Exam 2 - Liver And Pancreas Flashcards
Increased levels of bilirubin cause
Jaundice (icterus)
Serum bilirubin levels are abnormal when they exceed _____ however skin discoloration is not apparent until _____
Excess serum bilirubin level: 1.2 mg/dl
Skin discoloration: 2-3 mg/dl
How much bilirubin is formed daily?
250-350 mg
Within the hepatocyte, billirubin is…
- Conjugated with glucuronide to form billirubine diglucuronide secreted in bile
- This post-hepatic or conjugated billirubin is water-soluble and enters urine when serum levels are atypically high
- Billirubin in bile reaches intestines and is acted upon by bacteria to form stercobilin, a pigment of stool
- Portions of urobilin are absorped by intestines and after reaching circulation, some of this appears as urinary urobilin (urobilinogen)
Indirect vs direct bilirubin
Indirect: unconjugated, prehepatic
Direct: conjugated, posthepatic
Is prehepatic or posthepatic bilirubin insoluble in water?
Prehepatic bilirubin = unconjugated
Note: Posthepatic / conjugated bilirubin is water soluble and so it DOES appear in urine.
Obstructive jaundice (cholestasis) is caused by what?
Biliary obstruction
So bile “spills over” into tissue. Components are absorbed by circulation. Accumulated bilirubin is predominantly conjugated.
Jaundice associated with liver damage or dysfunction is often known as
Hepatic (hepatomegaly-cellular) jaundice
Causes of Hepatic (hepatomegaly-cellular) jaundice include
Cirrhosis, hepatitis, liver infarcts, toxic injury and defects in assimilation, conjugation and transport of bilirubin into bile
Atypically high conjugated bilirubin leads to a type of jaundice called
Choluric jaundice
Diffuses freely into blood and tissue fluids
Why are newborns often jaundice?
The hepatic mechanisms for conjugating and excreting often do not mature until about 2 weeks of age.
Mild unconjugated hyperbilirubinemia is frequent in young infarcts, especially premature and underweight.
Kernicterus
Infantile severe unconjugated hyperbilirubinemia with brain damage
What kind of bilirubin DOES enter the urine
Conjugated bilirubin
Acholuric jaundice
Unconjugated bilirubin that does not enter urine
3 Stages of cirrhosis
1- Fatty liver stage (fatty metamorphosis)
2- Alcoholic hepatitis
3- Cirrhosis (fibrosis) “end stage”
Mallory bodies are seen in which stage of liver disease
Alcoholic hepatitis
Biliary cirrhosis
Most damage occurs in periportal areas that surround bile ducts
“Pigment” cirrhosis is associated with
Hemachromatosis “bronze diabetes”
Accumulated iron and injury to hepatocytes and hepatic scarring
Hemosiderin
Insoluble aggregates consisting of degraded ferritin
Deposits are common in macrophages of the liver, spleen and marrow and hepatocytes
Systemic iron overload
Deposits accumulate and damage parenchymal tissues.
Causes of systemic iron overload:
Unregulated intestinal absorption, hemolytic anemia, multiple transfusions
Hemochromatosis “bronze diabetes” triad
Cirrhosis
Pancreatic fibrosis
Bronzed skin
(Also causes atypical arthritis)
What is the primary reason for hemochromatosis
Defect in chromosome 6 that affects regulation of intestinal absorption of iron
Secondary hemochromatosis may result from
Chronic hemolytic disorders and/or multiple transfusions
What is characterized by increased tissue iron generally limited to the macrophages with little effect on parenchyma
Hemosiderosis
Versus hemochromatosis which is asssociated with damaging parenchymal tissue deposits
Treatment (2) of hemochromatosis
Phlebotomy
Dietary restriction of iron
Hepatolenticular degeneration
Wilson’s disease
What condition is associated with disturbances in regulation of copper transport and excretion into bile
Wilson’s disease
In Wilson’s disease, copper accumulates in (4)
Liver, brain, eyes, kidneys
In Wilson’s disease, copper is deposited where in the eye and what is this called
Cornea-sclera junction; Kaiser Fleischer ring
Cholelithiasis (lith = stone)
Gall stones
4F risks of cholelithiasis
Female
Fat
Forty (older than)
Fertile
(And the 5th is Flatulence)
What are contributing factors of abnormal bile?
Hypercholesterolemia
Inadequate levels of bile acids
Hemolytic disease with hyperbilirubinemia
How does Hypercholesterolemia contribute to abnormal bile?
Causes chemical injury to gall bladder mucosa
Cholesterol absorbed by gall bladder diminishes motility of musculature and gives rise to “sluggish” gall bladder
Nucleation is promoted by increased
Mucin
Kidney stones vs Gall stones
Kidney stones = calcium
Gall stones = cholesterol
What are cholesterol stones
When the stone deposit is made up of 50% or more cholesterol
Pure stones
10% of all stones. Cholesterol (large, oval, small) and pigmented
How common are “Mixed” and “combined” stones?
80-90%
Cholecystitis
Inflammation of gall bladder
Majority of Cholecystitis is associated with
cholelithiasis (gall stones) 80-90% of the time
What contributes to chemical injury to bladder mucosa?
Hyperconcentrated bile
What enteric organisms are a concern with bacterial infection
E.coli and other organisms may enter gall bladder
What is the role in pathogenesis of pancreatic reflux?
