5. Hepatobilier

8/16/2019 5. Hepatobilier

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D4 USB

2016



ANATOMYAn adult human liver normally weih! "etween 1#4$

1#6 & '(#1$(#) l"*+t i! lo,ated in the riht u--er .uadrant o/ the

a"dominal ,avity re!tin u!t "elow the dia-hram The liver lie! to the riht o/ the !toma,h and overlie!

the all"ladder

+35 UN7T+ON 8

Synthe!i!Brea&downOther un,tion





SYNTHESISA lare -art o/ amino a,id !ynthe!i!

The liver -er/orm! !everal role! in ,ar"ohydrate meta"oli!m8Gluconeogenesis 'the !ynthe!i! o/ lu,o!e /rom ,ertainamino a,id! la,tate or ly,erol*

Glycogenolysis 'the "rea&down o/ ly,oen into lu,o!e*

Glycogenesis 'the /ormation o/ ly,oen /rom lu,o!e*

'mu!,le ti!!ue! ,an al!o do thi!* The liver i! re!-on!i"le /or the main!tay o/ -rotein

meta"oli!m !ynthe!i! a! well a! deradation

The liver al!o -er/orm! !everal role! in li-id meta"oli!m8Cholesterol synthesis

Lipogenesis the -rodu,tion o/ trily,eride! '/at!*#

The liver -rodu,e! ,oaulation /a,tor! + '9"rinoen* ++'-rothrom"in* 3 3++ +: : and :+ a! well a! -rotein 7-rotein S and antithrom"in



+n the 9r!t trime!ter /etu! the liver i! the main !ite

o/ red "lood ,ell -rodu,tion# By the (2nd wee& o/e!tation the "one marrow ha! almo!t ,om-letelyta&en over that ta!&# The liver -rodu,e! ande;,rete! "ile 'a reeni!h li.uid* re.uired /oremul!i/yin /at!# Some o/ the "ile drain! dire,tly into

the duodenum and !ome i! !tored in the all"ladder The liver al!o -rodu,e! in!ulin<li&e rowth /a,tor 1

'+=<1* a -oly-e-tide -rotein hormone that -lay! anim-ortant role in ,hildhood rowth and ,ontinue! tohave ana"oli, e>e,t! in adult!

The liver i! a maor !ite o/ throm"o-oietin -rodu,tion Throm"o-oietin i! a ly,o-rotein hormone thatreulate! the -rodu,tion o/ -latelet! "y the "onemarrow



B5A?DO@N

The "rea&down o/ in!ulin and other hormone!

The liver "rea&! down hemolo"in ,reatinmeta"olite! that are added to "ile a! -iment'"iliru"in and "iliverdin*

The liver "rea&! down or modi9e! to;i,!u"!tan,e! 'e## methylation* and mo!t

medi,inal -rodu,t! in a -ro,e!! ,alled drumeta"oli!m

The liver ,onvert! ammonia to urea



enuraianenuraian in!uline dan hormon lainnya#

ati menurai&an hemolo"in menyu!unmeta"olit# yan dima!u&&an &e &antunem-edu !e"aai -imen '"illiru"in dan"iliverdin*#

ati menurai&a -em"entu&an !enyawa to;i,'e;8 methyla!i* dan !e"aian "e!ar -rodu&!io"at dalam -ro!e! yan di!e"ut meta"oli!meo"at#

ati da-at men&onver!i amonia menadi urea#



OT5 UN7T+ON

The liver !tore! a multitude o/ !u"!tan,e!in,ludin lu,o!e 'in the /orm o/ ly,oen* vitaminA vitamin D vitamin B12 iron and ,o--er

