Exam 2 - Liver And Pancreas Flashcards by Kirsten Sparley

Increased levels of bilirubin cause

Jaundice (icterus)

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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

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How much bilirubin is formed daily?

250-350 mg

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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)

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Indirect vs direct bilirubin

Indirect: unconjugated, prehepatic
Direct: conjugated, posthepatic

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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.

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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.

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Jaundice associated with liver damage or dysfunction is often known as

Hepatic (hepatomegaly-cellular) jaundice

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Causes of Hepatic (hepatomegaly-cellular) jaundice include

Cirrhosis, hepatitis, liver infarcts, toxic injury and defects in assimilation, conjugation and transport of bilirubin into bile

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Atypically high conjugated bilirubin leads to a type of jaundice called

Choluric jaundice

Diffuses freely into blood and tissue fluids

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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.

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Kernicterus

Infantile severe unconjugated hyperbilirubinemia with brain damage

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What kind of bilirubin DOES enter the urine

Conjugated bilirubin

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Acholuric jaundice

Unconjugated bilirubin that does not enter urine

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3 Stages of cirrhosis

1- Fatty liver stage (fatty metamorphosis)
2- Alcoholic hepatitis
3- Cirrhosis (fibrosis) “end stage”

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Mallory bodies are seen in which stage of liver disease

Alcoholic hepatitis

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Biliary cirrhosis

Most damage occurs in periportal areas that surround bile ducts

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“Pigment” cirrhosis is associated with

Hemachromatosis “bronze diabetes”

Accumulated iron and injury to hepatocytes and hepatic scarring

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Hemosiderin

Insoluble aggregates consisting of degraded ferritin

Deposits are common in macrophages of the liver, spleen and marrow and hepatocytes

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Systemic iron overload

Deposits accumulate and damage parenchymal tissues.

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Causes of systemic iron overload:

Unregulated intestinal absorption, hemolytic anemia, multiple transfusions

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Hemochromatosis “bronze diabetes” triad

Cirrhosis
Pancreatic fibrosis
Bronzed skin

(Also causes atypical arthritis)

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What is the primary reason for hemochromatosis

Defect in chromosome 6 that affects regulation of intestinal absorption of iron

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Secondary hemochromatosis may result from

Chronic hemolytic disorders and/or multiple transfusions

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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