Pathophysiology of Liver Diseases

Pathophysiology of Liver Diseases ONG SUAN LING Liver Failure The liver is responsible for regulatory, detoxification, metabolic and synthetic activities. Liver cell known as hepatocyte, is responsible for about 500 or more specific biologic processes [2]. Liver failure occurs when large parts of the liver become damaged and the liver is dysfunction [1]. Liver failure occurs over many years and gradually. However, the acute liver failure is difficult to detect initially and occurs rapidly (as rapid as 48 hours) [1]. Chronic liver failure is caused by excessive alcohol intake, Hepatitis B or C, malnutrition, Hemochromatosis (body absorb and store too much iron) and cirrhosis (irreversible inflammatory disease) [2]. Figure 1 show the stages of liver damage which eventually lead to cirrhosis. Liver Hepatitis Hepatitis means inflammation of the liver. Hepatitis B and hepatitis C is the most common hepatitis which can lead to the liver damage caused by their chronic forms. Viral hepatitis is cleared from the body in a period ranging from weeks to months, by the immune system but when it is not as seen in chronic hepatitis, the disease must be managed medically [5]. Hepatitis can also be brought on by excess alcohol consumption or inherited (congenital hepatitis)[5]. When hepatitis left untreated, it can damage the liver over many years, eventually resulting in cirrhosis [5]. Liver Cirrhosis Cirrhosis is a condition in which normal, healthy hepatocyte are damaged and replaced by nodular and fibrotic tissue. A cirrhosis-damaged liver can cause decreased hepatic function and widespread disruption of many body functions [3]. For cirrhosis, the biliary channels become obstructed and caused portal hypertension. The hypoxic necrosis is developed as a result of blood circulation is shunted away from the liver (due to neovascularisation) [4] Figure 2 shows the normal appearance of the cells of the liver, compared to cells of cirrhotic livers. Hepatopulmonary syndrome (HPS) Hepatopulmonary syndrome is the clinical relationship between hepatic dysfunction and the existence of pulmonary vascular dilatation which can result in a range of arterial oxygenation abnormalities [6]. HPS is defined by the presence of chronic liver disease; abnormal arterial oxygenation or an arterial partial pressure of oxygen in the absence of an alternate cause; and evidence of intrapulmonary vascular dilatations (IPVDs) [7] Pathophysiology Hepatopulmonary syndrome occurs mostly in patients who have established cirrhosis and portal hypertension [8]. From a pathophysiological point of view, abnormal intrapulmonary vascular dilatation is linked to portal hypertension, which in itself leads to altered bowel perfusion and an increased rate of enteral translocation of gram-negative bacteria and endotoxin. This process in turn stimulates the release of vasoactive mediators, which include tumour necrosis factor, haem-oxygenase-derived carbon monoxide, and nitric oxide. The increased production of nitric oxide in the lung plays a central part in the pathogenesis of the hepatopulmonary syndrome [8]. Increased concentrations of exhaled nitric oxide are positively correlated with the increase of alveoloarterial oxygen difference. The constitutive and the inducible isoforms of nitricoxide synthase have been implicated in this process. In addition, the endothelin system, especially abnormal activation and increased expression of endothelial type B endothelin receptors, is implicated in the pathogenesis of the hepatopulmonary syndrome [8]. In patients who have pulmonary hypertension, endothelin predominantly exerts vasoconstrictive and mitogenic effects due to activation of type A and type B endothelin receptors on pulmonary arterial smooth muscle cells [8]. (Refer to figure 3) Figure 3 show in presence of portal hypertension, hepatic production occurs of endothelin-1 and expression of endothelial type B receptors, but no type A receptors increase in pulmonary vasculature. Signaling via endothelially expressed endothelin B receptor leads to increase NO production by eNOS, with the overall effect of pulmonary vascular dilatation. Below is how defective synthesis and metabolism of pulmonary vasoactive substance lead to intrapulmonary Vasodilation. Due to the vasodilation and development of shunt, the blood flow is not uniform leading to ventilatation-pefusion mismatch and also restricts the oxygen molecules to reach the centre of the capillaries and hemoglobin in the erythrocyte [9]. (Refer to figure 4) Figure 4: Ventilation-perfusion mismatches the oxygen reach the capillaries and blood. The nonuniform perfusion blood flow may lead to the formation of functional intrapulmonary vascular dilations which is the major cause of hypoxemia and the defining feature of HPS [9]. The hyperdynamic circulation as well as the increased cardiac output which associated with liver disease reduces the transit time of blood in the lung vasculature, thus the time available for the oxygen diffusion is reduced. This in turn contributes to the hypoxemia [9]. HPS also caused a decreased arterial partial pressure of oxygen (PO2) as a result of the inability of oxygen molecules to diffuse to the center of the dilated pulmonary capillaries to oxygenate the haemoglobin in the erythrocytes [8]. Figure 5 shows illustration of precapillary pulmonary vascular dilatations. On the other hand, the increasing of alveolar PO2 with supplement oxygen may increase the blood arterial PO2 and improve the hypoxemia [8]. HPS patients have been reported to have decreased pulmonary vascular resistance and decreased hypoxic pulmonary vascular constriction [8]. Hepatorenal syndrome (HRS) Hepatorenal syndrome (HRS) is generally occurs in patients with cirrhosis and portal hypertension [10]. HRS is characterised by major disturbances in circulatory function and renal failure [10]. Intense vasoconstriction of the renal circulation has resulted in renal failure [10]. The HRS is the final consequence of extreme underfilling of the arterial circulation secondary to arterial vasodilatation in the splanchnic vascular bed [10, 11]. The principle abnormality in the systemic circulation is low arterial pressure caused by greatly reduced total systemic vascular resistance [11]. The prognosis remains poor, particularly when there is rapidly progressive renal failure [11]. HRS occurs in the setting of cirrhosis predominantly, but it can also be developed in other types of chronic liver disease like alcoholic hepatitis. Figure 6: Proposed pathogenesis of HRS in cirrhosis, according to the arterial vasodilatation [13] The mechanism of HRS is vasoconstriction of the renal circulation is multifactorial, involving disturbance in the activity and circulatory function of systemic and renal vasoactive mechanisms [13]. There is severe arterial underfilling in the systemic circulation which is related to the portal hypertension [13]. The arterial underfilling is caused by the vasodilatation of the splanchnic circulation related to increased splanchnic production of vasodilator substances, particularly nitric oxide [17]. The increased activity of the vasoconstrictor systems caused greatly reduce in renal perfusion and GFR however tubular function is preserved [13,14,16]. The vasoconstrictor system has resulted in the retention in free water (arginine vasopressin) and retention in sodium (renin-angiotensin and sympathetic nervous system) that occurs in advanced cirrhosis [15, 16]. In the early phases of decompensated cirrhosis, increased synthesis of renal vasodilator factors (mainly prostaglandins) caused maintenance of renal perfusion within the normal range because of [17]. In later phases of the disorder, renal perfusion cannot be maintained because maximum activation of vasoconstrictor systems caused by the extreme arterial underfilling, has decreased production of renal vasodilator factors, or both, and lead to HRS developement [17]. The activation of vasoconstrictor systems also results in vasoconstriction of some vascular beds other than the kidneys, including the legs, arms and brain. Due to the greatly increased local production of vasodilators, the splanchnic area escapes the effect of vasconstrictors [18]. References Webmd.com. (2014).Liver failure causes, symptoms, treatments, tests more. [online] Retrieved from: http://www.webmd.com/digestive-disorders/digestive-diseases-liver-failure [Accessed: 11 Jan 2014]. Vitaltherapies.com. (2014).Liver disease | vital therapies. [online] Retrieved from: http://vitaltherapies.com/liver-disease/ [Accessed: 11 Jan 2014]. Hn632campus.wikispaces.com. 2014.HN632campus Cirrhosis. [online] Available at: https://hn632campus.wikispaces.com/Cirrhosis [Accessed: 11 Jan 2014]. Buob, S., Johnston, A. N., Webster, C. R. L. (2011). Portal hypertension: pathophysiology, diagnosis, and treatment.Journal of Veterinary Internal Medicine,25(2), 169-186. Livermd.org. (2014).Hepatitis cirrhosis. [online] Retrieved from: http://livermd.org/hepatitis.html [Accessed: 11 Jan 2014]. Krowka, M. J., Cortese, D. A. (1994). Hepatopulmonary syndrome. Current concepts in diagnostic and therapeutic considerations.CHEST Journal,105(5), 1528-1537. Fritz, J. S., Fallon, M. B., Kawut, S. M. (2013). Pulmonary Vascular Complications of Liver Disease.American journal of respiratory and critical care medicine,187(2), 133-143 Hoeper, M. M., Krowka, M. J., Strassburg, C. P. (2004). Portopulmonary hypertension and hepatopulmonary syndrome.The Lancet,363(9419), 1461-1468 Zhang, J., Fallon, M. B. (2012). Hepatopulmonary syndrome: update on pathogenesis and clinical features.Nature Reviews Gastroenterology and Hepatology,9(9), 539-549. Ncbi.nlm.nih.gov. (2014).Hepatorenal syndrome national library of medicine pubmed health. [online] Retrieved from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001519/ [Accessed: 12 Jan 2014]. Emedicine.medscape.com. (2014).Medscape: medscape access. [online] Retrieved from: http://emedicine.medscape.com/article/178208-overview#a0104 [Accessed: 11 Jan 2014]. Ginà ¨s, P., Guevara, M., Arroyo, V., Rodà ©s, J. (2003). Hepatorenal syndrome.The Lancet,362(9398), 1819-1827. Arroyo, V., Ginà ¨s, P., Gerbes, A. L., Dudley, F. J., Gentilini, P., Laffi, G., Schà ¶lmerich, J. (1996). Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis.Hepatology,23(1), 164-176. Arroyo, V., Guevara, M., Ginà ¨s, P. (2002). Hepatorenal syndrome in cirrhosis: pathogenesis and treatment.Gastroenterology,122(6), 1658-1676. Schrier, R. W., Arroyo, V., Bernardi, M., Epstein, M., Henriksen, J. H., Rodà ©s, J. (1988). Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis.Hepatology,8(5), 1151-1157. Schrier, R. W., Niederberger, M., Weigert, A., Ginà ¨s, P. (1994). Peripheral arterial vasodilatation: determinant of functional spectrum of cirrhosis. InSeminars in liver disease(Vol. 14, No. 1, pp. 14-22). Martin, P. Y., Ginà ¨s, P., Schrier, R. W. (1998). Nitric oxide as a mediator of hemodynamic abnormalities and sodium and water retention in cirrhosis.New England Journal of Medicine,339(8), 533-541. Angeli, P., Merkel, C. (2008). Pathogenesis and management of hepatorenal syndrome in patients with cirrhosis.Journal of hepatology,48, S93-S103.

Parts of Thesis

Parts of a Thesis (Descriptive Design) 1. Chapter 1 (The Problem: Rationale and Background) 1. 1 Statement of the Problem 1. 2 Hypotheses 1. 3 Theoretical/Conceptual Framework 1. 4 Significance of the Study 1. 5 Scope and Limitations of the Study 1. 6 Definition of Key Terms 1. 7 General Organization and Coverage of the Study 2. Chapter 2 (Review of Related Literature) 2. 1 Related Legal Bases 2. 2 Related Literature (Local and Foreign) 2. 3 Related Studies (Local and Foreign) . 4 Justification of the Present Study 3. Chapter 3 (Methodology) 3. 1 Research Design 3. 2 Determination of Sample Size 3. 3 Sampling Design and Technique 3. 4 The Subjects 3. 5 The Research Instrument 3. 6 Validation of the Research Instrument 3. 7 Data Gathering Procedure 3. 8 Data Processing Method 3. 9 Statistical Treatment 4. Chapter 4 (Results, Analysis and Interpretation) 5. Chapter 5 (Summary of Findings, Recommendations and Conclusions) 6. Bibliography 7. Appendix 8. Curriculum Vitae Parts of a Thesis (Experimental Design) 1. Chapter 1 (The Problem: Rationale and Background) 1. 1 Statement of the Problem 1. 2 Hypotheses 1. 3 Theoretical/Conceptual Framework 1. 4 Significance of the Study 1. 5 Scope and Limitations of the Study 1. 6 Definition of Key Terms 1. 7 General Organization and Coverage of the Study 2. Chapter 2 (Review of Related Literature) 2. 1 Review of Related Legal Bases 2. 2 Review of Related Literature (Local and Foreign) 2. Review of Related Studies (Local and Foreign) 2. 4 Justification of the Present Study 3. Chapter 3 (Materials and Methods) 3. 1 Research Method 3. 2 Materials 3. 3 Equipment/Apparatus and Utensils 3. 4 Procedure 3. 5 Training of Panelists 3. 6 Evaluation of the Results 3. 7 Statistical Treatment 4. Chapter 4 (Results and Discussion) 5. Chapter 5 (Summary of Findings, Conclusions and Recommendations) 6. References 7. Appendix 8. Curriculum Vitae

Essays on Literature Essay

1. How does societal condition affects in the past and present literary production? Literature is a mirror by which societal condition is reflected. This means that literary reproduction is often determined by the events that affect the lives of the people or the writer himself. For instance, if we are going to trace the evolution of Philippine Literature, we will be able to conjure up the ghost of the vanished centuries long before the coming of the Spaniards. During this period, literary production attained slow growth. We can generally infer that oral lore is the starting point of our literary heritage. Though, Alibata – the old Filipino alphabet is already known during this era, the production is very limited to writings on dried leaves, bamboo, or bark of a tree which aside from the fact that they were burned by the Spanish colonizer, they are often said to be perishable which could not last the test of time. Thus during this era, literature flourished through word of mouth. The slow growth of literary production prevailed not until the concerned literary geniuses are born and seriously compiled them as significant and immortal heritage. These, happened along with the introduction of papers and printing press where literary production gained stature and skyrocketed to a towering height. The industrialization of the society which was brought by the colonizers became an elixir of interest in writings. New types of Literature were produced such as, but not limited to, essays which commonly appeared in periodicals, novels such as Noli Me Tangere and the El Filibusterismo and other genre. In short, economic condition of the society affects literary production. It is evident in transformation from oral tradition, then to writings on perishable materials and eventually the introduction of ink, papers and printing press. Consequently, political conditions of the society can also be a determining factor for literary production. In the past centuries the content of the literature is influence by the church, writings were religious in tone. It shifted into nationalism and patriotism spearheaded by the propagandist. Then, with the coming of American colonizer, the idea of liberalism and democracy were introduced In the modern era, literary production attains even more awesome height with the establishment of factories of intellect – colleges and universities, where Filipino intellectual giants are continuously produced. They are the assets of Philippine literature. Thus, writings in different fields are unabatedly flourishing to portray the society. 