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148 Cards in this Set

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8 functions of the liver?
1. bile production

2. metabolizes drugs and hormones

3. synthesizes proteins, glucose, clotting factors

4. stores vitamins and minerals

5. converts ammonia to urea

6. converts fatty acids to ketones

7. excretes cholesterol and bilirubin

8. activates vitamin D. (which aids in absorption of calcium)
What does vitamin D aid in the absorption of?
calcium
What does bilirubin give bile? how?
it's color...thru the breakdown of old RBC
How much bilirubin is circulating in blood is a good indicator of what?
liver function
An increase in [bilirubin] concentration in blood can indicate what?
liver problems
Can free bilirubin make it's way through the blood on it's own? If not what must it do?
no...it must be protein bound
What does the liver convert free bilirubin to?
conjugated bilirubin
Why does the liver conjugate bilirubin?
it makes it soluble in bile so it can be excreted with bile
When bilirubin is secreted with bile where is it secreted to?
the small intestine
Once in the small intestine what happens to the bile and bilirubin?
50% of it is converted to very soluble urobilinogen and most of this gets recirculated back to the liver or secreted into the feces...a very small amount goes into circulation and thru the kidneys to be excreted
What is another name for jaundice?
icterus
What does jaundice (icterus) result from?
abnormally high accumulation of bilirubin in blood, yellowing of skin and tissues
4 major causes of jaundice (icterus)?
1. excessive destruction of RBCs (prehepatic)

2. impaired uptake of bilirubin by liver cells (intrahepatic)

3. decreased conjugation of bilirubin (intrahepatic)

4. obstructed bile flow (intrahepatic)
Where can obstructed bile flow occur? (2)
both intrahepatic

1. canliculi of hepatic lobules

2. intrahepatic or extrahepatic bile ducts (posthepatic)
4 liver enzymes where an increase may indicate hepatobiliary malfunction if too high? (doesn't necessarily correlate with how much damage)
1. alanine aminotransferase (ALT)

2. aspartate aminotransferase (AST)

3. y-glutamyltransferase (GGT)

4. Alkaline phosphatase
How are serum protein levels (albumin) related to hepatobiliary function?
if you see a decline in [albumin] in serum then you have liver dysfunction and the lower it is the worse it is
What is prothrombin time (PTT) and how is it related to hepatobiliary function?
clotting factors...if liver doesn't make it it takes longer to clot...indicates liver dysfunction
What is hepatitis?
inflammation of the liver
Some causes of hepatitis?
1. autoimmune disorders

2. reactions to drugs and toxins

3. secondary to other infections (such as malaria and mononucleosis)

4. hepatotropic viruses
Name 5 hepatotropic viruses?
1. hepatitis A virus (HAV)

2. hepatitis B virus (HBV)

3. Hepatitis B-associated delta virus ) (HDV)

4. hepatitis C virus (HCV)

5. Hepatitis E virus (HEV)
Name the 3 acute viral hepatitis's that are parenteral?
1. HBV

2. HDV

3. HCV
What does parenteral mean?
from body fluid to system
Name the 2 acute viral hepatitis's that are enteric?
1. HAV

2. HEV
What does enteric mean in relation to acute viral hepatitis?
associated with fecal to oral route
How do the different acute viral hepatitis's differ?
1. mode of transmission

2. incubation period

3. mechanism

4. degree and chronicity of liver damage

5. ability to evolve into carrier state
2 mechanisms of liver injury for acute viral hepatitis?
1. direct cellular injury

2. induction of immune response against viral Ags
3 phases of manifestation for acute viral hepatitis?
1. prodromal or preicterus period

