Accessory Organs Flashcards
(160 cards)
1
Q
Cholestasis
A
Reduction or blocked flow of bile
2
Q
Cholestasis: Consequences
A
• Since bile aids in the absorption of nutrients, if blocked, can lead to
malabsorption and nutrition deficiencies particularly fat soluble vitamins: A, D, E, K
3
Q
Cholestasis: Diagnostic Considerations
A
• Diagnose cholestasis on symptoms, signs and labs
. • But the CAUSE of cholestasis must be identified as well as any CONSEQUENCES.
4
Q
Cholestasis is seen in:
A
Both liver and gall bladder disease
5
Q
Cholestasis: Signs/Symptoms
A
• Jaundice
‘• Pruritis
• Stool: pale, foul
• Urine: dark
• May have Sx/Si related to the cause / nutritional issues
• Nausea or vomiting
• Inability to digest certain foods
• RUQ pain
• Fatigue
6
Q
Cholestasis: Labs
A
– Bilirubin: increased
– ALP: increased
– AST/ ALT: increases
7
Q
Cholestasis: Treatment
A
• Treatment:
– Treat underlying cause
– If chronic, consider fat soluble vitamin deficiencies: ADEK
8
Q
Protecting the Liver
A
• Choose a healthy diet.
• Maintain a healthy weight.
• Drink alcohol in moderation, if at all.
• Limit to < one drink a day (women) and < two drinks a day (men)
• Get vaccinated.
• Use medications wisely.
• Avoid contact with blood and body fluids.
• Watch what gets on your skin.
• Take care with aerosol sprays.
• Use ventilation or wear a mask when using toxic chemicals
• Avoid risky behavior: Sharing needles, unprotected sex, safe tattoos or body piercings
9
Q
Fatty Liver Disease
A
• Excessive accumulation of lipids in hepatocytes
10
Q
Fatty Liver Disease: Acute
A
– Acute: pregnancy (AFLP)
11
Q
Fatty Liver Disease: Chronic
A
– Chronic: metabolic (NAFLD), alcohol (ALD)
12
Q
Fatty Liver Disease: Most Common Type
A
NAFLD
13
Q
Chronic Fatty Liver Disease: Diagnosing
A
– May feel tired or have mild abdominal discomfort but otherwise have no symptoms.
– May first be discovered incidentally with routine liver function test
– On exam may have hepatomegaly but not tender (1/3)
14
Q
NAFLD vs. ALD: Associations, Alcohol, Progressions
A
Associations
-NAFLD: Associated with Metabolic issues
-ALD: Associated with Alcohol Liver Disease
Alcohol
-NAFLD: No alcohol use
-ADL: Excessive Alcohol Use
Progressions
-NAFLD: NASH, Cirrhosis
-ALD: Alcoholic hapatitis, cirrhosis
15
Q
Chronic Fatty Liver: Signs/Symptoms
A
-Mostly Asymptomatic
-IF Symptomatic: Fatigue, malaise, dull RUQ pain
-Exam: Hepatosplenomegaly (33%)
16
Q
Chronic Fatty Liver: Diagnosing
A
• Common clinical presentation:
“healthy” pt. (few to no sx) with
abnormal liver tests
• Most often diagnosed incidentally
on routine labs
• Confirm with CT (or MRI) and liver
biopsy
• Need to identify the cause:
– Metabolic: labs
– Alcoholic: history/ CAGE
17
Q
Chronic Fatty Liver: Treatment (Medical)
A
• Address cause/ risk factors:
– Lose weight
– Control cholesterol
– Control DM
– Stop drinking
• Protect liver!
18
Q
Chronic Fatty Liver: Treatment (Lifestyle)
A
• Healthy diet
• Maintain weight
• Exercise
19
Q
Hepatitis
A
Swelling and inflammation of the liver characterized by diffuse or patchy necrosis
20
Q
Hepatitis: Causes
A
Viruses, alcohol, drugs, metabolic
21
Q
Hepatitis: Complications
A
• Varices, portal hypertension protect against risk factors
22
Q
Hepatitis: Prognosis
A
– Can be self limited
– Or may lead to damage: cirrhosis, liver failure or cancer
23
Q
Hepatitis: History
A
• Symptoms may be non specific
• In chronic conditions may have even less symptoms
• Important to review for risk factors related to causes
24
Q
Hepatitis: Exam
A
• May not see abnormalities until late stages or when it progresses to other diseases
• May see signs of complications
25
Hepatitis: Diagnostics
Labs: viral, liver function, autoimmune
Diagnostics: US, biopsy
26
What acute hepatitis conditions can progress to chronic?
