Hepatic, Biliary, and Pancreas Flashcards
PART 1
PART 1
Functions of the hepatic system (liver)?
- Conversion and excretion of ______ and _________
- Sole source of ________ and other plasma proteins
- Produces ____ (500-1500 mls./day)
- Synthesizes ______ factors
- Absorbs and processes nutrients from the ___
- _________ (drugs, ETOH and toxins)
- _________ (glycogen, vitamins, iron)
- Synthesizes ____________
- bilirubin and ammonia
- albumin
- bile
- clotting factors
- gut
- detoxification
- storage
- cholesterol
- The liver reciever approximately __% of _________ even though it makus up only approximately 2-3% of total body weight.
- The _______ vein provides approximately / of blood supply while the hepatic artery provides the rest.
- 25%, CO
- portal vein, 2/3
What is the functional unit of the liver?
Liver Lobule
What are some S/Sx of hepatic disease?
- GI symptoms (N/V, Diarrhea, Constipation, Heartburn, Abdominal Pain, GI Bleeding)
- Edema/Ascites
- Dark Urine (bilirubin)
- Light/clay colored stools
What causes the urine to become dark with hepatic diseases?
Breakdown of hemoglobin produces bilirubin. Excess bilirubin in urine presents as dark urine and suggests liver damage.
Other S/Sx of hepatic disease:
- _____ _________ quadrant abdominal pain
- ___________ involvement (confusion, muscle tremors, sleep disturbances)
- Hepatic ______________ (abnormal development of bone)
- _________
- Skin changes such as _______ and bruising
- right upper quadrant
- neurologic involvement
- osteodystrophy
- osteoporosis
- jaundice
Jaundice is a _______, not a _________.
-symptom not a disease
Jaundice:
- _________ break down product of RBC in macrophages
- ________ discoloration of the skin, sclerae, and mucous membranes.
- Increased bilirubin production. Decreased processing of bilirubin.
- Hepatocyte dysfunction (hepatitis, hepatic disease, tumor), bilirubin accumulation.
- Impaired bile flow: caused by mechanical damage due to some obstruction of biliary tree
- Bilirubin
- Yellow
What is the treatment of Jaundice?
- resolve underlying disease
- return to normal color suggests resolution
- then activity and exercise can be resumed
What are the S/Sx of neurologic involvement in hepatic diseases?
- Confusion
- Sleep disturbances
- Muscle tremors
- Hyper reactive reflexes (ammonia)
Describe how the neurological system can be affected with hepatic disease.
- Ammonia converted into urea in the liver.
- Ammonia comes from the degredation of amino acids.
- Ammonia is then catabolized by the liver generating urea.
- Decreased urea production leads to ammonia accumulation in the blood and neurological symptoms.
What is flapping tremor?
- Elicited by attempted wrist extension while the forearm is fixed.
- Is the most common neurological abnormality associated with liver failure.
MSK pain location with hepatic disease tends to refer where?
Posterior thoracic pain (interscapular, R shoulder/upper trap/subscapular)
Hepatic _____________ is an abnormal development of bone/osteoporosis in individuals with chronic liver disease and leads to ___________/__________.
- hepatic osteodystrophy
- osteopenia/osteoporosis
- Healing of the liver occurs _______ with complete parenchymal regeneration or scarring or a combination.
- ________ hepatic injury results in fibrosis (cirrhosis).
- quickly
- Chronic
- ______ is a late stage of scarring (fibrosis) marked by degeneration of cells, inflammation, and fibrous thickening of tissue. It is typically a result of alcoholism or hepatitis.
- It is a progressive, patterned loss of healthy tissue which is replaced with _______ tissue.
- Significant loss of liver function is associated with loss of __% or more of liver function.
- Cirrhosis
- fibrotic
- 80%
Practice implications for Cirrhosis:
- Osteoporosis
- Impaired ________
- Impaired ________ performance/weakness
- Loss of ___________
- Deconditioning
- Ascites/bilateral edema of feet/ankles
- Blood loss
- _____ to reduce metabolic demand on the heart is recommended.
- posture
- muscle
- balance
- REST
Portal Vein:
- A vein conveying blood to the liver from the _____, ________, ________, __________, and ___________.
- Carries about __% of the blood going to the liver.
- Conducts blood to ________ _____ in the liver i.e. not a true vein.
- The ______ vein and _______ arteries deliver blood to the liver.
