Physiology of Liver, Liver Function tests, and

Pathophysiology of Jaundice
 LEARNING OBJECTIVES
The student will be able to: (MUST KNOW)
• List the functions of liver.
• Appreciate the importance of knowing hepatic physiology in learning medicine.
• Understand the functional architecture of hepatic lobule
• Outline the bilirubin metabolism.
• Comprehend the physiological basis of classification of jaundice.
• Appreciate the differences in laboratory findings of different types of jaundice.
 PHYSIOLOGY OF LIVER
• Liver is an essential organ as it is the center of all metabolisms and is crucial for many other
vital functions of the body. Therefore, liver dysfunctions result in major abnormalities of the body.
In adults, liver weighs about 1.5 kg. Liver is protected by a thin but strong capsule, called
Glisson’s capsule.
 FUNCTIONAL ANATOMY
The main function of the liver is the bile synthesis and secretion.
• The bile is secreted into hepatic ducts. The hepatic ducts join to form common hepatic duct.
• Bile is continuously formed and delivered to the gall bladder; the process known as bile
secretion.
• In the gall bladder, the bile is stored and concentrated and delivered via the common bile
duct into second part of duodenum in response to chyme entering the duodenum.
Blood Supply 
The Portal Vein
• Portal vein is formed by union of two veins, viz. superior mesenteric vein and splenic vein.
• Thus, portal vein supplies blood from most parts of the stomach and intestine as well as from the
spleen and pancreas.
• Therefore, portal blood is rich in end products of digestion, GI hormones and pancreatic
hormones.
• However, this blood is comparatively poor in oxygen.
Hepatic Artery: Hepatic artery contains pure arterial blood and is rich in oxygen.
Portal Circulation
• The portal vein and hepatic artery break up into large number of branches.
• Blood of these two sets of vessels get mixed up in the sinusoids of the liver. The hepatic cells
receive oxygen and nutrients from the sinusoids.
• The various substances produced by the liver, products of metabolism, the waste products and
the CO2 are discharged into the sinusoids.
• The sinusoids drain into central vein of the lobule.
• Central veins from different lobules unite to form larger veins, which in turn join ultimately and
drain into hepatic vein.
• The hepatic vein opens into the inferior vena cava.
Bile Secretion by Liver Cells
• The liver cells synthesize bile, which is first secreted to small canaliculi. The smaller canaliculi
join and ultimately form two hepatic ducts (right and left).
 HISTOLOGY OF LIVER
• Liver is formed by large number of lobules. Each lobule is delineated by a connective tissue
sheath.
• The individual lobule is polygonal in shape with a central vein at the center.
• From the central vein, plates of liver cells radiate like spokes of a bicycle wheel to the
periphery of the lobule.
• The plates are one cell thick and are separated by liver sinusoids.
• Liver cells have the capacity to regenerate.
Sinusoids and Bile Canaliculi
• In a typical lobule, between the plates of hepatic cells, the sinusoids are present that carry
blood.
• Each sinusoid receives blood from a branch of portal vein and hepatic artery of the portal
tract, and drains into the central vein.
• Wall of the sinusoids are mostly made up of endothelial cells, but at places macrophage cells,
called Kupffer cells, are occasionally present.
• The bile canaliculi run in between the two layers of cells. The liver cells synthesize bile acids
and transfer them into bile canaliculi.
• The space that lies between sinusoid and hepatocytes is the space of Disse (perisinusoidal
space). The space of Disse serves as a route through which hepatocytes remove certain
substances from blood and discharge certain products into the blood.
Portal triad
• Portal triads are typically found at the angles of liver lobules. Each portal triad consists of a
branch of portal vein, a branch of hepatic artery and a bile ductule.
• The angular space that contains portal triad and its surrounding connective tissue is called
portal canal.
• Portal sinusoids originating from portal veins remain in close proximity with bile canaliculi that
drain into interlobular bile duct.
• A small space between hepatocyte and portal canal is called space of Mall, the site of origin of
lymph in liver.
 FUNCTIONS OF LIVER
1.  Secretory functions: Liver forms and secretes bile into biliary tract.
2.  Metabolic functions: Liver is involved in metabolism of major nutrients such as carbohydrate,
fat, proteins, and fat soluble and water-soluble vitamins. Liver plays a central role in the
metabolisms of urea, iron and alcohol.
