LIVER [hepar (PNA, JNA, BNA)] — the unpaired body which is located in an abdominal cavity and relating to the alimentary system; is the largest gland in a human body, takes part in processes of digestion, a metabolism and blood circulation, carries out specific enzymatic and excretory functions.
- 1 The comparative anatomy and embryology
- 2 The histology
- 3 Physiology
- 4 the Biochemistry
- 5 Methods of a research
- 6 The pathological anatomy
- 7 Pathology
- 8 Operations
The comparative anatomy and embryology
At the lowest vertebral P. appears in the form of a tubular outgrowth of a gut which wall consists of an entodermalny epithelium. This blind outgrowth lies between leaves of a mesentery of a small bowel. At P.'s lancelet remains in the form of such rudiment. At fishes such rudiment burgeons in a mesenchyma of a splanchnopleura in which branches. Connecting fabric in which there pass numerous blood vessels accumulates on an epithelium of poorly canalized its branches. The treelike design of tubes and epithelial presents to tyazhy a basis of the developing P. U of Cyclostoma P.'s rudiment turns into complex tubular gland. Its output channels collect a secret (bile) from small tubules, in to-rye intercellular cracks open. At land animals the cellular mass of P. is condensed, its tubular structure is lost, the number of hepatic plates between sinusoids and number of hepatocytes in each hepatic plate decreases.
At the person P. it is put on the 3rd week of embryonic development. Protrusion of a ventral wall of initial department of primary average gut which corresponds to future duodenum appears at embryos 2,5 mm long. From an entodermalny vystilka of this protrusion P.'s rudiment — a hepatic diverticulum also develops. At an embryo 5 — 6 mm long in P.'s rudiment distinguish a cranial part from which hepatic plates, intra hepatic bilious channels and both hepatic channels develop; the caudal part including vesical department from which there are a gall bladder and a vesical channel, and the central part from which the general bilious channel forms. The mass of quickly breeding epithelial cells grows into a mesenchyma of a ventral mesentery, filling space between a cross partition, an umbilical and intestinal channel and a stomach. The system of hepatic sinusoid arising in a mesenchyma of a ventral mesentery connects later to branches of venous vessels. In the mesenchyma remaining between hepatic plates very much the centers of a hemopoiesis in the form of blood islands early appear; they can be located also in gleams of sinusoid.
Interior of a rudiment of P. is influenced by the veins passing through it to which hepatic sinusoids connect. Trabeculas of hepatic cells grow into layers of friable connecting fabric between umbilical and mesenteric veins from which left further are reduced, and from right the portal vein forms. In vesical department of a hepatic rudiment, continuous in the beginning, then there is hollow protrusion from which further form a gall bladder of Pi a vesical channel. Interlobular connecting fabric, and also connecting fabric and unstriated muscles of bilious channels are formed of leaves of a ventral mesentery and a mesenchyma the connective tissue capsule P. with a mesothelial layer. The remains of a mesenchyma in the developing P. join in intersticial connecting fabric, participate in creation of walls of sinusoidny circulatory capillaries and vessels between hepatic plates.
At a 6 weeks germ of P. macroscopically reminds mulberry berry. By 18th week of pre-natal development segments P.
== Anatomy == are designated
The item is located in a nadchrevya, occupying the right hypochondrium, actually epigastriß area and coming the left share into the left hypochondrium. The item has the irregular dome-shaped shape (fig. 1), henna-red color, soft, slightly elastic consistence, its weight (weight) apprx. 1500. Distinguish the upper surface of P. adjoining to a diaphragm, and lower, visceral, adjoining to abdominal organs. First (lower) line of P. acute, back — rounded off. From above it is possible to see P.'s division into the right and left shares between which border the crescent team of P. — transition of a peritoneum from an upper surface of P. to a diaphragm serves. Two longitudinal deepenings and a cross furrow on a visceral surface of P. divide it into 4 shares: right, left, square and having a tail. The right longitudinal deepening is in front designated as a pole of a gall bladder, is behind caused by a furrow of the lower vena cava. Behind is in the left longitudinal deepening fibrous tyazh (a venous sheaf) — the obliterated venous channel, in front — the round team of P. representing an overgrown umbilical vein. The upper bound of P. matching the level of a diaphragm goes dugoobrazno from the right tenth mezhreberye, from a point of its crossing with the average axillary line, to the left fifth mezhreberye, to a point of its crossing with the left sredneklyuchichny line.
In these points limits of the Item meet top and bottom. The lower bound of P. matches bottom edge of a costal arch on the right. From the conjunction the lower bound passes IX and VIII edges slantwise to the left to the conjunction of cartilages of the left VIII and VII edges, crossing the median plane of a body approximately on the middle of distance between a navel and a xiphoidal shoot of a breast.
A visceral surface of P. adjoins to some bodies adjoining to it. The left share of P. is adjoined by a cardial part of a stomach and a belly part of a gullet.
On a surface of the right share leave impressions a colon, the right kidney and an adrenal gland. The item almost from all directions it is covered with a peritoneum. The exception is made by its posterosuperior surface spliced with a lower surface of a diaphragm. The peritoneum passes from P. to a stomach and an upper part of a duodenum in the form of an omentulum which includes hepatogastric and hepatoduodenal sheaves. The number of peritoneal teams of P. joins also hepatonephric and coronal sheaves.
In P.'s fixing an important role is played by an union it with a diaphragm and the lower vena cava. Besides, P.'s deduction in a certain situation is promoted by pressure of a prelum abdominale and existence of sheaves.
The item it is surrounded with the thin fibrous cover consisting of network collagenic tyazhy with impurity of elastic fibers and separating P.'s parenchyma from a serous cover. In the field of P.'s gate the fibrous cover becomes thicker and together with a portal vein and own hepatic artery under the name okolososudi-stand the fibrous capsule (a portal path) enters gate of the Item. The fibrous cover, a portal path and intra hepatic connecting fabric are called a stroma of P. which borrows adults apprx. 4,3% of volume of body (at children to 6%).
Through P. in the pre-natal period there passes the placental blood enriched with oxygen and nutrients. She is brought on an umbilical vein which at P.'s gate enters a portal vein. In this place the venous channel going to the lower vena cava departs from it. After the birth the venous channel turns into a venous sheaf, and the rest of the obliterated umbilical vein remains in the form of a round team of P. S of 2 — 3 months of G1. acts from under a costal arch; it or is extended in length, or has the deckle-edged convex form. The child is born about rather big Item. It weighs on average 135 g that makes 4,5 — 5,5% of body weight. In the first months of life the relative sizes P. decrease, its bottom supports limits of the right costal arch on 1 — 2 cm. By 2 years P.'s weight increases twice, by 3 years — three times. Rather big left share of P. stretches to the left subcostal area and covers a spleen. By 7 years of border of P. correspond to that at the adult. By the period of puberty P.'s weight reaches on average 1350 and makes 3% of body weight.
P.'s parenchyma consists of segments (tsvetn. fig. 1) which cells develop bile (see), gathering in interlobular ductules. Following near interlobular blood vessels and connecting with each other, they form segmented and share channels, and then the general hepatic channel which leaves portal fissures (see. Bilious channels ). Intra hepatic bilious ways are isolated on shares. The right hepatic channel accepts bile from the front and back branches corresponding to the segments of the right share of the same name. The left hepatic channel which is formed of merge of medial and lateral branches belongs to two segments of the left share. According to an arrangement of bilious ways each of segments can be divided on top and bottom areas. Through borders between segments, as a rule, do not pass bilious ways and blood vessels. In a share having a tail of P. there are certain right and left canals.
Segment P. consider the pyramidal site of its parenchyma adjacent to a so-called hepatic triad (the branch of the 2nd order of a portal vein accompanying it a branch of own hepatic artery and the corresponding branch of a hepatic channel). The front segment of the right share is projected on front and upper parts of a phrenic surface of P., and a back segment P. Medialny occupies the tail of a phrenic surface both all visceral surface of the right share and lateral segments are divided by the left longitudinal deepening. Square and shares having a tail of P. make a medial segment, and actually left share matches a lateral segment, (tsvetn. fig. 2). The number and the nomenclature of segments are not completely developed. So, according to Kuino's (fig. 2) scheme in P. allocate 8 segments, in works of other researchers — to 26.
Blood supply. The item receives blood from the portal vein and own hepatic artery entering P.'s gate between leaves of a hepatoduodenal sheaf. Both vessels branch in P. to the general capillary network. Own hepatic artery is divided into the right and left branches corresponding to share arteries. From them arteries of segments begin: front and back — from the right share artery, medial and lateral — from left. They accompany the respective bilious canals and are dichotomizing divided into branches from which one goes to the upper area of a segment, another to lower. Blood supply of a share having a tail is provided by the right and left branches of own hepatic artery. Gradually becoming thinner, arterial branches become interlobular arteries, are located between segments of a liver and deliver them blood. The capillaries which are formed as a result of branching of arterioles are implemented between beams of segments of a liver and connect to sinusoidny capillaries of portal system. Through traffics between arterioles and venules on the periphery of segments can be considered as an arteriolovenu-lyarny anastomosis.
Portal vein (see) forms a portal sine from which the right and left branches and cross parts of a trunk of a share having a tail which are breaking up to 6 — 10 branches originate. There are 5 — 7 orders of branching of a portal vein before the thinnest interlobular branches turn into vokrugdolkovy (septal) veins (they precapillary, or terminal, venules). The septal veins going radially pass into sinusoidny capillaries, the general for arterial and portal system. Capillaries open in the central vein which received the name from location in the center of a segment. The drainage system of hepatic veins begins the central veins. Inserted and sublobular collective veins create eventually 3 — 4 main hepatic veins. Trunks of the right, average and left hepatic veins, short on an extent, open in the lower vena cava directly from P.'s parenchyma on its back surface. At their confluence in a wall of veins muscular presses (sphincters) are located.
Lymph drainage from P. it is made on superficial and deep limf, to vessels. Superficial limf, vessels follow in the thickness of the capsule P., forming limf, network with cells polygonal, extended or wrong rounded shape. Many loops are limited limf, the vessels having blind outgrowths and expansions. The capillary network gives rise collecting limf, to vessels, to-rye at merge pass into the taking-away vessels. Superficial limf, vessels anastomose with deep, beginning from around - lobular capillary networks. In segments limf, there are no capillaries. Interlobular limf, collectors join to limf, to the textures accompanying intra hepatic blood vessels and output bilious channels. Here the vessels going to P.'s gate or to its back surface to limf, to nodes of a back abdominal wall are made out deep taking away limf.
Innervation it is carried out by sympathetic, parasympathetic and sensitive nerve fibrils. In the nervous bunches entering P. on the course of a portal vein and own hepatic artery myelin fibers prevail. Distinguish the front hepatic texture surrounding own hepatic artery, and back, located near a portal vein and the general bilious channel. These textures form from branches of a celiac texture and chords of vagus nerves. In both textures there are numerous nerve knots. Participation in P.'s innervation of phrenic nerves is proved. Walls of veins P. are rich with adrenergic nerve fibrils. In walls of bilious channels cholinergic fibers which are not enough in a wall of a portal vein meet. The terminations of nerve fibrils with dense synoptic vesicles are found on average a layer of a wall of vessels up to their internal cover. In the field of sphincters of hepatic veins dense accumulations of nerve fibrils are allocated. The wall of a portal vein contains various sensitive nerve terminations which set allows to distinguish a portal reflexogenic zone. Existence of an efferent innervation of hepatic cells is not proved.
Radioanatomy. On P.'s roentgenogram gives an intensive homogeneous shadow. The contour of a phrenic surface of P. merges with a shadow of the right half of a diaphragm. Outside and front contours of the right share of P. equal, accurate. The lower contour of P. corresponds to its first line — from a shadow of a backbone it goes from top to bottom and knaruzh; on it it is possible to notice dredging in the field of P.'s gate and a pole of a gall bladder. With an outside contour of the right share of P. the lower contour forms an acute angle which does not exceed 60 °. The left share of P. at adults is projected on a shadow of a backbone and therefore it is visible to hl. obr. in the left side projection in which the shadow has it the form of the triangle turned by the basis to a front slope of a diaphragm, one party — to a front abdominal wall, and the second party — to a front wall of a stomach. At children the left share of P. is rather big, and its shadow is given from the image of a backbone to the left.
P.'s image in the plane, perpendicular to a longitudinal axis of a body, is received by means of a computer tomography (see the Tomography computer). On computer tomograms P.'s shadow is homogeneous, but in it narrow light strips of large veins and bilious channels appear; the gall bladder and the layers of fatty tissue surrounding it are accurately displayed.
P.'s Parenchyma is constructed of the cells of a ferruterous epithelium forming hepatic beams and plates of which segments of the Item consist. On cross section the hepatic segment has an appearance of a hexagon from which parties hepatic beams and sinusoidny capillaries reach for the center. In the middle of a hexagon of a hepatic segment there is the central vein. Intra lobular circulatory capillaries throughout are covered by an endothelium with flat, thin, porous cells to which star-shaped retikuloendote-liotsita adjoin. The hepatic cells surrounding P.'s sinusoids possess a large number of the cytoplasmatic microoutgrowths (mikrovorsin) increasing their soaking-up and excretory surface. Cells will be spaced from a surface of an endothelium of capillaries on nek-rum distance therefore between them the perisinusoidalny space — so-called space of Disse is formed. The space the Yew is reported through a time with capillaries and therefore it is filled with plasma. It is reported also with intersticial space of Moll from where the intercellular lymph on the periphery of a segment can flow in interlobular roots limf, systems.
Diameter of hepatic cells makes 18 — 40 microns depending on intensity of exchange processes and degree of fullness of a vascular bed blood. The sizes of hepatic cells can change even within a day. Their cytoplasm contains a large number of organellas, especially mitochondrions (see). There is well developed smooth and rough Endoplasmic reticulum (see). The lamellar complex (see Golgi a complex) is located between a kernel of the cell and a plasmolemma turned to a bilious capillary that explain it with participation in regulation of a bile production. Chromatin in a kernel is distributed evenly, except DNA, in it find an acid and alkaline phosphatase. The hepatocytes which are located on the periphery of a segment of P. possess well developed lamellar complex and less large, roundish mitochondrions; they are rich with a glycogen and enzymes of carbohydrate metabolism. In the central area of a segment of P. hepatocytes lighter, differ in activity of protein metabolism, show the expressed reaction to an alkaline phosphatase. In addition to functional features in hepatic cells age changes are observed. So, the percent of two-nuclear hepatocytes from 1,5% at the newborn reaches 8,3% at adults. At senile age in hepatocytes the pigment lipofuscin is postponed.
Hepatic plates are divided by sinusoidny capillaries with a diameter up to 30 microns and perisinusoidalny-m Disse's spaces. The wall of a sinusoidny capillary is constructed of one layer of endotheliocytes and has no basal membrane. Endotheliocytes have the flattened form and a numerous time in cytoplasm. In cytoplasm of endotheliocytes plentiful small mitochondrions, ribosomes are visible, the lamellar complex is well presented, and also it is a lot of intracellular inclusions from which one are constant as, e.g., vacuoles, others appear periodically at change of a functional condition of a cell. The large number of vacuoles facilitates transendothelial transfer of molecules. Endotheliocytes along with star-shaped retikuloendoteliotsita perform phagocytal function. In the place there began the sinusoid and at its falling into the central vein peculiar locking devices — precapillary and prevenozny sphincters are located. Assume that muscle and glomal cells can be their part. Sinusoidal capillaries with which the portal venous system comes to the end meet capillaries of an arterial tree of P. in peripheral and central areas of a segment of P.
P. performs diverse functions, the most important of which are homeostatic, metabolic, excretory, barrier and depositing. Implementation of these functions and P.'s participation in a metabolism are possible thanks to close connection of P. with other internals and blood. Anatomic situation, features of a structure, blood supply and a lymphokinesis define variety of functions P. So, connect distinction of functions of peripheral and central departments of segments of the Item with features of intra hepatic circulation. Hepatocytes of peripheral departments of hepatic segments accumulate various substances, including and vysokoergichesky connections (see), participate in a detoxication; hepatocytes of the central departments of hepatic segments carry out metabolism of bilirubin and excretion in bilious capillaries of a number of substances endo-and an exogenous origin.
The blood circulatory system of P. turns on two bringing blood vessels — a portal vein, through to-ruyu 70 — 80% of total amount of the inflowing blood, and own hepatic artery (20 — 30% of total amount of the blood inflowing to P.) and one carrying away — a hepatic vein arrive. For the purpose of clarification of a role of portal and hepatic systems in P.'s blood supply in 1877 N. V. Ekk made an attempt of switching off at a dog of portal venous blood supply of P. by imposing of an anastomosis (a fistula of Ek) between a portal and lower vena cava that led to death of animals owing to poisoning with the cleavage products of feedstuffs (first of all proteins) coming from intestines to the blood circulatory system, passing P. V 1893 I. P. Pavlov, having improved technology of operation and having developed a special diet of the operated animals, achieved their survival in 30% of cases.
Through a portal vein cleavage products of feedstuffs, products of hemolysis, etc. come to P. with blood. The blood rich with oxygen arriving through own hepatic artery washes hepatocytes of peripheral departments of segments of P. in the beginning, giving them a part of oxygen. To the central departments of hepatic segments the blood which was less oxygenated arrives that affects, e.g., at action of disturbing factors — hepatocytes of the central departments of segments of P. are injured stronger than peripheral. At rest, when in intra hepatic krovoo6rashchenii participates apprx. 25% of intra lobular capillaries, passes up to 30 — 35% of minute volume of blood through P. that makes 1460 — 1790 ml of blood in 1 min. The contact of hepatocytes with blood is promoted by the slow intraorganic blood stream caused by the considerable width of sinusoidny capillaries and existence in them and hepatic veins of the muscle fibers participating in regulation of speed of a blood flow (see. Portal blood circulation ).
The item actively participates in a lymphopoiesis. It is established that a considerable part of a lymph of a chest channel is formed in the Item. This lymph contains a large amount of protein that is explained by high-permeability of hepatic capillaries for proteins of plasma. The lymphopoiesis in P. promotes elimination of developments of stagnation at disturbances of blood circulation, to removal and neutralization inf. agents, to reduction of concentration of toxins.
In P. many substances and factors of the proteinaceous nature regulating coagulability of blood — components of a prothrombin complex are synthesized (factors of II, VII, IX, X), fibrinogen, factors of coagulation of V, XI, XII, XIII, and also antithrombin and antiplazmiya (see. Coagulant system of blood ).
The item plays an important role in maintenance of constancy of composition of blood that is provided with its participation in many exchange processes causing education, accumulation and allocation in blood of various metabolites, on the one hand, and absorption from blood, transformation and excretion of many substances — with another. Functions P. in a metabolism are connected with various structures of a hepatocyte. So, in its kernel synthesis of nuclear proteins, in kernels — synthesis and a transcription of RNA is carried out; in mitochondrions there is an oxidizing phosphorylation, protein synthesis and urea, oxidation of fatty acids and a cycle of Tricarboxylic acids; in a lamellar complex phosphorylation of glycoproteins, glikozaminoglikan, concentration of a protein are carried out; in lysosomes bile is formed, there is an intracellular digestion, defense reactions are carried out; synthesis of lipids is localized in a granular cytoplasmic reticulum, here and in a smooth cytoplasmic reticulum transformation of hormones is carried out.
The item participates in complex processes of exchange of proteins and amino acids (see. Nitrogen metabolism), in it the majority of proteins of a blood plasma is formed. Almost only in P. there is an ureapoiesis, she participates also in interamination and deamination of amino acids, formation of a glutamine, synthesis of creatine.
Plays an essential role of P. in lipid metabolism. Generally in P. triglycerides, phospholipids and bilious to - you are synthesized; a considerable part of endogenous cholesterol is formed; there is an oxidation of triglycerides, formation of acetone bodies. The item takes part in formation of lipoproteids — a transport form of triglycerides and some other low solubility substances in water. Lipid metabolism is closely connected also with zhelchevydelitelny function P. as bile is important for hydrolysis and absorption of fats in intestines (see the Lipometabolism).
The item actively participates in interstitial exchange of carbohydrates (see. Carbohydrate metabolism ) — in it there is a process glycogeniuses (synthesis of a glycogen) and a glycogenolysis. P.'s cells contain the enzymes including a galactose and fructose in metabolism. In Pg also sugar and a glycogen is formed of not carbohydrates (gliksneogeniye), there is an oxidation of glucose, education glucuronic to - you, participating in conjugation of a number of substances that increases their water solubility and facilitates removal from an organism.
P.'s participation in pigmental exchange consists in formation of bilirubin, its conjugation with glucuronic to - that and excretion in bile.
The item takes part in exchange of biologically active agents — hormones, biogenic amines, vitamins. In it the enzymatic inactivation of steroid hormones (glucocorticosteroids, Aldosteronum, androgens, estrogen), and also an inactivation of insulin, a glucagon, antidiuretic hormone, hormone of a thyroid gland is carried out; biogenic amines — serotonin, a histamine, catecholamines are metabolized.
P.'s participation in exchange of fat-soluble vitamins (A, D, E, K) begins already at their absorption which requires presence at intestines of bile. The item is the main place of synthesis of vitamin A; here biologically active forms of polyneuramin (pyridoxal phosphate), folic to - you (tetrahydrofolic to - that), sincaline (cytidinemonophosphate of sincaline) are formed.
Exchange of microelements is closely connected with P. The item synthesizes the proteins transporting iron (siderophilin) and copper (ceruloplasmin), participates in exchange of manganese, molybdenum, cobalt and some other metals (see. Mineral metabolism). P.'s role in exchange of sodium and potassium comes down to the fact that she participates in regulation of release of potassium kidneys, participating in exchange of Aldosteronum. With the regulating influence of II. on activity of Aldosteronum and antidiuretic hormone its participation in water exchange of an organism is connected (see Vodnosolevy exchange). In P. the albumine maintaining colloid and osmotic balance of blood is synthesized.
Excretory function P. provides removal from an organism with bile more than 40 connections both synthesized directly in P., and taken from blood (in most cases after metabolic changes in P.). The item it is also capable to excrete the substances connected with krupnomolekulyarny proteins and not water soluble. Treat number of the substances excreted by P. as a part of bile cholesterol, bilious to - you, phospholipids, bilirubin, many proteins, including having enzymatic activity (e.g., an alkaline phosphatase), urea, copper, alcohols, etc.
Process of bilification begins in a hepatocyte (see the Bile production?), where are synthesized cholesterol, bilious to - you and phospholipids; there is conjugation (conjugation) of bilirubin and other endogenous and exogenous substances that promotes their excretion from a hepatocyte.
Holesterin (see), bile acids (see) and phospholipids (see. Phosphatides ) are allocated from a hepatocyte in the form of a macromolecular complex or a micelle. Formation of a micelle is necessary for dissolution in water and excretion of cholesterol as sufficient solubility it is reached only in the presence of phospholipids, to-rye in itself are not dissolved in water, but in the presence of bile acids have very high solubility. Except bile acids, other organic anions, in particular bilirubin are a part of a micelle.
Secretion hydroxycholanic to - t from a hepatocyte due to increase in osmotic pressure in intercellular spaces causes flow of water. Speed of flow of water in intercellular spaces depends on the speed of release of bile acids hepatocytes. Thus the gepatotsitarny fraction of bile forms. Active transport of bile acids hepatocytes — the main, but not the only factor regulating the volume of the cosecreted bile. Formation of bile continues in iyerilobulyarny bilious tubules and interlobular or intra hepatic bilious channels created by their merge which epithelium is capable to cosecrete the fraction independent from bilious to - t — the liquid rich with electrolytes (sodium chloride, sodium bicarbonate).
On process of bilification in a hepatocyte metabolism of cholesterol and consequently, bile acids and phospholipids since synthesis of these substances is interconnected makes impact. They are subject to influence of hormones (in particular, sexual, especially estrogen), depend on a condition of enterohepatic circulation of compound components of bile and some other factors.
Regulation of further formation of bile in bilious channels and zhelchevydeleniya (see) it is carried out went. - kish. hormones. So, gastrin and secretin strengthen a zhelchevydeleniye, causing secretion in bile of the liquid enriched with bicarbonate, and the glucagon strengthens outflow of bile, without changing its electrolytic players. Hormone cholecystokinin exerts impact on outflow of bile from bilious channels and a gall bladder. The large role in regulation of a zhelchevydeleniye is played by a condition of a nervous system.
Barrier function P. is directed to protection of an organism against changes of the environment, promotes protection of cells of P., and also other bodies and fabrics from action of the damaging agents, to preservation of relative constancy of structure, physical. - chemical and biol, the properties of internal environment necessary for normal life activity of an organism. Barrier function P. is carried out special fiziol, mechanisms — barriers among which conditionally distinguish external and internal. The item as body is an external barrier, neutralizing a number of the toxic compounds alien to an organism which arrived with food or formed in intestines. The reticuloendothelial system P. which is also participating in neutralization of poisons and disease-producing agents also belongs to external barriers (see. Reticuloendothelial system ).
The internal barriers of P. regulating receipt from blood of energy resources and timely outflow of products of cellular metabolism provide constancy of optimum composition of intercellular (extracellular) lymph. Internal barriers also interfere with receipt from blood of alien and toxic agents. They are presented by gistogematichesky barriers (see. Barrier functions ), which basic structural elements are the endothelium of circulatory capillaries, a basal membrane, the main amorphous substance, fibers, intracellular barriers (lipoprotein membranes, systems of channels, a cytoplasmic reticulum, Golgi's device, a cellular cover). Internal barriers actively select substances, necessary for normal life activity, from blood and remove products of their exchange, defining a functional condition of body in general, its ability to resist to adverse effects. The delay of transition of alien substance from blood and surrounding fabrics through an internal barrier defines protective function of a barrier, and creation of optimal conditions for life activity of cellular and noncellular elements of body — its regulatory function.
Protective function P. consists in neutralization inf. and toxic agents. Nonspecific mechanisms of protection against infectious agents are connected with activity of star-shaped retikuloendoteliotsit, macrophages, the neutrophilic leukocytes which are carrying out capture and lysis of contagiums. Specific (immune) defense reactions are carried out as a result of activity first of all of lymphocytes limf, nodes P. and antibodies synthesized by them. Protection of an organism against the toxic agents arriving from the outside or formed during interstitial exchange is carried out in P. by chemical transformation of the substance leading to the reduction of toxicity or increase in water solubility facilitating its allocation. In processes of neutralization of toxic agents the microsomal enzymes of hepatocytes which are carrying out oxidation or recovery of toxic metabolites and alien substances are essential. Microsomal metabolic transformations concern preferential lipidorastvorimy connections; at the same time products of enzymatic reactions have, as a rule, big water solubility, than initial substrate. In Mick of gluttons reactions biol, oxidations — an aromatic hydroxylation, deamination, sulfooxidation are carried out. All of them demand presence of the recovered NADF and oxygen. Also such component of electronic transport system as R-450 cytochrome is of great importance. Oxidation of toxicants is provided also with not microsomal fermental systems — mitochondrial (aminoxidase) and cytoplasmatic (alcohol dehydrogenase, etc.). By oxidation in P. such substances as ethanol, phenobarbital, aniline, toluene, naphthalene, triptamin, a histamine and some other are metabolized.
Recovery processes are also carried out by enzymes of both microsomes, and other cellular structures. In hepatocytes there is a recovery nitro - and azosoy-dineiy, a recovery degalo-genprovaniye, recovery of double bonds. By recovery in P. Chlorali hydras, chloramphenicol, 2,4 dinitrophenol, steroid hormones are metabolized. In P. many pharmaceuticals, napr, cardiac glycosides and alkaloids are exposed to hydrolysis.
The conjugation conducting to an inactivation (neutralization) or solubilization and acceleration of removal of the formed products is of great importance. By conjugation a number of biologically active agents and products of interstitial exchange is inactivated: steroid hormones, biogenic amines and their metabolites, bilirubin, bilious to - you, and also exogenous substances — terpenes, aromatic hydrocarbons and their galogenopry izvodny. Connect to various neutralized substances glucuronic, sulfuric, acetic to - you, glycine, taurine, cysteine.