– Hepatitis B, C, D
27
Acute Hepatitis: Causes
• Infection: Viral A,B,C,D,E
-Toxin: Alcohol, Drugs/Herbs
-Immune: Autoimmune Hepatitis, Primary biliary cholangitis, acute episodes primary sclerosing cholangitis
-Metabolic: NASH
28
Acute Hepatitis: Signs/Symptoms (Early)
Early s/s (prodrome phase):
• Anorexia
• Malaise
• Nausea or vomiting
• Fever
• RUQ pain/discomfort
• Aches such as arthralgia
29
Acute Hepatitis: Signs/Symptoms (Icteric Phase)
• S/S of cholestasis
– Dark urine
– Jaundice (peaks 1-2 weeks)
• Diarrhea
• Headache
30
Acute Hepatitis: Exam (Icteric Phase)
• Jaundice
• Hepatomegaly with tenderness (edges remains soft and smooth)
• Splenomegaly (mild sx) (15-50%
• Lymphadenopathy
31
Acute Hepatitis: Diagnostics
• Liver function tests
(AST and ALT elevated out of proportion to alkaline phosphatase, usually with hyperbilirubinemia)
• Viral serologic testing
32
Chronic Hepatitis: More Common Causes
– NAFLD
– Hepatitis B and C
– Alcoholic hepatitis
– Autoimmune hepatitis
33
Chronic Hepatitis
• Chronic inflammation of the liver lasting over 6 months
34
Chronic Hepatitis: Diagnostic Challenges
– Can be insidious
– No history of other conditions such as acute hepatitis, NALFD
– Few to no symptoms (or symptoms are non specific)
– May not detect until advanced stage of cirrhosis
35
Chronic Hepatitis: First Indications
Abnormal liver tests
36
Chronic Hepatitis: Complications
-Thyroid, arthropathy, peripheral neuropathy
-Malabsorption related issues
-Other chronic liver disorders (primary biliary cholangitis)
37
NASH: Cause
Metabolic: Obesity, insulin, resistance, lipid issues
38
NASH: How to identify cause
• Rule in metabolic issues
• 3rd MC cause of liver disease
39
ALD: Cause, How to identify cause, Progression
-Cause: Alcohol
-How to identify cause: Rule in drinking
-Progression: May have progressed from fatty liver, may move to cirrhosis
40
Chronic Hepatitis: Viral
-Cause: Hepatitis Virus B,C,D
-How to identify cause: Viral labs, past history of acute hepatitis
-Progression: Progressed from acute viral condition, about 20% develop into cirrhosis
41
Chronic Hepatitis: Autoimmune
-Cause: Unknown
-Progression: May progress to cirrhosis
42
Chronic Hepatitis: Symptoms
-May be asymptomatic
-Non-specific type symptoms: Malaise, anorexia, fatigue, low-grade fever, non-specific upper abdominal discomfort
*jaunncide can be present but rare
-May have cholestasis: Pruritis, pale stools, steatorrhea
43
Chronic Hepatitis: Exam
– Hepatomegaly-75%
– Splenomegaly
44
Chronic Hepatitis: Diagnostics
-Liver function tests
-Biopsy (to stage)
-Additional testing to identify cause: Viral serology, autoantibodies, etc.
