E2 326 - Liver - Gallbladder Flashcards
What is the best question for a Hep A virus diagnostic question?
Travelled out of the Country?
PT is diagnosed with cholelithiasis (Gall stones), How was it formed?
Bile Stasis do to concentration of gallbladder material
Early Manfistation of Cirrhosis?
Either Asymptomatic or
- May have GI changes (N/V)
- Anorexia
- Liver is felt with Palpation
- Weightloss
Later Manfistation of Cirrhosis?
Bleeding
Why do we take lactulose for Cirrhosis?
To collect Ammonia from the gut & poop it out.
Primary cause of bleeding after the bile duct has been blocked because of Cholelithiasis (gallstones)
Vit K isn’t absorbed (Fat Soluble Vit that the liver needs to make clotting factor development)
Cause of bleeding for esophageal with a PT in end-stage cirrhosis?
Portal HTN causing weakening/distended veins (varices)
Findings for Chronic Pancreatitis
Abdominal Mass
Leukocytosis
High Fever
Pain description for Acute Pancreatitis?
Pain that radiates to the back and/or guarding of the abdomen
Cell that removes toxins & waste from the liver?
Kupffer Cells
The pathophysiologic basis of organ destruction in acute pancreatitis
Pancreatitis occurs when the enzymes produced by the pancreas cannot enter the duodenum & begin to digest the tissue of the pancreas.
Cholelithiasis Risk Factor
(Fair Fat & 40)
Obesity
Female
Middle age
Oral Contraception
Rapid weight loss
Native America
Genetic
Other gastric issues
Pt has stones in the gallbladder but hasn’t moved S/S
Typically asymptotic
What is Biliary Colic
Pain from gallbladder 30 minutes after eating fatty foods (Cholelithiasis)
Obstructed Bile Flow S/S -(7) (Cholelithiasis)
- Jaundice (Bile block)
- Dark Amber Pee & foamy if shaken (Bilirubin in pee)
- Clay Stool (No Bilirubin -> Urobilinogen in small Inte.)
- Steatorrhea (No fat breakdown stool fat)
- Pruritus
- Can’t take eating Fatty Meals
- Bleeding bc of no Vit K breakdown & Absorption
Cholecystitis
Acute or Chronic inflamed/ distention of the gallbladder
- Caused by lodged gallstone in the cystic duct
Pain similar to biliary colic
Cholecystitis pressure against the wall of the gallbladder can cause what 3 things?
- Ischemia
- Necrosis
- Perforation
(4) S/s more for Cholecystitis than Cholelithiasis
Fever
Leukocytosis
Rebound Tenderness
Guarding
Labs for Cholecystitis
Increased Bilirubin & Alk Phos
How to treat Cholecystitis
Treat the S/s
- Analgesic - Ketorolac (Pain)
- Antiemetics - N/v
- Antichol - stop spams/decrease secretions from gallbladder
Bile acids - Dissolve stones
If a PT can’t have surgery what is treatment for Cholecystitis?
Bile Acids to dissolve stones
Acute Pancreatitis
Usually mild but can develop into severe 20%x
- Caused by obstruction of outflow pancreatic enzymes due to gallstones, alcohol, drugs, or viral
- Autodigestion of the pancreatic by its enzymes
Pancreatic Enzymes (Trypsin) can cause:
Edema
Necrosis
Hemorrhage
Pancreatic Enzymes (Elastase) can cause:
Hemorrhage
Pancreatic Enzymes (Phospholipase A) can cause:
Fat Necrosis
Pancreatic Enzymes (Kallikrein) can cause:
Edema
Vascular Permeability
Muscle Contraction
(Shock)
Pancreatic Enzymes (Lipase) can cause:
Fat Necrosis
Acute Pancreatitis Manifest:
Pain - Severe
Timing - Sudden
Tenderness and Guarding
Acute Pancreatitis S/s
- N/V
- Abdominal Distention
- Hypoactive BS
- Fever
- Hypoten, tachycardia
- Jaundice
Lab for Acute Pancreatitis
- Glucose
- Increased Amylase
- Increased Lipase
- Increased WBC
Severe S/s of Acute Pancreatitis
- Abdomen Discolored (Blue or Green-yellow/brown)
(Ecchymoses - Rare) - Flanks (Grey Turner’s) - Your Turning the Pt grey Nurse Flanks.
- Periumbiical (Cullen’s Sign) Vampires don’t have belly buttons
What are Complications of Acute Pancreatitis
- Pseudocyst
- Abscess
- Breathing issues from Pain
-Pleural effusion bc of permeable veins - Hypotension to Shock
- Hypocalcemia Tentany
What is Pseudocyst
Fluid-filled sack outside of the pancreas.