Not all toxicants in the course of metabolic transformations are exposed to neutralization; in some cases in P. there is an education more toxics. So, toxicity for an organism of methyl alcohol completely is defined by products of its oxidation in P. — formaldehyde and ant to - that; weight of poisoning with ethylene glycol is directly proportional to extent of its oxidation to oxalic to - you.
The item carries out functions of external and internal deposition. External deposition consists in accumulation in a gall bladder of bile, internal — in accumulation in P. of carbohydrates, fats, mineral substances, hormones, vitamins, waters.
Stocks of a glycogen in P. (glikogenovy depot) can reach 20% of weight of body. Protein is deposited with P. in bigger quantity, than in other bodies. In physiological conditions fats in hepatocytes are found in small amounts and is normal, them contains in fabric P. to 5 — 6% of weight of body. At the use poor in proteins, rich with fats and carbohydrates of food, at acute starvation, some diseases the maintenance of lipids in P. can make 10 — 50% of weight of body. A number of vitamins — to 96% of the general contents in an organism of vitamin A, the most part of D2, D3, K, G, PP vitamins is deposited with P. The liver is depot of iron (it contains apprx. 15% of all iron in an organism), copper, zinc and other microelements, and also water.
Character and ratio of nervous and hormonal links of regulation fiziol, functions P. are studied insufficiently. There are proofs of participation in this regulation of c. and. page — bark of a great brain, a hippocampus, a hypothalamus, a mesencephalon. In regulatory processes century of N of page is of great importance. Regulatory influences of a nervous system concern not only secretory function P. in which they are shown most brightly, but also diverse functions P. in a metabolism. Nervous control of functions P. is mediated by the processes proceeding at the subcellular level such as natural change of activity of a number of enzymes, change of permeability of membranes, etc. Nervous control of functions P. is carried out in close interaction with hormonal regulation (see. Neurohumoral regulation ). Functions P. are influenced by hormones of a pinus (epiphysis), adenohypophysis, a thyroid gland, adrenal glands, a pancreas, gonads, intestines. The mechanism of effect of hormones comes down, apparently, to participation in metabolic processes in P. as regulators of activity of fermental systems, and also permeability biol, membranes.
Due to the variety of functions P. it plays an important role in activity of the main systems of an organism; changes of its functions are followed by disturbances of activity of these systems. Functional interaction of P. with the alimentary system gave the grounds some scientist to speak about gepatoenteral-ache to system. In P. the hydrolysates of feedstuffs arriving from intestines are late and exposed to further transformations. The emitted bile promotes efficiency of processes of splitting and absorption of lipids, participates in maintenance of normal structure of microflora in various departments of intestines, and also in regulation of motor function of intestines. Its regulating influence on absorption of microelements, vitamins and other substances is connected with the depositing function P. Close interaction of P. with other bodies went. - kish. a path explains the high frequency of the combined disturbances of functions of these bodies at various pathology.
Close connection between P. and a spleen allows to speak about hepatolienal system. Functional linkages between these bodies in many respects are defined by a community of blood circulation, a lymph drainage and an innervation. The liver and a spleen are biol, filters for the blood inflowing to them and play the leading role in processes of hemolysis. Destruction of hemoglobin happens hl. obr. in a spleen — the main supplier of the bilious pigments and iron coming to P. and which are emitted with bile. Preservation fiziol, hepatolienal bonds is necessary for efficiency of such functions P. as depositing (in particular, concerning water, blood), Disintoxication, synthetic (in particular, concerning synthesis of blood-coagulation factors), etc. The functional community of P. and a spleen is shown also that P. can compensate functions of a spleen in processes of a hemopoiesis, hemolysis, deposition of blood. Close connection of these bodies explains their frequent joint defeat (see. Hepatolienal syndrome ).
Items and kidneys quite often call gepatorenalny functional system. It is based on a community of a lymphokinesis and an innervation of these bodies, and also that P. and kidneys are the most important bodies of excretion with the functions which are mutually supplementing and compensating activity of each other. E.g., after bandaging of the general bilious channel the quantity of bilious pigments in urine considerably increases, and the nephrectomy is followed by sharp increase of content of residual nitrogen and an urea nitrogen in bile. Thanks to participation in processes of exchange of hormones and other biologically active agents P. exerts the regulating impact on many functions of kidneys, napr, filtering, a reabsorption. In the conditions of pathology quite often perhaps combined defeat of P. and kidneys (see. Hepato-renal syndrome ).
P.'s role in activity of cardiovascular system is diverse. Due to the participation in metabolism of a number of vasoactive substances (hormones, some enzymes) P. exerts the regulating impact on a vascular tone. It has ability quickly (due to the depositing function) and slowly (in connection with maintenance of colloid osmotic pressure of a blood plasma) to regulate the volume of intravascular blood. The item exerts also regulating impact on heart rate, size of minute volume of blood due to change of chemical composition of blood. Disturbances of functions P. lead to disorders of activity of cardiovascular system — changes of a vascular tone, hepatogenous dystrophy of a myocardium and some other processes are observed.
The general for P. and lungs are barrier function, desintoxication (an indole, skatole, microbic toxins), participation in an interstitial metabolism (cholesterol, polypeptides, ketone bodies). The item is one of important regulators of function of external respiration due to impact on chemical composition of blood.
The item participates in an immunopoeza and immunoregulation. In the embryonal period in it there is a generation of V-lymphocytes. The item regulates concentration in blood of antigens — in star-shaped retikuloendoteliotsi-ta concentrates and collapses to 95% of the substances having antigenic properties. P.'s cells are capable to produce the humoral factors possessing an immunodepressive effect, napr, and - the feto-protein and a lipoproteid studied by F. Chisari and soavt. (1976). These substances have the essential oppressing effect on T lymphocytes of blood. At the same time P. promotes maturing and activation of subpopulation of T lymphocytes — T-suppressors (see. Immunocompetent cells ).
The condition of acute tension — emotional, metabolic — in the absence of adaptation to it strengthens the nek-ry parties of functional activity of P. (power education, a specific detoxication) that in the early period of influence of an adverse factor is combined with a prevalence in P. of processes of a catabolism. At the same time contents in P. of a glycogen due to increase of its utilization and delay of synthesis decreases, concentration milk and pyroracemic increases to - the t, in connection with oppression of synthesis and strengthening of disintegration of proteins (first of all structural) increases amount of residual nitrogen and the content of protein nitrogen decreases. Redistribution of power educational processes leads to oppression of excretory function P. Extent of change of functions P. depends on duration and intensity of a condition of tension: in one cases as a result of strengthening of synthetic and power educational processes of a cell there comes the condition of adaptation, — at insufficiency of compensatory and reparative processes — develop profound changes up to a necrosis of hepatocytes in others. The long or often repeating conditions of tension can lead to the stable strengthening of synthetic processes in P. providing the increased resistance of body to action of adverse factors. Strengthening of synthetic processes in P. can lead to development of an adaptativny hepatomegalia. At excessive, inadequate strengthening of synthetic processes there can occur the expressed decrease in excretory function of hepatocytes up to development of the hidden or explicit manifestations of a cholestasia.
Character and dynamics of functional activity of P. in various unfavorable conditions correspond to the general scheme: adaptation —> disadaptation (failure at excessive on force or long action of an adverse factor), however depending on a type of the last nek-ry features, e.g. physical are observed. the overstrain is followed by the fast and considerable changing of exchange processes in P. which is characterized first of all by a massive glycogenolysis and an exit of glucose in blood, disturbance of electrolytic exchange. Thanks to great compensatory opportunities for P. short-term physical. overloads do not lead to permanent functional disturbances. Long physical. overloads cause essential shifts of intracellular exchange of proteins, carbohydrates, lipids and structural changes, napr, dystrophy of hepatocytes and considerable expansion of space of Disse.
In the conditions of overheating of an organism excretory function P. is considerably broken: intensity of a bile production decreases, function of bilious ways is oppressed motor evakuatornaya, the chemical composition of bile changes: content of bilirubin increases in it considerably (by 2 — 3 times) and contents bilious to - t decreases. The general overcooling of an organism leads to development of disturbances carbohydrate and a lipometabolism — in P. the maintenance of a glycogen decreases, activity of enzymes of carbohydrate metabolism changes, in hepatocytes lipids collect. Impact on an organism of ionizing radiation causes decrease in glikogenoobrazuyushchy, belkovoobrazuyushchy and protective functions P., the accelerated formation of cholesterol and bilirubin, increase in contents in it in fats, disturbance of contents and distribution nucleinic to - t and microelements; the bile production and zhelche-allocation are oppressed. Extent of these changes, and also reversibility of functional changes depend on the size of an absorbed dose of ionizing radiation.
Functions P. at children up to 5 — 8 years are characterized by a certain lability with which big fluctuations of concentration of glucose and the increased maintenance of a glycogen and milk to - you in blood, excessive adjournment of a glycogen in internals are connected the Lipemia, a bystry exhaustion of fat depos, inability to the full proteolysis, lability of water and mineral metabolism. At advanced and senile age disturbances of various functions P are observed. A structural basis of these changes are reduction of volume of hepatocytes and amount of DNA and RNA in cells, emergence in their cytoplasm of fatty inclusions and acid glikozaminoglikan. The oppression of belkovosintetichesky function P. which is shown a hypoalbuminemia, a hypoproteinemia is most characteristic. Also disturbances carbohydrate and a lipometabolism, the processes of deposition neutralizing and excretory functions are noted. The lack of reserve functionality of P. of this age can cause development patol, process in the conditions of increased requirements to functions P.
After absorption in intestines comes to P. the majority of nutrients — amino acids, monosaccharides, fat to - t, etc. In P.'s cells these substances turn into the connections of various structure necessary for plastic and energy demands of an organism. The item maintains constant concentration of nutrients in blood, indirectly influences preservation of balance of the liquids and many transport processes which are carried out by a blood plasma provides blood with proteins, phosphatides and the most part of cholesterol. Thanks to excretory function P. with bile from an organism are emitted cholesterol, bilious to - you, and also products of porphyrinic exchange and alien substances. P.'s cells provide neutralization of the alien substances and toxic products which are formed in an organism.
The chemical structure of P. is subject to the considerable fluctuations depending on structure of food, fiziol, conditions of an organism and other factors. In P.'s structure, according to S. M. The brine port (1966), enters: 70 — 75% of water, 12 — 24% of proteins and products of their disintegration, 2 — 6 °o lipids, 2 — 8% of carbohydrates, coenzymes, vitamins, hormones, various low-molecular organic matters, and also cations and anions of sodium, potassium, manganese, calcium, copper, iron, zinc, magnesium, chlorine, iodine, sulfur in total quantity no more than 1%.
Water content in P. can change considerably; e.g., at obesity water content in P. decreases to 60 — 55%, and in congestive P. — increases to 80%.
Proteins are presented by soluble and insoluble proteins, apprx. 2,5% from them — enzymes. P. contains 50 — 100 mg / 100 of free amino acids (during the calculation on nitrogen). The general content of nitrogen of all nitrogen-containing extractives P. makes about 250 — 300 mg / 100, and a considerable part of this nitrogen falls to the share of polypeptides. Contents nucleinic to - t considerably changes depending on a functional condition of body.
The ground mass of carbohydrates P. is made by a glycogen which concentration also fluctuates depending on a functional condition of body and some other factors. Content of glucose in P. considerably does not differ from its content in blood. In small amounts in P. it is possible to find fructose, in some cases — a galactose. Apprx. 10% of lipids of P. it is the share of triglycerides, apprx. 90% make phospholipids; content of cholesterol and its ethers usually does not exceed 0,5%.
The item synthesizes 13 — 18 g of albumine a day. The amino acids arriving with food or synthesized and which are formed at a catabolism of proteins in the Item are a source for formation of molecules of protein. Along with synthesis of own hepatic proteins of a cell of P. provide with them blood. All albumine of blood, 75 — 90% and - globulins, 50% of beta globulins is formed in P.; only in P. the prothrombin, fibrinogen, proconvertin, pro-accelerin are synthesized. In various elements of fabric of body proteinaceous complexes (glycoproteins, lipoproteids, ceruloplasmin, transferrin and some other) are formed. The amino acids which are formed at a catabolism of hepatic proteins and arriving from blood are used for synthesis of new molecules of proteins or are exposed to deamination, the proceeding hl. obr. in the Item. Eliminating of amino groups can be carried out by several ways major among which for P. are transaminirovapy (see) and oxidizing deamination (see). In the course of transamination the majority of amino acids participates (an exception the lysine, threonine and and - an amino group of arginine make). The greatest activity is shown in this respect glutaminic and asparaginic to - you. High activity of enzymes of transamination, especially alaninaminotranspherases (ALAT) and aspartate aminotransferases (ASAT) is characteristic of P.'s cells.
In P.'s cells are available a deaminase of D-and L-amino acids. About functional value of high activity of an oxidase of D-amino acids there are no reliable data; usually the protective role which consists in destruction of nefpziologichesky amino acids of a D-row is attributed to it.
The most important deaminizing enzyme is localized in mitochondrions of L - a glutamate-dehydrogenase which in an easily reversible test carries out transformation of a glutamate into L-ketoglutarate. This enzyme connects exchange of amino acids and carbohydrates as L-keto-glutaric to - that is substrate of a cycle Tricarboxylic to - t (see. tricarboxylic acids cycle ). Besides, as a result of action of L-glutamatdegidrogenazy in a combination with transamination there is possible a fixation (or education) free ammonia. The main way of binding of the ammonia released at deamination of amino acids, and also at hydrolytic decomposition of kislotoamidny groups of a L-glutamine and L-asparagine is education urea (see). Mochevinoob-razovaniye proceeds almost only in mitochondrions of cells of P. and is one of manifestations of its neutralizing function as ammonia has strong toxic effect on cells, especially c. N of page. A transport form of ammonia is the glutamine (and in insignificant degree asparagine) which is formed in P. and a brain. Glutamin (see) along with urea is one of end products of a nitrogen metabolism; in kidneys it catabolizes with formation of ammonia which is emitted with urine.
Synthesis creatine (see) proceeds in a liver and kidneys and is one of ways of neutralization of ammonia as as mother substance for formation of creatine serves the intermediate product of a mochevinoobrazovaniye — arginine.
P.'s pathology leads to the diverse disturbances of exchange of proteins and amino acids which are reflected on biochemical, composition of blood. The serious illness of P. proceeding with a syndrome of a cytolysis (see) is followed by decrease in the general protein content of blood due to disturbance of its synthesis in P. Boley this process is expressed at hron, P.'s defeats, napr, P.'s cirrhoses, hron, hepatitises. At a syndrome of a cholestasia and focal defeats of P. of changes in indicators of the general protein content in blood usually it is not observed.
Disturbance of proteinaceous and synthetic function P. also affects change of content in blood serum of a number of proteins, napr, blood-coagulation factors. At the same time as a result of defeat of a parenchyma of P. earlier and more often than others synthesis II, VII, IX and X factors is broken. At severe forms of pathology of P. deficit of I, V and X III factors, and in terminal cases and fibrinogen is observed. Connect development of an amyloidosis with disturbances of proteinaceous and synthetic function P. (see).
Reduction in the rate of deamination in P. leads to increase in level of free amino acids in blood serum and urine. So, if normal serum contains 5 — 8 mg / 100 ml of amine nitrogen, then at severe defeats of P. the quantity it can make 30 mg / 100 ml. Increase in amount of amino acids conducts to an aminoaciduria. In cases of heavy pathology of P. in urine crystals of a leucine and tyrosine are found. Synthesis of urea is broken only in the conditions of almost complete cessation of function P., napr, at defeat of 80% and more parenchyma of body. The increase in content in blood of ammonia which is often observed at P.'s cirrhosis is caused not so much by a liver failure, how many existence of a porto-caval anastomosis on which ammonia comes from portal to the general blood stream, passing the Item.
Depending on character and disease severity the amino-acid players of blood serum are changed. At a viral hepatitis the content of alanine, tyrosine, cystine, arginine, asparaginic to - you along with decrease in concentration of a lysine, glutaminic to - you, threonine and valine is increased. At a hepatic coma in blood the content of aromatic and sulfur-containing amino acids which amine and metilirovanny derivatives possess toxic action on a brain sharply increases. At P.'s defeats transport of amino acids from intestines, consumption by an organism of separate amino acids and their use in interstitial exchange changes.
Accumulation in an organism of free phenols is connected with disturbance of exchange of amino acids at a serious illness of P., to-rye are formed in intestines of amino acids under the influence of enzymes a protea and colibacillus. After absorption they come to P. and normal are completely brought out of an organism after conjugation with glucuronic or sulfuric to - that. At the strengthened formation of phenols and disturbance of conjugation existence of a porto-caval anastomosis creates conditions for intake of these substances in a big circle of blood circulation that leads to encephalopathy.
At such inborn disease, as cystinosis (see), exchange of cystine with secondary damage of kidneys is initially broken. The phenyl-pyruvic oligophrenia for the first time described in 1934 by A. Falling is connected with disturbance of exchange of phenylalanine. The disease is caused by genetically caused lack of P. of a fenilalaninoksidaza (see. Fenilketonuriya ). Deficit of enzyme of a histidase in P. causes development of a hereditary disease — histidinemias (see), shown lag of the child in psychological development.
Digestion of fat consists of emulsification and hydrolysis of molecules of triglycerides under the influence of lipases. In these processes the large role is played by surface-active bile acids (see). They emulsify fats, increasing a contact surface of substrate and the enzymes splitting them, activate steapsin and form with fat to-tami the complexes which are soaking up from intestines. At disturbance of a bile production (see) and a zhelchevydeleniya (see) fats are badly soaked up in intestines and emitted in the increased quantity with a stake. Most often it is observed at jaundice.
The item utilizes not only the lipids arriving from blood, but also fat to - you during the subsequent redistribution and mobilization of the deposited triglycerides from fatty tissue. Splitting of molecules of triglycerides on fat to - you and glycerin happens under the influence of intra liver lipolytic liver enzymes. In P.'s cells step disintegration of molecules fat to - t by beta oxidation, and also transformation fat to - t each other is made. Also the second component of neutral fat — glycerin is exposed to oxidation. The item contains specific enzyme — a glitserinkinaza which carries out activation of glycerin. As a result of influence glycerin-fosfatdegidrogenazy is formed dihydroxy acetone — substrate of glycolysis.
At a catabolism fat to - the t a staple is atsetil-KOA. Its most part is exposed in mitochondrions to full oxidation in a cycle of Tricarboxylic acids. A part atsetil-KOA is used for resynthesis of new molecules fat to - the t In P. is formed apprx. 10% of total quantity fat to - t. From atsetil-KOA in P. also acetone bodies are formed (acetoacetic to - that, beta and hydroxy-butyric to - that, acetone). Normal synthesis of acetone bodies is insignificant and their content in plasma does not exceed 1 mg / 100 ml. However the speed of their synthesis considerably increases at carbohydrate insufficiency or a diabetes mellitus as a result of increase in oxidation of fats, .mnogokratny in comparison with norm.
The item is one of the main places of synthesis triglycerides (see) and phospholipids (see. Phosphatides ). An initial product for this purpose is and - glycerophosphate. Free fat to - you before inclusion in processes of synthesis will be transformed in atsil-KOA which transfer on alpha glycerophosphate is provided by specific transferases. The major intermediate product is fosfatidny to - that in which molecule at synthesis of triglycerides there is eliminating of inorganic phosphate and accession of the third molecule activated fat to - you, and in case of formation of phospholipids (lecithin, kephalin) previously activated sincaline or a stake amine which synthesis and activation are carried out also in the Item join.
Phospholipids have a direct bearing on education in P. of lipoproteids — a transport form of triglycerides and some other low solubility substances in water (fat to - t, cholesterol and its ethers). Proteins and phospholipids, and also ATP are necessary for their normal education. Receives a considerable part of cholesterol of people with food, however the organism completely satisfies the need for it by endogenous synthesis from atsetil-KOA. In P. and intestines more than 90% of the cholesterol which is contained in an organism are formed. In P. also lecithin-cholesterol-acyl-transferase — the enzyme necessary for formation of ethers of cholesterol with fat is synthesized to-tami.
Frequent manifestation of disturbance of lipid metabolism in P. — her fatty dystrophy (see. Hepatoses ). In normal conditions fat makes 5 — 6% of P.'s weight, in the conditions of pathology contents it can reach 50%. The fat which is laid in P. on the chemical structure belongs to triglycerides (are available the description and such fatty dystrophy of P. at which in hepatocytes phospholipids collect).
Toxic influences, napr, ethanol, endocrine and metabolic disturbances (a diabetes mellitus, the general obesity), a hypoxia and some other are the reasons of fatty dystrophy of P. Fat in hepatocytes is laid as a result of the increased its receipt in P. with food or from fat depos and disturbance of metabolism of fat in P. (strengthening of synthesis fat to - t and triglycerides, suppression of oxidation fat to - t, decrease in education and an exit of lipoproteids, strengthening of peroxide oxidation unsaturated fat to - t). As a rule, fatty dystrophy of P. arises owing to disturbance of several links of exchange of fats.
Disturbance of exchange cholesterol (see) occurs at various patol. processes is also an important link of a pathogeny of an intra hepatic cholestasia. Synthesis of cholesterol in P. is controlled by many factors, including quantity soaked up in intestines and arrived in gepato tsit cholesterol. Disturbance of enterohepatic circulation bilious to - t as a result of, e.g., obturation of bilious channels leads to strengthening of synthesis of cholesterol in the Item. Hypercholesterolemia (see) and adjournment of cholesterol in fabrics are characteristic of primary biliary cirrhosis of the Item. The increased synthesis of cholesterol matters in a pathogeny of a cholestatic form of a viral hepatitis.
Disturbance of exchange bilious to - t at P.'s diseases is connected as with the injury of hepatocytes leading to disturbance of transformation of cholesterol in bilious to - you, and with disturbance of their enterohepatic circulation. Functional insufficiency of a hepatocyte (at virus and hron, hepatitis, P.'s cirrhosis) leads to decrease in enzymatic activity of a biotransform-tsionnoy of the system of microsomes responsible for exchange bilious to - t (first of all 12-a-hydroxylases) therefore education digidroksikho-lanovy to - t relatively amplifies.
At an early stage of obturatsionny jaundice high rates of a hydroxylation bilious to - t are observed. At long stagnation of bile activity of mitochondrial system of a hydroxylation is broken and there can be a shift towards dominance of dihydroxy - bilious to - t. Disturbances of conjugation bilious to - t are observed only at deep damages of a hepatocyte.
The item plays the leading role in numerous reactions of an intermediate metabolism of carbohydrates. Metabolism of the galactose coming to an organism as a part of lactose is carried out by its transformation into glucose. In P. (and in erythrocytes) the galactose is phosphorylated in the presence of a galakto-kinase with formation of galaktozo-1-phosphate. The last can turn into the UDF-galactose in one of two possible reactions. The first of them is catalyzed hexa-zo-1-phosphate-uridiltransferazoy. Normal this enzyme contains in P. of children in large numbers.
The second reaction is catalyzed galaktozo-1-phosphate-uridiltransferazoy — the enzyme which is present at P. of a fruit and the newborn in trace quantities; in P. oi is much more active than adults. The UDF-galactose with participation of an eshme-rlza (galaktovaldenaza) turns into UDF-glucose — an intermediate product of exchange of glucose. Disturbance of functions P. involves decline in the ability of an organism to use a galactose what the functional trial with loading a galactose is based on.
P.'s cells contain enzyme to a fruk-tokinaz thanks to which participation fructose turns into the fruktozo-1-phosphate which is split in P. zymohexase of type B. Besides, a part of fructose under the influence of a hexokinase turns into fruktozo-6-phosphate — an intermediate product of disintegration of glucose.
In the presence of vysokoergichesky connections in P.'s cells glucose can be synthesized from the predecessors with short carbon chains who are not among carbohydrates. Pyruvate or a lactate, so-called glucoplastic (glycogenous) amino acids (glycine, alanine, serine, threonine, valine, arginine, a histidine, proline, oxyproline, asparaginic and glutaminic to can be sources for a new growth of glucose (gluconeogenesis) - you), any other substances, to-rye in the course of a catabolism can turn into pyruvate or into metabolites of a cycle Tricarboxylic to - t.
The major biol, function is performed by P. thanks to ability to synthesize glycogen (see). During the strengthening of sugar in blood P. utilizes glucose and deposits it in the form of a glycogen, and at decrease — will mobilize a glycogen, transfers it to free glucose, and also strengthens a gluconeogenesis. Normal P. contains apprx. 100 g of a glycogen.
The Glyukozo-6-fosfat which is formed in P * at phosphorylation of the glucose (hexokinase reaction) arriving from blood or at disintegration of a glycogen, being oxidized, is an energy source. P.'s cells are capable to oxidize glucose in a tricarbonic acid cycle (see. Tricarboxylic acids a cycle), and also in reactions of a pentozo-phosphatic cycle. Apprx. 70% of gluco-zo-6-phosphate in P. about 30% — on a fosfo-glyukonatny (pentozo-phosphatic) way break up through a mode of formation of fructose diphosphate, and.
Synthesis of the glucuronic acid necessary for conjugation of low solubility substances in water (bilirubin, phenols) and for formation of the mixed polysaccharides is connected with exchange of glucose (hyaluronic to - you, a hondroitinsulfata, heparin).
Changes of energy balance at P.'s damages caused, e.g., by poisons, a virus of hepatitis, toxic products of bile are connected with the disturbances of structure and functions of mitochondrions of cells of P. leading to decrease in content of makroergichesky connections in hepatocytes. Disturbance of formation of makroergichesky connections leads to disorder of the functions P. demanding power consumption (synthesis of protein, etherification of steroid hormones) and also to change of permeability of membranes of cells of P. and disturbance of electrolytic balance. Deficit of energy leads also to strengthening of glycolysis therefore in cells the acid metabolites (milk and Pyroracemic to - you) causing decrease in pH collect. The metabolic acidosis is quite often observed at a hepatic coma when in blood and P.'s cells the lactate and pyruvate collect, and also tricarboxylic to - you a tricarbonic acid cycle. At the same time also accumulation in blood of sick derivatives of pyruvic acid — methyl-acetyl carbinol and 2,3 butylene glycols possessing toxic action on c comes to light. N of page.
A number of the hereditary enzymopathies caused by genetically caused deficit of the enzymes catalyzing processes of disintegration and synthesis of a glycogen is connected with disturbance of exchange of carbohydrates in P. (see. Glycogenoses ). Diseases which cornerstone disturbances of exchange of a glycogen are belong to primary glycogenoses (as a rule, shown at early children's age). The secondary glycogenosis develops at children (in isolated cases — at adults), patients with a diabetes mellitus and treated insulin. Aglikogenoz is characterized by insufficient synthesis of a glycogen which content in P. is considerably reduced. The disease develops in the first days of life of the child. The galactosemia (see) — rather rare hereditary disease which cornerstone disturbance of exchange of a galactose — a lack of hectare-laktozo-1-phosphatidyltransferase is — leads to accumulation in an organism of galaktozo-1-phosphate. Fruktozemiya (see) — hereditarily the caused intolerance of fructose connected with a shortcoming fruktozo-1-fosfataldolazy. Assume that symptoms of a disease are caused by excess accumulation of fruktozo-1-phosphate which blocks effect of phosphoglucomutase and thus breaks exchange of glucose.
At the person the main source bilirubin (see) hemoglobin which transformation into a bilious pigment happens in reticuloendothelial system, hl is. obr. in P., a spleen and marrow. Per day at the person about 1% of the circulating erythrocytes therefore 100 — 250 mg of bilirubin are formed breaks up. About 5 — 20% of bilirubin are formed not of hemoglobin of mature erythrocytes, and of other gemsoderzhashchy substances. Hepatocytes carry out capture of bilirubin from blood, its conjugation with glucuronic to - that with the participation of a glyukuroniltransferaza (formation of the connected or direct bilirubin) and excretion of water-soluble conjugates of bilirubin in bilious capillaries. Bilirubin conjugates also with sugars, glycine, sulfuric and phosphoric to-tami.
