Gen Path Exam 3 - Liver Disease Flashcards
1
Q
Which part of the biliary system?
Produces bile
A
Liver
2
Q
Which part of the biliary system?
Storage and release of bile into duodenum when food is eaten
A
Gallbladder
3
Q
Which part of the biliary system?
Transport bile from liver to duodenum
A
Bile duct
4
Q
What is bile composed of?
A
Bile acids/salts
Bilirubin
Cholesterol
Other waste products/pollutants
5
Q
Aids in digestion and absorption of fats
A
Bile
6
Q
Serves as primary pathway for elimination of bilirubin, excess cholesterol, and other toxic substances
A
Bile
7
Q
What are the 3 main things a Hepatic Panel detects?
A
Synthesis of liver enzymes
Bilirubin processing/bile secretion
Extent of liver damage
8
Q
Which part of the Hepatic Panel?
Total protein (albumin + globulins)
Albumin
Pro-thrombin time and INR
A
Synthesis of liver enzymes
9
Q
When measuring the synthesis of liver enzymes in the Hepatic Panel, what detects the presence and function of coagulation factors?
A
Pro-thrombin time and INR
10
Q
Which part of the Hepatic Panel?
Bilirubin
Alkaline phosphatase
Gamma-glutamyltransferase
A
Bilirubin processing/bile secretion
11
Q
When measuring the bilirubin processing/bile secretion in the Hepatic Panel, what is released with bile duct damage?
A
Alkaline phosphatase
12
Q
When measuring the bilirubin processing/bile secretion in the Hepatic Panel, what is released with bile duct damage, but is more specific since it is not present in bones?
A
Gamma-glutamyltransferase
13
Q
Which part of the Hepatic Panel?
Aspartate aminotransferase
Alanine aminotransferase
A
Extent of liver damage
14
Q
When measuring the extent of liver damage in the Hepatic Panel, what is more specific for liver damage?
A
Alanine aminotransferase
15
Q
What panel includes bilirubin, albumin, alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase?
A
Comprehensive metabolic panel
16
Q
The liver has a _________ functional reserve - only 10% normal tissue can sustain life; full regeneration within __________
A
large; 4 months
17
Q
T/F: Liver diseases are typically silent and insidious
A
True!
18
Q
What do most patients have at the time of referral?
A
Chronic liver disease
19
Q
T/F: Signs and symptoms of liver diseases appear weeks, months, or even years after onset of injury (may only be detected by lab abnormalities) with liver injury and healing being subclinical
A
True
20
Q
Clinical sign of underlying disease
A
Jaundice
21
Q
Yellow discoloration of skin, mucous membranes, and sclerae of eyes
A
Jaundice
22
Q
Caused by elevated serum bilirubin
A
Jaundice
23
Q
Pathogenesis depends on where bilirubin metabolism is altered
A
Jaundice
24
Q
Yellow breakdown product of RBCs, which becomes a component of bile
A
Bilirubin
25
What are the 3 reasons a person may have elevated bilirubin?
Bile isn't being formed
Breakdown of large amounts of blood
Obstruction of bile flow out of liver (tumor; gallstone)
26
T/F: Bilirubin alone is highly toxic and insoluble and can’t be excreted; it has to be managed
True
27
In bilirubin metabolism, what are RBCs consumed by?
Macrophages
28
In bilirubin metabolism, what is converted to biliverdin?
Protoporphyrin
29
In bilirubin metabolism, what is unconjugated to bilirubin?
Biliverdin
30
In bilirubin metabolism, what binds tightly to albumin?
Unconjugated bilirubin
31
In bilirubin metabolism, what does albumin carry to the liver?
Unconjugated bilirubin
32
In bilirubin metabolism, what conjugated bilirubin, making it water-soluble and non-toxic?
Uridine glucuronyl transferase (UGT)
33
In bilirubin metabolism, where is conjugated bilirubin transferred to form bile?
Bile canaliculi
34
In bilirubin metabolism, where is bile stored in the gallbladder released into to aid in digestion?
Small intestine
35
In bilirubin metabolism, what converts conjugated bilirubin to urobilinogen?
Intestinal flora
36
In bilirubin metabolism, what is oxidized to stercobilin and urobilin, which are mostly excreted in feces?
