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GI and Renal Exam 3 > 36 - Hepatobiliary System II > Flashcards

36 - Hepatobiliary System II Flashcards

1
Q

Describe alcoholic liver disease

A
  • Pathologic changes in patients with alcohol-induced liver disease
  • Develops in man who consumes > 80 g/day & woman > 40 g/day
  • There is no one type of person that develops alcoholism
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2
Q

Describe the types of liver disease progression

A

Hepatitis

  • Liver cell necrosis
  • Inflammation
  • Mallory bodies
  • Fatty change

Cirrhosis

  • Fibrosis
  • Hyperplastic nodules

Steatosis

  • Fatty change
  • Perivenular fibrosis
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3
Q

Describe the gross appearance of alcoholic hepatic steatosis

A

This alcoholic fatty liver (hepatic steatosis) is enlarged, soft, and yellow. It has a greasy texture.

Neutrophils will be present, fatty accumulation, lyced hepatocytes

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4
Q

Describe focal lytic necrosis and mallory bodies

A

Mallory bodies

  • Proteins that cannot be broken down
  • Not only in alcoholic liver disease, but is present here

Focal lytic necrosis

Pericellular fibrosis, Mallory bodies (black arrows) and small round red megamitochondria (red arrow) are typical findings in alcoholic steatohepatitis.

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5
Q

Alcoholic Hepatitis Longer Abuse - Chicken Wire Fibrosis

A
  • Stop eating
  • Only drinking
  • Malnutrition
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6
Q

What determines full blown alcoholic cirrhosis?

A

Nodules
- In alcoholic cirrhosis, nodules of regenerating hepatocytes consist of disordered cords of cells of irregular thickness.

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7
Q

Describe Alcoholic Steatohepatitis clinical presentation

A
  • Fever
  • Leukocytosis
  • Jaundice
  • Increase in AST - ALT 2 (still drinking)
  • Increased AP
  • Ultrasonography
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8
Q

What develops with alcoholic cirrhosis?

A
  • Severe portal hypertension
  • Ascites
  • Large veins

Can also effect brain, anemia, stocking glove neuropathy (nutritional aspect)

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9
Q

Describe the five year survival of patients who stop drinking

A

Five-year survival approaches 90% in abstainers who are free of jaundice, ascites, or hematemesis; it drops to 50% to 60% in those who continue to drink.

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10
Q

What are the proximate causes of death in end-stage alcoholics?

A
  • Hepatic coma
  • Massive GI hemorrhage
  • Infection
  • Hepatorenal syndrome following a bout of alcoholic hepatitis
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11
Q

What are the types of steatohepatitis?

A
  • Alcoholic steatohepatitis (ASH)

- Nonalcoholic steatohepatitis (NASH)

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12
Q

Describe the causes of Nonalcoholic steatohepatitis (NASH)

A

Insulin resistance/metabolic syndrome

  • Obesity
  • Diabetes
  • Hyperlipidemia

Drug hepatotoxicity

  • Tamoxifen
  • Nifedipine

Pregnancy

  • Small droplet fat
  • Very serious condition during pregnancy
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13
Q

Describe alcoholics who quit drinking and need a liver transplant

A
  • They go on the list if they stop drinking

- Sometimes just the stopping of drinking is enough to improve their condition enough to take them off the list

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14
Q

What are the three inborn errors of metabolism?

A
  • Hereditary hemochromatosis
  • Wilson disease
  • 1-antitrypsin deficiency
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15
Q

Describe hereditary hemochromatosis

A
  • Hereditary hemochromatosis is an inherited disorder that increases the amount of iron that the body absorbs from the gut.
  • Symptoms are caused by this excess iron being deposited in multiple organs of the body.
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16
Q

What causes hereditary hemochromatosis?

A

Many mutations in the body’s iron transport system can cause hemochromatosis; however, most cases are caused by mutations in the HFE gene

The treatment is giving blood - phlebotomy to get rid of excess iron

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17
Q

What tests results will you see in hereditary hemochromatosis?

A
  • High Serum Fe >300 mg/dL
  • High Transferrin saturation >2X
  • High Serum ferritin >2X
  • High Hepatic Fe index >2
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18
Q

Describe the transferrin and ferritin increases seen in hemochromatosis

A

If transferrin saturation and ferritin concentration are high, genetic testing for hemochromatosis is warranted.

Patients who are either homozygous for C282Y or heterozygous for C282Y and H63D have hereditary hemochromatosis.