Disturbance of exchange of bilirubin (see) leads to increase in its level in blood. At concentration of bilirubin in blood serum about 2 mg / 100 the ml appears visible jaundice (see). Allocate a hyperbilirubinemia at the expense of a free pigment and a hyperbilirubinemia owing to strengthening of the connected bilirubin. Preferential increase in content of free bilirubin in serum is observed at an increased hemolysis, insufficiency of capture of bilirubin P. and decrease in its pairing function (Gilbert's syndromes — Meylengrakhta, Krigler — Nayara). Preferential strengthening of the connected bilirubin in blood serum is observed at disturbance of a rkskretion of a pigment from hepatocytes (parenchymatous and other jaundices). The hyperbilirubinemia in all cases is result of disturbance of a dynamic equilibrium between education and release of bilirubin. Disturbance of conjugation is the cornerstone of enzymopathic jaundices at Gilbert's syndromes — Meylengrakhta and Krigler — Nayara (see. Hepatoses ), physiological and other jaundices of newborns (see. Jaundice, at children ). At syndromes the Cudgel — Johnson and the Rotor (see Hepatoses), takes the central place disturbance of excretion of bilirubin. For the jaundice connected with disturbance of passability of hepatic channels as a result of them intra-or extra-canalicular obturation, napr, a tumor or parasites, disturbance of excretion and regurgitation of bilirubin is characteristic.
The human body contains 3 — 6 g of iron. The item exerts a certain impact on process of absorption of iron in intestines. Assume that this influence is based on changes of reserves of iron in P. and depends also on a functional condition of hepatocytes and biliary secretion. After absorption in blood iron connects to synthesizable P. protein of globulinovy fraction — siderophilin (transferrin). Blood serum contains about 300 mkg! ml of transferrin. Constant concentration of iron in blood is maintained thanks to stocks it in cells of reticuloendothelial system P. Concentration of the iron which is in P.'s parenchyma and star-shaped reti-kuloendoteliotsita averages 80,2 mg at men, and women have 23,5 mg on 100 g of fabric. The main form of deposition is the metalloprotein the ferritin containing about 23% of iron. At surplus iron is laid also in the form of the hemosiderin containing apprx. 37% of iron. Increase in content of iron in blood serum is noted at a syndrome of a cytolysis that it is connected with disturbance of deposition of iron and its strengthened exit in blood. At mechanical jaundice the content of iron in blood serum does not change or goes down, and at hemolitic jaundice — increases.
The item plays an important role in exchange of copper. After absorption in intestines copper is deposited with P., and then is carried by a blood flow on an organism. At the same time 90 — 95% of copper are a part of the ceruloplasmin synthesized by cells P., and other part contacts albumine. Copper is emitted from an organism generally with bile; disturbance of a zhelchevydeleniye is followed by increase in a copper content in blood and the Item. At virus and hron, hepatitises, P.'s cirrhoses the copper content in blood and P. moderately raises, its allocation with a stake also increases.
The item is the main depot of zinc. It has a direct bearing on synthesis of tsinksoderzhashchy enzymes (a karboangidraza, carboxypeptide-zy, a glutamatdegidrogenaza, a lactate dehydrogenase) and to formation of complexes of zinc with pyridines, nucleotides, nucleosides. At P.'s cirrhoses the content of zinc decreases both in blood serum, and in
P. P. plays a part in exchange of manganese, molybdenum, cobalt, however their metabolism in P. is studied insufficiently. See also Nitrogen metabolism, In a one-salt metabolism, the Lipometabolism, Mineral metabolism, Carbohydrate metabolism.
Methods of a research
at recognition of diseases of P. the anamnesis is of Great importance. Complaints to pressure sense, weights and pain in the field of the right hypochondrium, bitterness in a mouth, jaundice, an itch of skin, decolourization of urine and a calla, and also complaints to nausea, weight in epigastriums, an eructation, locks, abdominal distention are most characteristic. From the complaints of the general character connected with disturbance of functions P. pay attention to weakness, the lowered working capacity, small appetite, weight loss, intolerance of alcohol and greasy food, impotence, disturbances of a menstrual cycle, bleeding. In the anamnesis of life it is necessary to find out whether was at the patient of the periods of starvation, to pay special attention to a systematic alcohol abuse, a possibility of intoxication hepatotropic poisons, napr, a dichloroethane, perchloromethane, etc., reception of such pharmaceuticals as aminazine, antituberculous remedies, etc. Instructions in the anamnesis on existence of jaundice and periodically arising pains in the field of the right hypochondrium are important.
At suspicion of hepatitis find out a possibility of the contact with sick hepatitis preceding this disease, and also operative measures and hemotransfusions. It is also necessary to consider belonging of the patient to groups of the increased risk concerning a viral hepatitis In (personnel of blood transfusion stations, centers of a hemodialysis, etc.), to find out whether the dispeptic, catarral or artralgichesky syndromes which are quite often observed at a viral hepatitis preceded emergence of jaundice. A certain value has identification of some hereditary diseases, napr, hepatocerebral dystrophy and pigmental hepatoses at the immediate family of the patient.
The most frequent symptoms of diffusion defeats of P. revealed at survey are jaundice (see), raschesa and a hyperpegmentation of skin, at a long cholestasia — manifestations xanthomatosis (see). At hron, P.'s diseases is more often on face skin, hands and in a so-called zone of a decollete small can be found teleangiectasias (see), the hyperemia of finger-tips and palms (a palmarny erythema), scanty pilosis in axillary areas and on a pubis are noted, men have an atrophy of testicles, a gynecomastia and female type of pilosis. In case of the sharp increase in the sizes P. caused, e.g., by a tumor or an echinococcus protrusion of a front abdominal wall in right hypochondrium and epigastriums can be observed; at ascites (see) increase in the sizes of a stomach with the tense, smooth skin and protrusion of a navel is noted; at considerable portal hypertensia on a front abdominal wall, quite often around a navel, the network of expanded veins («the head of a jellyfish») can be visible. During survey the hepatic smell which is compared to the sweetish smell inherent can be noted from a mouth of the patient svezhenarezan-ache P. of an animal (from chemical substances the close smell has methyl thiomethane). The hepatic smell is explained with existence in the air of the methyl mercaptan which is formed of methionine which collects much owing to disturbance in P. of processes of demethylation exhaled by the patient. It can appear also at reception of methionine in high doses.
Physical research. In the plan of the general inspection of abdominal organs (see. Stomach ) the Physical research P. enters; it is carried out by the methods and the principles developed by V.P. Obraztsov and N. D. Strazhesko.
The palpation is an important method a wedge, researches P. Normal in situation on spin at the relaxed muscles of a stomach of P. usually it is palpated under a costal arch on the right sredneklyuchichny line at once, and at a deep breath its lower bound falls by 1 — 4 cm \P.'s surface smooth, the bottom edge which is slightly pointed, equal, painless. The low arrangement of bottom edge of P. indicates its increase or omission that can be differentiated by means of percussion definition of the upper bound of the Item. At P.'s palpation it is necessary to aim to track all its bottom edge since P.'s increase can be diffusion or focal, napr, at a tumor, abscess. P.'s consistence normal soft; at an acute hepatitis and venous stagnation — more dense, elastic; at cirrhosis — dense, inelastic; at an amyloidosis and tumoral infiltration — stony. At venous stagnation and an amyloidosis P.'s edge happens roundish, at P.'s cirrhosis — acute. The chicken skin of P. is defined at focal defeat, napr, a tumor, an echinococcus or macronodular cirrhosis. Moderate morbidity of P. at a palpation is observed at its venous plethora and hepatitis, strong morbidity — at purulent processes. Identification is important for diagnosis of diseases of P. splenomegalies (see). So, at an acute hepatitis insignificant increase in a spleen, a consistence its soft comes to light, at hron, hepatitis and P.'s cirrhosis the considerable splenomegaly and sharp consolidation of tissue of spleen takes place.
Percussion allows to establish approximately P.'s borders, to reveal existence of ascites. For size discrimination of P. use a method of Kurlov by means of which establish: 1) the distance mezhduverkhny and lower borders of P. on the sredneklyuchichny line (normal the distance between limits of relative dullness makes 11 — 13 cm, between limits of absolute dullness of 9 — 11 cm), 2) distance between top and bottom P.'s borders on a front midline, and the upper bound corresponds to the place of crossing of the horizontal line at the level of the upper bound of P. on the sredneklyuchichny line with a front midline, and the lower bound decides on the help of percussion (normal this distance makes 10 — 12 cm, including relative dullness, and 7 — 9 cm, considering only absolute dullness); 3) distance from the lower bound of P. on the left costal arch (this border is defined, carefully percussing on edge of the left costal arch up from the VIII—IX level of edges) to the upper bound of P. on a front midline (normal this distance makes 9 — 11 cm, including relative dullness, and 6 — 8 cm, considering only absolute dullness). Mistakes in size discrimination of P. by means of percussion can be connected with change of height hundred;: I diaphragms (e.g., at ascites, a meteorism) or the upper bound of P. (e.g., at emphysema of lungs).
Auscultation is not of great importance for diagnosis of diseases of the Item. At a perihepatitis, metastatic tumoral defeat of P., and also in the nearest future after carrying out a puncture biopsy of P. over it the friction murmur of a peritoneum can be listened. At the expressed porto-caval anastomosis constant noise around a navel and in epigastriums is listened. Systolic noise over area P. can be noted at the strengthened local arterial blood-groove caused, e.g., by a tumor or cirrhosis of the Item.
Biochemical methods (hepatic tests) are important, and sometimes and the main a lab. by the methods of a research having diagnostic and differential and diagnostic value at many diseases of the Item.
For studying of pigmental exchange in blood serum and urine determine the level of bilirubin (see), investigate urobili-new bodies in urine and Calais (see. Urobilin ). One of the most exact is the method of definition of concentration of bilirubin in blood on Endrashika — to Klegkhorn — Grofu (see. Endrashika — Klegkhorna — Grofa a method ), which gives the chance to differentiate the jaundice caused preferential by accumulation in blood serum of free fraction of a pigment (hemolitic jaundice, Gilbert's syndrome) from jaundice with the prevailing increase in content in blood of the connected bilirubin (acute and hron, hepatitises, P.'s cirrhosis, mechanical jaundice). Unsharply expressed disturbances of absorption and pairing functions of hepatocytes can be revealed by means of test Bergman-on — Eylbotta who, despite its high sensitivity, is applied seldom since it cannot be carried out in the presence of a hyperbilirubinemia and is difficult technically.
Quantitative definition of bilirubin in urine big a wedge, does not matter. Normal urine contains the minimum quantity of bilirubin, a cut the lab does not come to light by means of usual. methods. Qualitative test of bilirubin in urine is carried out by means of Gmelin's reaction (see Gmelin test). It has great diagnostic value since sometimes test is positive before emergence of visible jaundice. Availability of bilirubin in urine demonstrates increase in content in blood of the connected bilirubin (the free fraction of a pigment is not excreted by kidneys) and, thus, always indicates the disturbance of excretory function of hepatocytes which is observed at P.'s defeat and mechanical jaundice in connection with build-up of pressure in bilious ways.
In urine apply qualitative test of Schlesinger which cornerstone formation of the tsinkurobilino-vy complexes fluorescing green light at addition to urine of zinc acetate is to definition of urobilinovy bodies. In urine urobilin appears in the increased quantity in case of its excess education in intestines, napr, at hemolitic jaundice, depressions of function of P. on metabolizing of urobilin that is observed at its diffusion defeats.
The quantitative definition of 1 urobilin in Calais based on reaction with Ehrlich's reactant is offered in 1925 A. Terwen. At parenchymatous and mechanical jaundice at which release of bilirubin with bile in intestines decreases the amount of 1 urobilin in Calais considerably decreases (up to a full acholia). At hemolitic jaundice release of 1 urobilin increases up to 2 g, sometimes up to 10 g at norm of 250 mg.
Among enzimologichesky tests the greatest practical application received definition of activity in blood serum of aminotransferases — alaninaminotranspherases (ALAT) and asparaginaminotransferaza (ASAT) relating to indicator enzymes. One of the most widespread methods of definition of activity of these enzymes is offered in 1957 by Reymanom and Frankel (S. Reiman, S. Frankel). It is based on reaction of interamination between ALAT or ASAT and and - ketoglutaro-howl to - that with education pyroracemic to - you. Activity of aminotransferases in blood serum is one of the most reliable indicators of process of a cytolysis in the Item. Increase in activity of aminotransferases is characteristic of diffusion defeats of P., and it is observed already at the minimum injury of hepatocytes in this connection the method is of great importance in early diagnosis of diseases of P. Sindr of a cytolysis at acute defeats of P. is followed by more expressed increase in activity of ALAT in comparison with activity of ASAT. Higher rates of activity of ASAT, than ALAT, are observed at an aggravation hron, P.'s diseases (hron, hepatitis, P.'s cirrhosis). At an acute liver failure activity amino-trasferaz falls almost to datum level at simultaneous deterioration in other indicators characterizing functions P. At an intra hepatic cholestasia (primary biliary cirrhosis of P.) or mechanical jaundice (tumors, cholelithiasis) activity of aminotransferases does not change or observed its more gradual increase to the moderate figures which are not reaching the level characteristic of an acute hepatitis. At P.'s cancer (primary or metastatic) moderate increase in activity of aminotransferases is also noted. In rare instances at the mechanical jaundice caused by a tumor or is more often cholelithiasis, the expressed rise in activity of aminotransferases is noted; falling of activity happens in 3 — 4 days after approach of jaundice. It is necessary to consider that activity of ASAT moderately increases at a myocardial infarction, pancreatitis, diseases of cross-striped muscles; activity of ALAT increases at some neyromuskulyarny frustration. Moderate increase in activity of aminotransferases is noted also at heart attacks of kidneys, lungs, a brain, poorly expressed increase — at hemolitic anemias, and also in the postoperative period.
From excretory enzymes the greatest value has definition of activity in blood serum of an alkaline phosphatase. For this purpose the method offered in 1933 by A. Bodan-sky, based on measurement of amount of the inorganic phosphorus which is chipped off from (3 glycerophosphates under the influence of an alkaline phosphatase is usually applied (see A. Bodan-sky a method). Increase in activity of an alkaline phosphatase is one of the most valuable indicators inside - and out of-pechenochiogo a cholestasia, and it can precede emergence of jaundice. Extent of increase in activity of an alkaline phosphatase depends on expressiveness and duration of a cholestasia. Especially high rates of its activity are observed at patients with mechanical jaundice of tumoral genesis and at primary biliary cirrhosis of the Item. At a syndrome of a cytolysis activity of an alkaline phosphatase remains normal. Because only one fraction (isoenzyme) of an alkaline phosphatase is enzyme, specific to P., increase in its general activity can be observed also at defeats of other bodies, napr, bones, kidneys, a placenta.
Sensitive indicator of defeat of P. is increase in activity in blood serum gamma glutamiltranspeptidazy (gamma GT) which main source in blood is P. Aktivnost u-GT in blood serum define by the method offered in 1969 by G. Szasz. It raises at acute and hron, diffusion defeat of P., and at acute hepatitises earlier, than activity of ALAT and ASAT. However normalization of activity, u-GT occurs later. At hron, P.'s defeats, napr, chronic hepatitis, definition of activity of gamma GT can have predictive value: increase in activity of enzyme testifies to the coming decompensation of functions P. Activity of gamma GT in blood serum is also the most sensitive and the earliest in comparison with others biochemical, tests an indicator of a cholestasia. Sharp increase in activity of gamma GT is characteristic of cancer of the Item. In the analysis of results of definition of activity of gamma GT in blood serum it is necessary to consider a possibility of its increase at alcohol intake and a number of pharmaceuticals, napr, barbiturates, antirheumatic means, corticosteroids.
From secretory enzymes the greatest value has definition of activity of cholinesterase by means of the modified method At an ergia (1952) based on decolourization of ferriferous complexes hydroxamic to - the t which are formed at interaction of hydroxylamine with ethers of sincaline. Activity of cholinesterase decreases in comparison with norm (130 — 310 units) according to weight and prevalence of process of a cytolysis. At an aggravation hron, P.'s defeats decrease of the activity is less expressed, than at an acute hepatitis. At a cholestasia activity of cholinesterase changes insignificantly.
For definition of the general protein content in blood serum at P.'s diseases use biuret reaction (see). Serious illness of P. with a syndrome of a cytolysis is followed by a subnormality (6,5 — 8,5 g / 100 ml) protein content due to oppression of synthetic function of the body which was more expressed at hron, defeats of the Item. At a cholestatic syndrome and focal defeats of P. the general protein content does not change.
Big a wedge, determination of content of protein fractions in blood serum matters. The most widespread method used with this tselyo — paper electrophoresis (see. Electrophoresis ). Normal in blood serum by means of this method allocate 5 fractions of proteins: albumine — 55,2 — 64,2%, alpha globulins — 2,0 — 5,6%, alpha 2 - globulins — 4,6 — 9,2%, beta globulins — 6,7 — 12,7% and gamma-globulins — 15,7 — 23,7%. Content of albumine in blood serum decreases preferential at diffusion defeats of P. with a syndrome of a cytolysis; at acute defeats the hypoalbuminemia is usually insignificant, at chronic can be considerable. Decrease in content of albumine is lower than 40% is an indicator hron, a liver failure. Substantial increase of level at - globulins reflects activity of mezenkhimalnovospalitelny reaction and is characteristic of diffusion hron, P.'s diseases, first of all hron, hepatitis and especially cirrhosis of the Item. Diagnostic value of changes of contents alpha and beta globulins is small. Increase of level a2-and beta globulins, in a terminal phase of a liver failure contents alpha is characteristic of a cholestasia and beta fractions of globulins decreases.
Fractionation of serum proteins by method of a diskelektro-forez in polyacrylamide gel (see. Electrophoresis ) gives the chance to receive apprx. 30 fractions of proteins with characteristic changes of their distribution: e.g., in the acute period of a viral hepatitis in pre-albuminous area there is protein fraction with the changed electrophoretic mobility, the quantity a2-poppy-roglobulinov increases, the maintenance of a number of immunoglobulins, including protein in the zone «bystry» of IgG and IgA, along with increase in amount of protein in a post-transfer-rinovoy of area decreases. At hron, P.'s defeats (hepatitis, P.'s cirrhosis) most jumps undergo fractions of makromolekulyar-ny proteins: the amount of a2-macroglobulins increases, the quantity of «slow» IgG and IgM goes down, the number of «bystry» IgG and IgA increases. Are characteristic increase in protein content in the zone «bystry» of IgG and IgA, a nek-swarm of mechanical jaundice decrease in protein content in albuminous area, significant increase in amount of protein in posttransferrinovy area.
The most widespread method of determination of content of lipoproteids in blood serum is the chemical method of Burstein (see. Burshteyna method ), based on sedimentation of beta lipoproteids by heparin. Changes of maintenance of fractions of lipoproteids depend hl. obr. from disturbance of a zhelchevydeleniye. Increase in maintenance of beta lipoproteids along with decrease alpha lipopro-teidov is characteristic of a cholestatic syndrome. Especially high rates of maintenance of beta lipoproteids in comparison with norm (350 — 600 mg / 100 ml) are noted at primary biliary cirrhosis of P. and mechanical jaundice with full obturation of hepatic channels. Decrease in contents alpha and beta lipoproteids is observed at a massive necrosis of a parenchyma of the Item.
The maintenance of glycoproteins in blood serum is defined by paper electrophoresis. The maintenance of the glycoproteins connected with albumine is normal, makes 10,4 — 16,6% (ag — 14,2 — 18,3%, a2 - 24,8-31,8%, (3 — 21,7 — 25,0%, at - 16,0 — 19,2%). Idea of contents and - gli-koproteidov can be received also by means of simple difenilamino-howl the reaction based on formation of colored compound at reaction of diphenylamine with neuraminic to - that, released as a result of hydrolysis of glycoproteins. Change of maintenance of glycoproteins in blood serum demonstrates first of all involvement in process of connecting fabric. At a viral hepatitis the maintenance of glycoproteins in albuminous fraction is lowered and increased in and - fractions, also indicators of difenilaminovy reaction are respectively raised. At development of a heavy liver failure the indicator by diphenyls - new reaction goes down. At hron, hepatitis and especially at P.'s cirrhosis the maintenance of glycoproteins in fraction of albumine goes down and level at-glycopro-teidov increases. For mechanical jaundice, especially tumoral genesis, increase in contents and - gli-koproteidov is characteristic.
Colloid reactions, or coagulative tests, reflect a ratio of fractions of proteins and proteinaceous complexes in blood serum, and also their chemical and physical. properties. Most widely use timolovy and sublimate tests (see. Coagulative tests). The thymol turbidity test is an indicator of process of a cytolysis in P. and has bigger value for a research of its functions at acute defeats. Change of indicators of sublimate test is noted at the long course of process, its transition in chronic and especially at cirrhosis of the Item.
Because in P. synthesis of many blood-coagulation factors is carried out, determination of their content has essential value for a research of functions of a liver. Change of maintenance of blood-coagulation factors depends on degree of a cytolysis and reaches the maximum value at an acute massive necrosis of P. Rasprostraneno also definition of prothrombin activity (prothrombin time) on Kvika (see. Prothrombin time ), which tends to decrease at diseases of the Item. At an acute massive necrosis of P. this indicator is sharply lowered.
From products of exchange of proteins determine the content in blood of ammonia, urea and free phenols. Content of ammonia is increased in comparison with norm (30 — 80 mkg / 100 in ml) at P.'s cirrhosis due to receipt it from intestines in the general blood stream through a porto-caval anastomosis. At a syndrome of a cytolysis increase in content of ammonia serves as an indicator of disturbance of mochevinoobrazovatelny function P. in blood that it is observed in a final stage of an acute massive necrosis of a parenchyma of body. Giperammoniye-miya it is not specific to P.'s defeat; it can be observed after massive went. - kish. bleedings, at some inborn defects of metabolism and some other patol, processes.
At portal hypertensia apply sometimes test with loading ammonia which gives the chance to define extent of porto-caval shunting and to indirectly estimate portability of food proteins.
Normal reception of 3 g of ammonium chloride is not followed by change of content of ammonia in blood. At the compensated P.'s cirrhosis the level of ammonia increases after such loading by 1,5 — 2 times, at dekompensirovanny — by 3 times and more.
Definition of urea in blood serum is carried out by means of a method of March (1965) based on measurement of intensity of an okratpi-vaniye of blood serum at its reaction with diatsetilmonooksimy. The B of communication with stability of mochevinoobrazovatelny function P. the content of urea in blood considerably decreases in comparison with norm (20 — 40 „W100 of ml) only at a heavy liver failure. At a gepatorenalny syndrome the content of urea is increased in connection with disturbance of secretory function of kidneys. Determination of content of free phenols in blood serum is carried out by means of a method of Myuttinga (1970) which cornerstone the modified diazo test with deproteined blood serum extract of free phenols is. Concentration of free phenols in blood serum in comparison with norm (0,16 — 0,30 mg / 100 ml) changes at a syndrome of a cytolysis, napr, as a result of an acute massive necrosis of a parenchyma of the Item. At P.'s cirrhosis perhaps moderate increase in content of phenols in blood serum due to receipt them from intestines in a blood stream on collaterals.
For a research of absorption and excretory functions P. enter the substances absorbed by it and emitted with bile into an organism (bilirubin, bromsulfoftalein, Bengalese pink, vofaverdin). Disturbance of absorption and excretory functions P. is determined by the raised delay of substance in blood, to reduction of its allocation in bile and to increase in removal of this substance with urine. Most often apply the bromsulfoftaleinovy and vofa-verdinovy tests relating to the most sensitive (see Bromsuljfoftaleinovaya test, Vofaverdinovaya test).
With a research objective of exchange of fats determine the content in blood serum of lipids, phospholipids, free cholesterol and its ethers, not esterified fatty acids. The general maintenance of lipids is defined by a gravimetric method — take lipids alcoholic and radio mix, evaporated and determine the weight of a solid residue. The expressed raising of maintenance of lipids in blood serum in comparison with norm (350 — 800 mg / iOO of ml) is noted at the jaundice caused by a cholestasia.
Phospholipids in blood serum define by Svetashev's method — Vaskovsky (1972): extract phospholipids Lowai chloroform-metano mix, burn and by colorimetry determine the content of inorganic phosphorus in the rest. The high level of phospholipids in blood serum in comparison with norm (110 — 275 mg / 00 ml) is characteristic of the jaundice caused by a cholestasia.
For definition of the general cholesterol, free cholesterol and its ethers it is recommended to use Zlatkis's method — Zac (1953), based on extraction of lipids by isopropyl alcohol with the subsequent colorimetric definition of cholesterol (gives colored compound at reaction with ice acetic to - that and ferric chloride).
Normal the general content of cholesterol makes 120 — 250 mg / 100 ml, content of free cholesterol — 36 — 100 mg / 100 ml, its ethers — 72 — 185 mg! 100 ml. Severe defeats of a parenchyma of P. lead to decrease in content of cholesterol and its ethers in blood serum. At a syndrome of a cytolysis the ratio between ethers of cholesterol and free cholesterol decreases; the progressing decrease in this ratio is an adverse predictive sign. Increase in level of cholesterol in blood serum is characteristic of the jaundice caused by a cholestasia; it is most expressed at biliary cirrhosis of the Item. Unsharp increase in level of cholesterol is observed in the period of reconvalescence of a viral hepatitis, at a fatty hepatosis.
Definition not esterified fat to - t carry out by means of a method of Dankumba (1962) based on their extraction by chloroform and colorimetric definition of the colored compound which is formed at addition to extract of trietanolamine, copper nitrate and acetic to - you. Increase in contents of these to - t in comparison with norm (8 — 20 mg / 100 ml) is observed at the majority of diffusion defeats of P., significant and permanent increase in their concentration is characteristic of the jaundice caused by a cholestasia.
Lipid metabolism is closely connected with exchange bilious to - t which determination has important practical value. To definition bilious to - t in blood serum apply a method of thin layer chromatography (see), consisting in allocation bilious to - t from blood serum with the help trichloroethane-ethanol, their division on plates with a thin coat of silica gel and flyuorometri-chesky definition of fractions. Their content in blood serum increases in comparison with norm (0 — 0,2 mg! 100 ml) as at a cytolytic, and cholestatic syndrome. The syndrome of a cytolysis leads to decrease in conjugation bilious to - t with glycine in P. therefore the relation of content of pair connections bilious to - t with glycine to their pair connections with taurine decreases. Than vyrazhenny a cytolysis in P., that 12 hydroxylation of cholesterol are more reduced that leads to relative increase in blood of contents chenodesoxycholic to - you in comparison with cholic to - that. At a cholestasia a ratio bilious to - the t changes a little; contents deoxycholic to - you at the expressed cholestasia decreases, and at a full acholia disappears from blood serum that is connected with disturbance of enterohepatic circulation bilious to - t.
From among carbohydrate load tests a nek-swarm practical value is kept by Bauer's test with loading a galactose, specific to defeat of a parenchyma of P. Zaderzhk of removal of a galactose from blood, connected with disturbance of splitting of carbohydrate in P., is observed at a syndrome of a cytolysis and reflects a functional condition
of P. S a research objective of the neutralizing function P. use test with the sodium benzoate by Kvik's method — Pytelya (see Kvik — Pytelya test). One of important ways of neutralization various ekzo-and endogenous connections is their conjugation in P. with glucuronic to - that. Assessment glyukuronizatsion-ache P.'s functions it can be made during the determination of quantity glucuronic to - you, allocated with urine per day. For definition glucuronic to - you in urine use Fishman's method — Green (1955), based on education during the heating glucuronic to - you with the concentrated chamois to - that connection, a cut at addition of naphtho-resorcin it is painted in violet color. Decrease in daily uric excretion glucuronic to - you in comparison with norm (431 — 597 mg) is characteristic of Gilbert's syndrome — Meylengrakhta (see Hepatoses, Jaundice) and is not observed at acute and hron, hepatitis, cirrhosis of the Item.
