L12 diag of liver and panc dis Flashcards
LO3: interp basic liv func tests-
- hepatocellul dam- liv not work. Aminotranferases (ALT/ST). Gamma glutamyl peptidases (gamma-GT).
- choelcystasis (bile ducts)- how gets rid bile prods. Post hepat. Bili. Alk Pase.
- cell dam= synthet func-alb. Prothrombin. Also aff enzs meas for liv func.
LO4: desc causes and effs jaundice.
-liv cell dam eg infec, tox, tum (us metast). Dam cells decr capac to sec bili so build in blood=jaund= yell pigm skin and eyes. Clinic defec over 40umol/L. Norm under 22.
-causes- fig out by blood test.
Pre hepat- haemolytic. Excess bili prod us due to incr haemolysis.
Hepat/intra hepat- parenchymal. Decr capac liv to sec conjug bili to blood.
Post hepat- cholestitic aka obstructive. Obstruc to drain of bile=back up to liv.
-bili to liv, conjug to gamma-GT. Then elim by bil tree to duod, changes in bowel, some reabs and excret in urine, some faeces. Build conjug bili in blood-faeces pale, streatorr, dark urine.
LO5: disting pre hepat, hepat, and post hepat jaund.
PRE:
-incr haemolysis, liv not cope incr bili.
-lab- unconjug hyperbili, reticulocytosis (excess immat BC), amaemia, incr LDH rel by RBC, decr hepatoglobin (binds free Hb as rel from breakd).
-causes:
Inher- often in kids. RBC mem defec. Hb abn. Metab defec.
Congenital hyperbili- eg Gilbert’s synd (too little gamma-GT), 5-10% pop, stress=yell, no clinic sig.
Acq- imm, mech, acq mem defec, infec, drugs, burns.
HEPATOCELLUL:
-derranged hepatoc func (AST and gammaGT). Elem of chelstasis. Swell liv cells so not rid of what can conjug=nice bili and ALP.
-lab- mixed unconjug and conjug hyperbili. Incr AST/LT=dam. incr ALP cholestasis swollen cells. Abn clott can’t synth CFs.
-causes-
Congenital- eg Gilbert’s synd.
Hepat inflamm- vir (hep, EBV), autoimm hepatitis, alc, haemochromatosis, Wilton’s dis hered.
Drugs eg paracetamol.
Cirrhosis- liv try regen in resp to dis, fail=dam. Alc, chronic hepatitis, metab disord.
Hep tumour- hepatocellul carcinoma. Metast.
POST/CHOLESTATIC:
- obstruc biliary sys. Intra/extra hepat. Block pass conjug bili.
-lab- conjug hyperbili. Dark urine. No urobilinogen in urine as no bili ent bowel. Incr canalicular enz (ALP). Incr liv enz (AST/LT)-mild hepatoc dam due to press.
-causes-
Intrahepat- hepat swell. Hep, drugs, cirrhosis, prim biliary cirrhosis.
Extra hepat- obstruc distal to bile canaliculi. Gallst, biliary stricture, carcinoma (head panc, ampulla, bile duct, port hepatis LN, liv metast), pancreatitis, sclerosing cholangitis.
-counoisies law- if non tend palpab gallbl, painless jaund unlikely due to gallst. Gallst formed over LT=shrunken fibrotic gallbl. Gallbl more often enlarged in pathol that= bili obstruc over ST (malig). Tend gallbl in acute cholecystitis, and tend and distend with microcele of empyema rel to gallst.
Hepatitis- acute/chronic.
-acute- hepatoc breakd- aminot rel, jaund.
Chronic dam-synth fail, decr alb, decr CF.
-causes-
-Vir- Hep A RNA, fecal oral, no prog=acute. HepB DNA, blood/saliva/ sex/ vertic spread=acute and chronic, hepatocellul carcinoma, 1% fulmin hepatitis. HepC RNA, blood, 50% chronic liv dis (30% cirrhosis, 5% HCC), somet asymp. HepD, EBV/CMV-yell fever.
acute vir hep= jaund, malaise. No specif tx-supp only.
-autoimm.
-toxin eg drugs- methyldopa, isoniazid.
-hered- alpha1 antitrypsin dis. Wilsons dis.
LO6: desc effs excess alc on liv. Key feats alc liv dis.
Consump req varies. Genet predisp.
- pathol- fatt change, alc hepatitis, cirrhosis.
- complics- HCC, liv fail, wernicke korsa koff synd, encephalopathy, atrophy=dementia and decr parenchyma, epilepsy.
