Hepatic, Biliary, and Pancreas Flashcards
(99 cards)
1
Q
PART 1
A
PART 1
2
Q
Functions of the hepatic system (liver)?
- Conversion and excretion of ______ and _________
- Sole source of ________ and other plasma proteins
- Produces ____ (500-1500 mls./day)
- Synthesizes ______ factors
- Absorbs and processes nutrients from the ___
- _________ (drugs, ETOH and toxins)
- _________ (glycogen, vitamins, iron)
- Synthesizes ____________
A
- bilirubin and ammonia
- albumin
- bile
- clotting factors
- gut
- detoxification
- storage
- cholesterol
3
Q
- The liver reciever approximately __% of _________ even though it makus up only approximately 2-3% of total body weight.
- The _______ vein provides approximately / of blood supply while the hepatic artery provides the rest.
A
- 25%, CO
- portal vein, 2/3
4
Q
What is the functional unit of the liver?
A
Liver Lobule
5
Q
What are some S/Sx of hepatic disease?
A
- GI symptoms (N/V, Diarrhea, Constipation, Heartburn, Abdominal Pain, GI Bleeding)
- Edema/Ascites
- Dark Urine (bilirubin)
- Light/clay colored stools
6
Q
What causes the urine to become dark with hepatic diseases?
A
Breakdown of hemoglobin produces bilirubin. Excess bilirubin in urine presents as dark urine and suggests liver damage.
7
Q
Other S/Sx of hepatic disease:
- _____ _________ quadrant abdominal pain
- ___________ involvement (confusion, muscle tremors, sleep disturbances)
- Hepatic ______________ (abnormal development of bone)
- _________
- Skin changes such as _______ and bruising
A
- right upper quadrant
- neurologic involvement
- osteodystrophy
- osteoporosis
- jaundice
8
Q
Jaundice is a _______, not a _________.
A
-symptom not a disease
9
Q
Jaundice:
- _________ break down product of RBC in macrophages
- ________ discoloration of the skin, sclerae, and mucous membranes.
- Increased bilirubin production. Decreased processing of bilirubin.
- Hepatocyte dysfunction (hepatitis, hepatic disease, tumor), bilirubin accumulation.
- Impaired bile flow: caused by mechanical damage due to some obstruction of biliary tree
A
- Bilirubin
- Yellow
10
Q
What is the treatment of Jaundice?
A
- resolve underlying disease
- return to normal color suggests resolution
- then activity and exercise can be resumed
11
Q
What are the S/Sx of neurologic involvement in hepatic diseases?
A
- Confusion
- Sleep disturbances
- Muscle tremors
- Hyper reactive reflexes (ammonia)
12
Q
Describe how the neurological system can be affected with hepatic disease.
A
- Ammonia converted into urea in the liver.
- Ammonia comes from the degredation of amino acids.
- Ammonia is then catabolized by the liver generating urea.
- Decreased urea production leads to ammonia accumulation in the blood and neurological symptoms.
13
Q
What is flapping tremor?
A
- Elicited by attempted wrist extension while the forearm is fixed.
- Is the most common neurological abnormality associated with liver failure.
14
Q
MSK pain location with hepatic disease tends to refer where?
A
Posterior thoracic pain (interscapular, R shoulder/upper trap/subscapular)
15
Q
Hepatic _____________ is an abnormal development of bone/osteoporosis in individuals with chronic liver disease and leads to ___________/__________.
A
- hepatic osteodystrophy
- osteopenia/osteoporosis
16
Q
- Healing of the liver occurs _______ with complete parenchymal regeneration or scarring or a combination.
- ________ hepatic injury results in fibrosis (cirrhosis).
A
- quickly
- Chronic
17
Q
- ______ is a late stage of scarring (fibrosis) marked by degeneration of cells, inflammation, and fibrous thickening of tissue. It is typically a result of alcoholism or hepatitis.
