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73 Cards in this Set

  • Front
  • Back
Unconjugated Bilirubin
Insoluble

not excreted

tight complex with Albumin
Conjugated Bilirubin
Water

Excreted in Urine

loosely bound in Albumin
Conjugated HyperBilirubinemia
1. impaired transport into CANALICULUS

2. Canalicular CHOLESTASIS
Unconjugated HyperBilirubinemia
1. impaired bilirubin UPTAKE

2. altered glucoronyl TRANSFERASE activity
Alcoholic Liver Disease
excessive ethanol consumption
1. hepatic steatosis (fatty liver disease)
2. Alcoholic Hepatitis
3. Cirrhosis
Alcoholic Consumption
12 beers / day
2 glasses of 80-proof liquor/day

for 10-20 years
Hepatic Steatosis w/ Alcohol
ethanol increases Lipolysis & delivery of Free Fatty Acids to the liver
Hepatic Steatosis
↑ fatty acid synthesis

↑ production of Triglycerides

↑impairs release of Lipoproteins

↓mitochondrial oxidation of Fatty Acids
Hepatic Steatosis
lipid lobules displace nucleus of hepatocytes
"signet ring appearance"

Gross enlargement & yellow-color
Alcoholic Hepatitis
Hepatocyte swelling & necrosis

Mallory Bodies

Neutrophilic reaction

Fibrosis -- activates stellate cells & portal fibroblasts
Mallory Bodies
red cytoplasmic inclusions of cytokeratin filaments
Alcoholic Cirrhosis
End-stage liver disease

Anorexia + Weight Loss + Weakness
Alcoholic Cirrhosis -- death
progressive Liver Failure

complications of Portal HTN

development of Hepatocellular Carcinoma
Alcoholic Cirrhosis---appearance
mis-shaped w/ surface Nodules

bridging fibrous septa + Parenchymal Nodules
diffuse disruption of architecture
Portal Hypertension
increase resistance to portal blood flow

1. ↑resistance @ sinusoids

2. ↑ portal venous flow b/c hyperdynamic circulation
Post Hepatic -- portal HTN
1. Inferior Vena Cava Thrombosis/clot

2. Hepatic Vein Thrombosis/clot

3. Veno-occlusive disease
Intrahepatic ---portal HTN
1. Cirrhosis
2. Sinusoidal Occlusion
Pre-hepatic -- portal HTN
1. Hepatic Artery Compromise

2. Portal Vein Onstruction/clot
Circulatory Disorders
the main category Portal HTN causes
Cirrhosis
most common cause of Portal Hypertension
Circulatory Disorders of Portal HTN
1. Impaired blood flow thru LIver

2. Hepatic Venous Outflow Obstruction
Physiologic Jaundice -- Newborn
after first 24-hours within first 2 weeks
Physiologic Jaundice
immature transhepatic clearance of bilirubin
Premature Infants --Jaundice
immaturity and Increased turnover of RBC
Breastfed Babies --Jaundice
presence of bilirubin deconjugating enzymes in breast milk
Physiologic Newborn Jaundice -- treatment
phototherapy -- absorption of light by unconjugated bilirubin generates water soluble isomers
Hereditary UNCONjugated Hyperbilirubemias
1. Gilbert syndrome

2. Crigler Najjar type I

3. Crigler Najjar type II
Hereditary CONJUGATED Hyperbilirubemias
1. Dubin Johnson syndrome

2. Rotor syndrome
Gilbert Syndrome
Autosomal recessive

Benign, common disorder

Mild fluctuating Hyperbilirubinemia w/ STRESS
Crigler Najjar Type II
Autosomal Dominant

generally mild

VERY Yellow skin

**Phenobarbital = (+) Hypertrophy of ER In hepatocytes
Crigler Najjar Type I
Autosomal Recessive

Fatal in neonatal period

Death due to Kernicterus in 18mos (if no transplant)
Hereditary UNCONjugated Hyperbilirubemia
due to mutations in UGT1A1
Gilbert syndrome & Crigler Najjar Type II
mutated UGT1A1 causes decrease activity of glucoronyl TRANSFERASE


decreased ability to conjugate bilirubin
Crigler Najjar Type I
mutated UGT1A1 results in lack of activity

no ability to conjugate bilirubin
Dubin Johnson Syndrome
Autosomal Recessive

lack of MDR2 canalicular protein

Chronic, recurrent Jaundice of varying intensity

Asymptomatic & normal lifespan
Rotor Syndrome
impaired bile formation/flow

normal liver

Jaundice w/ normal lives
Cholestasis
impaired bile formation and flow

due to obstruction of Bile channels & defects in hepatocyte bile secretion
Cholestasis
Jaundice + Xanthomas + Pruritis

deficiencies of Fat Soluble Vitamins A, D, E, K

↑ alkaline phosphatase & gamma glutamyl transferase
Cholestasis
Parenchyma
swollen hepatocytes, bile pigments in cytoplasm
dilated canaculi
apoptic cells
kupffer cells w/ Bile

