Clinical Nutrition: Hepatobiliary, Pancreatic, Metabolic Stress, and Burn Pathophysiology

Comprehensive practice flashcards reviewing clinical terms, diagnostic criteria, nutritional interventions, and pathophysiological mechanisms across gallbladder disorders, pancreatic conditions, metabolic stress, thermal burn management, hepatic failure, and non-alcoholic fatty liver disease.

Cholelithiasis

The formation or presence of calculi (gallstones) within the gallbladder, which may be composed predominantly of cholesterol or pigment polymers.

Choledocholithiasis

The presence of gallstones lodged in the common bile duct, preventing bile flow into the duodenum and resulting in fat malabsorption, dark amber urine, and clay-colored or gray stools.

Cholecystitis

Acute or chronic inflammation of the gallbladder, with approximately $90\%$ of cases caused by gallstone obstruction of the cystic duct, and remaining cases linked to ischemia, bacterial infection, chemical irritation, prolonged fasting, or trauma.

Secondary Biliary Cirrhosis

A form of chronic liver damage and fibrosis that develops when chronic obstruction of the extrahepatic biliary ducts causes bile to back up into the liver parenchyma.

Cholangitis

Infection and inflammation of the bile duct system occurring secondary to biliary stasis and obstruction in the common bile duct.

Murphy's Sign

A clinical diagnostic sign of acute cholecystitis characterized by sudden transient arrest of deep inspiration while an examiner deeply palpates the right upper quadrant of the abdomen.

Ursodeoxycholic Acid (Ursodiol / Actigall)

An oral bile acid dissolution medication prescribed to slowly dissolve radiolucent, noncalcified cholesterol gallstones in surgical candidates at high surgical risk.

Methyl Tert-Butyl Ether

A contact dissolution agent injected directly into the lumen of the gallbladder via catheter to dissolve cholesterol gallstones within $1$ to $3\text{ days}$.

Extracorporeal Shockwave Lithotripsy (ESWL)

A non-invasive medical procedure using acoustical shock waves focused on the gallbladder or biliary tree to fragment calculi into micro-particles capable of spontaneous passage.

Cholescintigraphy (HIDA Scan)

A nuclear diagnostic imaging exam wherein an intravenously injected technetium-labeled radiotracer is extracted by the liver, excreted into bile, and imaged to assess gallbladder ejection fraction and ductal patency.

Laparoscopic vs. Open Cholecystectomy

Surgical procedures for removing the gallbladder; the minimally invasive laparoscopic approach uses small abdominal trocar punctures, whereas the open technique requires a subcostal laparotomy incision.

Unconjugated Hyperbilirubinemia

An elevation in serum indirect bilirubin where conjugated bilirubin accounts for less than $15-20\%$ of the total, commonly observed in neonatal jaundice, hemolytic anemias, and hepatic conjugation deficits.

Conjugated Hyperbilirubinemia

An elevation in serum direct bilirubin where conjugated forms exceed $50\%$ of total circulating bilirubin, signaling post-hepatic cholestasis, biliary duct obstruction, tumor, or scarring.

Islets of Langerhans

Microscopic endocrine clusters within the pancreas comprising alpha cells ($\text{glucagon}$), beta cells ($\text{insulin}$), delta cells ($\text{somatostatin}$), and F/gamma cells ($\text{pancreatic polypeptide}$).

Acinar Cells

The functional exocrine units of the pancreas organized around ductules that synthesize and secrete inactive digestive proenzymes (zymogens) including trypsinogen, amylase, and lipase.

Pancreatic Pseudocyst

A localized peripancreatic fluid collection encapsulated by fibrous granulation tissue rather than a true epithelial lining, developing secondary to ductal disruption and enzyme leakage during pancreatitis.

Ranson's Criteria

A clinical prognostic scoring tool utilizing $11$ objective clinical and laboratory variables measured at admission and during the subsequent $48\text{ hours}$ to predict severity and mortality in acute pancreatitis.