45
Chronic Hepatitis: Lifestyle (Treatment)
-Rest
-Hydrate
-Balanced, nutritious diet
-Protect liver
-Avoid Alcohol
46
Chronic Hepatitis (Autoimmune): Epidemiology
– Female: 70-80% – Ages: 10-20 yo and 45-70 yo
(ages slightly vary in literature)
47
Chronic Hepatitis (Autoimmune): Cause
Unknown
48
Chronic Hepatitis (Autoimmune): Risk Factors
Risk factors:
– Female
– Hereditary
– Certain viral infections
– Associated with other autoimmune diseases*
49
Chronic Hepatitis (Autoimmune): Complications
-Anemia
-Acne
-Amenorrhea
-Hemolytic portal hypertension, esophageal varices
50
Chronic Hepatitis (Autoimmune): Progression
– May lead to cirrhosis, liver failure and cancer
51
Chronic Hepatitis (Autoimmune): Associated Conditions
• Celiac sprue
• Ulcerative colitis
• Primary biliary cholangitis
• Primary sclerosing cholangitis
• Nephritis
• Graves disease
• Type 1 diabetes
• Hashimoto’s disease
• RA
52
Fibrosis & Cirrhosis
53
Cirrhosis
• Progressive state: fibrosis/ scarring in liver becomes extensive
– Affects function (decreases)
– Often end stage of other diseases
– If not diagnosed early, more scar tissue forms
– Advanced stage is life threatening, leading to liver failure and liver cancer
54
Leading Cause of Death Worldwide
Cirrhosis
55
Cirrhosis: Progression Rate
• Progression rate varies from fibrosis to cirrhosis
56
Cirrhosis: Prognosis
• Prognosis:
– Irreversible
– Treatment is supportive
57
Cirrhosis: Causes (3)
-Infections
-Immune
-Cancers
-Other
58
Cirrhosis: Infections
-Viruses
-MC: Hepatitis A,B,C
59
Cirrhosis: Immune (3)
-Autoimmune Hepatitis
-Primary billary cholangitis
-Primary sclerosing cholangitis
60
Cirrhosis: Cancers
-Liver cell/adenoma
61
Cirrhosis: Other Causes
-Chronic alcohol abuse
-NALFD
-Certain medications and herbal compounds
62
Cirrhosis: Difficulties w/ diagnosing
• Sx may not develop for years
• 1/3 never develop symptoms
• Initial symptoms are vague and nonspecific
• Other symptoms related to complications
63
Cirrhosis: Complications
– Portal hypertension, GI bleeds (esophageal, gastric, or rectal varices,pulmonary hypertension), kidney injury
– Hormone imbalance, nutritional deficiencies, anemias, cholestasis, osteoporosis
64
Cirrhosis: Initial Symptoms
• General fatigue
• Malaise
• Anorexia
• Weakness
• Weight loss
65
Cirrhosis: Later Symptoms/Complications
• Anemias
• Jaundice
• Confusion
• Pruritus
• Peripheral neuropathy
• Axillary hair loss
• Dyspnea
• Portal hypertension
• Liver failure
• Ascites
• Acute kidney
66
Cirrhosis: Exam
-Liver tender, palpable & firm, blunt edge typically
Other signs related to complications
– Jaundice, petechiae, spider nevi, splenomegaly
– Ascites, caput medusa
– Clubbing, glossitis
– Muscle wasting
67
Cirrhosis: Diagnostics
-Liver function tests
-Determine cause: test for viruses, autoimmunity
-Anemia, CBC
-Biopsy: To determine severity, extent and cause
68
Cirrhosis: Lifestyle (Treatment)
-Stop drinking
-Supplements: Address nutritional deficiencies
69
Alcoholic Liver Disease: Progression
-Fatty Liver Disease: Fat on liver (Over 90%)
-Alcoholic Hepatitis: Inflammation/necrosis (10-35%)
-Alcoholic cirrhosis: Advanced fibrotic state (10-20%)
70
Alcohol Liver Disease: Risk Factors (5)
– Quantity/ duration of alcohol (usually over 8 years)
– Gender, genetics, metabolic traits
– Concomitant hepatitis C & iron accumulation
– Obesity
– Women: more likely to suffer liver damage
71
Alcoholic Liver Disease: Fatty Liver (Initial Stage)*
• Often reversible
• May / may not progress to other conditions
• Sxmost apparent 30’s/40’s
• Severe problems appear a decade later