2. What is the literary perspective in terms of time and subject of literary work? Literary perspectives in terms of time and subject can be further define as the focus or theme of a certain writing with respect to when the piece was written and how its time frame or the historical background affected the main concern of the literature. These are actually one of the critical approaches in the study of literature. It is a general notion that historical backgrounds of the society or the biographical background of the author influence the subject of a piece. It is essential to investigate and critically analyze the history for it will serve as the key to understand and evaluate the piece o literature. Much in the same way is the critical analysis of the traces of the life of the author for it has a significant effect on the theme structure and presentation of his writings. To clearly illustrate this notion let us consider the poem â€Å"When I see a Barong-Barong† by Maximo Ramos (1946). â€Å"When I see a Barong-Barong neighborhood In the heart of war-torn Manila† Here the word barong-barong significantly portrays the racial background of Ramos. It is a common symbol of a Filipino who still proudly standing after the Filipino-American War which he expressed on the second line â€Å"war-torn Manila†. It is certain that Ramos was able to portray in his poem the situation of the Filipinos during the period where they gained freedom after nearly a half thousands years of slavery under the colonizers. We can notice here how the time frame is noteworthy in each piece of literature. The subject may vary depending on the events that captured the emotion and intellect of the writer. This view of literary perspective is commonly known as Historical-Biographical Approach. 3. What make a writer in a certain literary period produce a literary piece As clearly stated by Kahayon and Zulueta, man’s thoughts and emotions that are coached in a beautiful language is literature. In other words, literature is a means of expressing the writer’s heart and mind. His feelings, aspirations, grieve, love, sentiments and others are best highlighted through literature. For instance, literary focus shifted from a religious tone toward patriotism and nationalism. This is known as the period of enlightenment. Distinct writers during the period like Jose Rizal, Andres Bonifacio, Apolinario Mabini, Emilio Jacinto, Jose Palma and others express their sentiments and aspirations for freedom through writings which eventually enrich the nationalistic behavior of our Filipino comrades who bravely fought against the 300-year-slavery under foreign conquerors. The barbaric Spanish occupation intensifies the strong will of the propagandist and revolutionaries to revolt against the dynamic force. Rizal’s â€Å"My Last Farewell† expresses his grief for his fatherland and his willingness to drench it with his own blood – his most admirable heroic deed – to revive its people and regain the freedom. Likewise Andress Bonifacio – the father of Filipino democracy wrote â€Å"Pag-Ibig Sa Tinubuang Lupa† which expresses his greatest love for our fatherland which paved the way for revolution. In short writers are able to write literary piece in a certain period as their response to his everyday efforts to live, to be happy in his environment and ultimately after laborious or bloody struggle for freedom and the happiness to reach his Devine Creator. Just like what Rizal said: â€Å"For I go where no slave before the oppressor bends Where faith can never kill, and God reigns o’er on high† 4. How does a literary product helps shape society? Give specific example. Literature is powerful. It has the ability to touch one’s life, transform the society from one condition to another and eventually shape the entire society. It can redefine culture and traditions and polish political situations. It can amazingly revive the forgotten centuries and immortalize people, places and events. The Filipino people, before the coming of the Spaniards were believed to be the servant of nature. They worship trees, stones, water, sun and anitos. Their religion is animalistic in nature. However, when the Spaniards set foot on the Philippine shore, the world’s sacred writings – the Holy Bible spread in the archipelago and educate our forefathers and consequently the modern generation. It redefines our belief, behavior, culture and traditions. It becomes a tool for the enlightenment of the society and brings order in every institution. Literature has the ability to polished political situation. Harriet Beecher Stowe of the