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Pathophysiology > Liver > Flashcards

Liver Flashcards

1
Q

what ducts converge to form the “common bile duct” and where do they come from?

A

gallbladder- cystic duct
liver- left and right hepatic duct
pancreas- pancreatic duct

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2
Q

how is the liver divided into lobes?

A

Divided into 2 large lobes (left and right) and 2 smaller lobes (caudate and quadrate)

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3
Q

what is the dual blood supply of the liver?

A

Has dual blood supply consisting of venous (portal) supply through the hepatic portal vein and an arterial supply through the hepatic artery

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4
Q

hepatic Portal supply carries ______ absorbed in the intestine, ______ from spleen, and ________ from the pancreas

A

nutrients and toxic materials- intestine
blood cells- spleen
insulin and glucagon- pancreas

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5
Q

the “end stage of liver disease”

A

cirrhosis

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6
Q

what organs drain into the portal vein?

A

spleen, stomach, pancreas and small bowel

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7
Q

the liver stores ____ mL of blood which can be shifted into the circulation during ________ and _____

A

450

hypovolemia and shock

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8
Q

In right sided heart failure, the pressure in the _____ increases and causes …

A

vena cava

…a back up of blood which accumulates in the liver

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9
Q

what are the lobules and sinusoids of the liver?

A

Lobules are the functional units of the liver (not to be confused with the “lobes” of the liver!!!)- within these are the hepatocytes
Sinusoids are channels in the liver and provide for exchange of substances btwn blood and liver cells;

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10
Q

sinusoids are lined with…

A

lined with typical capillary epithelial cells and Kupffer cells

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11
Q

what are kupffer cells?

A

Kupffer cells are large macrophages that phagocytize old blood cells, bacteria (especially enteric bacilli from intestines), and foreign material

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12
Q

sinusoids are where ____ flows through, canaliculis are where ____ flows through

A

sinusoids: blood
canaliculis: bile

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13
Q

what make up the hepatobiliary tree?

A

intrahepatic (inside liver) and extrahepatic (outside liver) bile ducts.. they unit to form the common bile duct

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14
Q

pancreatic bile duct joins the common bile duct at …

A

the ampulla of vater …which empties into the duodenum through the duodenum papilla

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15
Q

what does the sphincter of oddi do?

A

regulars flow of bile into duodenum (when clsoed bile will go back up into gallbladder)

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16
Q

what can cause obstructions in the bile duct? which is the worse one to have an obstruction in?

A

sludge and stones

- common bile b/c it backs up all routes

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17
Q

what drug would cause spasms of the sphincter of oddi?

A

morphine - don’t give as pain management to someone with possible gallbladder enlargement as itll cause backing up and more engorgement of gallbladder

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18
Q

3 main metabolic functions of the liver?

A
  1. carb metabolism
  2. lipid metabolism
  3. protein synthesis and conversion of NH3 (ammonia) to urea
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19
Q

carb metabolism in the liver (2 parts)

A

Stores excess glucose as glycogen and synthesizes glucose from amino acids
Converts excess carbs to triglycerides for storage in adipose tissue

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20
Q

lipid metabolism in the liver (3 parts)

A

Oxidation of free fatty acids to ketoacids
Synthesis of cholesterol, phospholipids, and lipoproteins
Formation of triglycerides from carbs and proteins

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21
Q

what happens when we break up triGs?

A

break up TriGs into glycerol and fatty acids— end product acetylCoA - citric acid cycle = energy

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22
Q

what does the liver produce proteins for?

A

some for its own needs, some to be exported for other parts of the body to use

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23
Q

what protein synthesized by the liver is of particular importance?

A

Albumin : contribution to plasma colloidal osmotic pressure and to the binding and transport of hormones, fatty acids, and bilirubin

*overall: albumin helps maintain homeostasis of oncotic pressures. low albumin = ascites b/c fluid SHIFTS out of plasma

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24
Q

protein synthesis and degradation involves what two parts?

A

transamination and deamination

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25
Q

transamination

A

NH2 (amine group) is transferred to an acceptor substance (making proteins)

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26
Q

deamination

A

removal of amino group from amino acids (proteins) and conversion of amino acids to ketoacids and ammonia (NH3)- which is bad. (breakdown of proteins) - excrete as urea

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27
Q

low albumin likely means …

A

chronic liver issue (really any chronic disease but likely a liver issue)

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28
Q

what can high NH3 levels cause? txt for this?