• Virtually all heavy drinkers develop
72
Alcoholic Liver Disease: Alcoholic Hepatitis*
• Progression from steatosis
• Appx. 35% alcoholic hepatitis
• Cirrhosis may or may not be present
• 30% develop cirrhosis (w/in 6 months)
• Most likely to occur in people who drink heavily for many years
• But not all heavy drinkers develop alcoholic hepatitis
• May occur even in those who drink moderately
73
Alcoholic Liver Disease: Alcoholic cirrhosis*
• 10-20% develop cirrhoris cirrhosis
• Advance stage-can cause liver failure
• Alcoholic hepatitis may or may not co-exist
74
Liver Cancer: Forms
• Many forms of liver cancer
– Many are metastases from other tumors
(colon, lung, renal, breast, ovarian, prostate)
75
Liver Cancer: Symptoms
– Jaundice, abdominal pain, weight loss,
fever, hepatomegaly, back pain
76
Diagnosis of Liver Cancer is found:
– Incidentally found through imaging or symptomatically
77
Liver Cancer: Treatment
– Surgery, chemotherapy, radiation, etc
– Not all forms are curable
78
Gall Bladder Disease: Risk Factors
– “The 5 F’s” (old saying)
• Female
• Family history
• “Fat” (obesity)
• Fertile (pregnancy)
• Forty (40) and over
79
Gall Bladder Disease: Signs/Symptoms
• RUQ pain
• Right shoulder or back pain
• Indigestion
• Nausea or vomiting
• Sx of cholestasis:
• Urinary changes: dark
• Clay colored stool
80
Gall Bladder Disease: Exam/Diagnostics
• RUQ tenderness
• Jaundice if blocked
(sx of cholestasis)
81
Cholelithiasis
• Presence of one or more calculi (gallstones) in gallbladder
– Most asymptomatic
82
Cholelithiasis: Most common occurrence
-Incidence increases w/ age
-highest in 5th & 6th decade
83
Cholelithiasis: Predisposing factors
The 5 Fs
-Female
-Fertile (pregnancy)
-Fat (obesity)
-Forties (40+)
-Flatuent
-Family History (May have DM, HRT)
84
Cholelithiasis: Symptoms
-Post prandial upper abdominal pain: often acute onset
-May radiate to right subscapular area or epigastrum
-Nausea, vomiting, dyspepsia, fatty food intolerance
85
Cholelithiasis: Exam
• Mild tenderness w/ palpation but no guarding or rebound
86
Cholelithiasis: Complications
• If obstructs gall bladder:can cause cholecystitis (inflammation of the GB)
• If stone moves into duct: choledocholithiasis
• Once in duct, if it causes obstruction of duct: cholangitis
• Once in duct, if it blocks ampulla de Vater: Pancreatitis
87
Choledocholithiasis
• Gallstones in the common bile duct
88
Choledocholithiasis: Complications
– Can cause obstruction (partial, complete)
– If infected, can become cholangitis
– if it blocks the ampulla of Vater, can cause pancreatitis
89
Cholecystitis
• Acute or chronic inflammation of the gallbladder
– Usually from gallstone blocking the cystic duct
– May also be acalculous
90
Cholecystitis: Complications
Infections, perforation, peritonitis, pancreatitis
91
Cholecystitis: Treatment
Gallbladder is often removed
92
Acute Cholecystitis
• Acute inflammation of the gallbladder
– Generally secondary to gallstone obstruction in >95%
93
When is Acute Cholecystitis most common?
• Most common: females in 5th & 6th decade
94
Acute Cholecystitis: Most have had prior attacks of
Biliary colic
95
Pain with cholecystititis is:
More severe & lasts longer
96
Acute Cholecystitis usually subsides & resolves
• Subsides in 2-3 days & resolves within 1 week in 85% of
patients
97
Acute Cholecystitis: Signs & Symptoms
• Intermittent –progress to constant
– More severe and longer than the biliary colic with gall stones
• RUQ pain
• May radiate to infrascapular
region or back
• Nausea & vomiting (>70%)
• Fever (33%)
• Jaundice (25-50%)
• Ingestion of large, fatty meal
before onset?
