Liver And Pancreas Flashcards
Define: icterus
Jaundice
What is jaundice?
Yellowing of the skin caused by increased levels of bilirubin (usually related to increased lysis of RBCs)
How much bilirubin before jaundice appears?
Usually bilirubin levels must reach close to double normal concentration before yellowing is evident.
How is bilirubin transported? Why?
Unconjugated bilirubin is water insoluble and must be transported with an albumin chaperone
What happens to conjugated bilirubin?
It is water-soluble and should be included in the bile. When elevated, may appear in urine.
What is the difference between indirect and direct bilirubin? Relationship to urine?
Indirect = unconjugated / insoluble / prehepatic. Cannot appear in urine.
Direct = conjugated / soluble / posthepatic. Can appear in urine when elevated?
What is hemolytic anemia and what is it’s relationship to jaundice?
Accelerated degradation of RBCs leading to excessive release of bilirubin
Define: cholestasis
Obstructive jaundice caused by biliary obstruction —> bile spills over into the tissues when the bile cannot move into the intestines normally due to obstruction
Define: hepato-cellular jaundice
Jaundice associated with liver damage
Which of these result in bilirubin in the urine?
- cholestasis
- hepatocellular jaundice
- hemolytic anemia
- choluric jaundice
- acholuric jaundice
Why??
Choluric jaundice = elevated conjugated or direct BR
Cholestasis is the only one that results in urinary bilirubin —> the problem is bile duct obstruction, which is post-conjugation
Acholuric jaundice = elevated unconjugated or indirect BR
Hemolytic anemia and liver failure both result in free unconjugated bilirubin —> not water soluble and therefore not in the urine.
Review: which are the fat-soluble vitamins?
A
D
E
K
What are the ingredients of bile?
Water Cholesterol Bile acids Bile salts Lecithin Bile pigments Inorganic ions
What is the van den Bergh reaction? What does it test for?
Tests for the presence of bilirubin in the blood. Distinguishes between direct and indirect.
[Mix serum and sulfanilic acid —> if turns red —> conjugated bilirubin is present
Serum, sulfanilic acid and alcohol —> if turns red —> unconjugated bilirubin is present]
Define: kernicterus
Brain damage in an infant due to jaundice
Define: cirrhosis
Diffuse scarring / fibrosis of the liver. Irreversible disruption of function with nodular hyperplasia (from past repair attempts)
Review: define ascites
Abdominal fluid due to accumulation of fluid (most often related to portal HTN)
Manifestations of cirrhosis
Portal HTN leading to:
- circulatory obstruction
- ascites
- esophageal varicosities
- splenomegaly
Review: most common varicosities?
- esophageal
- pampiniform plexus
- saphenous veins (lower leg)
- hemorrhoids
What are the 3 stages of cirrhosis?
- Fatty liver
- Alcoholic hepatitis
- Cirrhosis (fibrosis)
What are the characteristics of fatty liver?
- asymptomatic
- universal in heavy drinkers
- reversible with lifestyle changes
- normal function
- enlarged with greasy appearance
What are the characteristics of alcoholic hepatitis?
- Inflammation and necrosis of hepatocytes
- inclusion of Mallory bodies (hyaline deposits)
What are the symptoms of alcoholic hepatitis?
Possible sx include: Vomiting Anorexia Hepatomegaly Pain Jaundice
What are the characteristics of cirrhosis?
- Necrosis of hepatocytes
- Collagenous scarring
- slow progression
- irreversible
Threshold for risks associated with drinking?
36% of caloric intake
What is accumulating in pigment cirrhosis?
Iron
What is hemosiderin?
Complex of protein and ferric ions that is deposited in macrophages (liver, spleen, marrow) and hepatocytes —> formed when iron is in excess
What is bronze diabetes?
Hemochromatosis
What is the diagnostic triad for hemochromatosis?
- bronzed skin (jaundice)
- cirrhosis
- pancreatic fibrosis (eventually leads to Type II DM)
Hepatolenticular degeneration is the medical name for what condition?
Wilson’s disease
What is Wilson’s disease and what are the dominant features?
Dysfunction in copper regulation, resulting in copper accumulation in liver, kidneys, brain, eyes.
