Pathoma Chapter 11 Panc, GB and Liver
Terms in this set (82)
What is an annular pancreas?
The head of pancreas forms a ring around the duodenum
Which pancreatic enzyme must be activated first to activate all the others?
What types of necrosis do you see in acute pancreatitis?
Liquefactive and fat necrosis (peripancreatic fat)
Why can hypercalcemia lead to acute pancreatitis? Why do you see hypocalcemia in active acute pancreatitis?
Causes activation of enzymes
The Ca is being used up in saponification in fat necrosis
What are some causes of acute pancreatitis?
Alcohol (constricts sphincter of Oddi)
Trauma (seatbelt on a child in accident)
Rupture of posterior duodenal ulcer (head of panc is posterior to duodenum)
Clinical features of acute pancreatitis?
epigastric abd pain that radiates to back
nausea and vomiting
periumbilical and flank hemorrhage
elevated serum lipase and amylase; lipase more specific for panc damage
Complications of acute pancreatitis?
shock- due to peripancreatic hemorrhage and fluid secretion
DIC and ARDS
A pancreatic pseudocyst is
formed by fibrous tissue surrounding liquefactive necrosis. No true lining
Presents as abdominal mass with persistently elevated amylase
A pancreatic abscess is usually caused by
Why can pancreatitis cause DIC and ARDS?
pancreatic enzymes in blood will activate coag factors (secondary to vascular damage?)
In the lung, will chew on the alveolar/capillary factors
What are the common causes of chronic pancreatitis, by age group?
Why are amylase and lipase levels not useful in diagnosis of chronic pancreatitis, unlike acute?
Most of the pancreas has been destroyed in chronic, so there are less enzymes produced
What can chronic pancreatitis look like on imaging? What is the "chain of lakes" pattern?
Dilation of pancreatic ducts
What is a late complication of chronic pancreatitis?
Pancreatic ca presents late. What are the presenting symptoms, based on where the tumor is?
Tumors in the head of the pancreas will present with obstructive jaundice with
and palpable gallbladder
Secondary DM arises with tumors in the body or tail. If an elderly person presents with new onset DM, think pancreatic ca.
What is Trosseau sign?
Migratory widespread thrombi (swelling, erythema, tenderness in extremities); indicative of pancreatic carcinoma
What is the serum tumor marker for pancreatic ca?
What is a Whipple procedure?
Removal of head and neck of pancreas, proximal duodenum, and gallbladder
Tx: pancreatic carcinoma
What is biliary atresia?
Failure to form or early destruction of extrahepatic biliary tree. Biliary obstruction and jaundice in first 3mo of life. Progresses to cirrhosis
What substances increase solubility of cholesterol and bilirubin in bile?
Lecithin (phospholipids), bile acids
What are some (9) risk factors for cholesterol stones?
Fertile (multiple pregnancies or oral contraceptives)
Native American heritage
Why does estrogen increase risk for formation of cholesterol stones?
Increases HMG CoA reductase activity and increases LP receptors on hepatocytes
Why is Crohn's a risk factor for cholesterol stone formation?
Bile salts/acids are reabsorbed in the
, this is the area most affected in Crohn's.
Lipid lowering agents like Cholestyramine and Clofibrate can inc. risk for cholesterol stones. Explain how each works
Cholestyramine dec bile acid recycling ...less bile acids => less bile solubility
Clofibrate increases LPL activity, increase cholesterol content of bile
What are organisms that can cause bilirubin stones?
Ascaris lumbricoides (roundworm)
Clonorchis sinensis (Chinese liver fluke) - inc risk for stones, cholangitis, and cholangiocarcinoma
What is biliary colic?
Waxing and waning RUQ pain caused by the gallbladder contracting against a stone in the cystic duct
What causes RUQ pain radiating to R scapula?
What are the other signs/symptoms?
inc WBC count, nausea, vomiting, and inc serum phosphatase
What serum marker is increased in acute cholecystitis?
Serum alk. phos
What are Rokitansky-Aschoff sinuses and where do you see them?
Herniation of gallbladder mucosa down into muscular wall - Chronic cholecystitis
Presents vague RUQ pain, esp after eating?
What is a late complication of chronic cholecystitis?
porcelain gallbladder-> inc risk for ca
What is a bacterial infection of bile ducts?
What causes the infection?
How does it present?
ascending infection with enteric gram neg bacteria
sepsis, jaundice, and abdominal pain
How would a gallstone be large enough to occlude the small bowel escape? (gallstone ileus)
Cholecystitis results in fistula btw gallbladder and small bowel
Gallbladder ca is what type of cancer? What is a major risk factor? How does it present and in what population?
Gallstones - especially porcelain GB
Cholecystitis in an elderly women - not the normal demographic
What causes jaundice?
inc serum bilirubin
Normal bilirubin metabolism
1. RES macrophages consume RBC, break heme into __ and __
2. Protoporphyrin is converted into __, which is carried on __ to the liver.
3. __ in hepatocytes conjugates bilirubin
4. CB is transferred to __to form bile, which is stored in ___
5. Intestinal flora convert CB to __, which makes stool brown and urine yellow.
Fe and protoporphyrin
UGT (uridine glucuronyl transferase)
bile canaliculi, gallbladder
What are 4 syndromes/conditions that will increase the levels of UCB in blood? Explain each.
Extravascular hemolysis or ineffective erythropoeisis - high UCB overwhelms conjugating ability of liver
Physiologic jaundice of newborn - UGT activity is low
Gilbert syndrome - autosomal recessive, mild dec of UGT activity
Crigler-Najjar syndrome - congenital absence of UGT
What is a risk for a newborn with inc UCB levels?
