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33 Cards in this Set
- Front
- Back
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1. Hepatic injury
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• Large capacity for regeneration and healing
o Can do partial liver transplants • The replaced part will grow and look like a whole liver • Chronic injury leads to scaring and eventually cirrhosis o |
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Chirrhosis:
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• End-stage of chronic injury with fibrosis, liver failure and portal hypertension
• Cirrhosis is permanent • There isn’t any liver to regenerate or replace itself • Structure has been destroyed o Alcohol and HCV most common things that lead to chronic injury and eventually cirrhosis • |
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Normal functions of liver
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o Storage and release of blood to maintain adequate circulating volume
o Metabolism of nutrients • Blood vessels from digestive tract drain into the hepatic portal vein so the liver has the first chance to see all the stuff that comes out of the GI tract – except fats o Detoxification of poisons, toxins, drugs o Regulation of fluid and electrolyte homeostasis o Production of clotting factors o Production of bile acids and pigments • Bile • Digestion of fat • Cholesterol derivatives that emulsify fat • Pigments are products of hemoglobin metabolism • Heme pigments are in bile o Many more |
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2. Hepatic failure
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– different causes: due to chronic or acute
a. Clinical manifestations • Common signs and sx o GI symptoms • Diarrhea, constipation, nausea, indigestion, etc o Edema (generalized swelling) and ascites (extra fluid within the peritoneum space) o Dark urine • From heme products, when liver isn’t digsting heme proberly • Bilirubin is a product of heme breakdown o Steatorrhea • Fatty stools o RUQ pain • Liver pain o Jaundice (icterus) • Yellowing of body tissues and fluids related to build up of bilirubin – if it cant get to stool than it goes everywhere else in the body • Hepatic failure |
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o Encephalopathy
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– dysfunction of brain
• Decreasing level of alertness and consciousness • |
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Asterixis
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• Patients with liver failure will have a mechanical dysfunction in their hands
• Not unique to hepatic failure • Hand flapping • Marker of level of concentration and alertness • |
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High ammonia
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• Urea- nitrogen build up
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Renal failure
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• When liver failure, renal failure follows
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Endocrine changes
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– especially changes related to sex steroid hormones, normally metabolized in liver that don’t get metabolized
• Spider angimoas o In the skin o Small spider like blood vessels • Palmar erythema o Redness of the palms • Gynecomastia o Enlargement of breast tissue due to endocrine changes • |
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Jaundice
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• Associated with bilirubin levels
• Not just skin but all tissues • |
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Portal hypertension
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– related to the portal vein, GI drains into portal vein. – blood normally goes into liver, cant get into liver because of fibrous tissue/scaring – portal cant drain so the places that supply it build up – increased pressure
• Ascites – high venous pressure in the abdomen, push of fluid out of the Blood vessels, leak out into the peritoneal space, leads to generalized swelling • Varices - There other pathways to get blood past the portal vein, other veins get enlarged/dilated o Esophageal o Hemorrhoidal • Venus plexus connected to systemic and portal circulation o Caput medusae • Connection between systemic and portal circulation around the umbilicus, dilated veins around the area of the abdomen • |
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Fector hepaticus
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• Stink of liver death
• Breath of the patient – rotting flesh • |
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Coagulopathy
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• Liver produces most of the clotting factors
• If liver failure they will not have normal clotting • Abnormal bleeding • Impaired immune response 3. |
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Jaundice
• Definition |
o Yellowing of skin, sclerae, mucous membranes and excretions (sweat, ruine)