Portal Tracts
Bile ductular proliferation
Edema Bile pigment retention
Neutrophilic infiltration
Intrahepatic Biliary Tract Disease
Primary Biliary Cirrhosis

Secondary Biliary CIrrhosis

Primary Sclerosing Cholangitis
Primary Biliary Cirrhosis
Females

↑ serum IgM autoantibodies

dense lymphocytic infiltrate
Granulomatous destruction
Primary Sclerosing Cholangitis
Males

atrophy of bile duct epithelium

concentric peri-ductal fibrosis "onion-skin"

Lymphocytic infiltrate
Intrahepatic Biliary Tract disease
Pruritus + Jaundice + Malaise

Dark Urine + Light Stools + Hepatosplenomegaly

Conjugated Hyperbilirubinemia

↑alkaline phosphatase, bile acids, cholesterol
Hepatic Disease & Pregnancy
1. Pre-eclampsia / Eclampsia

2. Acute Fatty Liver of Pregnancy

3. Intrahepatic Cholestasis of Pregnancy
Pre-eclampsia
1. Maternal Hypertension
2. Proteinuria
3. Peripheral Edema
4. Coagulation abnormality & DIC

HELLP syndrome
HELLP syndrome of Hepatic Disease (pregnancy)
Hemolysis

Elevated Liver enzymes

Low Platelets
Eclampsia
HTN + Protein + Edema + Hyper-reflexia + Convulsion

hemolysis & elevated liver enzymes = Hepatic disease
Acute Fatty Liver of Pregnancy
3rd trimester presentation

Bleeding + Nausea/Vomiting + Jaundice + coma

Microvesicular Steatosis
Microvesicular Steatosis
confirms Acute Fatty Liver in pregnancy

Oil Red / Sudan Black stain on frozen tissue
Intrahepatic Cholestasis of Pregnancy
3rd Trimester (BENIGN condition)

Pruritus + Dark Urine + light stool + Jaundice

↑ risk Fetal Distress / Stillbirth / premature birth
Jaundice
yellowing of skin
Icterus
yellowing of sclerae (white part of eyes)
Kernicterus
rare type of brain damage associated w/ jaundice
Cholestasis
systemic retention of bilirubin and other solutes normally eliminated in Bile
Pruritus
itching of skin due to deposition of bile salts
Bile
thick, greenish yellow fluid made of . . .
1. bilirubin
2. Bile salts
3. Cholesterol
4. Electrolytes
Function of Bile
1. Emulsification of dietary Fat in lumen of gut

2. Elimination of Bilirubin, excess Cholesterol, Xenobiotics & waste products
Emulsification of Dietary Fat
in lumen of gut thru detergent action of bile salts
Elimination via Bile
removes Bilirubin, excess Cholesterol, xenobiotics, other waste products that are not water-soluble enough for urinary excretion
Bilirubin
end product of heme degradation
Heme oxygenase
converts Heme into Bilverdin
Biliverdin Reductase
converts Bilverdin in RBC into circulating "unconjugated" bilirubin
Ascites
accumulation of excess serous fluid

Cirrhosis most common cause

> 500 ml = detectable
Portal Hypertension -- Clinical consequences
1. Hepatic Encephalopathy

2. Esophageal Varices

3. Congestive Splenomegaly

4. Ascites
Sinusoidal Obstruction Syndrome
3 weeks after allogenic Bone Marrow Transplant

toxic injury = slough epithelium @ sinusoids

Sloughed off epithelium = obstruct sinusoidal bloodflow
Sinusoidal Obstruction
Ascites + Weight Gain + Jaundice

Tender Hepatosplenomegaly
Budd-Chiari syndrome
Liver Enlargement + Pain + Ascites

due to one of the following....
1. obstruction of 2 or more Hepatic veins
2. Inferior Vena Cava obstruction

**Needs SURGERY ASAP
Peliosis Hepatis
any condition in which Hepatic EFFLUX blood is obstructed

Sinusoidal Dilation is primary **
Peliosis Hepatis -- complications
potentially Fatal Intra-abdominal hemorrhage

assoc. with
CA, TB, AIDS, Post-transplant immunodeficiency
anabolic steroids
Liver Infarct
rarely occurs due to its dual blood supply

distal hepatic tissue is pale tan
Dual Blood supply to Liver
Portal Veins & Hepatic Arteries
Paasive Congestion
Right-sided cardiac decompensation

Centrilobular Atrophy
Centrilobular Necrosis
Left-sided heart failure

hypoxia = ischemic coagulative necrosis