, external nose was symmetrical. No abnormal discharges or flaring were noted.

Also, the nose was with uniform color with facial skin. Nasal septum was intact and in midline.

Patient was with NGT on his right nares.

Mouth

Upon inspection, endotracheal tube connected at the mechanical ventilator. Outer lips were

brownish pink and were dry. Teeth were shiny and yellow in color.

Neck

Upon inspection, neck veins were not distended or visible. Shoulder muscles were of

anatomically symmetrical.

Thorax and Lungs

The skin over the posterior thorax was intact and uniform in color with the rest of the body.

Also, chest expansion was symmetrical when air is administered through the endotracheal tube

connected to the mechanical ventilator. Crackles were noted upon auscultation.

Cardiovascular and Peripheral Vascular

Peripheral pulses were regular and present on all four extremities. Slow capillary refill time of 4-

5 seconds gathered upon three checks was noted.

Chest

No masses, lesions or any unusuality noted on patient’s chest.

Abdomen

Upon inspection, distended abdomen and ascites was noted. Abdomen was supple when

palpated. Size of abdomen was observed to be not appropriate for patient’s body. Abdominal

girth of 35 inches was taken. Caput medusae noted on the skin of the abdomen.

Genito-urinary

Upon inspection, no swelling, lesion or mass noted on the genitals of the patient. Patient is with

Foley catheter which is connected to a Urobag draining 100 cc of dark yellow colored urine.

Back and Extremities

Patient was not able to manifest movements on the upper body and lower body since the patient

was not conscious during the assessment. Bones appear to have no deformities. Elbows have no

deformities. However a grade 1 pitting edema was noted on all four extremities as skin does not

immediately (approximately 4 seconds) go back to its normal state when pressure is applied
C. Laboratory and Diagnostic Exam

Hematology clinical laboratory test

- are used to examine blood and blood components to determine if they are within normal

limits.Values outside the normal limits might be signs of a disease.Hematology tests count the

number of white and red blood cells and platelets. In addition, these tests measure the time

necessary for blood to clot and the capability of blood to carry oxygen throughout the body.

Hematology tests also determine inflammation and infection in the patient and the type of

infection.

Clinical chemistry

-(also known as chemical pathology and clinical biochemistry) is the area of clinical

pathology that is generally concerned with analysis of bodily fluids.

The discipline originated in the late 19th century with the use of simple chemical tests for

various components of blood and urine. Subsequent to this, other techniques were applied

including the use and measurement of enzyme activities, spectrophotometry, electrophoresis,

and immunoassay.

Most current laboratories are now highly automated to accommodate the high workload typical

of a hospital laboratory. Tests performed are closely monitored and quality controlled.

All biochemical tests come under chemical pathology. These are performed on any kind of body

fluid, but mostly on serum or plasma. Serum is the yellow watery part of blood that is left after

blood has been allowed to clot and all blood cells have been removed. This is most easily done

by centrifugation, which packs the denser blood cells and platelets to the bottom of the centrifuge
tube, leaving the liquid serum fraction resting above the packed cells. This initial step before

analysis has recently been included in instruments that operate on the "integrated system"

principle. Plasma is in essence the same as serum, but is obtained by centrifuging the blood

without clotting. Plasma is obtained by centrifugation before clotting occurs. The type of test

required dictates what type of sample is used.

Clinical chemistry
November 29,2013

TEST RESULT REFERENCE ANALYSIS AND INTERPRETATION

VALUE
Albumin 21 35.00-5.00g/L There is a decrease of albumin in the
blood plasma because of the decrease in
its production
Total bilirubin 409 0.00-24.00 umol/L Increase in total bilirubin may be due to a
progress liver damage.
Indirect 76 0.00-15.30 umol/L Serum indirect bilirubin may increase in
damage of uptake by the liver cells
or conjugation in the liver cells of
bilirubin due to the failure of change of
indirect bilirubin to conjugate bilirubin.

Direct bilirubin 333 0.00-5.00umol/L If the bile ducts are blocked, direct
bilirubin will build up, escape from the
liver, and end up in the blood. If the levels
are high enough, some of it will appear in
the urine. Only direct bilirubin appears in
the urine. Increased direct bilirubin usually
means that the biliary (liver secretion)
ducts are obstructed.
HEMATOLOGY
November 29,2013

TEST RESULT REFERENCE ANALYSIS AND INTERPRETATION

VALUE
Hematocrit 0.20 0.42-0.52 Because of the decrease in the RBC in the
blood, hematocrit as well would decrease
Hemoglobin 76 130.00-180.00 g/L Low hemoglobin is referred to as anemia
which may by the decreased erythropoietin
caused by cirrhosis of the liver.
WBC count 18.91 5.00-10.00x10 High levels indicate presence of bacterial
infection
RBC count 2.29 4.60-6.20x10 A decreased number of RBCs results from
the decrease erythropoietin production of the
liver
MCH 33 26-32pg Increase in MCH is usually caused by the
decreased erythropoietin production
MCHC 384 310.00-360.00g/L The mean corpuscular hemoglobin
concentration is at normal level.
SEGMENTERS 0.83 0.36-0.66 High numbers of segmenters mean infection.