The liver -rodu,e! al"umin the maor o!molar,om-onent o/ "lood !erum

The liver !ynthe!iCe! anioten!inoen a hormonethat i! re!-on!i"le /or rai!in the "lood -re!!ure

when a,tivated "y renin an enCyme that i!relea!ed when the &idney !en!e! low "lood-re!!ure



un!i ainnyaati menyim-an "anya& &andunan Cat

terma!u& lu&o!a 'dalam "entu& li&oen*vitamin A 3itamin D 3itamin B12 Be!i dan 7u#

ati mem-rodu&!i al"umin !e"aian "e!ar&om-onen o!molar -ada !erum darah#

ati men!inte!i! anioten!inoen hormon yan"ertanun awa" untu& menin&at&ante&anan darah &eti&a dia&ti&an oleh renin!e"uah enCim yan dile-a!&an &eti&a inalmera!a&an -enurunan te&anan darah#



+35 D+SAS

e-atiti! inammation o/ the liver ,au!ed mainly "yvariou! viru!e! "ut al!o "y !ome -oi!on! 'e## al,ohol*autoimmunity 'autoimmune he-atiti!* or hereditary,ondition!#

Non<al,oholi, /atty liver di!ea!e a !-e,trum in di!ea!e

a!!o,iated with o"e!ity and ,hara,teriCed a! ana"undan,e o/ /at in the liverE may lead to a he-atiti!7irrho!i! i! the /ormation o/ 9"rou! ti!!ue in the liver

re-la,in dead liver ,ell!# The death o/ the liver ,ell!,an /or e;am-le "e ,au!ed "y viral he-atiti!

al,oholi!m or ,onta,t with other liver<to;i, ,hemi,al!#7an,er o/ the liver '-rimary he-ato,ellular ,ar,inoma

or ,holanio,ar,inoma and meta!tati, ,an,er! u!ually/rom other -art! o/ the a!trointe!tinal tra,t*



AT+T+S

e-atiti! mean! inammation o/ the liver# Manyillne!!e! and ,ondition! ,an ,au!e inammation o/the liver /or e;am-le dru! al,ohol ,hemi,al!

and autoimmune di!ea!e!Many viru!e! /or e;am-le the viru! o/

mononu,leo!i! and the ,ytomealoviru! ,aniname the liver

There are !everal he-atiti! viru!e!E they have "eennamed ty-e! A B 7 D 'not ,on9rmed* and =

The mo!t ,ommon he-atiti! viru!e! are ty-e! A Band 7



3+5A AT+T+S A

THE VIRION: The viru!i! !mall 2Fnm indiameter o/ the

Picornaviridae '-i,oGvery !mall* rna/amily+t wa! tauht to "e an

enteroviru!

+t i! !-heri,al with a-rotein !hell whi,hen,a-!idate! a !inle!tranded 5NA o/ overF000 "a!e!



7+N+7A ATU5

The viru! i! a,.uired "y ine!tion# +t multi-lie! inthe inte!tine and invade! the "lood liver and!aliva "e/ore any ,lini,al mani/e!tation o/ the

di!ea!e a--ear!# Thi! -eriod o/ incubation la!t!an averae o/ 4 '2<6* wee&!

+n adult! the in/e,tion i! more !evere witheneral !ym-tom! malai!e and aundi,e

Haundi,e la!t! /or F<10 day! and the whole illne!!la!t! a"out 4 wee&!

ulminant i! very rare 0#)I o/ ,a!e!# Survivalwith ood medi,al treatment may "e J0I



ABO5ATO5Y D+A=NOS+SSerum IgM anti"ody i! -re!ent

durin the a,ute -ha!e anddi!a--ear! in ( month!# +t mayla!t u- to 2 year! in a /ew

,a!e!# The te!t i! 100I!en!itive and very !-e,i9,#

Serum IgG anti"ody develo-!a/ter the a,ute illne!! and-er!i!t! /or li/e re-re!entinimmunity

Serum transaminase ri!e withthe a,ute illne!! and returnnormal with re,overy# They!eldom are hiher than 1000# There i! no ,orrelation "etweentheir level and -rono!i!





