PATHO2) W4a- Alterations of Digestive Function Across the Lifespan

Portal Hypertension

-high BP in portal venous system bc resistance to portal blood flow

Intra hepatic (within) causes = inflammation, cirrhosis, hepatitis

Post hepatic (outside) causes = hepatic vein thrombosis / right heart failure (increases resistance)

Portal Hypertension - S/S

1) Varices

2) Splenomegaly

Varices (of Portal HTN)

1) Varices - distended tortuous collateral veins, prolonged pressure —> collateral veins open b/w Portal & Systemic Veins,

vomiting blood from bleeding esophageal varices = most common clinical manifestation

—> risk of Hemorrhage

Splenomegaly (of Portal HTN)

2) Splenomegaly - enlargement of spleen d/t increased splenic vein pressure

—> lead to thrombocytopenia & risk of hemorrhage

Cirrhosis

-irreversible inflammatory, fibrotic liver disease

-scarring —> biliary channels obstructed —> portal HTN

-severity and rate of progression depends on cause (multiple)

Ascites

-too much fluid peritoneal cavity —> abdominal distension + increased abdomen girth + weight gain

-#1 cause = cirrhosis (25% mortality in 1yr)

associated w/:

-portal HTN

-decrease albumin synthesized by liver (loss oncotic (pulling in of fluid pressure)

-splanchnic arterial vasodilation

-renal sodium and water retention

Paracentesis - procedure aspirate fluid to examine culture (not a cure, fluid returns)

treatment: give diuretics, albumin, & restrict sodium

Hepatic Encephalopathy

-neurological syndrome: behavioral, cognitive, motor fxn impaired due to toxic build up

-conditions develops rapid or slow

- neurotoxins from GI, bc of liver dysfxn, travels to brain

Hepatic Encephalopathy Early Signs/Symptoms

early s/s: change personality, memory loss, irritability, disinhibition, lethargy, sleep disturbances

Hepatic Encephalopathy Later Signs & Symptoms

later s/s: confusion, disorientation to time and space, asterixis (flapping tremor), slow speech, bradykinesia, stupor, convulsions, and coma

Asterixis

associated with Hepatic Encephalopathy

-flapping tremor of hands or feet

Jaundice (icterus)

-cause = hyperbilirubinemia (liver fxn is to break down bilirubin)

3 main causes:

1. BLOCKED Extra/Post Hepatic obstruction of bile

   1. common bile duct blocked (gallstone / tumor)

   2. bilirubin can’t flow bc gall stone or tumor

2. CANT EXCRETE Intra hepatic Obstruction of bile

   1. decreased ability of Liver to excrete BIlirubin

3. TOO MUCH Excessive production of unconjugated bilirubin

   1. excess RBC hemolysis: medications (Rifampin) or Genetic condition (Gilbert’s)

= dark urine, yellow sclera, yellow skin, light-clay colored stools

Hepatorenal Syndrome

functional renal failure develops bc advanced liver disease

Hepatorenal Syndrome Type 1 vs. Type 2

Type 1- drop in perfusion to kidneys bc varices bleeding or diuretic treatment

Type 2- ascites causing vasoconstriction and ineffective circulating blood (force + pressure)

Manifestation: oliguria + advanced liver disease s/s

may be acute or gradual*

Acute Liver Failure

-rare clinical syndrome resulting in severe impairment or necrosis of liver cells without preexisting liver disease/cirrhosis

-#1 cause = Acetaminophen overdose, tx = with N-Acetylcysteine

Alcohol Liver Disease causes & symptoms

toxic effects of alcohol & coexisting liver disease -

1. Alcoholic fatty liver: mild, asymptomatic, cessation = reversible

2. Alcoholic steatohepatitis: increased fat storage inflammation and necrosis with infiltration of immune cells

3. Alcoholic cirrhosis: scarring and fibrosis, alter structure/ obstructs liver channels

s/s: anorexia, nausea, jaundice, edema, advanced fatty infiltration or onset of alcoholic steatpohepatitis

Nonalcoholic fatty liver disease (NAFLD)

-infiltration of hepatocytes with fat occurring (in the absence of alcohol intake)

-may progress to nonalcoholic steatohepatitis, which may progress to cirrhosis and end-stage liver disease

Primary Biliary Cholangitis

-Chronic, slowly progressive, autoimmune, cholestatic liver disease, beginning in bile canaliculi and bile ducts

-accompanies other autoimmune diseases

-Manifestations: Pruritus, hyperbilirubinemia, jaundice, light/clay-colored stools —> may progress to cirrhosis, portal hypertension, encephalopathy

Viral Hepatitis

Systemic viral disease that primarily affects the liver:

-5 types (A, B, C, D, and E)- See Table 38.8

-Can cause acute, icteric illness B and C are most common causes

-Spectrum of manifestations ranges from absence of symptoms to fulminating hepatitis, with rapid onset of liver failure and coma