LYMPHOCYTE 0.09 0.22-0.40 The most common cause of temporary

lymphocytopenia is a recent infection. This
may be caused by the bacterial infection
MONOCYTE 0.08 0.04-0.08 An increase in monocytes is due to the
inflammatory reaction
CLINICAL CHEMISTRY
December 4,2013

TEST RESULT REFERENCE ANALYSIS AND INTERPRETATION

VALUE
BUN 156.91 mg/dl 19.55 Result is above the normal
CREA 3.24 mg/dl 0.06-1.40 Result is above the normal
SGOT 189.69 u/l <37 An increase in SGPT level is due to
impaired liver function caused by liver
cirrhosis. It can be caused by hepatic
inflammation (including infectious
mononucleosis, pancreatitis, alcohol,
viral hepatitis)

SGPT 78.24 u/l <41 An increase in SGPT level is due to

impaired liver function caused by liver
cirrhosis. It can be caused by hepatic
inflammation (including infectious
mononucleosis, pancreatitis, alcohol,
viral hepatitis)
HEMATOLOGY
December 4,2013

TEST RESULT REFERENCE ANALYSIS AND

VALUE INTERPRETATION
Hemoglobin 70 130.00-180.00 g/L Low hemoglobin is
referred to as anemia
which may by the
decreased erythropoietin
caused by cirrhosis of the
liver.
Hematocrit 0.20 0.42-0.52 Because of the decrease in
the RBC in the blood,
hematocrit as well would
decrease

RBC 2.04 4.60-6.20x10 A decreased number of

RBCs results from the
decrease erythropoietin
production of the liver

WBC 23.50 5.00-10.00x10 High levels indicate

presence of bacterial
infection.

CLINICAL CHEMISTRY
December 6,2013

TEST RESULT REFERENCE ANALYSIS AND

VALUE INTERPRETATION

CREA 315.39 64-104umol/l Result is above normal,

indicates

BUN 26.74 1.7-8.3 Result is above normal,

POTASSIUM 2.89 3.5-5.3 umol/l Result is below normal
thus indicates
Hypokalemia
Chapter III: definition and description of disease

Definition of the Disease

Cirrhosis is an inflammatory disease of the liver. The inflammatory process results in

irreversible fibrosis and scarring of hepatic tissue. Alcohol abuse is the primary cause of

cirrhosis. Other causes include biliary obstruction, hepatitis B and C, and metabolic defects such

as alpha 1 antitrypsin deficiency. The incidence of cirrhosis is highest in men between 40 and 60

years old. The development of cirrhosis occurs over many years before the person presents with

characteristic symptoms. Malnutrition contributes to the development of cirrhosis in people who

abuse alcohol. The description of hepatic function in cirrhosis can lead to the development of

ascites, portal hypertension , hepatic encephalopathy, and liver failure.

ANATOMY AND PHYSIOLOGY

Liver

The liver is the largest internal organ in the

body, and weighs about 3 pounds in an adult. The

liver is located in the right upper quadrant of the

abdomen, just below the diaphragm. A thick

capsule of connective tissue called Glisson's capsule

covers the entire surface of the liver. The liver is

divided into a large right lobe and a smaller left lobe. The falciform ligament divides the two

lobes of the liver. Each lobe is further divided into lobules that are approximately 2 mm high and

1 mm in circumference.

These hepatic lobules are the functioning units of the liver. Each of the approximately 1

million lobules consists of a hexagonal row of hepatic cells called hepatocytes. The hepatocytes

secrete bile into the bile channels and also perform a variety of metabolic functions. Between

each row of hepatocytes are small cavities called sinusoids. Each sinusoid is lined with Kupffer

cells, phagocytic cells that remove amino acids, nutrients, sugar, old red blood cells, bacteria and

debris from the blood that flows through the sinusoids. The main functions of the sinusoids are to

destroy old or defective red blood cells, to remove bacteria and foreign particles from the blood,

and to detoxify toxins and other harmful substances. Approximately 1500 ml of blood enters the

liver each minute, making it one of the most vascular organs in the body. Seventy-five percent of
the blood flowing to the liver comes through the portal vein; the remaining 25% is oxygenated

blood that is carried by the hepatic artery.

The hepatic portal system begins in the capillaries of the digestive organs and ends in the

portal vein. Consequently, portal blood contains substances absorbed by the stomach and

intestines. Portal blood is passed through the hepatic lobules where nutrients and toxins are

absorbed, excreted or converted.