Among methods of assessment of a functional condition of P. determination of content in blood serum of microelements — iron and copper is widespread. For determination of content of iron use a method Getz (1959) whose cornerstone the reaction of iron with O-phenanthroline leading to formation of colored compound is. Increase in level of iron in comparison with norm (80 — 140 mkg! 100 ml) are, as a rule, observed at a syndrome of a cytolysis; at acute defeats of P. it is expressed more, than at chronic. Level of iron in blood serum is increased also at hemolitic jaundice, hemochromatosis, a hemosiderosis.
The copper content is defined by a method of Raykhenberger (1955) which principle consists in formation of colored compound at reaction of copper with diethyldithiocarbamate of sodium. At a syndrome of a cytolysis the copper content moderately raises in comparison with norm (100 — 140 mkg! 100 ml), at a cholestasia — it is significantly higher than norm. Low level of copper in blood serum (it is lower than 80 mkg! 100 ml) it is characteristic of hepatocerebral dystrophy and it is combined with low level in blood of ceruloplasmin — the protein connecting copper.
At acute defeats and aggravations hron, P.'s diseases the maintenance of a histamine in blood determined by Shor (1959) method in comparison with norm (4 — 14 mkg / 100 ml) is increased; it is most big at a cholestatic form of a viral hepatitis.
Determination of content in erythrocytes of the recovered glutathione which thanks to existence of free sulphhydryl group takes a key position among biol, protective systems of membranes of the cells directed against destructive action of a row ekzo-and endogenous agents (peroxides, hydroperoxides, intermediary free radicals) whose content in blood at P.'s defeats increases is important. Definition to blood of the recovered glutathione is carried out by Boytler (1963) method based on reaction of this connection with a so-called reactant of Ell-man. Content of the recovered glutathione decreases in comparison with norm (31,6 — 33,2 mg! 100 ml) at a viral hepatitis, cirrhosis of the Item. Determination of content of the recovered glutathione has special value for differential diagnosis of cirrhosis of P. and hron, persistent hepatitis, at Krom the content of the recovered glutathione in blood does not change.
Results immunol, methods of a research in some cases promote specification of features of a current and the forecast of diseases P. Tak, connection between extent of decrease in number T - and V-lymphocytes in blood, on the one hand, and activity patol, process is established at hron, diffusion diseases of P., napr, hron, hepatitis — with another. Distinctions in the content of immunoglobulins of blood serum at individual diseases of P. are established — preferential raising of maintenance of IgG at hron, active hepatitis, IgM at primary biliary cirrhosis (especially in its initial stage) and IgA at alcoholic cirrhosis, and also decrease in maintenance of IgA at hron, active hepatitis and decrease in maintenance of all types of immunoglobulins at hron, a cholestasia.
Immunol, methods are the main in identification of specific markers of the infection caused by a virus of hepatitis B (antigens s, with and e of a virus and an antibody to them), and also a virus of hepatitis A (antigen of a virus and an antibody to it). For the purpose of their identification apply a counter immunoelectrophoresis (see), a radio immunological method (see), reaction of passive hemagglutination (see), double diffusion in gel (see Immunodiffusion).
The sensitization of immunocytes to own kernels of cells, mitochondrions, unstriated muscles, DNA, a lipoproteid of hepatic fabric is more often observed at generalized processes with autoimmune defeat of the Item. For definition of the circulating autoantibodies use a radio immunological method; the autoserotherapy of lymphocytes is revealed by means of reaction of braking of migration of leukocytes (see Macrophage fixation), by stimulations of T-rosetting (see Rosetting the test). The resistant autoserotherapy is inherent hron, to active hepatitis (its especially autoimmune option), P.'s cirrhosis; the passing autoserotherapy can be observed at the height of an acute hepatitis.
In the diagnostic purposes define a sensitization of immunocytes to the alcoholic hyalin allocated from homogenates P. of the dead from alcoholic hepatitis and also define antigen of an alcoholic hyalin in blood serum. For this purpose apply a method of immunodiffusion, reaction of binding complement (see).
For identification and - fetoprotein in blood serum use methods of immunodiffusion, an immunoelectrophoresis, radioimmunol, a research. Contents and - fetoprotein in blood serum considerably increases (to 500 pg! ml) at pregnant women (norm 4 — 10,5 ng! ml). Sharp increase in contents and - fetoprotein (to 10 000 ng/ml) is characteristic of primary cancer of P., but is observed also in the conditions of the expressed regenerator processes in the Item. Increase in contents and - fetoprotein in blood serum to 100 ng! the ml is a good predictive sign at a hepatic coma also above.
Due to the disclosure of a pathogenetic role of inborn insufficiency а^антитрипсина at hron, P.'s defeats are developed immunol. methods of identification of this enzyme in blood and G1 fabric. For this purpose use immunope-roksidazny and Immunofluorescent methods more often (see the Immunofluorescence). Decrease in contents а^анти-трипсина demonstrates the progressing defeat, a cut can lead to cirrhosis of the Item.
Endoscopic methods of a research. Ezofagogastroskopiya (see Ezofagoskopiya, Gastroscopy) allows to reveal varicose veins in a submucosa of a stomach and a belly part of a gullet; in most cases it is connected with portal hypertensia. Duodenoskopiya (see) has essential value (especially at a combination to a retrograde holangiografiya) in diagnosis of mechanical jaundice, detection of a varicosity of a duodenum. The main indication to a duodenoskopiya — cholestatic jaundice of not clear genesis.
The most frequent indications to peritoneoskopiya (see) — need of differentiation of chronic diseases of P. (first of all hepatomegalias), an unsuccessful puncture biopsy of P. and a contraindication to it, splenomegalies of not clear genesis, and also suspicion on focal defeats of P. (a tumor, a cyst).
X-ray inspection of a liver consists in the survey X-ray analysis allowing to judge size, situation P., existence of foreign bodys and concrements. The surface condition of P., existence of unions with it can be established by a research in the conditions of a pneumoperitoneum (see). The vascular system P. can be investigated by means of the selection ge-patikografiya or a tseliakografiya (see), portografiya (see), splenoportografiya (see). Apply to the research of an abscess cavity or a cyst which are located in P. abstsessografiya (see) and kistografiya. By a high-informative method rentgenol. researches P. the computer tomography is (see the Tomography computer).
The puncture biopsy is method intravital morfol, researches P. It is shown at a hepatomegalia of not clear genesis, disturbance of the functions P. at absence a wedge given, explaining these disturbances, need of differential diagnosis hron, diffusion diseases of P., jaundice of not clear genesis, suspicion of hemochromatosis, glycogenoses, an amyloidosis and nek-ry other rather rare diseases and patol, processes. For differential diagnosis inside - and an extrahepatic cholestasia, and also acute and hron, diseases of P. proceeding with jaundice, the puncture biopsy is made in the first 7 — 10 days after approach of jaundice. At the jaundice having big duration carrying out a laparoscopy (see Perito-neoskopiya), transdermal ascending is more preferable holangiografiya (see) or a trial laparotomy (see).
Contraindications to a puncture biopsy of a liver: hemorrhagic diathesis, jaundice lasting more than 1 month, suppurative processes (a pyoderma, purulent pleurisy, a purulent cholangitis), serious condition of the patient, suspicion of a cyst or a hemangioma of II. The puncture biopsy of P. is rather contraindicated at an idiopathic hypertensia of the III stage, anemia, cardiovascular insufficiency, ascites.
The puncture biopsy of P. is carried out after the research of a condition of coagulant system of blood (a bleeding time and a blood coagulation, prothrombin! activities, numbers of thrombocytes of blood). For carrying out a puncture biopsy of the patient does not need special preparation. The puncture is made in position of the patient on spin with the right hand, zakinuty for the head. Perkutorno on a perednebokovy surface is determined obtusion on the right, and in the place of the greatest dullness, as a rule in the field of the ninth — the tenth mezhreberiya, by the average axillary line, the place of a puncture is planned. Under local anesthesia of 0,5 — 2% solution of novocaine pierce skin and hypodermic cellulose with a needle of bigger diameter, than diameter of a tissue extractor. Into the place of a puncture of skin enter the tissue extractor connected to the 20 ml syringe, in Krom is 5 — ml sterile fiziol, solution. The needle is advanced to the level of intercostal muscles then ask the patient to hold the breath. At the time of breath holding advance a needle to the capsule P., wash out a gleam of a needle fiziol, the solution which is in the syringe and, delaying the piston on themselves, quickly advance a needle in fabric P. on depth of 1,5 — 2 cm (an intra hepatic phase of a puncture), and zatvkhm the bystry movement take it. The piece of fabric from a gleam of a needle is directed on gistol, a research. After a puncture biopsy of II. the patient shall spend 2 hours lying on the right side and during 24 hours to observe a bed rest. During this time watch health of the patient, define pulse rate and height of the ABP.
The most dangerous complication of a puncture biopsy of P. is bleeding under its capsule (see below Damages), in an abdominal or pleural cavity (see. Hemothorax , Bleeding ). Danger of bleeding increases with increase in diameter of a needle and lengthening of an intra hepatic phase of a puncture. Seldom puncture biopsy of P. is complicated by development peritonitis (see). Are in some cases observed pheumothorax (see) and pleural shock (see).
One of shortcomings of a puncture biopsy of P. is that the place of capture of punctate is to a certain extent accidental. At diffusion defeats of P. it has smaller value whereas at focal punctate from the site of not changed fabric which research yields «false-negative» result can be received. In this regard and hl. obr. because of danger of complications at focal defeats preference is given to the aim biopsy made during a peritoneoskopiya or a laparotomy (an intsizionny biopsy). Intsizionny biopsy of G1. it can be executed under local (minipaw-rotomiya) or the general anesthesia. It is accepted to avoid a biopsy of free edge of P. in connection with fiziol, development in it connecting fabric that complicates interpretation morfol, data.
The radio isotope research is of great importance for data acquisition about an arrangement, a form, size P., a condition of its separate shares and assessment of a functional condition of the Item. For obtaining the gamma and topographical image use radio pharmaceuticals (see), napr, zoloto-198, technetium-99” 1, indium-111 and indium-113t which colloid particles take reticuloendothelial cells of the Item from blood. The radio isotope research P. is conducted for the purpose of identification of focal or diffusion defeat of its parenchyma and definition of a condition of bilious ways. The gamma and topographical image of a liver is received by means of scanning (see) or stsintigrafiya (see) on the gamma camera. Normal the gamma and topographical image of P. in a front projection has the form of a rectangular triangle (fig. 3) on which upper contour the acting part adjacent to a diaphragm is visible, and concave, formed by adjacent heart. At persons of an asthenic constitution P.'s contours are extended in the vertical direction, at corpulent people — are flattened. Distribution of a radioactive nuclide in P.'s parenchyma rather uniform, the maximum concentration is noted in an upper half of the right share, intensity of the image falls at the edges in process of reduction of thickness of body. In a back projection of P. has the similar form, but smaller by the sizes. In normal conditions together with P. in a back projection the image of a spleen comes to light.
The main sign of volume defeat of P. (primary cancer, metastasises of cancer, cyst, abscesses) on stsintigramma is defect of accumulation which size depends not only on the sizes of the center of defeat, but also on depth of its bedding. Detection of the single centers to dia is possible. apprx. 3 cm, and in the left share of P. — to dia. 2 cm. In some cases at multiple metastasises of a tumor uneven distribution of radionuclide is noted, sites of loss of activity alternate with sites of intensive accumulation (fig. 4). At malignant tumors P. is increased, deformed, defect has uneven contours or accumulation of radionuclide is absent in all site (tsvetn. fig. 21 — 27). Cysts, P.'s abscesses surrounded with the unimpaired parenchyma have accurate contours, P. at the same time can be slightly increased and deformed. At acute hepatitises along with P.'s increase the uneven or increased accumulation of radionuclide in it is noted. Hron, hepatitis is characterized by blowup of P., diffusion and uneven decrease of the activity, and intensity of accumulation of radionuclide depends on extent of defeat of a parenchyma of body: at the edges, where thickness of body is less, there is more considerable accumulation of radionuclide. Increase in the sizes of a spleen and increase in activity of radionuclide in it is at the same time noted. At alcoholic defeat of P. along with change of its form and the sizes accumulation of colloid particles in cells of reticuloendothelial system P. decreases or completely stops.
Other methods of a research. A method of a reogepatografiya (see) it is based on registration of resistance of the alternating current of high frequency passing through fabric P.
Fluctuations of resistance of current are caused by change of a krovenapolneniye of body and are registered by means of a reograf. Reogepato-gramma allows to estimate the size and dynamics of a krovenapolneniye of vessels of the Item. In its analysis consider a regularity of waves, features of a form of a curve and a number of quantitative indices. The form and the main indicators of a reogepatogramma depend on age, growth, pulse rate, position of the body inspected, a degree of admission of a stomach and intestines, at women — on a phase of a menstrual cycle. Changes of a reogepatogramma are naturally observed at diffusion defeats; they are most expressed at cirrhosis P.
Metod of an ekhogepatografiya is based on definition of ability of fabric P. to reflect or absorb ultrasonic impulses (see. Ultrasonic diagnosis). At an acute hepatitis of an ekhogepatogramm does not differ from normal, on it only oversizes of body. At hron, hepatitis and a fatty hepatosis it is observed small - average and macrofocal inhomogeneity of fabrics. At P.'s cirrhosis the illegibility of borders of P. decides on average and macrofocal heterogeneous sites; in case of dominance at cirrhosis of melkoochagovy heterogeneous sites the illegibility of borders is more widespread, than at hron, hepatitis. Ekhogepatografiya has special value in diagnosis of focal defeats — abscesses, cysts, primary cancer of P. and metastasises of cancer in P.
See also Clearance .
The pathological anatomy
At granular dystrophy of P. is a little increased in sizes, fabric its dim on a section. Microscopically hepatocytes are increased in volume, contain a large number of proteinaceous granules in cytoplasm. Electronic microscopically swelling of mitochondrions and expansion of tanks of a cytoplasmic reticulum in which accumulations of protein are visible comes to light. Accumulation of proteinaceous granules is connected with processes of transformation of carbohydrates and fats in protein or with processes of decomposition of lipoproteidny complexes of membranes of cells. Granular dystrophy is reversible after elimination of the reasons which caused it.
Hyaline and drop dystrophy of P. develops at viral and alcoholic hepatitis, cirrhosis, a cholestasia, is characterized by emergence in cytoplasm of hepatocytes of large gialinopodobny proteinaceous inclusions, to-rye can merge and fill all cell. At electronic microscopic examination destruction of organellas comes to light. The denaturation of proteins of cytoplasm is the cornerstone of hyaline and drop dystrophy. This process is irreversible, leads to development of peculiar focuses of a coagulative necrosis in the form of so-called little bodies of Mallori (tsvetn. fig. 10). Gidropichesky dystrophy of P. arises at acute viral and toxic hepatitis, is characterized by emergence in cytoplasm of hepatocytes of the vacuoles filled with liquid. At the same time hepatocytes increase in volume and remind plant cells (balloon dystrophy) by outward.
Parenchymatous fatty dystrophy (see) is characterized by accumulation in cytoplasm of hepatocytes and star-shaped retikuloendoteliotsit (fig. 5, a), a thaw of fat. Fatty vacuoles (tsvetn. fig. 11) of several nearby cells can merge among themselves and form fatty cysts. At a histochemical research in hepatocytes triglycerides come to light, phospholipids are more rare, the content of RNA and activity an eye are reduced and-doreduktaz, however in the cytoplasm which is not occupied with fat the glycogen remains. On diffraction patterns in a hyaloplasma or in expanded tanks of a cytoplasmic reticulum inclusions with the characteristic alternating wavy lines (fig. 5,6) are visible. Localization of changes at fatty dystrophy is connected with a type of pathogenic influence and features of metabolism in different departments of a segment of a liver. The pathogenic factors coming to P. through blood affect first of all hepatocytes of the periphery of hepatic segments; preferential defeat of the centers of hepatic segments occurs at anemia, a hypoxia. The macroscopic type of P. at fatty dystrophy depends on degree of obesity. At focal process only small yellowish sites are visible, at diffusion — P. is increased, a flabby consistence. with the rounded first line. Fabric it on a section of yellow or yellowy-brown color («goose» P.).
Fatty dystrophy of P. at elimination of the reasons which caused it can be reversible. At the expressed defeat proteinaceous dystrophy joins (see) and there comes the necrosis of hepatocytes with the subsequent mesenchymal reaction and a collapse of a stroma; in some cases cirrhosis of the Item develops.
Parenchymatous carbohydrate dystrophy of P. is caused by disturbance of exchange glycogen (see). E.g., at a diabetes mellitus its contents in P. decreases and noted infiltration of hepatocytes by lipids. Accumulation of a glycogen happens at hereditary glycogenoses because of absence or insufficiency of the enzyme participating in its splitting. The glycogen can collect not only in cytoplasm, but also in kernels of hepatocytes. At microscopic examination in such kernels large vacuoles are visible (fig. 6, a).
P.'s amyloidosis is usually combined with an amyloidosis of other bodies, can be primary and secondary (see. Amyloidosis ). At an insignificant amyloidosis P. is not changed, at expressed — the hepatomegalia is noted. fabric of body gains a peculiar «grease» gloss on a section. Deposits of mass of amyloid between stars chaty retikuloendoteliotsi-ta.m, on the course of a reticular stroma, in stakes of vessels and hepatic channels and in portal paths are microscopically visible. At the expressed process amyloid is laid on all segment of P., squeezes hepatic plates, causes an atrophy of hepatocytes.
Adjournment of hemosiderin in P. leads to development hemosiderosis (see) which arises at diseases of blood, poisonings with hemolitic poisons, some inf. diseases, transfusion of inogruppny blood, hepatitises and cirrhoses of the Item. At the same time P. gains brown color. Histologically in its fabric the dark brown granules of a pigment giving positive reaction of Perls are found (see. Perlsa way ). They come to light preferential in periportal hepatocytes and star-shaped retikuloendote-liotsita. At hemochromatosis (see) deposition of iron it is caused by genetic disorders of its exchange and the increased use of exogenous iron. It in a large number comes to light in hepatocytes, star-shaped retikuloendotelio-tsita, an epithelium of intra hepatic bilious channels, in connecting fabric (tsvetn. fig. 12) is also absent in the regenerating hepatocytes. Lipidogenny pigments, napr, lipofuscin, are often postponed in the Item. Lipofustsin , (see) in the form of the yellowish or brown granules possessing an autoflyuorestsention is located at a biliary pole of the hepatocytes located preferential near the central veins (tsvetn. fig. 13). It is presented to Elektronnomikroskopicheski by the dense granules surrounded with a three-planimetric membrane. Tseroid comes to light in P. of the patients who transferred an acute hepatitis. He is considered a product of phagocytosis of nekrotizirovanny hepatocytes. Tseroid meets only in star-shaped retiku-loendoteliotsita in the form of small yellowy-brown granules a flavovirent autoflyuorestsention, does not contain iron; gives ShIK-polozhi-telnuyu reaction, it is painted by pyronin in brick-red color. On the diffraction pattern it is presented by a dense matrix and numerous small little bodies with the light center.
Disturbances of exchange of calcium in P. can have the nature of dystrophic calcification of gummas and the died parasites, more rare, napr, at damage of bones and diseases of kidneys — a type of small limy metastasises. Exchange of copper in P. is broken at gepato-tserebraljny dystrophy (see) and the diseases which are followed by a cholestasia. At primary biliary cirrhosis of P. copper is laid in its fabric in a complex with protein and comes to light during the coloring gistol. drugs orcein.
The necrosis in P. usually happens kollikvatsionny, in some cases — coagulative (see. Necrosis ). At a focal necrosis organellas are surprised, there are auto-phagosomas, the denaturation and coagulation of protein, fusion of sites of cytoplasm is observed. Refer formation of little bodies of Mallori to a focal coagulative necrosis, to a stake-likvatsionnomu — balloon dystrophy. The coagulative necrosis of separate hepatocytes is found at an acute hepatitis. Cells at the same time are reduced, with homogeneous eosinophilic cytoplasm and the wrinkled kernel. Such nekrotizirovanny cells which are located in gleams of sinusoid are called Kaunsilmen's little bodies (tsvetn. fig. 14). The coagulative necrosis can come in small groups of the hepatocytes which are located near the central veins and portal paths. The centers of a necrosis in the form of bridges can connect portal paths among themselves (fig. 6, b) or to the central veins. Such, so-called bridge-like, necroses as a result of the organization can often lead to development of cirrhosis of the Item. At toxic defeats of P. necroses appear around the central veins. Emergence them is connected with transformation of hepatotropic connections by enzymes of hepatocytes of this zone in toxic metabolites. Necroses in a periportal zone are formed at acute and hron, hepatitis, primary biliary cirrhosis of P. and are followed by destruction of a boundary plate. Nekrotizirovanny sites of an infiltrirovana lymphocytes, at mechanical jaundice they can be imbibirovana bile — so-called bilious heart attacks. On site nekrotizirovanny hepatocytes there comes the collapse of a stroma, in places of larger necroses growths of connecting fabric are found.
The acute general venous hyperemia of P. arises at an acute heart failure and is followed by expansion of the central veins, hemorrhages in the central departments of segments of P., necroses. In the general chronic venous plethora of P. distinguish three stages. The first stage (hyperemia) is characterized by P.'s increase and consolidation of its fabric. On a section the drawing of hepatic segments is underlined, the centers their dark red, the periphery keeps usual coloring. Microscopically the sharp plethora of the central veins and adjacent sinusoidny circulatory capillaries is found. In the second stage (congestive, or tsianotichesky, atrophies) P. is macroscopically reduced, fabric it on a section motley at the expense of sharply plethoric, sunk-down centers of hepatic segments and yellowy-brown peripheral departments («muscat» P.). Microscopically the sharp plethora of the central veins, an atrophy of pericentral hepatocytes is found (tsvetn. fig. 15) and reduction of contents of a glycogen in them. Hepatocytes of peripheral departments of hepatic segments are hypertrophied. «Muscat» P.'s development is connected with the fact that stagnation occurs in hepatic veins in the beginning, extending then to collective, central veins and to sinusoidny circulatory capillaries, to-rye extend in the center and average departments of segments of the Item. On the periphery of segments of P. it is interfered by more high pressure in branchings of own hepatic artery and portal vein. In the third stage (a tsianotichesky induration, or congestive fibrosis) the sclerosis of the central and collective veins, portal paths develops, there comes the atrophy of hepatocytes from pressure.
The local venous plethora having similar manifestations arises at disturbance of outflow of blood on hepatic veins (see Kiari a disease).
At the general anemia P. is macroscopically a little reduced, pale under the capsule and on a section. In it fatty dystrophy often develops.
The local anemia of a liver can arise at the expense of pressure upon it of the next bodies, but more often it occurs due to disturbance of a blood-groove on a hepatic artery and a portal vein. Its effects depend on caliber of the struck vessels and the general condition of blood circulation. Thrombosis of intra hepatic branches of a portal vein in the conditions of the complicated outflow of blood, napr, at right ventricular heart failure, conducts to an atrophy of fabric P., expansion of its sinusoidny circulatory capillaries. Such sites of dark red color (a red heart attack) with a clear boundary have the form of the wedge turned by top to an obturirovanny vessel. During the closing of branches of own hepatic artery there is an ischemic heart attack (see), sometimes with a hemorrhagic rim.
Disturbances of a lymphokinesis develop due to growth of connecting fabric and reorganization of body at P.'s cirrhoses (fig. 6, c). The lymph at the same time via the capsule P. transudes in an abdominal cavity that serves one of the reasons of development of ascites (see). In turn the lymphostasis leads to a hypoxia of fabric, strengthening of activity of fibroblasts that promotes progressing of cirrhosis of the Item.
At acute purulent diffusion hepatitis (see Hepatitis) exudate infiltrirut portal paths with development of purulent perikholangio-litas, at focal — P.
Obychno's abscesses are formed P.'s tuberculosis results from progressing of primary tuberculosis of intestines with hematogenous (through a portal vein) or (more rare) retrograde lymphogenous dissimination. Perhaps also P.'s defeat as display of hematogenous tuberculosis, is more often in the form of miliary tuberculosis (grumous hepatitis). Macroscopically at the same time under the capsule P. and less clearly on a section small grayish-white small knots are visible. Microscopically find small sites of a necrosis in early stages, infiltrirovanny leukocytes, proliferation of mesenchymal cells joins later, the necrosis gains lines of caseous, there are epithelial, lymphoid and colossal cells of Pirogov — Langkhansa, tubercular granulomas form (see), to-rye a thicket are located periportalno (tsvetn. fig. 16). Along with them find small knots from proliferating local mesenchymal cells and capillaries inside or in the centers of segments of the Item. They are considered as manifestation of nonspecific focal reaction. Carry also reactive hepatitis and fatty dystrophy to nonspecific reactions. On biopsy material dynamics morfol, changes of hillocks in the conditions of treatment is tracked by antituberculous remedies. In the beginning the lymphocytic shaft extends, there are plasmocytes, fibroblasts, macrophages, then connecting fabric expands. In the result of this process fibrosis can develop, and at widespread defeat — cirrhosis of the Item. At merge of hillocks small knots are formed, to-rye can involve in process bilious channels and messages to intrakanaliku-lyarny progressing of tuberculosis of the Item. Fusions of large tubercular small knots in P. can result cavities (see).
Primary tuberculosis of P. occurs extremely seldom at newborns at a transplacental drift of contagiums through an umbilical vein. Primary tubercular complex is formed (see. Primary complex) — primary affect in fabrics and tubercular lymphadenitis in the field of gate of the Item.
At inborn syphilis in P. intersticial hepatitis or miliary gummas come to light, to-rye microscopically have an appearance of the centers of a necrosis with insignificant inflammatory reaction and accumulations of treponemas. Further there is an infiltration of fabric lymphocytes, nonspecific granulyatsionny fabric develops. Gummas can be placed around bilious channels (pericholangitis) or vessels (periphlebitis). At intersticial hepatitis P. it is increased, dense, with a smooth surface, brownish-gray color («silicon» P.). Diffusion growth of connecting fabric in P.'s segments is microscopically noted, a part of hepatocytes is exposed to an atrophy, others have an appearance of huge multinuclear simplast.
The item at inborn syphilis of adults it is similar to P. at the tertiary period of the acquired syphilis which is characterized by formation of large gummas or growth and the subsequent wrinkling of granulyatsionny fabric. Gummas consist of the caseous necrotic masses surrounded with granulyatsionny fabric, infiltrirovanny lymphocytes and plasmocytes; epithelial and colossal cells meet seldom. During the healing of gummas the hems deforming the Item can be formed. At intersticial hepatitis in P. granulyatsionny fabric which during the scarring deforms P. (lobular P.) expands.
At histoplasmosis the hepatomegalia is noted. The small necroses containing the activator, proliferation of cells of a reticuloendothelium are microscopically visible. Further the granulomas similar on a structure to tubercular are formed. P.'s actinomycosis can develop as a result of distribution of process of the next bodies or a hematogenous way. In fabric P. there are solitary or multiple small knots having a cellular structure on a section and containing pus. Microscopically - it is sites of a necrosis with purulent fusion in the center; find druses of a fungus in them. Walls of abscesses are formed by granulyatsionny fabric with fields of ksantomny cells and epithelioid and cellular granulomas. At malaria P. is increased, gray-black color on a section. Mikrosrgopicheski find a hyperplasia of the star-shaped retikuloendoteliotsit containing hemomelanin, coarsening of a stroma, moderate diffusion fibrosis is noted. The ascaridosis can be followed by penetration of ascarids through the general bilious channel to intra hepatic canals that leads to formation of holangitichesky abscesses of the Item. From group of trematodes of damage to P. the hepatic fluke causes. At its maturing in G1. there is a necrosis of certain sites of a parenchyma around which inflammatory reaction develops and hemorrhages are found. At a schistosomatosis in 11. there are inflammatory infiltrates, granulomas, and then there occur sclerous changes.