Causes:
- cirrhosis
- lentiform nucleus degeneration (Parkinson like sx)
- Kayser Flesher ring
Define: cholelithiasis
Gallstones
What are gall stones made of?
Mostly cholesterol
Can gall stones be seen on imaging?
Sometimes. Rarely calcify, so not likely to show up on plain films
Who is at highest risk for gallstones?
The 4 F’s:
- female
- fat
- fertile
- 40+ (age)
What are “pure” gall stones?
Stones in the gall bladder made of all cholesterol. Large, oval, and only a few. May be pigmented with bilirubinate, giving them a blackberry appearance.
What are “mixed” or “combined” gall stones made of?
A combination of cholesterol and bilirubin. Tend to be many, faceted and variable in size.
Are pure or mixed gall stones more common?
Mixed - 80% to 90% (only about 10% are pure cholesterol)
What are the symptoms of gall stones?
Tend to be asymptomatic - 80% are silent unless they cause:
- biliary obstruction
- biliary colic
What is biliary colic?
Painful spasms associated with the passage of gall stones into the biliary tract
Define: cholecystitis
Inflammation of the gallbladder, acute or chronic
What are the 3 main causes of cholecystitis?
- Hyperconcentrated bile
- Bacterial infection, which usually follows concentration of bile (which causes mucosal injury, allowing bacteria to enter)
- Pancreatic reflux (mixing of pancreatic digestive enzymes into bile may cause mucosal damage)
What are the features of acute cholecystitis?
- right upper quadrant pain (DDX with appendicitis)
- bacteria present (80%)
- enlarged gallbladder
- edematous & hyperemic (red)
- mucosal ulceration
- biliary colic
What is the danger of severe acute cholecystitis?
Necrosis and gangrene of the gallbladder leading to peritonitis
What are the features of chronic cholecystitis?
- fibrotic
- either reduced in size or distended
- calcification may be present
What is “porcelain gallbladder”?
Calcification of the gallbladder
What are the most common tumors of the liver?
Metastasis of GI tumors via portal drainage
What infections affect the pancreas most?
- mumps
- hepatitis
What is the primary cause of acute pancreatitis?
Activation of pancreatic enzymes leading to “auto-digestion” via inappropriate trypsin activity
What is the dominant symptom of acute pancreatitis?
Severe pain with sudden onset, may refer to upper back. Usually follows meal or alcohol ingestion.
What are the causes of acute pancreatitis?
- chronic biliary disease
- chronic alcohol abuse
- obstruction (biliary stones)
- disturbed sphincter of Oddi allowing mixing of duodenal and pancreatic contents
What is chronic or relapsing pancreatitis?
Multiple episodes of pancreatic attacks, more mild than the acute form. Lead to:
- fibrosis
- atrophy
- pancreatic failure
Which is more common: acute or chronic pancreatitis?
Chronic
Chronic pancreatitis may be associated with what conditions?
- chronic liver disease
- alcoholism
Chronic pancreatitis may lead to what condition?
Type II DM - due to destruction of beta cells
What are the risk factors for pancreatic carcinoma?
- smoking
- high fat diet
- chemicals
- diabetes
What are the symptoms of pancreatic carcinoma?
None. Usually silent, and metastasizes early.
If adjacent nerves are affected, pain may be present
Review: what is Trousseau’s sign?
Spontaneous, migratory thrombosis
What are the most common pancreatic tumors?
What do they cause?
Benign beta cell tumors
Cause hypoglycemia
What is the Zollinger Ellison syndrome? (Triad)
- gastrin producing tumor of islet cells
- gastric hyperacidity
- intractable peptic ulcers
*multiple ulcers is most important sign
What is the 7th most common cause of death in the US?
Diabetes mellitus
What are common sites of organ damage due to diabetes?
Heart
- cardiovascular disease
- atherosclerosis
Kidney
- glomerular sclerosis
- renal atherosclerosis
Eyes
- retinopathy
- cataracts
- glaucoma
Peripheral nerves
What is the distribution pattern for DM-induced peripheral neuropathy?
Glove and stocking
Define: pyelonephritis
Urinary tract infection