Restriction of outflow through the hepatic portal system can lead to portal hypertension.

Portal hypertension is most often associated with cirrhosis. Patients usually present with

splenomegaly, ascites, GI bleeding and/or portal systemic encephalopathy.

The consequences of portal hypertension are due to portal

systemic anastomosis formed by the body as an attempt to bypass the

obstructed liver circulation. These collateral vessels form along the

falciform ligament, diaphragm, spleen, stomach and peritoneum. The

collaterals find their way to the renal vein where blood drained from

the digestive organs is let into the systemic circulation.

The liver is responsible for important functions, including:

 Bile production and excretion

 Excretion of bilirubin, cholesterol, hormones, and drugs

 Metabolism of fats, proteins, and carbohydrates

 Enzyme activation

 Storage of glycogen, vitamins, and minerals

  Synthesis of plasma proteins, such as albumin and globulin, and clotting factors

 Blood detoxification and purification

The liver synthesizes and transports bile pigments and bile salts that are needed for fat

digestion. Bile is a combination of water, bile acids, bile pigments, cholesterol, bilirubin,

phospholipids, potassium, sodium, and chloride. Primary bile acids are produced from

cholesterol. When bile acids are converted or "conjugated" in the liver, they become bile salts.

Bilirubin is the main bile pigment that is formed from the breakdown of heme in red blood

cells. The broken-down heme travels to the liver, where is it secreted into the bile by the liver.

Bilirubin production and excretion follow a specific pathway. When the reticuloendothelial

system breaks down old red blood cells, bilirubin is one of the waste products. This "free

bilirubin" is a lipid soluble form that must be made water-soluble to be excreted. The

conjugation process in the liver converts the bilirubin from a fat-soluble to a water-soluble form.

The liver also plays a major role in excreting cholesterol, hormones, and drugs from the body.

The liver plays an important role in metabolizing nutrients such as carbohydrates, proteins,

and fats. The liver helps metabolize carbohydrates in three ways:

 Through the process of glycogenesis, glucose, fructose, and galactose are converted to

glycogen and stored in the liver.

 Through the process of glycogenolysis, the liver breaks down stored glycogen to

maintain blood glucose levels when there is a decrease in carbohydrate intake.

 Through the process of gluconeogenesis, the liver synthesizes glucose from proteins or

fats to maintain blood glucose levels.

 The liver synthesizes about 50 grams of protein each day, primarily in the form of albumin.

Liver cells also chemically convert amino acids to produce ketoacids and ammonia, from which

urea is formed and excreted in the urine. Digested fat is converted in the intestine to

triglycerides, cholesterol, phospholipids, and lipoproteins. These substances are converted in the

liver into glycerol and fatty acids, through a process known as ketogenesis.

Prothrombin and fibrinogen, substances needed to help blood coagulate, are both produced

by the liver. The liver also produces the anticoagulant heparin and releases vasopressor

substances after hemorrhage.

Liver cells protect the body from toxic injury by detoxifying potentially harmful substances.

By making toxic substances more water soluble, they can be excreted from the body in the urine.

The liver also has an important role in vitamin storage. High concentrations of riboflavin or

Vitamin B1 are found in the liver. 95% of the body's vitamin A stores are concentrated in the

liver. The liver also contains small amounts of Vitamin C, most of the body's Vitamin D stores,

and Vitamins E and K.

Biliary tract

The biliary tract (or biliary tree) is the common anatomy

term for the path by which bile is secreted by the liver on its way

to the duodenum, or small intestine, of most members of the

mammal family. It is referred to as a tree because it begins with

many small branches which end in the common bile duct,

sometimes referred to as the trunk of the biliary tree. The duct is

present along with the branches of the hepatic artery and the portal vein forming the central axis

of the portal triad. Bile flows in opposite direction to that of the blood present in the other two

channels. The liver is usually excluded, but sometimes

included. Pressure inside in the biliary tree can give rise to

gall stone and lead to cirrhosis of the liver. Blockage can

cause jaundice.

The biliary tract can also serve as a reservoir for

intestinal tract infections. Since biliary tract is an internal

organ, it has no somatic nerve supply,and,therefore,colicky

pain due to infection and inflammation of the biliary tract is

not a somatic pain but it may be caused by luminal distension which causes stretching of the wall

(the same mechanism of pain in intestinal colic in intestinal obstruction in which intestine also

do not have somatic nerve supply)

The path is as follows:

 Bile canaliculi >> Canals of Hering >> bile ductules (in portal tracts) >> intrahepatic bile

ducts >> left and right hepatic ducts >>

 merge to form >> common hepatic duct >>

 exits liver and joins >> cystic duct (from gall bladder) >>

 forming >> common bile duct >> joins with >> pancreatic duct >>

 forming >> ampulla of Vater >> enters duodenum

 The anatomy of the biliary tree is a little complicated, but it is important to understand.