- It is a progressive, patterned loss of healthy tissue which is replaced with _______ tissue.
- Significant loss of liver function is associated with loss of __% or more of liver function.
A
- Cirrhosis
- fibrotic
- 80%
18
Q
Practice implications for Cirrhosis:
- Osteoporosis
- Impaired ________
- Impaired ________ performance/weakness
- Loss of ___________
- Deconditioning
- Ascites/bilateral edema of feet/ankles
- Blood loss
- _____ to reduce metabolic demand on the heart is recommended.
A
- posture
- muscle
- balance
- REST
19
Q
Portal Vein:
- A vein conveying blood to the liver from the _____, ________, ________, __________, and ___________.
- Carries about __% of the blood going to the liver.
- Conducts blood to ________ _____ in the liver i.e. not a true vein.
- The ______ vein and _______ arteries deliver blood to the liver.
A
- liver from the spleen, stomach, pancreas, gall bladder, and intestines
- 75%
- capillary beds
- portal vein and hepatic arteries
20
Q
Portal Hypertension:
- Portal hypertension is defined as an increase in hepatic sinusoidal blood pressure > __ mm
- ________ and abnormal liver architecture combine to form mechanical barriers to blood flow in the liver increasing the resistance and blood pressure in the hepatic portal system
- What contributes to this hypertension- probably ________ and accompanying fibrosis; compression of arteries.
A
- 6mm
- fibrosis
- cirrhosis
21
Q
- Increased portal pressure causes a __________ flow of blood back into the stomach, spleen, large and small intestine, rectum, and esophagus.
- The result of this are varices back upsteam, what is varices?
A
- retrograde
- an abnormally dilated vessel with a tortuous course (congestion)
22
Q
Describe these consequences of portal hypertension:
- Ascites
- Spleenomegally
- Hemorrhoids
- Varices
A
- Ascites- from increased hydrostatic venous pressure
- Spleenomegally- enlargement of the spleen caused by venous congestion in spleen
- Hemorrhoids- from venous congestion in the bowel
- Varices- esophagus, stomach, rectum, or umbilical area
23
Q
Hepatic __________ is a potentially irreversible decreased level of consciousness in people with severe liver disease. What is it thought to be caused by?
A
- Hepatic Encephalopathy
- Thought to be caused by elevated blood ammonia and altered neurotransmitter status in the brain.
24
Q
Describe how Hepatic Encephalopathy occurs.
A
- Ammonia is created by bacteria in the colon from the metabolism of protein and urea.
- Ammonia is absorbed into the portal blood system and transported to the liver where it is converted into urea
- But the diseased liver cannot metabolize the ammonia
- Blood ammonia levels go up impairing cognitive and motor function at the level of the brain
25
What are the S/Sx of Hepatic Encephalopathy?
- Depression, personality changes, impaired attention
- Drowsiness, sleep disorders, ataxia, asterixis, slurred speech, hyperreflexia
- Marked confusion, incoherent speech, muscle rigidity
- STUPOR, DECEREBRATE POSTURING, POSITIVE BABINSKI, DILATED PUPILS
26
Hepatic Encephalopathy Implications for the PT:
- Patient _______
- Impaired ______ and _______ integrity
- Impaired arousal
- Risk for pressure ulcers secondary to malnutrition, immobility, edema
- safety
| - motor and sensory
27
- ________ is an abnormal accumulation of fluid in the peritoneal cavity and is associated mostly with _______ and accompanying ______ _________.
- How is it managed?
- Ascites, cirrhosis and portal hypertension
| - Paracentesis, albumin comsumption, diuretics, sodium and fluid restriction
28
Ascites Implications:
- Accompanying impaired _______ and _________ function
- ___________
- ________ disorders
- Malnutrition
- Muscle degradation
- cardiac and respiratory
- lymphedema
- integumentary
29
PART 2
PART 2
30
- Hepatitis is an __________ condition of the liver caused by _______ by one of several viruses with specific affinity for the liver (A,B,C,D,E).
