Lecture 12-Liver and Pancreas Pathology

Question 1

Where are RBCs broken down?

Answer 1

Macrophages in spleen and liver

Question 2

What is bilirubin a product of ?

Answer 2

Heme breakdown

Question 3

Why does bilirubin have to be bound to albumin in the blood?

Answer 3

Because it is hydrophobic

Question 4

In the liver, what is bilirubin conjugated with and which enzyme does this?

Answer 4

Glucoronic acid by UDP glucuronyl transferase

Question 5

True or false: conjugated bilirubin is water soluble

Answer 5

TRUE

Question 6

How is failure of anabolism of the liver measured?

Answer 6

• albumin and coagulation factors(failure to produce -> prolonged INR)
• glycogen and haematopoeisis

Question 7

How is failure of catabolism of the liver measured?

Answer 7

• drugs
• hormones
• Hb
• poisons

Question 8

What is pre-hepatic jaundice?

Answer 8

Too much bilirubin due to excessive breakdown of heme

Question 9

What is intra-hepatic jaundice?

Answer 9

Failure of hepatocytes to conjugate and/or secrete bilirubin

Question 10

What is cholestasis?

Answer 10

Bile stuck in liver

Question 11

What is post-hepatic or obstructive jaundice?

Answer 11

Failure of biliary tree to convey conjugated bilirubin to the duodennum

Question 12

Describe the presentation of pre-hepatic jaundice

Answer 12

• mild yellow
• dark stools because lots of bilirubin is converted to stercobilin
• normal urine colour
• no pruritis
• increased serum bilirubin, increased urobilinogen, no conjugated bilirubin in urine

Question 13

Describe the presentation of intra-hepatic jaundice

Answer 13

• normal stools
• dark urine because conjugated bilirubin in blood moves to urine as it is not excreted into bile
• no pruritis
• increased serum bilirubin, normal urobilinogen, conjugated bilirubin in urine

Question 14

What can cause intra-hepatic jaundice?

Answer 14

Hepatitis and cirrhosis

Question 15

Describe the presentation of post-hepatic jaundice

Answer 15

• severe jaundice: green tinge
• pale stools
• dark urine
• pruritis because can’t secrete bile salts
• increased serum bilirubin, decreased urobilinogen, conjugated bilirubin in urine

Question 16

What can cause post-hepatic jaundice?

Answer 16

Pancreatic carcinoma, gallstone in bile duct

Question 17

What are the three markers of hepatocyte damage/dysfunction?

Answer 17

• alanine aminotransferase (ALT)
• alkaline phosphatase (Alk Phos)
• gamma glutamyl transferase (Gamma GT)

Question 18

Where is ALT released from?

Answer 18

Damaged hepatocytes

Question 19

Where is Alk Phos released from?

Answer 19

Liver canaliculi, bile ducts and bone

Question 20

Where is gamma GT released from?

Answer 20

Bile duct cells and to a lesser extend, hepatocytes

Question 21

What can cause increased ALT levels?

Answer 21

Hepatitis: viral, acute alcohol intake, fatty liver disease, drugs

Question 22

What can cause increased Alk Phos levels?

Answer 22

• Bile duct/liver disease with cholestasis: biliary obstruction, cirrhosis, liver mets, drugs
• Bone: mets, fratures, osteomalacia, hyperparathyroidism, growing bones

Question 23

What can cause increased Gamma GT levels?

Answer 23

Biliary duct obstruction, cholestasis, cirrhosis, liver mets, drugs, alchoholism

Question 24

Why can ultrasonography be used to diagnose liver conditions?

Answer 24

Detects biliary obstruction, hepatic fibrosis, fatty liver disease, portal hypertension, ascites, gallstones and liver mets

Question 25

What happens to hepatocytes in hepatitis?

Answer 25

Become inflamed and can't function properly

Question 26

True or false: hepatitis increases serum NH3 which is produced by colonic bacteria and deamination of AA

Answer 26

TRUE

Question 27

What are the symptoms of hepatitis?

Answer 27

Unwell, anorexia, fever, RUQ pain, dark urine, jaundice

Question 28

What are the blood test findings in hepatitis?

