Test 4-Renal & Urological Flashcards
Decreased perfusion of the kidneys activates what system?
RAAS
The RAAS system increases what?
Sodium and water retention (can lead to hypertension)
Kidneys produce _____ to increase red blood cells
Erythropoietin
Kidneys synthesize ______ which helps absorb _______
Vitamin D; Calcium
Failing kidneys does what to RBCs
lowers them
What happens to calcium levels in the blood in kidney failure?
Hypocalcemia
A problem before the kidneys
Prerenal dysfunction
A problem after the kidneys
Postrenal dysfunction
Results from an injury to the kidney itself
Intrarenal dysfunction
What causes intrarenal dysfunction?
Nephrotoxic drugs, streptococcal infections, and systemic diseases
What causes prerenal failure?
Heart failure, trauma, and shock
Prerenal failure occurs when?
Blood flow and perfusion to the kidneys is reduced
Postrenal failure occurs when?
An obstruction prevents outflow from the kidneys
What is the classic back pain sign from the kidneys called?
Costovertebral angle pain
Blood in the urine
Hematuria
Proteins in the urine
Proteinuria
Measures urine concentration
Specific Gravity
Glucose in the urine most commonly results from what?
Hyperglycemia (can indicate diabetes)
What can be seen in urine after intense exercise?
Proteins
What in the urine may indicate damage to structures of the renal system?
Blood
What in the urine may indicate liver damage?
Bilirubin and Urobilinogen
What in the urine may indicate an infection of the renal system?
Nitrates and leukocyte esterase
What are 2 waste products that should be filtered and removed by the kidneys?
Blood Urea Nitrogen (BUN) and Creatinine
Increased _____________ may indicate reduced glomerular filtration rate (GFR)
serum creatinine
An increase in BUN levels
Azotemia
What are two forms of kidney dialysis?
- Peritoneal dialysis
2. Hemodialysis
What is the most common urological problem?
Obstruction
Distention of the renal pelvis
Hydronephrosis
Dilation of the ureter
Hydroureter
Stones located anywhere in the urinary tract
Urolithiasis
Stones can be categorized based off of what?
Their location
What is the most common cause of UTIs?
E. coli
Asymptomatic bacteriuria is diagnosed when?
2 consecutive urine cultures grow a colony count exceeding 100,000 bacteria
Bladder walls shows small tears and hemorrhages when the bladder is distended
Non-ulcerative interstitial cystitis
A lesion called a Hunner ulcer is present on histological exam of the bladder wall
Ulcerative interstitial cystitis
What interstitial cystitis (IC) is relieved with attempts to empty the bladder?
Ulcerative IC
What is the most common form of bladder cancer?
Transitional cell carcinoma
Doctor who cares for the kidneys
Nephrologist
Doctor who cares for the whole renal/urological system
Urologist
What is excessive in parathyroid conditions?
Calcium
Kidneys are a major player in _____ excretion
Potassium
Kidneys maintain what balance?
Acid-Base (Bicarbonate: Metabolic Buffer)
Kidneys make sure there is not too much or too little what in the body?
Water
What percentage of the body’s blood is filtered through the kidneys?
20%
Kidneys require ______ pressure to function
Hydrostatic
Blood begins process of filtration pushed through hydrostatic pressure through what part of the Nephron?
Bowman’s Capsule
The amount of blood filtered the glomerulus per minute
Glomerular filtration rate (GFR)
At what age does the GFR decrease?
30 years old
What part of the Nephron does more water absorption than electrolytes take place?
Proximal tubule
What part of the Nephron does more electrolyte absorption than water take place?
Distal tubule
What part of the Nephron is where most water and salt is reabsorbed and urea is excreted?
Loop of Henle
The breakdown product of muscle excreted by the kidneys
Creatinine
Increased creatinine indicates what?
Kidneys are not functioning properly
What creatinine test is the more common lab test?
Serum
A ________ GFR indicates decreased renal function
Decreased
________ levels of BUN indicate decreased renal function
Increased
Urea is what kind of waste?
Nitrogenous
What are the risk factors for kidney stones?
- Dehydration
- Hypercalcemia
- Hyperparathyroidism
- Gout
What kind of diet should people with recurrent kidney stones avoid?
Purine diet (Meats)
The formational of stone (calculi) in the kidney.