3.  Synthetic functions: Liver is the major organ for the synthesis of proteins that include clotting
factors, acute phase proteins that mediate inflammation, hormone binding proteins, lipids,
carbohydrates, vitamins and bile salts.
4.  Storage functions: Liver stores glucose, protein, fat, and vitamins. These nutrients are released
from liver and utilized during their scarcity, and are stored in liver when they are in excess.
5.  Detoxifying action: Liver detoxifies many chemicals. Toxins released from infecting organisms
are neutralized in liver.
6.  Degradation of drugs and chemicals: Liver is the site of inactivation of many drugs. Liver
degrades enzymes, hormones, cytokines and various other chemicals.
7.  Excretory function: Liver excretes bile pigments, cholesterol, and some metals.
8.  Immunity: Kupffer cells of liver are part of mononuclear phagocyte system (reticuloendothelial
system) that forms the nonspecific defenses of the body. These cells phagocytose and kill
microorganism.
9.  Endocrine functions: Liver converts vitamin D3 to 25-hydroxyvitamin D3. Liver is a major site
for conversion of T4 to T3. Somatomedin (insulin-like growth factor) that mediates important
functions of growth factor is secreted from liver. Many hormones like insulin, glucagon, growth
hormone, GI hormones etc. are degraded in liver.
 LIVER FUNCTION TESTS
A. Tests for manufacture and excretion of bile
1. Bilirubin estimation
I. In serum
II. In feces
III. In urine
2. Urobilinogen
3. Bile acids (bile salts)
4. Bromosulphalein excretion
B. Serum enzyme assays
1. Alkaline phosphatase
2. -Glutamyl transpeptidase
3. Transaminases (aminotransferases)
I. Aspartate transaminases or AST
II. Alanine transaminases or ALT
4. Other serum enzymes
III. 5 Nucleotidase
IV. Lactate dehydrogenase
V. Choline esterase
C. Tests for metabolic functions
1. Amino acid and plasma protein metabolism
VI. Serum proteins
VII.Immunoglobulins
VIII.Clotting factors
IX. Serum ammonia
3. Lipid and lipoprotein metabolism
4. Carbohydrate metabolism
D. Immunologic tests
I. Nonspecific immunologic reactions
II. Antibodies to specific etiologic agents
E. Ancillary diagnostic tests
III. Ultrasonography
IV. FNAC and/or percutaneous liver biopsy
 PATHOPHYSIOLOGY OF JAUNDICE
• Jaundice is the yellowish discoloration of sclera, skin and mucous membrane due to the
deposition of bilirubin. This happens when concentration of bilirubin increases in blood.
Bilirubin is the product of hemoglobin breakdown.
Red Cell Breakdown
Hemoglobin Catabolism
• Macrophages split hemoglobin into heme and globin.
• Globin is degraded into amino acids that enter the amino acid pool
• Heme is catabolized by the microsomal oxygenase system to release iron, which joins the iron
pool of the body.
• Some of the heme molecules are simultaneously oxidized to biliverdin.
• Then, biliverdin is reduced to bilirubin by the enzyme biliverdin reductase. Bilirubin for its
lipophilic nature crosses cell membrane easily. However, for its water-insolubility, it is transported
in body fluids only after conjugation in the liver or in combination with albumin.
Bilirubin Metabolism
• Bilirubin released from macrophages enters the blood stream, where it forms a complex with
albumin. Bilirubin-albumin complex is split in the liver, bilirubin enters liver cells and albumin
stays back in the blood.
• In liver cells, bilirubin undergoes three-step metabolism: uptake, conjugation and excretion.
1.  Uptake: Bilirubin after splitting from albumin-bilirubin complex is transported into the hepatocyte,
where it forms a complex with a cytoplasmic protein, called ligandin. Formation of bilirubin-
ligandin complex prevents bilirubin to return back to the blood as the complex is too big to pass
through the liver cell membrane.
2. Conjugation: Hepatocytes conjugate bilirubin with glucuronic acid, which takes place in the
endoplasmic reticulum and involves UDP-glucuronic acid and glucuronyl transferase. This forms
bilirubin glucuronide.
