Liver, gallbladder, pancreas, and bile duct

two main causes of liver dysfunction

1.) cholestasis - bile flow obstruction

2.) hepatocellular injury

Hepatitis

viral or toxic acute liver inflammation and cellular injury.

1.) hepatitis A - transmitted through fecal/oral route, vaccine available, full recovery possible

2.) hepatitis B - blood to blood & sexual content transmission, no cure but treatment available and vaccine available for prevention

3.) hepatitis C - blood to blood transmission, no vaccine but curable through treatment

chronic hepatitis

inflammation and necrosis of hepatic tissue lasting longer than six months. caused by toxicity, hepatitis B & C, and autoimmunity. Manifests as weight loss, anorexia, fatigue, hepatomegaly and elevated LFTs and bilirubin.

Non-alcohol related fatty liver disease (NAFLD)

buildup of extra fat in liver cells not caused by alcohol consumption. Caused by insulin resistance which leads to the shifting of fatty acids from adipose tissue to non-adipose tissue.

• steatosis: abnormal accumulation of fat in a cell leading to interrupted function or cell rupture

stages of NAFLD

1.) healthy liver

2.) NAFLD - large droplets of fat in liver tissue (reversible)

3.) non-alcoholic steatohepatitis (NASH)- asymptomatic. Fat in cells starts causing inflammation and death, as well as fibrosis (reversible)

4.) cirrhosis - scarring and dead cells all throughout the liver tissue (non-reversible)

alcohol related liver disease

• alcohol related hepatitis - acute and reversible

• alcohol related cirrhosis - permanent; 60% mortality at 4 years

cirrhosis

irreversible damage with widespread destruction of hepatocytes and presence of fibrosis or scarring

• steatosis and cellular injury lead to inflammation, fibrosis, and scarring. These changes will cause an impaired hepatic function.

portal hypertension

elevated pressure in the portal vein (due to increased scarring or fibrosis from cirrhosis) causes a backup of blood from the GI tract. This blood must return to the heart, so it creates alternate pathways through the development of collateral circulation. These new vessels are called varices, and they are fragile and prone to rupture.

• varices

• caput medusa - vessels become visible on abdomen

• hepatomegaly

• splenomegaly - leads to impaired spleen function

• ascites

• peripheral edema

ascites

peritoneal effusion

hepatomegaly

enlargement of the liver beyond its normal size. caused by inflammation or congestion

how do lab levels change with liver dysfunction?

1.) ammonia levels rise (leading to hepatic encephalopathy - alteration in mental status and cognitive function in presence of liver failure)

2.) albumin levels decrease leading to fluid shifts

3.) increased bile salts

4.) decreased coagulation factors

5.) elevated bilirubin levels (hyperbilirubinemia and jaundice)

6.) Alaine transaminase (ALT) - normal 5-40 units/mL but elevated in liver disease. An LFT (liver enzyme) that is a marker for hepatocellular injury.

7.) Aspartate transaminase (AST) - normal 5-35 units/mL but elevated in liver disease. An LFT that is a marker for hepatocellular injury.

8.) Alkaline phosphatase (ALP) - normal 35-150 units/mL but elevated in liver disease. An LFT that is a marker for hepatocellular injury.

spontaneous bacterial peritonitis

bacterial infection of the peritoneal cavity related to cirrhosis. GI flora travel outside of intestine to ascitic fluid (because of fluid shifts)

biliary cholangitis

An autoimmune disease causeing destruction of bile ducts leading to cirrhosis

cholelithiasis

presence of gallstones in the gallbladder

1.) biliary sludge - highly concentrated bile

2.) biliary stasis - delayed emptying of gallbladder

3.) gallstone (calculi) formation

calculous cholecystitis

inflammation of the gallbladder plus stones

• acalculous cholecystitis - inflammation without stones

• manifests: right upper quadrant pain, nausea and vomiting, heartburn, fullness after eating, fever, murphy’s sign (pain with abrupt inspiration during palpation)

choledocholithiasis

gallstones lodged in the common bile duct causing bile to back up into liver. Causes increased bilirubin and bile salts leading to jaundice and pruritis

cholangiocarcinoma

cancer of the gallbladder and/or biliary tract. Metastasis is rapid, and signs often are delayed, appearing in late stages.

acute pancreatitis

inflammatory disease of the pancreas

• caused by many things. obstruction (obstruction causes a backup of digestive enzymes and begins autodigestion), alcohol (ethanol triggers the accumulation of enzymes, their premature trigger, and autodigestion), autoimmune disease, hypothermia, pregnancy, scorpion venom (?), ERCP, splenic artery emboli, and unknown causes

• nausea, vomiting, epigastric pain, diarrhea, pyrexia tachycardia

• cullen’s sign - dark blue/purple periumbilical discoloration

• grey turner sign - dark blue/purple flank discoloration

chronic pancreatitis

chronic inflammation and fibrosis of the pancreas

pancreatic cancer

high mortality rate due to a late display of symptoms, during which the disease has already progressed quite far.