Liver, Gallbladder, Pancreas

Question 1

serum bilirubin: direct

Answer 1

conjugated bilirubin

Question 2

serum bilirubin: total

Answer 2

conjugated + unconjugated

Question 3

How do you find unconjugated bilirubin?

Answer 3

total bilirubin - direct bilirubin

Question 4

What are life threatening complications of liver disease?

Answer 4

• multiple organ failure
• coagulopathy
  
  • too much clotting
  • not enough clotting
  • inappropriate clotting
• hepatic encephalopathy
  
  • always blamed on ammonia (lipophillic waste product – crosses BBB)
• hepatorenal syndrome
  
  • kidneys not damaged, just a really low GFR
• esophageal varicies rupture
• hepatocellular carcinoma

Question 5

Whats the problem with increased unconjugated bilirubin?

Answer 5

• it is insoluble in water and tightly bound to albumin, so it cannot be excreted by the kidney
• the fraction that is not bound to albumin will:
  
  • diffuse into tissues (especially brain, causing brain damage)
    
    • build up in tissues → characteristic jaundice, Itching, pruritis
  • produce toxic injury
  • increases in hemolytic disease of the newborn
    
    • skin can conjugate bilirubin in the presence of UV light
  • may lead to severe neurological damage

Question 6

Cirrhosis and portal hypertension: picture

Answer 6

Question 7

How are hepatitis A & E similar?

Answer 7

• typically self limiting
• 2 - 8 incubation
• do not cause carrier state
• do not cause chronic hepatitis
• do not cause cancer
• oral transmission - poor hygiene/infrastructure
• not usually present in US

Question 8

Compare hepatitis A & E

Answer 8

• hepatitis A
  
  • common childhood disease in developing countries
  • adult infection more dangerous
  • sporadic infections - associated w/ oysters, etc
• hepatitis E
  
  • sporadic infections are rare
  • typically endemic and seen in travelers
  • high (20%) mortality rate in pregnant women

Question 9

How are hepatitis B, C, and D similar?

Answer 9

• blood borne
• parenteral transmission - close personal contact
• present in US
• cause carrier state
• cause chronic hepatitis
• cause cancer (*HDV no increase over HBV)
  
  • hep B and C cause liver CA
• Hep D- can only be acquired with Hep B
  
  • Hep B vaccine effective

Question 10

Describe the physical characteristics of a liver with alcoholic cirrhosis.

Answer 10

• characteristic diffuse nodualrity induced by underlying scarring
• average nodule size is 3 mm in this close up view
• greenish tint is caused by bile stasis

Question 11

What are 2 other secondary iron overload diseases?

Answer 11

• transfusions
  
  • 1 transfusion = .25 g of iron
• ineffective erytropoiesis
  
  • B thalassemia
  • sideroblastic anemia

Question 12

What is primary sclerosiing cholangitis?

Answer 12

• intrahepatic + extrahepatic bile ducts
• associated with ulcerative colitis (70%)
  
  • develops after UC - unsure of relationship
    
    • not sure if caused by or is a component of UC
• elevated alkaline phosphatase
• generally without AMA (< 10%)

Question 13

What are some primary causes and characterstics of primary carcinoma of the liver (hepatocellular carcinoma)?

Answer 13

• arise from hepatocytes
• causes
  
  • HBV
    
    • early HBV gives greater HCC rate
    • spread mother to child
  • chronic liver disease (hep C and alcohol)
  • alflatoxin - used to be common in peanut butter, toxin made by fungus
  • tyrosinemia (rare, but 40% get HCC)
  • cirrhosis (85 - 90% - not necessarily cause)
• rate of HCC varies with HBV rate worldwide