Hepatic, Pancreatic & Biliary- PT 1 Flashcards
Location of the liver
Just below the respiratory diaphragm Predominantly on the right side (head) with a portion crossing mid line (tail)
Most superior part of liver
Dome of the right lobe
True/False- The liver is a large organ that spans many vertebral levels
True
Where is the peak of the dome of liver located during expiration?
At around T8-T9
Posterior location of the liver
approximately T9 to L1 at mid line which varies in persons. Moves up a level or two with inhalation Moves down with exhalation
Location of the fundus of gallbladder (head)
Below the edge of the liver, in contact with the anterior abdominal wall at the tip of the 9th right coastal cartilage
Functions of the Liver – >500 separate functions, but most importantly:
- Regulates blood composition, including the amounts of glucose (sugar), protein, and fat that enter the bloodstream.
- Removes bilirubin and other toxins from the blood.
- Processes most of the nutrients absorbed by the intestines during digestion and converts those nutrients into forms that can be used by the body.
- Stores nutrients- Vitamin A, Iron, and other minerals.
- Makes cholesterol, vitamin A, substances that help blood clot, and certain proteins.
- Sole source of albumin and other plasma proteins
- Filters all blood from the GI tract (“first pass”) – catches Drugs, Chemicals, Toxins, Bile Acids
What is Bile?
greenish/brown fluid, made from cholesterol in liver, stored in gall bladder, which breaks down fats into fatty acids in the GI tract
What is Bilirubin?
A by-product of the breakdown of red blood cells.
Function of the Gall bladder
Produce, Transport, and Store Bile
True/False- You cannot live without your gall bladder?
False- You can live without it, especially if the bile starts turning into stones that clog the ducts
Exocrine functions of the Pancreas
Exocrine cells produce digestive enzymes to help with the digestion of food. “These exocrine cells release their enzymes into a series of progressively larger tubes (called ducts) that eventually join together to form the main pancreatic duct. The main pancreatic duct runs the length of the pancreas and drains the fluid produced by the exocrine cells into the duodenum, the first part of the small bowel.”
Location of the Pancreas
Behind the stomach, anterior to L1-L3 vertebral bodies. It is about 6 inches long, wide at the head then tapered through the body to the other end (tail)
Parts of the gall bladder
Fundus Body Infundibulum Neck
Cholelithiasis
- Presence or formation of gallstones.
- Can be asymptomatic,
- Detected incidentally during medical imaging
- Problems arise if a stone leaves the gallbladder and causes obstruction somewhere else in the biliary system
Cholecystisis
Inflammation of gallbladder Occurs when the gallstone enters the cystic duct and becomes lodged there.
Obstruction of either the hepatic or common bile duct by a stone or spasm results in:
- Blockage of the bile from exiting the liver where it is formed.
- Jaundice is the first symptom If an infection develops and backs up into the liver, a condition called Cholangitis can occur- potentially life threatening condition.
Cholangitis
An infection that develops when bile is backed up inside of the liver- potentially life threatening condition.
Hepatic &; Biliary S&S (all)
Most acute conditions include: Hepatitis, Drug-induced Hepatitis, and Ingestion of Hepatotoxins
Pain referral patterns RiMS -
- Right shoulder regions,
- Mid back, and
- Scapular
Skin changes – jaundice, when bilirubin 5-6 mg/dL; may see in sclera of eye first (bilirubin 2-3 mg/dL)
Hepatic &; Biliary S&S:- Most acute conditions include: (3)
- Hepatitis
- Drug-induced Hepatitis, and
- Ingestion of Hepatotoxins
Hepatic & Biliary S&S:- Pain referral patterns (RiMS) -
- Right shoulder regions
- Mid back, and
- Scapular
Hepatic & Biliary S&S:- Skin changes
Jaundice, when bilirubin 5-6 mg/dL; may see in sclera of eye first (bilirubin 2-3 mg/dL)
Primary pain patterns from the liver, gallbladder, and common bile duct.
- Presents typically in mid epigastrium or right upper quadrant of the abdomen
- Innervation of the liver and biliary system is through the autonomic nervous system from T5-T11
- Referred pain from the liver occurs in the thoracic spine from approx. T7-T10 and/or to the right of mid line, possibly affecting the R shoulder (R phrenic nerve)
- Referred pain from the gallbladder can affect the R shoulder by the same mechanism The gallbladder can also refer pain to the R inter scapular (T4 or T5 to T8) or R sub scapular area
Innervation of the liver and biliary system
Through the autonomic nervous system from T5-T11
Referred pain from the liver occurs:
In the thoracic spine from approx. T7-T10 and/or to the right of mid line, possibly affecting the R shoulder (R phrenic nerve)
Referred pain from gallbladder:
Can affect the R shoulder by the same mechanism as liver
The gallbladder can also refer pain to the R inter scapular (T4 or T5 to T8) or R sub scapular area
Hepatic & Biliary S/S: (8)
↑ bilirubin, vascular dilations,↑estrogen, and ↑ blood toxins due to poor cleansing in the liver can result in:
- Spider angioma,
- Pruritis (itching)
- bruising,
- Palmar erythema
- Opaque nails (nails of Terry)
- Xanthelasma (from cirrhosis)
- “flapping tremor” (called Asterixis)
- Ascites
Spider angioma
Permanently enlarged and dilated capillaries visible on the surface of the skin, caused by vascular dilation. Capillary radiations could be flat or raised in the center. SA present on the upper half of the body , primarily on the face, neck, chest, or abdomen, and occurs as a normal development or in association with pregnancy, chronic liver disease, or estrogen therapy. They do not go away when the underlying condition is treated. can be removed cosmetically with laser treatment.