2. icterus period

3. convalescent period
What does prodromal mean?
state where signs and symptoms are not specific enough to know whats going on
What does preicterus mean?
pre-jaundice
What does icterus mean?
jaundice
What does convalescent mean?
symptoms dissipitate
Describe what a carrier state is?
no symptoms, but infected
Which acute viral hepatitis's can exist in a carrier state, which cannot?
HBV, HCV, and possibly HDV.......Not HAV
Describe structure of HAV virus?
small, no envelope, RNA-containing
HAV is resistant to what?
environmental stressors such as heat and drying (so can last long time)
Transmission of HAV?
fecal to oral
Where does HAV primarily replicate?
liver
Is there a vaccine available for HAV?
yes
Is HAV usually benign?
yes, and self-regulated (very rare instances of fulminant disease)
HAV does not have what state?
no carrier state
Where would you usually see an outbreak of HAV in US?
usually community wide in lower SES...higher in men...children and native americans at greatest risk
7 risks factors for HAV?
1. contact with HAV pos. person

2. employment/attendance at daycare

3. travel to developing countries

4. raw shellfish consumption

5. sexual contact

6. IV drug users

7. food or H2O outbreaks
Does HAV have a long term infection?
no
Most HAV infected people recover within how long?
2 months...usually benign and self limiting
Why are children <5yo often a source of spread for HAV?
because asymptomatic
Unlike children adults with HAV are usually what?
symptomatic...have jaundice...flu-like symptoms
Symptoms of HAV in adults?
jaundice, flu-like, nausea, vomiting, low-grade fever, loss of appetite
Prevention of HAV?
Hygiene...hand washing, etc....prohylaxis

vaccination (2 doses of inactivated virus)
Structure of HBV virus?
dbl-stranded DNA...hepadnavirus
The damage in HBV comes from what?
host immune response
4 outcomes of HBV?
1. acute hepatitis

2. chronic hepatitis

3. chron. prog. to hepatic necrosis

4. fulminant hepatitis with hepatic necrosis
Is there a vaccine for HBV?
yes
Transmission of HBV?
via blood and body fluids
HBV is how big of an issue?
huge
6 risks factors for HBV?
1. blood transfusions

2. IV drugs

3. Tattoos, piercings, acupuncture

4. perinatal transmission

5. sexual activity

6. healthcare professionals
How long is the incubation period for HBV?
4-6 months
What is more serious HAV or HBV?
HBV
What happens to the liver in HBV?
increased enzymes...damaged due to immune response
The liver damage from HBV results in the decreased ability to do what?
produce plasma proteins...lack of prothrombin so increased clotting time (or prothrombin time)...so ability to clot is reduced
7 symptoms of HBV?
1. jaundice

2. fatigue

3. malaise

4. joint aches

5. low grade fever

6. nauseas

7. vomiting

8. abdominal pain
Tx for acute HBV?
monitor liver function (enzymes, and prothrombin time)
Tx for chronic HBV?
reduce inflammation, symptoms, infectivity...interferon to boosts immune system...lamivudine (antiviral) and adefovir dipivoxil (nucleotide analogs..block viral DNA/RNA replication)
If there is a liver failure due to cirrhosis because of HBV what can you do?
transplant
How long after HBV does it take the liver to return to normal?
within 16 weeks
How many people with HBV develop chronic hepatitis?
a small percentage...higher incidence of hepatocellular carcinoma in these people
What is cirrhosis?
inflammation and scarring
The number one way to prevent HBV?
hep. B vaccine (recombinant DNA technology)
Besides the vaccine, 4 other ways to prevent HBV?
1. blood screen transfusions

2. mandatory reporting allows tracking

3. avoid sexual contact with infected

4. infants born to HbsAg+ moms should receive immunoglobulin plus the vaccine within 12 hours
If you have HDV then what else do you have?
HBV
HDV is not harmful on its own...what else does it req?
HBV
HDV is a defective what?
defective RNA virus (replication defect)
HDV often does what to HBV?
increases the severity of it
Routes of transmission for HDV are similar to what?
HBV
HDV co-infection with HBV is a severe ? disease. It has a ? risk of infection also?
severe acute disease...low risk of infection
What occurs in a superinfection of HDV on top of chronic HBV?
1. usually dev. chronic HDV

