HIGH YIELD LIVER/GALLBLADDER (PATHOMA) -- Leah Flashcards
Biliary Atresia:
- age group
- cause
- presentation
- babies
- failure to form/ destruction of EXTRAhepatic biliary tree
- jaundice (conjugated bilirubin) –> cirrhosis
Cholelithiasis is the big word for _____.
- three causes
- most common type?
- gallstones
1. supersaturation (cholesterol or bile)
2. decreased bile or phospholipids
3. stasis
**Most common type = cholesterol (90%); bile less common.
Cholesterol stones:
- color
- xray appearance
- major risks
-yellow
-radiolucent
-FAT FERTILE FEMALE FORTY
(ALSO– clofibrate)
What does radioLUCENT mean? OPAQUE?
(Sorry, dumb card guys, I know. But I mess these up.)
- Lucent= too “L”ight to be seen
- Opaque= seen on xray
Bile stones:
- color
- xray appearance
- 2 risk factors
- pigmented (dark)
- radiopaque
- (clonorchiasis, ascaris lumbricoides)
Gallstones:
- most common presentation
- possible complications
- usually ASYMPTOMATIC!!!!
- until they cause….. biliary colic, cholecystitis, ascending cholangitis, gallstone ileus, gallbladder cancer
Biliary colic:
what is it?
-waxing/ waning RUQ pain caused by gallbladder contracting against a stone in the cystic duct
Common bile duct obstruction may lead to?
-acute pancreatitis/ obstructive jaundice
What is unexplained jaundice in and older person until proven otherwise?
-PANCREATIC CANCER BECAUSE THIS CAN BLOCK COMMON BILE DUCT.
Acute cholecystitis:
- cause?
- how is it different from biliary colic?
- risk?
- stone in cystic duct –> dilation/ pressure ischemia/ bacterial overgrowth of the gallbladder
- more constant RUQ pain, also see that “pericolic –however you say it– fluid” on U/S (not mentioned in pathoma) ++ fever, N/V, ^^WBC also seen (patient is SICK, not just in pain)
- risk gallbladder rupture
Chronic cholecystitis:
- classic histo findings
- classic xray finding + risk
- gross appearance
- cause
- herniation of mucosa into muscular wall (Rokitansky Aschoff sinuses)
- porcelain gallbladder –> risk carcinoma (take it out!!)
- shrunken/ fibrotic gallbladder
- chemical irritation 2ndary to long standing cholelithiasis
Ascending cholangitis:
- cause
- presentation
- risk
- bacterial (#1 gram neg) infection of bile ducts
- SEPSIS + abdominal pain +jaundice
- more common with choledocholithiasis
Cause of gallstone ileus
-fistula between gallbladder and small bowel –> stone gets stuck in intestine –> obstruction
Gallbladder carcinoma
- type
- major risk factor
- presenation
- adenocarcinoma
- stones major risk
- cholecystitis in ELDERLY (DOESNT FIT THE FAT, FERTILE, FORTY, FEMALE) criteria
Jaundice
- bilirubin level when icterus (yellow eyes) begins
- most dangerous type?
- 2.5 mg/dl
- kernicterus (DEPOSITS IN BABY’S BASAL GANGLIA.)
Describe steps of leading up to the synthesis of conjugated bilirubin in a healthy person (4)
- reticuloendothelial macs break down RBCs
- Heme –> protoporphyrin –> unconjugated bili
- unconjugated bili to liver via albumin
- unconjugated –> conjugated via uridine glucuronyl transferase (UGT)
How is conjugated bilirubin removed from the body?
Intestinal Flora:
conjugated bili –> stercobilin + urobilin
(sterco goes to stool, uro to urine)
What can overwhelm the bilirubin conjugating ability of the liver?
Two assc findings?
- hemolysis/ ineffective erythropoiesis
- jaundice
- dark urine
- pigminted gallstones
What causes physiologic jaundice of the newborn?
Treatment?
- ineffective UGT enzyme
- phototherapy makes UCB water soluble
Gilbert Syndrome & Crigler- Najjar:
- enzyme effected?
- difference in presenation?
- type of jaundice?
- both effect UGT; low in gilbert but ABSENT in CN
- Gilbert- benign; transient stress induced jaundice
- CN: kernicterus + fatal
- both cause ^^UNconjugated bili UCB
Dubin Johnson & Rotor Syndromes
- defect
- type of jaundice
- difference in clinical presentation?
- deficient bile canalicular transport protein (AR)
- causes ^^ CB
- DUBIN causes a DARK liver; Rotor does not.
(I think of Dubin Johnson as a black man….)
Obstructive Jaundice:
- type?
- two other lab findings?
- stool? urine?
- other symptoms?
- Conjugated
- ^^ urine urobilinogen + alk phos
- pale stool, dark urine
- pruritis, xanthomas, fat malabsorption
Possible causes of obstructive jaundice:
- stones
- cancers (pancreatic v cholangiocarcinoma)
- parasites/ liver fluke
Viral hep:
- type of ^^ bili?
- why?
- urine findings?
- conjugated + unconjugated
- inflammation disrupts BOTH hepatocytes + bile ductules
- dark urine but low –> normal urobilinogen
Hepatitis:
- fecal/ oral variants
- ineffective type?
- types spread by blood/ sex?
