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Block 10 Week 4 > Usera > Liver 1 > Flashcards

Usera > Liver 1 Flashcards

1
Q

what does the portal vein carry?

A

venous blood rich in nutrients from the alimentary tract

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2
Q

what does the hepatic artery carry?

A

arterial blood rich in oxygen from the celiac axis

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3
Q

what is the blood supply of the liver?

A
  1. portal vein

2. hepatic artery

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4
Q

what veins drain the liver?

A

hepatic veins

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5
Q

what vein drains the R lobe?

A

right hepatic vein

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6
Q

what does the middle hepatic vein drain?

A

the middle of the L lobe & some of the R lobe

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7
Q

what vein drains the left lateral lobe?

A

L hepatic vein

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8
Q

what % do the portal vein & hepatic artery contribute to the liver?

A

portal vein = 60-70%

hepatic artery = 30-40%

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9
Q

what 3 things make up the portal triad (tract)?

A

portal vein
hepatic artery
bile duct

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10
Q

what shape is a liver lobule?

A

hexagonal

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11
Q

what is the orientation of a liver lobule?

A

oriented around a hepatic VEIN w/ portal tracts at the periphery

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12
Q

define “centrilobular”

A

area of the liver closest to the hepatic vein

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13
Q

define “periportal”

A

area of the liver closest to the portal tract

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14
Q

which model is used to describe the histopathology of the liver?

A

liver lobule model

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15
Q

what shape is a liver acinus?

A

triangular

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16
Q

where is the apex of a liver acinus?

A

near the hepatic vein

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17
Q

where is the base of a liver acinus?

A

formed by penetrating vessels of portal tract

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18
Q

what zone of a liver acinus is closest to the portal tract?

A

zone 1

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19
Q

what zone of a liver acinus is closest to the hepatic vein?

A

zone 3

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20
Q

which model is used to describe the physiologic relationship of hepatocytes & blood supply of the liver?

A

acinus model

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21
Q

the liver is vulnerable to a wide variety of WHAT KINDS of insults?

A
  1. metabolic
  2. toxic
  3. microbial
  4. circulatory
  5. neoplastic
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22
Q

when do clinical detection & sx of hepatic decompensation occur in liver dz?

A

weeks, months, or many years after the onset of injury

INSIDIOUS ONSET

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23
Q

what can confirm the presence of liver dz but not define the CAUSE of liver dz (generally speaking)?

A

biochemical tests that detect abn liver fxn

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24
Q

what 3 tests evaluate hepatocyte INTEGRITY?

A
  1. AST
  2. ALT
  3. LDH
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25
Q

what 5 tests evaluate biliary excretory fxn?

A
  1. serum bilirubin
  2. urine bilirubin
  3. alk phos
  4. GGT (gamma-glutamyl transpeptidase)
  5. 5’-nucleotidase
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26
Q

what are the 3 types of serum bilirubin?

A
  1. total
  2. direct
  3. delta
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27
Q

what are the 3 tests that evaluate hepatocyte FXN?

A
  1. albumin
  2. ammonia
  3. prothrombin time
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28
Q

what are the 5 patterns of liver injury?

A
  1. inflammation
  2. intracellular
  3. necrosis
  4. regeneration
  5. fibrosis
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29
Q

what is the most severe clinical consequence of liver dz?

A

hepatic failure

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30
Q

when do you get hepatic failure?

A

loss of 80-90% of hepatic fxnal capacity

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31
Q

what are the 3 categories of hepatic failure?

A
  1. acute liver failure
  2. chronic liver dz
  3. hepatic dysfxn w/o overt necrosis
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32
Q

what is the most common route with the endpoint of cirrhosis?

A

chronic liver dz

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33
Q

what is the criteria for chronic liver dz?

A

hepatic necrosis & inflammation present for at least 6 mos

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34
Q

what’s happening in hepatic dysfxn w/o overt necrosis?

A

viable hepatocytes w/o the ability to perform metabolic fxns

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35
Q

what is fulminant liver failure?

