Accessory Organs Flashcards
Cholestasis
Reduction or blocked flow of bile
Cholestasis: Consequences
• Since bile aids in the absorption of nutrients, if blocked, can lead to
malabsorption and nutrition deficiencies particularly fat soluble vitamins: A, D, E, K
Cholestasis: Diagnostic Considerations
• Diagnose cholestasis on symptoms, signs and labs
. • But the CAUSE of cholestasis must be identified as well as any CONSEQUENCES.
Cholestasis is seen in:
Both liver and gall bladder disease
Cholestasis: Signs/Symptoms
• Jaundice
‘• Pruritis
• Stool: pale, foul
• Urine: dark
• May have Sx/Si related to the cause / nutritional issues
• Nausea or vomiting
• Inability to digest certain foods
• RUQ pain
• Fatigue
Cholestasis: Labs
– Bilirubin: increased
– ALP: increased
– AST/ ALT: increases
Cholestasis: Treatment
• Treatment:
– Treat underlying cause
– If chronic, consider fat soluble vitamin deficiencies: ADEK
Protecting the Liver
• Choose a healthy diet.
• Maintain a healthy weight.
• Drink alcohol in moderation, if at all.
• Limit to < one drink a day (women) and < two drinks a day (men)
• Get vaccinated.
• Use medications wisely.
• Avoid contact with blood and body fluids.
• Watch what gets on your skin.
• Take care with aerosol sprays.
• Use ventilation or wear a mask when using toxic chemicals
• Avoid risky behavior: Sharing needles, unprotected sex, safe tattoos or body piercings
Fatty Liver Disease
• Excessive accumulation of lipids in hepatocytes
Fatty Liver Disease: Acute
– Acute: pregnancy (AFLP)
Fatty Liver Disease: Chronic
– Chronic: metabolic (NAFLD), alcohol (ALD)
Fatty Liver Disease: Most Common Type
NAFLD
Chronic Fatty Liver Disease: Diagnosing
– May feel tired or have mild abdominal discomfort but otherwise have no symptoms.
– May first be discovered incidentally with routine liver function test
– On exam may have hepatomegaly but not tender (1/3)
NAFLD vs. ALD: Associations, Alcohol, Progressions
Associations
-NAFLD: Associated with Metabolic issues
-ALD: Associated with Alcohol Liver Disease
Alcohol
-NAFLD: No alcohol use
-ADL: Excessive Alcohol Use
Progressions
-NAFLD: NASH, Cirrhosis
-ALD: Alcoholic hapatitis, cirrhosis
Chronic Fatty Liver: Signs/Symptoms
-Mostly Asymptomatic
-IF Symptomatic: Fatigue, malaise, dull RUQ pain
-Exam: Hepatosplenomegaly (33%)
Chronic Fatty Liver: Diagnosing
• Common clinical presentation:
“healthy” pt. (few to no sx) with
abnormal liver tests
• Most often diagnosed incidentally
on routine labs
• Confirm with CT (or MRI) and liver
biopsy
• Need to identify the cause:
– Metabolic: labs
– Alcoholic: history/ CAGE
Chronic Fatty Liver: Treatment (Medical)
• Address cause/ risk factors:
– Lose weight
– Control cholesterol
– Control DM
– Stop drinking
• Protect liver!
Chronic Fatty Liver: Treatment (Lifestyle)
• Healthy diet
• Maintain weight
• Exercise
Hepatitis
Swelling and inflammation of the liver characterized by diffuse or patchy necrosis
Hepatitis: Causes
Viruses, alcohol, drugs, metabolic
Hepatitis: Complications
• Varices, portal hypertension protect against risk factors
Hepatitis: Prognosis
– Can be self limited
– Or may lead to damage: cirrhosis, liver failure or cancer
Hepatitis: History
• Symptoms may be non specific
• In chronic conditions may have even less symptoms
• Important to review for risk factors related to causes
Hepatitis: Exam
• May not see abnormalities until late stages or when it progresses to other diseases
• May see signs of complications
Hepatitis: Diagnostics
Labs: viral, liver function, autoimmune
Diagnostics: US, biopsy
What acute hepatitis conditions can progress to chronic?