98
Acute Cholecystitis: Exam
-Murphy’s Inspiration Sign (+)
99
Acute Cholecystitis: Diagnostics
-US to diagnose
-Liver function tests, CBC
100
Chronic Cholecystitis
101
Chronic Cholecystitis
• Long standing gallbladder inflammation
– Always due to gallstones
– Prior episodes of cholecystitis
– Long term can begin to become fibrotic
– Porcelain gallbladder: extensive calcification of fibrosis
102
Chronic Cholecystitis: Symptoms
Recurrent biliary colic
– No fever (fever suggests acute state)
103
Chronic Cholecystitis: Treament
Laparoscopic cholecystectomy (remove the gall bladder)
104
Cholangitis
• Inflammation and/or infection of the hepatic & common bile ducts
– Associated with common bile duct obstruction
– Obstruction causes rapid proliferation of bacteria
– Other causes: biliary tract stenosis, tumor, parasites
105
Cholangitis: Peak Incidence
7th decade: unusual < 50 yo
106
Cholangitis: Complications
Pancreatitis
107
Cholangitis: Development
70-90% of cases:
• Gallstone partially blocks duct
• Bacteria from duodenum ascends into gall bladder •
-Infection with inflammation sets in
10-30% of cases
• Blockage caused by strictures, tumors, etc
• Still allows bacteria to ascend & cause infection
108
Cholangitis: Development
70-90% of cases:
• Gallstone partially blocks duct
• Bacteria from duodenum ascends into gall bladder • Infection with inflammation sets in
10-30% of cases
• Blockage caused by strictures, tumors, etc
• Still allows bacteria to ascend & cause infection
109
Cholangitis: Signs & Symptoms
• Acute onset
• Charcot’s triad: (mc sx)
– RUQ pain
– Jaundice
– Fever
• Dark colored urine
• May have other symptoms if there are complications
110
Cholangitis: Exam
– Murphy’s is not positive
111
Cholangitis: Diagnostics (4)
– Labs: WBC ,ALP & bilirubin
– Ultrasound
112
Cholangitis has a ___% mortality rate
50%
113
Primary Biliary Cholangitis (PBC)
• Autoimmune progressive destruction of intrahepatic (liver) bile ducts
114
PBC leads to: (3)
– Leads to cholestasis, cirrhosis, liver failure
115
PBC: Etiology
• 95% of patients are female age 35-70
– Genetic predisposition prevalent
• Up to 84% of pts have at least one other autoimmunity:
– Sjogren’s syndrome, RA, Raynaud’s phenomenon, scleroderma, thyroiditis
116
PBC: Development of Sx
• Sx may develop at any stage: 50% have no sx, other sx may have for months/ years
117
PBC: Signs & Symptoms
• 50% of pts have no sx
• Initial sx tend to be:
– Fatigue & pruritus (50%)
– Dry mouth / eyes
Other possible sx:
• RUQ pain (10%)
• Musculoskeletal
complaints (up to 70% )
• Peripheral neuropathy
– Sx related to other
autoimmune disorders
118
PBC:Exam
-Non-Tender hepatomegaly (25%)
-Splenomegaly (15%)
-Jaundice (10%)
119
PBC:Diagnostics (4)
• Diagnostics:
– Liver function tests
– AMA (elevated in 95%)
– US, liver biopsy
120
PBC: Treatment
• No specific treatment
– Depends on status of pt
• Focus on management of complications
• Avoid alcohol & hepatotoxic drugs
• Osteoporosis, vitamin A, K, E deficiency common
121
Primary Sclerosing Cholangitis
• Autoimmune disease: Progressive inflammation and scarring of bile ducts
– Affects both intrahepatic and extrahepatic ducts
– Bile duct blockage causes bile to accumulate in liver, damaging liver and causing fibrosis/cirrhosis
122
Primary Sclerosing Cholangitis: Etiology
• 2:1 male to female starting around 20-
-More than 80% have ulcerative colitis
123
Primary Sclerosing Cholangitis: Complications
– Malabsorption issues
– Leads to cirrhosis, liver failure & liver cancer
124
Primary Sclerosing Cholangitis: Treatment
• Tx: liver transplant
– Supportive care: fat soluble vitamins A,D, E, K
125
Primary Sclerosing Cholangitis: Signs/Symptoms
• Fatigue
• Severe jaundice
• Intense pruritis
• Dark urine
• Malabsorption
• Steatorrhea
• Cholangitis (bile duct infection)(Charcot’s triad)
• Hepatomegaly
• Portal hypertension
126
Primary Sclerosing Cholangitis: Diagnostics