AT+T+S B

e-atiti! B viru! 'B3* i! a mem"er o/ thee-adnaviru! /amily

The viru! -arti,le 'virion* ,on!i!t! o/ anouter li-id envelo-e and an i,o!ahedralnu,leo,a-!id ,ore ,om-o!ed o/ -rotein

The nu,leo,a-!id en,lo!e! the viral DNAand a DNA -olymera!e that ha! rever!etran!,ri-ta!e a,tivity

The outer envelo-e ,ontain! em"edded-rotein! whi,h are involved in viral"indin o/ and entry into !u!,e-ti"le,ell!

The viru! i! one o/ the !malle!t envelo-edanimal viru!e! with a virion diameter o/

42 nm "ut -leomor-hi, /orm! e;i!tin,ludin 9lamentou! and !-heri,al "odie!la,&in a ,ore

The!e -arti,le! are not in/e,tiou! and are,om-o!ed o/ the li-id and -rotein that/orm! -art o/ the !ur/a,e o/ the virionwhi,h i! ,alled the !ur/a,e antien'B!A* and i! -rodu,ed in e;,e!! durin

the li/e ,y,le o/ the viru!#K

http://en.wikipedia.org/wiki/Hepatitis_B

http://en.wikipedia.org/wiki/Hepatitis_B



T5ANSM+SS+ON

e-atiti! B ,an !-read "y 8

Se;ual ,onta,t

The tran!/er o/ "lood or !erum throuh

!hared needle! in dru a"u!er! A,,idental needle !ti,&! with needle!

,ontaminated with in/e,ted "lood

Blood tran!/u!ion!

emodialy!i! and

By in/e,ted mother! to their new"orn!

The in/e,tion al!o ,an "e !-read "y

tattooin "ody -ier,in and !harinraCor! and tooth"ru!he! 'i/ there i!,ontamination with in/e,ted "lood*



NUA5ANe-atiti! B da-at ditular&an melalui8

u"unan !e&!ual

darah atau !erum melalui arum !untu& dalam

-enyalahunaan o"at# &e,ela&aan arum !unti& denan arum yan telah

ter&ontamina!i oleh in/e&!i darah#

Tran!/u!i darah#

emodialy!i! dan

+n/e&!i oleh i"u melalui &eturunannya#+n/e&!i da-at ua di!e"ar&an melalui -em"uatan tato

tindi& dan -enunaan "er!ama -i!au ,u&ur dan !i&at ii#'i&a terda-at &ontamina!i oleh darah yan terin/e&!i*#



ATO=NS+S





ABO5ATO5Y D+A=NOS+S



ABO5ATO5Y D+A=NOS+S





AT+T+S 7





e-atiti! 7e-atiti! 7 viru! '73* "eru&uran &e,il 'diameter )0 nm* ter"un&u!tunal -o!itiv !e"aai 5NA viru!#

3iru! ini hanya di&enal !e"aai anota dari enu! hepacivirus dalam/amily 'faviviridae)#

Terda-at 6 enoti-e viru! he-atiti! 7 yan teridenti9&a!i '!e"aai ,ontoh8enoti-e 1 enoti-e 2 d!t#*#

=enom terdiri dari ) dan ( yan tida& ditran!la!i&an dalam wilayah')UT5 dan (:5* yan memili&i !edi&it varia!i !.uen,in untu& !emuaenoti-e dan -entin untu& tran!la!i oleh -rotein viru! dan re-li&a!i viru!#

73 memili&i -rotein !tru&tural yan !e!uai denan inti -rotein dan dua

-em"un&u! li&o-rotein 1 dan 2#rotein non !tru&tural terma!u& -rotea!e! 'NS2( dan NS(* heli,a!e

'!e"uah enCim yan tida& mele-a!&an do"el !trended a!am nu&leat*#'NS(* dan 5NA< "erantun -ada 5NA -olymera!e 'NS)B* menunu&&an!eumlah /un!i -o&o& untu& !i&lu! hidu- viru!#



T5ANSM+SS+ON

Vertical transmission refers to the transmission

of a communicable disease from an infected

mother to her child during the birth process.