(Acute Pancreatitis)
Pseudocyst fluid is?
Necrotic (Dead) Product & Secretions
(Acute Pancreatitis)
Can Pseudocyst be a palpable Epigastric Mass?
Yes it can be
(Acute Pancreatitis)
If the the pseudocyst perforates what can happen?
It can become peritonitis (Dangerous - May need Surgery)
(Acute Pancreatitis)
What is a Pancreatic Abscess?
A Large fluid-fill cavity Inside the Pancreas
(Acute Pancreatitis)
What is Pancreatic Abscess fluid made of?
Necrosis of the Pancreas
(Acute Pancreatitis)
what can Pancreatic Abscess lead to?
Infection or perforation
(Acute Pancreatitis)
S/s of Pancreatic Abscess?
It can look like Pancreatitis
- Abdominal Mass
- High Fever
- Leukocytosis
(Acute Pancreatitis)
What is Chronic Pancreatitis
Progressive Fibrotic Disease of the Pancreas
- Toxic Metabolites cause inflamed cytokine & help destroy the islet of Langerhans & damage of acinar cells
What is the primary cause of Chronic Pancreatitis?
Alcohol most common
Can be:
- Genetic
- Smoking
- Gallstone
Two Major Signs of Chronic Pancreatitis?
Pain & Weight loss
Chronic Pancreatitis can it cause?
Diabetes & Fat Absorption issues
What is the main drug for Chronic Pancreatitis?
Pancrelipase to help replace pancreatic enzyme
If a PT has Chronic Pancreatitis, what must they do every time they eat?
Take their Pancrelipase (Yes Snacks)
Liver Facts
- Largest organ in the body
- 3 pounds
- 5-7% of CO
- RUQ
- Left & Right Lobes
-Central Vein - Can regenerate some
Liver Function (Metabolism & Storage)
Breakdown of: Fat, Cho, Proteins, vit & minerals
Breakdown & use of Drugs
Liver Function (Blood Volume Reservoir)
Distend/ Compresses to alter the Circulation of blood
Liver Function (Blood Filter)
Helps Purify blood with Kupffer Cells to remove waste
Liver Function (Clotting Factor)
Creation of Prothrombin & Fibrinogen
Why do we care for the liver function?
Because it can affect all functions
- Breakdown of Food
- Clotting
- Blood filtration
- Circulation
Where does the liver receive blood via the Portal circulation?
To the liver from the Upper and lower GI, Spleen, and Pancreas via the portal vein and sent to the lobes.
For drugs think “First pass Effect”
Liver Function Test (Labs Trends)
Increase Enzymes
* ALT
* AST
*Alk Phos
- Increased Bilirubin
- Increased Serum Ammonia
- Decreased Serum Protein
- Decreased Albumin
- Increased Prothrombin Time (PT)
Labs Trend for Bilirubin (LFT)
Increased Bilirubin
Labs Trend for Serum Ammonia (LFT)
Increased Serum Ammonia
Labs Trend for Serum Protein (LFT)
Decreased Serum Protein
b/c malabsorption
Labs Trend for Serum Albumin (LFT)
Decreased Serum Albumin
b/c malabsorption
Labs Trend for Prothrombin Time (PT) (LFT)
Increased Prothrombin Time (PT)
b/c no clotting factor
What is Jaundice
D/t Bilirubin is increased
- Hemolytic - Breaking down to many RBC
- Hepatocellular - Liver can’t break down Bilirubin
- Obstructive - Decrease of the flow of bile (Generally Gallstones)
What is Hemolytic Jaundice
Hemolytic - Breaking down to many RBC
What is Hepatocellular Jaundice
The liver can’t break down Bilirubin
What is Obstructive Jaundice
Obstructive - Decrease of the flow of bile (General Gallstones)
What is Bilirubin
By product heme from hemoglobin
- Can be Direct (Conjugated) or Indirect (Unconjugated
What is Direct (Conjugated) Bilirubin
Elevated due to Liver working but can’t remove bilirubin. Caused by Bile Duct obstruction (Maybe Gallstone)
Made up of 30%
What is Indirect (unconjugated)
Elevated due to impaired liver or Making too much Bilirubin
Made up of 70%
Where to see Jaundice in darker tone people?