- liver from the spleen, stomach, pancreas, gall bladder, and intestines
- 75%
- capillary beds
- portal vein and hepatic arteries
Portal Hypertension:
- Portal hypertension is defined as an increase in hepatic sinusoidal blood pressure > __ mm
- ________ and abnormal liver architecture combine to form mechanical barriers to blood flow in the liver increasing the resistance and blood pressure in the hepatic portal system
- What contributes to this hypertension- probably ________ and accompanying fibrosis; compression of arteries.
- 6mm
- fibrosis
- cirrhosis
- Increased portal pressure causes a __________ flow of blood back into the stomach, spleen, large and small intestine, rectum, and esophagus.
- The result of this are varices back upsteam, what is varices?
- retrograde
- an abnormally dilated vessel with a tortuous course (congestion)
Describe these consequences of portal hypertension:
- Ascites
- Spleenomegally
- Hemorrhoids
- Varices
- Ascites- from increased hydrostatic venous pressure
- Spleenomegally- enlargement of the spleen caused by venous congestion in spleen
- Hemorrhoids- from venous congestion in the bowel
- Varices- esophagus, stomach, rectum, or umbilical area
Hepatic __________ is a potentially irreversible decreased level of consciousness in people with severe liver disease. What is it thought to be caused by?
- Hepatic Encephalopathy
- Thought to be caused by elevated blood ammonia and altered neurotransmitter status in the brain.
Describe how Hepatic Encephalopathy occurs.
- Ammonia is created by bacteria in the colon from the metabolism of protein and urea.
- Ammonia is absorbed into the portal blood system and transported to the liver where it is converted into urea
- But the diseased liver cannot metabolize the ammonia
- Blood ammonia levels go up impairing cognitive and motor function at the level of the brain
What are the S/Sx of Hepatic Encephalopathy?
- Depression, personality changes, impaired attention
- Drowsiness, sleep disorders, ataxia, asterixis, slurred speech, hyperreflexia
- Marked confusion, incoherent speech, muscle rigidity
- STUPOR, DECEREBRATE POSTURING, POSITIVE BABINSKI, DILATED PUPILS
Hepatic Encephalopathy Implications for the PT:
- Patient _______
- Impaired ______ and _______ integrity
- Impaired arousal
- Risk for pressure ulcers secondary to malnutrition, immobility, edema
- safety
- motor and sensory
- ________ is an abnormal accumulation of fluid in the peritoneal cavity and is associated mostly with _______ and accompanying ______ _________.
- How is it managed?
- Ascites, cirrhosis and portal hypertension
- Paracentesis, albumin comsumption, diuretics, sodium and fluid restriction
Ascites Implications:
- Accompanying impaired _______ and _________ function
- ___________
- ________ disorders
- Malnutrition
- Muscle degradation
- cardiac and respiratory
- lymphedema
- integumentary
PART 2
PART 2
- Hepatitis is an __________ condition of the liver caused by _______ by one of several viruses with specific affinity for the liver (A,B,C,D,E).
- Infection can result in _____ or ________ inflammation of the liver.
- What are some other viruses that can cause hepatitis?
- inflammatory, infection
- acute or chronic
- Epstein-Barr, CMV (cyto-megalovirus)
- Most people with chronic hepatitis are __________.
- How is it diagnosed?
- asymptomatic
- symptoms, physical exam, blood test
What are the symptoms of viral hepatitis?
- N/V
- poor appetite, wt loss
- weakness
- jaundice, dark urine
- pale or clay-colored stool
- fatigue
- most people have vague or no symptoms at all
Viral Hepatitis Prognosis:
- Depends on ______ of hepatitis, presence of liver ___________ and development of ________.
- Occurence of liver cancer and/or cirrhosis _______ the progression.
- Mod-to-severe _______ consumption.
- type, comorbidities, cirrhosis
- hastens
- ETOH
Hepatitis A:
- Formerly known as “_________ hepatitis”
- Spread by close personal contact or oral-fecal contamination of water and food, poor hand hygeine, shared use of oral utensils.
- Hepatitis A is _______ and ____-________
- Most persons with _______ disease recover with no lasting liver damage; rarely fatal
- ______ contagious
- preventable with __________
- “infectious hepatitis”
- benign and self-limiting
- acute
- highly
- vaccine
Hepatitis B:
- Formerly known as “_______ hepatitis”
- Spread by blood transsfusions, needle sticks, IV drug use/shared needles, dialysis, sexual contact, exchange of body fluid.
- Considered a ____ because it is transmitted via sexual intercourse
- Incubation period about ___ days
- Most persons with ______ disease recover with no lasting liver damage; rarely fatal
- “serum hepatitis”
- STD
- 90
- acute
- Who is most at risk for Hepatitis B?