Urobilinogen
37
In bilirubin metabolism, what is reabsorbed into blood and filtered by kidney and makes urine yellow?
Urobilin
38
Makes urine yellow
Urobilin
39
Makes stool brown
Stercobilin
40
Steps of bilirubin metabolism
1. Macrophages eat RBCs
2. Protoporphyrine -> biliverdin -> UCB
3. Albumin carries UCB to liver
4. UGT -> CB-> makes it water-soluble and non-toxic
5. CB goes to bile canaliculi -> forms bile -> stored in gallbladder
6. Bile released into small intestine to aid digestion
7. Intestinal flora converts CB -> urobilinogen
8. Urobilinogen -> stercobilin and urobilin -> excreted mostly in feces
9. Some urobilin reabsorbed into blood -> filtered by kidney -> urine is yellow
41
Lab findings in extravascular hemolysis or ineffective erythropoiesis
High UCB
42
Lab findings in physiologic jaundice of newborn
High UCB
43
Lab findings in biliary tract obstruction (obstructive jaundice)
Low CB
Low urine urobilinogen
High alkaline phosphatase
44
Lab findings in viral hepatitis
High UCB
High CB
45
What are the 5 key causes of jaundice?
Extravascular hemolysis
Ineffective erythropoiesis
Physiologic jaundice of newborn
Biliary tract obstruction (obstructive jaundice)
Viral hepatitis
46
Inflammation of the liver
Hepatitis
47
Term that is often used to describe diseases caused by specific viruses that infect the liver (hepatotropic)
Hepatitis
48
A severe, life-threatening form of acute hepatitis
Fulminant hepatitis
49
Six different hepatitis viruses have been identified, but what types cause the majority of problems?
A, B, C
50
Symptoms < 6 months: jaundice with dark urine (due to CB), fever, malaise, nausea and elevated liver enzymes (ALT, AST)
Acute Hepatitis
51
Symptoms > 6 months: risk for progression to cirrhosis
Chronic Hepatitis
52
What viruses are transmitted in in a similar manner and many patients have coinfection, which increases risk for hepatic dysfunction?
HBV
HCV
HIV
53
When should you get a med consult?
Non-specific history of hepatitis and signs/symptoms of jaundice
54
Which hepatitis viruses are spread oral-fecal?
HAV
HEV
55
Which hepatitis viruses are spread parenteral (childbirth, unprotected sex, IV drug abuse, needle stick)
HBV
HCV
56
Which hepatitis virus is commonly acquired by travelers?
HAV
57
Which hepatitis virus is commonly acquired from contaminated water or undercooked seafood?
HEV
58
Which hepatitis viruses have the following symptoms?
Fever, jaundice, fatigue, loss of appetite
HAV
HEV
59
Which hepatitis virus has the following symptoms?
Most have mild to no symptoms
30% have anorexia, fever, jaundice, RUQ pain
HBV
60
Which hepatitis virus has the following symptoms?
85% of acute cases are asymptomatic
HCV
61
Which hepatitis viruses are acute only (no carrier or chronic state)?
HAV
HEV
62
Which hepatitis virus?
10% develop chronic disease
Of those, 30% develop cirrhosis and 3% develop HCC
HBV
63
Which hepatitis virus?
80-90% develop chronic disease
Of those, 33% develop cirrhosis and 2.5% develop HCC
HCV
64
Which hepatitis viruses are diagnosed by:
IgM -> active infection
IgG -> protective; indicated prior infection or immunization
HAV
HEV
65
Which hepatitis virus is diagnosed by the following diagnostic antibodies:
IgM for HB core antigen (anti-HBc)
HB surface antigen (HBsAg)
AST, ALT, bilirubin may be elevated
HBV
66
Which hepatitis virus is diagnosed by recovery:
HbsAg clears and antibodies (anti-HbsAg) appear
HBV
67
Which hepatitis virus is diagnosed by immunity:
IgG anti-HBc
HBV
68
Which hepatitis virus is diagnosed by HCV RNA (often persistent even if antibodies present)?
HCV
69
Which hepatitis viruses have a vaccine?
HAV
HBV
70
Which hepatitis virus?
Treated with IFN or nucleotide/nucleoside inhibitors
HBV
71
Which hepatitis virus?