Kernicterus - UCB is fat soluble and can deposit in basal ganglia -> neurological deficits and death
Tx with phototherapy
What is the difference clinically between Gilbert and Crigler-Najjar syndromes?
Gilbert is usually asymptomatic unless stressed (infection) (mild deficit of UGT)
Crigler usually has fatal kernicterus (total absence of UGT)
What is Dubin-Johnson syndrome?
Autosomal recessive deficiency of bilirubin canalicular transport - can conjugate but not into bile (inc CB). Not clinically significant
What is Rotor syndrome?
SImilar to Dubin-Johnson but lacks liver discoloration
What are the serum markers for obstructive jaundice?
Inc CB (has been conjugated but can't escape biliary tract)
Dec urine urobilinogen (CB isn't reaching intestinal flora to be converted)
Inc alk. phos
Clinical features of obstructive jaundice
Dark urine (bilirubinuria), pale stool
Pruritis bc of inc plasma bile acids
Steatorrhea (no bile)
What happens to CB/UCB in viral hepatitis?
Both increase because inflammation is disrupting both the hepatocytes and bile ductules
Destruction of hepatocytes will inc. UCB
Destruction of bile ductules will inc CB
What are the levels of urine bilirubin/urobilinogen in viral hepatitis?
Inc urine bilirubin (dark urine)
Urobilinogen is normal or decreased because less bilirubin is entering duodenum - leaking into blood)
Viral hepatitis is usually due to which 3 viruses?
Hepatitis virus, EBV, CMV
What is the ALT/AST ratio in viral hepatitis?
In alcohol-related liver disease?
Acute hepatitis presents as
jaundice (mixed CB and UCB) with dark urine, fever, malaise, nausea, and elevated liver enzymes
Inflammation in acute viral hepatitis occurs where?
lobules of the liver and portal tracts and is characterized by apoptosis of hepatocytes
Inflammation in chronic viral hepatitis is predominantly in the ____?
What can it progress to?
Symptoms of acute viral hepatitis last how long?
Symptoms of chronic viral hepatitis last how long?
< 6 months
> 6 months
HAV vs. HEV
Both are fecal-oral tx, cause
IgM indicates active infection, IgG indicated immunity.
HAV - travelers - endemic to third world countries
HEV - contaminated water or undercooked seafood
What is the special risk with HEV?
Causes fulminant hepatitis in pregnant women (liver failure with massive liver necrosis)
How do you get HDV?
Need preexisting infection with Hep B--> superinfection
HDV + HBV-> co-infection, less severe
How can you tell infection/resolved infection with HCV?
HCV-RNA confirms infection
Dec RNA indicates recovery
What is the first serological marker to rise in Hep B infection?
key marker of acute infection
What serological marker for Hep B indicates the person can infect others?
HBeAG (need envelope)
How can you distinguish a resolved HBV infection from an immunized individual?
Resolved - will have Abs to HBc and Hbs -->
Immunized - Ab only to Hbs
Fibrosis in cirrhosis is mediated by
What are some clinical signs of cirrhosis/liver failure?
Asterixis, mental status changes, coma due to inc serum ammonia causing encephalopathy
Gynecomastia, spider angioma, palmar erythema due to hyperestroginism (liver is normally responsible for inactivating estrins and synthesizing estrogen binding protein)
How do we follow the degree of coagulopathy in liver disease?
What is the metabolite of alcohol that directly damages the hepatocytes?
Acetaldehyde - damages mitochondria
What are the Mallory bodies in alcoholic hepatitis?
damaged intermediate filaments within hepatocytes
Finish alcohol related liver disease and NAFLD
Pathophysiology of hemochromatosis
Mutation in __ gene
AR defect in iron transport from enterocytes to blood (normally they won't pass along unless there is need for Fe)
HFE gene (C282Y) - cysteine replaced by tyrosine at aa 282
Triad in hemochromatosis, other findings
(from iron deposition)
Lab findings in hemochromatosis
Inc ferritin (more stored)
Dec TIBC (more bound)
Inc serum iron
Inc % saturation
What stain can you use to distinguish iron deposition in the liver from normal lipofuscin pigment ->hemochromatosis
Wilson's disease is on the __ gene, it is autosomal __
What normally binds copper in serum?
Presentation of wilson's disease?
What are the copper rings in Wilson's disease called? Where are they?
What is the treatment for Wilson's disease?
Primary biliary cirrhosis is autoimmune destruction of the bile ducts (intrahepatic). What is the Ab?
This pathology presents with "onion skin" appearance and "beading" of the bile ducts
Primary sclerosing cholangiitis - periductal fibrosis
Primary sclerosing cholangiitis is associated with this disease and this serum marker
What is damaged in Reye's syndrome? What disease looks like a viral illness but the required treatment is aspirin?
Mitochondria of hepatocytes
What is a hepatic adenoma? What causes it to grow?
related to oral contraceptive use
Grows with exposure to estrogen - risk of rupture esp. during pregnancy
What is a toxin associated with HCC?
Afloxotins from Aspergillus (p53 mutations)
What is Budd Chiari syndrome?
liver infarction secondary to hepatic vein obstruction
presents with painful hepatomegaly and ascites
**hepatocellular carcinoma gives an increased risk for Budd Chiari syndrome
What is the serum tumor marker for HCC?
What cancers commonly metastasize to liver?
*see multiple nodules on free edge of liver
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