Nephrolithiasis
Nephrotic Syndrome is caused by:
- HTN
- Glomerulonephritis
- Diabetes
- Autoimmune
What is the pathology of Nephrotic Syndrome?
Endothelial cell and basement membrane damage leads to loss of protein (albumin) leads to edema because of decreased oncotic pressure
Infection of the kidney
Nephritis
Clinical presentation of Nephrotic Syndrome
- Albuminera
- Low blood albumin levels
- Edema
60% of Acute Kidney Injuries (AKI) are _____ disorders
Prerenal
What are the first organs to sense a drop in blood pressure?
Kidneys
What are the four phases of AKI?
- Initial insult (condition disrupts kidney function)
- Oliguria (low GFR, low urine output, fluid overload)
- Diuresis (large unconcentrated urine outflow)
- Recovery (healthy nephrons take over function of damaged nephrons)
What is the patho of AKI?
Decreased GFR of the blood leads to azotemia, high serum creatinine, and fluid retention
The higher the category of CKD in GFR indicates what?
The higher level of disease
What neurological condition is caused from Chronic Renal Failure?
Encephalopathy (Causes confusion, stupor, and coma)
What conditions in the blood result because of CRF?
Anemia and Thrombocytopenia
What electrolyte and mineral imbalances happen because of CRF?
Potassium, Calcium, and Vitamin D
Where is peritoneal dialysis inserted?
Through the abdomen
What is hemodialysis given through?
- a central line
- arteriovenous fistula (vibrates)
What in males can cause an urological obstruction?
Benign prostatic hypertrophy (BPH)
Obstruction of the kidneys can lead to:
Hydronephrosis and hydroureter
Symptoms of nephritis:
Fever, chills, pain, CVA tenderness, frequency, dysuria
Infection of the bladder
Cystitis
How does cystitis occur?
When bacteria enters the bladder
What symptoms present in elderly with a UTI?
- confusion
- disorientation
- hyptotension
UTIs in elderly can lead to what?
Urosepsis (caused by bacterial endotoxins)
Inflammation of the bladder not associated with a known bacteria
Interstitial cystitis
What does micturate mean?
To urinate
When the endocrine system is in dysfunction what is the body suffering from?
Hormone deficiency
Hormone excess
Hormone resistance
What are the three keys to understanding the disorders of the endocrine system?
- normal functioning
- hypofunction vs hyperfunction
- location of the dysfunction
The regulatory link that keeps the body’s hormones in balance
negative feedback system
The hypothalamus secretes what?
Corticotropin-Releasing Factor (CRF)
CRF stimulates what?
The pituitary gland
Pituitary gland secretes what?
Adrenocorticotropic Hormone (ACTH)
ACTH stimulates what?
The adrenal gland
The adrenal gland secretes what?
Cortisol
What gland senses increased levels of cortisol?
The pituitary gland
When the negative feedback system fails, what does it result in?
Dysregulation of hormones
When the endocrine gland secretes an inadequate amount of hormone
Hypofunction
When the endocrine gland secretes an excessive amount of hormone
Hyperfunction
The endocrine gland itself causes the dysfunction is what type of endocrine disorder?
Primary
The pituitary gland causes the dysfunction is what kind of endocrine disorder?
Secondary
The hypothalamus is the root of dysfunction in an endocrine disorder
Tertiary
The pituitary is comprised of how many sections?
- Anterior pituitary
2. Posterior pituitary
What tropic hormones does the anterior pituitary gland release?
FSH, LH, Adrenocorticotropic hormone, TSH, Prolactin, Growth Hormone
What hormones are released by the posterior pituitary gland?
ADH and oxytocin
ADH and oxytocin are created where?
Hypothalamus
Disorders of ADH result from
fluctuating water and ADH levels
Occurs from a lack of secretion of ADH from the posterior pituitary
Central diabetes insipidus
What is SIADH?
Syndrome of Inappropriate ADH
Overproduction of ADH
SIADH
What glands regulate the body’s metabolism?
