Liver, gallbladder n' such Flashcards
Premature activation of what enzyme in particular causes pancreatitis? What does this cause?
trypsin–this causes activation of other enzymes
What two types of necrosis ensue d/t pancreatitis?
- Liquefactive
- Saponification / fat necrosis
What are the two most common causes of pancreatitis? How?
- EtOH (contracts sphincter of Oddi)
- Gallstones (blocks drainage)
What cause the saponification seen in pancreatitis?
Digestion of fat surrounding pancreas
How does EtOH cause pancreatitis?
Contraction of the sphincter of Oddi, causing backup of enzymes and pancreatic juices
How do gallstones cause pancreatitis?
Blockage of the duct of Vader
What is the most common traumatic cause of pancreatitis?
Seatbelt smashing in car accidents
How does hypercalcemia cause pancreatitis?
Activates enzymes
What are the two metabolic disturbances that can lead to pancreatitis?
- Hypercalcemia
- Hyperlipidemia
Which virus can cause pancreatitis?
Mumps
Rupture of what part of the duodenum (e.g from an ulcer) ( will lead to acute pancreatitis? anterior or posterior)
Posterior
What are the classic s/sx of pancreatitis?
Epigastric pain that radiates to the back with n/v
What causes the periumbilical and flank hemorrhage in pancreatitis?
Necrosis spread to these two regions as well
What enzymes are elevated in acute pancreatitis? Which is more specific?
Lipase
and amylase, but not specific
What is the metabolic disturbance that acute pancreatitis causes? Why?
Hypocalcemia d/t saponification (uses up Ca)
What causes shock seen in acute pancreatitis?
Damage of the blood vessels
What causes the pancreatic pseudocyst seen in acute pancreatitis? What can this cause if it ruptures?
Fibrous tissue surrounds pancreatic necrosis. Amylase within this can cause damage if released
What is the usual bacterial cause of a pancreatic abscess?
E.Coli
How can acute pancreatitis cause DIC? ARDS?
Amylase can activate coagulation factors and destroy lung tissue.
What is chronic pancreatitis, and what is the most common cause of it in adults? Children?
- Recurrent bouts of acute pancreatitis, resulting in fibrosis
- Adults = EtOH
- Children = CF
What should you think if a patient with a recent bout of pancreatitis has persistently high amylase levels, despite resolution of acute phase?
pseudocyst
What are the s/sx of chronic pancreatitis?
- Pancreatic insufficiency
- Epigastric pain radiating to the back
What causes the pancreatic insufficiency seen in chronic pancreatitis? How does this manifest itself?
- Fibrosis
- Steatorrhea and malabsorption issues
Are amylase and lipase good indicators for chronic pancreatitis? Why or why not?
No, because most of the pancreas has been destroyed
What are the radiological findings of chronic pancreatitis?
Dystrophic calcification
What endocrine disorder can result from chronic pancreatitis? How?
DM– damage to the beta cells
What CA are patients with chronic pancreatitis at an increased risk for? From what tissue in the pancrease does this usually arise from?
-Pancreatic adenocarcinoma– from the ducts
In what age group is adenocarcinoma of the pancreas most common?
Elderly
What are the two major risk factors for pancreatic carcinoma?
Smoking and chronic pancreatitis
What are the s/sx of pancreatic adenocarcinoma?
epigastric pain and weight loss
What are the classic findings of adenocarcinoma in the head of the pancreas?
- Palpable gallbladder
- Jaundice
- Pale stools
Thin elderly pt with new onset DM is suspicious for what?
pancreatic adenocarcinoma
What is the tumor marker for pancreatic adenoCA?
CA19-9
—-What is the treatment for pancreatic adenoCA? Prognosis?—
—–Whipple procedure
(removal of duodenum, head of pancreas, and gallbladder
-Poor prognosis—-
What is biliary atresia?
Failure to form, or early destruction of the extrahepatic biliary tree
How does biliary atresia present? What type of bilirubin is elevated in this disorder?
- Jaundice, progressing to cirrhosis early in life
- Direct (conjugated) bili is elevated
What are the three causes of cholelithiasis?
- Supersaturation of cholesterol or bilirubin
- Decreased phospholipids / bile acids
- Stasis
How does cholestyramine cause an increased risk for cholelithisasis?