Mother-to-child transmission of hepatitis C has

been well described, but occurs relatively

infrequently

Transmission occurs only among women who

are HCV !" positive at the time of delivery#

the ris$ of transmission in this setting is

appro%imately & out of '((

"mong women who are both HCV and H)Vpositive at the time of delivery, the ris$ of

transmitting HCV is increased to appro%imately

*+ out of '((.

The ris$ of vertical transmission of HCV does

not appear to be associated with method of

delivery or breastfeeding



3+5US



3+5US

e-atiti! 7 viru! lewat arum !unti& atau

tran/u!i darah yan ter&ontamina!i viru! "arrier he-ato!it re-li&a!i viru! re-li&a!iDNA











LIVER FUNCTION



LIVER FUNCTION

TEST

un!i e&!&re!i 8 "iliru"in a!am em-edu

un!i !inte!i! 8 -rotein 'al"umin* li-id li-o-rotein urea dan /a&tor -em"e&uan#

un!i meta"oli!me 8 amonia &ar"ohidrat







ABUM+NAl"umin i! a -rotein made !-e,i9,ally "y the liver and ,an"e mea!ured ,hea-ly and ea!ily

+t i! the main ,on!tituent o/ total -roteinE the remainin/ra,tion i! ,alled lo"ulin 'in,ludin the immunolo"ulin!*

Al"umin level! are de,rea!ed in ,hroni, liver di!ea!e !u,ha! ,irrho!i!# +t i! al!o de,rea!ed in ne-hroti, !yndromewhere it i! lo!t throuh the urine

oor nutrition or !tate! o/ -rotein ,ata"oli!m may al!o lead

to hy-oal"uminaemia The hal/<li/e o/ al"umin i! a--ro;imately 20 day!

Al"umin i! not ,on!idered to "e an e!-e,ially u!e/ul mar&ero/ liver !yntheti, /un,tionE ,oaulation /a,tor! '!ee "elow*are mu,h more !en!itive#



ABUM+NAl"umin meru-a&an -rotein yan ter"entu& !-e!ial oleh hati danda-at teru&ur denan murah dan mudah#

Al"umin memili&i un!ur -o&o& dari &e!eluruhan -roteinEmenandun /ra&!i yan di!e"ut lo"ulin 'terma!u&

immunolo"ulin*# Humlah al"umin menurun -ada !aat -enya&it hati &roni! !e-erti

,irrho!i!# +a ua a&an menurun -ada !aat !indrom ne-roti&dimana a&an hilan melalui urin#

Nutri!i yan "uru& atau "erhentinya -ro!e! &ata"oli!me ua

menadi -enye"a"hy-oal"uminaemia#@a&tu -aruh al"umin adalah !e&itar 20 hari#

Al"umin tida& memili&i &eunaan &hu!u! dalam /un!i !inteti&hatiE /a&tor &oaula!i 'lihat di "awah* meru-a&an hal yan le"ih!en!iti/#



ATS=T

Alanine tran!amina!e 'AT* al!o ,alled Serum=lutami, yruvate Tran!amina!e 'S=T* orAlanine aminotran!/era!e 'AAT* i! an enCyme

-re!ent in he-ato,yte! 'liver ,ell!*@hen a ,ell i! damaed it lea&! thi! enCyme into

the "lood where it i! mea!ured#

AT ri!e! dramati,ally in a,ute liver damae !u,h

a! viral he-atiti! or -ara,etamol 'a,etamino-hen*overdo!e

levation! are o/ten mea!ured in multi-le! o/ theu--er limit o/ normal



ATS=TAT 'Alanin Tran!mina!e* ua di!e"ut !e"aai!erum =lutami, yruvate Tran!mina!e 'S=T*atau alanin amino tran!/era!e 'AAT* adalah

enCim yan terda-at di dalam he-ato!it '!el hati*#?eti&a !el ini ru!a& !el a&an meru!a& enCim ini

dalam darah dimana ia terda-at didalamnya#

AT menin&at !e,ara ,e-at dalam &eru!a&an hati

yan -arah !e-erti viru! he-atiti! atau &arenaover do!i! -ara,etamol 'a,etamino-hen*#

?enai&an ini a&an menin&at dari "ata! ata!normal#



ASTS=OT

A!-artate tran!amina!e 'AST* al!o ,alled Serum=lutami, O;aloa,eti, Tran!amina!e 'S=OT* ora!-artate aminotran!/era!e 'ASAT* i! !imilar to AT in

that it i! another enCyme a!!o,iated with liver-aren,hymal ,ell!