– Hepatitis B, C, D
Acute Hepatitis: Causes
• Infection: Viral A,B,C,D,E
-Toxin: Alcohol, Drugs/Herbs
-Immune: Autoimmune Hepatitis, Primary biliary cholangitis, acute episodes primary sclerosing cholangitis
-Metabolic: NASH
Acute Hepatitis: Signs/Symptoms (Early)
Early s/s (prodrome phase):
• Anorexia
• Malaise
• Nausea or vomiting
• Fever
• RUQ pain/discomfort
• Aches such as arthralgia
Acute Hepatitis: Signs/Symptoms (Icteric Phase)
• S/S of cholestasis
– Dark urine
– Jaundice (peaks 1-2 weeks)
• Diarrhea
• Headache
Acute Hepatitis: Exam (Icteric Phase)
• Jaundice
• Hepatomegaly with tenderness (edges remains soft and smooth)
• Splenomegaly (mild sx) (15-50%
• Lymphadenopathy
Acute Hepatitis: Diagnostics
• Liver function tests
(AST and ALT elevated out of proportion to alkaline phosphatase, usually with hyperbilirubinemia)
• Viral serologic testing
Chronic Hepatitis: More Common Causes
– NAFLD
– Hepatitis B and C
– Alcoholic hepatitis
– Autoimmune hepatitis
Chronic Hepatitis
• Chronic inflammation of the liver lasting over 6 months
Chronic Hepatitis: Diagnostic Challenges
– Can be insidious
– No history of other conditions such as acute hepatitis, NALFD
– Few to no symptoms (or symptoms are non specific)
– May not detect until advanced stage of cirrhosis
Chronic Hepatitis: First Indications
Abnormal liver tests
Chronic Hepatitis: Complications
-Thyroid, arthropathy, peripheral neuropathy
-Malabsorption related issues
-Other chronic liver disorders (primary biliary cholangitis)
NASH: Cause
Metabolic: Obesity, insulin, resistance, lipid issues
NASH: How to identify cause
• Rule in metabolic issues
• 3rd MC cause of liver disease
ALD: Cause, How to identify cause, Progression
-Cause: Alcohol
-How to identify cause: Rule in drinking
-Progression: May have progressed from fatty liver, may move to cirrhosis
Chronic Hepatitis: Viral
-Cause: Hepatitis Virus B,C,D
-How to identify cause: Viral labs, past history of acute hepatitis
-Progression: Progressed from acute viral condition, about 20% develop into cirrhosis
Chronic Hepatitis: Autoimmune
-Cause: Unknown
-Progression: May progress to cirrhosis
Chronic Hepatitis: Symptoms
-May be asymptomatic
-Non-specific type symptoms: Malaise, anorexia, fatigue, low-grade fever, non-specific upper abdominal discomfort
*jaunncide can be present but rare
-May have cholestasis: Pruritis, pale stools, steatorrhea
Chronic Hepatitis: Exam
– Hepatomegaly-75%
– Splenomegaly
Chronic Hepatitis: Diagnostics
-Liver function tests
-Biopsy (to stage)
-Additional testing to identify cause: Viral serology, autoantibodies, etc.
