Exam 3: Liver Pathophysiology

Question 1

Bile flows from the liver into the duodenum when:

Answer 1

Eating - otherwise into the gallbladder

Question 2

Bile is composed of:

Answer 2

Bile acids
Bile salts
Bicarb
Wastes from the liver

Question 3

Liver produces ___% of the body’s daily lymph:

Answer 3

50%

Question 4

Liver lymph differs from the rest of the body’s in this way:

Answer 4

High in protein

Question 5

The liver is “mushy” because:

Answer 5

Very little structural tissue/basement membrane

Question 6

Proteins synthesized by the liver:

Answer 6

Albumin
Fibrinogen
Prothrombin
Lipoproteins

Question 7

Bile is positively/negatively charged and hydrophilic/hydrophobic:

Answer 7

Negatively

Hydrophobic

Question 8

25% of the body’s cholesterol is in this organ:

Answer 8

Brain

Question 9

Bridging fibrosis is:

Answer 9

A reversible (early on) linking of regions of the liver by fibrous strands; caused by inflammation

Question 10

This occurs in the liver when fibrosis continues to develop along with parenchymal injury:

Answer 10

Liver divides into nodules of regenerating hepatocytes surrounded by scar tissue

Question 11

Role of stellate cells in liver injury:

Answer 11

With inflammation, stellate cells lay down dense extracellular collagen matrix (causing fibrosis)

Question 12

Activated stellate cells in the liver are called:

Answer 12

Myofibroblasts

Question 13

Lab tests for hepatocyte integrity:

Answer 13

Serum aspartate aminotransferase (AST)

Serum alanine aminotransferase (ALT)

(Old names SGOT, SGPT)

Question 14

Typical AST/ALT values:

Answer 14

< 50

Question 15

Lab tests for biliary tract integrity:

Answer 15

Serum alkaline phophatase (AP/ALP/ALKP)

Serum ɣ-glutamyltransferase (GGT)

Question 16

Alk phophatase not a reliable indicator for biliary disease by itself because:

Answer 16

Also found in bone cells

Question 17

Lab tests for serum bilirubin:

Answer 17

Direct (conjugated)

Total (conjugated + unconjugated)

Question 18

Lab tests for hepatocyte functioning:

Answer 18

Serum albumin
Prothrombin time
Serum ammonia

Question 19

Using serum albumin as an indicator of liver functioning:

Answer 19

If serum albumin is ↓ and total protein is too, liver is not working well

If serum albumin is ↓ but total protein is okay, liver is okay - it only makes enough albumin to bring oncotic pressure up to normal

Question 20

Ammonia builds up during liver failure due to:

Answer 20

Inability to metabolize/digest nitrogenous byproducts from gut bacteria via the urea cycle

Question 21

Estrogen-related abnormalities in liver disease:

Answer 21

Hypogonadism
Gynecomastia
Palmar erythema
Spider angiomas

Question 22

Blood sugar abnormality in liver disease:

Answer 22

Hypoglycemia; liver no longer making/breaking down glucose

Question 23

Normal liver venous pressure:

Answer 23

10mmHg

Question 24

S/s of hepatic portal hypertension:

Answer 24

Ascites
Esophageal varices
Hemorrhoids
Caput medusae
Splenomegaly

Question 25

Coagulopathy seen in liver failure:

Answer 25

Impaired clotting and clot breakdown; liver makes both clotting factors and plasminogen

Question 26

Life threatening complications of liver failure:

Answer 26

``` Multiple organ failure Coagulopathy Hepatic encephalopathy Hepatorenal syndrome Varices rupture Hepatocellular carcinoma ```

Question 27

Normal bilirubin production amount and sources:

Answer 27

0.2 - 0.3 g/day Primary source: breakdown of senescent erythrocytes Minor source: degradation of tissue heme-containing proteins

Question 28

Extrahepatic bilirubin binds to:

Answer 28

Serum albumin, for delivery to the liver and hepatocellular uptake

Question 29

Liver processing of bilirubin:

Answer 29

Glucoronidation into bilirubin monoglucuronides/diglucuronides (conjugated bilirubin), which are excreted into bile

Question 30

Gut processing of conjugated bilirubin:

Answer 30

Gut bacteria deconjugate bilirubin and degrade it to urobilinogens + pigment residues Most excreted into feces, some reabsorption/re-excretion into bile

Question 31

Three causes of jaundice related to ↑ unconjugated bilirubin:

Answer 31

Excess bilirubin production Reduced hepatic uptake Impaired conjugation

Question 32

Two causes of jaundice related to ↑ conjugated bilirubin:

Answer 32

Decreased hepatocellular excretion | Impaired bile flow

Question 33

Pathogenesis of unconjugated bilirubin jaundice:

Answer 33

Fraction tightly bound to albumin is insoluble, so not excreted by kidney Unbound fraction diffuses into tissues (esp. brain) and produces toxic injury

Question 34

Pathogenesis of conjugated bilirubin jaundice:

Answer 34

Soluble in water, weak albumin binding, so excreted by kidney Mild jaundice without tissue injury

Question 35

Jaundice tx for hemolytic disease of the newborn:

Answer 35

UV light; skin can conjugate bilirubin under UV

Question 36

Changes seen in parenchyma d/t cholestasis:

Answer 36

Enlargement of bile canaliculi Apoptosis of hepatocytes Bile uptake by Kupffer cells

Question 37

Changes seen in portal tracts d/t cholestasis:

Answer 37

``` Bile duct proliferation Edema Bile pigment retention Neutrophilic inflammation Toxic degeneration of neighboring hepatocytes ```