Uncertain. When it occurs, mixing of the pancreatic secretions with bile may contribute to mucosal injury by activation of pancreatic enzymes.
When is bacteria present, in acute or chronic cholecystitis?
Acute cholecystitis (80% of the time vs 30% of the time with chronic)
Presentation/symptoms of acute cholecystitis
Enlarged, edematous and hyperemia (red)
Steady, progressive right upper quadrant or epigastric pain and tenderness with fever, leukocytosis and nausea
Morphology of chronic cholecystitis
Gall bladder is often fibrotic and reduced in size.
In some chronic cholecystitis cases the gall bladder may be distended (_______)
Mucocele, “hydrops”
In chronic cholecystitis, calcified gallbladders is known as
“Porcelain gall bladder”
Symptoms of chronic cholecystitis
Right epigastric pain, nausea, intolerance of fatty foods
What is a first sign of liver tumor
Hepatomegaly
Most common cause for enlarged liver
Fatty liver caused by poor diet, obesity, alcohol, OTC meds (because liver processes)
Causes of hepatocarcinoma
- Hepatitis B (HPB)
- Aflatoxin (peanuts)
- Cirrhosis
Primary malignant tumors of the liver 93)
1- Hepatocarcinoma
2- Cholangiocarcinoma (of bile ducts)
3- Hemangiosarcoma (vascular)
Crohn’s, cystic fibrosis, (some) parasites, exposure to chemical agents can all lead to what primary malignant liver tumor
Cholangiocarcinoma (of bile ducts)
Gall bladder causes how many deaths per year?
5,000
What are symptoms of malignant gall bladder tumors?
Resembles cholecystitis and cholelithiasis: not much happens.
Diagnosis is 1% for 5 year survival
Pancreatitis: what is it and what are some causes of it
Inflammation of pancreas
Caused by infection, trauma, ischemia, drugs, hyperthermia, secretory obstruction, etc
Acute pancreatitis is associated with
Enzyme activation within pancreas that contributes to “auto digestion”
What are symptoms of acute pancreatitis
Sudden pain “acute abdomen”
It’s the reason for about 1/500 emergency room admissions
Mild acute pancreatitis vs severe acute hemorrhagic pancreatitis
Mild: self-limiting
Severe: extensive damage and possible death
Severe pancreatitis is also called
Acute hemorrhagic pancreatitis
Pathogenesis of severe (acute hemorrhagic) pancreatitis
Normally, pancreatic enzymes are activated in the gut and do not injure the pancreas. In acute pancreatitis, activation of trypsin may be a key step since it has the capacity to activate other enzymes (elastases, collagenases, phospholipidase, etc.) and the kinin system within the pancreas.
Causes of severe acute pancreatitis
Chronic biliary disease and chronic alcohol abuse
Symptoms of severe acute pancreatitis
Sudden, intense, CONSTANT pain
Sudden, intense, constant pain that refers to upper back and usually follows meal or alcohol ingestion
Severe (acute hemorrhagic) pancreatitis
What is more common: chronic or acute pancreatitis
Chronic
What kind of pancreatitis occurs after multiple episodes that contribute to fibrosis, parenchymal atrophy and ultimately, pancreatic failuter
Chronic (relapsing) pancreatitis
Pancreatic carcinoma symptoms
Vague and mild early on.
What cell type is pancreatic carcinoma
Duct cell
Risk factors of pancreatic carcinoma
Smoking, diet, chemicals, more frequent in African-Americans and diabetics
When pancreatic carcinoma is located in pancreatic head, obstructive jaundice is likely. This may be associated with
Courvoisier’s “sign”
About 10% of obstructive jaundice is likely exhibit increased tendency for spontaneous (migratory) thrombosis which is associated with
Trousseau’s sign
What are two islet cell tumors?
1 - Beta cell tumors (insulinomas)
2 - Gastrin-producing tumors (gastrinomas)
What kind of islet cell tumor might cause hypoglycemia
Beta cell tumor
What kind of islet cell tumor includes a classic “triad” and is the second most common form of islet tumor?
Gastrin-producing tumors
What is the classic “triad” of gastrin-producing tumors and what is it known as
Zollinger Ellison syndrome
1 - gastrin producing islet cell tumor
2 - gastric hyperaciditiy
3 - intractable multiple peptic ulcers (stomach, duodenum, esophagus, jejunum)
Type I IDDM
Insulin dependent diabetes mellitus “juvenile onset”
Type II NIDDM
Non-insulin independent diabetes myelitis “adult onset”
Secondary contributing factors to diabetes mellitus
Inflammatory, surgical, neoplasticism or other conditions that damage islet tissue.
Dysfunction of pituitary or suprarenal glands, certain drugs, etc.
When do chronic lesions appear in Type I and Type II Diabetes?
10-15 years
Glomerular sclerosis
Nephropathy
DM causes ___% legal blindness in US
15%
What is a common lesion of the eyes that is associated with disease of retinal vessels with exudation, fibroproliferative responses, microaneurysms, hemorrhages
Retinopathy
DM is most common metabolic cause for
Peripheral neuropathy
Is Peripheral neuropathy unilateralal or bilateral
Bilateral. Because its systemic disease
Type I diabetes and the 3 Ps
Polyuria
Polydipsia
Polyphagia