Thyroid glands
Insufficient levels of T3 and T4
Hypothyroidism
Symptoms of hypothyroidism
- weight gain
- fatigue
- feelings of being cold
- decreased heart rate
- confusion
The most common cause of hypothyroidism
Hashimoto’s Thyroiditis
Excessive amounts of T3 and T4
Hyperthyroidism
Symptoms of hyperthyroidism
- Weight loss
- Tremors
- Increased HR
- Feelings of being warm
The most common cause of thyroid hyperfunction
Grave’s disease
Four small glands located posterior to the thyroid gland
Parathyroid
________ hormone regulates calcium levels
Parathyroid Hormone (PTH)
Parathyroid hormone lowers _______ levels
Phosphate
Parathyroid dysfunctions come in which 2 forms?
- Primary (problem with PTH itself)
2. Secondary (due to problems w/calcium levels)
How does primary hypoparathyroidism occur?
Due to the destruction or removal of the PTH glands
Lack of PTH results in what 2 conditions?
Hypocalcemia and Hyperphosphatemia
How does secondary hypoparathyroidism occur?
From any disorder that causes hypercalcemia
What is the main cause of primary hyperparathyroidism?
Tumors of the parathyroid gland
What typically causes secondary hyperparathyroidism?
Kidney failure (lowers calcium levels)
What is the work horse of the body?
The adrenal gland
How many parts does the adrenal gland consist of?
The cortex and the medulla
What does the adrenal cortex produce?
- Mineralcorticoids (aldosterone)
- Glucocorticoids (cortisol)
- Androgens
What is the adrenal cortex stimulated by?
- CRH from the hypothalamus
- ACTH from the anterior pituitary
What does the adrenal medulla produce?
- Epinephrine
- Norepinephrine
Why does the adrenal medulla release epinephrine and norepinephrine?
In response to SNS activation
What is the condition characterized by a lack of hormones from the adrenal cortex?
Addison’s Disease
Decreased cortisol causes what?
Hypoglycemia
Decreased aldosterone has what effect on sodium and potassium?
Decreased sodium; increases potassium
Reduced androgens may suppress what in women?
Libido
Due to a pituitary disorder in which not enough ACTH is produced
Secondary adrenal insufficiency
An excess of adrenal cortex hormones results in what condition?
Cushing’s disease
A tumor of the pituitary gland produces elevated
ACTH
What does elevated ACTH do to blood glucose
Increases it (decreases wound healing)
What condition is characterized by a moon face and buffalo hump?
Cushing’s disease
A hyperactive adrenal gland disorder characterized by high cortisol; ACTH is low
Cushing’s syndrome
Prolonged used of ___________ can result in Cushing’s syndrome
Corticosteroids
A disorder of the adrenal medulla (hallmark of adrenal excess)—increases epinephrine and norepinephrine
Pheochromocytoma
Disease of glucose regulation
Diabetes
Elevated glucose in the blood
Hyperglycemia
Which cells of the pancreas release insulin?
Beta cells
What helps move glucose from the blood and into body cells?
Insulin
Low glucose in the blood
Hypoglycemia
Stimulates the liver to release glucose in the blood
Glucagon
Which diabetes is characterized by the lack of insulin?
Type 1 Diabetes
Pancreas can produce insulin, but the cells have become resistant to accept it
Type 2 Diabetes
Risk factors for type 2 diabetes
- obesity
- lack of activity
Three common tests to test for diabetes include:
- Fasting blood glucose level
- Oral glucose tolerance test
- Glycated hemoglobin test (A1c test)
How many months does the A1c monitor?
the preceding 3 months
Which diabetes always needs insulin?
Type 1 diabetes
What are the three lifestyle modifications when treating diabetes?
- Diet (50% carbs; 30% fats; 20% proteins)
- Exercise
- Health Maintenance
Which organ produces glucose?
Liver
Which organ absorbs insulin?
Small intestine
Which organ releases insulin?
Pancreas
Which medicines help the pancreas produce insulin?
Sulfonylureas and Meglitinides
What two things do biguanides and thiazolidinediones do?
- prevents the liver from producing more glucose for the blood
- help cells become more sensitive to insulin
What are the two categories of insulin?
- Conventional
2. Insulin analogues
What is insulin classified off of?
Onset of action
Rapid acting, Intermediate acting, Long-acting
High blood glucose levels damage what cells?
Endothelial
The three classic symptoms of diabetes
Polyuria, Polydipsia, Polyphagia
What is the endocrine system consisted of?
- Glands
- Specialized cell clusters
- Hormones
What is the role of the endocrine system?