+t i! rai!ed in a,ute liver damae "ut i! al!o -re!ent inred "lood ,ell! and ,ardia, and !&eletal mu!,le and i!there/ore not !-e,i9, to the liver

The ratio o/ AST to AT i! !ometime! u!e/ul indi>erentiatin "etween ,au!e! o/ liver damae

levated AST level! are not !-e,i9, /or liver damaeand AST ha! al!o "een u!ed a! a ,ardia, mar&er



ASTS=OTA!-artat tran!amina!e 'AST* yan ua di!e"ut Serum

=lutami& o&!aloa!etat Tran!amina!e 'S=OT* atau a!-artateaminotran!/era!e 'ASAT* miri- denan AT yaitu enCim lainyan tee&um-ul denan !el<!el -aren&im hati#

Serum ini a&an menin&at &eti&a teradi &eru!a&an hati a&ut#Sel ini ua "erada -ada !el darah merah dan otot antundan ran&a# Oleh &arena itu tida& hanya !-e!i9& untu& hati!aa#

5a!io AST untu& AT ter&adan "eruna untu& mem"eda&an-enye"a" &eru!a&an hati#

enin&atan &adar AST tida& !-e!i9& untu& &eru!a&an hatidan AST ua diuna&an !e"aai -enanda antun#



A?A+ OSATAS

Al&aline -ho!-hata!e 'A* i! an enCyme in the

,ell! linin the "iliary du,t! o/ the liver

A level! in -la!ma will ri!e with lare "ile du,t

o"!tru,tion intrahe-ati, ,hole!ta!i! orin9ltrative di!ea!e! o/ the liver

A i! al!o -re!ent in "one and -la,ental ti!!ue

!o it i! hiher in rowin ,hildren 'a! their "one!

are "ein remodelled* and elderly -atient! withaetP! di!ea!e



A?A+ OSATASAl&ali /o!/ata!e 'A* adalah enCim dalam !el<!elyan mela-i!i !aluran em-edu -ada hati#

&adar A dalam -la!ma a&an menin&at !e!uai

denan "e!arnya o"!tru&!i !aluran em-edu&ole!ta!i! intrahe-ati& atau -enya&it in9ltrati/hati#

A ua terda-at di dalam tulan dan arinan

-la!enta !ehina enCim ini le"ih "anya -ada-ertum"uhan ana&<ana& '!elama tulan mere&ama!ih dalam taha- -er&em"anan* dan -a!ienoran tua denan -enya&it aet#

TES FUNGSI HTI



TES FUNGSI HTI

nCim yan dile-a!&an dari !el yan

!a&it

AST =OT 8 mito&ondria dan

!ito-la!maAT =T 8 !ito-la!ma

A 8 !inu!oid endotelium vena

!entral -eri/er==T 8 !aluran em-edu dan e-itel

&andun em-edu

EN!IM EN!IM HTI



EN!IM"EN!IM HTIL#LI $HOS$HTSE% L$

Terda-at di hati 'he-ato"ilier* tulan'o!teo"lat* tu"ulu! inal e-itel u!u! dan-la!enta

