GI: Pancreas, Liver, Gallbladder Flashcards by James Wren

Developmental malformation in which the Pancreas forms a Ring around the Duodenum
Risk of Duodenal obstruction
Embryology tie-in w/ Head of Pancreas

Annular Pancreas

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Inflammation and Hemorrhage of the Pancreas
Autodigestion of Pancreatic Parenchyma by Enzymes
Trypsin activates other Pancreatic enzymes
Liquefactive Hemorrhagic Necrosis and Fat Necrosis
A/w Alcohol (Sphincter of Oddi) and Gallstones
Trauma, Hypercalemia, Hyperlipidemia, Drugs, Scorpion Stings, Mumps, Rupture of a Posterior Duodenal Ulcer (Head of Pancreas sits posterior)
Pain radiates to the Back a ‘Boring’
Nausea and Vomiting
Periumbilical and Flank Hemorrhage (Periumbilical soft tissue and Retroperitoneum)
Elevated Serum Lipase and Amylase
Phospholipase –> ARDS
Hypocalcemia w/ Saponification of Fat Necrosis

Acute Pancreatitis

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Fibrosis of Pancreatic Parenchyma
2^nd to Recurrent Acute Pancreatitis
Alcohol (Adults) and Cystic fibrosis (Children);
Most –> Idiopathic
Epigastric abdominal pain –> Radiates to the Back
Pancreatic insufficiency –> Results in Malabsorption w/ Steatorrhea and Fat-soluble Vit. Def. (ADEK)
Amylase and Lipase are not useful Serologic markers –> Destroyed
Dystrophic Calcification of Pancreatic Parenchyma on Imaging
‘Chain of Lakes’ pattern due to dilation of Pancreatic Ducts
2^nd to Diabetes Mellitus –> Late complication due to Destruction of Islets
Increased risk Pancreatic Carcinoma (Adenocarcinoma of Pancreatic ducts)

Chronic Pancreatitis

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Adenocarcinoma arising from the Pancreatic Ducts
Elderly (avg. 70 y.o.), < 5% 5-year survival
Smoking and Chronic Pancreatitis
Epigastric Abdominal pain and Weight loss
Obstructive Jaundice w/ Pale stools and Palpable gallbladder, a/w Tumors that arise in the Head of the Pancreas
2^nd Diabetes Mellitus; a/w Tumors in Body or Tail of Pancreas
Pancreatitis
Migratory thrombophlebitis (Trousseau sign); Swelling, Erythema, Tenderness in extremities (10%)
Serum Tumor marker CA 19-9
Surgical en bloc of Head and Neck, proximal Dudenum, and Gallbladder –> Whipple procedure
-> 1 yr. survival < 10%

Pancreatic Carcinoma

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Failure to form or early Destruction of Exrahepatic Biliary Tree –> No lumen
Leads to Biliary Obstruction w/in first 2 months of life
Jaundice and progresses to Cirrhosis –> Pale stool

Biliary Atresia

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Solid, Round stones in Gallbladder
Precipitation of Cholesterol or Bilirubin in Bile
Supersaturation of Cholesterol or Bilirubin
Decreased Phospholipids (Solubilize cholesterol)(lecithin) or Bile acids
Stasis
RUQ pain, Nausea, Vomiting, Low-grade Fever, Leukocytosis
Gangrene of the Gallbladder, Peforation, Fistula, Bowel obstruction, etc…
Clofibrate – Lipid lowering agent used to control High Cholesterol

Cholelithiasis (Gallstones)

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Radiolucent (10% are opaque), Cholesterol monohydrate
Age (40s), Estrogen (Female gender, Obesity, Multiple pregnancies, Oral contraceptives, Hormone replacement therapy
Fat, Female, Forty, Fertile, and Fucks (5 –F’s)
Clofibrate – lipid lowering agent used to control for High Cholesterol (Hmg)
Native American Pima and Navajo Indian ethnicity
Crohn disease – dmg to terminal ilieum –> decreased Bile reuptake –> increased cholesterol precipitation
Cirrhosis – decreased productionof Bile salts