- Regulates the body’s metabolic activities
- Maintains homeostasis
What are the three processes of endocrine dysfunction?
- hormone deficiency
- hormone excess
- hormone resistance
What are the causes of endocrine dysfunction?
- autoimmunity
- chemical mediator dysfunction
- tumor
- trauma/ischemia
- removal
A disorder characterized by the body making too little ADH from the posterior pituitary or lack of response from the kidneys to ADH
Diabetes Insipidus
What does Diabetes Insipidus cause?
The body to lose too much water, leads to dehydration, frequent urination and thirst. Can cause confusion.
What is the effect of SIADH?
The body holds on to water which leads to fluid volume overload, hyponatremia, weakness, confusion, and H/A
What is another name from Acromegaly?
Gigantism
What are some symptoms of acromegaly?
- Large jaws and facial bones
- Large hands, feet, and long bones
An autoimmune destruction of the thyroid, a congenital condition called cretinism, lack of iodine, or lack of stimulation due to lack of TSH from the anterior pituitary are causes of what condition?
Hashimoto’s Thyroiditis
An autoimmune stimulation of the thyroid, thyroiditis, tumors of the thyroid, too much iodine intake, excessive stimulation of TSH from the anterior pituitary are all causes of what condition?
Grave’s Disease
What condition causes lethargy, hypotension, N&V, anorexia, hypoglycemia, aldosterone imbalance leading to hyponatremia, hyperkalemia, darkening of the skin and mucous membranes, personality change and emotional lability?
Addison’s Disease
Which condition can cause weight gain in the central area of the body, facial edema, stretch marks, hirsutism, fat on the cervico-thoracic region?
Cushing’s Disease/Syndrome
Diabetes is a disorder of _________ metabolism.
Carbohydrate
High blood glucose damages what cells?
Endothelial
High blood glucose promotes an environment that prevents healthy cell healing and promotes _______ growth.
Pathogen
What will be in a person’s urine with diabetes?
Sugar or Ketones (Glycosuria/Ketonuria)
What are the normal capillary blood sugars?
70-100 mg/dL
What is the normal Hgb A1C levels for a person without diabetes?
<5.7
In a patient with diabetes, what does the ADA recommend for their A1C levels?
<6.5
Why is C-Peptide looked at in Diabetes?
Because when insulin is secreted, so is C-Peptide. Low or absent C-Peptide levels indicate type 1 diabetes
How many months does the A1C look at?
Previous 3 months (due to the hemoglobin turnover rate)
Why are minimal ketones present in Type 2 Diabetes?
Because insulin is present, so fat is not broken done
Why are ketones present in Type 1 Diabetes?
Cells think they are starving so the body compensates by breaking down fat which results into fatty acids that are converted to ketones
Which type of diabetes leads to a state of metabolic acidosis?
Type 1
A symptom of DKA that involves hyperventilation as the body attempts to compensate for metabolic acidosis through the respiratory system by blowing off CO2
Kussmaul’s respiration
Which diabetes is characterized by ketone breath/body odor?
Diabetic Ketoacidosis (Type 1)
What are symptoms of hypoglycemia?
- Shaking
- Sweating
- Anxious
- Dizziness
- Hunger
- Tachycardia
- Impaired Vision
- Weakness/Fatigue
- Headache
- Irritable
What is the 15 x 15 rule in acute hypoglycemia?
Treat with 15 gm of carbs and recheck the blood sugars in 15 minutes
What are the long term complications of diabetes?
- Cerebrovascular disease
- Retinopathy
- Heart disease
- Nephropathy
- Autonomic neuropathy
- Poor WBC function
- PAD
- Peripheral neuropathy
The disorders of the upper GI tract affect what?
- esophagus
- stomach
- small intestine
What are some self-induced causes of upper GI disorders?
- smoking
- alcohol abuse
- frequent use of NSAIDs
Difficulty swallowing; what causes it?
Dysphagia (normally result of neuromuscular dysfunction)
stomach acid that flows backwards, enters the esophagus, and causes pain/discomfort; what causes it?
GERD (happens when the LES does not close properly)
Inflammation of the esophagus; what causes it?
Esophagitis (can arise from acid reflux, candida albicans infection, or ingestion of chemicals)
Upper GI bleeding (UGIB) can lead to what?
