S7) Liver and Pancreatic Pathology Flashcards
Describe the anatomical relationship of the liver with the gallbladder and duodenum
Outline the transport and metabolism of bilirubin
Identify 3 ways in which we can measure liver dysfunction
- Failure of anabolism
- Failure of catabolism and excretion
- Markers of hepatocyte damage/dysfunction
Identify 4 things produced by the liver (anabolism)
- Albumin
- Glycogen
- Coagulation factors
- Haematopoiesis (in foetus / adult with bone marrow failure)
In terms of anabolism, identify 2 indicators of poor liver function
- Hypoalbuminaemia due to failure to produce albumin
- Prolonged prothrombin time (PT/INR) due to failure to produce coagulation factors
Identify 5 things broken down by the liver (catabolism)
- Drugs
- Hormones
- Haemoglobin
- Poisons
- Aged RBCs (after splenectomy)
Identify and describe 3 abnormalities of bilirubin production/excretion
- Pre-hepatic jaundice: too much bilirubin e.g. haemolytic anemia
- Intra-hepatic jaundice: failure of hepatocytes to conjugate and/or secrete bilirubin e.g hepatitis, cirrhosis
- Post-hepatic jaundice: failure of the biliary tree to convey conjugated bilirubin to duodenum e.g. biliary tree obstruction
How can excess bilirubin be measured?
Conjugated bilirubin is water soluble so when elevated, serum levels can be measured with a dipstick (dark yellow)
Identify 3 signs of pre-hepatic jaundice
- Raised serum bilirubin
- Increased urinary urobilinogen
- No conjugated bilirubin present in urine
Identify 4 symptoms of pre-hepatic jaundice
- Mild jaundice (lemon tinge)
- Stools may be very dark
- Normal urine colour
- No pruritis
Identify 3 signs of intra-hepatic jaundice
- Raised serum bilirubin
- Normal urinary urobiliogen
- Conjugated bilirubin present in urine
Identify 4 symptoms of intra-hepatic jaundice
- Moderate jaundice
- Stools normal
- Urine dark
- No pruritis usually
Identify 3 signs of post-hepatic jaundice
- Raised serum bilirubin
- Decreased urinary urobilinogen
- Conjugated bilirubin present in urine
Identify 4 symptoms of post-hepatic jaundice
- Severe jaundice (green tinge!)
- Stools pale
- Urine dark
- Pruritis
Identify 3 enzyme markers of hepatocyte damage/dysfunction
- Alanine aminotransferase (ALT) is released by inflamed/damaged hepatocytes
- Alkaline phosphatase (Alk Phos) is present in the liver canaliculi, bile ducts and bone
- Gamma-glutamyl transferase (Gamma GT) is present in bile duct cells
A raised ALT is due to hepatitis.
Identify 4 causes of hepatitis
- Viral (A, B, C etc.)
- Acute alcohol intake
- Fatty liver disease
- Drugs/toxins
Identify 2 main causes of a raised Alk Phos
- Bile duct/liver disease with cholestasis
- Bone disease
Identify 4 conditions which lead to bile duct/liver disease presenting with a raised Alk Phos
- Biliary obstruction
- Cirrhosis
- Liver metastases
- Drugs
Identify 4 conditions which lead to bone disease presenting with a raised Alk Phos
- Bone metastases/fracture
- Osteomalacia
- Hyperparathyroidism
- Paget’s disease of bone
Identify 5 causes of a raised Gamma GT
- Biliary duct obstruction/cholestasis
- Cirrhosis
- Liver metastases
- Drugs
- Alcoholism
Identify 4 common liver and bile duct diseases
- Hepatitis
- Cirrhosis
- Gallstones and biliary tract obstruction
- Liver metastases
How does liver failure present?
- Increased susceptibility to infections
- Increased susceptibility to toxins and drugs
- Increased blood ammonia (failure to clear ammonia via urea cycle)
Identify 6 symptoms of hepatitis
- Malaise
- Anorexia
- Fever
- Right upper quadrant pain
- Dark urine
- Jaundice
What are the typical blood test findings in acute hepatitis?
- Normal albumin and INR
- High serum bilirubin
- Very high serum ALT
- Normal/slightly raised Alk Phos
- Normal/slightly raised Gamma GT
What is cirrhosis?