Cholesterol Stones

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Black pigmented Stones composed of Calcium salts and Unconjugated Bilirubin (UCB)
Radiopaque
A/w Chronic hemolytis anemias, Cirrhosis, Bacterial infection, and Parasites
A/w Extravascular Hemolysis (Reticular endothelial
–> Splenic Macrophages –> Unconjugated bilirubin)(increased Bilirubin in bile) and Biliary tract infection
(E coli, Ascaris lumbricoides, and Clonorchis sinensis)

Bilirubin Stones

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Common Roundworm that infects 25% of the Worlds population, especially in areas w/ Poor sanitation (Fecal-oral transmission)
Infects the Biliary tract
Increases risk for Gallstones

Ascaris lumbricoides

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Endemic in China, Korea, and Vietnam (Chinese Liver flukes)
Infects the Biliary tract
Increases the risk of Gallstones
Cholangitis
Cholangiocarcinoma

Clonorchis sinensis

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Waxing and Waning RUQ Pain
Gallbladder contracting against a Stone lodged in the Cystic duct
Symptoms relived when Stone passes
Common Bile duct obstruction may result in
*Acute Pancreatitis** or Obstructive Jaundice

Biliary Colic

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Acute Inflammation of the Gallbladder wall
-> squeezes blood vessels –> Ischemia
Impacted stone in Cystic duct
-> Dilation w/ Pressure ischemia
Bacterial overgrowth (E coli)
Inflammation and Bloating
RUQ Pain –> Radiating to Right Scapula, Fever w/ increased WBC count, Nausea, Vomiting, and increased Serum Alkaline Phosphatase (Duct dmg)
Risk of rupture if left untreated

Acute Cholecystitis

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Chronic inflammation of Gallbladder
Chemical irritation from Longstanding cholelithiasis w/ or w/out Superimposed bouts of Acute cholecystitis
A/w Herniation of Gallbladder mucosa into Muscular Wall (Rokitansky-Aschoff sinuses)
Vague RUQ Pain, Postprandyl pain
Porcelain Gallbladder is a late complication – Shrunken, Hard Gallbladder due to Chronic Inflammation, Fibrosis, and Dystrophic Calcification
Increased risk for Carcinoma
Tx: Coholecystectomy, esp. w/ Porcelain Gallbladder

Chronic Cholecystitis

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Bacterial infection of the Bile ducts
A/w Ascending infection w/ Enteric Gram-Negative bacteria
Presents as Sepsis (High Fever and Chills), Jaundice, and Abdominal Pain
Increased incidence w/ Choledocholithiasis (stone in Biliary duct –> decreases flow washout)
Triad: Epigastric / RUQ pain, Fever, and Jaundice

Ascending Cholangitis

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Gallstone enters and Obstructs the Small Bowel
Due to Cholecystitis w/ Fistula formation between the Gallbladder and Small Bowel

Gallstone Ileus

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Adenocarcinoma arising from the Glandular epithelium that lines the Gallbladder-wall
Gallstones are a Major risk factor, esp. w/ Porcelain Gallbladder
Clonorchis sinensis (Liver Flukes)
Cholecystitis in an Elderly Woman (40 – 70 y.o.)
-> Gallbladder Carcinoma –> Poor prognosis
Klatskin tumor - carcinoma of the Bifurcation of the Right and Left Hepatic Bile ducts

Gallbladder Carcinoma

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Yellow discoloration of the Skin and Scleral Icterus
Increased Serum Bilirubin > 2.5 mg/dL
A/w Bilirubin metabolism disturbance

Jaundice

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High lvls of UCB overwhelm the conjugating ability of the Liver
Increased UCB (not water soluble)
Dark urine due to increased urine Urobilinogen, increased Conjugated-UCB
Increased Risk for Pigmented Bilirubin Gallstones