o Hyperbilirubinemia • Increase in bilirubin in the blood • Normally excreted by liver, not reabsorbed o Other sx’s • Pruitus • Generalized itchyness of the skin • Sx’s of disease causing the jaundice – not a disease in itself o w/u should include all possible causes of liver disease o tx underlying cause |
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4. Portal hypertenison
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• Increased blood pressure in portal circulation
o Most common cause is cirrhosis o Other cause • Thrombus, tumor, etc. o Leads to • Collateral dilation and back up of tissue fluid • Splenomegaly o Only vein that drains the speen goes right into the liver o Spleen becomes large and swollen • Ascites o Two contributing factors • Increase in venous pressure helps push fluid out of vessels and into abdomen • Decreased albumin in the blood (hypoalbuminemia) • Albumin is protein normally in the blood • Produced by the liver • Binding and carrier protein • One of major osmotic contributors to the blood • Draws fluid from the abdomen into the blood • With out it, more fluid moves out of vessels and into tissues • Varices and hemorrhoids o Caput medusae • Encephalopathy o Gets worse o In normal person gi absorbs toxins from diet, most are destroyed by liver before they get to the rest of the body. o If liver isn’t doing job and blood from GI is going elsewher |
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5. Ascites
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• Causes
o Most commonly cirrhosis with portal hypertension, hypoalbumenemia and hyperaldosteronism (produced from kidneys) • Contributes to decrease in sodium • Osmotic imbalance o Congestive heart failure, constrictive pericarditis (inflammation around heart), abdominal malignancies, malnutrition • No protein in diet • Get wasting of tissues • Due to no albumin and due to • CM o Abdominal swelling and pain o Respiratory distress • Pressure on diaphragm o Bacterial infection • TX o Treat underlying cause o Fluid and Na restriction o Diuretics o Drain fluid directly • Temporarily decreases discomfort • Accumulates very rapidly o TIPSS |
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6. Hepatic Encephalopathy
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• Causes
o Acute and chronic liver disease o Elevated ammonia • TX o Antibiotics • Bacteria in gut contribute to toxins o Lactulose o Peritoneal dialysis • Putting fluid intentionally into the abdomen and then draining it out o Liver transplant • Prognosis o Mortality high if underlying cause untreated |
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7. Hepatitis (General)
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• Liver inflammation
o Virus • Infects cells of liver o Chemical • Mushroom toxin • Carbon tetrachloride • Alcohol o Autoimmune o Drugs • Acetaminophen • Toxic if normal dosage is exceeded • Valproic acid, etc. o Multiple causes are additive in effect • |
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o General term for chronic inflammation and injury to liver
o Most common causes • Hep B with or without D, Hep C o Can lead to cirrhosis and or hepatocellular carcinoma • Cancer of the liver cells • Chronic inflammation of liver at risk of hepatocellular carcinoma |
8. Viral hepatitis
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9. Toxic hepatitis
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• Drug (dose related or idiosyncratic), chemical or herbal/botanical hepatotoxins
o Acetominophen (dose level), alcohol, amantia mushrooms, phenytoin (idiosyncratic), isoniazid, etc • Pre-existing liver disease, multiple compounds and other co-morbidities may contribute to severity of injury • TX by removal of offending agent, rest, symptomatic relief, gastric emptying (to get rid of anything that hasn’t been absorbed yet), etc • Liver transplant if fulminant liver failure |
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10. Alcoholic liver disease
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• Most common cause of liver dz in western world
• Acute and chronic inflammation • Cirrhosis irreversible • Few sx until cirrhosis • TX o Abstinence, nutritional support, vitamins, fluids • Prognosis good if alcohol stopped before irreversible injury o If not, cirrhosis, portal hypertension and hepatic failure result |
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11. Autoimmune inflammatory liver disease
• Autoimmune hepatitis |
o Leads to severe liver injury and failure
o Unknown cause o Usually good response to immunosuppressant drugs • |
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Primary biliary (bile ducts) cirrhosis
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o Slowly progressive autoimmune destruction of small intrahepatic bile ducts
o Leads to bile acid buildup, cirrhosis and liver failure o Associated with other autoimmune diseases o More common in women (10:1) • |
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Sclerosing cholangitis
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o Inflammatory autoimmune disease of intrahepatic and extrahepatic bile ducts