- Infection can result in _____ or ________ inflammation of the liver.
- What are some other viruses that can cause hepatitis?
- inflammatory, infection
- acute or chronic
- Epstein-Barr, CMV (cyto-megalovirus)
31
- Most people with chronic hepatitis are __________.
| - How is it diagnosed?
- asymptomatic
| - symptoms, physical exam, blood test
32
What are the symptoms of viral hepatitis?
- N/V
- poor appetite, wt loss
- weakness
- jaundice, dark urine
- pale or clay-colored stool
- fatigue
- most people have vague or no symptoms at all
33
Viral Hepatitis Prognosis:
- Depends on ______ of hepatitis, presence of liver ___________ and development of ________.
- Occurence of liver cancer and/or cirrhosis _______ the progression.
- Mod-to-severe _______ consumption.
- type, comorbidities, cirrhosis
- hastens
- ETOH
34
Hepatitis A:
- Formerly known as "_________ hepatitis"
- Spread by close personal contact or oral-fecal contamination of water and food, poor hand hygeine, shared use of oral utensils.
- Hepatitis A is _______ and ____-________
- Most persons with _______ disease recover with no lasting liver damage; rarely fatal
- ______ contagious
- preventable with __________
- "infectious hepatitis"
- benign and self-limiting
- acute
- highly
- vaccine
35
Hepatitis B:
- Formerly known as "_______ hepatitis"
- Spread by blood transsfusions, needle sticks, IV drug use/shared needles, dialysis, sexual contact, exchange of body fluid.
- Considered a ____ because it is transmitted via sexual intercourse
- Incubation period about ___ days
- Most persons with ______ disease recover with no lasting liver damage; rarely fatal
- "serum hepatitis"
- STD
- 90
- acute
36
- Who is most at risk for Hepatitis B?
- __-__% of chronically infected persons develop chronic liver disease.
- Is there a vaccine?
- healthcare workers who come in contact with blood
- 15-25%
- Yes
37
Hepatitis C:
- Leading cause of ________ liver disease transmitted by contact with blood of an infected person.
- ______ illness is uncommon.
- __-__% of newly infected persons develop a chronic infection. __-__% develop cirrhosis.
- __-__% of newly infected persons clear the virus.
- Is there a vaccine?
- chronic
- acute
- 75-85%, 5-20%
- 15-25%
- No
38
What is the treatment of Hepatitis C?
- Interferon-stimulates the immune system to attack the virus
- Ribavirin-anti-viral drug used in tandem with interferon
- New direct acting antiviral agents (curative, 8-12 week course of oral medication)
39
Who should be tested for Hepatitis C?
- Recieved organ transplant before 1992
- Have ever injected drugs
- Recieved blood product used to treat clotting problems that was made before 1987
- Born between 1945 and 1965
- Have had long term kidney dialysis
- Children born to HCV-positive mothers
40
What is autoimmune Hepatitis?
Immune reaction launched against cellular material in liver.
41
What are some other viral causes of Hepatitis?
- CMV
- Epstein-Barr
- Yellow Fever
42
Other Causes of Liver Disease:
- _____ and _____-induced liver disease.
- ______ liver (fat accumulations -> inflammation -> scarring (cirrhosis)
- ______ abuse
- drug-induced and toxin-induced
- fatty
- ETOH
43
10 million Americans are alcoholics and about 10-15% of theses will develop cirrhosis.
-Describe this pathogenesis.
- Mitochondrial damage occurs
- Excessive fat content in the liver leads to inflammation which degeneration of hepatocytes
- Degenerated hepatocytes can stimulate an autoimmune reaction that causes further damage: alcoholic “hepatitis”
- Nutritional-deficit injury: occurs because most alcoholics do not eat right
44
PART 3
PART 3
45
What is the biliary system?
Transportation route for bile into the duodenum with a storage site in the gallbladder.