Extravascular Hemolysis
or
Ineffective Erythropoiesis

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Newborn Liver has transiently low UGT activity (UGT1A1 activity, decreased excretion)
Increased UCB –> Fat soluble –> Depositions in Basal Ganglia of the Brain (Kernicterus) –> Neurological deficits and Death
Tx: Phototherapy (makes UCB water soluble) –> urinate out Bilirubin

Physiologic Jaundice of the Newborn

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Mildly low UGT activity (UGT1A1)
(UDP-glucuronosyltransferase deficiency)
Autosomal recessive
Increased UCB
Diffuse Hepatocellular disease
Jaundice during stress (e.g. Fasting, Severe Infection); otherwise not clinically significant

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Gilbert Syndrome

Absence of UGT (severe)
(Deficiency of UGT1A1 activity)
–> Unconjugated hyperbilirubinemia
Increased UCB
Type I - Kernicterus - Usually fatal - Autosomal recessive - Fatal in Neonatal period
Type II - Jaundice - Autosomal Dominant w/ variable penetrance - Generally mild, occasional Kernicterus

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Crigler-Najjar Syndrome

Deficiency of Bilirubin Canalicular ABC transport protein (cMOAT)
Impaired biliary excretion of bilirubin glucouroides due to Mutation in Multiple Drug-resistant Protein 2 (MRP2) –> Pigmented Cytoplasmic Globules ‘BLACK’
Benign Autosomal recessive
Increased CB (Conjugated Hyperbilirubinemia)
Normal AST and ALT
No Clinical Consequences
The Liver is dark; otherwise, not clinically significant –> ‘Pitch Black Liver’ ‘Pitch Dark’ – Gallbladder cannot be visualized
Similar to Rotor Syndrome –-> Normal appearance, Gallbladder can be visualized

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Dubin-Johnson Syndrome

A/w Gallstones, Pancreatic Carcinoma, Cholangiocarcinoma, Parasites, and Liver Fluke (Clonorchis sinensis)
Increased CB
Decreased Urine Urobilinogen
Increased Alkaline phosphatase
Dark urine (Bilirubinuria) and Pale stool
Pruritus due to increased Plasma bile acids
Hypercholesterolemia w/ Xanthomas
Steatorrhea w/ Malabsorption of Fat-soluble vit. (ADEK)

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Biliary Tract Obstruction

(Obstructive Jaundice)

Inflammation disrupts Hepatocytes and Small Bile Ductules
Increased in Both CB and UCB
Increased AST and ALT
Dark urine due to increased Urine Bilirubine
Urine Urobilinogen is normal or decreased

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Viral Hepatitis

* **Fecal-oral transmission** * Herpesvirus naked capsid RNA * HAV is commonly acquired by **Travelers - 'Infectious'** * HEV is commonly acquired from **Contaminated water or Undercooked seafood - 'Enteric'** * Acute Hepatitis; No Chronic state * Anti-virus IgM marks active Infection * Anti-virus IgG is protective, and its presence indicates prior infection or immunization (HAV only) * HEV infection in **Pregnant Women** is a/w **Fulminant Hepatitis** (Liver Failure w/ Massive Liver Necrosis)

Hepatitis A (HAV) and Hepatitis E (HEV)

* '**Serum'** * **Hepadnavirus enveloped DNA** * **Parenteral transmission** (Childbirth, Unprotected intercourse, Intravenous Drug Abuse [IVDA], and Needle stick) * **'Ground glass'** Hepatocytes (due to cytoplasmic HBsAg) * Results in Acute Hepatitis * Chronic disease occurs in 20% of cases --\> a long-term risk of Hepatocellular carcinoma in pts. infected w/ HBV. * Vaccine

Hepatitis B (HBV)