Chronic Hepatitis: Lifestyle (Treatment)
-Rest
-Hydrate
-Balanced, nutritious diet
-Protect liver
-Avoid Alcohol
Chronic Hepatitis (Autoimmune): Epidemiology
– Female: 70-80% – Ages: 10-20 yo and 45-70 yo
(ages slightly vary in literature)
Chronic Hepatitis (Autoimmune): Cause
Unknown
Chronic Hepatitis (Autoimmune): Risk Factors
Risk factors:
– Female
– Hereditary
– Certain viral infections
– Associated with other autoimmune diseases*
Chronic Hepatitis (Autoimmune): Complications
-Anemia
-Acne
-Amenorrhea
-Hemolytic portal hypertension, esophageal varices
Chronic Hepatitis (Autoimmune): Progression
– May lead to cirrhosis, liver failure and cancer
Chronic Hepatitis (Autoimmune): Associated Conditions
• Celiac sprue
• Ulcerative colitis
• Primary biliary cholangitis
• Primary sclerosing cholangitis
• Nephritis
• Graves disease
• Type 1 diabetes
• Hashimoto’s disease
• RA
Fibrosis & Cirrhosis
Cirrhosis
• Progressive state: fibrosis/ scarring in liver becomes extensive
– Affects function (decreases)
– Often end stage of other diseases
– If not diagnosed early, more scar tissue forms
– Advanced stage is life threatening, leading to liver failure and liver cancer
Leading Cause of Death Worldwide
Cirrhosis
Cirrhosis: Progression Rate
• Progression rate varies from fibrosis to cirrhosis
Cirrhosis: Prognosis
• Prognosis:
– Irreversible
– Treatment is supportive
Cirrhosis: Causes (3)
-Infections
-Immune
-Cancers
-Other
Cirrhosis: Infections
-Viruses
-MC: Hepatitis A,B,C
Cirrhosis: Immune (3)
-Autoimmune Hepatitis
-Primary billary cholangitis
-Primary sclerosing cholangitis
Cirrhosis: Cancers
-Liver cell/adenoma
Cirrhosis: Other Causes
-Chronic alcohol abuse
-NALFD
-Certain medications and herbal compounds
Cirrhosis: Difficulties w/ diagnosing
• Sx may not develop for years
• 1/3 never develop symptoms
• Initial symptoms are vague and nonspecific
• Other symptoms related to complications
Cirrhosis: Complications
– Portal hypertension, GI bleeds (esophageal, gastric, or rectal varices,pulmonary hypertension), kidney injury
– Hormone imbalance, nutritional deficiencies, anemias, cholestasis, osteoporosis
Cirrhosis: Initial Symptoms
• General fatigue
• Malaise
• Anorexia
• Weakness
• Weight loss
Cirrhosis: Later Symptoms/Complications
• Anemias
• Jaundice
• Confusion
• Pruritus
• Peripheral neuropathy
• Axillary hair loss
• Dyspnea
• Portal hypertension
• Liver failure
• Ascites
• Acute kidney
Cirrhosis: Exam
-Liver tender, palpable & firm, blunt edge typically
Other signs related to complications
– Jaundice, petechiae, spider nevi, splenomegaly
– Ascites, caput medusa
– Clubbing, glossitis
– Muscle wasting
Cirrhosis: Diagnostics
-Liver function tests
-Determine cause: test for viruses, autoimmunity
-Anemia, CBC
-Biopsy: To determine severity, extent and cause
Cirrhosis: Lifestyle (Treatment)
-Stop drinking
-Supplements: Address nutritional deficiencies
Alcoholic Liver Disease: Progression
-Fatty Liver Disease: Fat on liver (Over 90%)
-Alcoholic Hepatitis: Inflammation/necrosis (10-35%)
-Alcoholic cirrhosis: Advanced fibrotic state (10-20%)
Alcohol Liver Disease: Risk Factors (5)
– Quantity/ duration of alcohol (usually over 8 years)
– Gender, genetics, metabolic traits
– Concomitant hepatitis C & iron accumulation
– Obesity
– Women: more likely to suffer liver damage
Alcoholic Liver Disease: Fatty Liver (Initial Stage)*
• Often reversible
• May / may not progress to other conditions
• Sxmost apparent 30’s/40’s
• Severe problems appear a decade later