Answer 28

- normal albumin/INR - increased serum bilirubin - conjugated bilirubin in urine - very high serum ALT - normal Alk Phos and gamma GT

Question 29

What is liver cirrhosis?

Answer 29

Liver fibrosis -> shrunken, hard, nodular liver

Question 30

What can fibrosis lead to?

Answer 30

- Pressure and occlusion or hepatic sinusoids -> portal hypertension -> diverts nutrient-rich blood away from liver -> ascites - pressure on bile canaliculi decreases its ability to excrete toxins - hepatocytes replaced by fibrous tissue which decreases albumin production

Question 31

What are the causes of liver cirrhosis?

Answer 31

Alcohol, viral, hepatitis, fatty liver disease, idiopathic

Question 32

What are the complications of cirrhosis?

Answer 32

- oesophageal varices - haemorrhoids - caput medusa (blood flows in the wrong direction through ligamentum teres)

Question 33

What are the symptoms of cirrhosis?

Answer 33

Fatigue, bleeding easily, ascites, swollen legs, weight loss, jaundice, haematemesis, melaena, confusion, drowsiness and slurred speech

Question 34

What are the blood test findings in cirrhosis?

Answer 34

- may all be normal - decreased albumin/prolonged INR - increased bilirubin - increased ALT - normal Alk Phos - raised gamma GT if alcoholic

Question 35

What is the treatment for cirrhosis?

Answer 35

No treatment but can deal with complications/have liver transplant

Question 36

What causes biliary duct obstruction?

Answer 36

Gallstones from gallbladder blocking common bile duct and carcinoma of the head of the pancreas

Question 37

What is cholangitis?

Answer 37

Infection in bile ducts due to E Coli (most common)

Question 38

What are the triad of symptoms (Charcot's triad) of cholangitis?

Answer 38

Fever RUQ pain Jaundice

Question 39

What are the two main things leading to the formation of gallstones?

Answer 39

Excess cholesterol crystallising or excess bilirubin

Question 40

Why is biliary colic not a true colic?

Answer 40

The pain is constant

Question 41

Where is pain felt in biliary colic?

Answer 41

RUQ but can radiate to tip of right scapula/shoulder

Question 42

What can precipitate biliary colic?

Answer 42

Fatty meal

Question 43

How long can biliary colic last for?

Answer 43

6 hours

Question 44

What is acute cholangitis?

Answer 44

If gallstone obstructs cystic duct, it can lead to stasis of gallbladder contents which can cause infection

Question 45

What are the symptoms of acute cholangitis?

Answer 45

Gallbladder pain, unwell, pyrexia, tender over gallbladder

Question 46

What are the lab findings in liver metastases?

Answer 46

- increased bilirubin - conjugated bilirubin in urine - raised Alk Phos - ALT and gamma GT slightly raised - normal albumin and INR

Question 47

What is acute pancreatitis?

Answer 47

Due to premature activation of pancreatic proteases in pancreas rather than duodenum -> autodigestion

Question 48

What is chronic pancreatitis due to?

Answer 48

- Due to repeated low grade pancreatitis -> fibrosis | - Alcohol abuse

Question 49

What happens in chronic pancreatitis?

Answer 49

Pancreas becomes calcified and patients suffer severe epigastric and back pain -> opiate addiction and suicide

Question 50

What can cause acute pancreatitis?

Answer 50

- alcohol | - gallstones -> outflow obstruction, pancreatic duct hypertension and toxic effect of bile salts can activate enzymes

Question 51

What are the symptoms of acute pancreatitis?

Answer 51

Epigastric pain through back, vomiting

Question 52

What are the lab findings for acute pancreatitis?

Answer 52

Increased serum amylase/lipase | CT for necrosis/pseudocyst (=fluid collection pushing through lesser sac)

Question 53

What is the treatment of acute pancreatitis?

Answer 53

Analgesia and fluids

Question 54

What is the most common type of carcinoma in the pancreas?

Answer 54

Ductal adenocarcinomas in the head of the pancreas

Question 55

Why does pancreatic carcinoma present late?

Answer 55

It is retroperitoneal (therefore low survival)

Question 56

What are the symptoms of pancreatic carcinoma?

Answer 56

Anorexia, malaise, fatigue, epigastric/back pain, dark urine, pale stools, pruritis, weight loss