HBV Acute Stage

* *Increase* HBsAG (Hepatitis B surface marker antigen) * *Increase* HBeAG and HBV DNA (envelope Antigen Transmission) * IgM – HBcAB – core Acute Battle

HBV Window Stage

* IgM – HBcAB – core Acute Battle

HBV Resolved Stage

* IgG – HBcAB – core Acute Battle * IgG – HBsAB – surface Acute Battle (protective)

HBV Chronic Stage

* *Increase* HBsAG (\> 6 months) * *+/-* HBeAG and HBV DNA indicates infectivity * IgG – HBcAB – core Acute Battle

HBV Immunization Stage

* IgG – HBsAB – surface Acute Battle (protective)

* **'Post-transfusion'** and **'non-A, non-B'** * **Flavivirus enveloped RNA** * **Parenteral transmission** (IVDA, Unprotected intercourse) * Risk from transfusion is almost nonexistent due to screening of the blood supply * Results in Acute hepatitis; Chronic disease occurs in most cases --\> 'Necrosis w/ portal bridging' * HCV-RNA test confirms infection ELISA * *Decreased* RNA levels indicate recovery * Persistence indicates Chronic disease

Hepatitis C (HCV)

* **'Delta'** * Defective enveloped circular RNA * Dependent on HBV for infection * Superinfection upon existing HBV is more severe than Coinfection (Infection w/ HBV and HDV at the same time) * Dx: Anti-HDV ELISA

Hepatitis D (HDV)

* **End-stage liver damage** - -\> Disruption of Normal Hepatic parenchyma * Bands of Fibrosis and Regenerative nodules of Hepatocytes * Prothrombin time (PT) assess coagulopathy due to Liver disease * Fibrosis is mediated by **TGF-β**; from **Stellate cells** which lie beneath the endothelial cells that line the Sinusoids * Portal Hypertension leads to Ascites (fluid), Congestive Splenomegaly / Hypersplenism (consume RBCs and Platelets) and Portosystemic shunts (esophageal varices, hemorrhoids, and caput medusae) and Hepatorenal syndrome (rapidly developing Renal failure secondary to Cirrhosis) * Decreased detoxification results in Mental status change, Asterixis, Coma * Gynocomastia, Spider angiomata and Palmar erythema due to Hyperestrinism * Jaundice * Decreased Protein Synthesis leads to Hypoalbuminea w/ Edema and Coagulopathy due to *decreased* clotting factors

Cirrhosis

* **Dmg to Hepatic Parenchyma** * **Fatty Liver** – accumulation of Fat in Hepatocytes (Steatosis) * Heavy and Greasy Liver * Alcoholic Hepatitis results from Chemical injury to Hepatocytes (Binge) * **Acetaldehyde mediates dmg** * Swelling of Hepatocytes w/ formation of **Mallory bodies** (dmg to **_cytokeratin intermediate filaments_**), Neutrophils, Fatty change, necrosis and acute inflammation * Fibrosis around the Central vein * Painful Hepatomegaly w/ (AST \> ALT) * May result in Death

Alcohol-Related Liver Disease

* **Fatty change**, Hepatitis, and/or Cirrhosis that develop **w/out Exposure to Alcohol** or other known insult * A/w Obesity, Hyperinsulinemia, Insulin resistance, Type 2 Diabetes mellitus * Lipid accumulation in Hepatocytes - -\> Steatohepatitis --\> Cirrhosis * M = F * Diagnosis of exclusion; ALT \> AST

