Jaundice, weight loss, epigastric pain
Pancreatic cancer
2 major risk factors for pancreatic cacner
Smoking
Chronic Pancreatitis
Unique findings in carcinoma of the HEAD of the pancreas
also seen in periampullary cancer
Conjugated hyperbilirubemia / Jaundice
Pale Stools
Dark urine (due to CB)
Itching
Serum marker for pancreatic cancer
CA 19-9
biliary atresia embryo defect
Failure to form the extrahepatic biliary tree
biliary atresia presentaion
conjugated hyperbilirubinemia/pale stool
Jaundice and cirrhosis in an INFANT
Risk factors for CHOLESTEROL stone formation
Supersaturation of bile
DECREASED bile acid, decreased phosphatidylcholine
GB Stasis, high estrogen, low cck, high progesterone
Cholesterol stone, gross and Xray
Radiolucent…may possibly be radiopaque
Yellow/faceted
Bilirubin stones, gross and Xray
Radio-opaque
Black (no infection)
Causes of brown pigmented stones
Biliary Tree infection
the causative organism of acute cholangitis
E.coli
RUQ pain radiating to the shoulder, Nausea and Vomiting
Acute Cholecystitis
Acalculous Cholecystitis causes
Critically ill patients (burns, sepsis) to develop cholecystitis w/o stones
Also in biliary sludge.
Which type of calcification causes porcelan gallbladder
Dystrophic- think carcinoma
Most common pathogens causing ascending cholangitis
gram negative enterics
Parasites that target the liver
Triad of symptoms for Acute ascending cholangitis
Sepsis
Jaundice
Abdominal pain
Biggest risk factor for ascending cholangitis
Choledocolithiasis
RLQ pain, SBO, Xray reveals air in the biliary tree
Gallstone illeus
Gallbladder carcinoma arises from
glandular epithleium –> Adenocarcinoma
Classic patient with gallbladder cancer is
Elderly female with cholecystitis
Unconjugated hyperbilirubinemia labs (hemolysis)
Increased UB
Increased urine Urobilinogen (more shunted during enterohepatic cycling)
No urine CB
Conjugated hyperbilirubinemia labs
Increased CB
no Urine urobilinogen (no CB made it to the gut to be converted)
Increased Urine CB and bile salts (CB refluxes backward into sinusoids)
Mixed hyperbilirubinemia is a result of
Hepatitis (viral or alcoholi)
Physiologic jaundice of newborn defect
low UDPgluconyltransferase levels –> high UCB
Physiologic jaundice of newborn tx and mechanism
Phototherapy –> converts UCB to CB
Gilbert syndrome
mildly low UDPgluconyltransferase levels
Crigler Najjar 1 syndrome
ABSENT UDPgluconyltransferase levels –> high UCB
Crigler najjar presentation
neonatal kernicterus
Gilbet inheritance
AR
Dubin Johnson and Rotor syndrome defect and inheritance
Bilirubin canalicular transport protein defect –> high CB
AR
Classic 5 symptoms in biliary tract obstruction
Dark urine (CB) Pale stool Pruritis Xanthomas Steatorrhea
Why do hepatitis patients have dark urine
Increased urine CB
Pregnant woman develops acute onset Jaundice, ascites, AST, ALT through the roof then dies
Hepatitis E
Confirmatory marker for active hepatitis C infection
HCV RNA / IgM
markers for chronic hepatitis C
HCV RNA / IgG –> IgG is NOT protective
Which hepatitis depends on hepatitis B for infection
Hepatitis D
Superinfection is worse than Coinfection
3 Indicator of active HepB infection
HBsAg, High AST/AlT, Presence of HBc antibody
HBeAg / HBV DNA
what is the only marker present in the window phase?