- __-__% of chronically infected persons develop chronic liver disease.
- Is there a vaccine?
- healthcare workers who come in contact with blood
- 15-25%
- Yes
Hepatitis C:
- Leading cause of ________ liver disease transmitted by contact with blood of an infected person.
- ______ illness is uncommon.
- __-__% of newly infected persons develop a chronic infection. __-__% develop cirrhosis.
- __-__% of newly infected persons clear the virus.
- Is there a vaccine?
- chronic
- acute
- 75-85%, 5-20%
- 15-25%
- No
What is the treatment of Hepatitis C?
- Interferon-stimulates the immune system to attack the virus
- Ribavirin-anti-viral drug used in tandem with interferon
- New direct acting antiviral agents (curative, 8-12 week course of oral medication)
Who should be tested for Hepatitis C?
- Recieved organ transplant before 1992
- Have ever injected drugs
- Recieved blood product used to treat clotting problems that was made before 1987
- Born between 1945 and 1965
- Have had long term kidney dialysis
- Children born to HCV-positive mothers
What is autoimmune Hepatitis?
Immune reaction launched against cellular material in liver.
What are some other viral causes of Hepatitis?
- CMV
- Epstein-Barr
- Yellow Fever
Other Causes of Liver Disease:
- _____ and _____-induced liver disease.
- ______ liver (fat accumulations -> inflammation -> scarring (cirrhosis)
- ______ abuse
- drug-induced and toxin-induced
- fatty
- ETOH
10 million Americans are alcoholics and about 10-15% of theses will develop cirrhosis.
-Describe this pathogenesis.
- Mitochondrial damage occurs
- Excessive fat content in the liver leads to inflammation which degeneration of hepatocytes
- Degenerated hepatocytes can stimulate an autoimmune reaction that causes further damage: alcoholic “hepatitis”
- Nutritional-deficit injury: occurs because most alcoholics do not eat right
PART 3
PART 3
What is the biliary system?
Transportation route for bile into the duodenum with a storage site in the gallbladder.
- _____ is a dark green to yellowish fluid produced by the liver.
- What is the purpose of bile?
- What does biliary obstruction cause?
- Bile
- Helps emulsify the lipids in food. This process greatly increases surface area for the action of the enzyme pancreatic lipase.
- Prevents the flow of bile to the duodenum resulting in accumulation of bile in the blood and causing jaundice.
- Bile is moved to the gall bladder through the right and left _________ ducts which join to form the common hepatic duct. Bile must then move through the _______ duct to reach the gall bladder.
- The common hepatic duct joins with the cystic duct to form the ______ _____ duct.
- The _________ duct joins the common bile duct and the common bile duct continues on to enter the ___________.
- hepatic ducts, cystic duct
- common bile duct
- pancreatic duct, duodenum
- What is the function of the gallbladder?
- Movement of bile to and from the gallbladder is via ________ action of muscles in the cystic duct.
- Stores and concentrates bile by absorbing water through the wall of the gallbladder.
- peristaltic
Most common biliary diseases are due to either _______ (___________) or __________ of the gallbladder (___________).
- gallstones (cholelithiasis)
- inflammation (cholecysstitis)
__________ is a “gallstone disease” and is one of the most common GI diseases in the US and a major reason for abdominal surgery.
Cholelithiasis
What are the risk factors for gallstones?
- Age
- Genetics
- Decreased physical activity
- Obesity
- Poor lipid profile
- RA
- TPN (total parenteral nutrition)
- Liver disease
- Gastric bypass surgery
- DM
- Gallstones form in the ___________ and form when the composition of _____ changes.
- ________ stones make up 80% of all cases while ________ salt stones make up the other 20%.
- 75% are __________, while 25% become ___________.
- gall bladder, bile
- cholesterol (80%), bilirubin salt (20%)
- asymptomatic, symptomatic
What is the most frequent site of obstruction with gall stones?
-cystic ducts
What are the symptoms of cholelithiasis (gall stones)?
- Abdominal pain
- R upper quadrant
- Abdominal tenderness and muscle guarding
- Pain may radiate to shoulder and upper back
- 50% with symptomatic gall stones will have a recurrent episode
- How are gall stones diagnosed?
- What is the treatment of gall stones?
- ultrasound
- surgery (cholecystectomy)
What are the implications for a therapist when talking about gall stones?
Physical activity may play an important role in the prevention of symptomatic gallstones disease.