- A/E = fecal oral (A trAvel, E sEEfood)
- D= “D”ependent in HBV, otherwise ineffective
- B/C= “B”LOOD AND “C”EX
Two Hep strains that can cause CHRONIC hep?
- B : 20% cases
- C: most all cases
Hep strain that can cause fulminant hep in pregnant women?
-Hep E
Ig that marks ACTIVE/NEW disease? Confers IMMUNITY?
- IgM= new/ active
- IgG= protective
Serologic markers for ACUTE HEP:
- HBsAG
- HBeAG
- HBV DNA
- HBcAB-IgM
Serologic markers during “window” period?
-^^^IgM against HBcAG only.
Serologic markers following immunization against hep?
-^^ IgG against HBsAG only.
Serologic markers for resolved hep?
-^^ IgG against both HBs and HBc ag’s
Serologic markers for CHRONIC hep?
What strains cause this?
- HBsAG more than 6 months
- +/- HBeAG/ HB DNA
- IgG against HBcAG
-20% hep C, ~100% hep C
Viruses that can cause hepatitis (3)
- hepatits virus
- EBV
- CMV
Histo of acute v chronic hep?
- acute: inflammation of TRACTS + LOBULES and hepatocyte apoptosis
- chronic: inflammation of ONLY PORTAL TRACTS + possible cirrhosis progression.
Cirrhosis:
two histo features
cells that mediate?
cytokine that mediates?
- bands of fibrosis + regenerative nodules
- Ito/stellate cells, stimulated by TGF-B
Four general complications of cirrhosis
- ascites
- HSmegaly
- shunts (i.e. varices)
- hepatorenal syndrome (renal failure)
Liver damaged causes decreased detox (NO MORE OF THE EFFING CYPS. I THINK I WANT CIRRHOSIS).
What is the result?
- mental status change, asterixis –> ammonia induced coma
- spider angiomatoma, gynecomastia (^^androgen –> estogen), palmar erythema
**asterixis = flapping tremor
Two main results of decreased protein synthesis by the liver?
- hypoalbuminemia –> edema
- coagulopathy
1 cause liver disease in western world?
-Alcohol (AFLD) –> acetaldehyde mediated damage
But…. NON alcoholic fatty liver (obesity related) is quickly on the rise!
How to diagnose NAFLD?
- ALT higher than AST; AST higher with alcohol use
- diagnosis of exclusion
Alcoholic fatty liver disease
- 2 histo findings
- cure?
- mallory bodies
- fat in hepatocytes
-resolves with abstinence UNLESS cirrhosis is reached (occurs in 10-20%)
Primary Haemochromatosis
- inheritance pattern
- HLA linkage
- effect on liver?
- risk?
- treatment?
**Also: what causes “secondary” type?
-AR defect in iron absorption
(HFE gene mutation –> ^hepcidin –> ^ iron)
-^^ iron due to transfusions in secondary type
- H(A3)machromatosis= HLA-A3 linkage (MHC1)
- damage by free radicals
- HCC risk ^^
- treat with phlebotomy
Haemochromatosis:
classic symptomatic triad?
labs?
two histo findings?
- cirrhosis, DM, bronze skin
- high ferritin, serum iron and %saturation
- low TIBC
- brown pigment in hepatocytes, prussian blue stain +
Wilsons Disease
- Whats the mutation?
- Labs? (3)
- Triad of symptoms
- AR mutation in ATP mediated Cu transport –> copper incorporated in ceruloplasmin
- urinary copper, low ceruloplasmin, copper in liver
- kid with neuro maifestations, cirrhosis, & kayser fleisher rings
Wilsons Disease:
- assc risk?
- treatment?
- ^^ HCC risk (just like haemachromatosis)
- treat with penicillamine chelation
Primary “biliary cirrhosis” and “sclerosing cholangitis”:
in terms of location, whats the difference?
which causes ^^ risk of cholangiocarcinoma?
- biliary cirrhosis= intrhepatic ducts only
- sclerosing cholangitis= intra + EXTRAhepatic ducts … so ^^ risk cholangiocarcinoma
Primary biliary cirrhosis:
- histo
- assc Ab
- population
-granulomatous inflammation
-antimitochondrial ab
~40 years of age, women
Primary sclerosing cholangitis:
- classic histo
- classic CT
- assc disease/ Ab
- periductal fibrosis + onion skinning
- beaded appearance on imaging
- p-ANCA, ulcerative colitis
Reyes:
cause + presentation
- kids: viral illness + aspirin
- liver failure, encephalopathy, hypoglycemia, can be FATAL
ONLY reason to kid aspirin to kids?
-Kawasaki Disease
Hepatic Adenoma:
association?
malignant?
- OCPs, regresses with cessation
- OMA= benign BUT risk rupture + bleeding esp with estrogen exposure
Hepatocellular Carcinoma:
three possible causes?
marker?
prognosis?
- cirrhosis, chronic hep B/C, aflatoxins (p53 mutations, think MOLDY PEANUTS!!)
- marker AFP
- poor prognosis
What is Budd-Chiari?
-hepatic vein obstruction –> liver infarct –> hsmegaly + ascites
(can be caused by tumor compression i.e. hepatocellular carcinoma)
From where are tumor mets most commonly
- Cancer Sometimes Penetrates Benign Liver
- Colon
- Stomach
- Pancreas
- Breast
- Lung
How do you diagnose mets?
-HSmegaly, NODULAR FREE EDGE OF LIVER.