- alc metab liv only. Breakd prods event dam liv cells=fatt change init then die=cirrhosis.
LO7: des conseqs of liv cirrhosis.
-liv cell necrosis then insular regen and fibrosis= incr resis to blood flow and decr liv func.
Port sys drains GIT. IMV, SMV, splenic converg= port vein ent liv prov 70% liv blood. NO valves, rel low press sys. Incr resis=backflow.
-causes- alc, hepB/C, biliary cirrhosis, autoimm hepatitis, haemochromatosis, Wilsons.
-clinic feats-
Liv dysfunc- jaund, anaemia, bruising as decr CF, palmar eryth. fibrotic contracture of flexor tendons in hands, unkn why, imm med. also flap tremor as metabol build.
Portal HTN.
Spont bact peritonitis.
-investig- incr AST/LT. Incr ALP. Incr bili. Decr alb. Reduc clott. Decr Na.
-manage- stop alc. Treat complics. Transl.
-specif causes-
-Prim bili cirrhosis- chronic obstruc bile ducts. Clinic= jaund, pruritis, xanthelasma, hepatosplenomeg. Supp tx then transl.
-hered haemochromatosis- autos recess. Abn iron transp forms iron deposits. Clinic= cardiomyop, bronze diab, pit hypog admiss, hepatitis/cirr, hyper pigm skin. Venesection tx.
-Wilsons- autos recess. Disord Cu transp forms deposit, less in skin. Clinic- hepatitis/cirr. Basal ganglia-Parkinson’s type syn- tremor, dysarthria, dementia. Kidn tubule degen. Kaser- fleischer ring rnd eye. Penicillamine tx-chelation.
-a1 antitrypsin defic- autos recess. Clinic= cirr, emphysema at bases-tend yng. Lung and liv transplants tx.
LO8: outl how liv dis may= PHTN and appreciate assoc pathol.
-fibrosis incr resis=as cites and divers blood through Porto-ven anast, esp in LO=varices, eas dam= haematemesis.
HTN= port ven press over 20mmHg from intra/extrahepat port ven comp or occlus.
-causes-
Obstruc port vein- congenital, thrombosis, ext comp by tum.
Obstruc flow in liv- cirr, hepat scler, schistosomiasis, sarcoidosis.
-Porto-sys anast- port vein joins sytemic BS. Eg Oesoph br of IMV (port) and infer rectal veins (sys). Port tribs of mesent and retroperit veins. Port veins of liv, and veins of ant abdo wall. Port br in liver and diaph (bare area).
Retrograde flow= areas of anast dilates eg veins bott oesoph=eas rupt. Proced balloon stop bleed above port press or LT bypass anast, high mort. Comm oesoph and rectum.
-clinic- spleen omen due to press. Ascites as low alb. Spider naevi oestrog dep, can’t get rid (esp male)= vess dilat, also man gynacomastia. Caput medusae- recanal umb vein. Oesoph/ rectal varices- ven dilat, protrude to lumen, rupt/ulcer=haemorr diffic stop. As cites and musc waste as low prot.
-fulmin hepat fail- and/or sev acute decomp and liv fail. Decr hepat func- hepat enceph 2 mnth after diag liv dis, poss link to brain oedema. Decomp as incr metab demand.
Causes- HepA/D/E. Drugs eg paracetamol, isoniazid, ecstasy. Wilsons. Preg. Reyes synd. Alc.
Feats- jaund. enceph as not rid NH3, diff X BBB to CNS=confus, aggress, brain swell. Decr LOC. hypog sign fatal w/o transpl. Decr K/Ca. Haemorr- no CF and dilat vess!
Manage- spec liv func. Supp therap. Liv transplants.
-hepat enceph- NH3 and hypoalb=odema. Precip by sepsis/infec, constipat as incr tox abs, diuretics, GI bleed as blood dig tox, alc withdraw. Clinic- flap tremor, decr LOC, personality change, intellec decr=constrictional apraxia, slow slurred speech.
-hepat tum-
Benign- haemangioma. Focal modular hyperplasia. Liv cell adenoma. Liv cysts. Polycystic liv. Cystadenoma.
Malig- prim HCC. Sec metast- colorectal 50%, neuroendoc, panc, breast, stom, lung. Ovary, kidn. 20 cases liv metast for 1 HCC. Maj metast due to port ven drain from GIT.
-dis of gallbl and bil tree. =obstruc jaund. Stor and pass bile liv to duod. Rem water and salt. Pathol- obstruc eg gallst, bil stricture, atresia in newborn, CA panc, pancreatitis. Also infec, inflamm, neoplasia.
