Final: Ch 30 Hepatobiliary & Exocrine Pancreas Disorders Flashcards
liver gross anatomy
inferior to diaphragm under ribs - can’t be palpated unless enlarged
arterial blood via hepatic artery, venous blood via portal vein
drained by hepatic vein
the hepatic duct and cystic duct (gallbladder) meet to form which duct
the common bile duct –> empties into duodenum
what is the functional unit of the liver
liver lobule
liver lobules are organized around a central ___, which drains to the hepatic ____
vein, vein
plates of hepatocytes are separated by ________
sinusoids
hepatocytes produce ____, which flows to the _____ duct
bile, bile
Kupfer cells are what
macrophages
metabolic functions of the liver: carbohydrates
glycogen storage
gluconeogenesis
metabolic functions of the liver: lipids
acetyl-CoA –> ketones (used for energy by other tissues)
acetyl-CoA –> HMG-CoA –> bile salts/cholesterol
most cells metabolize ____ for energy via acetyl-coA
fats
cholesterol is stored or exported as _________
lipoprotein
metabolic functions of the liver: proteins
synthesis - albumin, fibrinogen
use aa for gluconeogenesis
deamination –> ammonia –> urea –> renal excretion
synethesis of nonessential aa
transamination
ammonia is also produced in the ____ by ________
gut, bacteria
bile production and flow
produced in liver –> duodenum –> emulsify fat
some bile is reabsorbed into portal circulation
how is bilirubin formed
hemoglobin –> heme –> biliverdin –> free bilirubin
free bilirubin to liver bound to plasma proteins –> bile
jaundice
caused by elevated serum bilirubin
easily seen in eyes (scleral icterus)
prehepatic jaundice
RBC destruction (post-transfusion)
intrahepatic jaundice
low bilirubin uptake or conjugation by liver
posthepatic jaundice
obstructed bile flow (stones)
cholestasis
low bile production and flow
high bilirubin and cholesterol in the blood
intrahepatic cholestasis
from liver disease or shock
extrahepatic cholestasis
duct obstruction
gallstones, pancreatitis, tumor
symptoms of cholestasis
pruritus
hyperlipidemia
poor absorption of fat soluble vitamins
high serum alkaline phosphatase
liver function tests
direct and indirect bilirubins
elevated enzymes suggest hepatocyte damage
ALT (alanine aminotransferase)
AST (aspartate aminotransferase)
total protein, clotting factors, albumin (low in disease)
imaging/biopsy
viral hepatitis overview
liver injury causes necrosis
chronic carrier state also possible with HCV (or HBV)
3 stages
3 stages of viral hepatitis
prodromal
icterus
convalescence
prodromal stage
general malaise & GI symptoms
fever & chills
icterus stage
jaundice
pruritis
liver tenderness
worsening of prodromal symptoms
convalescence stage
jaundice and other symptoms disappear
hepatitis A
benign and self-limiting
ssRNA virus replicates in liver, excreted in bile
doesn’t cause chronic infection
vaccine available
hep A symptoms, transmission, Ab
N/V, malaise, abd pain, jaundice, dark urine
fecal-oral (contaminated water/milk, shellfish)
Ab give immunity and mark infection
hepatitis B
dsDNA virus that can produce acute or chronic hepatitis, cirrhosis, or acute hepatic necrosis
transmitted through blood or bodily fluids
hep B Dx, vaccine?
viral antigens and Ab measured in blood
vaccine available
hepatitis C
ssRNA virus - world’s leading cause of chronic hepatitis, cirrhosis, and liver cancer
spread through drug use/sexual contact/ blood
long incubation period
hep C symptoms, Dx
initial symptoms non-specific or asymptomatic
causes jaundice and cirrhosis but not usually acute failure
virus and Ab tests available
hepatitis D
commonly superimposed on HepB infection
makes HepB infection worse
hepatitis E
non-enveloped ssRNA virus
transmitted fecal-oral, contaminated water
20 million infections
hep E is ____-______ but may develop into _______ hepatitis
self-limiting (resolves in 4-6 wks), fulminant hepatitis (acute liver failure)
hep E is most prominant where
east and south asia
china has vaccine but it’s not available globally
$1000 pill for Hep C cure
Sovaldi
84k for full treatment
chronic viral hepatitis
infection persists for 3-6 mnths or more
ALT & virus levels elevated
causes chronic liver disease, cirrhosis, and cancer
from hep B, C, or D
Rx for chronic viral hepatitis
inferferons and anti-viral drugs
liver transplant
primary biliary cirrhosis
chronic liver disease - autoimmune destruction in small bile ducts –> liver failure
insidious onset and slow progression
Rx for primary biliary cirrhosis
symptomatic only until failure then liver transplant
secondary biliary cirrhosis
from prolonged duct obstruction with gallstones
hepatic drug metabolism phase 1
chemical modifications by liver enzymes (cytochrome P450)
induced (EtOH) or suppressed (cimetidine H2r blocker)
hepatic drug metabolism phase 2
conversion of lipid-soluble substances to water soluble form
drug-induced liver disease
tylenol is hepatotoxic
some drugs are cholestatic - antipsychotics and antibiotics
alcohol induced liver disease
alcohol absorbed from GI tract including stomach
2 phases of metabolism in hepatocytes
microsomal ethanol-oxidizing system (MEOS) uses cytochrome P450
alcohol dehydrogenase
uses NAD to make NADH
NAD depletion/NADH excess in alcohol induced liver disease
lowers gluconeogenesis –> hypoglycemia and less beta-oxidation –> fatty liver
are the metabolic end products of alcohol breakdown toxic?