- Sclera
- Palms
- Soles
- Mucas Membranes
Urine may be Dark in all people
S/s of Jaundice
Pruitis
Dark urine
Clay Stools
Elevated Liver Enzymes
What is Viral Hepatitis
Causes inflammation of the liver
Main types (HAV, HBV, HCV)
What is Viral Hepatitis - Pathogenesis
Virus -> immune inflammation -> Lysis of infection Cells -> Edema & Swelling of Tissue -> Tissue Hypoxia -> Hepatocyte death
Viral hepatitis S/s
Similar for all
- Many Asymptomatic
- No S/s -> mild -> Liver Failure
Viral hepatitis LFT lab trends
Elevated LFTs (Trend & Not All Pts)
Viral hepatitis Path of disease
Prodromal -> Icteric -> Recovery
Prodromal for Viral hepatitis S/s
2 weeks after exposure
- Fatigue
- Anorexia
- Malaise
- N/V
- Ha
-Feel more pain (Hyperalgesia)
- Low Fever
Highly transmissible
What stage are you highly transmissible for Viral hepatitis?
Prodromal
What stage does Jaundice begin for viral hepatitis?
Iceric
What S/s viral hepatitis in the Icteric Stage?
- Jaundice
- Dark Urine
- Clay stool
- Enlarged liver that hurts to palpate
Fatigue - Increased abdominal Pain
(Last 2-6 weeks)
How long to reach the Recovery phase for Viral Hepatitis
6-8 weeks
but the Liver Remains Enlarged/ tenderness
What Viral Hepatitis Complications can happen?
Chronic Hepatitis
Liver Cirrhosis
Liver Cancer
Fulminant Viral hepatitis - Acute Liver Failure
Hepatitis A (HAV) Transmission
via Fecal-oral, Parental, Sex
Hepatitis A (HAV) S/s
Acute fever
Usual Mild Severity
Fatigue
N/A
Stomach Pain
Can Hepatitis A (HAV) become Chronic Hepatitis
No, will not lead to Chronic Hepatitis
Hepatitis A (HAV) Affects Who & how to prevent?
Kids & Adults
Wash Hands & Vaccine
Hepatitis b (HBV) Transmission
Via Parental, Sex
Insidious Onset 60- 100 days to see signs
Hepatitis B (HBV) Affects Who & how to prevent?
Any age but Generally not kids
HBV Vaccine, Safe Sex, Hygiene
Can Hepatitis B (HBV) become chronic?
Yes, HBV can become chronic
Hepatitis C (HCV) Transmission
Via Parental, Sex, medical mistakes, Mother to fetus
Insidious Onset 60- 100 days to see signs
What percent of Hepatitis C (HCV) become chronic?
80% of people affected by HCV will become chronic
Hepatitis C (HCV) Affects Who & how to prevent?
Any age,
Blood Screening, Hygiene, No Vaccine
New Treatment Available
Vaccine for Hep A Series
2x (6months apart)
Recommend for
- All kids 12 months & older
- High-Risk groups
Vaccine for Hep B Series
3x (4 months apart)
Recommend for All newborns
Disadvantage of drugs for HBV
- length of time on the med
- cost of the med & s/e with other meds
Combine the two = High rate of relapse
When do we treat HBV with drugs
High-Risk Pts only
- Increase AST Levels
- Hepatic Inflammation
- Advanced Fibrosis
How is HCV treatable now?
New drug Direct-Acting Antiviral Therapy
Limit a day of Tylenol should a Hepatitis pt follow?
2g instead of the normal 4g
What is Cirrhosis?
Irreversible inflammatory Fibrotic Disease
Structure changes & Chaotic Fibrosis obstructed biliary channels -> Jaundice & Portal HTN
Can the scarring during Cirrhosis be regenerated?
No, because regeneration is disrupted by Hypoxia, necrosis, atrophy, & liver failure
Can you stop the progression of Cirrhosis
Yes if you stop the cause. Stop drinking
What causes Cirrhosis (4)
- Hepatitis B&C
- Alcohol
- Idiopathic
- Fatty Liver Disease (Nash - NAFLD)
Alcoholism & Liver Disease Stages
- Alcoholic Fatty Liver - Asysmtomic (Can Fix)
- Alcoholic Steatohepatitis - Inflamed, destroyed Hepatocytes (can’t fix Damage but less)
- Alcoholic Cirrhosis - Fibrosis & Scarring affect liver structure (Nonreversable)
Cirrhosis S/s
GI changes
~ N/V
~ Anorexia
~ Farting
~ Change in habit
Fever, Weight loss
Palpable Liver
Cirrhosis S/s Late
Jaundice
Peripheral Edema
Decreased Albumin & PT
Skin Lesions
Bleeding Problems
Portal HTN
Varices because of bleeding
Ascites
Etc
What is Portal Hypertension?
Resistant portal blood flow -> leads varices & Ascites
What is Hepatic encephalopathy?
30-45% of Cirrhosis Pt will develop with LOC changes from Mild Changes to Coma
What is the primary chemical driver for LOC in cirrhosis PTs.
Ammonia measured via labs