What are the usual post-op exercises for any surgical procedure?
- breathing
- bed positioning
- coughing wound splinting if needed
- compressive stockings and leg exercises
Cholelithiasis (gall stones) Implications for PT:
- Physical activity may play an important role in the prevention of __________ gallstone disease in up to a third of all cases.
- Laparoscopic cholecystectomy
- Many individuals still experience referred pain to the right shoulder for __-__ hours.
- Usual postoperative care-breathing, turning, coughing, wound splinting, compressive stockings, and leg exercises
- symptomatic
- 24-48
What is a complication of gall stones defined as calculi in the common bile duct that can cause pancreatis?
Choledocholithiasis- calculi in the common bile duct, can cause pancreatitis.
PART 4
PART 4
Pancreas Gross Anatomy:
- Found in the __________.
- Extends from behind the ________ to the left upper abdomen near the spleen.
- Drains into the inner curvature of the ___________.
- _______ ______ drains the organ, joining with the common bile duct which in turn drains into the duodenum.
- abdomen
- stomach
- duodenum
- Pancreatic duct
The pancreas functions both as an _______ and ________ gland.
- endocrine
- exocrine
- What is an endocrine gland?
- What is an exocrine gland?
- Endocrine- Ductless glands that secrete their products, hormones, directly into the blood.
- Exocrine- Glands that secrete substances onto an epithelial surface by way of a duct.
In regards to the pancreas as an endocrine gland, it secretes ______ and ________ hormones.
-insulin and glucagon
________ is a peptide hormone that regulates the metabolism of carbohydrates, fats, and protein by promoting the absorption of glucose from the blood into liver, fat, and skeletal muscle cells. It is calorie _________.
- Insulin
- conserving
_________ is a peptide hormone, produced by alpha cells of the pancreas. It functions to raise the concentration of glucose and fatty acids in the bloodstream. It favors energy __________.
- Glucagon
- utilization
What is the exocrine gland function of the pancreas?
Secretes HCO3- and a number of digetive enzymes into the pancreatic duct which in turn conducts these molecules to the epithelial lining of the duodenum.
- What region of the pancreas contains its endocrine cells?
- What are the 3 types of cells it houses and their function?
-Islets of Langerhans
- Alpha Cells (A cells): secrete glucagon
- Beta Cells (B cells): secrete insulin
- Delta Cells (D cells): secrete somatostatin (growth hormone-inhibiting hormone GHIH)
Insulin secretion is regulated by circulating _______ levels.
glucose
Actions of Insulin:
- Stimulate cellular uptake of _________ thus reducing the circulating levels.
- Stimulates __________ and ___________ which favor the utilization of available glucose.
- Inhibits ____________ and ______________ which inhibits the storage of glucose.
- Stimulates cellular uptake of amino acids.
- glucose
- glycolysis and glycogenolysis
- gluconeogenesis and glycogenolysis
Insulin is an ___________ hormone.
anabolic
Insulin favors the immediate use of glucose and the _________ of glucose.
storage
What has the opposite effect of insulin and is released from A cells in response to declining insulin levels? It works to increase the concentration of glucose and fatty acids in the blood stream. It is a ________ hormone.
- glucagon
- catabolic
What are the exocrine functions of the pancreas?
- Digestive enzymes ESSENTIAL for processing food.
- HCO3 neutralizes the acidic pH of the gastric juices.
_______ _______ are the specialized organelle in pancreatic acinar cells for digestive enzyme storage.
Zymogen granules
What exocrine enzymes are secreted by the pancreas?
- Proteases (digest proteins and peptides to single amino acids)
- Pancreatic lipase (digests triglycerides, monoglycerides, and FFAs)
- Amylase
Zymogens are a storage form of digestive enzymes, do they have catalytic activity?
Not until they are transformed.
- _____ _________ occurs when there is an abnormal activation of digestive enzymes within the pancreas.
- It results in the ____________ of the pancreas.
- Acute Pancreatitis
- autodigestion
What are some causes of Acute Pancreatitis?
- Gallstones
- Chronic ETOH consumption
- Idiopathic
- Pancreatic cancer
- Drugs
What are the symptoms of Acute Pancreatitis?
- Pain, N/V, anorexia
- Abdominal pain (sharp and severe), position changes do not alleviate the pain
- Pancreatitis can be _____ or _______.
- It is a _______ disease (hyperglycemia, hypoxemia, kidney failure, hypovolemia and shock, jaundice and portal vein thrombosis)
- acute or chronic
- systemic
What is the treatment of Acute Pancreatitis?
