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Osteopathy Y3S1 > Week 3 - Liver, Gall Bladder, Pancreas and Associated Disorders > Flashcards

Week 3 - Liver, Gall Bladder, Pancreas and Associated Disorders Flashcards

1
Q

Outline the hormonal and nervous controls that regulate the secretion of bile and pancreatic juice.

A

Hormonal regulation
1. CCK (cholecystokinin) and secretin released by duodenal enteroendocrine cells, in response to fatty, acidic or protein-rich chime

  1. CCK involved in pancreatic secretion (enzyme component), gall bladder contraction and relaxation of the hepatopancreatic sphincter
  2. Secretin is involved in pancreatic secretion (H2O and HCO3- component) and bile secretion

Also note: return of bile salts from enterohepatic circulation leads to bile secretion

Nervous regulation:
1. Vagal stimulation leads to pancreatic secretion and gall bladder contraction

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2
Q

List the components of pancreatic juice.

A

Key contents: enzymes, water and electrolytes (HCO3)

Pancreatic enzymes (PLAN)

  • proteases
  • lipases
  • amylase
  • nucleases
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3
Q

List the nutrients absorbed by each GIT region.

A

Stomach: water, alcohol

Duodenum: iron, calcium, fats, sugars, water, proteins, vitamins, magnesium, sodium

Jejunum: sugars, proteins

Ileum: bile salts, vitamins B12, chloride

Colon: water, electrolytes

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4
Q

Differentiate the terms cirrhosis and hepatocellular failure

A

Cirrhosis refers to structure change of the hepatocyte, whilst hepatocellular failure refers to the impaired hepatocyte function

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5
Q

List the sphincters of the biliary tree

A

Sphincter of the pancreatic duct - around the terminal part of the pancreatic duct

Sphincter of the bile duct - around terminal part of the bile duct

Hepatopancreatic sphincter (sphincter of Oddi) - found around the hepatopancreatic ampulla

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6
Q

Is this organ covered by peritoneum?

A 
Gall bladder surface attached to liver has an adventitia
Peritoneal surface (not attached to an organ) is covered by serosa
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7
Q

Attachments or location of round ligament

A

Contained within the free edge of the falciform ligament

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8
Q

Attachments or location of smaller omentum

A

Connects to the lesser curvature of the stomach and proximal part of the duodenum to the liver

Liver attachments: fissures of the ligamentum venosum and porta hepatis (undersurface)

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9
Q

Describe some potential clinical features of liver cancer

A
  • irregular hepatomegaly, RUQ pain, jaundice
  • symptoms of cirrhosis e.g. ascites
  • constitutional symptoms (e.g. anorexia, weight loss, fever)
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10
Q

Explain how pancreatic proteases interact with the enzymes of the intestinal brush border.

A

Enteropeptidase (brush border enzyme) also converts pancreatic proteases to their active form

(trypsinogen to trypsin; chymotrypsinogen to chymotrypsin)

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11
Q

Define the term cystic fibrosis

A

A disorder of exocrine glands, in which the secretions of the lungs, pancreas, bile ducts and reproductive tract have increased viscosity

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12
Q

List the potential modes of transmission for the hepatitis viruses (HAV, HBV, HCV). Which of these viruses are vaccine-preventable?

A

HAV

  • transmission by faecal/oral route
  • yes to vaccination

HBV

  • transmission by parenteral (via blood), sexual contact and perinatal
  • yes to vaccination

HCV

  • transmission by parenteral, perinatal (via placenta), possibly sexual
  • vaccination not available
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13
Q

What is the neurovascular supply of the gall bladder?

A

Arterial supply: cystic artery (off right hepatic artery)

Venous drainage: cystic vein drains directly into liver or into portal vein

Nerve supply:

  • parasympathetic: CNX vagus
  • sympathetic: splanchnic nerve (T5-T9) via celiac plexus
  • sensory: right phrenic nerve (important for pathology of GB visceral referred pain to right shoulder)
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14
Q

Describe the potential complications of cirrhosis. Are you able to identify the pathological basis for each complication?

A

Portal hypertension
- structural change to hepatocyte obstructs nutrient flow (leads to ascites due to accumulation of fluid in peritoneal cavity; splenomegaly due to passive congestion; varicose veins)

Hepatocellular failure

  • hepatic encephalopathy
  • coagulation defects
  • endocrine changes
  • peripheral oedema
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15
Q

What are the parts of the gall bladder?