LO9: desc causes and conseqs gallst.
-bile alc and chol reach critic conc=precip. Most asymp. Move to neck/ducts=bil colic. Sev RUQ pain, worse by inspiration. Gen last hrs, end when stone move back to gallbl bod or to int.
-irrit bil tree dur obstruc may= cholecystitis- inflamm of duct, often foll by infec. Pain sim to colic but longer and often fever. Need surg. Laparoscopic rem gallbl.
-cholelithiasis=gallst. 10-20% pop. Aetiol/RFs- fem, aging, obes or rap weight loss, multiparty, diet, dev countries, drugs eg OCP, ileal dis/resec (crohns), haemolytic dis eg SC.
-types stones- mixed 80%. Chol and Ca and bile pigm. Pure chol 10%, us solit, up to 5cm. Pigm 10%, Ca bilirubinate, multip small black, us the ones that block duct.
-complics- biliary colic- Hartmanns punch impact ion of stone. Gallbl contrac and distension= intermittent pain post prandial.
Cholecystitis infec- stones may be acacullus (isch/infec). Odema >mucosa> ulcer> fibropurulent exudate. Pain, SIRs, pyrexia, sepsis.
Microcele- impact of stone. Painf distens. Muc sec.
Epyema- is superald infec. Pus.
Obstruc jaund.
Asc cholangitis- stone out gallbl block duct=jaund and infec. Life threat. Charcots triad- RUQ pain, jaund, fever.
Acute pancreatitis.
Biliary-enteric fistula/gallst ileus- fistula gallst to duod. Large stone obstruc ileum.
Gallbl carcinoma- 2% all CA. Assoc gallst?
Gallbl perforat.
LO10: desc causes and conseqs acute pancreatitis.
-panc can become inflamed acute/chronic may dev tums, often aggress poor prog.
Acute when enzs of acinar cells activ premat in ducts. Eg due to obstruc outflow, infec, hyper stim panc sec often by alc. Partic proteolytic. Sev constant upper abdo pain rad to back. Panc enzs to blood incr amylase found. Life threat.
-panc endoc insulin, glucagon, somatostat. Exoc fluid HCO3, enzs protease, amylase, lipase. Close to duod, CBD. Port vein. Coeliac trunk.
-acute pancreatitis- odema, haemorr, necrosis.
Chronic- fibrosis, calcification.
-acute causes- gallst, alc, trauma, steroids, mumps, autoimm, scorpion bite, hyper lip, ERCP/iatrogenic, drugs.
Pathogenesis- duct obstruc= jaund and bile reflux. Acinar dam from reflux/drugs. Protease tiss destruc. Lipase fat necrosis. Elastase BV destr. Panc breakd, systemic I’ll, after yng as alc/gallst yng norm.
-Biochemical alt- incr amylase, decr Ca, hyperg, incr ALP and bili.
-clinic- sev pain, vom, dehyd, shock/SIRs.
-tx- supp for pain etc. LT ICU.
-mort 10% overall, sev form 30%. Haemorr 50%.
-chronic pancreatitis- parenchymal destr, fibrosis, loss acini, duct stenosis. As rep inflamm due to gallst, CF, bil dis, alc.
Clinic- pain, malabs (streatorr, decr alb, decr wieght). DM, jaund. Calcification in panc.
LO11: desc presentat carcinoma of panc.
- often caught late so no cure. 90 duct all carcinoma. 5% all CA death. Aetiol- smoking, beta napthylamine, Benzedrine, familial pancreatitis.
- clinic- init asymp. Obstruc jaund as CA wrap CBD- palpab gallbl. Pain as coeliac axis lot nerves, CA erodes. Vom erode duod. Carcinomatosis. Malabs. DM.
- whipped surg- rem panc, duod, bile duct. Join SI.
- prog- 5th CA death UK. 5-15% suitab for resective surg, lot mort and morb. 15-35% 5 yr surv. Overall 1yr surv 12%. As invade loc v fast, few symp early.
LO1: desc role of liv in handling bile pigm, horms, drugs, toxins incl alc.
LO2: desc funcs of liv in relat to blood prot.
Liver funcs:
- bile prod and excret. Fail= jaund.
- carb, prot, lip mate ab. Fail=maln.
- prot synth. Fail=low blood prot=odema as fluid out.
- vit D synth.
- detox. Fail= can’t deal with metabols.
- vit and min stor.
- phagoc. Fail= infec.