• Endoscopic (ERCP)
127
Pancreatitis
• Inflammation of the pancreas
• Can be acute or chronic
– Acute: can be life threatening
– Chronic: often result of fibrosis
128
Pancreatitis: Causes (2)
• Causes:
– Most common condition: gall stones
– Alcohol abuse
– Other
129
Pancreatitis: Pathology
• Pathology: conditions cause the release of activated pancreatic enzymes
– Pancreatitis is a secondary effect
130
Acute Pancreatitis
• Inflammation of the pancreas
• Sudden onset
• Can be life threatening…EMERGENCY
131
Acute Pancreatitis: Causes (2)
• Most common (80%): gallstones and alcohol abuse
• Other acute causes
132
Acute Pancreatitis: Diagnosis
– Diagnosis based on clinical presentation and labs
• Specifically amylase and lipase
133
Acute pain that is intense radiating into the back and boring: Only 2 DDxs
AAA and Pancreatitis
134
Appencitis is a common ddx for:
Meckel’s Diverticulum
135
Acute pancreatitis: Symptoms
• Pain
– Sudden onset
– Steady pain, peaking within 10-30 minutes
– Epigastric region
– May radiate to back (50%)
• Fever
• Shock and confusion
136
Acute Pancreatitis: Differential Diagnosis
Dissecting anuerysm
137
Acute Pancreatitis: Exam
• Tachycardia
• Abdominal guarding
• Distention
• Hypoactive bowel sounds
• Palpable abdominal mass with tenderness
138
Acute Pancreatitis: Diagnostics (4)
• Amylase & lipase
– Elevated first day
– Return to normal in 3-7
-WBCs elevated
• CT , endoscopy
• Ultrasound if gallstones suspected
139
Chronic Pancreatitis
• Persistent inflammation of pancreas
– Permanent structural damage
– Decline in exocrine & endocrine function
140
Chronic Pancreatitis: Causes
• Causes (U.S.):
– Alcohol (<50%)* Change to 50%
– Idiopathic (15-25%)
– Other: autoimmune, hereditary, stenosis
141
Chronic Pancreatitis: Development
• Development:
– Initial symptoms: recurrent pain
– Later complications may develop: malabsorption, DM
142
Chronic Pancreatitis: Diagnosing
• Diagnosing can be difficult
• Based on clinical suspicion as labs can often be normal
• Imaging can confirm: CT
• May see late pancreatic calcification on x-ray (30%)
• Must exclude pancreatic cancer as source of pain
143
Chronic Pancreatitis: Symptoms
• Pain
– Recurrent
– Severe-may last hours or several days
– Epigastric & LUQ pain
– May radiate to back
• Weight loss
• May have other symptoms related to malabsorption or glucose intolerance
144
Chronic Pancreatitis: Diagnostics
• Amylase and lipase
– Often normal
– Late stages may be abnormal
• Other labs may be
abnormal due to malabsorption/ DM
145
Chronic Pancreatitis: Treatment (Medical)
• Frequent, small volume low fat meals
• Fasting during episodes
146
Chronic Pancreatitis: Treatment (Lifestyle)
• Avoid alcohol
• Pancreatic enzymes
147
Pancreatic Cancer is considered a:
• “Silent killer”: early stages nonsymptomatic
• 2010: 43,000 diagnosed
– Poor prognosis: 38,000 died
– Fewer than 5% survive after 5 years
148
Appendicitis
• Acute inflammation of appendix
149
Appendicitis: Epidemiology
– Occurs in 5-10% of population
– Most commonly between 10-30 years old
150
Appendicitis is considered a:
• Emergency ..can rupture
151
Appendicitis: Classic Symptoms
• Pain
– Initially epigastric or
periumbilical –Localizes to RLQ within 12-18 hrs
– May also have flank pain
• Nausea, vomiting, anorexia
• Low grade fever
• Rosvings, psoas sign, obturator
sign, McBurneys, sign
152
Rosvings Sign
Rebound test: palpate LLQ with pain referral to RLQ
153
Psoas Sign
Pain with right thigh extension
154
Obturator Sign
Pain with internal rotation of flexed right thigh
155
Obturator Sign
Pain with internal rotation of flexed right thigh
156
McBurney’s Sign
Point of maximal tenderness in RLQ …1/3 in from ASIS
157
Dunphy Sign
RLQ pain with coughing (nice to know)
158
Markle Sign
Heel drop causes pain
159
Appendicitis: Diagnostics
• Primarily diagnosis is clinical and requires immediate referral
160
Appendicits: Treatment
• Urgent surgery