A

encephalopathy that develops w/i 2 wks of jaundice

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36
Q

what is acute liver failure?

A

liver dz assoc w/ encephalopathy w/i 6 mos after dx

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37
Q

what is sub-fulminant liver failure?

A

encephalopathy that develops w/i 3 MONTHS of jaundice

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38
Q

what are the 4 main causes of acute liver failure?

A
  1. drugs
  2. toxins
  3. infxn
  4. autoimmune
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39
Q

what drugs can cause acute liver failure?

A 
acetaminophen
rifampin
isoniazid
MAOIs
halothane
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40
Q

what toxins can cause acute liver failure?

A

carbon tetrachloride

shrooms

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41
Q

what infxns can cause acute liver failure?

A

hep A

hep B

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42
Q

what are the 7 clinical signs of hepatic dysfxn?

A
  1. jaundice
  2. easy bruising (coagulopathy)
  3. hypoalbuminemia
  4. hyperammonemia
  5. hypoglycemia
  6. fetor hepatis
  7. hyperestrinism
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43
Q

what are the 5 sx of hyperestrinism?

A
  1. hypogonadism
  2. gynecomastia
  3. spider angiomas
  4. palmar erythema
  5. muscle wasting (shoulder girdle atrophy)
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44
Q

how do you get hepatic encephalopathy?

A

blunt shunting away from the liver > toxic metabolites enter the CNS

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45
Q

what is hepatorenal syndrome d/t?

A
  1. poor renal perfusion & renal vasoconstriction (NOT renal pathology!)
  2. activated renal sympathetic nervous system d/t vasoconstriction of arterioles
  3. synthesis of renal vasoactive mediators
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46
Q

what are the sx of hepatorenal syndrome?

A
  1. hyperosmolar urine
  2. hyponatremic urine
  3. no proteinuria
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47
Q

what are the complications of hepatic failure?

A
  1. severe coagulopathy
  2. encephalopathy
  3. hepatorenal syndrome
  4. multiple organ failure
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48
Q

what is a complication of portal HTN?

A

esophageal varices

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49
Q

what is hepatic encephalopathy?

A

disorder of neurotransmission in the CNS & neuromuscular system assoc w/ HIGH AMMONIA

50
Q

what is the spectrum of disturbances of consciousness in hepatic encephalopathy?

A

subtle behavior diffs to confusion, stupor, coma, & death

51
Q

what are the neurologic signs of hepatic encephalopathy?

A

rigidity
hyperreflexia
asterixis

52
Q

what is hepatorenal syndrome?

A

renal failure in pts w/ severe chronic liver dz w/ no intrinsic cause for renal failure

53
Q

what is the common end stage to many underlying liver dzs?

A

cirrhosis

54
Q

how do you get hypoperfusion in cirrhosis?

A

fibrosis > vascular disruption > hypoperfusion

55
Q

what type of regeneration do you get w/ cirrhosis?

A

nodular

56
Q

what kind of disruption is there w/ cirrhosis?

A

parenchymal/fxnal

57
Q

what is the most common cause of cirrhosis?

A

alcoholic liver dz

58
Q

what are the 2 RARE causes of cirrhosis?

A

Wilson dz

Alpha-1 ATD

59
Q

besides booze, what can cause liver cirrhosis?

A
  1. viral hepatitis
  2. biliary dz
  3. hemochromatosis
  4. Wilson dz (rare)
  5. alpha-1 ATD (rare)
  6. cryptogenic cirrhosis
60
Q

what 3 things make up “cryptogenic cirrhosis”?

A
  1. NASH
  2. autoimmune
  3. other
61
Q

what do hepatic stellate cells aka ito cells normally do?

A

vitamin A storage

62
Q

what happens to hepatic stellate cells aka ito cells in response to inflammatory cytokines or toxin exposure?

A

they transform into myofibroblasts & deposit collagen 1 & 3

63
Q

T/F: end-stage cirrhosis is non-specific

A

TRUE

64
Q

what are the 3 morphological characteristics of cirrhosis?