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19
Q

Describe the trend in patients with hemochromatosis

A

There is an exponential increase in the levels of serum ferritin concentration

By age 30 it causes progressive tissue injury and by 40 we see cirrhosis with organ failure

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20
Q

What are all the complications of hemochromatosis?

A

Slide 57

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21
Q

Describe the histological cahnges in hemochromatosis

A

X

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22
Q

Describe WIlson disease

A
  • Wilson’s disease is a hereditary disease that causes the body to retain copper.
  • Patients have decreased ceruloplasmin and excessive deposition of copper.
  • The copper buildup leads to damage in the kidneys, brain, and eyes. If not treated, Wilson’s disease can cause severe brain damage, liver failure, and death.
  • Symptoms usually appear between the ages of 6 and 20 years, but can begin as late as age 40.
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23
Q

Describe the clinical appearance of Wilson disease

A

Children

  • Hepatitis
  • Acute/chronic/fulminant

Adults

  • Neurologic/psychiatric disease
  • Untreated: fatal
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24
Q

How do you diagnose Wilson disease?

A
  • Low serum ceruloplasmin (250 μg/g tissue)
  • Urinary copper (Levels above 100μg/24h – NL is 10-30 μg/24h)
  • Kaiser-Fleischer rings
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25
Q

What are Kaiser-Fleischer rings?

A

Brown rings around the eye

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26
Q

Describe cirrhosis seen in Wilson disease

A

x

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27
Q

WHat is the treatment for Wilson disease?

A

Chelating agents

28
Q

What is alpha 1 antitrypsin deficiency?

A
  • Autosomal recessive
  • Primary liver metabolic disease
  • Primary genetic liver disease in children
  • 2nd cause of liver transplantation in children
29
Q

Describe the clinical picture of alpha 1 antitrypsin deficiency

A
  • Neonatal hepatitis/cholestasis
  • Adults: chronic hepatitis /cirrhosis
  • Hepatocellular carcinoma
  • Liver transplantation
30
Q

Describe the diagnosis of alpha 1 antitrypsin deficiency

A
  • Low serum α1AT
  • Abnormal electrophoretic α1AT
  • Liver biopsy
31
Q

Describe the protein buildup in alpha 1 antitrypsin

A

X

32
Q

Describe liver cell adenoma

A
  • Young women
  • Oral contraceptives
  • Glycogen storage disease
  • May rupture in pregnancy
  • May harbor hepatocellular carcinoma
33
Q

Describe the treatment for liver cell adenoma

A
  • Remove the tumor
  • It is usually well-defined, so not that hard to remove
  • We don’t want it to rupture so we take them out
  • Usually benign
34
Q

Describe hepatocellular carcinoma

A
  • MUCH worse

- This one is malignant

35
Q

What are the risk factors for hepatocellular carcinoma?

A
  • Cirrhosis
  • Alcoholism
  • HBV, HCV
  • Hereditary hemochromatosis
  • α1AT deficiency
36
Q

Describe the clinical appearance of hepatocellular carcinoma

A
  • Painful hepatomegaly
  • Abdominal mass
  • Weight loss
  • Portal/hepatic vein thrombosis
  • Hemorrhagic ascites
  • Hepatic failure
  • Massive bleeding
37
Q

How do you diagnose hepatocellular carcinoma?

A
  • Ultrasound
  • Angiography
  • CT
  • MRI
  • Elevated AFP >1000
38
Q

Describe the formation of hepatocellular hepatocellular carcinoma

A
  • Differentiation

- Not going to test you on oncogenes

39
Q

Describe the tumor of a hepatocellular carcinoma

A
  • ## Large mass with smaller masses around it throughout the liver
40
Q

Describe cholangiocarcinoma

A

Malignant primary tumor of the bile duct epithelium

41
Q

What are the risk factors for cholangiocarcinoma?

A

Risk factors

  • Primary sclerosing cholangitis
  • Thorotrast
  • Liver flukes

Note: a thorotrast is a colloidal suspension of thorium dioxide that was used until the 1950s as an intravascular contrast agent.

42
Q

Describe the tumor of a cholangiocarcinoma

A

Slide 81

43
Q

Describe metastatic tumors that go to the liver

A
  • The most common malignant tumor of the liver
  • Common primary site: GI tract, breast, lung, pancreas, melanoma
  • Multiple, nodular
  • Hepatomegaly
  • Jaundice
  • High liver enzymes
44
Q

What are the three types of gall stones?

A

Cholelithaisis

  • Cholesterol stones
  • Pigmented stones
  • Mixed
45
Q

Describe cholesterol stones

A

Biliary hypersecretion of Cholesterol/supersaturation of bile with cholesterol

46
Q

Describe pigmented stones

A

Predominantly bilirubin calcium salts

47
Q

What are the four contributing factors for cholelithiasis?