yes, acetaldehyde
mechanism of damage in alcohol induced liver disease
unknown but there are fatty changes
hepatitis and cirrhosis result
cirrhosis compresses/disrupts hepatic vein branches –> portal HTN
nonalcoholic fatty liver disease
seen w/ insulin resistance and higher liver uptake of FA
Rx: weight loss and avoid alcohol
cirrhosis
end stage of chronic liver disease
diffuses fibrosis and destruction of vascular and biliary channels
leads to portal HTN, biliary stasis, and liver failure
causes of cirrhosis
alcohol abuse
viral hepatitis
mineral deposits (hemochormatosis Fe, Wilson disease Cu)
non-EtOH liver disease including biliary obstruction
symptoms of cirrhosis
weight loss
ascites
hepatomegaly
abd pain
jaundice
portal HTN
high resistance to blood flow from liver –> high portal pressure
pre-hepatic causes of portal HTN
portal vein thrombosis or compression (cancer)
intra-hepatic causes of portal HTN
cirrhosis
post-hepatic causes of portal HTN
Rt HF
Budd-Chiari syndrome (occlusion of hepatic vein or IVC)
complications of portal HTN
ascites - high pressure low COP
splenomegaly - less blood
portosystemic shunts - venous collaterals
high pressure of portal HTN can cause
esophageal varices
dilated veins around umbilicus
reverse flow - toxic to systemic circulation
Rx of portal HTN
balloon tamponade
reduce GI blood flow w/ endoscopic sclerosis
vessel ligation
drugs
surgical shunt of portal vein blood to systemic circulation
liver failure
most severe complication of liver disease
decreased clotting factors
lower metabolism (higher function of steroid hormones)
hepatorenal syndrome (renal failure 2ndary to hepatic failure)
cause of liver failure
encephalopathy - blood bypasses liver and neurotoxins like ammonia buildup
Rx for liver failure
stop alcohol
prevent infection
limit protein, give carbs
liver transplant
2 types of liver cancer
primary - hepatocellular carcinoma
metastatic - most common: from colon, breast, of lung
risk factors, symptoms for primary liver cancer
viral hepatitis
weakness, anorexia, fatigue –> ascites + jaundice
Rx of primary liver cancer
subtotal hepatectomy
chemo/radiation are palliative
cholelithiasis
gallstones: 4/5 made of cholesterol, other bile salts/bilirubin
abrupt onset but transient pain
predisposing factors for cholelithiasis
excess cholesterol in bile - obesity/birth control pill
stasis of bile - liver disease/obstruction
inflammation of gallbladder - high water/bile salt absorption
cholecystitis
inflammation secondary to obstruction from stones
caused by sepsis, trauma, infection
acute or chronic
symptoms of cholecystitis
persistent pain
fever
n/v
Dx/Rx of cholecystitis
ultrasound, CT
surgery
choledocholithiasis
stones in CBD
can cause sepsis, shock, and pancreatitis
acute pancreatitis
reversible inflammation caused by activation of pancreatic enzymes outside the cut
trypsinogen -> trypsin –> others activated
pancreas digests itself
causes of acute pancreatitis
CBD obstruction w/ gallstones –> bile reflux to pancreas
alcohol abuse increases pancreatic secretions
symptoms of acute pancreatitis
pain
fever
shock
acute pancreatitis can cause
ATN
ARDS
multiple organ failure
death
Dx of acute pancreatitis
high serum amylase and lipase
CT
Rx of acute pancreatitis
NG suctino
pain relief (demerol lowers duct spasms)
NPO
IV fluids
chronic pancreatitis
caused by alcohol abuse and not reversible
2ndary to chronic duct obstruction
Rx of chronic pancreatitis
no alcohol
treat gallstones
give pancreatic enzymes
pancreatic cancer
mostly adenocarcinomas
symptoms from mass and mets
jaundice and pain
Dx/Rx of pancreatic cancer
Dx: high bilirubin and alk. phos, CT, ultrasound
Rx: palliative