• Heme is converted to biliverdin by heme oxidase, and biliverdin is converted to bilirubin by
biliverdin reductase.
• Unconjugated bilirubin bound to albumin enters liver and get conjugated by the action of
glucuronosyl transferase, to from bilirubin diglucuronide.
• Following enterohepatic circulation, bilirubin is excreted through bile into intestine, where it is
converted to urobilinogen by bacterial reduction.
• Urobilinogen is further converted into stercobilinogen.
• A fraction of urobilinogen is absorbed into blood from intestine and excreted in urine as urinary
urobilinogen. Urobilinogen content of stool and urine indicates rate of hemolysis
3.  Excretion: Bilirubin glucuronide is excreted from hepatocytes into the biliary canaliculi.
Fate of Conjugated Bilirubin
• In large intestine, bilirubin is acted upon by the bacterial flora, where glucuronic acid is split and
bilirubin undergoes a series of reduction reactions to from stercobilinogen.
• Stercobilinogen, a colorless compound has two fates:
1.  In intestine, 80% of stercobilinogen is oxidized to stercobilin, which is excreted in stool.
2.  The remaining 20% stercobilinogen is absorbed into the portal circulation and re-excreted by
liver into the bile, and re-enters the intestine. In urine, the stercobilinogen is called urobilinogen.
3. Conjugated bilirubin is not reabsorbable, whereas its metabolic product, urobilinogen is
reabsorbed and enters enterohepatic circulation.
Normal Plasma Bilirubin Level: The normal concentration of bilirubin in plasma is 0.2–0.8 mg/dL.
Jaundice is detected clinically only when the bilirubin level exceeds 2 mg/dL.
 HEMOLYTIC JAUNDICE
• Hemolytic jaundice occurs from increased destruction of red cells or their precursors in the
marrow (Table 13.1), causing increased bilirubin production.
• Jaundice due to hemolysis is usually mild because the healthy liver can excrete a bilirubin load
of six times of its normal concentration.
• However, this does not happen in newborn. Hence, hemolytic jaundice is common in
newborn
• Heme is converted to biliverdin by heme oxidase, and biliverdin is converted to bilirubin by
biliverdin reductase (Fig. 13.2).
• Unconjugated bilirubin bound to albumin enters liver and get conjugated by the action of
glucuronosyl transferase, to from bilirubin diglucuronide.
• Following enterohepatic circulation, bilirubin is excreted through bile into intestine, where it is
converted to urobilinogen by bacterial reduction.
• Urobilinogen is further converted into stercobilinogen.
• A fraction of urobilinogen is absorbed into blood from intestine and excreted in urine as urinary
urobilinogen. Urobilinogen content of stool and urine indicates rate of hemolysis
• As unconjugated bilirubin is mostly bound to protein (bilirubin-albumin complex), bilirubin is
not filtered in the glomerulus and therefore, there is no excretion of bilirubin in urine.
• Hence, hemolytic jaundice is called acholuric jaundice.
• However, urine color may become brown due to excretion of urobilinogen in urine.
• Increased quantity of fecal stercobilinogen can cause dark-brown colored stool.
• The plasma bilirubin is usually less than 6 mg% and liver function tests are usually normal.
• For details of ‘Liver Function Tests’ in jaundice, refer the Chapter 84, in GI System.
 TYPES OF JAUNDICE
• Clinically, jaundice is detected when bilirubin level is more than 2 mg/dL. Bilirubin level between
0.8 to 2 mg% is called latent or subclinical jaundice. Jaundice first appears in sclera, because
bilirubin has an extremely high affinity for scleral protein called elastin.
• Physiologically, the causes of jaundice are divided broadly into two categories: increased
production of bilirubin and decreased excretion of bilirubin.
Increased Production of Bilirubin
• Production of bilirubin is increased in hemolysis. Therefore, the jaundice is called hemolytic
jaundice. This is seen in hemolytic anemias.
Decreased Excretion of Bilirubin
• The excretion of bilirubin is impaired when liver cannot conjugate bilirubin efficiently, which is
called hepatic jaundice, or when conjugated bilirubin cannot be excreted in bile due to biliary
obstruction, which is called obstructive jaundice.
