GI Accessory organs Flashcards
Prehepatic Jaundice
Overproduction of unconjugated bilirubin from excess RBC breakdown and the liver cannot keep up
- High unconjugated (indirect)
- Decreased hct
Hepatic jaundice
Liver inability to take, conjugate and conjugae bilirubin. Conjugated will leak out of hepatocytes.
Occurs in hepatitis and Cirrhosis
- High unconjugated + conjugated
- High LFT
- Dark urine
Post hepatic jaundice
Failure to reach duodenum
- Intrahepatic - swelling or fibrosis
- Extrahepatic - cholestitis, gallstones, pancreatic cancer
- High conjugated (direct) bilirubin
- Dark urine
- Steatorrhea - pale coloured stool
- High cholesterol
- Accumulation of bile salts in skin = pruritis
- Vit K deficiency
Viral hepatitis
Infection of liver causing damage from cytotoxic cytokines and NK cells that destroy the infected hepatocytes. Chronic infection leads to scarring then cirrhosis
1) Hepatitis A
- Fecal oral route
- Poor hygiene, handling of food, sanitation, crowded places
- Diagnosed by HAV-specific antibodies, PCR test
2) Hepatitis B
- Higher pravelence
- Blood and body fluids
3) Hepatitic C
- Liver damage, through blood
- No vaccination
Viral hepatitis clinical manifestations
- RUQ pain = liver enlargement
- Fatigue, myalgia, arthralgia, malaise, anorexia, fever
- Jaundice
Chronic can lead to liver scarring, cirrhosis and failure, with more risk to develop cancer
NAFLD = non alcoholic fatty liver disease
Ranges from simple to severe cirrhosis
Accumulation of fat in the liver cells without alcohol, usually in obesity or DM2
Often adymptomatic
Toxic/Drug induced hepatitis
Symetic posison (e.g. gold, carbon tetrachloride) or those converted in liver to toxic live Tylenol or alcohol
Liver necrosis can occur in 2-3 days
Liver Cirrhosis
Irreversible fibrosis and conversion of liver to abnormal nodules - caused by viral hepatitis B&C, NAFLD, toxic/drug, autoimmune
Excessive alcohol is leading cause
Hepatocyte dyfunction as inadequate blood flow occurs
Complication - portal HTN, varices, ascites/edema, HE, coaguabulity, billary obstruction, hepatorenal syndrome, bacterial peritonitis
Portal hypertension
Structural change where the hepatic portal vein becomes obstructed, causing backup of blood into spleen = Splenomegaly, thombocytopenia due to trapping plateltys and WBC
- Signs of bleeding/bruising
Varices made as collateral circulation
Varices
Created to bypass the liver.
Distended and tortuous collateral veins that are fragile, commonly in esophagus, abdomen or hemorrhoidal
- Cause hematemesis or melena
- Esophageal burst commonly causing life threatening GI bleeds
Ascites/edema
Accumulation of fluid in abdomen due to portal HTNN, more hepatic lymph, less albumin (liver makes albumin!! so less oncotic pressure), hyperaldosteronism (liver breaks down aldosterone)
= Abdomen distention, dependent edema, weight gain, hypokalemia
Hepatic Encephalopathy
i) Ammonia rich blood shunted past liver due to collateral veins/varices
ii) Dysfunctional hepatocytes cannot convert it into urea
= sleep disturbances, coma, asterixis, fetor hepaticus (neurotoxic)
Coagulopathy/anemia
Pancytopenia due to
- Portal HTN causing splenomegaly and trapping it
- Clotting factor not produced in liver
- Unable to excrete bile for vitamin K absorption
- Esophageal varices = bleeding/hemorrhage
Other manifestations of cirhosis
i) Jaundice - Hepatic jaundice as intrahepatic damage - mix of conjugated and unconjugated
ii) Infections - portal HTN so bypass filtering ingested bacteria
iii) Hepatorenal syndrome - sudden decrease in urine, high BUN/creatinine
iv) Hormonal - steroid hormones not broken (aldosterone, estrogen, etc)= water retention, testiculat atrophy, gynecomastia, amonrrhea, spider angioma, palmar erythema, abnormal hair growth
iv) Drug toxicity - elevated levels of drugs = toxic
Gallbladder
RUQ - Concentrates bile products by liver
- Bile made up water, bile salts, cholesterol and bilirubin
Cholelithiasis (calculi) risk factors
4 F
1) Female - estrogen increases biliary cholesterol. Pregnancy, birth control pills and replacement esp
2) Fetile
3) Forty
4) Fat (drastic weight loss also as it increases blood cholestrole)
Stone created when there is too much cholesterol or too much bilirubin
Acute cholecystitis
1) Calculus
- Gallbladder lodges in cystic stone
- Pressure builds up and reduce blood flow = ischemia, necrosis, scarring and perforation
2) Acalculous (no stone)
- Biliary statis
- Starvation, hypovolemia, less blood glor = pancreatic enzyme build up and lead to inflammation
Cholecystitis clinical manifestation
1) Pain - triggered after high fat meal in RUQ
- Pain can radiate to right shoulder/scalpula
- Biliary colic - when stone moves, spasm causes pain
2) Murphy sign
- Palpate to feel inflamed gallbladder
3) Rebound tenderness
4) Indigestion, N/V
5) Fever
6) Post-hepatic jaundice = blocks bilirubin from exiting
7) Fatty stool
Pancreas
Endocrine
- Alpha makes glucagon, beta makes insulin
- Enzymes trypsinogen for protein, amylase for carb, lipase for fat
Retroperitoneal to stomach
Acute pancreatitis
Acute inflammation of pancreas from abnormal activation of pancreatic enzymes that self-digest the pancreases
Causes
i) Gallstones - Block common bile duct, pancreatic juice and bile
ii) Alcohol
iii) Genetics, meds, virus, hypercalcemia, high triglyceride, surgery. Trauma
What occurs
1) Lipolysis = fat necrosis
2) Proteolysis = protein breakdown causing thrombosis and gangrene
3) Necrosis of blood vessels = bleeding!