P.'s atrophy can be one of displays of the general exhaustion. At the same time P.'s weight is reduced to 1000 — 600 g, a surface its wrinkled, a keen first edge, fabric on a section of brown color. Microscopically the sizes of hepatic segments and hepatocytes are reduced, in cytoplasm of cells grains of lipofuscin are visible. The local atrophy of P. can develop as a result of insufficiency of blood supply on a hepatic artery or a portal vein, from pressure a tumor, a cyst, etc.
The hypertrophy and P.'s hyperplasia usually develop in the course of its regeneration. Fiziol, P.'s regeneration proceeds slowly though P. has very high ability to reparative regeneration. After 2/3 P.' resection the mass of body is recovered to initial level in 2 weeks after operation. At the same time on site P.'s resections the connective tissue hem is formed, and regenerator processes are developed in the remained part of body, i.e. proceed as a regeneration hypertrophy (see). After a resection intensive synthesis of DNA in periportal hepatocytes, and then and in others begins, extending towards the central vein (tsvetn. fig. 17). High regenerator ability of hepatic fabric is noted also after diffusion defeats of its parenchyma. In these conditions along with proliferation of hepatocytes intracellular regeneration due to which polyploid and multinuclear hepatocytes are formed is of particular importance (fig. 6, d). After small necroses and P.'s resection its regeneration can be full (restitution). The extensive necroses and defeats caused by long influence of a pathogenic factor lead to incomplete regeneration — substitution with substitution of a parenchyma a connective tissue hem. The remained hepatic fabric is exposed hyperplasia (see) as a result of which its parenchyma gradually takes a form of small knots — false segments. Hepatocytes in them differ in polymorphism, many large hepatocytes meet several kernels. Active fibrosis of P. is connected with excess growth of collagen due to formation of new fibers fibroblasts or lipocytes (cells of Ito); passive fibrosis is caused by a collapse of a stroma. Usually fibrosis accompanies various forms of defeat of P. and rather seldom is the main characteristic of process, it affects function P. a little and is not shown clinically, but in some cases, napr, at inborn fibrosis, leads to development of portal hypertensia (see). Pericellular fibrosis comes around separate hepatocytes or their small groups. If process takes all segments of P. or their majority, it is called diffusion fibrosis; it can arise at alcoholic defeats, inborn syphilis, a hypervitaminosis And. Focal fibrosis — small sites of fibrosis in P.'s segments or small knots (usually during the healing of granulomas). Zone fibrosis can be centrolobular (at alcoholic defeats), portal (at a schistosomatosis) and periportal (at disturbances of outflow of bile). Multilobulyarny fibrosis is characterized by substitution by connecting fabric of several next segments of P., napr, after massive necroses of the Item. Bridge-like fibrosis develops between portal paths, napr, at disturbances of outflow of bile, after an acute hepatitis, between the central veins, napr, at disturbances of venous outflow, between the central veins and portal paths (after the postponed hepatitis). Pe-riduktalny fibrosis develops at primary sclerosing cholangitis, perivenulyarny — at alcoholic hepatitis, a schistosomatosis. It is assumed that the prolonged phase of fibrosis can precede formation of many forms cirrhosis (see). In this phase, in case of elimination etiol, a factor, cirrhosis is still reversible process. Involution of fibrosis can be accelerated, stimulating regeneration of the Item.
Early postmortem changes of P. come in the agonal period. At the same time swelling of mitochondrions, destruction of their cristas, expansion of a cytoplasmic reticulum, loss of a glycogen is noted. In further cytoplasm of hepatocytes becomes granular, kernels piknotich-ny, there is a diskompleksation of hepatic plates and separate hepatocytes, expansion of perpsi-nusoidny spaces. In the conditions of venous stagnation the sharp imbibition of P. by blood with a picture of a pseudomelanosis can be observed. Penetration of microorganisms through a portal vein and bilious channels leads to cadaveric decomposition of P., sometimes to development of cadaveric emphysema.
According to the international nomenclature of diseases of the Item (1976) distinguish: defects of situation and form P., hepatitises, hepatoses, P.'s cirrhoses, P.'s fibroses, its focal defeats, defeats of vessels of P., defeat of intra hepatic bilious channels and parasitic diseases.
Distinguish anomalies of situation, a form and the mixed anomalies. Very exceptional cases of an arrangement of P. in left hypochondrium can be carried to anomalies of situation at usual position of other abdominal organs.
The insignificant anomalies of a form which are shown in change of the sizes of various departments of P. and depth of furrows meet quite often and do not influence function of body. P.'s underdevelopment is noted at 25% of children with inborn malformations and early post-natal thrombosis of a portal vein. The hypoplasia of the left share and increase in a square share of the Item belong to anomalies of a form. Agenesias P. is described in single observations. So seldom the inborn hypoplasia of P. at which weight it at the adult does not exceed 1% of body weight meets (it is normal of 2 — 3%). Cases of an inborn hepatomegalia at which do not find any patol are described. changes, except increase in the Item. A peculiar anomaly of a form P. is the so-called share of Ridel for the first time described in 1888 by B. Rhee-delem. Ridel's share has the form of language, coming from edge of the right (square) or seldom left share of P. and formed by normal hepatic fabric. Ridel's share is usually found accidentally since it does not cause any painful feelings and the lab is not followed by changes. indicators. However at 1/3 patients this anomaly is combined with cholecystitis and tends to independent disappearance after a cholecystectomia.
Rather often the additional shares of P. having various sizes and usually close to the Item meet. Unlike an ectopia of hepatic fabric in other bodies additional shares of P. are connected to it a vascular and secretory or fabric leg. Sometimes the additional share of P. is located supradi-afragmalno and connects to P. the leg which is containing an artery, a vein, a bilious channel and passing through an opening in a diaphragm.
Carry an atresia of intra hepatic bilious channels which frequency averages 1 case on 20 — 30 thousand childbirth to anomalies of development of P. At the same time the essence patol, changes consists not in inborn absence (an agenesia of bilious channels), and in disturbance of their passability owing to an obliteration or an underdevelopment. An atresia of intra hepatic bilious channels, according to Landinga (V. N. of Landing, 1974) and Haas (Haas, 1978) — manifestation of the obstructive cholangiopathy of newborns caused as is assumed, a virus of hepatitis B, is more rare a virus of hepatitis A and a rubella. Along with the defeat of a parenchyma of P. which is shown in the form of typical symptoms of inborn hepatitis at an obstructive cholangiopathy of newborns the system of bilious channels is involved in inflammatory process. In bilious channels vacuolar dystrophy of an epithelium, a necrosis of separate cells, inflammatory infiltration of walls are noted. Together with alterativny processes there are a regeneration and fibrosis. Progressing of these processes leads to closing of a gleam of bilious channels and development of cirrhosis of P.
Among injuries of various abdominal organs of damage of P. are the heaviest and difficult for recognition. Distinguish closed and opened (at the getting wounds of chest and belly cavities) damages of the Item. They can be isolated, combined (at damage of other bodies) and combined (at impact on an organism of several striking factors, napr, a mechanical injury, thermal damage, impact of ionizing radiation, etc.).
The closed injuries of a liver, by data K. D. Mi-keladze and E. I. Kuzanov (1965), make up to 17,8% among all closed injuries of abdominal organs.
According to C.3. Gorshkov and V. S. Volkov (1978), they were observed at V3 of patients with the closed injuries of a stomach.
The closed P.'s damages happen at transport incidents, accidents on construction or production owing to direct stroke to the area of an arrangement of body, P.'s prelum, falling from height more often. P.'s ruptures are possible also at a sharp muscle tension of a prelum abdominale. P.'s damages at newborns at the heavy course of childbirth are known, and also as a result of excessively vigorous carrying out an artificial respiration.
Direct sharp strokes to the area P. lead to education varied in form and depth of the ruptures of body (fig. 7) having the sagittal direction at lateral blows and cross — at ventral. The short, falling on the small square blows can be followed by formation of the dispersing cracks multiple zvezdoobrazno. Sometimes the capsule of body at the same time remains unimpaired, subcapsular hematomas and ruptures of a parenchyma of body are formed. They are unsafe because of the arising complications: hemobilias (see) — intake of blood with bile in intestines, and also the subsequent (later a nek-swarm time, sometimes several days after an injury) the rupture of the capsule P. and bleeding in an abdominal cavity which received the name double-stage or two-phase, ruptures of the Item. At fractures of edges their acute fragments can be implemented into a parenchyma of body. At sudden blows in the field of the left half of a body P.'s ruptures can be result of antiblow it about a costal arch or a backbone. At a prelum (between two objects, arrival crush or a separation of sites G1, various in size, happens a wheel) or falling from height often. These heaviest damages of body are followed by massive bleeding and a zhelcheistecheniye in an abdominal cavity. The focal necroses of a parenchyma of P. developing in the subsequent in connection with accession of an infection and a fibrinolysis can lead to secondary bleedings.
In patholologically the changed P., especially at a hepatomegalia owing to the postponed diseases, napr, malaria, even the insignificant injury can lead to a rupture of body. Such gaps quite often mistakenly take for spontaneous.
The closed P.'s damages are characterized by quickly progressing serious condition of the victim. In a wedge, a picture symptoms of shock and intra belly bleeding prevail, to-rye, mutually burdening each other, lead to cardiopulmonary frustration and the death of the patient. In these cases the increasing pallor of skin, cold sweat, an adynamia, tachycardia, the progressing hypotonia, a hypovolemia, a hypoxia are characteristic. The palpation in the area P. is usually painful, is available limited (in right hypochondrium) or more diffuse muscle tension of a front abdominal wall, dullness at percussion in the right side area of a stomach, can be defined Shchetkin's symptoms — Blyumberg and Kulenkampff. In blood the hemoglobin content and number of erythrocytes quickly decreases at increase of a leukocytosis to 20 — 30 thousand in 1 mkl.
At subcapsular hematomas of P. the condition of patients at first after an injury remains satisfactory, pulse, ABP and breath are close to norm. Pains only in the field of a bruise disturb. The stomach is soft, it is moderately painful in the field of an injury. 2 — 3 days later in process of increase in a hematoma and development of inflammatory changes in a parenchyma the increased painful P. begins to be palpated, there are subfebrile temperature, an ikterich-nost of skin and scleras, there is a leukocytosis, enzymatic activity increases. At the proceeding bleeding, a thicket on 3 — the 13th days after an injury, there can come the rupture of the capsule of a hematoma and its emptying in an abdominal cavity. At the time of a gap severe pains in right hypochondrium and symptoms of peritonitis develop, displays of intra belly bleeding soon develop.
The hematomas located in the central departments of P. in a wedge, the relation are even more artful. They quite often are not followed expressed a wedge, manifestations and remain not distinguished sometimes even after a laparotomy. However several months later after an injury on site the central hematomas of II. traumatic adventitious cysts, intra hepatic and subphrenic abscesses can be formed, and also there are limited necroses owing to a prelum a hematoma of a parenchyma of body.
At a part of patients the course of a disease can accept cyclic character when the periods of temporary improvement are replaced by the next aggravations proceeding with fever (t ° to 38 ° above), the perspiration, anemia, yellowness of scleras and skin caused by infection of a hematoma or posttraumatic hepatitis. Characteristic sikhmptom is hemobilias, connected with intake of blood from a hematoma to the bilious canals of the Item damaged at an injury. Pains in right hypochondrium, caused by stretching blood of bilious channels are characteristic of it; bleeding (quite often plentiful and repeating) in went. - kish. a path, shown a hematemesis or a melena, and also the moderate jaundice caused by obstruction of bilious channels clots. With the advent of bleeding of pain, and then and jaundice disappear as blood is not late in bilious ways.
Diagnosis of the closed P.'s damages quite often presents considerable difficulties. Especially often it is observed at alcoholic intoxication, a craniocereberal injury, spinal fractures, bones of a thorax, a basin and the damages of a musculoskeletal system which are combined with P. V damage cases when patients are in extremely heavy or unconsciousness, P.'s damages sometimes find only on opening. Diagnosis of the central hematomas of P. and double-stage ruptures of body can appear extremely difficult.
On a possibility of damage of P. can specify anamnestic data on an injury to areas P., detection of grazes and hemorrhages in this area, fractures of the lower edges on the right, and also existence of symptoms of intra belly bleeding and symptoms of peritonitis. However these a wedge, manifestations of a nepatognomo-nichna, and in some cases it is necessary to use special diagnostic methods of a research — laboratory, radiological and tool.
Repeated (in 15 — 30 min.) researches of hemoglobin, hematocrit and quantity of erythrocytes allow to reveal decrease in these indicators. At the same time bigger significance is usually attached to definition of a hematocrit. A precursory and constant symptom of damage of P. is the leukocytosis and increase in activity of transaminases.
Rentgenol, the research at heavy damages of P. is not shown. At the patients who are in satisfactory condition at damage to area of an upper surface of P. high standing and limited mobility of a diaphragm, fractures of edges are noted; at the combined injury of bodies of a thorax — pneumo - and a hemothorax; at the combined injury of abdominal organs — free gas and horizontal levels in intestines. P.'s scanning, the selection tseliakografiya (see), a splenoportografiya (see) and umbilikalny a time-togepatografiya (see an aortografiya) can be applied at subkapsulyarny and the central hematomas of the Item. They are most shown at suspicion on two-phase damage of body since allow to find ruptures of large arterial branches. At serious condition of patients and in an urgent surgery use of these methods is usually impossible. At fractures of edges novocainic blockade of intercostal nerves after which in case of P.'s damage pains and muscular protection of an abdominal wall do not disappear has a certain differential and diagnostic value.
An important diagnostic method of a research is the laparocentesis of a front abdominal wall which is carried out by means of one or several thick needles or by use of the so-called rummaging catheter (see. Laparocentesis ). Existence in punctate of fresh blood in which determine the level of hemoglobin, quantity of erythrocytes and presence of bilious pigments, testifies to P. V rupture doubtful cases, especially at the combined injury, the laparoscopy allowing to establish character and localization of damage of P., and also to reveal subkapsulyarny hematomas on a front and lower surface of body can be used. When at P.'s damages gleams of hepatic veins gape, this research is unsafe because of a possibility of a gas embolism. In not clear cases and the remaining suspicion on P.'s damage it is necessary to resort to a diagnostic laparotomy (see) which is less dangerous to the patient, than the overdue operation fraught in most cases by a failure. In diagnosis active dynamic overseeing by a condition of the patient, a wedge, data and a lab is important. indicators. At simple bruises of P. improvement of the general condition of the patient and subsiding of local signs is observed; at internal bleeding the state it worsens.
Open damages, or wounds, subdivide on chipped and cut, napr, knife, and fire (fraction, bullet, fragmental). Distinguish also through, nonperforating and gutter wounds of P. V peace time of wound of P. make 60 — 80% of all injuries of this body. Most of victims, as well as at the closed P.'s damages, make men at the age of 20 — 29 years.
A zone of damage at a chipped and cut wound of P. usually small — within the wound channel. At gunshot wounds multiple ruptures of a parenchyma of P. and necroses in a circle of the wound channel, and also a zone of destruction in the central departments of body and even a partition of the Item are characteristic. In this regard gunshot wounds are followed by heavy shock and considerable blood loss that, undoubtedly, influences an outcome; they are, as a rule, combined with damage of other bodies of an abdominal or chest cavity (see. Torakoabdominalny damages ), what even more makes heavier a condition of victims and worsens results of treatment. A wedge, manifestations at P.'s wounds are close to those at the closed its damages and depend on time which passed from the moment of an injury, its character and size of blood loss.
Diagnosis of wounds of P. is less difficult, than the closed damages of body. On an arrangement of a wound or a projection of the wound channel at through wounds it is possible to establish localization of defeat of P., at the same time, however, it is necessary to consider position of a body at the time of wound. Zhel-cheistecheniye, allocation of pieces of hepatic fabric or loss in a wound of site P. are direct symptoms of its wound.
Complications can arise in various terms after P. K damage by it belong: 1) internal bleeding in an abdominal cavity owing to a rupture of a subcapsular hematoma of P. or in intestines as result of a traumatic hemobilia; 2) pyoinflammatory processes — P.'s abscesses, subphrenic, over - and subhepatic abscesses, an angiocholitis (in the presence of communication between intra hepatic bilious channels and the infected posttraumatic cavities of P.); 3) the complications connected with a zhelcheistecheniye — bilious peritonitis, bilious pleurisy and bronkhobiliarny fistulas (at thoracoabdominal wounds), outside bilious fistulas; 4) other bilious and hepatic complications — an intra hepatic pseudocyst, the posttraumatic cicatricial stenosis of intra hepatic bilious channels which is followed by an atrophy of the corresponding zones P., sometimes with disturbance of outflow of bile, P.'s dystrophy of a traumatic origin, an embolism of a pulmonary trunk by the sequestered sites of a parenchyma of P. through the injured veins of body.
Treatment of damages of P. operational. At the same time tactics concerning the closed and open defeats of body is almost uniform — operation is performed urgently even if the condition of the patient is on the verge of terminal. The delay of an operative measure for removal of the victim from a condition of traumatic shock at the proceeding bleeding only aggravates weight of shock and general condition of the patient. Overdue operation is followed, as a rule, by adverse results and the high lethality reaching according to D.F. Skripnichenko (1970), V. I. Petrov and A. I. Mariyev (1976), apprx. 60%. At the same time, postponing operation and hoping for spontaneous treatment at a chipped and cut wound or a small rupture of P., the surgeon subjects life of the patient of big danger. Waiting tactics is possible only at satisfactory condition of the patient and absence a lab. and a wedge, given about the proceeding internal bleeding and the phenomena of peritonitis, and also at precisely established diagnosis of a subcapsular or central hematoma of P.; at the same time the high bed rest and dynamic observation during 2 weeks is necessary.
An operative measure at patients with P.'s damage pursues the following aims: final stop of bleeding and zhel-cheistecheniye, processing of a blemished surface of body for the prevention of development of complications (peritonitis, repeated bleedings, bilious fistulas). Operation is performed under the general anesthesia with constant massive hemotransfusion (in enough and with a necessary speed) and introduction of the means normalizing a hemodynamics.
After opening of an abdominal cavity it is necessary to make quickly P.'s audit, since its convex surface where gaps are located more often, and having found damage, to carry out a temporary stop of bleeding or a hard tamponade of the bleeding wound a big gauze napkin, either a prelum of the respective sites of body hands, or manual crossclamping of a hepatoduodenal sheaf.
Temporary crossclamping of the main vessels of a liver is made by means of soft intestinal terminals, an artery forceps of Satinsky or a tourniquet. After that immediately start performance of the main intervention on a liver, considering that the termination of blood supply more than for 10 — 15 min. leads to irreversible changes in fabric of body. After the specified term the prelum of vessels of P. needs to be stopped, having plugged the bleeding wound; in case of need after their small break it is possible to press again (discontinuous occlusion), having increased thereby time of the general switching off of body from blood circulation up to 20 — 25 min. Same it is possible to achieve by means of a local hypothermia for what P. lay over sterile cellophane or rubber sacks with ice. The intra belly hypothermia at a temperature of Item 29 ° increases P.'s resistance to a hypoxia that allows to make crossclamping of a hepatoduodenal sheaf on more long term.
The blood which streamed in an abdominal cavity in case of lack of damage of hollow bodies can be again transfused to the patient. Reinfusion of the blood which is previously filtered through 8 layers of a gauze can be made even in the presence of impurity of bile to it.
The choice of a method of operation depends on the nature of damage of P., localization and an arrangement of a wound, intensity of bleeding, the general condition of the patient. Superficial wounds and the small not bleeding ruptures of a parenchyma of P. can be left without processing since their sewing up sometimes is followed by bleeding and it appears more traumatic. Such damages of P. can be covered with a big epiploon and to drain subhepatic space. The small moderately bleeding P.'s ruptures take in separate noose or P-shaped sutures (see Seams surgical) a simple or chrome-plated catgut that provides a necessary hemostasis. On more extended and deep wounds of P. put special stitches. Most often use Kuznetsov and Pensko-go, Oppel, Telkov's seams (fig. 8, and, c). It is necessary to impose them so that also the bottom of a wound was surely taken, a cut otherwise can form further a basis for formation of a deep hematoma of the Item. If bleeding from depth of a wound does not manage to be stopped underrunning or it is dangerous because of a possibility of damage of the main vessels of body, it is possible to use hard packing of a wound of P. gauze napkins, a cut it is better to combine with introduction of an absorbable gelatin sponge, or to resort to biol, a tamponade — an epiploon, a muscle on a leg, etc. (see the Tamponade). In similar cases it is possible to apply glue sealing of a wound by means of a needleless injektor (according to O. B. Milonov).
Leaving of tampons in P.'s wound on a long term is undesirable since not always provides a reliable hemostasis and quite often is followed by a number of complications (secondary bleeding, a hemobilia, abscesses, etc.). Leave tampons in a wound only in urgent cases. At crushes of a parenchyma of body impractical fabrics P. excise after bandaging them at the basis. The visible bleeding blood vessels take styptic clips and tie up, the damaged bilious channels sheathe atrazmatichesky needles with synthetic thread. After the made processing sewing up before contact of edges of such wound is not always possible, especially if it takes the zhelobovaty form, because of eruption of fabrics P. or danger of formation of a regional necrosis. In these cases, according to T. T. A tung tree (1972), after achievement of a hemostasis it is possible to leave a wound not sewn up, but it is good to drain it, combining with concealment by an epiploon. At the extended and deep wounds which are partially separating rather large fragments of P. resort to its resection up to hemihepatectomies (see).
If the wound is located on a back surface of P. and it is not possible to take in it, use a technique of a hepatopexy (see. Splanchnoptosia ), hemming edges of a wound to a parietal peritoneum. At the same time a diaphragm, densely adjoining to P.'s surface, closes a wound and promotes a stop of bleeding. With the same purpose use plastics a crescent linking and the site of a diaphragm on Petrovsky (fig. 9, and, b).
Operation finish with obligatory drainage (see) over - and subhepatic spaces of an abdominal cavity the rubber tubes brought through an operational wound to a front abdominal wall or through counteropenings. At an unreliable hemostasis resort to an additional tamponade gauze napkins.
After operation continue holding antishock actions, hemotransfusion and blood substitutes, proteinaceous drugs, gamma-globulin, carry out massive antibioticotherapias). Drainages delete on 5 — the 7th day, tampons (gradually tightening) — on 10 — the 12th day. At a favorable current of the postoperative period next day after operation allow to drink, from the 2nd day begin feeding.
In the postoperative period secondary internal bleedings can be observed, it is purulent - necrotic complications, bilious peritonitis. bilious fistulas, posttraumatic hepatitis, traumatic cysts.
Secondary intra belly bleedings arise owing to an insufficient hemostasis of damages of P. during operation or the intervention of the fibrinolysis (see) caused by disturbance of coagulant system of blood which arose later, a cut quite often arises after .massivny hemotransfusions. In later period of bleeding in an abdominal cavity are a consequence it is purulent - necrotic changes of the Item. Bleedings in went. - kish. a path hemobilias result. At development of secondary intra belly bleeding carry out hemotransfusion and a repeated operative measure.
Purulent complications from P. meet most often. Abscesses — intra hepatic, subhepatic and suprahepatic concern to them (subphrenic), the suppurated hematomas, it is purulent - necrotic changes in area of the stitches put on P. P.'s abscesses arise owing to infection of the bilious and bloody contents which accumulated in deep departments of body, usually under incorrectly (too superficially) put stitches or a gauze tampon. Their symptomatology reminds a wedge, a picture of the suppurated central hematoma of P., and also the abscessing purulent cholangitis (see).
Subphrenic and subhepatic abscesses are formed on the basis of an okoloranevy necrosis of hepatic fabric, the suppurated podkapsul-ny hematomas, and also the infected accumulations of blood in subphrenic and subhepatic areas. For the purpose of prevention of these complications carefully exempt an abdominal cavity at the end of operation from blood and clots, drain over - and subhepatic spaces, considerably delete the damaged fabrics, carry out antibioticotherapias). Subphrenic abscesses (see) can be formed also in later period, 2 months later and more after operation.
Treatment operational — opening and drainage of abscess. For this purpose usually use extra peritoneal accesses; at subhepatic localization abscess can be opened at partial cultivation of edges of an operational wound. The delay with operational treatment can lead to spontaneous opening of abscess in an abdominal cavity and to development of purulent peritonitis.
Bilious peritonitis (see) arises at defective processing of a wound of P., it is purulent - necrotic complications — at insufficient drainage of an abdominal cavity. The bilious fistulas (see) developing sometimes after operation can be outside and internal (biliodigestivny, bi-liobronkhialny, etc.). Traumatic cysts of P. arise sometimes at patients with the central hematomas of body several months later or years after an injury. At the same time there are an abdominal pain, weakness, pallor, perspiration, an ik-terichnost of scleras and skin, in an upper half of a stomach the tumor, sometimes fluctuating is defined. The diagnosis is specified with the help rentgenol, and special methods of a research. Treatment operational — opening and drainage of a cyst.
Posttraumatic hepatitis is shown by jaundice, subfebrile temperature, decrease in functions P. and a leukocytosis. Treatment conservative.
The result of damages of P. is in direct dependence on timeliness of operation, size of blood loss, character, volume and prevalence of damages. According to Krostueyt (R. W. Crosth-wait, 1962), at P.'s damage with simultaneous damage of one more body the lethality makes 11%, two bodies — 23,6%, three — 28,4%, four-five — 84,6%. Blood loss and shock, and in the postoperative period — specific complications are the most frequent causes of death (secondary internal bleeding, gnoynonekrotichesky complications, bilious peritonitis, etc.). Thanks to improvement of diagnosis and methods of treatment the lethality at P.'s damages decreases. According to Morton (J. Morton, 1972), with damages by P. for 1939 — 1954 the lethality made 20,6% of 1068 patients, for 1954 — 1962 — 14,4%, and for 1962 — 1970 — 11,7%, and at the closed injury of P. it decreased with 71% (for the first period) to 30,5% (in the next years).
The long-term results after operational treatment of damages of P. are more favorable that is substantially caused by P.'s ability to regeneration and recovery of functions after damages and even extensive resections of body.
Especially it is necessary to allocate the injuries of a liver connected with carrying out various diagnostic manipulations, for example punctures, biopsies, a laparoscopic research, a transdermal transhepatic holangiografiya, a hepatostomy, transhepatic drainage of bilious channels, etc. P.'s damages can be caused by actions of the surgeon during operation as a result of which, especially against the background of patol, changes of body, subcapsular hematomas, cracks and ruptures of a parenchyma of P., damage of the capsule P. and fabric of body are formed. By data to Fegereshan (I. Fagara§anu, 1976), in similar cases the heavy complications demanding an urgent operative measure are observed. P.'s damages arise also sometimes during the holding resuscitation actions (the closed cardiac massage, an artificial respiration). These facts testify to need of careful and careful carrying out manipulations on P. and timely acceptance of the necessary measures preventing emergence of complications.
Fighting injuries of a liver carry to number of the most difficult for diagnosis and treatment of injuries of abdominal organs. They are also subdivided on opened and closed. By experience of the Great Patriotic War at the closed injuries of a stomach fighting damages of P. took the fourth place among the closed injuries of abdominal organs. Open damages of P. made 20,2% among all injuries of abdominal organs. Among open damages gunshot wounds of P. — bullet and fragmental meet more often (through, blind and tangent). Fighting damages of P. can be single or multiple, isolated or combined. The closed P.'s damages subdivide into damages with disturbance and without disturbance of an integrity of the capsule; they can be superficial (cracks) and deep. The form of cracks and deep ruptures of P. can be various — more often linear or twisting, sometimes star-shaped. The prevailing direction of cracks and P.'s ruptures — sagittal. The heaviest damages of P. — crushes and separations of its parts. At the closed P.'s damages formation of subcapsular superficial and deep (central) hematomas is possible, to-rye can cause a secondary rupture of the capsule P.