• Virtually all heavy drinkers develop
Alcoholic Liver Disease: Alcoholic Hepatitis*
• Progression from steatosis
• Appx. 35% alcoholic hepatitis
• Cirrhosis may or may not be present
• 30% develop cirrhosis (w/in 6 months)
• Most likely to occur in people who drink heavily for many years
• But not all heavy drinkers develop alcoholic hepatitis
• May occur even in those who drink moderately
Alcoholic Liver Disease: Alcoholic cirrhosis*
• 10-20% develop cirrhoris cirrhosis
• Advance stage-can cause liver failure
• Alcoholic hepatitis may or may not co-exist
Liver Cancer: Forms
• Many forms of liver cancer
– Many are metastases from other tumors
(colon, lung, renal, breast, ovarian, prostate)
Liver Cancer: Symptoms
– Jaundice, abdominal pain, weight loss,
fever, hepatomegaly, back pain
Diagnosis of Liver Cancer is found:
– Incidentally found through imaging or symptomatically
Liver Cancer: Treatment
– Surgery, chemotherapy, radiation, etc
– Not all forms are curable
Gall Bladder Disease: Risk Factors
– “The 5 F’s” (old saying)
• Female
• Family history
• “Fat” (obesity)
• Fertile (pregnancy)
• Forty (40) and over
Gall Bladder Disease: Signs/Symptoms
• RUQ pain
• Right shoulder or back pain
• Indigestion
• Nausea or vomiting
• Sx of cholestasis:
• Urinary changes: dark
• Clay colored stool
Gall Bladder Disease: Exam/Diagnostics
• RUQ tenderness
• Jaundice if blocked
(sx of cholestasis)
Cholelithiasis
• Presence of one or more calculi (gallstones) in gallbladder
– Most asymptomatic
Cholelithiasis: Most common occurrence
-Incidence increases w/ age
-highest in 5th & 6th decade
Cholelithiasis: Predisposing factors
The 5 Fs
-Female
-Fertile (pregnancy)
-Fat (obesity)
-Forties (40+)
-Flatuent
-Family History (May have DM, HRT)
Cholelithiasis: Symptoms
-Post prandial upper abdominal pain: often acute onset
-May radiate to right subscapular area or epigastrum
-Nausea, vomiting, dyspepsia, fatty food intolerance
Cholelithiasis: Exam
• Mild tenderness w/ palpation but no guarding or rebound
Cholelithiasis: Complications
• If obstructs gall bladder:can cause cholecystitis (inflammation of the GB)
• If stone moves into duct: choledocholithiasis
• Once in duct, if it causes obstruction of duct: cholangitis
• Once in duct, if it blocks ampulla de Vater: Pancreatitis
Choledocholithiasis
• Gallstones in the common bile duct
Choledocholithiasis: Complications
– Can cause obstruction (partial, complete)
– If infected, can become cholangitis
– if it blocks the ampulla of Vater, can cause pancreatitis
Cholecystitis
• Acute or chronic inflammation of the gallbladder
– Usually from gallstone blocking the cystic duct
– May also be acalculous
Cholecystitis: Complications
Infections, perforation, peritonitis, pancreatitis
Cholecystitis: Treatment
Gallbladder is often removed
Acute Cholecystitis
• Acute inflammation of the gallbladder
– Generally secondary to gallstone obstruction in >95%
When is Acute Cholecystitis most common?
• Most common: females in 5th & 6th decade
Acute Cholecystitis: Most have had prior attacks of
Biliary colic
Pain with cholecystititis is:
More severe & lasts longer
Acute Cholecystitis usually subsides & resolves
• Subsides in 2-3 days & resolves within 1 week in 85% of
patients
Acute Cholecystitis: Signs & Symptoms
• Intermittent –progress to constant
– More severe and longer than the biliary colic with gall stones
• RUQ pain
• May radiate to infrascapular
region or back
• Nausea & vomiting (>70%)
• Fever (33%)
• Jaundice (25-50%)
• Ingestion of large, fatty meal
before onset?
