The Liver

II Osteopathy of the Individual Organs


images


5 The Liver


6 The Gallbladder


7 The Stomach


8 The Duodenum


9 The Spleen


10 The Pancreas


11 The Peritoneum


12 The Jejunum and Ileum


13 The Colon


14 The Kidneys


15 The Urinary Bladder


16 The Uterus/Fallopian Tubes/Ovaries


17 The Thorax



5 The Liver


Anatomy


General Facts


Macroscopic subdivision of the liver is into:


image left and right lobe


image caudate lobe


image quadrate lobe


The liver is covered by peritoneum, except for the “bare area,” which is directly connected to the diaphragm. It weighs about 1.5–2.5 kg, although the effective weight is only about 400 g because the gravitational force of the thoracic organs (vacuum in the thorax), on the one hand, and the abdominal organ pressure, on the other, reduce it.


Blood flow through the liver is about 1.5 L/min.


Location


The liver is located in the right upper abdomen below the diaphragm.


Cranial Boundary

image anterior: fifth intercostal space (ICS) on the right to the sixth ICS on the left


image on the left side; extending roughly to a vertical line through the body via the center of the left inguinal ligament


image posterior: T8–T9


Caudal Boundary

image anterior: lower costal arch ascending from right to left past the center line


image posterior: T11-T12


Topographic Relationships


image dorsolateral and anterior on the right: abdominal wall and ribs 8–11


image diaphragm


image gallbladder


image hepatic/cystic/common bile duct


image inferior vena cava


image portal vein


image proper hepatic artery



images

Fig. 5.1 Attachments of the liver.


image esophagus


image stomach


image right adrenal gland


image right kidney


image duodenum: superior and descending part


image right colic flexure


image indirect contact to pleura, lung, pericardium, and heart


Attachments/Suspensions


image pressure in the abdominal cavity


image turgor


image coronary ligament


image left and right triangular ligament


image falciform ligament


image round ligament of the liver


image lesser omentum (hepatoduodenal and hepatogastric ligaments)


image hepatorenal ligament


image inferior vena cava


Circulation


Arterial

Hepatic artery proper from the celiac trunk.


Venous

image portal vein (collects blood from the spleen, distal esophagus, stomach, small intestine, colon, upper rectum, pancreas, and gallbladder)


image inferior vena cava


Lymph Drainage

The lymphatic vessels run parallel to the blood vessels.


Innervation

image sympathetic nervous system from T7 to T10 via the greater and lesser splanchnic nerve


image switchover in the celiac plexus


image vagus nerve


image The liver capsule is innervated via the phrenic nerve (C3–C5).


Organ Clock

Maximal time: 1–3a.m.


Minimal time: 1–3p.m.


Organ–Tooth Interrelationship

Organs and teeth have a relationship to each other that is comparable to the system of connective tissue zones on the back or the foot reflex zones. Disorders or even just functional disturbances of an organ are reflected in the weakening of a tooth, the adjoining gum, or the nearby mucous membranes. The tooth can hurt without a corresponding lesion being present. Likewise, it is possible that the tooth, gums, or mucous membranes are inflamed.


Similarly, a damaged tooth also affects the corresponding organ. This can reach the point where an organic disturbance can be cured only after the tooth or gums have healed up.


For osteopaths, it is therefore important to know the interrelationships of each organ and tooth, and to take countermeasures against misdiagnoses and mistreatments early on. For this reason, the tooth associated with the organ is identified here. In this context, always remember that the adjoining gum and mucous membranes are part of this relationship as well.




  • Canine tooth in the upper jaw on both sides

Movement Physiology according to Barral


Mobility

The liver displays mobility in three planes, as follows.



images

Fig. 5.2 Mobility and motility of the liver in the frontal plane.


Frontal Plane

During inhalation, the diaphragm leads the lateral parts of the liver inferiorly to medially. Looked at from the front, the liver rotates in a counterclockwise direction.


The axis of movement is a sagittotransverse axis through the left triangular ligament.


Sagittal Plane

In this plane, the liver tilts with the cranial parts anteriorly while at the same time shifting the caudal edge posteriorly. The frontotransverse axis of movement runs approximately through the coronary ligament.



images

Fig. 5.3 Mobility and motility of the liver in the sagittal plane.


Transverse Plane

The liver carries out a leftward rotation along a frontosagittal axis through the inferior vena cava as an approximate anatomic landmark. Looked at from above, this is a counterclockwise rotation.


Motility

The motions of motility correspond in direction and axis to those of mobility.



images

Fig. 5.4 Mobility and motility of the liver in the transverse plane.