A

Fundus: wide end, projects from the inferior border of the liver

Body: contacts the visceral surface of the liver

Neck: narrow tapered region, makes an S-shaped bend and is continuous with the cystic duct

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16
Q

Describe the potential complications of gallstones. How might these complications present?

A 
Acute cholecystitis (impaction of cystic duct results in biliary stasis, thus acute inflammation)
Chronic cholescystitis (GB wall becomes fibrotic and shrunken followed by repeated bouts of acute inflammation)
Mucocele development (GB becomes distended with mucoid watery fluid)
Infection (increased risk of bacterial infection, persistent inflammation and infection can result in empyema)
Increased risk for carcinoma (mechanism unknown)
Choledocholithiasis (impaction of gallstone in the bile duct results in inflammation of bile duct) 
Acute pancreatitis (obstruction at hepatopancreatic ampulla generates back-pressure, causes secretions to flow back up the pancreatic duct)
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17
Q

Provide examples of viral agents capable of causing hepatitis

A

Hepatitis A, B, C, D and E

Other viruses: Epstein Barr virus, cytomegalovirus

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18
Q

Compare the structure of a lobule to that of a hepatic acinus. Describe the directions of blood flow and bile flow.

A

Lobule - hexagonal in shape, with plates of hepatocytes that radiate outward from a central vein and portal tracts are found at each corner of the lobule

Hepatic Acinus - based on three zones corresponding to different degrees of oxygenation; kernel-shaped that is centred upon a portal tract

Blood flows from portal tract to central vein (via sinusoids); Bile flow from central areas to portal tracts (via bile canaliculi)

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19
Q

Outline the potential clinical features of cystic fibrosis

A

Pulmonary features

  • mucous plugging and impaired mucociliary function
  • recurrent infections and chronic inflammation (fibrosis)

Pancreatic features

  • reduced or absent pancreatic enzymes
  • malabsorption occurs due to impaired digestion

Biliary features
- cholestasis can result in secondary biliary cirrhosis and cholelithiasis

Reproductive features
- sub-fertility or infertility

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20
Q

Define the term porta hepatis. What structures pass through the porta hepatis?

A

Porta hepatis is a transverse fissure on the visceral surface of the liver, between the caudate and quadrate lobes

  • portal vein
  • hepatic artery
  • hepatic nerve plexus
  • hepatic ducts
  • lymphatic vessels
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21
Q

How would you introduce the gall bladder (structure/function/location) in the setting of lab exam?

A

Structure: pear-shaped muscular sac 7-10cm in length, covered by peritoneum

Location: lies in the gall bladder fossa on the visceral surface of the liver

Function: storage and concentration of bile

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22
Q

Compare the two blood supplies of the liver (portal vein vs. hepatic artery)

A 
Portal vein (70%) provides nutrient-rich blood supply from stomach and intestines
Hepatic artery (30%) provides oxygen-rich blood supply
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23
Q

List the three types of jaundice and provide an example for each. Identify the aspect of bilirubin metabolism that is affected

A

Classification of jaundice is based on where bilirubin metabolism is affected:

Haemolytic jaundice
- due to excessive RBC destruction, which overwhelms the liver’s ability to form conjugated bilirubin (e.g. thalassaemia)

Hepatic jaundice
- due to impaired hepatocyte functions (such as impaired uptake or intracellular transport of bilirubin or reduced enzymatic activity) (e.g. drug toxicity or alcoholic hepatitis)

Cholestatic jaundice
- due to obstruction of intrahepatic or extrahepatic bile ducts (e.g. neoplasia)

24
Q

How would you introduce the liver (structure/function/location) in the setting of a lab exam?

A

Structure: The liver is a large, complex organ divided into 4 irregular lobes

Location: located in the RUQ and LUQ of the abdomen, and is separated from the thoracic cavity by the diaphragm

Function: The liver is primarily involved in synthesis, detoxification, metabolism and storage, excretion and has an immune function.

25
Q

List some risk factors that are associated with the formation of gallstones

A
  • Adults < 40 years old, stones are more common in women

- obesity, increased age, multi-parity diabetes, diets high in refined sugar, ileal disease

26
Q

Describe the mechanism by which chronic alcohol abuse causes liver damage

A
  • alcohol causes induction of oxidases
  • these enzymes aid metabolism but damage hepatocytes with chronic exposure
  • liver damage is dose related
27
Q

What are some osteopathic implications of viral hepatitis?