-Elevations in AST/ALT present

-Chronic active hepatitis- predisposition to cirrhosis and liver cancer

Occurs with HBV, HCV, or HBV/HDV

Phases of Hepatitis

1. Incubation: before illness; ranges from 15-180 days depending on virus type

2. Prodromal: Fatigue, anorexia, n/v, HA, ending with appearance of jaundice; virus highly transmissible

3. Icteric: Jaundice, light stool, dark urine, enlarged liver in URQ

4. Recovery: Resolution of jaundice; liver function returns in 2-12 weeks

Gallstones (cholelithiasis)

Risks: Obesity, Middle age, Female, Oral contraceptive use, Rapid weight loss, Native American ancestry, Genetic predisposition/Family History, Gallbladder, pancreas, or ileal disease

Gallstones 3 types

-Formed from impaired metabolism of cholesterol, bilirubin, and bile acids

-Type depends on chemical composition:

A. Cholesterol: Formed from bile that is supersaturated with cholesterol produced by the liver

B. Pigmented brown: Formed from calcium bilirubinate and fatty acid soaps that bind with calcium

C.Black: Composed of calcium bilirubinate with mucin glycoproteins, associated with chronic liver disease and hemolytic disease (red blood cells rapidly destroyed)

Gallstones (pt. 3)

-Often asymptomatic or vague

-classic symptoms. = Epigastric and right hypochondrium pain

-Intolerance to fatty foods (makes pain worse)

Cholecystitis

-Inflammation of gallbladder or cystic duct

-caused by a gallstone lodged in the cystic duct

-Pain is similar to that caused by gallstones = colicky abdominal pain in URQ

-Fever, leukocytosis, rebound tenderness, and abdominal muscle guarding are common findings

Pancreatitis

-Inflammation of the pancreas

-Develops bc of obstruction to the outflow of pancreatic digestive enzymes caused by bile and pancreatic duct obstruction

Acute Pancreatitis

-mild + resolves spontaneously

-result from cellular injury from alcohol, drugs, or viral infection

-Cardinal manifestation: epigastric or midabdominal constant pain

Chronic Pancreatitis

-Process of progressive fibrotic destruction of the pancreas

-chronic alcohol abuse

- continuous or intermittent abdominal pain and weight loss

-Risk factor for pancreatic cancer

Esophageal Cancer

rare but metastasizes quickly

-Squamous cell carcinoma

-Associated with smoking tobacco & chronic alcohol consumption

Adenocarcinoma: Associated with obesity, GERD (Barrett’s Esophagus = exposed to so much acid content that dysplasia occurs), and smoking tobacco

-Frequent symptoms = chest pain + dysphagia (swallowing pain)

Stomach Cancer

-Associated with atrophic gastritis + H. pylori

-Sporadic, associated with consumption of salted and preserved foods, low intake of fruits and vegetables, & use of tobacco and alcohol

-Vague early symptoms: loss of appetite, malaise, and indigestion

-Later symptoms: unexplained weight loss, upper abdominal pain, vomiting, change in bowel habits, and anemia

Colon and Rectal Cancer

-sporadic or associated with a family history of colorectal cancer (genogram)

-Caused by multiple gene alterations + environmental interactions

-Familial adenomatous polyposis or Hereditary nonpolyposis

-Colorectal polyps: Benign projection from epithelium, associated with development of Cancer

-Neoplastic polyps: Premalignant

-Goal is to find and remove during early screening colonoscopy

-Symptoms: depends on the location, size, and shape of the lesion in GI tract. silent in the early stages

Cancer of GI tract

1. Ascending Colon (30%): pain, mass, change in bowel habits, anemia

2. Transverse Colon (10%): pain, obstruction, change in bowel habits, anemia

3. Descending Colon (15%): pain, change in bowel habits, bright red blood in stool obstruction

4. Rectum 20% and sigmoid colon 25%: blood in stool, change in bowel habits, rectal discomfort

Liver Cancer

- usually caused by metastasis from elsewhere in the body

-Hepatocellular carcinoma:

-Usually, asymptomatic; but as progresses worsening jaundice and loss of appetite with progression

-Associated with chronic hepatitis & cirrhosis

Gallbladder Cancer

-Usually caused by metastasis: Biliary reflex, gallstones, infection, & obesity also risk factors.

-Chronic inflammation may trigger dysplasia, may progress to metaplasia

-Early stages usually asymptomatic; Usually caught in late stages with steady RUQ pain

Pancreatic Cancer

-cause: unknown

-Risks: smoking, high fat diet, chronic pancreatitis, Family History, Obesity, DM

-Chronic pancreatitis and inflammatory cytokines support tumor growth

-Can arise from exocrine (outer pancreatic cells) or endocrine cells (inner)

-Lymphatic invasion occurs early & rapidly: When symptoms occur, there usually has been a malignant transformation —> low survival rates