A
  • supersaturation
  • gallbladder hypomotility
  • crystal nucleation
  • accretion within the gallbladder mucous layer
48
Q

What are the clinical features of cholelithiasis

A
  • 70 to 80% of gallstone patients remain asymptomatic throughout life
  • Symptoms include – spasmodic, colicky pain owing to obstruction of bile ducts by passing stones
  • Gallbladder obstruction causes right upper abdominal pain
  • Pain after fatty meal
49
Q

Describe the use of US and ERCP in the diagnosis of cholethiasis

A

Slide 89

50
Q

Describe the microscopic appearance of acute cholecystitis

A

Slide 90

51
Q

Describe chronic cholecystitis

A

Both gross and microscopic morphology is highly variable!
Usually GB is somewhat thickened and fibrotic but it may be normal in thickness although it is usually less pliable.

Usual Microscopic Appearance

  • Collagen in wall (scarring)
  • Lymphocytes
  • Plasma cells
  • Macrophages

The amount of inflammation varies from a heavy infiltration to just a few inflammatory cells.

52
Q

Describe the appearance of chronic cholecystitis

A

Slide 92

53
Q

Describe carcinomas of the gallbladder

A
  • Fifth most common cancer of the digestive tract
  • Slightly more common in women, presents in patients in their sixties
  • Gallstones coexist in 60 to 90% of patients
  • Most are adenocarcinomas, rarely squamous cell carcinoma
  • Tumors are usually unresectable when discovered
54
Q

Describe the clinical features of a carcinoma of the gall bladder

A
  • Clinical features: Symptoms are insidious and indistinguishable from those caused by cholelithiasis; prognosis is poor

If the gall bladder becomes porcalinized (calcified) it needs to be removed

55
Q

What are the types of pancreatitis

A

Group of disorders characterized by inflammation of pancreas

  • Acue pancreatitis
  • Chronic pancreatitis
56
Q

What are the etiologies of acute pancreatitis?

A

Metabolic
- Alcoholism, hypercalcemia

Mechanical
- Gallstones, Trauma

Vascula
- Shock, Atheroembolism

Infectious
- Mumps, Coxasackievirus, Mycoplasma pneumoniae

Drugs

57
Q

What is the clinical course of acute pancreatitis?

A
  • Acute epigastric pain with radiation to the back
  • Shock
  • Mortality rate high, about 10 to 15%
  • Full blown acute pancreatitis is a medical emergency
58
Q

Describe the laboratory findings in acute pancreatitis

A
  • Elevation of serum amylase during first 24 hrs
  • Rising serum lipase levels within 72 to 96 hrs (more specific)
  • Hypocalcemia may result from precipitation of calcium soaps in fat necrosis—poor prognosis
  • Radiographic images: enlarged inflamed pancreas——pancreatic pseudocyst
59
Q

Describe the gross and microscopic appearance of acute pancreatitis

A

Slide 99

  • Dark red to black hemorrhage
  • Chalky white necrosis of interstitial and peripancreatic fat
60
Q

Describe chronic pancreatitis

A

Progressive inflammatory disease of the pancreas

Characterized by the clinical triad of:

  • diabetes
  • steatorrhea
  • calcifications on radiographs
61
Q

Describe the morphological changes seen in chronic pancreatitis

A

Along with PERMANENT impairment of function and IRREVERSIBLE morphologic changes

Causes

  • most common cause = alcohol ingestion (70% of cases)
  • next most common cause = idiopathic
  • n.b. gallstone disease causes
62
Q

Describe the gross and microscopic appearance of chronic pancreatitis

A

Slide 104

63
Q

Give a summary of acute and chronic pancreatitis

A

Slide 105

64
Q

Describe carcinoma of the pancreas

A
  • 60% arise in the head; 10% in the body; and 10% in the tail; in 20% the tumor diffusely involves the entire gland
  • All are adenocarcinomas arising from ductal epithelium
  • Some may secrete mucin and may have abundant fibrous stroma

VERY AGGRESSIVE - very low survival - once you find it, the patient usually already have mets

65
Q

What are the complications of pancreatic carcinoma?

A

Primary effects

  • Mets to lung, liver peritoneum
  • Pancreatic carcinoma
  • Abdominal pain (perineural lymphatic invasion)

Secondary effects

  • Weight loss
  • Obstructive jaundice
  • Courvoisier gallbladder
  • Migratory thrombophlebitis

GI and Renal Exam 3 (15 decks)

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