al/ li/e ( $ F hari

GMM GLUTMYL TRNSFERSE%GGT

Terda-at di !el hati !aluran em-eduinal u!u! dan -an&rea! -ro!tat

al/ li/e ( $ 4 hari

Menin&at -ada al&oholi& o"e!e tera-i

a,etamino/en do!i! tini

EN!IM EN!IM HTI



EN!IM"EN!IM HTI

LCTTE &EHY&ROGENSE% L&HD 1 2 terutama di otot antun inal dan

eritro!it

D 4 ) terutama di hati dan otot !&elet

al/ li/e J $ 12 am

'"NUCLEO TI&SE% '"NT

Terda-at di !ela-ut !inu!oid dan !aluran "ilierMenuat&an -enin&atan A &arena

anuan hati

EN!IM EN!IM HTI



EN!IM"EN!IM HTICHE

7 -!eudo<7 terda-at di !erum antun "aian -utih ota& 'white matter*-an&rea! dan hati

al/ li/e J $ 10 hariA,7 true<7 terda-at di !el darah

merah -aru<-aru lim-a !el !ara/ !ina-! motor end -late dan "aian a"u<a"udari ota? 'rey matter*



(ILIRU(IN

rythro,yte! 'red "lood ,ell!* enerated in the "onemarrow are di!-o!ed o/ in the !-leen when they etold or damaed

Thi! relea!e! hemolo"in whi,h i! "ro&en down toheme a! the lo"in -art! are turned into aminoa,id!

The heme i! then turned into un,onuated "iliru"inin the reti,uloendothelial ,ell! o/ the !-leen

Thi! un,onuated "iliru"in i! not !olu"le in water it

i! then "ound to al"umin and !ent to the liver+n the liver it i! ,onuated with lu,uroni, a,id "y

the enCyme =lu,urono!yltran!/era!e ma&in it!olu"le in water



Biliru"inritro!it '!el darah merah* yan diha!il&an oleh !um!um

tulan "ela&an a&an di"uan di lim-a &eti&a mere&a telahmenadi tua atau ru!a&#

+ni a&an mele-a!&an hemolo"in yan di-e,ah &e heme!e"aai "aian lo"in yan "eru"ah menadi a!am amino#

heme ini &emudian "eru"ah menadi "iliru"in ta& ter&onua!idalam !el reti&uloendotelial lim-a#

"iliru"in ta& ter&onua!i ini tida& larut dalam air yan&emudian teri&at oleh al"umin dan di&irim &e hati#

Dalam hati ia a&an ter&onua!i denan a!am lu&uronat olehenCim lu!urono!iltran!/era!e !ehina mem"uatnya larutdalam air#



B++5UB+N

Mu,h o/ it oe! into the "ile and thu! out into the!mall inte!tine

Some o/ the ,onuated "iliru"in remain! in thelare inte!tine and i! meta"oli!ed "y ,oloni,"a,teria to uro"ilinoen whi,h i! /urthermeta"oliCed to !ter,o"ilinoen and 9nally o;idi!edto !ter,o"ilin

Thi! !ter,o"ilin ive! /e,e! it! "rown ,olor

Some o/ the uro"ilinoen i! rea"!or"ed and e;,retedin the urine alon with an o;idiCed /orm uro"ilin



B++5UB+NBanya& dari "iliru"in yan ma!u& &e em-edu dan&eluar melalui u!u! &e,il#

Be"era-a "iliru"in ter&onua!i a&an teta- "erada

dalam u!u! "e!ar dan dimeta"oli!me oleh "a&teri&olon menadi uro"ilinoen yan !elanutnyadimeta"oli!me untu& !ter&o"ilinoen dan a&hirnyadio&!ida!i menadi !ter&o"ilin#

!ter&o"ilin ini yan mem"eri&an warna ,o&lat -ada

&otoran#

Be"era-a uro"ilinoen di!era- dan die&!&re!i&an &edalam urin "er!ama denan "entu& yan tero&!ida!iyaitu uro"ilin#







5A+D TST



M+75OT+T5 AT +SA



SAND@+7 +SA



?OMT+T+3 +SA



+ND+57T +SA



DNA 75



5A T+M 75



5NA 75



T5ANS75+TAS 75

535S



535S

T5ANS75+TAS 75



'5+A*

Documents

5. Hepatobilier