A

polyarthralgia affecting small joints may mimic a musculoskeletal complaint

must consider these findings in context of patient history

28
Q

Summarise the different types and functions of pancreatic enzymes

A

Proteases digest proteins
Lipases digest emulsified fats
Amylase digests starch
Nucleases digest nucleic acids

29
Q

Attachments or location of falciform ligament

A

Connects liver to anterior abdominal wall and diaphragm

30
Q

Describe clinical features associated with each stage of alcohol-related liver damage

A

Stage 1: +/- hepatomegaly

Stage 2: tender hepatomegaly, fever, jaundice, ascites

Stage 3: ascites, splenomegaly, varicose veins, jaundice, RUQ pain

31
Q

Attachments or location of left and right triangular ligaments

A

Right: situated at the right extremity of the bare area

Left: continuous with falciform ligament anteriorly

32
Q

What is the structure of the biliary tree?

A

Bile entering the bile ducts eventually enters the left and right hepatic ducts

These drain into the left and right lobes of the liver

Then, unite to form the common hepatic duct

Common hepatic duct emerges with cystic duct of the gall bladder to form the bile duct

Hepatopancreatic ampulla is formed by the union of bile duct and major pancreatic duct

33
Q

Identify where the digestive enzymes are found in the different regions of the GIT.

A

CHO digestion

  • Salivary amylase (oral cavity, pharynx, oesophagus)
  • Pancreatic amylases (lumen of SI)
  • Disaccharidases (epithelium of SI - brush border)

Protein digestion

  • pepsin (stomach)
  • pancreatic trypsin and chymotrypsin and pancreatic carboxypeptidase (lumen of SI)

Nucleic acid digestion

  • Pancreatic nucleases (lumen of SI)
  • Nucleotidases, nucleosidases and phosphatases (epithelium of SI - brush border)

Fat digestion
- bile salts and pancreatic lipase (lumen of SI)

34
Q

What causes (other than alcohol) can lead to cirrhosis?

A

Liver tumours

35
Q

What are the functions of bile?

A

Digestion and absorption

  • emulsification of large fat particles into small droplets
  • this increases SA available for lipases to act upon the fat molecules
  • bile salts and phospholipids interact with the breakdown products of fat digestion (forming micelles)
  • micelles ‘ferry’ free fatty acids and monoglycerides to the intestinal mucosa for absorption

Excretion of waste products

  • bilirubin and excess cholesterol
  • pathologies that interfere with bilirubin excretion can result in jaundice
36
Q

What type of gallstone is most common in Western countries?

A

Cholesterol gall stone

37
Q

Attachments or location of ligamentum venosum

A

In the foetus, connects the left umbilical vein to the IVC (allows blood to bypass the liver)

38
Q

List the risk factors for primary liver cancer

A
  • cirrhosis, viral hepatitis (HBV, HCV)
  • exposure to aflatoxins (produced by mould - agriculturalists at risk)
  • male (sex)
39
Q

Attachments or location of coronary ligament

A

Demarcates the bare area of the liver (where the liver is not covered by peritoneum)

40
Q

Discuss the role that digestive enzymes play in the chemical breakdown of food

A

Digestion involves hydrolysis, where water is added to each molecular bond that has been broken

Digestive enzymes:

  • are produced by various organs of the GIT
  • act as organic catalysts (accelerate chemical reactions without appearing in the final product)
  • each enzyme possess an active site for a specific substrate
  • function optimally at a specific pH
  • most are synthesised as zymogens (proenzymes)
41
Q

Name the lobes of the liver

A

Right lobe, quadrate lobe, caudate lobe, left lobe,

42
Q

Describe the surfaces of the liver. Are these surfaces covered by peritoneum?

A

Diaphragmatic surface

  • smooth, dome-shaped and convex
  • related to the concave, inferior aspect of the diaphgram
  • covered with peritoneum, except posteriorly where the bare area of the liver lies in contact with the diaphragm

Visceral surface

  • inferior and posterior aspect
  • is covered with peritoneum, except near the gall bladder and porta hepatis
43
Q

List the components of bile.

A 
Bile pigments (bilirubin)
Phospholipids 
Bile salts
Cholesterol, triglycerides 
Electrolytes
44
Q

Summarise the pathophysiology of cystic fibrosis

A

CFTR (gene) located on chromosome 7 codes for membrane-bound chloride channel

Affected chloride channels are non-responsive to intra-cellular signalling that would normally open the channel

Secretions of affected cells contain inadequate amounts of chloride and water

The abnormal secretions are viscid and are retained by the affected glands

Secretions that may be affected:

  • pulmonary mucous
  • pancreatic enzymes
  • sweat
  • bile
  • reproductive secretions
45
Q

What is the venous drainage of the liver?