US vividly convey the sad fate of slaves in his â€Å"Uncle Tom’s Cabin† which became the basis of democracy. He emphasized that black American should have equal rights with the whites. His masterpiece severely criticized the racial discrimination which in due course led to the recognition of the rights of the black American. In the Philippines, the writings of the propagandist and revolutionaries assuage the sufferings of the Filipinos. The Noli Me Tangere exposed the evils of the Spaniard and the fake and hungry-wolves-like Spanish friars. It heightens the nationalism. Finally, literature as a great ocean of thought that is piled from the vanished centuries immortalized the characters of Plato, Aristotle, St. Thomas Aquinas and other great Philosopher who molded the morality, virtue and ethical standard of the society. 5. How does a piece of literary product help you mold you life? Literature is an indispensable aspect of my life as a student of Teacher Education Program. This is a viable tool in facing the complexities of the challenges of Teaching. Through reading different literary works from around the world such as English and American, Afro-Asian and other famous literature I was able to indulge in the richness of our second language. It laid the foundation of strong human being which is vital as I enter the world of Teaching. It gives me a full grasp of why Teaching is the noblest profession. I appreciate my career to a great extent which more than words can express. Reading patiently from the works of famous writers of different generations enables me to experience life vicariously, thus widening the horizon in tracing the little rills of humankind which help me in my voyage to a great ocean of thought. I admire the writings of our Filipino comrade, for they instill great values of being a Filipino – a distinct race among the rest in the world. It might be corny to say but I am proud to express that through the writings of Rizal, Bonifacio, Santos, Palma and other Filipino writers – I am a Filipino. Most of all – what I love among the world’s masterpieces which I am struggling to understand with the guidance of the Devine Providence – The Holy Bible. This is the sacred writings which I can turn to in any moment of my life. The kind of literature that we read defines our character. They say: â€Å"Tell me who your friends and I will tell you who you are. † I say: â€Å"Tell me what you read and I will tell you who you are. †

Acts of Heroism Essay - 874 Words

What makes the acts of heroism different from the daily life of others? To people the act of heroism can be from their favorite sports player or an actor. But, to some they could be there family member. Each heroic act in the society is faced with great challenges but the hero never backs down. In addition, heroic acts have many different purposes in our society. The acts of heroism are considered as an inspiration to others and a reference but, it takes certain attribute such as courage and selflessness. Acts of heroism done by heroes demonstrates leadership and to make our society a better place. For instance, Mohandas K. Gandhi helped gain freedom for the colored without violence but giving speeches. This demonstrates that Gandhi†¦show more content†¦This quote also demonstrates that if you don’t break the rules then the community wouldn’t know about the injustice. The people who break the rules to get equal rights didn’t think about themselves, instead everyone else that was facing the same problem and Martin Luther King was one of them. It shows that they aren’t selfish and willing to stand up to be a leader. In conclusion, heroism contributes to our society in a positive way. The acts of heroism are never selfish or foolish but instead are fearless and valiant. Acts of heroism done by heroes are never afraid to die or to face whatever lies ahead. They aren’t the people that don’t stand above others. For example, in October Sky Homer did many things that most people wouldn’t have done which were to build rockets. He keeps on doing it even though most people had doubts that he would succeed. Homer was favored to be a coal miner like his father, but he doesn’t have any interest in it. Homer showed no fear to his principle and to his dad. The act was never selfish, it benefit a great number of people because he gave hope to his society by proving that anything is possible. Homer’s idea got his friends to become a person that they have never thought of. Furthermore, his actions weren’t foolish at all because he got in to a good college and later worked for NASA. What Homer accomplished during his life explain the idea of heroism and his act of heroism shows what heroism shouldn’t be. Moreover an exampleShow MoreRelatedHeroism Is An Act Of Bravery864 Words   |  4 PagesNoa Ben Artzi-Pelossof states, â€Å"Heroism is about taking an action which represents a breakthrough, and then assuming full responsibility for it, even if it’s a failure.† In other words, people shall take matters into their own hands. 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