- Hematemesis: blood in vomit
- Melena: blood in stool
What is a condition in the esophagus that is typically a result of hepatic portal hypertension?
Esophageal varices
A portion of the stomach that pushes upward through the opening in the diaphragm which disrupts the closure of the LES
hiatal hernia
A condition in the pyloric valve that prevents the stomach from emptying normally
Pyloric Stenosis
An inflammatory erosion of the stomach or duodenal lining
Peptic Ulcer Disease (PUD)
What are some causes of PUD (peptic ulcer disease)?
- H. Pylori Infection
- NSAIDs
- stress
- caffeine
- smoking
What is a symptom of PUD?
Pain between meals that is alleviated with eating
The rapid emptying of gastric contents
Dumping syndrome
How many forms can gastritis occur?
2
- Acute- usually caused from medications (NSAIDs)
- Chronic- H. Pylori most common cause
Infections of the small intestine, stomach, and large intestine lead to what?
Gastroenteritis
What causes gastroenteritis?
- Norovirus
- E-Coli (157)
- Salmonella
- Shigella
- C-Diff
What is the most common symptom of gastroenteritis?
Diarrhea
An autoimmune response to a gluten-derived peptide that causes inflammation in the intestinal villi?
Celiac disease
How can celiac disease be confirmed?
Through antibody testing and an intestinal biopsy
Inflammation of the peritoneal membrane
Peritonitis
What is the cause of peritonitis?
Caused by bacterial infection or leakage of intestinal contents
What are the triad of symptoms of peritonitis?
- abdominal pain
- rigidity
- rebound tenderness
Affects the entire GI tract and the whole thickness of the GI wall
Crohn’s Disease
Which disease has skip lesions and cobblestoning?
Crohn’s Disease
Affects only the large intestine, begins in the rectum and extends upwards
Ulcerative Colitis
What layers of the intestinal wall are effected in Crohn’s disease?
Upper layers only
Formation of an anal fistula and anal fissure are common in what disease?
Crohn’s disease
Pseudopolyps are common in what disease?
Ulcerative colitis
Inflammation of the appendix resulting from blockage of the appendix and bacterial growth
Appendicitis
What is the pH of the stomach?
1.5-2
Small outpouchings of the weakened intestinal wall that become inflammed
Diverticulitis
What are the three alterations in motility of the large intestine?
- irritable bowel syndrome (IBS)
- Bowel obstruction
- Volvulus
When the motor functions of the bowel slow down or increase?
Irritable bowel syndrome (can be bouts of diarrhea, constipation, and abdominal distention)
What is the etiology of IBS?
no known etiology
What is the physical obstruction of the bowel called?
Mechanical obstruction
What is a nonmechanical obstruction of the bowel?
Weakened intestinal muscles
What are the bowel sounds in a complete bowel obstruction?
there are no sounds
When the large intestine becomes twisted
Volvulus
What can a volvulus lead to?
Bowel obstruction and ischemia
What are the roles of the liver?
- Body’s processing plant
- Aids in digestion
- Aids in fat, protein, and carbohydrate metabolism
- Filters and detoxifies the blood
- Synthesizes albumin
- Converts bilirubin
What is the most common cause of dysphagia?
Stroke
Elevated Bilirubin levels in the blood
Hyperbilirubinemia
Why does hyperbilirubinemia occur?
- increased RBC hemolysis
- hepatocellular injury
- bile duct obstruction
What causes an UGIB?
- Peptic ulcer disease (generally in stomach or lower intestine)
- Alcoholism
Elevated bilirubin can result in what physical symptom?
Jaundice (yellowing of the skin)
Portal hypertension increases the risk of what?
- Esophageal varices
- Upper GI bleed
How does portal hypertension occur?
Blood comes from the GI tract, which normally goes to the liver, but begins to back up
Dilated, superficial veins that become visible around the umbilicus
Caput Medusa
The enlargement of the liver is called what
hepatomegaly
What can liver damage lead to?
- hepatomegaly
- RUQ tenderness
- decreased coagulation factors (clotting disorders/prolonged PT)
- elevated ammonia levels
- caput medusa
Who does hiatal hernia occur most in?
The elderly
What do liver function tests measure?
hepatic injury
Hepatocellular injury can be measuring by checking for what liver enzymes?
