Unit 4 - liver, gall bladder, and pancreas

Question 1

hepatomegaly

Answer 1

from inflammation and swelling within the hepatic parenchymal tissue
- palpate inferior hepatic margin

Question 2

Elevated Liver Enzymes-Liver Profile

Answer 2

Aspartate aminotransferase (AST) (Liver parenchyma)
 Alanine aminotransferase (ALT) (Liver parenchyma)
 Lactic Dehydrogenase (LDH) (Liver parenchyma)
 Alkaline phosphatase (APT) Biliary ducts)	
Gamma glutamyl-transferase (GGT) (Biliary ducts)

Question 3

Portal hypertension and splenomegaly

Answer 3

due to occlusion of the venous drainage from the liver via the hepatic veins into the inferior vena cava
- causes passive congestion in the hepatic portal and splenic veins, resulting in fluid back up and swelling in the organs

Question 4

caval obstruction with pedal edema

Answer 4

due to occlusion of the venous drainage from the liver via hepatic veins into inferior vena cava, causing passive congestion in the lower extremities

Question 5

depression of the clotting mechanism (prothrombin time)

Answer 5

• conversion of vitamin K to prothrombin is impaired
• prothrombin time normal is 11-15 sec; reduced w liver disease
• test is INR

Question 6

Circulating Plasma Protein is Decreased - serum total protein in blood is __

Answer 6

7.0gms/dl, which is 7% of body weight

Question 7

Anasarca

Answer 7

• generalized edema

- Hypoproteinemia & Hypoalbumenemia

Question 8

Jaundice

Answer 8

Elevated Plasma Bilirubin

Question 9

Ascites

Answer 9

due to hepatic portal enlargement
- Hepatic Portal Vein occlusion with passive congestion
Abdominal organs “weep” fluid (plasma)
- Compression of Hepatic Lymphatic Vessels-“weep” fluid (lymph)
- Hypoalbuminemia (decreased plasma proteins)
- Sodium/H2O retention due to decreased renal circulation

Question 10

other signs of liver disease/summary

Answer 10

• pruritus
• gynecomastia (breast enlargement)
• hepatomegaly, splenomegaly
• red palms and spider nevi
• hemorrhagic tendency
• ascites, anasarca

Question 11

End stage liver

Answer 11

Liver has lost all its ability to function

Question 12

Model for End-Stage Liver Disease-MELD

Answer 12

scoring system for stages of liver failure
40 or more — 71.3% mortality
30–39 — 52.6% mortality
20–29 — 19.6% mortality
10–19 — 6.0% mortality
≤9 — 1.9% mortality

Question 13

common causes of liver disease

Answer 13

infections: bacteria, viruses, fungi
toxic damage
neoplasia
autoimmune - hepatitis

Question 14

Hepatitis A virus

Answer 14

Oral-fecal route mode of entry
28 day incubation
4-6 week course (self-limiting)
Serological Blood Marker-Anti HAV IgM antibodies
Vaccine-1992
Inactivated HAV

Question 15

s/s of hep A

Answer 15

Constitutional
 Nausea & Diarrhea
 Jaundice with Pruritus
 Hepatomegaly
 Elevated  liver enzymes (AST, ALT, LDH)
 Aversion to food

Question 16

Hepatitis B

Answer 16

DNA Virus
Transmission and entry
Inoculation
Oral-fecal route
STD
Dental or Medical Procedures
Childbirth
120 day incubation
Variable course (usually self-limiting)

Question 17

components and blood markers of Hep B

Answer 17

Diagram shows that HBV has an incomplete ring of circular DNA within a core particle (HBcAg).

Surrounded by an intermediate protein coat (HBeAg) and a surface protein coat (HBsAg).

Anti-HBV antibodies
HBV Surface Antigen (HBsAG)
Australian Antigen
Hepatitis Associated Antigen (HAA)

Question 18

s/s Hep B

Answer 18

Constitutional
 Nausea & Diarrhea
 Jaundice with Pruritus
 Hepatomegaly 
 Elevated liver enzymes (AST, ALT, etc.)
 Aversion to food

Question 19

recovery of Hep B

Answer 19

vaccine
90%-complete recovery
-2%-HBV carriers
10%-chronic, progressive hepatitis and hepatic cirrhosis
May develop 1° Hepatocellular Cancer

Question 20

Hepatitis C

Answer 20

RNA Virus
Incubation Period: 50-60 Days
transmission/entry: Initially Blood Transfusion Related
Injecting Drug Use
Dental or Medical Procedures 
Childbirth
Tattoos
STD

Question 21

hep C blood markers and outcomes

Answer 21

Serologic Blood Marker: Anti-HCV Antibodies
No current vaccine
1-6% may be HCV Carriers
50% Develop Chronic Hepatitis
20% Develop Cirrhosis and/or Hepatocellular carcinoma

Question 22

Hep C s/s

Answer 22

Constitutional
 Nausea & Diarrhea
 Jaundice with Pruritus
 Hepatomegaly 
 Elevated liver enzymes (AST, ALT)
 Aversion to food

Question 23

Hepatitis D

Answer 23

RNA Virus

In combination with hepatitis B virus-highest overall mortality rate of all the acute viral hepatitis infections-at 20%.