Treated with combo antiviral therapy which is very effective - goal is sustained virologic response or "cure" (undetectable RNA within 6 months of tx)
HCV
72
Which hepatitis virus?
95% of infections are curable, but tx is very expensive (100k)
HCV
73
Which hepatitis virus?
Infection in pregnant women causes fulminant hepatitis (liver failure w/ massive necrosis)
HEV
74
Which hepatitis virus?
Only hep virus that is a DNA virus
HBV
75
Which hepatitis virus?
Reinfection can occur even after tx
HCV
76
Which hepatitis virus?
Dependent on HBV for infection; superinfection upon existing HBV is more severe than coinfection
HDV
77
What diagnosis?
Elective dental tx should be deferred until resolution of active disease; emergency tx should be done in hospital dental clinic
Acute HBV or HCV
78
What diagnosis?
Elective and emergency dental tx should be done in hospital dental clinic
Chronic HBV or HCV with significant hepatic dysfunction
79
What diagnosis?
Can receive elective tx w/o special precautions
Chronic HBV or HCV without significant hepatic dysfunction
80
What is the leading cause of liver disease in most Western countries?
Alcoholic liver disease
81
Causes damage to hepatocytes due to alcohol consumption (generally binge drinking)?
Alcoholic liver disease
82
What is alcoholic liver disease mediated by?
Acetaldehyde
83
Alcohol metabolite
Acetaldehyde
84
What are the 3 types of damage in alcoholic liver disease?
Steatosis
Alcohol hepatitis
Fibrosis-cirrhosis
85
Fat accumulation in hepatocytes
Steatosis
86
Which type of damage in alcoholic liver disease?
Liver is large, soft, yellow, and greasy ("fatty liver")
Steatosis
87
Which type of damage in alcoholic liver disease?
Often asymptomatic or mild RUQ discomfort, fatigue, weight loss
Steatosis
88
Which type of damage in alcoholic liver disease?
Hepatocyte swelling with necrosis and acute inflammation
Alcohol hepatitis
89
Which type of damage in alcoholic liver disease?
Painful hepatomegaly
Elevated liver enzymes (AST > ALT)
Jaundice
Portal hypertension (splenomegaly, ascites)
Malnutrition and vitamin deficiencies (thiamine, B12)
Malaise, weight loss, fever, nausea, vomiting
Alcohol hepatitis and fibrosis-cirrhosis
90
What is the tx for alcoholic liver disease?
Stop drinking
Supportive care
Liver transplant in later stages
91
Same clinical symptoms and gross/histologic changes as noted in alcohol-related liver disease, but without alcohol exposure
Non-alcoholic fatty liver disease
92
Is non-alcoholic fatty liver disease common?
Yes!
93
What is non-alcoholic fatty liver disease associated with?
Obesity w/ insulin resistance
Type 2 DM
94
In non-alcoholic fatty liver disease, free fatty acids from adipose tissue accumulate in _____________, stimulating more fatty acid production
hepatocytes
95
What is the most common cause of incidental elevation of serum transaminases?
Non-alcoholic fatty liver disease
96
Diagnosis of exclusion; ALT > AST
Non-alcoholic fatty liver disease
97
Major drug metabolizing and detoxifying organ - very susceptible to injury
Liver
98
What are the 3 mechanisms of drug-induced liver damage?
Direct toxicity
Hepatic conversion to active toxin (metabolite)
Drug or metabolite acts as hapten -> binds to cellular protein, making it immunogenic
99
In drug-induced liver damage, drug rxns can be what 2 things?
Predictable (dose-dependent)
Idiosyncratic (unpredictable)
100
What type of drug rxn?
Acetaminophen converted to toxic metabolite
Predictable (dose-dependent)
101
What type of drug rxn?
Immediate or delayed (weeks to months)
Idiosyncratic (unpredictable)
102
Progressive, diffuse fibrosis/scarring of the liver
Cirrhosis
103
Regenerative nodules surrounded by fibrous bands
Cirrhosis
104
Focal nodules of viable liver parenchyma remain between the bands of scar tissue
Cirrhosis
105
What are the causes of cirrhosis in the US?
HCV
Alcoholic liver disease
Non-alcoholic steatohepatitis (NASH)
106
What are the causes of cirrhosis in the developing world?