Atlanta Classification (Acute Pancreatitis)

A consensus system categorizing acute pancreatitis into Mild (no organ failure or complications), Moderate-Severe (transient organ failure resolving within $48\text{ hours}$), and Severe (persistent single- or multi-organ failure lasting $> 48\text{ hours}$).

Ligament of Treitz

A suspensory fibromuscular band at the duodenojejunal junction; infusing enteral nutrition distal to this anatomical landmark bypasses cephalic and gastric triggers, avoiding stimulation of pancreatic exocrine secretions.

Acute Necrotizing Hemorrhagic Pancreatitis

A life-threatening complication of acute pancreatitis marked by extensive parenchymal auto-digestion, tissue necrosis, retroperitoneal vascular erosion, and substantial mortality approaching $19-30\%$.

Pancreatic Enzyme Replacement Therapy (PERT)

Orally ingested microencapsulated pancrelipase formulations (containing lipase, protease, and amylase) taken with all meals and snacks to manage malabsorption in exocrine pancreatic insufficiency.

Azotorrhea

The excessive excretion of nitrogenous compounds and unabsorbed peptide products in the feces resulting from defective pancreatic proteolytic enzyme output.

Distal Pancreatectomy

A surgical resection removing the body and tail segments of the pancreas along with the spleen, commonly performed for benign or neuroendocrine lesions not involving the pancreatic head.

Total Pancreatectomy

Complete surgical extirpation of the pancreas, gallbladder, common bile duct, spleen, duodenum, and partial stomach, inducing absolute apancreatic diabetes and severe exocrine insufficiency.

Metabolic Stress

A hypermetabolic, catabolic systemic state triggered by severe injury, infection, surgery, or tissue necrosis, characterized by accelerated proteolysis, glycogen depletion, and altered neuroendocrine signaling.

Ebb Phase

The immediate hemodynamic instability phase following trauma lasting $2-48\text{ hours}$, characterized by hypovolemia, tissue hypoperfusion, depressed cardiac output, reduced body temperature, and decreased metabolic rate.

Flow Phase

The secondary post-resuscitation metabolic phase characterized by profound hypermetabolism, sustained proteolysis, elevated cardiac output, stress hyperglycemia, and increased energy expenditure.

Positive Acute-Phase Proteins

Hepatic plasma proteins whose synthesis increases in response to inflammatory cytokines ($\text{IL-1}$, $\text{IL-6}$, \text{TNF-\alpha}), including C-reactive protein, fibrinogen, haptoglobin, and serum amyloid A.

Negative Acute-Phase Proteins

Circulating transport proteins synthesized by the liver whose production is downregulated during inflammatory states due to hepatic reprioritization, notably albumin, prealbumin, and transferrin.

C-Reactive Protein (CRP)

A sensitive positive acute-phase reactant synthesized by hepatocytes that circulates at $< 1\,\text{mg/dL}$ under basal conditions and increases up to $1000\text{-fold}$ within $2\text{ hours}$ of acute injury or sepsis.

Systemic Inflammatory Response Syndrome (SIRS)

A widespread pro-inflammatory cascade defined by meeting two or more criteria: heart rate $> 90\,\text{bpm}$, respiratory rate $> 20\,\text{bpm}$ (or $\text{PaCO}_2 < 32\,\text{mm\,Hg}$), temperature $> 38\,^\circ\text{C}$ or $< 36\,^\circ\text{C}$, and WBC count $> 12{,}000/\text{mm}^3$, $< 4{,}000/\text{mm}^3$, or $> 10\%$ immature bands.

Sepsis

A life-threatening systemic organ dysfunction caused by a dysregulated, aberrant host inflammatory immune response to a proven or suspected infection (meeting SIRS criteria plus infection).

Septic Shock

A severe subclass of sepsis manifesting persistent arterial hypotension refractory to crystalloid fluid loading, profound cellular metabolic defects, and serum lactate concentrations exceeding $4\,\text{mmol/L}$.

Multiple Organ Dysfunction Syndrome (MODS / MOSF)

The progressive, sequential failure of two or more independent physiological organ systems in an acutely ill patient following prolonged SIRS, shock, sepsis, or multiple sequential traumatic hits.