Cirrhosis is a condition caused by liver fibrosis, producing a shrunken hard nodular liver
Identify 3 consequences of liver fibrosis
- Portal hypertension due to pressure and occlusion of the hepatic sinusoids
- Reduced excretion due to pressure on the bile canaliculi
- Reduced albumin and clotting factor production due to replacement of hepatocytes by fibrous tissue
Identify 4 main causes of liver cirrhosis
- Alcohol
- Consequence of viral hepatitis (B,C)
- Fatty liver disease
- Idiopathic
Identify 3 sites of portosystemic anastomoses
- Anorectal junction
- Ligamentum teres of falciform ligament
- Oesophagogastric junction
In two steps, explain how oesophageal varices results from liver cirrhosis
- Pressure and occlusion of the hepatic sinusoids leads to portal hypertension
- Portal hypertension leads to portosystemic shunting, including oesophageal varices
Identify 5 symptoms of cirrhosis
- Fatigue/weakness
- Ascites
- Swollen legs (hypoproteinaemia)
- Weight loss
- Jaundice
What are the typical blood test findings for cirrhosis?
- May all be normal
- May show a low albumin and/or prolonged INR
- May show a raised bilirubin
- May be a slight rise in ALT (if ongoing inflammation)
- May be very mild raise in Alk Phos (if cholestasis)
- May show a raised Gamma GT (if alcoholism)
What is the treatment of cirrhosis?
- Fibrosis is irreversible so a liver transplant is needed
- Treatment is aimed at managing the complications
What are the 2 main causes of gall bladder obstruction?
- Gallstone migration from the gallbladder into common bile duct
- Carcinoma of the head of pancreas
What are the typical laboratory findings in post-hepatic/obstructive jaundice?
- Normal serum albumin and INR
- Normal/slightly raised serum ALT
- Very high serum bilirubin
- Conjugated bilirubin present in the urine
- Raised Alk phos and Gamma GT
What is cholangitis?
Cholangitis is an infection in the bile ducts and a life-threatening complication of bile duct obstruction, commonly caused by E. Coli
Why do gallstones develop?
Gallstones develop in the gallbladder due to chemical imbalances in the bile
Biliary colic is not true colic.
What is it?
- Biliary colic is pain in the right upper quadrant that radiates to the tip of the right scapula/right shouder
- It is often precipitated by eating a fatty meal and lasts up to 6 hours
What is acute cholecystitis?
Acute cholecystitis is inflammation of the gallbladder, occurring when a gallstone blocks the cystic duct and commonly caused by E.coli
Apart from severe gallbladder pain, how does a patient with acute cholecystitis present?
- Systemically unwell
- Pyrexia
- Tenderness over the gallbladder
Why is the liver a common site for metastases?
The liver is designed to filter the blood entering it and cancer cells can lodge in the filter
What are the laboratory findings in liver metastases?
- Raised serum bilirubin
- Conjugated bilirubin present in the urine
- Raised Alk Phos
- Slightly raised ALT and Gamma GT
- Normal serum albumin and INR
What are the two forms of pancreatitis?
- Acute
- Chronic
What is acute pancreatitis?
- Acute pancreatitis is a common condition arising from the premature activation of pancreatic proteases in the pancreas itself rather than in the duodenum
- These proteases then autodigest the pancreas and the retroperitoneum
Identify and describe the 2 main causes of acute pancreatitis
- Alcohol alters the balance between proteolytic enzymes and protease inhibitors, thus triggering enzyme activation
- Gallstone obstruction causes pancreatic duct hypertension and the toxic effect of bile salts contribute to enzyme activation (biliary acute pancreatitis)
What is chronic pancreatitis?
- Chronic pancreatitis is rare condition caused by alcohol abuse where repeated low grade pancreatitis causes pancreatic fibrosis
- The pancreas becomes calcified and patients suffer severe epigastric and back pain that leads to opiate addiction and not infrequently suicide
State 2 symptoms of acute pancreatitis
- Epigastric pain that goes through to the back
- Vomiting
How can the diagnosis of acute pancreatitis be confirmed?
- Raised serum amylase / serum lipase
- CT scan used to look for pancreatic necrosis/pseudocyst
Describe the treatment of acute pancreatitis
- Analgesia
- Supportive treatment
- Fluid resuscitation
What is pancreatic cancer?
- Pancreatic carcinoma is a condition resulting from the uncontrolled cell growth in the pancreas which metastasises to the rest of the body
- Nearly all are ductal adenocarcinomas and most are in the head of the pancreas
Describe the clinical presentation of pancreatic carcinoma
- Anorexia, malaise, fatigue
- Significant weight loss
- Epigastric and/or back pain
- Dark urine
- Pale stools
- Pruritis