IgM against the core
Markers for a cleared hepB infection
IgG against the surface Ag
Markers for hepB vacccination
IgG against the surface Ag/no other antibodies are present
Marker for the chronic carrier state
IgG against the core
+ Surface antigen (>6 months)
+ or HBV DNA
Cell type that mediates liver cirrhosis
Stellate cells that secrete TGFB
4 consequenses of hyperesternisim in cirrhosis
Gynecomastia
Testicular atrophy
Spider angioma
Palmar erythema
2 consequences of decreased proten synthesis in cirrhosis
hypoalbuminemia –> edema
coagulopathy
how to tell if elevated alkaline phosphatase is of liver orgin?
y-glutamyltranspeptidase will also be increased
What is the underlying mechanism of tissue damage in hemochromatosis?
Free radical generation via the Fenton Rxn
Hemochromaosis defect
Overactivation of HFE gene (C282Y)
What does HFE code for?
Hepcidin
Hepcidin function
Inhibit the release of iron from cell into blood
relationship of hepcidin and ferroportin
indirect. High hepcidin = low ferroportin
Iron studies in hemochromatosis (ferritin,TIBC, serum Fe, transferrin, %saturation)
Ferritin high
Low TIBC
High Serum Fe
High %sat
How to differentiate between lipofuscin and iron?
Prussian Blue stains iron
2 other organs affected in hemochromatosis
Testes and heart (cardiomyopathy)
Pt presents with darkening of skin, polyuria and polyphagia
Hemochromatosis (this bronze diabetes)
Wilson disease mutation and inheritance
AR
ATP7B gene
Wilson disease udnerlying defect
Defective ATP mediated hepatocyte/copper transfer –> copper accumulates in liver
mechanism of damage in wilson disease
Free radical production
Wilson Dz labs (urinary Cu, serum free Cu, TOTAL Cu, cerruloplasmin)
Increased Urinary Cu
Increased Free serum Cu
Decreased TOTAL Cu (low cerruloplasmin)
45y/o female with SLE presents with generalized itching
Primary biliary cirrhosis
25 year old male with hx of bloody diarrhea and abdominal pain presents with jaundice
Primary sclerosing cholangitis
serum marker for PSC
p-ANCA
Baby has fever, mom gives a fever reducer, baby develops jaundice, hypoglycemia, vomiting
Reye Syndrome
hepatic adenomas are associated with which 2 substances
Birth control pills
Anabolic steroids
Classic case for hepatic adenoma rupture
Healthy girl on birth control pills or male body builder suddenly develops severe RUQ pain, hypotension and death
how does aflatoxin induce hepatocellular carcinoma
p53 mutation
hepatocellular carcinoma tumor marker
Alpha Fetoprotein
5 most common tumors that met to liver
Colon > Stomach > Pancreas > lung / breast
“Cancer Sometimes Penetrates Benign Liver”
PE signs of 2 most common causes of Obst jaundice
Palpable gallbladder that is non tender- Suggestive of adenocarcinoma of the head of the pancreas
Non-palpable gall bladder: Stone in CBD
Imaging technique for acute cholecystitis diagnosis
Hepatobiliary iminodiacetic acid scan (HIDA)
Effect of estrogen on cholesterol/stones
Increases HMGCoA reductase –> increases risk of stones
Well circumscribed liver mass with cystic blood filled spaces, and vascular proliferation
Cavernous Hemangioma
hepatolenticular degeneration (AKA)
Wilson Disease
Which inflammatory cell mediates alcoholic hepatitis?
Neutrophils
cholangiocarcinoma is associated with which other cancer
ulcerative colitis
Deficiency of vitamin ADEK
Gallstone, steatorrhea
night blindness, squamous metaplasia of resp. epithelium, osteomalacia, bleeding tendency - seen in___
Gallstone, steatorrhea
isolated deficiency of Vit D seen in ___________
Uremia/renal failure
Casue of renal stone in steatorrhea
Increased oxalate absorption from GIT
Casue of gall stone in crohns disease
Decreased reabsorption of BS from GIT/Ilium