46
- _____ is a dark green to yellowish fluid produced by the liver.
- What is the purpose of bile?
- What does biliary obstruction cause?
- Bile
- Helps emulsify the lipids in food. This process greatly increases surface area for the action of the enzyme pancreatic lipase.
- Prevents the flow of bile to the duodenum resulting in accumulation of bile in the blood and causing jaundice.
47
- Bile is moved to the gall bladder through the right and left _________ ducts which join to form the common hepatic duct. Bile must then move through the _______ duct to reach the gall bladder.
- The common hepatic duct joins with the cystic duct to form the ______ _____ duct.
- The _________ duct joins the common bile duct and the common bile duct continues on to enter the ___________.
- hepatic ducts, cystic duct
- common bile duct
- pancreatic duct, duodenum
48
- What is the function of the gallbladder?
| - Movement of bile to and from the gallbladder is via ________ action of muscles in the cystic duct.
- Stores and concentrates bile by absorbing water through the wall of the gallbladder.
- peristaltic
49
Most common biliary diseases are due to either _______ (___________) or __________ of the gallbladder (___________).
- gallstones (cholelithiasis)
| - inflammation (cholecysstitis)
50
__________ is a "gallstone disease" and is one of the most common GI diseases in the US and a major reason for abdominal surgery.
Cholelithiasis
51
What are the risk factors for gallstones?
- Age
- Genetics
- Decreased physical activity
- Obesity
- Poor lipid profile
- RA
- TPN (total parenteral nutrition)
- Liver disease
- Gastric bypass surgery
- DM
52
- Gallstones form in the ___________ and form when the composition of _____ changes.
- ________ stones make up 80% of all cases while ________ salt stones make up the other 20%.
- 75% are __________, while 25% become ___________.
- gall bladder, bile
- cholesterol (80%), bilirubin salt (20%)
- asymptomatic, symptomatic
53
What is the most frequent site of obstruction with gall stones?
-cystic ducts
54
What are the symptoms of cholelithiasis (gall stones)?
- Abdominal pain
- R upper quadrant
- Abdominal tenderness and muscle guarding
- Pain may radiate to shoulder and upper back
- 50% with symptomatic gall stones will have a recurrent episode
55
- How are gall stones diagnosed?
| - What is the treatment of gall stones?
- ultrasound
| - surgery (cholecystectomy)
56
What are the implications for a therapist when talking about gall stones?
Physical activity may play an important role in the prevention of symptomatic gallstones disease.
57
What are the usual post-op exercises for any surgical procedure?
- breathing
- bed positioning
- coughing wound splinting if needed
- compressive stockings and leg exercises
58
Cholelithiasis (gall stones) Implications for PT:
- Physical activity may play an important role in the prevention of __________ gallstone disease in up to a third of all cases.
- Laparoscopic cholecystectomy
- Many individuals still experience referred pain to the right shoulder for __-__ hours.
- Usual postoperative care-breathing, turning, coughing, wound splinting, compressive stockings, and leg exercises
- symptomatic
| - 24-48
59
What is a complication of gall stones defined as calculi in the common bile duct that can cause pancreatis?
Choledocholithiasis- calculi in the common bile duct, can cause pancreatitis.
60
PART 4
PART 4
61
Pancreas Gross Anatomy:
- Found in the __________.
- Extends from behind the ________ to the left upper abdomen near the spleen.
- Drains into the inner curvature of the ___________.
- _______ ______ drains the organ, joining with the common bile duct which in turn drains into the duodenum.
- abdomen
- stomach
- duodenum
- Pancreatic duct
62
The pancreas functions both as an _______ and ________ gland.
- endocrine
| - exocrine
63
- What is an endocrine gland?
| - What is an exocrine gland?
- Endocrine- Ductless glands that secrete their products, hormones, directly into the blood.
- Exocrine- Glands that secrete substances onto an epithelial surface by way of a duct.
64
In regards to the pancreas as an endocrine gland, it secretes ______ and ________ hormones.