• Hepatic jaundice commonly occurs in viral hepatitis and obstructive jaundice is commonly seen
in gall stones (stone in the common bile duct) or stricture of bile duct. However, hepatic and
obstructive jaundice overlap in their pathophysiologic processes.
• In hepatic jaundice, narrowing of biliary canaliculi occurs very often resulting in intrahepatic
obstruction (stasis). This adds an obstructive element to the hepatic jaundice.
• In obstructive jaundice, biliary stasis behind the site of obstruction causes damage to the
hepatocytes. This adds hepatocellular element to the obstructive jaundice.
Laboratory Diagnosis of Jaundice
Hemolytic Jaundice
• Excessive production of bilirubin allows liver to conjugate more than the normal quantity of
bilirubin.
• Therefore, more quantity of bilirubin glucuronide is delivered to the intestine. Consequently,
the amount of stercobilinogen formed in the intestine is increased.
• This leads to increased excretion of fecal stercobilinogen and urinary urobilinogen.
• Bilirubin in plasma forms a complex with albumin, which can’t be excreted in the urine.
Therefore, hemolytic jaundice is acholuric jaundice. Liver function tests are usually normal.
Hepatic Jaundice
• In hepatic jaundice, all three steps of bilirubin metabolism (uptake, conjugation and excretion)
are affected. But as mentioned earlier, the rate-limiting step is excretion, and therefore that
may be the most affected. Therefore, not only the conjugation of bilirubin is impaired, but also
some amount of conjugated bilirubin is not excreted in bile.
• The conjugated bilirubin that accumulates in liver cells diffuses across the cell membrane into
the bloodstream. Thus, in hepatic jaundice the blood contains excess of bilirubin-albumin
complex as diseased liver may not be able to conjugate all the load of bilirubin. Also, conjugated
bilirubin diffuses back into the bloodstream.
• Consequently, conjugated bilirubin (bilirubin glucuronide) is excreted in the urine. This
makes urine yellow due to the presence of urinary bilirubin.
• Bilirubin excreted in bile is reduced. Hence fecal stercobilinogen and urinary urobilinogen
are reduced.
• Plasma albumin may be low as diseased liver cannot synthesize the normal amount of albumin.
Plasma globulins are high in liver disease because of a rise in the gamma-globulin fraction.
Thus, albumin-globulin ratio is altered.
• Neonatal jaundice could be due to defective conjugation of bilirubin.
Obstructive Jaundice
• Obstructive jaundice occurs due to obstruction to bile secretion into intestine.
• In obstructive jaundice, no bile reaches the intestine. Hence, neither bilirubin nor bile salts is
present in the intestine. Therefore, no fecal stercobilinogen is formed, and stool becomes clay
colored.
• Also, urinary urobilinogen is absent.
• As bile salt is reduced in intestine, there is an increased fecal excretion of fat (steatorrhea).
• The conjugated bilirubin accumulates proximal to the obstruction, and is regurgitated by the liver
cells into the bloodstream. Therefore, the level of conjugated bilirubin in the blood is high,
which is excreted in urine and causes deep yellow urine.
• Like conjugated bilirubin, bile salts are also regurgitated into the blood stream, and excreted in
urine. Initially liver function tests are normal. But, later, prolonged biliary stasis damages the liver
and impairs liver functions
van den Bergh test: van den Bergh test detects whether bilirubin is conjugated or not. The test is
based on the principle that excess of water soluble bilirubin-glucuronide gives a reddish-violet
colour when brought in contact with diazo reagent.
• If the colour appears immediately, the test is said to be direct positive.
• If the color appears late, or only after addition of alcohol, the test is said to be indirect positive.
• In hemolytic jaundice, the van den Bergh test is indirect positive
• In obstructive jaundice, it is direct positive.
• In hepatic jaundice, the test may be biphasic, i.e. an atypical color develops almost immediately.
In the intestine, bilirubin is converted to urobilinogen by bacterial
reduction. Urobilinogen is further converted to stercobilinogen and
stercobilin that are excreted in stool.
A small fraction of urobilinogen is absorbed from intestine and
excreted through urine as urinary urobilinogen .