A
  1. bridging fibrosis
  2. parenchymal nodule formation
  3. architectural distortion
65
Q

what is bridging fibrosis?

A

deposition of types I & 3 collagen into the space of Disse

66
Q

what facilitates bridging fibrosis?

A

activation of stellate cells into myofibroblasts

67
Q

what causes bridging fibrosis? (4 things)

A
  1. chronic inflammation
  2. cytokine pdtion
  3. disruption of the ECM
  4. direct stimulation by toxins
68
Q

what is parenchymal nodule formation?

A

after injury, surviving hepatocytes regenerate as spherical nodules w/i the fibrous septa

69
Q

what does fibrosis do in the context of parenchymal nodule formation?

A

creates new vascular channels btwn portal vessels & hepatic veins

70
Q

what are the consequences of fibrosis in parenchymal nodule formation?

A
  1. compromises delivery of blood to hepatocytes

2. compromises hepatocyte’s ability to secrete into plasma

71
Q

why do you get architectural distortion in cirrhosis?

A

diffuse fibrosis

diffuse parenchymal injury

72
Q

what is portal HTN?

A

inc pressure in portal system d/t arterial pressures being imposed on the portal system

73
Q

what are the 3 types of portal HTN?

A
  1. prehepatic
  2. intrahepatic
  3. posthepatic
74
Q

what are the 3 causes of prehepatic portal HTN?

A
  1. obstructive thrombosis
  2. massive splenomegaly
  3. portal vein constriction
75
Q

what are the 5 causes of intrahepatic portal HTN?

A
  1. cirrhosis
  2. schistosomiasis
  3. massive fatty change
  4. diffuse granulomatous dz
  5. nodular regenerative hyperplasia
76
Q

what are the 3 causes of posthepatic portal HTN?

A
  1. right sided heart failure
  2. constrictive pericarditis
  3. hepatic vein outflow obstruction
77
Q

what 2 things increase in portal HTN?

A
  1. resistance

2. flow

78
Q

where do you get increased resistance in portal HTN?

A

at the level of the sinusoids

79
Q

what 2 things does increased resistance cause?

A
  1. contraction of vascular smooth muscle cells & fibroblasts

2. disruption of blood flow d/t scarring & parenchymal nodule formation

80
Q

why do you get increased flow in portal HTN?

A

d/t hyperdynamic circulation

81
Q

what does increased flow cause in portal HTN?

A

arterial vasodilation in the splanchnic circulation which leads to inc venous efflux in the portal system

82
Q

what is ascites?

A

accumulation of serous fluid in the peritoneal cavity

83
Q

what are 4 things that can give you ascites?

A
  1. sinusoidal HTN
  2. hypoalbuminemia
  3. thoracic duct overflow
  4. splanchnic vasodilation + hyperdynamic circulation
84
Q

what happens d/t the rise in portal system pressure?

A

blood flow reversal (portal to systemic) d/t dilation of collateral vessels + dvlpmnt of new vessels

85
Q

where are the 4 important porto-systemic shunts (bypasses) important in portal HTN?

A
  1. cardioesophageal jxn
  2. rectum
  3. retroperitoneum
  4. falciform ligament & umbilicus
86
Q

what can happen at the cardioesophageal jxn d/t portal HTN?

A

esophageal varices, which are prone to rupture

87
Q

what can happen at the rectum d/t portal HTN?

A

hemorrhoids

88
Q

what can happen at the falciform ligament & umbilicus d/t portal HTN?

A

caput medusae

89
Q

what is a normal bilirubin level?

A

0.3-1.2 mg/dL

90
Q

when does bilirubin become clinically evident (how high does it get)?

A

2-2.5 mg/dL

91
Q

which bilirubin is water soluble: conjugated or un?

A

conjugated is water soluble

unconjugated is insoluble

92
Q

which bilirubin is in a TIGHT complex w/ albumin: conjugated or un?

A

UNconjugated

conjugated is loosely bound

93
Q

which bilirubin can cause toxic injury: conjugated or un?