-insulin and glucagon
65
________ is a peptide hormone that regulates the metabolism of carbohydrates, fats, and protein by promoting the absorption of glucose from the blood into liver, fat, and skeletal muscle cells. It is calorie _________.
- Insulin
| - conserving
66
_________ is a peptide hormone, produced by alpha cells of the pancreas. It functions to raise the concentration of glucose and fatty acids in the bloodstream. It favors energy __________.
- Glucagon
| - utilization
67
What is the exocrine gland function of the pancreas?
Secretes HCO3- and a number of digetive enzymes into the pancreatic duct which in turn conducts these molecules to the epithelial lining of the duodenum.
68
- What region of the pancreas contains its endocrine cells?
| - What are the 3 types of cells it houses and their function?
-Islets of Langerhans
- Alpha Cells (A cells): secrete glucagon
- Beta Cells (B cells): secrete insulin
- Delta Cells (D cells): secrete somatostatin (growth hormone-inhibiting hormone GHIH)
69
Insulin secretion is regulated by circulating _______ levels.
glucose
70
Actions of Insulin:
- Stimulate cellular uptake of _________ thus reducing the circulating levels.
- Stimulates __________ and ___________ which favor the utilization of available glucose.
- Inhibits ____________ and ______________ which inhibits the storage of glucose.
- Stimulates cellular uptake of amino acids.
- glucose
- glycolysis and glycogenolysis
- gluconeogenesis and glycogenolysis
71
Insulin is an ___________ hormone.
anabolic
72
Insulin favors the immediate use of glucose and the _________ of glucose.
storage
73
What has the opposite effect of insulin and is released from A cells in response to declining insulin levels? It works to increase the concentration of glucose and fatty acids in the blood stream. It is a ________ hormone.
- glucagon
| - catabolic
74
What are the exocrine functions of the pancreas?
- Digestive enzymes ESSENTIAL for processing food.
| - HCO3 neutralizes the acidic pH of the gastric juices.
75
_______ _______ are the specialized organelle in pancreatic acinar cells for digestive enzyme storage.
Zymogen granules
76
What exocrine enzymes are secreted by the pancreas?
- Proteases (digest proteins and peptides to single amino acids)
- Pancreatic lipase (digests triglycerides, monoglycerides, and FFAs)
- Amylase
77
Zymogens are a storage form of digestive enzymes, do they have catalytic activity?
Not until they are transformed.
78
- _____ _________ occurs when there is an abnormal activation of digestive enzymes within the pancreas.
- It results in the ____________ of the pancreas.
- Acute Pancreatitis
| - autodigestion
79
What are some causes of Acute Pancreatitis?
- Gallstones
- Chronic ETOH consumption
- Idiopathic
- Pancreatic cancer
- Drugs
80
What are the symptoms of Acute Pancreatitis?
- Pain, N/V, anorexia
| - Abdominal pain (sharp and severe), position changes do not alleviate the pain
81
- Pancreatitis can be _____ or _______.
- It is a _______ disease (hyperglycemia, hypoxemia, kidney failure, hypovolemia and shock, jaundice and portal vein thrombosis)
- acute or chronic
| - systemic
82
What is the treatment of Acute Pancreatitis?
- IV fluids
- analgesics
- NPO/stop feeding the patient
- Severe pancreatitis: Admission to ICU
83
What are the PT implications for Acute Pancreatitis?
- Presents with back pain.
- Pancreatic scarring may occur and limit trunk extension.
- Don't feed the patient if NPO.
- Bed positioning: side-lying, knee-chest position with a pillow pressed against the chest or sitting with trunk flexed.
84
PART 5
PART 5
85
Chronic Pancreatitis:
- Characterized by the development of __________ changes in the pancreas secondary to chronic inflammation.
- Chronic _________ pain, ______ abuse, decreased apetite, weight loss, poor QOL.
- _________ pain with radiation to the back.