Physiology


Metabolic Functions of the Liver


image lipolysis (metabolism of fatty acids up to coenzyme A)


image production of ketone bodies from fat, e.g., in hunger periods or in badly adjusted diabetes mellitus with bad breath smelling of acetone


image lipogenesis (production of triglycerides)


image glycogenesis and glycogenolysis


image gluconeogenesis (synthesis of glucose from lactate or amino acids)


image formation of proteins from amino acids (e.g., albumin, globulin, fibrinogen, prothrombin, vitamin K-dependent coagulation factors)


image breakdown of proteins, e.g., estrogen


image production of urea from brain—toxic ammonia, the product of protein breakdown


image breakdown and excretion of exogenous toxins, e.g., medications


image storage organ, e.g., for glycogen, or vitamin A or B12


image production and excretion of bile


image synthesis and processing of cholesterol


image location of blood production up to the sixth fetal month


The liver metabolizes all three basic elements of food (carbohydrates, fats, and proteins) in different ways, therefore playing a dominant role in intermediary metabolism.


Pathologies


Symptoms that Require Medical Clarification




  • Icterus
  • Recurrent upper abdominal complaints
  • Fever of uncertain origin
  • Acute inflammation
  • Cachexia

Icterus


Definition. The deposition of bilirubin causes a yellow coloration in blood plasma and connective tissue. With regard to connective tissue, the sclerae turn yellow first, followed by the skin. This phenomenon occurs when the concentration of bilirubin in the plasma exceeds 0.30–5 mmol/L.


Types



  • Prehepatic icterus: the rate of erythrocyte breakdown is increased. With the liver functioning normally, the amount of accumulating hemoglobin is greater than the liver’s capacity to process it. A possible cause is a congenital hemolytic anemia, e.g., thalassemia.
  • Intrahepatic icterus: the liver cells are damaged and lose their ability to break down hemoglobin. A possible cause is acute hepatitis.

    images

    Fig. 5.5 Microscopic anatomy of the liver. The oxygenrich blood from the branch of the hepatic artery proper and the oxygen-deficient but nutrient-rich blood from the portal vein together flow into the central vein. The numerous metabolic processes of the liver take place in the liver cells. The cells receive the necessary oxygen and “building blocks” from the mixed blood in the sinus of the liver.


image Posthepatic icterus (obstructive icterus): in this form of icterus, the bile ducts are compromised. They can be blocked both within the liver, e.g., in a cirrhosis, and outside the liver by a tumor or gallstones in the common bile duct. Additional causes are:



  • fatty liver
  • hepatitis
  • papillary stenosis
  • cholangitis
  • pancreatic head carcinoma
  • pancreatitis

Acute Hepatitis


Definition. Infection of the body with a pathogenic virus that affects the liver cells.


Hepatitis A

Infection. The hepatitis A virus (HAV) is most often transmitted fecally or orally, although sexual or perinatal transmission is also possible. One risk factor is traveling to southern vacation areas: even in Europe, a clear north-south divide exists in the spread of hepatitis A infection.


Clinical. The period of incubation is 14–40 days. Most frequently, we see a prodromal stage with flulike and gastrointestinal symptoms (feeling of fullness, lack of appetite, nausea, diarrhea, fever, joint pain). This is followed by the organ manifestation with icterus, sensitivity to pressure in the liver, signs of liver cell degradation, and in a fifth of all cases splenomegaly.


The course of the disease is an average of 4–8 weeks; life-long immunity remains. This type has neither virus carriers nor chronification.


Hepatitis B

Infection. In the case of the hepatitis B virus (HBV), the path of transmission is parenteral (plus needle puncture wounds), sexual contact, or perinatal. Worldwide, about 200 million people are infected.


Clinical. The period of incubation is 60–120 days. A nonspecific preliminary stage can be missing; organ manifestation runs a much more serious and drawn-out course than in hepatitis A. Nevertheless, most hepatitis B infections are asymptomatic.


In 5–15% of infections, the acute form turns into the chronic form, which can lead to cirrhosis of the liver or a primary liver cell carcinoma. The disease takes a lethal course in 2–15% of all cases, but there are also healthy and infectious virus carriers.


Active immunization is advised.


Hepatitis D

Infection. The delta virus is attached to the B virus and utilizes parts of the HBV for its own reproduction. The path of infection is parenteral or by sexual contact. Endemic regions are southern Italy, the Balkans, the Near East, Africa, and South America.


Clinical. The period of incubation for simultaneous infection with HBV is 12–15 weeks. If a patient with persistent HBV is infected, the incubation period is clearly shorter, around 3 weeks.


The infection entails a serious negative effect on the liver, and not uncommonly also liver failure. Approximately 80% of hepatitis D virus (HDV) infections become chronic.