• Can be associated with ulcerative colitis o Pathology • Obstructs bile flow • Pruitis, jaundice, etc • Leads to cirrhosis and hepatic failure o TX and prognosis • Anti-immune drugs not very effective • Transplant can help occasionally • Transplanted liver can be attacked as well • Predisposes to cholangiocarcinoma |
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12. Hepatic neoplasm’s
• Hemangioma |
o Benign tumor
o Tumor of blood vessels o Associated with higher estrogen levels o F>M o Slow growing o Usually asx • |
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Adenoma
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o Benign tumor
• Hepatocytes o F>M o Growth assoc, with androgens/estrogens o Presents with pain due to hemorrhage or necrosis o Some resolve with discontinuation of oral contraceptives or androgens o Others can be surgically resected • Malignant transformation rare |
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13. Hepatocellular carcinoma
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• Etiology/risk
o HBV, HCV, and or cirrhosis • CM o Mild fever, Gi sx o Jaundice, RUQ pain, R shoulder pain (, hepatomegaly, weight loss o End-stage cachexia (muscle wasting), tumor rupture, portal/hepatic vein thrombosis, portal hypertension and metastasis • DX o High alpha-fetoprotein o Biopsy • Prevention o Vaccination and avoidance of viruses, alcohol • TX o Surgery, chemotherapy, radiofrequency albation, etc • Prognosis o Untreated, uniformly fatal o Best survival in early disease, totally removed in non cirrhotics |
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14. Metastatic tumors
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• Common cause of liver tumors
o More common than HCC • Sources o Colorectal, stomach, pancreas, esophagus, lung, breast, etc • TX and prognosis o Depends on type and extent |
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15. Acute pancreatitis
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• Etiology/pathology
o Alcoholism and gallstones most common o Leakage of pancreatic enzymes into surrounding tissues • Necrosis, hemorrhage, fat necrosis, aggressive inflammation • Massive release of cytokines, enzymes o Systemic illness (kidneys, lungs, shock, coma, etc) o SX • N/V, fever, tachycardia, malaise, mild jaundice, abdominal pain radiating to back • Later ARDS (acute respiratory distress syndrome), renal failure, peritonitis, shock, etc o DX • Elevated serum amylase and lipase • Normally not found in blood • Made and found in the pancreas • When pancreas leaks • U/S and CT of abdomen o TX • Withhold oral food • Food stimulates pancreatic secretion • Fluid replacement • Fluid flows into abdomen • Bed rest • Remove gallstones if indicated o Prognosis • Most recover fully in self-limited fashion • Severe disease can lead to coma, cardiopulmonary collapse and death |
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16. Chronic pancreatitis
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o Etiology
o Cystic fibrosis in children o Alcoholism in adults o Chronic inflammation, fibrosis and progressive functional impairment o Acute pancreatitis attacks may be superimposed on chronic disease o Prognosis o Malabsorption and diabetes mellitus (damage to islet cells) chronically o Avoid by prevention of further injury |
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17. Pancreatic cancer
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o Etiology
o Ductal adenocarcinoma most common • Arises from ducts of pancreas, duct lining cells o Risks o Increased risk • Aferican am and jewish • 70-80 yo • DM, chronic pancreatitis, etc • Males o SX o Initially vague o Later, pain, cachexia (muscle wasing), ascites, biliary obstruction and jaundice o TX o Stenting • Of pancreatic duct if blocked by tumor o Resection if possible |
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18. Cholelithiasis
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– gall stones or bile stones
o Etiology o Cholesterol or bile pigment stones o Risks o Age, high estrogen levels, DM, high fat diet, rapid weight loss, prolonged fasting, females (fat, fair, fertile, forty, flatulent, female) o CM o Asx or o Fatty food intolerance o Obstruction • Biliary colic • Peristalsis of gall bladder o DX o History, U/S, ct scan o Tx o Asx – no tx o Sx – limit fats, cholecystectomy o Prognosis o Good unless severe complications of obstruction, infection and rupure • Pancreatitis, cholecystitis, cholangitis, etc |
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19. Cholelithiasis diseases
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o Choledocholithiasis – stone in a duct
o Stones (calculi) in common bile duct o May be asx or biliary colic, obstruction with jaundice, fever, cholangitis or pancreatitis o DX and TX – endoscopic retrograde cholangiopancreatography (ERCP) or surgery o Cholecystitis o Etology • Acute or chronic • Obstruction of cystic duct • Inflammation and infection o SX • RUQ pain • Murphy’s sign o DX • Exam, U/S or CT • Blood tests – wbc, alkaline phosphotase, GGT (enzymes elevated when there’s damage to the gall bladder), etc o TX • cholesystectomy |