2. high risk of severe liver disease
HDV transmission is essentially the same as what?
HBV transmission
What is a permucosal exposure?
sexual contact
HBV-HDV "co-infection" vs. HBV-HDV "superinfection"?
co = acute HBV

super = Chronic HBV
How do you generally prevent HBV-HDV?
by preventing HBV
HCV is what structurally?
single stranded RNA virus...distantly related to viruses causing yellow fever and dengue fever
How many genotypes and subtypes of HCV?
6 geno...over 50 sub
What accounts for most US cases of HCV? What is it associated with?
genotype 1...associated with severe liver disease
What genotypes of HCV are most responsive to antiviral therapy?
2 and 3
What is HCV formerly known as?
non-A, non-B hepatitis
HCV is the most common cause of what? (3)
1. chronic hepatitis

2. cirrhosis

3. hepatocellular carcinoma
HCV is largely what? Why?
undiagnosed...bc most not clinically ill, but chronically infected
How long do those with HCV have risks for chronic liver disease?
decades after initial infection
6 risk factors for HCV?
1. IV drug use

2. transfusion, transplant from infected donor (bf 1992)

3. occupational exposure to blood (but prevalence not greater than general public)

4. iatrogenic (unsafe injections)

5. birth to HCV-infected mom

6. sex with infected partner
HCVs incubation period? compare to that of HAV and HBV?
6-7 weeks (longer than HAV, shorter than HBV)
Most with Chronic hepatitis due to HCV are what?
asymptomatic
Although those with HCV may be asymptomatic what 4 things can still occur?
1. necrosis

2. fibrosis

3. cirrhosis

4. hepatocellular carcinoma
5 factors promoting the progression or severity of HCV?
1. alcohol

2. age 40>

3. HIV, HAV, HBV co-infection

4. male gender

5. HCV genotype (type 1 is worst)
Prevention of HCV? (3)
(remember passed same as others)

1. avoid contact with blood, blood products, bodily fluids

2. vaccine dev. difficult because of different genotypes

3. vaccinate against HAV and HBV (to avoid co-infection)
Cure for HCV?
no cure
Which type of hep. has just recently been identified?
hepatitis E
Structure of hep. E?
single-stranded RNA
transmission of Hep. E?
fecal to oral
Where is Hep E a problem?
in developing countries
How is Hep E similar to Hep A?
both are acute and self limiting...does not progress to chronic hepatitis
4 ways for travelers to prevent HEV infection?
1. avoid drinking H2O, shellfish, fruit, veggies

2. IG prepared from donors in western countries does not prevent infection

3. unknown efficacy of IG prepared from donors in endemic areas

4. future vaccine (?)
Chronic hepatitis is accompanied by chronic inflammtion of what? For how long?
the liver for more than 3-6 months
Chronic hep. is accompanied by persistently elevated levels of what?
serum aminotransferase
5 causes of chronic hepatitis?
1. HBV

2. HCV

3. HDV

4. autoimmune hepatitis

5. drug induced hepatitis
3 outcomes of chronic hepatitis?
1. chronic liver disease

2. cirrhosis

3. hepatocellular carcinoma
primary reason for liver transplant in adults?
hepatocellular carcinoma (from chronic hepatitis)
5 common clinical features of chronic hep?
1. fatigue

2. malaise

3. loss of appetite

4. occasional jaundice

5. elevated liver enzymes depend upon level of disease activity
There are no what for chronic hep?
simple, effective txs
Autoimmune hepatitis is often seen with what?
other autoimmune diseases...circulating autoantibodies
Autoimmune hep is common in whom?
young girls and women
Who is always at more risk for autoimmune diseases?
young girls and women
Pathology of autoimmune hep? (4)
1. genetically predisp. person comes in contact with environ. trigger...triggers autoimmune response

2. autoimmune destruction of liver cells causes necrosis

3. destruction of liver cells progresses to cirhossis

4. may progress to liver failure
The symptoms of autoimmune hep are similar to what? What do they include?
sim. to symptoms of other chronic hep.