The first medical and pre-medical aid by P. which was injured with fighting damages consists in imposing of an aseptic bandage on a wound, introduction of analgetics and bystry evacuation from the battlefield. During the rendering the first medical assistance enter antitetanic serum, tetanic anatoxin, antibiotics of a broad spectrum of activity, anesthetics then victims are evacuated on a stage of rendering the qualified medical aid.
During the rendering the qualified medical aid allocate: groups of victims with the expressed symptoms of the proceeding intra belly bleeding who are immediately sent to the operating room; wounded in state of shock of the II—III degree (but without symptoms of bleeding) who are sent to antishock chambers; wounded with the getting wounds of abdominal organs who are sent to the operating room. Injured with suspicion on the closed P.'s damage make a diagnostic laparocentesis (see), at an opportunity a laparoscopy (see. Peritoneoskopiya ).
By the most effective method of anesthesia at fighting damages of P. consider an endotracheal anesthesia nitrous oxide with addition of ether.
The main quick access to P. in field conditions is midsection. At damage of the right share and rear edge of P. it is reasonable to supplement midsection with the section going parallel to the right costal arch with crossing of a round team of P. or it is possible to use transphrenic access. After a temporary stop of bleeding, careful and methodical audit of subphrenic space and other areas of an abdominal cavity start surgical treatment of damages of P. which consists foreign bodys, the smashed impractical fabrics at a distance. At through and nonperforating wounds of P. carefully clear the wound channel of a wound detritis and tampon it an epiploon on a leg or in rare instances a gauze tampon. The injured gall bladder is taken in or deleted. After surgical treatment on P.'s wound put catgut stitches.
At wounds in the field of a phrenic surface of P. when imposing of styptic seams is complicated, resort to a hepatopexy according to Alferov — a podshivaniye of free edge of P. to the peritoneum covering a diaphragm. At the same time P.'s wound densely nestles on a diaphragm, and bleeding stops.
During a laparotomy also open and empty subcapsular hematomas. Operations on P. finish with removal from an abdominal cavity of clots and introduction to a root of a mesentery of a small bowel of solution of novocaine and antibiotics of a broad spectrum of activity. Bring drainages to the taken-in P.'s wounds.
During the rendering specialized medical aid by P. which was injured with fighting damages perform prevention and treatment of the arisen complications (peritonitis, eventration of intestines, outside bilious fistulas, etc.), and also make operative measures if they were not executed earlier.
Number of the main nozol. forms at which the main thing is P.'s defeat, exceeds 50. Hepatitises, P.'s cirrhoses, fatty and pigmental hepatoses concern to the most important of them acute virus and hron.
Hepatitis (see) depending on prevalence of process can be focal and diffusion, depending on duration of a current — acute and chronic. The major factors leading to development of an acute hepatitis are various causative agents of infections and toxic agents. The reason of acute hepatitises, in addition to a virus of an infectious disease (see a viral hepatitis), enteroviruses, causative agents of acute intestinal infections, a virus of an infectious mononucleosis, leptospira, etc. most often are. Can lead impact of ionizing radiation to development of an acute hepatitis.
Acute alcoholic hepatitis develops, as a rule, at hron, alcoholism, against the background of alcoholic fatty P., fibrosis or cirrhosis of the Item often proceeds. In development of alcoholic hepatitis the products of reoxidation of lipids which are strong cellular poisons can play a part. Damage of a parenchyma can be caused also by immune mechanisms what cytotoxicity of lymphocytes in relation to autologous P. Mogut's tissue testifies to be observed a cholestatic form of alcoholic hepatitis with dominance of signs cholestasia (see), anicteric — with a characteristic morfol., a wedge, and biochemical, signs at which there is no jaundice, and subclinical — with total absence a wedge, manifestations in the presence of characteristic morfol, and biochemical, symptoms of hepatitis. The combination of acute alcoholic hepatitis to P.'s obesity, a lipidemia and hemolitic anemia is allocated under the name of a syndrome to Tsiva.
Morphologically acute alcoholic hepatitis is characterized by balloon dystrophy, obesity and a necrosis of hepatocytes, adjournment in them an alcoholic hyalin, infiltration by polymorphonuclear cells, centrolobular fibrosis. The disease begins sharply after the short preicteric period and more often proceeds hard. Patients show complaints to weakness, loss of appetite, nausea, abdominal pains, quite often intensive. From objective symptoms increase and P.'s morbidity, fever, usually moderate jaundice are most characteristic. In blood — the anemia, a leukocytosis with shift of a formula to the left accelerated by ROE. In blood serum the content of bilirubin and activity of aminotransferases (ASAT with high value of coefficient of de Ritis — the relation of ASAT to ALAT is preferential) increase, the hyperferremia, a prothrombinopenia are observed. Often biochemical signs of a cholestasia — increase in blood serum of activity of an alkaline phosphatase, leucineaminopeptidase and especially at-glutamiltranspeptida-zy, increase in content of cholesterol, p-lipoproteids, bilious to - t come to light. Content of immunoglobulins in blood serum is moderately increased, at the same time the IgA level is considerably increased.
Identification in blood serum by means of various immunol, methods of antigen of an alcoholic hyalin and antibodies to it is important for recognition of acute alcoholic hepatitis. Antigen is defined in an early phase of alcoholic hepatitis and disappears in the next 5 weeks after the termination of alcohol intake. Elimination of antigen from blood serum is followed by short-term emergence of the corresponding antibodies; at the progressing alcoholic hepatitis they it is long remain in blood serum.
Lech. actions at acute alcoholic hepatitis include a bed rest, a carbohydrate-rich high-calorific diet, disintoxication means, vitamin therapy, anabolic, symptomatic means.
The forecast can be favorable. However in some cases the disease proceeds very hard — the liver failure quickly progresses (see), ascites, encephalopathy develop; patients perish at the phenomena of a hepatic coma (see). The outcome of acute alcoholic hepatitis in hron, hepatitis and P.'s cirrhosis, especially in the conditions of the proceeding alcohol abuse is possible.
Medicamentous and toxic hepatitises can develop at reception of various pharmaceuticals (antibiotics, antituberculous remedies, antimetabolites, anti-inflammatory drugs, p-adrenoblockers and many others), and also toxins. Special exposure of P. to pathogenic action of these agents is explained first of all by the functional and anatomic position of body causing concentration in it various substances which are soaking up in intestines and also the most important role of P. in metabolism of connections of an exogenous origin. P.'s defeats at medicamentous and toxic influences pathogenetic are heterogeneous. Allocate the defeats connected with the direct damaging action etiol, the agent (or his metabolites) and mediated, at the expense of hypersensitivity reaction. The first of them (so-called predictable defeats of P.) develop, as a rule, at all persons treated to action the agent at exceeding of its certain dose; patol, process is rather specific to each specific agent. The substances possessing direct toxic action on P. are perchloromethane, phosphorus, tetracyclines. P.'s defeats developing in connection with hypersensitivity of an organism to etiol, to the agent (so-called unpredictable, or idiosyncratic, P.'s defeats), can be caused immune (an allergy, an autoallergy) or metabolic (abnormal metabolism of the agent) by reactions. These defeats are observed only at individuals, do not depend on a dose of the entered agent and have a polymorphic picture. More often than others Ftorotanum, a-Methyldopum, streptocides cause idiosyncratic damages of a liver. Nek-ry substances, napr, an isoniazid, aminazine, are capable to cause P.'s damage in both described ways. At direct toxic defeats of P. the period between the first receipt in an organism etiol, the agent and development of a disease usually short (several hours are frequent), at idiosyncratic defeats it can proceed from several hours to several months.
A wedge, symptoms of defeat of P. are preceded sometimes by a prodromal stage — weakness, anorexia, abdominal pains. At direct toxic defeats of P. signs of defeat of other bodies and systems of an organism can be observed. Such extrahepatic manifestations of hypersensitivity as, e.g., an arthralgia, a dieback, fever, a leukocytosis with eosinophilic shift are characteristic of idiosyncratic defeats of P. regarding cases. Morfol., a wedge, and biochemical, manifestations of medicamentous defeats of P. are various and substantially depend on character etiol, the agent. Regarding cases, at action, e.g., of Ftorotanum, antituberculous remedies, they are indistinguishable from symptoms of a cytolytic form of a viral hepatitis. Signs of an acute hepatitis — inflammatory infiltration of portal fields and in P.'s segments, dystrophy and a necrosis of hepatocytes are morphologically noted. The item it is increased, painful, the splenomegaly is quite often noted. In blood serum activity of aminotransferases increases, the content of bilirubin increases. The course of hepatitis usually favorable, however is possible development of a hepatic coma. In other cases, at effect, e.g., of aminazine, androgens, gestagen, into the forefront signs of an intra hepatic cholestasia act. Morphologically accumulation of components of bile in hepatocytes and the bilious courses, the alteration of hepatocytes connected with stagnation of bile, mesenchymal cellular reaction are defined; jaundice, an itch of skin, an acholia a calla, biochemical, signs of a cholestasia are characteristic. At P.'s defeat by tetracyclines (it is especially frequent at pregnant women) the acute fatty hepatosis, clinically and biochemical shown signs of a syndrome develops cytolysis (see). So polimorfna toxic defeats P. Tak, at poisoning with perchloromethane in its fabric are observed fatty infiltration of hepatocytes, centrolobular necroses, hemorrhages and leukocytic infiltration; development of an acute massive necrosis of a parenchyma is possible. P.'s defeat at poisoning with organochlorine compounds (hexachlorane, a dichloroethane) has character of a fatty hepatosis.
At medicamentous hepatitis immediately cancel the corresponding medicine. Treatment of these hepatitises is based on use of disintoxication means and vitamins; also symptomatic treatment is carried out.
The forecast of medicamentous and toxic hepatitises considerably is defined by character etiol, the agent. At effect, e.g., of phosphorus, some organic toxins the lethality can reach 50%; development hron is possible, hepatitis,
P. P.'s cirrhosis process at any infection proceeding with a virusemia can be involved in patol. Weight and the nature of defeat of body are defined at the same time by a gepatotropnost of the activator and (frequent) character of an immune response or influence formed in the course inf. process of toxins. In most cases at the same time there is nonspecific reactive hepatitis which is morphologically shown by the minimum alteration of hepatocytes and unsharply expressed cellular reaction in a stroma; a wedge, and biochemical, displays of hepatitis can be absent or be minimum. Heavier damages of P. (a necrosis of hepatocytes, the expressed inflammatory reaction) are observed at yellow fever, a cytomegaly and inf. a mononucleosis, is more rare at an adenoviral infection, a rubella, a pas-ramiksovirusnoy, enteroviral, herpetic infections.
At to yellow fever (see) the necrosis of hepatocytes (in hard cases — submassive) and the minimum mesenchymal reaction is noted. The hepatomegalia, jaundice, by means of biochemical are observed, researches are found signs of disturbance of functions P. (a hypoalbuminemia, decrease in maintenance of blood-coagulation factors, hypochilesterinemias). At a favorable outcome P.'s structure is completely recovered; transition in hron, hepatitis or P.'s cirrhosis is not observed.
P.'s defeat at cytomegalies (see) comes to light at newborns more often. Also the splenomegaly, jaundice, change of functional hepatic trials are observed gepato-. Morphologically at the same time in fabric P. find huge multinucleate cells with large inclusions in kernels, a necrosis of hepatocytes, limfogistiotsitarny infiltration of portal fields. Are possible transition in hron, hepatitis and development of cirrhosis of P. U of adults hepatitis at a cytomegaly develops seldom, as a rule at an aggravation of latent infection, napr, in the conditions of treatment immuno depressants.
P.'s defeat at an infectious mononucleosis (see the Mononucleosis infectious) is characterized by a moderate hepatomegalia, a splenomegaly. Activity of aminotransferases in blood serum is increased slightly or moderately, considerably hyperactivity of at-glutamil-transpeptidase, an alkaline phosphatase, lactate dehydrogenase. Infiltration of fabric P. of a mononuklearama (including atypical), activation and a hemosiderosis of star-shaped retikuloendoteliotsit, defeat of a parenchyma with dystrophy and a necrosis of hepatocytes can morphologically be found; signs of a cholestasia can be observed. The bed rest, a diet hyposensibilizing cure, vitamins, for the expressed intoxication — corticosteroids are shown. Forecast favorable.
Hepatoses (see) are characterized by primary disbolism of hepatocytes, are morphologically shown by their dystrophy without essential cellular reaction in a stroma. Nek-ry hepatoses are nozol, forms, others have character of syndromes. To number of the most important in a wedge, the relation of hepatoses fatty, Cholestatic hereditary pigmental hepatoses, gepato-tserebraljny dystrophy (see), hemochromatosis belong (see).
Hepatoses can be connected with genetically determined disturbance of lipid metabolism and are in most cases diseases of accumulation. At the most part accumulation of lipids comes from them in elements of reticuloendothelial system, but is sometimes preferential in parenchymatous cells P., napr, at Volman's disease and a disease of accumulation of ethers of cholesterol.
Volman's disease (a family visceral xanthomatosis) — the rare disease which is observed at children in the first weeks of life. Intracellular accumulation of triglycerides and ethers of cholesterol is its cornerstone, it is preferential in P. and a mucous membrane of intestines, connected with insufficiency of lizosomalny acid esterase. Morphologically in hepatocytes, and also histiocytes find the numerous, surrounded with membranes fatty drops giving to cells a foamy look. Quickly enough in P. there comes fibrosis. In adrenal glands deposits of salts of calcium are found. The main a wedge, symptoms are the fever, vomiting, a diarrhea expressed gepato-and a splenomegaly, a steatorrhea. Jaundice is usually observed, functional trials of P. Vozmozhno development of cirrhosis of P. V treatment are often changed the favorable effect renders the strengthened introduction to an organism of cholesterol.
A disease of accumulation of ethers of cholesterol — the rare disease developing at children's age. The insufficiency of lizosomalny acid esterase and triglyceride lipase causing accumulation of neutral fat and ethers of cholesterol preferential in P., intestines and marrow is the cornerstone of a disease. Morphologically in hepatocytes at the same time accumulations of the lipids having an appearance of acerate crystals or drops, surrounded with membranes come to light. «Foamy» histiocytes meet. P.'s fibrosis develops seldom. The disease usually proceeds is latent, its only symptom is the hepatomegalia. In blood serum the level of ethers of cholesterol, phospholipids and triglycerides is increased, increase in concentration of bile acids (preferential honodezoksikholevy) is often observed. Symptomatic treatment. Forecast favorable.
At hepatic porphyrias (see) morphologically in P. find a necrosis of single cells, an easy siderosis, fatty infiltration, fibrosis. Development of exacerbations of a disease at action of a number of the factors increasing the need for gem and inducing thus increase in synthesis and - ami-nolevulinovoy to - you and various porphyrines possessing possibly toxic action is characteristic. Pharmaceuticals (especially barbiturates), alcohol, hormones (estrogen, androgens) and some other are among such factors. By means of biochemical, methods of a research disturbances of bromsulfoftaleinovy test, tranzitorny increase in content in blood of bilirubin, enzymes (AT, the Expert of AT Is scarlet), cholesterol can come to light. More detailed a wedge, a picture of hepatic porfgfiya, their treatment and the forecast — see. Porphyrias .
P.'s defeats are expressed at a glycogenosis of the I—IV, VI, IX and X type (see. Glycogenoses ). The I type is most often observed, at Krom increase in hepatocytes in connection with accumulation in their cytoplasm of the vacuoles containing a glycogen and triglycerides morphologically comes to light. Fibrosis, cirrhotic changes of P. usually are absent. The increased P. is palpated much, the spleen is not increased. Functional trials of P. are usually not changed. At a glycogenosis of the II type adjournment of a glycogen happens in all bodies, including in P. (in lysosomes of hepatocytes). By the item it is moderately increased, functional hepatic trials are not changed. At a glycogenosis of the III type morfol, changes in P. correspond to that at the I type. The hepatomegalia, sometimes a splenomegaly are clinically characteristic, development of cirrhosis of the Item is possible. At a glycogenosis of the IV type accumulation in P. of amylopectin is observed, also the splenomegaly is noted gepato-; hepatic tests are changed. Fibrosis and cirrhosis of the Item develop. At a glycogenosis VI, IX and X types hepatocytes are increased (especially by peripheries of hepatic segments) in connection with accumulation of the vacuoles containing a glycogen. Fibrosis is absent. The disease usually proceeds latentno, and the only thing a wedge, a symptom is the hepatomegalia. More detailed a wedge, a picture of glycogenoses, their diagnosis, treatment and the forecast — see of a likogenoza.
At galactosemia (see) P.'s defeat it is caused by toxic effect of galaktozo-1-phosphate. The phenomena of a cholestasia are morphologically characteristic accumulation of fat in hepatocytes; during the progressing of process cirrhosis of the Item forms. An early symptom of defeat of P. — the jaundice developing in the first days after the birth. As a rule, the hepatomegalia is observed. At development of cirrhosis of P. the splenomegaly, a phlebectasia of a front abdominal wall, ascites come to light. More detailed a wedge, a picture of a galactosemia, its diagnosis, treatment and the forecast — see the Galactosemia.
At fruktozemiya (see) P.'s defeat connect with excess accumulation in an organism of fruktozo-1-phosphate. At the beginning of a disease accumulation of fat in hepatocytes, in the subsequent is noted fibrosis and P. Chasto's cirrhosis can develop the hepatomegalia, seldom jaundice is defined. At development of cirrhosis of P. the splenomegaly, ascites, symptoms of a liver failure develop. More detailed a wedge, a picture of a fruktozemiya, its treatment and the forecast — I eat. Fruktoze-mi I.
P.'s defeat at tyrosinosis (see) develops, apparently, as a result of toxic action of aromatic derivatives of tyrosine. Morphologically at the same time accumulation of fat in hepatocytes takes place, there is a necrosis of hepatocytes. In an acute stage of the disease developing usually in the first 2 — 6 months of life, P.'s defeat is shown by the hepatomegalia raised by bleeding in 1/3 cases — jaundice. There are symptoms of a liver failure. Hron, forms of a tyrosinosis develop in connection with evolution of acute defeat of body or proceed at early stages latentno, being shown is later symptoms of the created cirrhosis P. Podrobney a wedge, a picture of a tyrosinosis, its treatment and the forecast — see the Tyrosinosis.
At tuberculosis (see) typical granulematozny defeat of P., merge of the breaking-up granulomas is observed can be followed by formation of tuberculomas (see). Clinically miliary tuberculosis of G1. it is quite often shown by a hepatomegalia, jaundice, a splenomegaly. At a tubercular cholangitis pains in the right upper part of a stomach are noted jaundice. Indicators of functional trials are often changed — a delay of a bromsulfoftalein, increase in activity of an alkaline phosphatase and aminotransferases in blood serum, shifts of a proteinogramma. Bacterial is important for diagnosis intravital morfol, and. research of fabric P. The X-ray analysis at which the centers of calcification of the Item can be found has retrospective diagnostic value. Treatment is directed to a basic disease. The forecast at timely begun treatment favorable.
The nature of defeat of P. at the acquired syphilis (see) depends on a stage of a disease. At secondary syphilis of P. process approximately is involved in 10% of cases in patol. Infiltration of portal fields, a necrosis of hepatocytes, proliferation of star-shaped retikuloendoteliotsit are morphologically noted. By the item at the same time it is increased, quite dense consistence. Quite often jaundice develops, activity of an alkaline phosphatase in blood serum which does not correspond to others a wedge, and a lab often sharply increases. to signs of a cholestasia. Activity of aminotransferases is moderately increased. The diagnosis is established with the help morfol, by researches P. (biopsy) taking into account a wedge, and anamnestic data.
Tertiary syphilis of G1. it is characterized by formation of gummas — large granulomas with the central caseous necrosis and the connective tissue capsule. Healing of gummas is followed by formation of hems. Gummous defeat of P. usually proceeds asymptomatically, but local pains, fervescence are sometimes noted. At the expressed cicatricial process are observed jaundice. portal hypertensia, ascites. The laparoscopy with an aim biopsy has the major diagnostic importance. Treatment is directed to a basic disease. The forecast more often favorable — at specific treatment is observed involution of process.
Cirrhoses of a liver (see) — the progressing P.'s diseases which are characterized by dystrophy and a necrosis of a hepatic parenchyma, its nodal regeneration, diffusion growth of connecting fabric and deep reorganization of very tectonics of body.
Fibrosis — the overdevelopment of connecting fabric connected with a new growth of collagenic fibers or with a collapse of a reticulin stroma of the Item. In most cases fibrosis is morfol, a symptom of defeats of P. of various genesis, in certain cases it can be primary. Periportal and subkapsulyarny fibrosis of P. without essential damage of hepatocytes can be observed, e.g., at some toxic (vinyl chloride, arsenic) defeats of II. Process usually proceeds asymptomatically, only regarding cases symptoms of portal hypertensia develop. Carry also gepatoportalny sclerosis to P.'s fibrosis — the disease of not clear etiology which is characterized by portal and often septal fibrosis of P., shown symptoms of portal hypertensia.
Kongenitalny fibrosis of P. — the rare disease inherited on autosomal recessively type, which is quite often combined with inborn defects is especially frequent with a polycystosis of kidneys. At morfol, a research diffusion growth of the connecting fabric which is accurately delimited from a parenchyma of the Item comes to light. Portal fields are expanded and connected among themselves by the connective tissue tyazha of various thickness which are often containing the extended shape of a cavity, covered by cells of an epithelium of the bilious courses. The major wedge, symptoms — a splenomegaly, went. - kish. bleedings — are connected with the developing portal hypertensia (see). Ascites, as a rule, is absent. Abdominal pains and fever are often observed that is especially characteristic at the advanced children's age and at adults. Level of bilirubin, albumine, activity of aminotransferases, the maintenance of blood-coagulation factors in blood serum are not changed, moderately hyperactivity of an alkaline phosphatase. Crucial diagnostic importance has morfol, a research of the material received by means of a biopsy of the Item. The differential diagnosis is carried out with P.'s cirrhosis and other diseases causing portal hypertensia. Symptomatic treatment. At often repeating went. - kish. bleedings imposing of a porto-caval anastomosis, in the presence of a cholangitis — use of the antibiotics of a broad spectrum of activity which do not have side effect is recommended.
Abscesses of a liver — limited suppurations of a parenchyma of body. They can be single and multiple, the last of usually small size. Are located more often in the right share of P., contain dense pus with off-flavor and quite often melted sequesters of hepatic fabric; have no the expressed piogenic membrane. Arise gematogenno, by transfer of a contagium on system of a portal vein from the inflammatory centers of abdominal organs at an acute appendicitis more often (see the Pylephlebitis), an ulcerative enteritis or colitis, peritonitis. They can have also a holangiogenny origin as a result of the ascending infection at a purulent cholangitis or cholecystitis. Less often P.'s abscesses arise at hit of contagiums through system of own hepatic artery from a big circle of blood circulation at a felon, a furunculosis, an anthrax, parotitis, osteomyelitis, and also during some inf. diseases, napr, typhoid. In certain cases suppuration develops in P. owing to infection already existing patol, formations of body — echinococcal or not parasitic cysts, the breaking-up malignant tumors, hematomas, wounds, foreign bodys. Transition of inflammatory process from adjacent bodies is possible. In some cases primary source of an infection does not manage to be found. Depending on an etiology distinguish bacterial (coccal, bacillar and mixed) and parasitic abscesses (amoebic, the expert-karidnye, echinococcal, etc.)
Besides, distinguish P.'s abscesses resulting from suppuration of not parasitic cysts, granulomas at syphilis or P.'s tuberculosis and also suppurations of hematomas, wounds or cracks and in the field of an arrangement of foreign bodys of the Item.
Bacterial abscesses of P. in modern conditions meet quite seldom thanks to improvement of methods of treatment of acute purulent diseases, use of antibiotics of a broad spectrum of activity and antiseptic agents (before an operative measure). Bacterial abscesses of P. equally often occur at men and women, usually at the age of 30 — 45 years. The first a wedge, signs quite often are the tremendous oznoba (several times in days) which are followed high razma-be rude temperatures, pouring then, constant tachycardia (pulse rate reaches 120 blows in 1 min.), even during the periods of remission, and a high leukocytosis (30 — 40 thousand in 1 mkl). In several days local symptoms appear: feeling of weight and a raspiraniye in right hypochondrium, pains to the areas P. irradiating in the right shoulder girdle, the right infrascapular or lumbar area, P.'s increase and morbidity in the area P. at effleurage, a muscle tension of a front abdominal wall in right hypochondrium, protrusion of a costal arch and a smoothness of intercostal spaces on the right, increase in hepatic dullness. Along with it there are also general symptoms — weight loss, an adynamia, skin becomes dry, flabby, sometimes with an icteric shade, face skin gets earthy coloring. The expressed jaundice develops late and demonstrates diffusion toxic damage of a parenchyma of P. or a prelum of the right, left or general hepatic channel. In blood disappearance of eosinophils, a lymphopenia and the accelerated ROE are noted very high leukocytosis (to 40 thousand in 1 mkl) with a deviation to the left; in urine — an easy albuminuria, presence of bilious pigments, as at a septic state. At rentgenol. a research find high standing (on one-two mezhreberye) the right dome of a diaphragm and restriction or its full immovability, sometimes an exudate in the right pleural cavity; at localization of abscess in the left half of P. — the shift of a stomach in the field of small curvature. Polyposition rentgenol, the research allows to differentiate P.'s abscess from subphrenic abscess. Localization of abscess can be revealed by means of a stsintigrafiya by radioactive gold — 198ai (fig. 10), and also at ultrasonic echolocation of the Item. In the presence of large solitary abscesses on P.'s angiogram avaskulyarny sites decide on the shift of vessels in a circle of abscess.
Diagnosis of single large abscesses of P. at expressed a wedge, a picture and accurate rentgenol, data does not present special difficulties. At the same time anamnestic data on the acute appendicitis postponed in recent times, cholecystitis, an anthrax, etc. have important diagnostic value. At multiple small abscesses of P. with malovy-razhenny local manifestations establishment of the correct diagnosis quite often is extremely difficult because they can proceed unnoticed against the background of a wedge, pictures of the basic or primary disease which is followed by accurately outlined peritoneal, pleural and pulmonary symptoms or pictures of sepsis (see). The differential diagnosis is carried out with under phrenic abscess (see), pylephlebitis (see), to the sacculated purulent pleurisy (see).
The course of abscesses of P., as a rule, heavy, progressing, quite often leading to a lethal outcome, especially at purpose of inadequate or untimely treatment, and also at development of complications.
P.'s abscesses clinically can atypically proceed; e.g., at subphrenic localization of abscess into the forefront symptoms of pleurisy or pneumonia — cough, a pleural rub, rattles (a pleuropulmonary form) sometimes act; the prevalence of dysuric frustration (a renal form) is characteristic of a zadnenizhny arrangement of abscess of P. Also septic form which is characterized by hl meets. obr. symptoms of the general purulent intoxication. In 25 — 30% of cases the course of abscesses of P. is followed by development of complications. The heaviest among them are perforation of abscess in a free abdominal cavity with development of peritonitis (see), intra belly bleeding (see), perforation in subphrenic space with formation of epiphrenic abscess (see), in a pleural cavity with development of an empyema of a pleura (see. Pleurisy ), abscess of a lung (see. Lungs ), hepatobronchial fistula, a purulent pericardis (see), cardiac tamponades (see). The break of abscess in a gleam of a stomach, intestines, in a gall bladder or bilious channels, perinephric cellulose, etc. is possible (less often).
