Hepatic, Pancreatic and Biliary Pathology Flashcards
Signs and Symptoms of Hepatic Disease - Dark Urine and Light Stool
• Inability of liver or biliary system to excrete bilirubin
• Association with jaundice
Main symptom
Signs and Symptoms of Hepatic Disease - Skin Change
Yellow eyes: bilirubin 2-3 mg/dL.
Yellow skin: bilirubin above 3 mg/dL.
Spider angiomas: increased estrogen levels due to liver impairment.
Palmar and plantar erythema.
Changes in Urine, Stool, Skin Color - Diseases
- Hepatitis
- Cirrhosis
- Hepatotoxic medication
- Gallbladder
- Pancreatic cancer
Signs and Symptoms of Hepatic Disease - Neurological Symptoms
Neurotoxins impairs peripheral nerve function
• Confusion
• Sleep disturbance
• Muscle tremors
• Hyperreactive reflexes
• Asterixis (flapping tremor): Inability to maintain wrist extension with forward flexion of the upper extremities.
Signs and Symptoms of Hepatic Disease - Hepatic Osteodystrophy
Metabolic bone disease (osteoporosis) (joint pain) • Cholestasis (bile flow suppression) • Hepatocellular disease - Primary biliary cirrhosis - Primary sclerosing cholangitis - Alcoholic liver disease
Signs and Symptoms of Hepatic Disease - MSK Location of Pain
- Thoracic pain between scapulae
- Right shoulder
- Right upper trapezius
- Right interscapular
- Right subscapular areas
Hepatic Disease - Special Implications for Therapist
Promote rest and healing, intense exercise avoided.
Increased risk of coagulopathy: Risks with manual therapy, intense exercises.
Liver flap or asterixis (tremor) can be observed in uremia, respiratory failure, and severe heart failure.
Liver Disease Complications
- Jaundice (iceterus)
- Cirrhosis
- Portal Hypertension
- Hepatic Encephalopathy
- Ascites (fluid in stomach)
- Hepatorenal Syndrome
Liver Disease Complications - Jaundice (Iceterus)
• Liver can’t process bilirubin efficiently • Over production of bilirubin • Decreased uptake of bilirubin • Impaired bile flow • >2mg/dL Yellow
Liver Disease Complications - Cirrhosis + Symptoms
Main complication. Normal tissues are replaced by fibrosis and nodular regeneration. Portion not working, repeated damage, liver gets bigger.
• Fatigue (unexplained)
• Weight loss (unexplained)
• Pruritus
• Jaundice
• Coagulopathies (blood doesn’t coagulate)
• Loss of ability to metabolize drugs
Liver Disease Complications - Portal Hypertension - Implication for Therapist
Increase in portal pressure > 6mmHg
Implication for therapist: patient education on how to avoid excessive intraabdominal pressure.
Liver Disease Complications - Hepatic Encephalopathy
Relates to the amount of poison the brain will have from the liver.
Grade 1: slight personality changes, short attention span, mild confusion and slight tremor.
Increasing symptoms up to grade 4 which is comatose.
Liver Disease Complications - Ascites
- Fluid in peritoneal cavity mainly due to portal hypertension
- Most often caused by decompensated liver
Liver Disease Complications - Hepatorenal Syndrome
• Severe complication of advanced cirrhosis associated with
poor survival (because drugs stop working).
• Consequence of abnormal hemodynamics
• Kidney failure → Systemic organ failure → complete organ failure.
Hepatitis
- Acute or chronic
- Caused by a virus, chemical, alcohol, drug reaction
- 6 different virus: A, B, C, D, E, Fulminant (rapid progression)
Mild to Moderate Acute Hepatitis
Inflammation of Liver.
Symptoms appear much faster.
Chronic Hepatitis - Description and Physio Treatment
chronic necroinflammatory injury
• Can lead to cirrhosis and end-stage liver disease
Maintain muscle mass, ease pain, try to slow down decline of patient.
Chronic Hepatitis - Symptoms Advanced and Not
Advanced: • Nausea • Poor appetite • Weight loss • Jaundice • Dark urine • Abdominal pain • Easy bruising • GI bleedings • HE with mental confusion Not advanced: asymptomatic, may have mild fatigue, malaise, loss of appetite, joint pain.
Acute Liver Failure - Definition
Fulminant Hepatic Failure.
rapidly progressing form of liver injury/inflammation without prior liver disease. Develop over days to week.