1. fatigue, malaise

2. anemia

3. jaundice
Middle-aged women with autoimmune hep may have what kind of antibodies?
ANA...anti-nuclear antibodies
Mortality for those with autoimmune hep?
high mortality
Diagnosis for autoimmune hep is accomplished how?
differential diagnose (so rule out other types of chronic hep...HBV, HCV based upon antibodies assoc. with them)
In autoimmune hep there is a marked elevation of what?
serum IgG
3 antibodies associated with autoimmune hep?
1. ANA

2. anti-smooth muscle Abs

3. anti-LKM Abs (anti-liver-kidney microsomal)
Why may corticosteroids be used with autoimmune hep?
because they reduce inflammation and it is an inflammatory cond....however this may slow progression but may still see cirrhosis and liver failure (need transplant)
How many alcoholics develop cirrhosis?
10-20%
What does liver pathology develop from in alcoholic liver disease?
as a result of alcohol's toxic effects on hepatocytes
End product of alcohol metabolism?
acetaldehyde, free radicals responsible for alterations that cause liver injury
Acetaldehyde has toxic effects on what?
hepatocytes and liver fcn
3 things that acetylaldehyde injury are related to?
1. avg qty consumed of alc.

2. age (affects alc. metabolizing abilities of liver and resistance to hepatotoxic effects)

3. Gender: women produce more acetyaldehyde than men, bc this system is suppressed by testosterone
What does NAD stand for?
nicotinamide adenine dinucleotide
What is NAD?
a cofactor reqd for alcohol metabolism...also for metabolism of pyruvates, urates, and fatty acids
Alcohol metabolism competes for what?
NAD
Decreased alc. metabolism leads to an accumulation of what?
lactic acid
Decreased alc. metabolism leads to impaired what?
gluconeogenesis (formation of glucose from AAs)
What does fatty liver disease come from?
alcohol abuse
What is another name for fatty liver disease?
steatosis
In fatty liver disease where is the fat accumulation?
in hepatocytes
4 things that lead to fatty liver disease (steatosis)?
1. fat from diet, alc. increases lipolysis and delivery of FFA to liver

2. alc. increases FA synthesis

3. Alc. decreases oxidation of FA

4. Alc. impairs release of lipoproteins
What is alcoholic hepatitis an intermediary stage between?
steatosis (fatty liver dis) and cirrhosis (fibriotic cond. of liver)
Alc. hepatitis does what to hepatocytes?
inflammation and necrosis
4 signs and symptoms of alc. hep?
1. hepatic tenderness, pain

2. anorexia, nausea

3. jaundice

4. ascites (fluid accum)
What is the end stage of alcohol liver disease?
alcoholic cirrhosis
What is alc. cirrhosis the result of?
repeated alcoholic insults to the liver
What does alcoholic cirrhosis designate?
the end-stage of alcoholic liver disease
What does alc. cirrhosis look like visually?
fine, uniform nodules on liver surface
3 complications of alcoholic liver disease?
1. alcoholic encephalopathy

2. portal htn

3. bleeding
What is cirrhosis?
end stage of chronic liver disease
In cirrhosis what is much of the functional liver replaced by?
fibrous tissue
In cirrhosis what is disrupted?
normal flow thru the liver
3 manifestations of cirrhosis?
1. heptomegaly (increase in size)

2. wt. loss

3. jaundice
How would a liver with cirrhosis feel?
hard with nodules
7 complications of cirrhosis?
1. portal htn

2. splenomegaly (thrombocytopenia)

3. ascites

4. esophageal varices (bleeding)

5. spider angiomas

6. palmer erythema

7. encephalopathy
What is portal htn?
sustained portal vein pressure greater than 12mmHg (normal is 5-10)
Cause of Portal HTN?
any cond. increasing resistance to hepatic blood flow