Hepatic and Biliary Disorders - Merck Manuals Professional Edition

Approach to the Patient With Liver Disease

The liver is a metabolically complex organ. Hepatocytes (liver parenchymal cells) perform the liver’s metabolic functions:
Testing for Hepatic and Biliary Disorders

Laboratory tests are generally effective for the following:
Alcohol-Related Liver Disease

Alcohol consumption is high in most Western countries. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), 8.5% of US adults are estimated to have alcohol use disorder in any 12-month period (see Alcohol Use Disorders and Rehabilitation). The male:female ratio is about 2:1. Disorders of the liver that occur in people with alcohol use disorder, often in sequence, include
- Alcohol-Related Liver Disease
Drugs and the Liver

Liver disease may have complex effects on drug clearance, biotransformation, and pharmacokinetics. Pathogenetic factors include alterations in intestinal absorption, plasma protein binding, hepatic extraction ratio, liver blood flow, portal-systemic shunting, biliary excretion, enterohepatic circulation, and renal clearance. Sometimes alterations increase levels of bioavailable drug, causing normal medication doses to have toxic effects. However, levels and effects for an individual drug are unpredictable and do not correlate well with the type of liver injury, its severity, or liver test results. Thus, no general rules are available for modifying drug dosage in patients with liver disease.
- Effects of Liver Disease on Drug Metabolism
- Liver Injury Caused by Drugs
Fibrosis and Cirrhosis

Hepatic fibrosis is overly exuberant wound healing in which excessive connective tissue builds up in the liver. The extracellular matrix is overproduced, degraded deficiently, or both. The trigger is chronic injury, especially if there is an inflammatory component. Fibrosis itself causes no symptoms but can lead to portal hypertension (the scarring distorts blood flow through the liver) or cirrhosis (the scarring results in disruption of normal hepatic architecture and liver dysfunction). Diagnosis is based on liver biopsy. Treatment involves correcting the underlying condition when possible.
Gallbladder and Bile Duct Disorders

The liver produces about 500 to 600 mL of bile each day. Bile is isosmotic with plasma and consists primarily of water and electrolytes but also organic compounds: bile salts, phospholipids (mostly lecithin), cholesterol, bilirubin, and other endogenously produced or ingested compounds, such as proteins that regulate gastrointestinal function and drugs or their metabolites. Bilirubin is a degradation product of heme compounds from worn-out red blood cells (RBCs) and is the pigment that gives bile its yellow-green color.
Hepatitis

Hepatitis is inflammation of the liver characterized by diffuse or patchy necrosis.
Liver Masses and Granulomas

Isolated hepatic cysts are commonly detected incidentally on abdominal ultrasonography or CT ( 1). These cysts are usually asymptomatic and have no clinical significance. The rare congenital polycystic liver is commonly associated with polycystic disease of the kidneys and other organs. It causes progressive nodular hepatomegaly (sometimes massive) in adults. Nevertheless, hepatocellular function is remarkably well preserved, and portal hypertension rarely develops. Occasionally, very large cysts cause pain or symptoms from compression of other organs. In these instances, intervention such as cyst marsupialization or drainage can be considered; however, cysts often recur. Thus, rarely, significant symptoms or quality-of-life issues warrant consideration of liver transplantation.
Vascular Disorders of the Liver

The liver has a dual blood supply. The portal vein (which is rich in nutrients and relatively high in oxygen) provides two thirds of blood flow to the liver. The hepatic artery (which is oxygen-rich) supplies the rest. The hepatic veins drain the liver into the inferior vena cava. When portal vein blood flow increases, hepatic artery flow decreases and vice versa (the hepatic arterial buffer response). This dual, reciprocally compensatory blood supply provides some protection from hepatic ischemia in healthy people.