A

Hepatic veins open into the IVC just inferior to the diaphragm

46
Q

Discuss the pathophysiology associated with cholesterol stone formation

A

occurs when factors alter the ratio related to the solubility of cholesterol in bile (cholesterol : bile salts : phospholipids)

crystal forms when bile is supersaturated with cholesterol

47
Q

Identify and describe the stages of alcoholic liver damage

A

Stage 1: fatty liver

  • excessive alcohol can lead to destruction of rough ER in hepatocytes, which reduces the number of lipoproteins synthesised and secreted
  • this causes cells to become swollen with lipids
  • mild to moderate changes are reversible

Stage 2: alcoholic hepatitis

  • usually superimposed on fatty liver
  • hepatocyte necrosis induces the infiltration of inflammatory cells

Stage 3: liver cirrhosis

  • irreversible
  • regenerating hepatocytes do not comform to normal cytoarchitecture (nodules formation)
  • structural changes obstruct nutrient flow (impaired hepatocyte function)
  • death occurs due to complications (leading to hepatocellular failure, portal hypertension)
48
Q

What is the most common form of primary liver tumour? What type of tissue does this tumour originate from?

A 
Hepatocellular Carcinoma (Hepatoma)
originate from epithelial cells
49
Q

Define the term jaundice

A

Refers to the yellow appearance of the skin, sclerae and mucous membrane; it is an important sign of liver disease

50
Q

Summarise the clinical features that might be associated with acute hepatitis

A

Stage 1: Preclinical

  • asymptomatic, but virus actively replicating
  • spread during this phase is a concern

Stage 2: Prodromal/Pre-icteric

  • anorexia (loss of appetite), nausea, vomiting, malaise, headache
  • mild fever, diarrhoea, upper abdominal discomfort

Stage 3: Icteric

  • jaundice develops
  • possibly tender hepatomegaly +/- splenomegaly
  • HBV: polyarthralgia affecting small joints, skin rash

Stage 4: Convalescent
- symptoms subside over a course of several weeks

51
Q

How would you introduce the pancreas (structure/function/location) in the setting of a lab exam?

A

Structure: elongated, tadpole-shaped gland that is ~15cm long

Location: found in the epigastric and left hypochondriac regions; transversely behind stomach, in between spleen and duodenum

Function: functions both as an exocrine and endocrine gland. For example, pancreatic enzymes assist in the chemical digestion of proteins, lipids and carbohydrates, whilst insulin produced by the pancreas helps to regulate blood glucose levels.

52
Q

Indicate the specific function of each enzyme involved in chemical digestion.

A

CHO digestion

polysaccharides + salivary amylase = smaller polysaccharides or maltose

polysaccharides + pancreatic amylase = maltose and other disaccharides

disaccharides + dissacharidases = monosaccharides

Protein digestion

proteins + pepsin = small polypeptides

polypeptides + pancreatic trypsin and chymotrypsin = smaller polypeptides

small polypeptides + pancreatic carboxypeptidase = amino acids

amino acids or small peptides + dipeptidases, carboxypeptidase, and aminopeptidase = amino acids

Nucleic acid digestion

DNA or RNA + pancreatic nucleases = nucleotides

nucleotides + nucleotidases = nucleosides

nucleosides + nucleosidases and phosphatases = nitrogenous bases, sugars, phosphates

Fat digestion

fat globules + bile salts = fat droplets

fat droplets + pancreatic lipase = glycerol, fatty acids, glycerides

53
Q

Which forms of cancer commonly metastasise to the liver?

A

lung, breast, GIT, skin (melanoma)

54
Q

Name the cells located in the exocrine portion of the pancreas. What is their function?

A

Acinar cells - form the bulk of the pancreas; possess abundant rough ER and inactive enzymes (zymogen granules) and secrete enzyme-rich pancreatic juice into the ductal system

Ductal cells - secrete water and HCO3

55
Q

Differentiate the terms digestion and absorption.

A

Digestion refers to the catabolic process that breaks down complex food molecules to monomers

whilst…

Absorption is the passage of digested end products from the lumen of the GIT through mucosal cells into the blood or lymph

Osteopathy Y3S1 (11 decks)

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