Question 38

% of liver function that must be lost for hepatic failure to occur:

Answer 38

80-90%

Question 39

Special problems r/t hepatic failure:

Answer 39

Hepatic encephalopathy | Hepatorenal syndrome

Question 40

Cirrosis causes hepatic portal hypertension by:

Answer 40

Impairing blood flow through liver via fibrosis/scarring

Question 41

Downstream effects of hepatic portal hypertension:

Answer 41

Ascites Portosystemic shunts Splenomegaly

Question 42

Three clinical states of hepatitis:

Answer 42

Carrier/asymptomatic Acute viral hepatitis Chronic viral hepatitis

Question 43

Common characteristics of HAV/HEV:

Answer 43

``` Self-limiting 2-8 week incubation Acute only - no carrier or chronic states Do not cause cancer Fecal-oral transmission Not common in US ```

Question 44

HAV-specific characteristics:

Answer 44

Common childhood disease in developing countries; more dangerous in adults Sporadic infections - associated with oysters and warm-water seafood

Question 45

HEV-specific characteristics:

Answer 45

Endemic and seen in travellers; sporadic infections rare 20% mortality rate in pregnant women

Question 46

Characteristics of HBV, HCV, and HDV:

Answer 46

Can cause carrier state, chronic hepatitis, and cancer Parenteral transmission Present in the US

Question 47

HDV-specific trait:

Answer 47

Only survives along with coexisting HBV infection

Question 48

ETOH effect on hepatocytes:

Answer 48

Can no longer incorporate fatty acids into lipoproteins for export --> hepatic steatosis (fatty liver)

Question 49

Relationship between hepatic steatosis and alcoholic hepatitis:

Answer 49

Steatosis can turn into hepatisis with severe exposure; abstinence can have hepatitis revert to steatosis

Question 50

Incidence of alcoholic liver diseases:

Answer 50

Hepatic steatosis: 90-100% Alcoholic hepatitis: 10-35% Cirrhosis: 8-20%

Question 51

Physical characteristics of cirrhotic liver and causes:

Answer 51

Nodularity from fibrous scarring Greenish tint from bile Yellowish tint from bilirubin

Question 52

The body's only way of eliminating iron is:

Answer 52

Bleeding

Question 53

Hemochromatosis is:

Answer 53

The uncontrolled uptake of iron

Question 54

Demographics and genetic basis of hemochromatosis:

Answer 54

Mostly males (5-7:1) in their 50s or older Autosomal recessive, affecting 0.5% of people 10% are heterozygous carriers

Question 55

Sequelae of hemochromatosis:

Answer 55

Cirrhosis (100%) DM (75-80%) Skin pigmentation (75-80%)

Question 56

Bantu siderosis is:

Answer 56

Another primary iron overload condition

Question 57

Three secondary iron overload causes:

Answer 57

1. Transfusion (0.25 gm/unit) 2. β-thalassemia 3. Sideroblastic anemia

Question 58

Describe primary biliary cirrhosis:

Answer 58

Destruction (often fatal) of intrahepatic bile ducts, most commonly with antimitochondrial antibodies present

Question 59

Lab abnormalities seen in primary biliary cirrhosis:

Answer 59

Elevated alk phos & cholesterola | Hyperbilirubinemia late in disease

Question 60

Describe secondary biliary cirrhosis:

Answer 60

``` Obstruction of the extrahepatic biliary tract due to: Gallstones Biliary atresia Malignancy (biliary tree/pancreas) Surgical strictures ```

Question 61

Describe primary sclerosing cholangitis:

Answer 61

Destruction of intra- and extrahepatic bile ducts Associated with ulcerative colitis (develops 2nd) but no antimitochondrial antibodies Elevated alk phos

Question 62

Manifestations of hepatic vein outflow obstruction:

Answer 62

``` Ascites Hepatomegaly Abdominal pain Elevated transaminases Jaundice ```

Question 63

Manifestations of impaired intrahepatic blood flow:

Answer 63

Ascites (cirrhosis) Esophageal varices Elevated transaminases

Question 64

Manifestations of impaired portal vein inflow:

Answer 64

Ascites Esophageal varices Splenomegaly Intestinal congestion

Question 65

Manifestations of impaired hepatic artery inflow:

Answer 65

Ischemia to bile ducts/parenchyma | Loss of graft in transplant

Question 66

Causes of hepatocellular carcinoma:

Answer 66

``` HBV Chronic liver disease (HCV, ETOH) Aflatoxin (from peanuts) Tyrosinemia Cirrhosis ```

Question 67

Relationship between HBV and HCC:

Answer 67

Early infection with HBV gives increased risk of HCC

Question 68

Prognosis for HCC:

Answer 68

Mean survival 7 months

Question 69

Risk factors for cholesterol gallstones:

Answer 69

``` Fair (or Native American) Forty (older) Female Fertile Fat Gallbladder stasis Hyperlipidemia ```

Question 70

Risk factors for pigment gallstones:

Answer 70

Chronic hemolytic syndrome Biliary infection GI disorders (Crohn's) Asian descent

Question 71

Choledocholithiasis is:

Answer 71

Presence of stones in the biliary tree, not the gallbladder

Question 72

Sequelae of choledocholithiasis:

Answer 72

``` Biliary obstruction Pancreatitis Cholangitis Hepatic abscess Chronic liver disease/biliary cirrhosis Acute calculous cholecystitis ```

Question 73

Major causes of acute pancreatitis:

Answer 73

``` IGETS Idiopathic (most common) Gallstones (2nd most common) Ethanol Trauma Steroids ```