- IV fluids
- analgesics
- NPO/stop feeding the patient
- Severe pancreatitis: Admission to ICU
What are the PT implications for Acute Pancreatitis?
- Presents with back pain.
- Pancreatic scarring may occur and limit trunk extension.
- Don’t feed the patient if NPO.
- Bed positioning: side-lying, knee-chest position with a pillow pressed against the chest or sitting with trunk flexed.
PART 5
PART 5
Chronic Pancreatitis:
- Characterized by the development of __________ changes in the pancreas secondary to chronic inflammation.
- Chronic _________ pain, ______ abuse, decreased apetite, weight loss, poor QOL.
- _________ pain with radiation to the back.
- Pain relieved by knee to chest or bending forward.
- Diabetes
- irreversible
- abdominal pain, opioid abuse
- epigastric
Pancreatic Cancer:
- Adenocarcinoma >__ yo.
- 70% of blockage occurs at the ______ of the pancreas.
- More common in _________.
- Diagnosed as an advanced disease.
- Wt loss, pain, jaundice.
- Impaired ________, _______ performance, and ROM.
- Intractable ____ pain.
- 55 yo
- head of the pancreas
- blacks
- posture, muscle performance, and ROM
- back pain
What is a whipple procedure?
-Done to remove a tumor in the head of the pancreas, ampulla, or the first part of the duodenum.
What is resected?
- Head of pancreas
- Gallbladder
- End of common bile duct
- Ampulla
- Duodenum
- Possible part of stomach
DM Type I:
- Accounts for __-__% of all cases of DM.
- Type IA = ?
- Type IB = ?
- Regardless of the type, these patients are on indefinite _______ therapy.
- 5-10%
- Type IA = Autoimmune destruction of B cells resulting in an insulin deficiency.
- Type IB = Insulin deficiency with no evidence of autoimmune disease.
- insulin
What are the complications that can arise from DM Type I?
- Diabetic ketoacidosis
- Hyper- and hypoglycemia
- Coma induced by hypoglycemia
What is diabetic ketoacidosis?
Accelerated degredation of fatty acids -> formation of ketones -> lowers blood pH
What are the clinical features of DM?
- Polyuria- Excessive urination/clear the excess glucose.
- Polydipsia- Excessive thirst.
- Polyphagia- Excessive appetite.
- Weight loss- Excessive fat catabolism.
- Ketoacidosis- Secondary to increased fat catabolism.
DM Diagnostic Values:
- What is the normal fasting glucose levels?
- What is the IFG (impaired fasting glucose) levels?
- What is the provisional diagnosis of diabetes levels?
- FPG <100 mg/dl (5.6 mmol/l) = normal fasting glucose
- FPG 100–125 mg/dl (5.6–6.9 mmol/l) = IFG (impaired fasting glucose)
- FPG ≥126 mg/dl (7.0 mmol/l) = provisional diagnosis of diabetes
FPG = fasting plasma glucose
What is the optimal Hb A1C level?
<7% or g/dl
DM Type II:
- Acounts for __-__% of all cases of DM.
- Is reaching epidemic proportions in this country.
- Can reflect an insulin ________ and/or _________.
- Patients may or may not be on insulin therapy.
- 80-90%
- deficiency and/or resistance
_______ syndrome is a pre-diabetic syndrome. What are the components of it?
Metabolic Syndrome
- Dyslipidemia
- HTN (increased Na retention)
- Abdominal obesity
- Insulin resistance
- Proinflammatory state
- Prothrombin state
- Large waist (>35in women, >40in men)
Diabetic Retinopathy:
- Diabetic Retinopathy can take __-__ years to appear.
- __% been found to have retinopathy at time of diagnosis.
- After 20 years, __% of type IIs will have retinopathies.
- Progression can be slowed with glycemic control.
- 5-20
- 21%
- 60%
Diabetic Nephropathy:
- Diabetes is the most common cause of ______, responsible for approximately __% of all cases.
- 20-30% of all diabetics will develop ESRD.
- ________ and ______ control reduce risk and slows progression of nephropathy.
- ESRD
- 40%
- glycemic and HTN control
Diabetic Neuropathy:
- Involves damage to nerves (______, ______, and _________).
- Often involves ______ extremities.
- Characterized by loss of sensation; sensation of numbness, tingling, and burning; and ______ weakness.
- sensory, motor, and autonomic
- lower
- muscle weakness
___________ ________ ______ Syndrome is an inflammatory syndrome characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism
Diabetic Charcot Foot Syndrome