A

UNconjugated can cause toxic injury > kernicterus

conjugated is non-toxic

94
Q

which bilirubin can be excreted in urine: conjugated or un?

A

conjugated can be excreted

unconjugated cannot, even if levels are high

95
Q

what is the physiologic reason for jaundice?

A

bilirubin pdtion exceeds hepatic clearance

96
Q

T/F: you can get jaundice d/t too much conjugated OR unconjugated bilirubin

A

TRUE

although >50% are d/t conjugated

97
Q

what 3 things will give you unconjugated hyperbilirubinemia?

A
  1. overpdtion
  2. gilbert’s syndrome
  3. impaired conjugation
98
Q

what is Gilbert’s syndrome?

A

defective unconjugated bilirubin uptake

99
Q

what are 2 causes of impaired conjugation that can result in unconjugated hyperbilirubinemia?

A
  1. neonatal jaundice

2. Criglar-Najjar, types 1 & 2

100
Q

which type of criglar-najjar is auto recessive & severe?

A

type 1

101
Q

which type of criglar-najjar is autosomal dominant and less severe?

A

type 2

102
Q

what 2 syndromes can cause conjugated hyperbilirubinemia?

A
  1. rotor syndrome

2. dubin-johnson syndrome

103
Q

how is dubin-johnson syndrome inherited?

A

autosomal recessive

104
Q

what are the 2 types of neonatal jaundice?

A
  1. physiologic jaundice

2. breast milk jaundice

105
Q

how does physiologic jaundice work?

A

mild unconjugated hyperbilirubinemia d/t immature hepatic conjugation & excretion system

106
Q

how does breast milk jaundice work?

A

there are bilirubin-deconjugating enzymes in breast milk

107
Q

what thing does crigler-najjar involve?

A

UGT1A1

108
Q

which type of crigler-najjar has ABSENT UGT1A1 activity?

A

type 1

type 2 is just decreased

109
Q

T/F: gilbert syndrome is innocuous

A

true

110
Q

T/F: crigler-najjar type 1 is fatal in the neonatal period

A

TRUE

111
Q

what is the defect in bilirubin metabolism in dubin-johnson syndrome?

A

impaired excretion of bilirubin glucuronides d/t mutation in MRP2

112
Q

what is the defect in bilirubin metabolism in rotor syndrome?

A

decreased hepatic uptake & storage

113
Q

what is cholestasis?

A

impaired bile formation & bile flow

leads to accumulation of bile pigment in hepatic parenchyma

114
Q

what 2 things can cause cholestasis?

A
  1. extra or intrahepatic obstruction of bile channels
  2. defect in bile secretion
    (i. e. biliary obstruction or hepatocyte dysfxn)
115
Q

what are the signs of cholestasis?

A
  1. jaundice
  2. pruritis
  3. xanthomas
  4. silver stool
  5. elevated alk phos
  6. intestinal malabsorption (vit A, D, K)
116
Q

what is neonatal cholestasis?

A

prolonged conjugated hyperbilirubinemia

not a specific entity & not necessarily inflammatory

117
Q

what are the 5 possible causes of neonatal cholestasis?

A
  1. bile duct obstruction
  2. neonatal infxn
  3. toxic
  4. metabolic dz
  5. idiopathic neonatal hepatitis
118
Q

what 5 bacterial infxns can cause hepatic failure?

A
  1. extrahepatic (sepsis)
  2. Staph aureus
  3. Typhoid fever (Salmonella typhi)
  4. treponema pallidum (chlamydia)
  5. ascending biliary infxn (cholangitis)
119
Q

what 7 parasitic infxns can cause hepatic failure?

A
  1. malaria
  2. schistosomiasis
  3. strongyloidiasis
  4. cryptosporidiosis
  5. leishmaniasis
  6. echinococcosis
  7. liver flukes
120
Q

what are the 3 things listed under parasitic DZ instead of infxn?

A

echinococcal cyst
clonorchis sinensis
fasciola hepatica

121
Q

name 2 kinds of abscess you can get in your liver

A
  1. bacterial

2. amoebic

Block 10 Week 4 (9 decks)

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