- Aspartame aminotransferase (AST)
- Alanine aminotransferase (ALT)
Inflammation of the liver
Hepatitis
Which form of hepatitis are transmitted by the fecal-oral route?
Hep A & E
Which form of hepatitis is primarily transmitted via blood through IV drug usage?
Hep C
Which form of hepatitis is spread by blood products, body fluids, and sexual contact?
Hep B
One of the most common liver disorders in the United States
Nonalcoholic fatty liver disease
Epigastric and/or abdominal pain is usually present how long after eating in PUD?
2-3 hours
Nonalcoholic fatty liver disease is associated with what syndrome?
Metabolic
Which hepatitis may present as an acute, reversible condition?
Alcoholic hepatitis
What does alcohol do to the liver?
Damages it; alcohol is a toxin to the liver
What are three accessory organs that participate in the function of the GI tract
- gallbladder
- pancreas
- biliary duct
Dysfunction in the gallbladder can affect dysfunction in what other organ?
Pancreas (and visa versa)
Inflammation of the gallbladder
Cholecystitis
Cholelithiasis
Gallstones
What are the most common gallstones?
Cholesterol stones
What are the risk factors of the gallbladder disease?
- age
- female disease
- obesity
What are the symptoms of gallbladder disease
- nausea
- vomiting (especially after high fat meals)
- RUQ pain that radiates to the shoulder area
Biliary duct obstruction can lead to what?
Liver dysfunction
Increase in the osmotic load presented to the intestinal lumen because of diminished absorption
Osmotic diarrhea
Mucosa lining is inflamed, edematous, and unable to reabsorb fluid or nutrients
Inflammatory diarrhea
Occurs when an organism stimulates the intestine to secret fluid and mucus
Secretory diarrhea
Caused by intestinal neuromuscular disorders
Motility diarrhea
Biliary duct obstruction can lead to what in the bloodstream?
Bilirubin and bile salts
When pancreatic dysfunction occurs, the pancreas is vulnerable to _________
autodigestion (pathophysiology of pancreatitis)
Inflammation of the pancreas
Pancreatitis
What are the two types of pancreatitis?
- acute
2. chronic
Celiac disease leads to malabsorption of what essential nutrients?
- Vitamin D
- Vitamins
- Fat
- Proteins
- FeSO4
Small intestines are often due to _________
surgical adhesions or scar tissue
What is the number 1 cause of chronic pancreatitis?
Heavy alcohol use
Pancreatic calcifications observed on an abdominal xray are conditied pathological signs of what condition?
Chronic pancreatitis
Pancreatic cancer has a _____ mortality rate
high
Cancer of the pancreas most commonly arises from where?
Ductal cells
Signs and symptoms of pancreatic cellular damage include:
- elevation of pancreatic amylase and lipase in blood
- sudden onset of paint that radiates to back
- Cullen and Grey Turner sign (indicates bleeding in retroperitoneal area)
How long do you have to listen for absent bowel sounds?
5 minutes
Which inflammatory bowel disease can predispose to colon cancer?
Ulcerative colitis
Varicosities of the lower rectum that includes pain, burning and itching
Hemorrhoids
Bleeding in the stool that is bright red comes from ________
large intestine
The presence of diverticula is called
diverticulosis
Unconjugated bilirubin is often _______
prehepatic (typically seen in newborns)
Conjugated process is often _______
intrahepatic
Posthepatic hyperbilirubinemia happens where?
After the liver
What is another name for jaundice?
Icterus
Signs of liver dysfunction
- elevated bilirubin levels
- low albumin
- prolonged bleeding times
- elevated liver functions (AST and ALT)
Symptoms of hepatitis
- dark urine
- splenomegaly
- jaundice
- Flu-like symptoms: anorexia, fatigue, fever, nausea, vomiting
- hepatomegaly
Cirrhosis and liver failure decreases what liver functions?
- detoxification
- bile synthesis and fat digestion
- albumin synthesis
Why can dysfunction of the gall bladder lead to dysfunction of the pancreas?
-the common bile duct becomes obstructed with gallstones
Who are most likely to develop gallstones?
-Full, fertile, females over 40; high calorie; high cholesterol diets
Alcohol ______ damages cells of the pancreas.
directly
Collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue; if ruptures, can lead to relapse of pancreatitis.
Pseudocyst of the pancreas
What is amylase and lipase?
Digestive enzymes