Question 24

Hep D blood markers

Answer 24

Serologic Blood marker

HDV total antibodies- indicates acute or chronic HDV infection.

Question 25

Hepatitis E

Answer 25

``` RNA Virus-1955 Oral Fecal Transmission Route Incubation period: 3-8 weeks Has a preventive vaccine Comparable to HAV-symptoms/severity Self-limiting, 2% mortality rate 20% mortality rate in pregnancy Fulminant liver failure-3rd Trimester ```

Question 26

Cirrhosis

Answer 26

Replacement of Normal Liver tissue with non-functional fat and connective (scar) tissue Most cirrhosis is alcohol related (Laennec’s Cirrhosis)

Question 27

Non-Alcoholic Fatty Liver Disease (NAFLD)

Answer 27

>10% Liver Fat-May develop Cirrhosis Diabetes mellitus Elevated Cholesterol and Triglycerides Obesity

Question 28

Post-necrotic Cirrhosis

Answer 28

Toxins, Drugs | - tylenol

Question 29

Biliary Cirrhosis

Answer 29

(Post Hepatic Obstructive) | Sclerosing cholangitis-autoimmune

Question 30

Cirrhosis Progression

Answer 30

Development of a Fatty Liver Replacement with nodular scar tissue End stage liver disease (ESLD) Hepatocellular failure

Question 31

Hepatocellular Failure

Answer 31

End Stage Liver Disease (ESLD) Mortality 100%-Uniformly Fatal Liver Transplant

Question 32

Contributing events to Morbidity & Mortality

Answer 32

Hemorrhage/Internal Bleeding Depression of the Clotting Mechanism Easy Bleeding Prothrombin time, INR Low levels of Cytokine Thrombopoietin ``` Failure to detoxify ammonia (NH3) into Urea NH3 is converted to NH4+ (Ammonium Ion) Metabolic Acidosis (pH) ```

Question 33

ammonia

Answer 33

Ammonia combines with water to form the Ammonium ion Ammonium ionizes (disassociates) to ammonia and free hydrogen As hydrogen ion concentration rises: H+ increases-pH falls Blood/Body Fluid becomes acidic Thus, Metabolic Acidosis (pH <7.35)

Question 34

Hepatic encephalopathy stages

Answer 34

``` Stage 1 - Personality changes Stage 2 - Muscle involvement Fasciculations, Asterixis Stage 3 - Violence Stage 4 - Hepatic Coma Hepatic fetor-mercaptans (sulfur compounds) & dimethyl sulfide from Cysteine “Breath of the Dead” ```

Question 35

Glasgow Coma scale

Answer 35

Rates consciousness scale 3-15 Rates eye, verbal, motor responses 3=deep unconscious state, unresponsive 15=fully awake

Question 36

Acute pancreatitis

Answer 36

``` Inflammation of pancreatic tissue and ducts Swelling and Pain (intense) Overuse of Alcohol Gall Stones Severe pain-often refers to the back 95% resolution in a few days-few weeks ``` Prolonged cases result in auto-digestion of the pancreas

Question 37

Chronic pancreatitis

Answer 37

Chronic, ongoing pancreatic inflammation May develop from acute pancreatitis or chronic alcohol abuse In children-Cystic Fibrosis Gradual replacement of functional tissue with scar tissue

Question 38

Pancreatic Neoplasia

Answer 38

Benign Cysts and Tumors ``` Malignant Tumors (5 year survival < 5%) Occur most often in African-American males Risk factors: Smoking Diabetes mellitus Aging African American Male ```

Question 39

Cholelithiasis (Gall Stones)

Answer 39

Females > Males Disease of older individuals (>65 years) Often seen in females 40-50 years of age

Question 40

6 F's of gall stones

Answer 40

“Fair, Fat, Female, Fertile, Flatulent, Forty”

Question 41

etiology of gall stones

Answer 41

Precipitation of cholesterol and bile pigments Stasis of bile Biliary Tract Bacterial infection

Question 42

s/s gall stones

Answer 42

Pain-upper right quadrant May radiate to the mid upper back & shoulder Relief-pain food pattern