Permissive Underfeeding

A deliberate hypocaloric, high-protein enteral nutrition strategy for critically ill obese patients providing $11-14\,\text{kcal/kg}$ actual weight ($22-25\,\text{kcal/kg}$ IBW) and $2.0-2.5\,\text{g protein/kg}$ IBW to minimize metabolic complications.

Cachexia

A complex metabolic wasting syndrome marked by involuntary loss of lean body mass and adipose tissue, driven by chronic cytokine excess and glucocorticoids, and resistant to standard nutritional support.

Superficial Dermal Burn

A partial-thickness burn injury limited to the papillary dermis, characterized by blister formation, intense pain, moist erythema, intact capillary blanching, and an edema layer lifting necrosis away from viable tissue.

Deep Dermal Burn

A burn destroying the majority of the dermal thickness down to the reticular layer, marked by a dry white-to-red surface, adherent necrotic zone, sluggish capillary refill, and a smaller edema margin.

Full Thickness Burn

A severe burn injury involving complete thermal destruction of both epidermis and the entire dermis into subcutaneous structures, producing an insensate, tough, avascular, leathery eschar.

Rule of Nines

A rapid anatomical estimation tool that quantifies the percentage of total body surface area ($\text{TBSA}$) burned by assigning sections of the adult body values of $9\%$ or multiples thereof.

Parkland Formula

A resuscitation formula estimating crystalloid infusion in burn patients during the initial $24\text{ hours}$: $\text{Fluid Volume} = 4\,\text{mL} \times \text{body weight (kg)} \times \%\text{TBSA burned}$, giving $50\%$ in the first $8\text{ hours}$ and $50\%$ over the next $16\text{ hours}$.

Curling's Ulcer

An acute stress erosion or ulceration of the gastric or duodenal mucosa caused by severe hypovolemic hypotension, tissue ischemia, and mucosal necrosis following major burn trauma.

Escharotomy

A surgical longitudinal incisional release through inelastic, full-thickness burn eschar down to subcutaneous fat, performed to decompress underlying edema and restore compromised distal or ventilatory blood flow.

Fasciotomy

A surgical incision extending through skin, subcutaneous tissue, and the deep fibrous muscular fascia, performed to relieve elevated intracompartmental pressures caused by deep tissue injury or high-voltage burns.

Compartment Syndrome

An elevation of interstitial pressure within an inelastic fascial compartment that impairs capillary microcirculation and induces tissue ischemia, identified by the 7 Ps (Pain, Pallor, Pulselessness, Pressure, Poikilothermia, Paresthesia, and Progression).

Nitrogen Balance

A laboratory assessment measuring net whole-body protein equilibrium, calculated by subtracting total nitrogen excretion ($\text{TUN}$ or calculated from $\text{UUN}$ plus skin and stool allowances) from total dietary nitrogen intake.

Curreri Formula

An empirical equation used to estimate peak caloric requirements in thermal injury: $\text{Total Energy (kcal/day)} = (25 \times \text{weight in kg}) + (40 \times \%\text{TBSA burned})$.

Kupffer Cells

Specialized resident hepatic macrophages positioned within the sinusoidal lumen that clear particulates, endotoxins, circulating antigens, and senescent erythrocytes from portal venous inflow via phagocytosis.

Fulminant Hepatitis

A clinical syndrome characterized by sudden, severe, and massive hepatic parenchymal destruction, rapid development of encephalopathy, coagulopathy, and severe jaundice within $2-8\text{ weeks}$ of onset in individuals without prior cirrhosis.

Cirrhosis

The histopathologic end stage of chronic hepatic injury defined by diffuse fibrous septa formation, structural vascular distortion, and regenerative parenchymal nodules replacing functional liver architecture.

Wilson's Disease (Hepatolenticular Degeneration)

An inherited autosomal recessive metabolic disorder of copper excretion into bile, producing toxic copper accumulation in hepatocytes, basal ganglia, and the corneas.

Kayser-Fleischer Rings

Pathognomonic greenish-gold or bronze pigmented copper rings in Descemet's membrane at the outer limbus of the cornea, visible in Wilson's disease.