A

high NH3 levels = altered mental status (messes with neurons), confused, can seem drunk.
-May have asterixis (“liver flap” - you have flex hand and it begins to pulse)

txt : lactulose- makes you poop (binds NH3 and gets it out of the system)

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29
Q

3 functions of the liver, are the separate or dependent on each other?

A

dependent

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30
Q

what is the first pass effect in regards to drugs?

A

Once the medication/drug/toxin enters into the liver, it is degraded until a much smaller amount of the bioavailable drug actually is passed to the systemic circulation.

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31
Q

what is bile made of?

A

Made of water, bile salts, bilirubin, cholesterol, and other by-products

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32
Q

what is secretion of bile essential for?

A

digestion (emulsification): fats

absorption: fats and vitamins from intestine

33
Q

____ are the most important component of bile for digestion

A

bile salts!

34
Q

what “path” do bile salts take?

A

Bile salts travel the circuit of intestine–> portal circulation in distal ileum –> liver 18 times before it meets its final resting place (kidneys as urine or in stool)

35
Q

what is the recirculation of bile called?

A

enterohepatic circulation

36
Q

what gives bile its yellow/green color?

A

bilirubin

also give stool and urine their color

37
Q

where does bilirubin come from ?

A

RBC –> Hgb broken down –> unconjugated (non-watersoluble) bilirubin –> attaches to albumin for transport –> transformed into conjugated (water soluble) in the hepatocytes –> secreted into bile and secreted into small intestine –> half is converted to urobilinogen

38
Q

where does urobilinogen go on to be absorbed ?

A

portal circulation, kidneys (rarely) or excreted in stool

most is reabsorbed back through portal circulation and excreted in bile

39
Q

abnormal levels of unconjugated or conjugated… where would these indicate an issue in regards to the liver?

A

prehepatic issue- unconj

hepatic issue- conj

40
Q

direct and indirect/free bilirubin are the same as …

A

direct: conjugated

indirect/free: unconjugated

41
Q

what would increased direct or indirect bilirubin indicate?

A

increased Indirect bili : think increased production of bili, decreased uptake of bili by liver, or decreased conjugation of bili by the liver

increased Direct bili: think decreased secretion and obstruction

42
Q

total serum bilirum (direct + indirect) is normall what level?

A

0.1-1.2 mg/dL

43
Q

what is jaundice and at what levels of bilirubin will you notice it?

A

Yellow discoloration of skin and deep tissues resulting from abnormally high levels of bili in blood (b/c of destruction of RBCs)
You can notice jaundice around total bili levels of 2-2.5 mg/dL

(gardner said some people it may have to be over 3 to see)

44
Q

if you dont notice jaundice of the skin, where else might you see it?

A

sclera of eyes, mucus membranes

45
Q

3 possible causes of jaundice

A

prehepatic: excessive RBC destruction
intrahepatic:
posthepatic: osbtruction of bili-flow

46
Q

most common cause of prehepatic jaundice? what level will be elevated

A

hemolytic disease of newborn

unconjugated/indirect will be elevated

47
Q

causes of intrahepatic jaundice?

A

Decreased bili uptake by the liver
Decreased conjugation of bili
Probable issues with secretion of bili from liver

other possibles (may not be pertinent to know)

  • -Drug-induced cholestasis
  • -Hepatocellular liver damage
  • -Hepatitis, cirrhosis, liver CA
48
Q

cause of posthepatic jaundice? which level will be elevated?

A

some kind of obstruction from tumor or stone (cholelithiasis)
direct/conjugated will be elevated

49
Q

normal levels of direct/conjugated and indirect/unconjugated

A

direct: 0.1-0.5
indirect: 0.1-0.7

50
Q

perhepatic jaundice (usually of hemolysis of newborn): how does it present?

A

Typical presentation: mild jaundice, elevated unconjugated bili, stools are normal color, no bili in the urine

51
Q

mild unconjugated hyperbilirubinemia is common in the first _____ of life.. what to txt?

A

2 weeks

get then eating/drinking regularly and it should go away

52
Q

intrahepatice/hepatocellular jaundice is caused by…

A

disorders that effect livers ability to remove bili from the blood or conjugate it … bili then cant be eliminated in bile;
can also affect ability to secrete bili from the liver

53
Q

presentation of intrahepatic jaundice (signs and labs)

A
  • conjugated AND/OR unconjugated bili levels can be elevated
  • dark urine
  • serum “alk phos” is slightly elevated
  • mild jaundice
54
Q

what is alk phose?