50% of cases caused by Acetaminophen hepatotoxicity.
Acute Liver Failure - Symptoms
• Encephalopathy: ff Ammonia > 200 μM : intracranial pression and cerebral edema • Liver failure • Infection • Hypoglycemia • Coagulation defect. Mortality rate <90% with no treatment.
Liver Neoplasm Cancer - Groups
- 3 groups
- Benign
- Primary malignant: Arising from liver itself, almost always in cirrhotic liver.
- Secondary or Metastatic malignant
Benign Liver Neoplasm - Cavernous Hemangioma - Description, Symptoms and Special Implication for Therapist
Blood-filled mass of variable size. abdominal mass is the most common finding.
Symptoms: asymptomatic until large, feeling of fullness, upper abdominal pain.
For therapist: Avoid increased intraabdominal pressure.
Appropriate breathing during exercises.
Benign Liver Neoplasm - Adenomas - Risk Factors, Symptoms and Special Implication for Therapist
Oral contraceptive is a risk factor. Risk of hemorrhage.
Symptoms:
• Right upper quadrant abdominal pain.
If hemorrhage:
• Pain, Fever, Circulatory collapse.
Special implication for the therapist:
• Unlikely to see a patient pre-op: high risk of rupture and hemorrhage. Chest physio after surgery.
Malignant Liver Neoplasm - Hepatocellular Carcinoma - Risk Factors and Symptoms
Risk factors: alcohol and cirrhosis. Symptoms: • Right abdominal pain • Weight loss, Poor appetite/early satiety • Weakness, Fatigue • Diarrhea, Constipation • Jaundice
Summary of Referred Pain - Liver
Under right nipple.
Less: right shoulder, mid/low thoracic pain.
Acute Pancreatitis - Etiology/Pathogenesis
- Gallstones
- Chronic alcohol consumption
- Trauma
- Infectious agents
- Medication
Acute Pancreatitis - Clinical Manifestation
Mild: no organ failure, nonspecific abdominal pain.
Moderately severe: organ failure for less than 48h. Local and/or systemic complication.
Severe: persistent organ failure.
Mild to moderate symptoms:
• severe right upper quadrant abdominal pain
• nausea
• anorexia
• vomiting
Related to gallstones: same as ↑ + radiating pain to the back and maximal intensity of pain within 10-20 min.
Acute Pancreatitis - Special Implications for Therapist
- Most likely to see acute pancreatitis when an undiagnosed patient present with back pain
- Loss of spinal extension because of scar tissue
- Might be related to GI condition
- Preferred position : leaning forward, sitting up, lying on left side in fetal position
Chronic Pancreatitis - Clinical Manifestation
Abdominal pain : epigastric region + referred pain to the back
• Nausea and vomiting
Decreased appetite
Weight loss
Worse after eating
• Relieved by bringing knees to chest or bending forward
Steatorrhea
Chronic Pancreatitis - Special Implications for the Therapist
Back pain may be the presenting symptom. Pain increases without doing anything
Alcohol-related pancreatitis often have peripheral neuropathy.
Pancreatic Cancer - Clinical Manifestation
• Initially non specific and vague: - Anorexia - Nausea - Fatigue - Pruritus • Jaundice • Weight loss • Significant pain
Cholelithiasis (Gallstones) - Risk Factors
Increasing age Genetic Factors Decreased physical activity Pregnancy Obesity Diet Diabetes mellitus
Cholelithiasis (Gallstones) - Clinical Manifestation
• Severe abdominal pain (from 30min to 6hours)
- Right upper quadrant (below sternum)
- Referred pain to right shoulder and upper back
- Nausea and vomiting
Cholelithiasis (Gallstones) - Special Implication for Therapist
- Physical activity as prevention
- Deep breathing
- Physical movement and activity as tolerated
- Heating pad on the abdomen
- Usual precaution for postoperative activities (breathing, turning, coughing,…)
Gallbladder and Biliary Tract Neoplasm - Clinical Presentation
If symptomatic, often incurable. • Mimics gallstone disease • Right upper quadrant pain radiating to the upper back • Nausea and vomiting • Progressive jaundice • Weight loss • Anorexia • Fatty food intolerance Special implication for therapist same as gallbladder.
Summary of Referred Pain - Gallbladder
Below nipple pain.
Less: upper shoulder, inferior angle of scapula and upper medial side of scapula pain.