The forecast of bacterial abscesses of P., especially multiple, is always serious. The operational lethality, according to G. A. Gomzyakov, makes 26 — 50%. Decrease it depends on timely elimination of the center of an infection which was a source of formation of abscess, and an early operative measure concerning abscess of the Item.
Treatment of bacterial abscesses of P. operational: broad opening of abscess, whenever possible full removal of its contents and drainage of the formed cavity in II. Apply an endotracheal anesthesia with muscle relaxants to anesthesia (see. Inhalation anesthesia). Depending on localization of abscess operation is carried out by means of abdominal, transpleural or ekstraserozny access. The first is applied most often, usually according to Fedorov or Kokher; at localization of abscess in the left share of P. make an upper median laparotomy (see); in some cases use the combined accesses that, however, increases degree of operational risk.
After P.'s exposure it is attentively examined and carefully palpated. Sites of gray-white color, and also the place of protrusion or limited commissural process can correspond to localization of abscess. At an arrangement in deep departments of body more dense roundish education quite often is possible to probe it, a cut can cause a symptom of fluctuation. In these cases apply a diagnostic puncture a needle of a large diameter and on receipt of pus open abscess on a needle with blunt instrument (tweezers, a styptic clip), and then enter a finger, open adjacent cavities and evacuate contents by means of a suction. The formed cavity in P. is drained, at bleeding tamponed gauze napkins, a styptic sponge. If at survey and a palpation abscess is not defined, make diagnostic punctures of P. diversely and on various depth.
At an arrangement of abscess lateralno in upper part P. it is reasonable to use Transpleural approach. Thus after a subperiostal resection of one-two lower edges and opening of a pleural sine sew intercostal muscles and a back leaf of a periosteum with a diaphragm, isolating a pleural cavity. Then cut a diaphragm in the sheathed site, find abscess in P. and after isolation open with its gauze napkins. It is vnebryushinno and vneplevralno possible to open the abscesses which are localized on a back surface of P. by flaking of a parietal pleura; at front abscesses of P. make an attempt of flaking of a parietal peritoneum. These approaches demand very high surgical equipment, are long and are not always successful. For prevention of peritonitis and a pyothorax use two-stage operations: at first open only an abdominal cavity and enter the delimiting gauze tampons to that site P. where in 5 — 7 days opening of abscess is supposed. The low-justified delay of the main intervention limits use of this operation.
In the early period of a disease, and also in the first days of the postoperative period also the chemotherapy shall be carried out antibiotiko-. Among antibiotics give preference to the drugs possessing a broad spectrum of activity and creating high concentration in cells of G1. and bile. Tetracyclines doxycycline (Vibramycinum) and Metacycline (Rondomycinum), and also the erythromycin entered both intravenously, and inside concern to them. Also levomycetinum, cephalosporins and aminoglycosides, from antibacterial agents — a dioxidin, from himiopreparat — the truck-gin are recommended.
Operational treatment of multiple small abscesses of P. striking quite often almost all its fabric is unpromising. The undertaken operative measure gives the chance to establish the contagium sowed from contents of abscess and to define sensitivity it to antibiotics. Treatment comes down to a massive antibiotiko-and chemotherapy, at the same time, in addition to intravenous, also transumbilikalny administration of medicines is reasonable. Carry out also transfusion of fresh blood, blood substitutes, enter vitamins, appoint a high-calorific diet.
In the postoperative period, in addition to usual all-surgical complications (suppuration of a wound, pneumonia, etc.), the expiration of bile on a drainage, and in the subsequent formation of bilious fistulas is possible. They are in most cases closed further independently, but sometimes demand difficult reconstructive operations on change of fistula in a gut (see. Bilious fistulas).
Secondary abscesses of P. arise at suppuration of not parasitic cysts, disintegration of malignant tumors, syphilitic and tubercular granulomas of P., at P.'s damages
Distinguish not parasitic and parasitic cysts of a liver. Not parasitic cysts meet extremely seldom. They are true and false. True cysts of P. develop from distopi-rovanny rudiments of the bilious courses, to-rye, stretching setserniruyu-shcheysya liquid, turn into cysts. Unlike adventitious cysts they are covered by an epithelium from within (cylindrical or cubic) and contain the transparent or muddy liquid having sometimes a yellowish or brownish shade; in some cases in their contents there is an impurity of bile. True cysts of P. subdivide on autonomous and connected with hepatic channels. Autonomous cysts of P. happen single (solitary) and multiple. Solitary cysts can be ONE - and multichamber; sometimes reach the huge sizes and contain several liters of liquid. Multiple cysts of P. usually small, are located both on a surface, and in the depth of body. According to B. E. Linberg (1925), the polycystosis of P. which is quite often combined with similar defeat of other bodies also concerns to them (kidneys, a pancreas, ovaries). At a polycystosis of a cyst, having various size, are located preferential on P.'s surface, quite often covering all its anteroinferior part, hanging down in places in the form of a cluster of grapes. They contain transparent liquid in which find albumine, cholesterol, bile acids, sometimes fatty acids, bilious pigments, erythrocytes, leukocytes.
Autonomous not parasitic cysts of P. meet at women at the age of 30 — 50 years more often. They develop slowly, for several decades, often absolutely asymptomatically. At solitary cysts patients sometimes find in themselves a tumor in a stomach which does not disturb them, however complain of moderate pains to the areas P. amplifying in vertical position and feeling of weight to epigastriums more often. In the subsequent pains become more intensive, have constant character, vomiting, a diarrhea, weakness are noted, ascites and jaundice seldom develop. In some cases there can be severe pristupoobrazny pains on all stomach caused, probably, by small ruptures of a wall of a cyst and small bleeding. At big cysts symptoms of a prelum of the next bodies are possible (a stomach, a duodenal and cross colon). At a polycystosis it can be palpated increased an ilotnoelastichesky consistence painless by the Item.
Complications — hemorrhage in a cavity of a cyst, an empyema of cyst, perforation of a wall of a cyst.
Diagnosis on the basis of physical data is complicated. By means of a holangiografiya, scanning, stsintigrafiya, an angiography find volume defeat of body, by means of a laparoscopy sometimes it is possible to reveal the cystous nature of education. An important sign is the found polycystosis of other bodies. The differential diagnosis is carried out with an echinococcosis (see), P.'s tumors, an edema of a gall bladder, a cyst of a pancreas (see), hydronephrosis (see), an oothecoma (see).
Treatment of autonomous not parasitic cysts operational — enucleation and removal of solitary cysts, if necessary with a regional or segmented (share) resection of P. Vozmozhno opening of a cyst, removal of contents and sewing up by a vvorachivaniye in its walls, an obliteration of a cavity by means of glue, a takhmponada its epiploon on a leg. At an empyema of cyst make opening and drainage of her cavity. At multiple small cysts and P.'s polycystosis the kistotomiya with a partial resection of a free wall of a cyst is shown.
The forecast after an operative measure favorable. At a polycystosis after a kistotomiya, and sometimes and resections of walls of a cyst are possible a recurrence.
Not parasitic cysts of P. connected with intra hepatic bilious channels also meet extremely seldom. They are in the form of two forms: diseases Punished also Grumbakh's diseases — Buriyona — Overa. Both diseases representing cystiform expansions of intra hepatic bilious channels of inborn character have the transmissible genetic nature (are transmitted to posterity through several generations) and meet at men more often.
J. Caroli's disease is for the first time described in 1953 Mr. of J. Caroli and is early germinal anomaly of larger bilious channels which is localized in one segment (share) or has diffusion character, extending to all bilious tree (fig. 11). Bilious channels are expanded, have the rounded, cylindrical or pear-shaped shape. Due to the existence of messages between cysts and biliary system this disease is followed by development cholestasia (see), an intra hepatic lithiasis (see. Cholelithiasis ) and hron, inflammatory process in bilious ways. Its wedge, manifestations — recurrent cholangitis (see), arising at children's age, hron, sepsis (see), hepatic and subphrenic abscesses.
Diagnosis of a disease of Karoli is difficult. The disease can be suspected at the repeating attacks of a cholangitis, fever of not clear origin of young age. Expansion of intra hepatic bilious channels and an intra hepatic lithiasis can be established by means of a retrograde pankreatokholangiografiya (see Pankreatokholangiografiya retrograde) or an intraoperative holangiografiya (see); the transdermal transhepatic holangiografiya at biliary sepsis can lead to generalization of process, formation of outside fistula. Ekhografiya (see Uljtrazvukovaya diagnosis), scanning (see), the selection arteriography (see Seldinger a method) are important additional methods of a research.
Operational treatment (a lobectomy, a segmentectomy) is radical only at local defeat. At diffusion forms only palliative interventions are possible: a biliodigestivny anastomosis (it is better tsisto-or a gepa-tikoyeyunostomiya with an anastomosis across Ru), a removing calculus, outside drainage of cysts. The best results were observed at the combined operations. Forecast, as a rule, adverse. The liver failure is the most frequent reason of a lethal outcome.
Grumbakh's disease — Buriyona — Overa is result of later changes arising in the pre-natal period during formation of bilious channels. Fibrous and cystous defeat of P. of which involvement in process of small bilious channels and periportal fibrosis are characteristic is the cornerstone of a disease. At the same time, in addition to intra hepatic segmented expansions of the bilious courses, proliferation of the small expanded bilious tubules which are reported among themselves in periportal spaces is found. The disease comes to light at early children's age and is characterized by the progressing portal hypertensia with repeated intestinal bleedings. Treatment — palliative imposing of a porto-caval anastomosis. Forecast adverse.
Adventitious cysts are formed of hematomas after P.'s damages, the cavities which remained after an ekhino-kokkektomiya or opening of abscesses of the Item. Walls of these cysts usually dense, fibrous, sometimes calciphied, not falling down; their inner surface unlike true cysts is formed by granulyatsionny fabric. Adventitious cysts are filled with muddy liquid, are more often localized in the right share of P. and in most cases clinically are not shown. Cysts of the considerable sizes can cause symptoms of a prelum of the next bodies, pain and feeling of weight in epigastriums; in the field of an arrangement of a cyst protrusion is noticeable. Complications — hemorrhages in a cavity of a cyst, its suppuration, perforation and a rupture of a wall of a cyst. The diagnosis is complicated, existence in the anamnesis of an injury of P. or operations on the Item matters.
Treatment operational: enucleating or removal of a cyst, at impossibility of its removal make P.'s resection together with a cyst (see the Hemihepatectomy), at suppuration — opening and drainage of a cavity, in some cases carry out a tamponade of a cavity of a cyst by an epiploon.
The forecast after an operative measure favorable.
Defeats of vessels
Damage of a hepatic artery is observed at various diseases, napr, atherosclerosis, a hypertension, a nodular periarteritis, a system lupus erythematosus and some other.
Thrombosis of own hepatic artery (e.g., at a nodular periarteritis, atherosclerosis, an obliterating thromboangitis, P.'s injury) and its embolism (at a bacterial endocarditis, defects of aortal and mitral valves of heart) can lead to development of a heart attack P. Velichina of a heart attack depends usually on caliber of the struck vessel. Usually P.'s heart attack is followed by sudden emergence of pain in right hypochondrium, P.'s sensitivity at a palpation, a protective muscle tension of a front abdominal wall. Soon after developing of a large heart attack of P. there are fever and jaundice which quickly accrues; the leukocytosis, the accelerated ROE are noted. Indicators of functional trials, as a rule, testify to the expressed liver failure (see): the hyperbilirubinemia, decrease in maintenance of factors of coagulability of blood and activity of cholinesterase in blood serum are noted. Treatment is directed to a basic disease, fight against a liver failure and consecutive infection is carried out. The forecast depends on a basic disease, the sizes of a heart attack and a possibility of accession of consecutive infection.
Aneurism (see) a hepatic artery it is more often localized in its trunk or the right branch. Diameter of aneurism can make from several millimeters to 10 cm and more. In many cases of an aneurysm of own hepatic artery proceeds asymptomatically, and its first signs are shown only at development of complications. The most frequent complication is the break of aneurism of a hepatic artery in bilious ways, a duodenum, free abdominal cavity or to a portal vein. Quite often aneurism of a hepatic artery is exposed to thrombosis. In the presence of large aneurism sometimes it is possible to palpate the pulsing weight over which systolic noise is listened. Indicators of functional trials of P. do not change. With the diagnostic purpose hepatic is applied arteriography (see). Treatment operational. The forecast is more often favorable.
Malformations of a portal vein are observed seldom. Treat them: a syndrome of the open arantsiyevy channel providing in the embryonal and post-natal periods communication between the lower hollow and portal vein; falling of a portal vein into the lower vena cava and narrowing of a portal vein. These malformations, as a rule, are followed by the portal hypertensia (see) defining a wedge, a current and tactics of treatment. Kryuvelye's syndrome — Baumgarten (see Kryuvelye — Baumgarten a syndrome) — not fusion of an umbilical vein which is followed by P.'s atrophy without morfol, symptoms of cirrhosis of II. and splenomegalies. Rather rare, but serious illness of a portal vein would be p to an ilefla and t (see).
Kiari's disease (see. Kiari disease ) it is caused by partial or full obstruction of hepatic veins, it is characterized by the phenomena of portal hypertensia, ascites and a liver failure. Venno-okklyuzionnaya the disease of hepatic veins of small and average caliber is more often observed at children on the island of Jamaica, in South Africa and Australia. Separate cases are celebrated also in other countries, including in the USSR. The netrombotichesky obliteration of hepatic veins, stagnation in the centers of segments of P., an atrophy and a necrosis of hepatocytes, fibrosis of fabric of body is morphologically characteristic. Allocate acute, subacute and hron, forms of a disease. The acute beginning with pains in right hypochondrium, ascites, the hepatomegalia moderated by jaundice is characteristic of an acute form. The subacute form of a venno-occlusal disease of P. is characterized by a hepatomegalia, the ascites moderated by change of functional trials of P. and usually passes in hron, the form proceeding as P.'s cirrhosis with portal hypertensia. The diagnosis is established on the basis of yielded the anamnesis and results morfol, by researches of the fabric P. received by means of a biopsy. Symptomatic treatment. The forecast at an acute form adverse — approximately in 30% of cases comes death from a liver failure, P.'s cirrhosis
=== Parasitic diseases === develops in 30% — P.'s Defeat at the majority of parasitic diseases is not beyond the reactive hepatitis proceeding is hidden and shown only morfol, changes of fabric, and regarding cases by insignificant disturbances of functions P. At an amebiasis (see), an echinococcosis (see) and some other parasitic diseases patol, process in P. gets independent a wedge, value.
In a pathogeny of defeat of P. at opisthorchosis (see) the leading role allergic processes play, matter mechanical obturation of bilious ways parasites and a consecutive bacterial infection. For a wedge, pictures pains in right hypochondrium are characteristic, moderate increase in P., a subikterichnost of skin or jaundice is frequent as hepatic colic; development hron, diffusion defeats of P., napr, cirrhosis of the Item is in certain cases noted.
At a fascioliasis (see) obstruction of hepatic channels parasites is possible, at their passing through walls of intra hepatic channels — formation of mikroabstses-owls. In an acute stage of a disease pains in right hypochondrium, a hepatomegalia, fever, the expressed eosinophilia are noted. Later the symptoms connected with a cholestasia — jaundice and a skin itch dominate. Biochemical first of all signs of a cholestasia are defined. Characteristic complications are the purulent cholangitis, a cholelithiasis. Development of secondary biliary cirrhosis P.
Shistosomatoz is possible (see) it is characterized by toksiko-allergic defeat of P. Morfologicheski education in a liver of the granulomas which are quite often containing eggs of a parasite is characteristic of an acute stage of a disease. Further expansion and fibrosis of portal fields, a thickening of walls, fibrinferments, an obliteration of gleams of small branches of a portal vein are noted. In an acute stage of a disease the hepatomegalia and P.'s sensitivity at a palpation are noted; in late stages symptoms of portal hypertensia dominate. Jaundice is observed seldom. From a lab. given signs of a cholestasia and a disproteinemia are most characteristic of a late stage of a disease. The forecast at out of time begun treatment adverse.
At ascaridosis (see) the most frequent form of defeat of P. is the reactive granulematozny hepatitis developing sometimes in a migratory phase of a disease. Sometimes at an ascaridosis parasites get into bilious ways that can lead to their full obturation with development of mechanical jaundice. Process can be complicated by the changes connected with stagnation and infection of bile — P.'s abscesses, and also a pylephlebitis.
Professional defeats can arise in connection with action of various harmful production factors chemical, physical. or biol. origins. Among them chemical factors since many chemical substances applied in production activity of the person possess a potential hepatotoxic have major importance. Among .organichesky connections galogenovy derivatives of alkanes, olefins and aromatic compounds, and also nitro - and aminoaromatic compounds are of great importance.
The chemical connections possessing toxic action on P. can come to an organism through respiratory tracts, went. - kish. path or skin. Through respiratory tracts the connections having a sufficient volatility and, as a rule, not possessing irritant action on skin and mucous membranes come to an organism. The vast majority of the chemical connections causing professional damages to P. possess direct toxic action of pathogenic action of hepatotropic agents can increase by P. Vyrazhennost at pregnancy, against the background of preexisting P.'s defeats, starvation, unbalanced food (proteinaceous deficit, excess of fats), at simultaneous impact on an organism of alcohol, some pharmaceuticals, etc. Impact of chemical connections can conduct to acute, subacute or hron, to defeat of the Item.
Acute and subacute professional defeats of P. are observed seldom that is explained by improvement of working conditions, the accident prevention, failure from use or sharp reduction of use of a number of highly toxic chemical connections in production. Wedge, a picture of such defeats of P. of a polimorfn, considerably is defined by character etiol, the agent. Easy acute toxic defeats of P. usually proceed quickly with moderate dysfunction of P., weak or moderate jaundice and come to an end with recovery at the termination of contact with the hepatotropic agent. Are characteristic of crushing toxic defeat of P. a pain syndrome, quite often progressing jaundice, can develop an acute liver failure (see). Recovery, as a rule, occurs quicker and with the smaller residual phenomena, than at a viral hepatitis. In the absence of repeated contact with the toxic agent perhaps absolute recovery. The residual phenomena can have character of dyskinesia of bilious ways (see. Bilious channels), cholecystitis (see), vegetative reactions. In the result of subacute necrotizing defeats of P. cirrhosis P.
Hron can develop. professional defeats of P. can lead to development of cirrhosis of P., a gepatoportalny sclerosis, late hepatic porphyria and tumors of the Item. Cirrhosis (see) most often develops in the result of subacute toxic defeat of the Item. Development of cirrhosis of P. at long contact with such chemical connections as, e.g., the perchloromethane and inorganic insecticides containing arsenic is observed seldom. The Gepa-toportalny sclerosis is characterized by fibrosis of portal fields and adjournment of collagen in Disse's spaces that leads to portal hypertensia. This defeat of P. is noted at persons, is long contacting to vinyl chloride and drugs of arsenic. A late skin porphyria (see. Porphyrias ) seldom arises in professional conditions. Believe that chemical agents, napr, hexachlorobenzene, at the same time play a role of the factor revealing the preexisting defect of the Item. Many chemical connections finding application in production are capable to cause malignant tumors of P. in an experiment, however the possibility of development of cancer of P. in the person as a result of long contact with these substances in conditions of production is not proved. However it is known that at long impact on an organism of vinyl chloride and inorganic compounds of arsenic cases of an angiosarcoma of P. V to diagnosis of professional defeats of P. are observed data of the anamnesis (contact with the toxicants possessing hepatotropic action), detection of the same diseases among certain professional groups, results of clinical laboratory inspection are important (identification in biol, circles of the toxic agent or his derivatives). At hron, influence of professional vrednost early identification of defeat of the Item is important. Methods of a research of functions P. — bromsulfoftaleinovy test, definition of activity of enzymes in blood serum are for this purpose used biochemical. Because a wedge, manifestations of professional defeats of P. are not specific, at suspicion on them careful differential diagnosis with the diseases having similar a wedge, symptomatology (a viral hepatitis, medicamentous and alcoholic defeats of P.) shall be carried out.
Treatment at acute toxic defeats of P. shall begin with the actions directed to the termination of intake of toxicant in an organism, its maximum neutralization and removal from an organism. For this purpose apply a gastric lavage via the probe (see the Gastric lavage), a hemodialysis (see), exchange hemotransfusions (see), hemosorption (see t. 10, additional materials) and a limfosorb-tion (see), an artificial diuresis, detoksikatsionny specific antidotal therapy (see Poisonings). Means of pathogenetic and symptomatic therapy which choice is defined by the nature of the available disturbances are applied. The forecast of professional defeats of P. at timely begun treatment favorable.
For the purpose of prevention of professional defeats of P. make professional selection (do not allow patients with P.'s diseases to work with the substances possessing a potential hepatotoxic), strictly monitor observance of safety regulationss, sanitary and hygienic norms in production rooms, an optimum diet (a diet, protein-rich and vitamins), sharply limit or exclude impact on an organism of other hepatotropic agents (alcohol, some pharmaceuticals).
Disturbance of activity of a nervous system at diseases of a liver. At acute and hron, P.'s diseases irrespective of the reasons which caused them all parts of the nervous system with formation of a complex of the symptoms corresponding a wedge can be surprised. to manifestations encephalopathies (see), myelipathies (see), neuropathies (see) and neurosis-like frustration. For designation mental and cerebral nevrol, disturbances of a hepatogenous origin widely use the term «encephalopathy».
Issues of a pathogeny of cerebral disturbances at P.'s diseases finally are not resolved. Damage of a brain is connected with action of many factors: disturbance of metabolism of ammonia, increase in blood of amino acids and products of their oxidation (phenols, amines, indoles), especially R-phenyl ethyl of amine, the oktopamin acting as false neurotransmitters. An important role is played by accumulation pyroracemic, milk, low-molecular fat to - t, deficit of coenzyme A, disturbance of electrolytic and acid-base balance, activity To - Na-of stimulated ATP-ase, disturbance of transmembrane permeability. Action of these factors on a brain is connected with P.'s insufficiency owing to a necrosis and switching off of its parenchyma at the expense of this or that patol, process, and also formation of both natural, and artificial (surgical) bypass collaterals from system of a portal vein in system of venas cava.
Disturbance of consciousness is one of the main symptoms of hepatogenous encephalopathy. In initial stages it can be shown by block, confusion, then attacks of an amentiv-but-delirious state with psychomotor excitement, nonsense, hallucinations, the subsequent retro and antegrade amnesia, escaping of an attack or transition to a soporous state and a coma (see). Emotional and strong-willed disturbances consist of euphoria, disinhibition, attacks of a depression. The akinetic mutism can be extreme expression of emotional and motivational disturbances (see the Speech, frustration).
At hepatogenous encephalopathy classical forms seldom meet aphasias (see), agraphias, alexias, apraxias (see). The impossibility of performance of these or those functions (the letter, reading, the movement) is connected first of all with space agnosia, instability of orientation in surrounding, in the place, time. Intellectual disturbances accrue in process of progressing of hepatogenous encephalopathy and can lead to weak-mindedness. The important place in disorder of intellectual functions is taken by disturbances of memory — from lungs to a typical korsakovsky syndrome (see).
Extrapyramidal disturbances are characterized by trembling like «wave of wings», parkinsonism (see), is more rare a choreoathetosis (see. Hyperkinesias ). Myoclonias of various expressiveness — from myoclonic twitchings to so-called myoclonic storms are characteristic of final stages of encephalopathy. Extrapyramidal disturbances are often accompanied cerebellar, expressed in unsteadiness of gait, an intentsioiny tremor. Pyramidal frustration in the prevailing most cases have no character of rough paralyzes and paresis, are characterized by revival and asymmetry of deep reflexes, emergence patol, reflexes of feet. Damages of cranial nerves are characterized generally by insufficiency of the central type VII and XII of cranial nerves, more rare a pseudobulbar syndrome. Epileptiform syndrome (see) it is shown by all-convulsive and jacksonian attacks, difficult and simple absentias epileptica. The headache which is often combined with meningeal symptoms, vomiting is noted at most of patients.
The sequence of emergence, options of combinations of the specified symptoms and syndromes can be various. On speed of development, a current, expressiveness of symptoms allocate acute, subacute, chronic and latent encephalopathies. Hron, options of encephalopathy with duration of a current up to several years more often are connected with operation of a decompression for portal hypertensia — imposing of a porto-caval anastomosis.
Emergence of hepatogenous myelipathies is connected with stagnation in venous system of a spinal cord owing to portal hypertensia. They are characterized by gradual development of the lower spastic paresis. The polyneuropathic syndrome at P.'s diseases carries st weed algichesky character more often though also motive disturbances are described. Refer insufficiency of function P., a drunkenness, a vitamin deficiency of group B to the reasons of emergence of a polyneuropathy. Neurosis-like disturbances at P.'s diseases are most often presented by a neurotic syndrome.
Treatment hepatogenous nevrol, disturbances is defined by their character. All options of encephalopathy demand implementation of the actions directed to reduction of a giperammoniyemiya (see), correction of electrolytic disturbances, mediator shifts by means of L-DOFA and antiserotoninovy means (Stugeronum), to dehydrational therapy, vitamin therapy and other measures of fight against a liver failure (see).
According to the international histologic classification (1978) tumors of P. divide them on epithelial, not epithelial, mixed, not classified, tumors of the hemopoietic and adenoid tissue, metastatic tumors, epithelial anomalies and opukholepodobny diseases.
the Most extended from benign epithelial tumors by P. are adenomas (see. Adenoma ). Macroscopically P.'s adenomas have an appearance of single or multiple roundish formations of various size. Microscopically distinguish hepatocellular adenoma and adenoma of intra hepatic bilious channels. Growth of adenomas of P. slow, asymptomatic. Only at achievement of the big sizes they can clinically be defined in the form of plotnoelastichesky, sometimes painful consolidations in the area P. The diagnosis is established with the help rentgenol, researches, an angiography and a laparoscopy.
At a tomography of adenomas on computer tomograms accurate defect which in usual pictures is not visible is defined. The angiographic picture depends on development of vessels in adenoma. Slabovaskulyarizirovanny adenomas move apart arterial vessels of P. and cause the low-vascular site in a phase of a gepatogramma. In richly you-kulyarizirovannykh adenomas the expanded, unevenly located vessels with equal contours are visible; in a phase of a gepatogramma adenoma is allocated as a contrast roundish spot. Considering a possibility of a malignancy of adenoma, it is deleted by excision or a resection of a share of the Item. The forecast after operational treatment favorable.
From benign not epithelial tumors of P. the hemangioma (see), coming from venous vessels is more often observed (fig. 12, a). It occurs at various age, a thicket at women. Proceeds usually asymptomatically and it is shown clinically only at achievement of the big sizes, a spontaneous gap with the phenomena of an acute abdomen (see) or malignancies. The hemangioma can be found on the roentgenogram if it contains bone crossbeams or calciphied phleboliths. At an angiography a contrast agent fills vascular spaces of a hemangioma and is long is late in them.
Meet a lymphangioma less often (see) and benign connective tissue tumors (a lipoma, fibroma), to-rye have symptomatology, similar with other benign tumors of P., a wedge, a picture and treatment.
Enclavomas of P. belong to tumors of the embryonal nature, or to teratomas (see). They meet at children more often, but can be also at adults. These tumors usually are located within one share of P. and are characterized by rather favorable forecast after radical operations.
Among etiol, the factors and the reasons promoting developing of primary cancer of P. allocate helminthic invasions of P., alimentary factors, P.'s cirrhoses, inf. the diseases proceeding with defeat of the Item. The viral hepatitis, malaria, an amebiasis, tuberculosis and other infectious and parasitic diseases can exert impact on developing of primary cancer of P. From helminthic invasions the conducting place in an etiology of cancer of P. is taken by the Opisthorchosis. The schistosomatosis is often combined with P.'s cancer. There are data on a role in development of primary cancer of P. of an aflatoxin. The proteinaceous insufficiency causing development of a kwasiorkor (a children's pellagra), a lack of vitamins, especially groups B, constant alcohol abuse are considered as the factors promoting development of cancer of the Item.