Palmar Erythemia
Caused by liver impairment. Presents as a warm redness of the skin over the palms and soles of the feet in the Caucasian population darker skin tones may change from a tan color to a grey appearance Look for other signs of liver disease such as nail bed changes, spider angioma, liver flap, BIL carpal and tarsal tunnel syndrome. Can occur in healthy people and in association with non-hepatic diseases.
Nails of Terry
Opaque nail plate with a narrow line of pink at the distal end instead of the more normal pink nail plate in Caucasian. Can also present as a result of malnutrition, DM, Hyperthyroidism, Trauma, sometimes unknown (ideopathic)
Xanthelasma
Multiple soft yellow plaques involving the eyelids (lower and upper) Lipid-laden foam cells seen in the dermis tend to cluster around blood vessels. Lipid deposits can also be seen along the extensor surfaces of the body such as the heels, elbows or dorsum of hands
Flapping Tremor
Elicited by attempted wrist extension while the forearm is fixed. Most common neurological abnormality associated with liver failure. Can also be observed in uremia, respiratory failure and severe heart failure. The tremor is absent at rest, decreased by intentional movement and maximal on sustained posture. Usually bilateral, although one side may be affected more than another.
Most common neurological abnormality associated with liver failure.
Flapping Tremor
Liver Disorder- Viral Hepatitis (Everything)
- Hepatitis A&E – fec-oral transmission; easily spread; usually result of poor sanitation or food contamination (there is a vaccine for HEV)
- Hepatitis B,C,D, and G – bloodborne transmission from blood or other bodily fluids
- HBV may be fatal (vaccine required for health workers)
- HDV must have HBV present to co-infect
- HCV – growing concern over transplants and ACL allografts; not generally a big risk for healthcare workers
- HGV is a designation for a virus, percutaneous transmission, lasts about 10 years; primarily seen in IV drug users
- Use universal precautions of handwashing, gloves, gown if needed for all viral hepatitis
Hepatitis A&E
Fec-oral transmission; easily spread; usually result of poor sanitation or food contamination (there is a vaccine for HEV)
Hepatitis B,C,D, and G
Bloodborne transmission from blood or other bodily fluids
Hepatitis B Virus (HBV)
May be fatal (vaccine required for health workers)
Hepatitis D Virus- (HDV)
Must have HBV present to co-infect
Hepatitis C Virus (HCV)
Growing concern over transplants and ACL allografts; not generally a big risk for healthcare workers
Hepatitis G Virus (HGV)
A designation for a virus, percutaneous transmission, lasts about 10 years; primarily seen in IV drug users
Four stages of hepatitis
- Incubation/preclinical, 10-50 days - asymptomatic
- prodromal/preicteric, lasts 1-3 weeks – you start to get sick
- Icteric, lasts 2-4 weeks – active illness- fluey, malaise, fever, jaundace
- Recovery/convalescence, lasts 3-4 months – easily fatigued
Chronic Hepatitis (Everything)
- Prolonged (6 months or more) liver inflammation after unresolved viral hepatitis, or associated with chronic active hepatitis (CAH)
- CAH can be caused by virus, drug sensitivity (INH for TB, Aldomet for hypertension, statin drugs)
- Treated with steroids,interferon-alpha-2b injections-
- Pegasys interferon treatment
- Side effects of fatigue, headache, ,myalgia, fever, irritability, GI upset
-
Wilson’s Disease – autosomal recessive disorder in which copper excretion is impaired
- Neurological presentation, dyskinesia (chorea)
- Treated with chelation, moderately successful
- Hematochromatosis – excess iron Nonviral hepatitis – alcohol, drugs, chemicals
Chronic Hepatitis duration
Prolonged (6 months or more) liver inflammation after unresolved viral hepatitis, or associated with chronic active hepatitis (CAH)
Cause of Chronic Active Hepatitis (CAH) (2)
Virus, Drug sensitivity (INH for TB, Aldomet for hypertension, statin drugs)
**It looks like INH is also refered to as Isoniazid.
Treatment of CAH
- Steroids,
- Interferon-alpha-2b injections
- Pegasys interferon treatment
Side effects of CAH Treatment (6)
- Fatigue
- Fever
- Irritability
- GI upset
- Headache
- Myalgia
Chronic hepatitis- Wilson’s Disease
- Autosomal recessive disorder in which copper excretion is impaired
- Neurological presentation, dyskinesia (chorea)
Wilson’s Disease- Treatment
Chelation- moderately successful
Wilson’s Disease- Neurological presentation
Dyskinesia (chorea)
Hematochromatosis
Excess iron
Nonviral hepatitis- causes
Alcohol, Drugs, Chemicals