- Pain relieved by knee to chest or bending forward.
- Diabetes
- irreversible
- abdominal pain, opioid abuse
- epigastric
86
Pancreatic Cancer:
- Adenocarcinoma >__ yo.
- 70% of blockage occurs at the ______ of the pancreas.
- More common in _________.
- Diagnosed as an advanced disease.
- Wt loss, pain, jaundice.
- Impaired ________, _______ performance, and ROM.
- Intractable ____ pain.
- 55 yo
- head of the pancreas
- blacks
- posture, muscle performance, and ROM
- back pain
87
What is a whipple procedure?
-Done to remove a tumor in the head of the pancreas, ampulla, or the first part of the duodenum.
What is resected?
- Head of pancreas
- Gallbladder
- End of common bile duct
- Ampulla
- Duodenum
- Possible part of stomach
88
DM Type I:
- Accounts for __-__% of all cases of DM.
- Type IA = ?
- Type IB = ?
- Regardless of the type, these patients are on indefinite _______ therapy.
- 5-10%
- Type IA = Autoimmune destruction of B cells resulting in an insulin deficiency.
- Type IB = Insulin deficiency with no evidence of autoimmune disease.
- insulin
89
What are the complications that can arise from DM Type I?
- Diabetic ketoacidosis
- Hyper- and hypoglycemia
- Coma induced by hypoglycemia
90
What is diabetic ketoacidosis?
Accelerated degredation of fatty acids -> formation of ketones -> lowers blood pH
91
What are the clinical features of DM?
- Polyuria- Excessive urination/clear the excess glucose.
- Polydipsia- Excessive thirst.
- Polyphagia- Excessive appetite.
- Weight loss- Excessive fat catabolism.
- Ketoacidosis- Secondary to increased fat catabolism.
92
DM Diagnostic Values:
- What is the normal fasting glucose levels?
- What is the IFG (impaired fasting glucose) levels?
- What is the provisional diagnosis of diabetes levels?
- FPG <100 mg/dl (5.6 mmol/l) = normal fasting glucose
- FPG 100–125 mg/dl (5.6–6.9 mmol/l) = IFG (impaired fasting glucose)
- FPG ≥126 mg/dl (7.0 mmol/l) = provisional diagnosis of diabetes
FPG = fasting plasma glucose
93
What is the optimal Hb A1C level?
<7% or g/dl
94
DM Type II:
- Acounts for __-__% of all cases of DM.
- Is reaching epidemic proportions in this country.
- Can reflect an insulin ________ and/or _________.
- Patients may or may not be on insulin therapy.
- 80-90%
| - deficiency and/or resistance
95
_______ syndrome is a pre-diabetic syndrome. What are the components of it?
Metabolic Syndrome
- Dyslipidemia
- HTN (increased Na retention)
- Abdominal obesity
- Insulin resistance
- Proinflammatory state
- Prothrombin state
- Large waist (>35in women, >40in men)
96
Diabetic Retinopathy:
- Diabetic Retinopathy can take __-__ years to appear.
- __% been found to have retinopathy at time of diagnosis.
- After 20 years, __% of type IIs will have retinopathies.
- Progression can be slowed with glycemic control.
- 5-20
- 21%
- 60%
97
Diabetic Nephropathy:
- Diabetes is the most common cause of ______, responsible for approximately __% of all cases.
- 20-30% of all diabetics will develop ESRD.
- ________ and ______ control reduce risk and slows progression of nephropathy.
- ESRD
- 40%
- glycemic and HTN control
98
Diabetic Neuropathy:
- Involves damage to nerves (______, ______, and _________).
- Often involves ______ extremities.
- Characterized by loss of sensation; sensation of numbness, tingling, and burning; and ______ weakness.
- sensory, motor, and autonomic
- lower
- muscle weakness
99
___________ ________ ______ Syndrome is an inflammatory syndrome characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism
Diabetic Charcot Foot Syndrome