Decreased reuptake of bile acids, which is needed for solubility
How does stasis in the bile duct lead to gallstones?
Bacteria deconjugate the heme into bili, leading to bili
What is the most common type of gallstones in the west? How do they appear on imaging?
- Cholesterol stones
- Usually radiolucent (don’t appear)
Why is it that estrogen increases the risk for cholelithisais? (2)
- Increases HMG-CoA reductase and cholesterol synthesis
2. Estrogen also increase cholesterol receptors on liver
How does clofibrate increase the risk for gallstones?
It increases the rate of HMG CoA reductase action, leading to increased cholesterol synthesis, and decreases bile acid
What ethnicity has a higher rate of cholelithiasis?
Native americans
What is the IBD that increases the risk for cholelithisasis? Why?
- Crohn’s disease
- Ileum is damaged, so there is poor uptake of bile acids and salts, causing precipitation of cholesterol
How does cirrhosis increase the risk for gallstones?
Decreased production of bile salts
What are the causes of bilirubin stones? (2) How do they appear grossly?
- extravascular hemolysis
- Biliary tract infections
-Black or darkly pigmented stones
What are the three infectious agents that increase the risk for the development of a gallstone (hint: 1 bacteria + 2 parasites)?
- E.coli
- Ascaris lumbricoides
- Clonorchis sinensis
What are the five key complications that can result from gallstones?
- Biliary colic
- Acute and chronic cholecystitis
- Ascending cholangitis
- Gallstone ileus
- Gallbladder CA
What is biliary colic?
Intermittent RUQ abdominal pain caused by contractions of the gallbladder against a stone.
What is acute cholecystitis?
Acute inflammation of the gallbladder caused by an impacted stone in cystic duct and bacterial overgrowth
What is the classic presentation of acute cholecystitis? (3)
- RUQ pain with radiation to the right scapula
- Fever + leukocytosis
- N/v
What will happen to a gallbladder in acute cholecystitis if left untreated?
Rupture
Why is alk phos elevated in gallbladder issues?
Alk phos a key component of the endothelial cells of the gallbladder tract
What is chronic cholecystitis?
Chronic inflammation of the gallbladder due to longstanding chemical irritation from cholelithiasis
What are Rokitansky-Aschoff sinuses? What disease are these seen in?
gallbladder mucosa that dives down into the wall. Classic for chronic cholecystitis
What is the classical s/sx of chronic cholecystitis?
Vague RUQ pain after eating
What is the long term complication of chronic cholecystitis?
-Porcelain gallbladder–dystrophic calcification of the gallbladder
What is Porcelain gallbladder? What is the risk of leaving this untreated?
- Dystrophic calcification of the gall bladder secondary to chronic cholecystitis
- Predisposes to gallbladder cancer
What is the treatment for chronic cholecystitis?
Cholecystectomy
What is ascending cholangitis?
Bacterial infection of the bile ducts
How does ascending cholangitis present?
Sepsis, jaundice, and abdominal pain
What type of bacteria usually cause ascending cholangitis?
Enteric, Gram negative
What poses an increased risk of developing ascending cholangitis? How?
Choledocholithiasis– decreased flow of bile allows bacteria to grow upwards in the bile duct
What is a gallstone ileus? How do these occur?
-Gallstone that enters and obstructs the small bowel–usually the result of a fistula development between the gallbladder and the duodenum, which allows for a large stone to pass through and obstruct the ileocecal junction
What cancer is associated with cholecystitis?
Adenocarcinoma from the gland cells of the gallbladder
What is the major risk factor for the development of gallbladder adenoCA
Gallstones
—-What is the classical presentation of gallbladder carcinoma?—-
—-Cholecystitis in an elderly women—-
Jaundice occurs when serum bilirubin rises above what level?
> 2.5 mg/dL
What is the transporter for the heme component of Hb when it is broken down in the blood? Where does this go?
Albumin, goes to the liver
What causes the brown coloration of stool? Yellow urine?
Urobilinogen
What changes bili to urobilinogen?
Intestinal bacteria
What causes the increased risk of pigmented gallstones in hemolysis of ineffective erythropoiesis?
Increase in bili being poured out of the liver
What causes the dark urine in hemolysis/ineffective erythropoiesis?
increase in urine urobilinogen,. NOT due to the increased unconjugated bili