The liver's cells (hepatocytes) excrete bile into canaliculi, which are intercellular spaces between

the liver cells. These drain into the right and left hepatic ducts, after which bile travels via the

common hepatic and cystic ducts to the gallbladder. The gallbladder, which has a capacity of 50

milliliters (about 5 tablespoons), concentrates the bile 10 fold by removing water and stores it

until a person eats. At this time, bile is discharged from the gallbladder via the cystic duct into

the common bile duct and then into the duodenum (the first part of the small intestine), where it

begins to dissolve the fat in ingested food.

The liver excretes approximately 500 to 1000 milliliters (50 to 100 tablespoons) of bile

each day. Most (95%) of the bile that has entered the intestines is resorbed in the last part of the

small intestine (known as the terminal ileum), and returned to the liver for reuse.
The many functions of bile are best understood by knowing the composition of bile:

1. Bile Salts (cholates, chenodeoxycholate, deoxycholate): these are produced by the liver's

breakdown of cholesterol. They function in bile as detergents that dissolve dietary fat and

allow it to be absorbed. Hence, disruption of bile excretion disrupts the normal absorption

of fat, a process called malabsorption. Patients develop diarrhea because the fat is not

absorbed (steatorrhea) , and develop deficiencies of the fat-soluble vitamins (A, D, E, and

K).

2. Cholesterol and phospholipids-while only

4% of bile is cholesterol, the secretion of

cholesterol and its metabolites (bile salts)

into bile is the body's major route of

elimination of cholesterol. Phospholipids,

which are components of cell membranes,

enhance the cholesterol solubilizing

properties of bile salts. Inefficient excretion

of cholesterol can cause an increased serum cholesterol. This predisposes to vascular

disease (heart attacks, strokes, etc.)

3. Bilirubin-while this comprises only 0.3% of bile, it is responsible for bile's yellow color.

Bilirubin is a product of the body's metabolism of hemoglobin, the carrier of oxygen in

red blood cells. Disruption of the excretion of this component of bile leads to a yellow

discoloration of the eyes and skin (jaundice).

4. Protein and miscellaneous components

Bile production and recirculation is the main excretory function of the liver. Tumors that obstruct

the flow of bile from the liver can also impair other liver functions. Therefore, it is necessary to

understand these other functions to understand the symptoms that these tumors can cause. These

include:

Metabolic functions, such as the maintenance of glucose (blood sugar) levels

Synthetic functions, such as the synthesis of serum proteins such as albumin, blood clotting

(coagulation) factors, and complement (a mediator of inflammatory responses)

Storage functions, such as the storage of sugar (glycogen), fat (triglycerides), iron, copper, and

fat soluble vitamins (A, D, E, and K)

Catabolic functions, such as the detoxification of drugs

Circulation of the blood in blood vessels

There are two circulatory routes of blood

as it flows through the blood vessels: the

systemic and the pulmonary circulation. In

systemic circulation, blood flows from the left

ventricle of the heart through blood vessels to

all parts of the body (except gas exchange

tissues of lungs) and back to the atrium. In

pulmonary circulation on the other hand, venous

blood moves from the right atrium to right ventricle to pulmonary artery to lung arterioles and

capillaries where gases exchanged; oxygenated blood returns to the left atrium via pulmonary

veins; from left atrium, blood enters the left ventricle.

Hepatic Portal Circulation

The veins of the hepatic

portal circulation drain the

digestive organs, spleen, and

pancreas and deliver this blood to

the liver through the hepatic portal

vein. When you have just eaten,

the hepatic portal blood contains

large amounts of nutrients. Since

the liver is a key body organ

involve in maintaining the proper

glucose, fat and protein concentrations in the blood, this system “takes a detour “to ensure that

the liver processes these substances before they enter the systemic circulation. As blood flows

slowly through the liver, some of the nutrients are removed to be stored or processed in various

ways for later release to the blood. The liver is drained by the hepatic veins that enter the inferior

vena cava. Like the portal circulation that links the hypothalamus of the brain and the anterior

pituitary gland, the hepatic portal circulation is a unique and unusual circulation. Normally,
arteries feed capillary beds, which in turn drain into veins. Here we see veins feeding the liver

circulation.

The inferior mesenteric vein, draining the terminal part of the large intestine, drains into

the splenic vein, which itself drains the spleen, pancreas and the left side of the stomach. The

splenic vein and superior mesenteric vein (which drains the small intestine and the first part of

the colon) join to form the hepatic portal vein. The L. Gastric vein, which drains the right side of

the stomach, drains directly into the hepatic portal vein.