Acute Cholecystitis: Exam
-Murphy’s Inspiration Sign (+)
Acute Cholecystitis: Diagnostics
-US to diagnose
-Liver function tests, CBC
Chronic Cholecystitis
Chronic Cholecystitis
• Long standing gallbladder inflammation
– Always due to gallstones
– Prior episodes of cholecystitis
– Long term can begin to become fibrotic
– Porcelain gallbladder: extensive calcification of fibrosis
Chronic Cholecystitis: Symptoms
Recurrent biliary colic
– No fever (fever suggests acute state)
Chronic Cholecystitis: Treament
Laparoscopic cholecystectomy (remove the gall bladder)
Cholangitis
• Inflammation and/or infection of the hepatic & common bile ducts
– Associated with common bile duct obstruction
– Obstruction causes rapid proliferation of bacteria
– Other causes: biliary tract stenosis, tumor, parasites
Cholangitis: Peak Incidence
7th decade: unusual < 50 yo
Cholangitis: Complications
Pancreatitis
Cholangitis: Development
70-90% of cases:
• Gallstone partially blocks duct
• Bacteria from duodenum ascends into gall bladder •
-Infection with inflammation sets in
10-30% of cases
• Blockage caused by strictures, tumors, etc
• Still allows bacteria to ascend & cause infection
Cholangitis: Development
70-90% of cases:
• Gallstone partially blocks duct
• Bacteria from duodenum ascends into gall bladder • Infection with inflammation sets in
10-30% of cases
• Blockage caused by strictures, tumors, etc
• Still allows bacteria to ascend & cause infection
Cholangitis: Signs & Symptoms
• Acute onset
• Charcot’s triad: (mc sx)
– RUQ pain
– Jaundice
– Fever
• Dark colored urine
• May have other symptoms if there are complications
Cholangitis: Exam
– Murphy’s is not positive
Cholangitis: Diagnostics (4)
– Labs: WBC ,ALP & bilirubin
– Ultrasound
Cholangitis has a ___% mortality rate
50%
Primary Biliary Cholangitis (PBC)
• Autoimmune progressive destruction of intrahepatic (liver) bile ducts
PBC leads to: (3)
– Leads to cholestasis, cirrhosis, liver failure
PBC: Etiology
• 95% of patients are female age 35-70
– Genetic predisposition prevalent
• Up to 84% of pts have at least one other autoimmunity:
– Sjogren’s syndrome, RA, Raynaud’s phenomenon, scleroderma, thyroiditis
PBC: Development of Sx
• Sx may develop at any stage: 50% have no sx, other sx may have for months/ years
PBC: Signs & Symptoms
• 50% of pts have no sx
• Initial sx tend to be:
– Fatigue & pruritus (50%)
– Dry mouth / eyes
Other possible sx:
• RUQ pain (10%)
• Musculoskeletal
complaints (up to 70% )
• Peripheral neuropathy
– Sx related to other
autoimmune disorders
PBC:Exam
-Non-Tender hepatomegaly (25%)
-Splenomegaly (15%)
-Jaundice (10%)
PBC:Diagnostics (4)
• Diagnostics:
– Liver function tests
– AMA (elevated in 95%)
– US, liver biopsy
PBC: Treatment
• No specific treatment
– Depends on status of pt
• Focus on management of complications
• Avoid alcohol & hepatotoxic drugs
• Osteoporosis, vitamin A, K, E deficiency common
Primary Sclerosing Cholangitis
• Autoimmune disease: Progressive inflammation and scarring of bile ducts
– Affects both intrahepatic and extrahepatic ducts
– Bile duct blockage causes bile to accumulate in liver, damaging liver and causing fibrosis/cirrhosis
Primary Sclerosing Cholangitis: Etiology
• 2:1 male to female starting around 20-
-More than 80% have ulcerative colitis
Primary Sclerosing Cholangitis: Complications
– Malabsorption issues
– Leads to cirrhosis, liver failure & liver cancer
Primary Sclerosing Cholangitis: Treatment
• Tx: liver transplant
– Supportive care: fat soluble vitamins A,D, E, K
Primary Sclerosing Cholangitis: Signs/Symptoms
• Fatigue
• Severe jaundice
• Intense pruritis
• Dark urine
• Malabsorption
• Steatorrhea
• Cholangitis (bile duct infection)(Charcot’s triad)
• Hepatomegaly
• Portal hypertension
Primary Sclerosing Cholangitis: Diagnostics