According to a number of researchers, cancer cases of P. correspond to incidence of cirrhoses of P. Sochetaniye of these diseases, according to G. D. Koshug (1976) and Schmitz (A. Schmitz, 1971), are observed in 37 — 97% of cases. Quite often hepatocellular cancer of P. arises against the background of postnecrotic cirrhosis of the Item.
Primary cancer of P. differs in irregularity of distribution in various regions that can be connected with social and climatic conditions, character of food, prevalence of viral diseases or helminthic invasions, race of patients. In a number of the countries of Asia and Africa primary cancer of P. makes 25 — 50% of all tumors. In the majority of the developed countries of Europe and America primary cancer of P. meets much less often, making from 0,4 to 3% of all forms of cancer. In the European part of the USSR the frequency of cancer of P., according to pathoanatomical researches, does not exceed 1 — 2% in relation to other tumors while in the Tyumen region and in the Far East he meets more often. Growth of incidence of primary cancer of P. is connected with increase in life expectancy of the population and growth of incidence of cirrhoses P.
Rak of a liver meets usually aged 40 years, in the underdeveloped countries of Asia and Africa cancer of II are more senior. it is observed more often at younger age. At men P.'s cancer is observed by 3 — 5 times more often than at women.
Macroscopically distinguish knotty, massive and diffusion growth forms of a tumor. Knotty meets most often, it is characterized by existence of single or multiple nodes of various size (fig. 12, b). Around large nodes small, apparently metastatic, small knots can be located. At a massive form of cancer of P. the large tumoral node (fig. 12, c) occupies usually right share of the Item. At a diffusion form of cancer in P. the small tumoral small knots disseminated through all parenchyma come to light.
On a microscopic structure P.'s cancer is divided into the hepatocellular, making 70 — 85%, and cholangiocellular. Hepatocellular cancer has trabecular or tubular type of a structure, its also polymorphocellular form (fig. 13) meets. Cholangiocellular cancer consists of the cells similar to an epithelium of bilious channels. Besides, tumors of the mixed structure at which elements of hepatocellular and cholangiocellular cancer at the same time are found meet. Also undifferentiated forms of cancer can come to light.
Metastasises at primary cancer of P. have character of intra hepatic planting; often nodes at gate of the Item are surprised hepatic limf. In the lymphogenous way usually metastasizes cholangiocellular cancer while hematogenous innidiation is more characteristic of hepatocellular (hematogenous metastasises are found more often in lungs). Metastasises of hepatocellular cancer in some cases keep nek-ry funkts, features of hepatocytes, in particular ability to cosecrete bile.
Klien, a picture of cancer of P. is diverse. The imperceptible beginning, lack of accurate symptoms and bystry development of a disease is characteristic. Constant symptoms of cancer of P. are weakness, weight loss, decrease in working capacity. Anorexia, nausea, vomiting, temperature increase are often noted. From local symptoms the feeling of weight, a raspiraniye and pain in right hypochondrium and epigastriums, a hepatomegalia are characteristic. At a palpation of a tumor morbidity in epigastriums is noted. Late symptoms of a disease are the moderate jaundice, expansion of superficial veins of a front abdominal wall, ascites developing in some cases a splenomegaly.
At a diffusion form of cancer of P. the symptoms caused by a tumor as if accumulate on a wedge, displays of cirrhosis of P. Pechen in these cases increases slightly and the tumor is not palpated. Anemia, ascites, the progressing cachexia are observed.
Intravital and especially timely cancer detection of P. presents great difficulties. It is connected with absence accurate a wedge, pictures, developing of cancer against the background of the previous diseases, in particular P.'s cirrhosis, and great compensatory opportunities P. Naiboley important, but late symptoms of cancer of P. are the progressing P.'s increase, the solid and pulled surface of P. defined at a palpation, existence of a solitary node, complication of the existing cirrhotic process, intra belly bleeding, a combination of a hepatomegalia to ascites.
Use in a wedge, practice of the radio isotope research allowing to reveal defects of accumulation of radionuclides and the angio-gepatografiya giving the chance to gain an impression about a condition of venous and arterial system P., the computer tomography reflecting anatomic changes of body, an ultrasonic ekhografiya and a laparoscopy allowed to improve diagnosis of cancer of G1. At arteriography in nodes of hepatocellular cancer the numerous, randomly located arteries with an uneven gleam, places interrupted, and also separate accumulations of a contrast agent are found. Cholangiocellular cancer has rather small blood supply therefore at arteriography the arrosion of vessels in the field of a tumor and the shift of segmented arteries of the Item is noted preferential. At rentgenol, a research! tumors of the big size can be suspected on P.'s increase, a pushing off of the next bodies, and also emergence of metastasises of lungs, bones. On computer tomograms both primary node, and affiliated nodes are defined in the form of defects in a shadow of the Item. If the tumor is followed by a prelum of a hepatic channel and development of jaundice, then at a holangiografiya it is possible to find defect of filling or a stenosis of a channel.
Majority of indicators lab. researches and functional trials have no diagnostic value and can play an additional role, reflecting dynamics a wedge, courses of a disease. An important role in timely diagnosis of cancer of P. is played by definition of serum protein and - fetoprotein which is found in blood serum in 60 — 80% of patients with hepatocellular cancer; at cholangiocellular cancer this reaction usually is negative. At recognition of primary cancer of P. it is important to consider that in P. malignant tumors of other localizations, napr, a carcinoma of the stomach, lungs, intestines, a pancreas, etc. often metastasize. Rather small metastasises of cancer in P. diagnose by means of an angiography, apply a laparoscopy (tsvetn. 18 — 20). In well vaskulyarizirovanny metastasises (sarcomas, hypernephromas, horionepitelioma, insulinoma, cancer of a thyroid gland) small vessels, fasciculate, contrast «spots», infiltration of walls of small arteries come to light. Badly vaskulyarizirovanny metastasises (cancer of a lung, a gullet, a stomach, a pancreas) push aside adjacent arterial vessels, squeeze them; in a parenchymatous phase of a research defects of filling are defined. Similar multiple defects are observed on computer tomograms of the Item.
Cancer therapy of P., as a rule, combined. Radical operation shall include not only an oncotomy, but also P.'s resection within the autonomous vascular pool. The anatomic resection of a liver is carried out in the form of a left-side lobectomy (a resection II and III segments on Kui-but), a left-side hemihepatectomy (removal II, III and IV segments), a right-hand hemihepatectomy (a resection V, VI, VII and VIII segments). It is important for carrying out a resection of P. that the tumor did not reach its gate. Conditions for a resection are adverse at an arrangement of a tumor in the depth of fabric of body, its back surface and is close to gate of II.
Contraindications to P.'s resection are its scattered defeats, spread of a tumor to P.'s gate or the lower vena cava, ascites, jaundice, the expressed P.'s cirrhosis, the acute course of primary cancer of P., sharp disturbances of functions P. In some cases P.'s resection is applied with the palliative purpose, napr, at intra belly the bleeding caused by a rupture of a tumor put haemo static stitches with a tamponade biol, or carry out by fabrics P.
Inogd's resection at treatment of primary and metastatic tumors of P. apply bandaging of a hepatic artery provided that a considerable part of hepatic fabric is not struck.
Use of antineoplastic means yields the best results at their leading directly to a zone of a tumor, napr, through an umbilical vein after its catheterization. At the same time through an umbilical vein it is possible to enter also means which action is directed to improvement of function P. The most effective method of introduction of antineoplastic means consider intra arterial — by direct catheterization of a hepatic artery, its catheterization through other arteries and transdermal carrying out the probe on Seldingera (see Seldinger a method). Most often apply the second option of catheterization of a hepatic artery, in particular through the right gastroomental artery. For regional chemotherapy use 5-ftoruratsit, Cyclophosphanum, TIOTEF, a methotrexate. Introduction by means of special pumps of the antineoplastic means divorced on fiziol, solution or 5% solution of glucose is recognized reasonable long (for 1 — 2 week). It gives the chance to bring medicinal substance directly to the tumoral center, to reduce the general toxicity and side reactions at increase in a course dose of drugs, to influence antineoplastic funds for all phases of division of tumor cells.
The forecast at P.'s cancer adverse. Can be the cause of a lethal outcome as development cachexias (see), and bleeding from a tumor or varicose veins of a gullet (see. Portal hypertensia), a liver failure (see), thrombosis of a portal vein (see).
Operative measures on P. concern to the most difficult in abdominal surgery. They demand from the surgeon of special knowledge, skills and experience, and also existence of the corresponding equipment and tools.
Preoperative preparation. Training of patients for operation on P. provides recovery broken or compensation of the lost functions of body which arose under influence is long the existing focal diseases of P. which caused disturbances of metabolism, especially protein and carbohydrate metabolism. In some cases disturbances of functions P. proceed latentno, are shown also by a disproteinemia (due to increase r-and ^-globulinovy fractions), decrease in anti-toxic, absorption and excretory functions P., and also reduction of content in blood of redoxon. Preoperative preparation shall provide taking into account specific features of patients creation of the mode of rest — reduction physical. loadings, emotional pressure, purpose of high-calorific, digestible food with dominance of proteins, carbohydrates, a complex of vitamins, performing medicinal therapy by lipotropic means (lipocainum, methionine), appointment spasmolytic, antihistamines, glucocorticoids for reduction of inflammatory process and increase in disintoxication function P. At immediate surgeries, Disintoxication therapy (Haemodesum, solutions of glucose with insulin and a complex of vitamins intravenously), administration of proteinaceous drugs, albumine, electrolytes is shown to the expressed intoxication of an organism, at the phenomena of a hepatopathy — glutaminic to - you, at hypotonia — glucocorticoids, cardiovascular means.
During the training of patients for operation it is necessary to carry out correction of protein metabolism, to influence increase in functional activity of P., normalization of coagulant system of blood (at patients with a cholestasia). For this purpose recommend intravenous drop injection of plasma, a protein, albumine, a reopoliglyukin, Haemodesum, intramuscular injections of ATP, hypodermic administration of vitamins of Vg and Wb, and also intravenous administration ascorbic to - you. The covering of a metabolic cost of an organism requires appointment high-calorific (to 3000 kcal a day) a carbohydrate and proteinaceous diet, and also intravenous injections of 10% of solution of glucose (1000 — 1500 ml) with necessary amount of insulin. The patient with mechanical jaundice, considering disturbance of synthesis of phthiocol and decrease in coagulant properties of blood — administration of Vikasolum and calcium chloride before achievement of level of a prothrombin not less than 70%. For reduction of a painful skin itch appoint methyl-testosterone, Pipolphenum, Dimedrol. Duration of preoperative preparation shall not exceed 6 — 10 days, especially in the presence of obturatsionny jaundice. At changes from other systems and bodies (breath, digestion, cardiovascular, etc.) the preparation for surgery is carried out according to a condition of patients by the standard principles. For prevention of purulent complications usually before operation appoint antibiotics.
Patients with traumatic damages of P. in most cases need an immediate surgery therefore opportunities for their preparation are usually extremely limited. First of all hold events for fight with shock (see) and blood loss (see). For hemotransfusion and blood substitutes it is necessary to use veins of an upper half of a body (upper extremities, subclavial) since during operation there can be a need for crossclamping of a hepatoduodenal sheaf and the lower vena cava. At purpose of anesthetics it is recommended to avoid the opiates causing a spasm of sphincters of the general bilious channel and a hepatopancreatic ampoule that strengthens a cholestasia and the expiration of bile through the damaged channels of the injured sites P. Continuous evacuation of congestive gastric contents by means of the probe entered in Nov is reasonable. It facilitates breath and promotes removal of the toxic products which are formed in connection with an atony of a stomach and a gastrointestinal staz. Constant catheterization of a bladder saves from a reflex ischuria, helps with diagnosis and definition of efficiency of treatment of shock.
Features of anesthesia. The risk of anesthesia at operations on P. depends on character and degree initial morfol, and functional disturbances, danger of development of a hypoxia and hypotension during operation, and also in connection with a hepatotoxic of the majority of anesthetics. Before operation it is necessary to pay special attention to anamnestic data with the purpose of identification of the effects postponed inf. diseases and poisonings, and also to a complex research of a functional condition of the Item.
For premedication use Seduxenum, Promedolum, antigistakhmin-ny drugs (Dimedrol, Suprastinum, Pipolphenum), atropine, fentanyl, Droperidolum. Usually avoid purpose of derivatives of a fenotiazin, napr, aminazine, oppressing function P.
The greatest distribution was gained by an intravenous introduction anesthesia drugs for a neyroleptanalgeziya, 1 — 1,5% solutions of barbiturates (in the absence of the expressed hypoproteinemia). With success steroid drugs (viadril), hydroxybutyrate of sodium, and also mix of oxygen, nitrous oxide and cyclopropane can be used (by Shane's method — Ashmana).
Apply the means exerting the minimum toxic impact on P. at adequate degree of an analgesia, anesthesia and optimum oxygenation of an organism to maintenance of the main anesthesia. Positive takes are received during the use of a neyroleptanalgeziya against the background of inhalation of nitrous oxide with oxygen, mixes of nitrous oxide with cyclopropane and oxygen, mix of nitrous oxide and oxygen with small doses of ether. The chloroform, Ftorotanum, Penthranum and other galoidsoderzhashchy means possessing gepatotok-sichnostyo are contraindicated. At the choice of muscular relaxants it is important to consider decrease of the activity of pseudo-cholinesterase, especially in the presence of jaundice. The dose of the depolarizing muscle relaxants shall be reduced; at long operations preferential use the anti-depolarizing Muscle relaxants.
During operations on P. big danger is constituted by development of a hypoxia, hypotension and hypovolemia. In prevention and treatment of a liver failure the leading role is played by maintenance of adequate artificial ventilation of the lungs, timely elimination of a hypovolemia (Transfusion therapy) and hypotensions, correction of disturbances of acid-base equilibrium, electrolytic balance, vitamin exchange, coagulant and anticoagulative systems of blood.
Accesses at liver operations are important especially not only for performing surgery, but also for a favorable current of the postoperative period. The considerable exposure of body is carried out to avoid unexpected bleeding during operation from easily vulnerable P., and also to cope quickly with it if it arose. Broad access allows to make audit of all departments of II. and surrounding bodies that is necessary for establishment of prevalence of defeat and assessment of a condition of healthy sites of body, and also for the solution of a question of volume and the nature of surgery and for successful carrying out operation.
It is offered apprx. 50 various accesses to P., however broad use only the few from them found (fig. 14) in surgical practice. Not all offered accesses provide bystry approach to P., an atravmatichnost and a possibility of performance of radical operation. All existing accesses to P. can be subdivided on transabdominal, transthoracic, combined (a torakofrenola-parotomiya, sternomediastino a laparotomy) and extracavitous (extrapleural and ekstraperitonealny). At focal defeats of body and in an urgent surgery of P. at its traumatic damages most often use various a trance - and thoracoabdominal accesses, extracavitous — apply only at purulent diseases of the Item. The choice of access depends as well on localization patol, process in the Item. If the center of defeat is located in its right half, it is reasonable to use only an abdominal part of torakolaparotomny access in the beginning and, having only convinced of a possibility of radical intervention, to make broad opening of the right pleural cavity. In cases when defeat is limited to the left half of P., it is necessary to begin operation with upper median laparotomies (see) which if necessary can be easily transformed practically to any abdominal or thoracoabdominal access. After a laparotomy approach to upper parts of P. can be facilitated by crossing of round and crescent sheaves and pulling up of body for them. Big mobility of P. is reached by crossing of the right and left triangular sheaves.
P.'s audit and abdominal organs for the purpose of detection of operability patol, process — the most important moment of an operative measure. It includes establishment of the final diagnosis, specification of localization and prevalence of focal process, clarification of interest of portal and caval gate of P., definition of a condition of not struck departments of body (existence of an atrophy or compensatory hypertrophy), identification of the remote metastasises and diseases of other abdominal organs. It is obvious that rather wide quick access is necessary for performance of these tasks.
During the planning of less extensive operations on P., napr, at an echinococcosis, other approach to quick access is necessary absolutely. It shall provide opening and emptying of a cyst only; only at localization of an echinococcus in upper part P. it is necessary to use a thoracolaparotomy. Accesses during the opening and drainage of abscesses of the Item are even more limited. For reduction of risk of infection of an abdominal or pleural cavity in these cases usually use approach out of the specified cavities (see. Subphrenic abscess).
Operative measures on P. are extremely various on the volume, technical complexity, appointment and risk for the patient. They are various also on range — from the simplest, napr, sewing up of small chipped wounds or a hepatotomy (a small section of the capsule and P.'s parenchyma), to the most difficult — a hemihepatectomy (see) or removals of the most part of body.
Operations on P. carry out in various occasions at wounds and the closed traumatic damages of its parenchyma (cracks, gaps, crushes), focal defeats (parasitic, tumoral, cystiform, purulent diseases — abscesses, purulent cysts) and, at last, at cirrhoses of a liver.
Indications to an operative measure at injuries are internal bleeding and bilious peritonitis, life-threatening the victim; at tumors — danger of the disease; at cysts — a possibility of development of complications (suppuration, gaps). Operations in most cases make in a planned order and only at injuries — according to the emergency indications.
The nature of operations on P. undertaken in these cases is extremely various. At P.'s wounds of a wound take in the seams which are specially offered for this purpose. At localization of wounds on a phrenic or nizhnezadny surface of body where them to carry out sewing up extremely difficult, make a hepatopexy or plastics a rag from a diaphragm on Petrovsky. In cases of extensive damages of P. (gaps, crushes) undertake a tamponade of a wound (a gauze napkin, an epiploon on a leg), economical resections of body (only impractical fabrics) or more extensive — like regional or segmented resections of a liver.
At volume defeats of P. also carry out various operative measures. At inborn (not parasitic) cysts of P. make their extirpation more often or (at impossibility of allocation) anastamosing of a cavity of a cyst with went. - kish. a path (tsistogastro-or a jejunostomy with an inter-intestinal anastomosis across Ru or Brown). Echinococcal cysts of P. completely manage to be removed without opening of their gleam (an ideal ekhinokokkektomiya) seldom, only at a regional or superficial arrangement of a parasite. It is necessary to consider that this operation, besides, is unsafe because of a possibility of a rupture of a thin-walled cyst and planting of an abdominal cavity affiliated bubbles. Carry out an ekhino-kokkektomiya by opening and the subsequent removal of contents and covers of a parasite more often (see. Echinococcosis ); the cavity which is formed in P. limited to the fibrous capsule is processed by 3% solution of formalin in glycerin and take in or drain. The fibrous capsule needs to be deleted only in cases of its calcification because of a possibility of formation of not healing purulent fistulas. Ways of elimination of a cavity of the fibrous capsule are various: sewing up by seams from within as a capitonnage across Delbe (see. Capitonnage ), packing by the remains of freely lying fibrous capsule, an epiploon on a leg, pasting of its walls tsianokrilatny glue, etc. Drainage is applied at an empyema of cyst. In rare instances resort to palliative operation — an ekhinokokktomiya (opening and drainage of a parasitic cyst without removal of all its elements). In connection with an echinococcosis resort to P.'s resection seldom.
At benign and malignant tumors of P., including and metastatic, and also at an alveococcosis make radical and palliative interventions. Anatomic resections of P. (a hemihepatectomy, a lobectomy, a segmentectomy) and atypical resections of P. concern to the first (regional, wedge-shaped, cross); to the second — various zhelcheotvodyashchy operations (a hepatostomy, a gepatokho-langiostomiya — creation of outside bilious fistula, a holangioyeyunosto-miya, a holangiokholetsistoyeyunostomiya, a cholangiogastrostomy, a rekanalization of intra hepatic bilious channels, a transhepatic holangioyeyu-nostomiya, etc.). At alveococcosis (see), in addition to radical interventions, make also conditionally radical when delete the most part of tissue of parasite, and subject the left its site (usually in a zone of gate of P.) to processing by antiparasitic drugs or to cryoinfluence, at Krom the parasite perishes; to the specified palliative operations a cavernostomy, kavernoyeyuno-, the kavernoga-strostomiya and a resection — a kuskovaniye increase (removal only of a part of tissue of parasite).
The hepatotomy — a section or division of a parenchyma of P. — can be carried out in the acute or stupid way, tools or fingers of the surgeon (a so-called digitoklaziya). Apply the combined technique more often — cut the capsule P. a scalpel or an electroknife, and move apart fabric of body a packer. The hepatotomy is made for the exposure of a surface of abscess, cysts, tumors located in the depth of P. and also allocation of intra hepatic bilious channels. From small vessels of a parenchyma of body apply the tampons moistened hot fiziol, solution, an absorbable gelatin sponge to a stop of the bleeding which is inevitably arising at the same time. At damage of larger vessels their coagulation or sewing up is necessary. At the same time the deep «blind» wound P. Gepatostomiya can be formed carry out by a vshivaniye of edges of a wound of P. to regions of a wound of a front abdominal wall or by means of a rubber or plastic tube which one end is in artificially created cavity in a parenchyma of body, and another — is brought outside through a separate section in a front abdominal wall. This operation offered for outside removal of bile at high impassability of extrahepatic bilious channels is applied seldom since cannot provide considerable outflow it through the crossed small bilious channels of a parenchyma of body especially as hepatic channels of shares have among themselves no anastomosis.
Gepatokholangiostomiya — imposing of an anastomosis between a large intra hepatic bilious channel and the outside environment — is applied to removal of bile at impassability of hepatic channels in the field of gate of the Item. Operation difficult technically. For its performance use thin plastic drainages, to-rye enter into the hepatic canal through an aspirating needle or after carrying out special metal tubes-in-tubatorov of the increasing diameter; the second end of a drainage is removed outside through a puncture opening or a separate section in a front abdominal wall. This operation is more effective, than a hepatostomy. She in most cases allows to achieve full permission of obturatsionny jaundice, however shall be applied only at heavy patients with symptoms of a liver failure when it is impossible to create internal removal of bile in went. - kish. path.
P.'s resections technically are the most difficult operations, to-rye are accompanied by big risk in connection with profuse bleedings during operation and heavy complications after it. Mortality after these interventions, according to various data, depending on character and extensiveness of defeat of body", a type of a resection and other factors makes 8-66%.
From the point of view of technology of performance of operation distinguish two ways of a resection essentially different from each other: atypical and anatomic. The first carry out after preliminary imposing of haemo static seams of Kuznetsov and Pensky, Oppel or other on site P. which is subject to removal. The second — provide preliminary bandaging of a portal triad or are more rare transparenchymatous bandaging of vessels and bilious channels with the subsequent removal of an affected area of P. on avascular zones according to a segmented structure of body. For the purpose of reduction of operational blood loss at resections And. (especially atypical) the method temporary is applied (for 10 — 15 min.) crossclampings of a hepatoduodenal sheaf which at discontinuous occlusion and in combination with a moderate hypothermia of P. allows to prolong time of crossclamping of vessels up to 20 — 25 min.
Atypical and anatomic resections of P. have the identical rights of nationality, however it is necessary to consider that atypical resections are possible during removal of sites P. which are in a zone of final branches of vascular and secretory structures of body. They are simpler, m removal of healthy fabrics P are carried out quicker and with naimen-tp i. Their negative side are quite frequent postoperative bleedings and biliary complications, and also regional necroses of a parenchyma in a zone of the put stitches. According to most of researchers, it is reasonable to apply this method at rather small resections in cases of a regional or peripheral arrangement of focal defeats of P., but taking into account topography of vascular system of body.
Anatomic resections are more difficult and quite often are followed by big losses of functionally full-fledged hepatic fabric. They are shown at localization patol, process within one or several segments P. without transition to an opposite half of body, at intact sosudistosekretorny elements in a zone of portal and caval gate and existence of the expressed compensatory hypertrophy of not struck
P. V departments more exceptional cases combine P.'s resection with interventions on other abdominal organs. The decision on production of the combined operation shall be made individually, taking into account prevalence patol, process, a functional condition of a liver and qualification of the surgeon. It shall not be beyond reasonable radicalism.
The aspiration of surgeons to have an opportunity to operate on Sukhoi of P. was the basis for development of a method of its full vascular isolation by switching off from blood circulation of both portal, and caval vessels by simultaneous crossclamping of a hepatoduodenal sheaf and the lower vena cava P., however no more than for 20 min. is lower and higher. Use of a hypothermia of P., according to G. M. Maslov (1971), increases this term up to 40 min., and in combination with temporarily imposed selezenochno-femoral shunt — up to 80 min. For the prevention of the hemodynamic disturbances which are inevitably arising at occlusions of the lower vena cava endocaval shunting is developed. It has undoubted advantage before other ways of full switching off of P. as keeps a blood stream on the lower vena cava that allowed to apply it in a wedge, practice at the injuries and focal defeats located near large vessels or the lower vena cava. Use of the silastikovy catheter with razduvny barrels entered into the lower vena cava above and below a confluence of hepatic veins simplified this operation as allowed to avoid diaf-ragmo-and pericardiotomies. In experimental conditions the method of full temporary switching off of vessels of P. using the cardiopulmonary bypass is developed. However for implementation in a wedge, practice it needs further studying.
The postoperative period
In the postoperative period the main objectives of an intensive care are providing the necessary energy balance of an organism by administration of carbohydrates (300 — 500 g a day), correction of protein, water-salt, vitamin metabolism, acid-base equilibrium, maintenance of adequate gas exchange and a hemodynamics. Timely use of means of an intensive care prevents development of a liver failure, a gepatorenalny syndrome. During the first 3 days after operation on P. patients shall be in intensive care unit. In case of traumatic shock and blood loss the actions begun for fight against them in the operating room continue. Secondary bleedings sometimes are quickly distinguished on intensive intake of blood on drainages. Emergence of bile in them testifies to insufficiency of seams of P. or to sliding of a ligature from a bilious channel; at the same time it is necessary to exclude developing of peritonitis. Hemorrhagic and biliary complications can be expected at the patients who transferred P.'s resection in the first 5 days after operation. Due to the metabolic shifts, first of all a hypoalbuminemia, administration of seralbumin (to 50 g a day during 2 weeks), fibrinogen, gamma-globulin is necessary. The hypoglycemia is korrigirut introduction of necessary amount of glucose or a dextran. In a case gipoprotrombinemtsh administration of phthiocol, and also repeated hemotransfusions of fresh blood (it is better directly from the donor), plasmas, blood substitutes is obligatory. For prevention of purulent complications appoint antibiotics of a broad spectrum of activity within 10 — 12 days.
At a favorable current of the postoperative period next day after operation to the patient allow to drink, for the second day after operation begin feeding of patients. Drainages delete on 5 — the 7th day, and in case of need they can be left for more long term. Tampons after preliminary pulling up delete on 8 — the 10th day, remove seams in the same terms. At extensive operational wounds after each bandaging the stomach is densely shrouded in a towel which end is fixed, napr, sewn, for the purpose of prevention of eventration. Postoperative complications of the general character (pneumonia, suppuration of an operational wound, etc.) after P.'s resections are observed not more often than after other extensive abdominal organs operations. In case of development of the specific complications connected with P.'s damage, postoperative maintaining is individual.
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A. F. Blyuger; V. G. Akopyan (malformations), L. I. Aruin (stalemate. An.), V. A. Valuk (physical.), R. I. Gabuniya (I am glad.), O. A. Dolina (anest.), A. A. Klimenkov, A. B. Itin (PMC.), AA. 3. Krupnikova (patol.), V. V. Kupriyanov (AGE), P. G. Doctor, V. A. Makarova (change of a nervous system), O. B. Milonov (hir. diseases, damages, operations), L. D. Lindenbraten (rents.), A. Ya. Mayore (biochemical), I. N. Novitsky (methods of a research, pathology, physical.), A. I. Chalganov, A. A. Shalimov (soldier.).