Nonalcoholic Fatty Liver Disease

* **Excess body Iron (Fe)** leading to deposition in tissues and Organ dmg, **HFE, HJV, TFR1, TFR2** * Tissue dmg is mediated by Generation of Free Radicals - -\> **Fenton Rxn --\> Heart, Pancreas, and Liver** * _Autosomal Recessive_ defect in Iron absorption (primary) or Chronic transfusions (secondary) * Primary Hemochromatosis mutations in **HFE, gene**, usually **Chrom 6p21.3 -** **C282Y --\> Increases small intestine absorption of Fe** * Cysteine replaced by Tyrosine at AA 282 * **Triad: Cirrhosis, 2^nd Diabetes Mellitus, Bronze skin** * Dilated Cardiobyopathy, Cardiac Arrhythmias, Gonadal dysfunction (atrophy) * 5x M \> F, Common among Northern European descent * Brown pigment in Hepatocytes * *Increased* risk of Hepatocellular carcinoma - -\> Free radicals --\> Dmg DNA * Tx: Phlebotomy and Chelating agents (Deferoxamine)

Hemochromatosis * Hemosiderosis = Acquired disorder of Fe overload due to repeated blood transfusions in pts. w/ Thalassemia * Hemochromatosis = Inherited disorder

* Hepatolenticular degeneration --\> genetic disorder * _Autosomal recessive_ defect (**chrom 13q14.3** **ATP7B gene**) - -\> **P-type ATPase -** ATP-mediated hepatocyte Copper **transport into Bile and Ceruloplasmin** * Lack of Copper transport into Bile * Lack of Copper incorporation into Ceruloplasmin – carries copper in Blood * Copper builds up in Hepatocytes, Leaks into Serum, Deposits in Tissues * Copper-production of Hydroxyl Free Radicals - -\> Tissue Damage * Childhood or Adolescence cirrhosis (Liver disease) * Neurologic manifistations (Behavior, Dementia, Chorea, Parkinsonian) * **Kayser-Fleisher rings** in the Cornea * *Increased* Urinary Copper * *Increased* Hepatocellular carcinoma * Tx: **D-penicillamine** (chelates copper)

Wilson Disease

* **Autoimmune Granulomatous destruction of Intrahepatic Bile Ducts** * Women (avg. age is 40 y.o., 35 - 65 y.o's) * 10x Females \> Males * A/w other Autoimmune diseases (Sjogren Syndrome (70%), Scleroderma (5%), Typhoid disease (20%) Rheumatoid arthritis or SLE) * Unknown etiology * **Antimitochondrial autoantibodies (AMA) (90%)** are present - **AMA + ANA + ANCA** * Obstructive jaundice - **_Florid duct lesions_ and Loss of Small ducts** * Pruritus, Xanthomas, Xanthelasmas, Serum Cholesterol, Fatigue * Cirrhosis is a late complication

Primary Biliary Cirrhosis

* **Segmental Inflammation and Fibrosis of Intrahepatic and Extrahepatic Bile Ducts** * Periductal Fibrosis w/ ‘**onion-skin**’ appearance: Concentric Fibrosis around Bile ducts and Segmental stenosis of Bile ducts w/ **_Bending and Strictures_** * Uninvolved regions are dilated resulting in a ‘**Beaded appearance'** of Bile duct * **A/w Ulcerative colitis, IBD (70%), Pancreatitis, Fibrosing disease (Retroperitoneal diseases)** * Males (70%) w/ 20 - 40 y.o's * Unknown etiology; a/w Ulcerative Colitis and **p-ANCA** * Obstructive jaundice, and late Cirrhosis * ***Increased*** risk for **Cholangiocarcinoma**

Primary Sclerosing Cholangitis

* **Fulminant Liver failure** and **Encephalopathy** in **Children** w/ **Viral illness w/ take Aspirin** * Varicella or Influenza * Likely related to Mitochondrial dmg of Hepatocytes * Hypoglycemia * Elevated Liver enzymes * Causes Hepatic Fatty change (microvesicular steatosis) and Cerebral edema / Encephalopathy * Nausea and Vomiting --\> Coma and Death