4) Release of more enzymes = vasodilation
5) Inflammatory mediators
Acute pancreatitis clinical manifestation
Pain - LUQ, mid gastric area that can radiate to back, left shoulder
N/V
Jaundice
Hemorrhage from breakdown of blood vessels
- Cullens sign and grey turner
- Tachycardia, hypovolemic shock
Fever from inflammation
Pancreatic enzymes in blood - high amylase and lipase
Hypocalcemia as FA bind to calcium
Hypovolemia - vasodilation, bleeding
Pulmonary - inflammatory cytokines
Hyperkalemia - cell death spills potassium
Propranolol (Indrel)
Non-selective beta blocks
MOA
- Block cardiac beta 1/d + renal beta 1
- Reduce HR, dorce of contraction, renin and CO
Indication = PORTAL HYPERTENSION
AE
- Bradycardia, AV heart block, arrthymia
- Bronchoconstriction
NC
- HR before administer
- HF - SOB, edema, weight gain
- Do NOT abruptly stop
- RR, O2, WOB - CI in COPD or asthma
Precaution!!!
- Severe allergies - epi activates beta 1 in heart and 2 in lungs, which is blocks so epi wont work!!
- Hypoglycemic unawareness
- Cardiac/resp - exacerbates HF
Lactulose (Enulose)
Osmotic laxative
MOA - Metabolizes into acid, lowering colon pH and inhibiting ammonia from entering blood
indication = HEPATIC ENCEPHALOPATHY
AE
- Diarrhea, crmaping, bloating
- Hyperglycema
- dehydration/electrolyte
NC
- CVS - Hydration/electrolyte
- GI and neurological
Albumin 25% (HSA)
IV injection to restore oncotic pressure by withdrawing fluid from interstitial places
- Administered AFTER ascites removed
AE
- Hypervolemia - circulatory overload
- Hypersensitivity
CI - renal insufficiency, HF, anemia
NC -
- Stop in signs of hypersensitised immediately
- Monitor blood work for electrolyte
- Fluid overload - HF, pulmonary edema, HTN
= VS, HA, edema, JVD, crackles, S3/S4, urine ouput, WOB
Spironolactone (Aldactone)
Potassium sparing diuretic
MOA
- Block aldosterone to prevent H20/Na reuptake to excrete sodium and keep potassium
Indication - ascites/peripheral edema
AE
- Hyperkalemia - paresthesia, muscle weakness, fatigue, bradycardia, arrythmias
- Hypotension
- Diarrhea/Abdominal cramping
NC
- Fluid statis - weigh, I&O, edema, lung, skin turgor, mucous membranes
- Electrolyte imbalance for sodium - anorexia, muscle weakness, confusion, thirst, seizure
- VS, serum electrolyte, BUN/CR
Liver assessment
- HE - Asterixis, drowsy, insomnia, fetor hepaticus - check LOC
- CVS - BP, pulse
Findings
- Caput medusa - snake shape on adomen
- Spider angioma - red spidery skin marks
- Protuberant belly from ascites
- Palmary erythma - redness in palm
- Abdominal striae
- Gynecomastia/testicular atrophy
Lab tests for liver
- Bilirubin = high due to inability to conjugate
- Hypokalemia = aldosterone
- Hypoglycemia = liver cannot glycogenolysis
- Less albumin
- Low RBC, platelet, EBC = Portal HTN causing splenomegaly and blocking
- High cholesterol - less bile to digest fat
- High LFT
- High INR - no vitamin K and clotting factors produced
- High ammonia - breakdown of protein that cant become urea
Gallpladder
Phrenic nerve causes referred pain to the right shoulder/back
- 30 min after fatty meal
- Monitor BP, pulse, RR, O2, post-hepatic jaundice, sweating
- Murphy sign
- Melena? steatorrhea?
LAB WORK
- INR/aPTT due to no vitamin K
- WBC - Inflammation
- Cholestrol - obstruction of bile means no digestion of fat (post-hepatic jaundice)
- High bilirubin - conjugated
- High LFT
Endoscopic retrograde cholangiopancreatography (ERCP)
Specialiased technique of endoscope inserted into pancreatic duct
Risk of perforation, infection and pancreatitis
Pancrease
- Pain in LUQ, radiate to back as retroperitoneal
- Leaning forward helps with pain
- Hypovolemia esp in bleeding, sepsis or inflammatory
- Jaundice
- Hyperglycemia - beta cells destroyed
- Cullen sign and Grey turner
LAB WORK
- High WBC - inflammation
- Low HgB - Pancreatic enzymes breakdown blood vessels and cause hemorrhage
- High glucose
- Low calcium - free FA from lipolysis bind to blood calcium
- Hyperkalemia - cells break and spill potassium
- High blood amylase and lipase