A

Alkaline phosphatase is an enzyme present in the bile duct epithelium and canalicular membrane of hepatocytes

the cells within bile duct send this out when its obstructed (can be gallstones, malignancies)

55
Q

posthepatic jaundice is caused by what?

A

Occurs when bile flow is obstructed between the liver and the intestine; obstruction will be located somewhere btwn the junction of the right or left hepatic duct and the point where the bile duct opens into the intestine

56
Q

common causes of posthepatic jaundice

A

strictures of bile duct, gallstones, tumors of bile duct or pancreas

57
Q

common presentation of posthepatic jaundice

A

elevated conjugated bili

  • stools are clay colored, urine is dark
  • alk phos is very high
  • aminotransferases increase ( AST/ALT liver enzymes- elevated = liver injury)
58
Q

what is cholestasis?

A

Impaired bile formation and bile flow which leads to accumulation of bile pigment in the parenchymal tissues of the liver
causes accumulation of bilirubin, cholesterol, and bile acids in the blood

59
Q

causes of cholestasis? (5)

A

Can be caused by intrahepatic or posthepatic issues:

  1. primary biliary cirrhosis
  2. primary sclerosing cholangitis (disease of large bile ducts)
  3. cholelithiasis
  4. common duct strictures
  5. obstructing neoplasms
60
Q

cholestasis: presentation (PE and labs) (4)

A 
pruritis (elevated plasma bile acids. bile in skin = irritation)
Skin xanthomas (fatty deposits on eyelids) 
Elevated alk phos (b/c obstruction at some level) 
Nutritional deficiencies: vit A, D, and K
61
Q

what are AST and ALT?

A 
Alanine aminotransferase (ALT)-liver specific
Aspartate aminotransferase (AST)-derived from organs other than the liver
- used for liver "function" tests : aka to see how much of liver is injured
62
Q

when will you see a rise in AST/ALT?

A

In liver damage, you typically see a rise in both values.

EXCEPT in: Liver damage d/t alcoholism:

63
Q

liver damage from alcohol will usually show an AST/ALT ratio of what?

A

usually see a 2:1 ratio of AST/ALT

64
Q

true tests of hepatobiliary function are what?

A

PT, PTT, INR

65
Q

what is PT? what are the normal levels for it?

A 
Prothrombin time (PT) helps to assess the liver’s ability to synthesize coagulation factors (factors I, II, V, VII, X) 
PT normal levels 12-13 seconds
66
Q

when is PT/INR prolonged? (4)

A 
PT /INR prolonged in:
Coagulation factor deficiency
Vitamin K deficiency
Disseminated intravascular coagulation (DIC)
Acute Liver disease
67
Q

what are factor I and II (measured by PT)?

A

I- fibrinogen

II- prothrombin

68
Q

coagulation abnormalities associated with advanced liver disease … (2)

A
  1. Prolonged PT with lesser prolongation of PTT

2. Thrombocytopenia: secondary to congestive splenomegaly. Alcohol causes suppression of platelet production

69
Q

albumin assesses liver’s ____ function. albumin levels decrease in what cases?

A

Albumin: assesses the liver’s synthetic function
(Synthesized by the liver)
Albumin levels decrease in liver dz, inflammatory dz, severe trauma, malnutrition, nephritic syndrome

70
Q

what are the normal albumin levels?

A

Albumin normal levels: 3.4 - 4.7

71
Q

what does alk phos measure? where do you find it?

A

AP measures hepatic excretory function

Present in the membranes between liver cells and the bile duct

72
Q

alk phos is released in disorders affecting what? what can it also be indicative of?

A

and is released by disorders affecting the bile duct (like obstruction), but can also be indicative of cancer with mets to the bone

73
Q

normal alk phos level

A

Alkaline phosphatase (AP): 41-133 units/L

74
Q

normal GGT level

A

y-glutamyltransferase (GGT): 9 - 85 units/L

75
Q

what does GGT levels measure?

A

Along with alk phos, it measures the excretory function of the liver
Thought to function in the transport of amino acids and peptides into liver cells and is a sensitive indicator of hepatobiliary disease
(more of a secondary test)

76
Q

elevated GGT levels mean what?

A

Elevated levels are present in alcohol abuse

77
Q

in what order will you choose labs to draw for suspected liver issues?

A

start with CBC, CMP, PT/PTT and maybe (if AP elevated and AST/ALT elevated) maybe GGT, then bilirubin last

78
Q

what liver tests are not included in CMP?

A

direct and indirect individual levels (total is included)

PT and PTT, INR

Pathophysiology (28 decks)

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