Reye Syndrome

* **Benign Tumor of Hepatocytes (Liver cell adenoma)** * A/w **Oral contraceptive** / anabolic steroids and Type I glycogen storage disease, in **Young Women** * Regress upon cessation of Oral contraceptive drugs * Microscopically tissue resembles normal Liver but lack of Portal tracts **No Kupffer cells** * Risk of Rupture and Intraperitoneal bleeding, especially during Pregnancy * Tumors are Subcapsular and **Grow w/ Exposure to Estrogen**

Hepatic Adenoma

* **Malignant tumor of Hepatocytes (Asia, Japan, and sub-Saharan Africa)** * **"Eosinophilic Hepatocytes" w/ non-cirrhotic liver and fibrous collagen bundles** * Chronic Hepatitis (**HBV** and **HCV**), and 4x Male \> Female * **Cirrhosis** (Alcohol, Nonalcoholic Fatty Liver disease, Hemochromatosis, Wilson disease, and **A1AT** deficiency) * **Aflatoxin B1** derived from Aspergillus (induced **p53** mutations) - **β-Catenin** - a/w APC * *Increased* risk for **Budd-Chiari syndrome** * Liver infarction secondary to Hepatic vein obstruction * Painful Hepatomegaly and Ascites **RUQ** * Tumors often detected Late --\> masked by Cirrhosis; poor prognosis, **Increased** **AST and ALT** * Serum Tumor marker is **_α-fetoprotein_**

Hepatocellular Carcinoma

* More common than primary liver tumors * Multiple well circumscribed masses * Detected as Hepatomegaly w/ nodular Free edge of the Liver * Colon * Stomach * Pancreas * Breast * Lung * Metastatic Melanoma

Metastasis to Liver

* Accumulation of Cholesterol-laden Macrophages w/in the Mucosa of the Gallbladder wall * Yellow speckling of the Red-tan mucosa - "**Strawberry gallbladder"** * **Liped-laden Macrophages** w/in **Lamina Propria**

Cholesterolosis

* Recent immigrants from Mexico, South America, India, etc. * *Entamoeba histolytica* * Necrotic abscess filled w/ Brown Pastelike Material **'Anchovy paste'** * Tx: ABX w/ or w/out Surgical drainage

Amebic Liver Abscess

* Most common genetic disease requiring Liver transplantation in Children * _Autosomal recessive_ **disorder of Protein folding** * Production of **α-1-AT** produced by **Pi gene** (chrom 14) accumulates in Hepatocytes --\> Liver damage * Inhibition of Proteases; Neutrophil elastase, Cathepsin G, and Proteinase 3 --\> **Pulmonary Emphysema** * PiS (mild varient) * PiZ (markedly reduced levels) * PiZZ (severly reduced levels) * **Micronodular cirrhosis** w/ *increased* risk of **Hepatocellular carcinoma** and **Panacinar emphysema** (lungs) * PAS positive, Eosinophilic cytoplasmic globules w/in Hepatocytes - **Round - Oval Cytoplasmic Globular inclusions in Hepatocytes** * Tx: Smoking cessation and Liver Transplantation

α-1-Antitrypsin Deficiency

* **Hepatic vein Thrombosis** - occlusion of Two or more Hepatic veins by a Thrombus --\> Hemodynamic Liver Disease --\> Pain and Ascities * A/w **predisposing for Thrombosis**; **_Polycythemia vera_**, Pregnancy, Oral contraceptives, Paroxysmal Nocturnal hemoglobinuria, or Hepatocellular carcinoma * Abdominal pain, Hepatomegaly, Ascites, and Death * **Microscopic Centrilobular Congestion and Necrosis**

Budd-Chiari Syndrome

* Asymptomatic * Solid tumor in the Right lobe of the Liver * Consiting of a Fibrous core w/ Stellate projections * NOT a/w use of Oral contraceptives * Contains **Biliary epithelium** and **Kupffer cells** (Technetium scans show uptake)

Focal Nodular Hyperplasia

GI: Pancreas, Liver, Gallbladder Flashcards

(49 cards)