• Endoscopic (ERCP)
Pancreatitis
• Inflammation of the pancreas
• Can be acute or chronic
– Acute: can be life threatening
– Chronic: often result of fibrosis
Pancreatitis: Causes (2)
• Causes:
– Most common condition: gall stones
– Alcohol abuse
– Other
Pancreatitis: Pathology
• Pathology: conditions cause the release of activated pancreatic enzymes
– Pancreatitis is a secondary effect
Acute Pancreatitis
• Inflammation of the pancreas
• Sudden onset
• Can be life threatening…EMERGENCY
Acute Pancreatitis: Causes (2)
• Most common (80%): gallstones and alcohol abuse
• Other acute causes
Acute Pancreatitis: Diagnosis
– Diagnosis based on clinical presentation and labs
• Specifically amylase and lipase
Acute pain that is intense radiating into the back and boring: Only 2 DDxs
AAA and Pancreatitis
Appencitis is a common ddx for:
Meckel’s Diverticulum
Acute pancreatitis: Symptoms
• Pain
– Sudden onset
– Steady pain, peaking within 10-30 minutes
– Epigastric region
– May radiate to back (50%)
• Fever
• Shock and confusion
Acute Pancreatitis: Differential Diagnosis
Dissecting anuerysm
Acute Pancreatitis: Exam
• Tachycardia
• Abdominal guarding
• Distention
• Hypoactive bowel sounds
• Palpable abdominal mass with tenderness
Acute Pancreatitis: Diagnostics (4)
• Amylase & lipase
– Elevated first day
– Return to normal in 3-7
-WBCs elevated
• CT , endoscopy
• Ultrasound if gallstones suspected
Chronic Pancreatitis
• Persistent inflammation of pancreas
– Permanent structural damage
– Decline in exocrine & endocrine function
Chronic Pancreatitis: Causes
• Causes (U.S.):
– Alcohol (<50%)* Change to 50%
– Idiopathic (15-25%)
– Other: autoimmune, hereditary, stenosis
Chronic Pancreatitis: Development
• Development:
– Initial symptoms: recurrent pain
– Later complications may develop: malabsorption, DM
Chronic Pancreatitis: Diagnosing
• Diagnosing can be difficult
• Based on clinical suspicion as labs can often be normal
• Imaging can confirm: CT
• May see late pancreatic calcification on x-ray (30%)
• Must exclude pancreatic cancer as source of pain
Chronic Pancreatitis: Symptoms
• Pain
– Recurrent
– Severe-may last hours or several days
– Epigastric & LUQ pain
– May radiate to back
• Weight loss
• May have other symptoms related to malabsorption or glucose intolerance
Chronic Pancreatitis: Diagnostics
• Amylase and lipase
– Often normal
– Late stages may be abnormal
• Other labs may be
abnormal due to malabsorption/ DM
Chronic Pancreatitis: Treatment (Medical)
• Frequent, small volume low fat meals
• Fasting during episodes
Chronic Pancreatitis: Treatment (Lifestyle)
• Avoid alcohol
• Pancreatic enzymes
Pancreatic Cancer is considered a:
• “Silent killer”: early stages nonsymptomatic
• 2010: 43,000 diagnosed
– Poor prognosis: 38,000 died
– Fewer than 5% survive after 5 years
Appendicitis
• Acute inflammation of appendix
Appendicitis: Epidemiology
– Occurs in 5-10% of population
– Most commonly between 10-30 years old
Appendicitis is considered a:
• Emergency ..can rupture
Appendicitis: Classic Symptoms
• Pain
– Initially epigastric or
periumbilical –Localizes to RLQ within 12-18 hrs
– May also have flank pain
• Nausea, vomiting, anorexia
• Low grade fever
• Rosvings, psoas sign, obturator
sign, McBurneys, sign
Rosvings Sign
Rebound test: palpate LLQ with pain referral to RLQ
Psoas Sign
Pain with right thigh extension
Obturator Sign
Pain with internal rotation of flexed right thigh
Obturator Sign
Pain with internal rotation of flexed right thigh
McBurney’s Sign
Point of maximal tenderness in RLQ …1/3 in from ASIS
Dunphy Sign
RLQ pain with coughing (nice to know)
Markle Sign
Heel drop causes pain
Appendicitis: Diagnostics
• Primarily diagnosis is clinical and requires immediate referral
Appendicits: Treatment
• Urgent surgery