Protection against this infection is achieved by immunization against HBV.


Hepatitis C

Infection. The hepatitis C virus (HCV) is spread via injection or sexual transmission. It is found in 0.5–1.5% of all blood donors. Anti-HCV is clearly more common in people who have experienced an HBV infection.


Clinical. The period of incubation is 5–12 weeks. Asymptomatic courses are possible. Nevertheless, 50% of infections take a chronic course, and transition to cirrhosis or hepatocellular carcinoma is not uncommon.


There is no immunization.


Hepatitis E

Infection. The path of transmission for the hepatitis E virus (HEV) is fecal-oral. In developing countries, it is held responsible for epidemics of HEV infection.


Clinical. The course is identical to that of hepatitis A. There are no chronic courses or healthy virus carriers.


Women who become infected with HEV in the last trimester of pregnancy die in about 25% of cases.


Chronic Hepatitis


Definition

This condition refers to inflammatory liver disorders that persist for 6 months or longer without improvement.


Causes

image HBV infection


image HCV infection


image HDV infection


image autoimmune hepatitis


image toxins (alcohol, medications)


Clinical. We distinguish between a persistent and an aggressive type. The persistent type is marked by nonspecific symptoms such as fatigue, weight loss, and diffuse upper abdominal complaints. The prognosis is favorable.


Aggressive chronic hepatitis manifests in a disease progression with not only nonspecific symptoms but also signs of liver cirrhosis, e.g., esophageal varices.


Fatty Liver


Definition. Fatty liver refers to an increase of fat deposits in the liver cells. If more than 50% of the cells are affected, we talk about a fatty liver. If less than 50% of cells are affected, we call the condition fatty degeneration of the liver.


Causes


image alcohol abuse


image adiposity


image diabetes mellitus


image pregnancy


image toxins, e.g., poisonous mushrooms


Clinical. In most cases, hepatomegaly manifests with no complaints. The symptoms depend on the cause.


Liver Damage from Alcohol


Definition. Toxic effect on the liver as a result of excess alcohol or alcohol abuse.


Clinical


image fatty liver


image steatosis hepatitis or acute alcohol hepatitis with signs of liver insufficiency to the point of liver failure with:



  • pressure pain in the liver
  • nausea, and also weight loss
  • fever
  • icterus
  • ascites
  • hepatosplenomegaly
  • encephalopathy

image alcoholic liver cirrhosis


Cirrhosis of the Liver


Definition. Irreversible change in normal liver tissue with fibrosis and destruction of the physiologic microscopic lobe structure.


Causes


image alcohol


image HBV, HCV, HDV


image medications


image cystic fibrosis


image chronic right cardiac insufficiency


Clinical. Liver insufficiency with:


image structural tissue change: enlargement of the liver with hardening and bumpy surface (the liver shrinks terminally) and hypoperfusion of the liver


image icterus


image hepatic encephalopathy


image ascites and ankle edema (albumin deficiency)


image anemia


image a bleeding tendency


Estrogen dominance with:


image spider angioma


image men with loss of chest hair, abdominal baldness, testicular atrophy


image palmar erythema


image gynecomastia


Portal hypertension with:


image hypersplenism with bone marrow changes and pancytopenia and hemorrhagic diathesis


image splenomegaly


image esophageal varices


image caput medusae


image external hemorrhoids


image ascites


General symptoms:


image fatigue


image reduced productivity


image nonspecific upper abdominal complaints


image cachexia


Portal Hypertension


Definition. Increased pressure in the portal vein system of more than 15 mmHg.


Causes. The blood flow in the portal vein system is blocked. This obstruction in blood flow can be prehepatic, intrahepatic, or posthepatic.


Possible causes include:


image prehepatic: portal vein thrombosis


image intrahepatic: cirrhosis of the liver


image posthepatic: right cardiac insufficiency


Clinical. Development of portacaval bypass circuits with:


image esophageal varices


image caput medusae


image external hemorrhoids


image ascites (transudation of plasma fluid, e.g., via the mesenteric veins)


image splenomegaly


Primary Hepatocellular Carcinoma


Definition. This is the most common malignant liver tumor. It develops from degenerated liver cells. Make sure that you distinguish it from liver metastases of extrahepatic tumors.


Causes


image alcohol abuse


image chronic HBV and HCV


image aflatoxin poisoning (ergot alkaloids)


Clinical


image symptoms of a decompensated liver cirrhosis


image cachexia


Osteopathic Practice


Cardinal Symptoms




  • Fatigue
  • Icterus

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Mar 4, 2017 | Posted by in ORTHOPEDIC | Comments Off on The Liver

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