HBV
HCV
107
Pt may be clinically silent without symptoms; only elevated AST and ALT
Cirrhosis
108
If symptomatic, pt will present with anorexia, weight loss, weakness, debilitation, signs of liver failure and portal hypertension
Cirrhosis
109
What is the tx for cirrhosis?
Transplant
110
Is fibrosis of the liver reversible?
NO
111
What do many patients with cirrhosis die from?
Liver failure
Hepatocellular carcinoma (HCC)
112
What are the 3 potential complications of cirrhosis in regard to dental tx?
1. Unpredictable drug metabolism (only occurs with severe disease)
2. Impaired hemostasis and bleeding (thrombocytopenia and low coagulation factors)
3. Increased risk of infection
113
Most important and severe consequence of
liver disease
Liver failure
114
Will not occur until 80-90% of the liver cells
(hepatocytes) are destroyed
Liver failure
115
What are the potential causes of liver failure?
Acute - drugs (50% acetaminophen), HAV, HBV
Chronic liver diseases that cause cirrhosis
116
Clinical features include:
Jaundice- when severe leads to pruritis (itching)
Peripheral edema
Spider angioma formation
Multiple organ system failure
Coagulopathy (Bleeding)
Encephalopathy (confusion, stupor)
Coma
Liver failure
117
What is the tx for a pt with liver failure that has sufficient residual viable tissue?
Regeneration with supportive care
118
What is the tx for a pt with liver failure that has insufficient viable tissue?
Transplant
119
Prognosis is poor - pts die within weeks to months
Liver failure
120
Where does all gastrointestinal, splenic, and pancreatic venous blood drain?
Portal vein
121
Regulates nutrients and filters toxins
Portal vein
122
Where does hepatic vein drain into?
IVC
123
What are the 3 portal collaterals?
Esophageal veins
Hemorrhoidal veins
Periumbilical veins
124
What is the dual blood supply of the liver?
Hepatic artery
Portal vein
125
What causes impaired venous return BEFORE the liver?
Portal vein obstruction
Thrombosis
126
What causes impaired venous return IN the liver?
Cirrhosis
127
What causes impaired venous return AFTER the liver?
Hepatic vein obstruction
Chronic passive congestion (R sided heart failure, lung disease)
128
Pathogenesis is impeded venous return from right heart causes blood stasis in liver
Chronic passive congestion
129
Caused most often by COPD or restrictive pulmonary disease leading to R heart failure
Chronic passive congestion
130
Gross pathology is nutmeg liver
Chronic passive congestion
131
Malignant tumor of hepatocytes
Hepatocellular carcinoma (HCC)
132
Risk factors are:
Chronic hepatitis (HBV, HCV)
Cirrhosis
Aflatoxins from aspergillus (induce p53 mutations) -> synergistic w/ HBV
Hepatocellular carcinoma (HCC)
133
Why are tumors of the liver often detected late?
Symptoms masked by cirrhosis
134
Where do tumors of the liver commonly metastasize?
Lung
135
All cancers drained by the _______ system
metastasize to _______: lower esophagus,
stomach, intestine, gallbladder, pancreas
portal; liver
136
Most often represents crystallized cholesterol in the bile
Cholelithiasis (gallstones)
137
Risk factors:
Increasing age
Female
Obesity
Family history
Living in an industrialized society
Cholelithiasis (gallstones)
138
Gallstones may be present for _________ before symptoms develop
decades
139
Is Cholelithiasis (gallstones) usually symptomatic or asymptomatic?
Asymptomatic
140
If symptomatic, what will a person with Cholelithiasis (gallstones) experience?
Biliary colic
Acute cholecystitis
Chronic cholecystitis
141
Stone in cystic duct; wax/wane RUQ pain may resolve if stone passes
Biliary colic
142
Impacted stone in cystic duct with bacterial infection; severe RUQ abdominal pain, fever, nausea, vomiting
Acute cholecystitis
143
Vague RUQ pain especially after meals
Chronic cholecystitis
144
What is the tx for Cholelithiasis (gallstones)?
Cholecystectomy
145
Surgical removal of gall bladder
Cholecystectomy
146
Is the prognosis for Cholelithiasis (gallstones) good or bad?
Good