Hemochromatosis

An inborn iron-storage disease characterized by inappropriately increased intestinal iron absorption, leading to progressive parenchymal iron deposition, hepatomegaly, bronze skin pigmentation, diabetes, and heart failure.

Portal Hypertension

Sustained elevation of pressure within the hepatic portal venous system resulting from architectural scarring that increases sinusoidal vascular resistance to portal blood flow.

Esophageal Varices

Pathologically dilated, fragile submucosal portosystemic collateral veins that form in the lower esophagus and gastric cardia secondary to portal hypertension, susceptible to life-threatening rupture and hematemesis.

Ascites

The pathological collection of free fluid inside the peritoneal cavity, driven by portal hypertension, hypoalbuminemia with diminished plasma oncotic pressure, and secondary renal sodium and water retention.

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

An angiographically placed expandable metal stent deployed between an intrahepatic branch of the portal vein and a hepatic vein to bypass sinusoidal resistance and decompress portal venous hypertension.

Paracentesis

The bedside needle drainage of peritoneal ascitic fluid, requiring adjunctive intravenous albumin replacement when fluid evacuation exceeds $6\,\text{L}$ to prevent circulatory dysfunction.

Hepatic Encephalopathy (HE)

A spectrum of reversible neurocognitive abnormalities seen in advanced liver failure, caused by failure of hepatic detoxification of gut-derived neurotoxins (chiefly ammonia) and characterized by confusion, asterixis, and coma.

Asterixis

An involuntary, non-rhythmic, bilateral flapping tremor of the wrist seen upon sustained dorsiflexion of the hands, pathognomonic of Stage 2 and 3 hepatic encephalopathy.

Fetor Hepaticus

A distinctive sweet, musty, or sulfurous odor on the breath of individuals with advanced hepatic failure, caused by volatile mercaptans bypassing hepatic clearance.

Wernicke-Korsakoff Syndrome

A neurological condition caused by thiamin ($\text{Vitamin B}_1$) deficiency, presenting as acute encephalopathy (confusion, ataxia, ophthalmoplegia) and progressing to chronic anterograde and retrograde amnesia with confabulation.

Child-Turcotte-Pugh (CTP) Score

A clinical scoring system categorizing cirrhotic prognosis and surgical risk into classes A, B, and C based on serum albumin, total bilirubin, prothrombin time/INR, ascites, and degree of encephalopathy.

Model for End-Stage Liver Disease (MELD)

A validated statistical scoring algorithm based on serum bilirubin, serum creatinine, and INR utilized to predict $3\text{-month}$ mortality and prioritize candidates on organ allocation waitlists for liver transplantation.

Lactulose

A non-absorbable synthetic disaccharide that acidifies colonic contents to trap unionized ammonia ($\text{NH}_3$) as ammonium ions ($\text{NH}_4^+$) and produces an osmotic laxative effect to treat hepatic encephalopathy.

Non-Alcoholic Fatty Liver Disease (NAFLD)

A spectrum of hepatic pathology not attributable to alcohol abuse, characterized by macrovesicular steatosis with variable progression to non-alcoholic steatohepatitis (NASH), fibrosis, and cirrhosis.

Non-Alcoholic Steatohepatitis (NASH)

A progressive subset of NAFLD marked histologically by hepatic steatosis combined with lobular inflammation, hepatocellular ballooning injury, oxidative stress, and collagenous fibrogenesis.

Hepatic Steatosis Grading

A histological staging system quantifying intrahepatic fat accumulation: Grade $0$ ($< 5\%$ hepatocytes affected), Grade $1$ ($< 33\%$), Grade $2$ ($> 33\%$), and Grade $3$ ($> 66\%$).

Two-Hit Hypothesis (Fatty Liver Disease)

A pathogenic model wherein the first hit consists of insulin resistance and intrahepatic triglyceride accumulation, followed by secondary hits involving oxidative stress, mitochondrial injury, lipid peroxidation, and pro-inflammatory cytokines.

High-Fructose Corn Syrup (HFCS)

An industrial caloric sweetening agent that bypasses regulatory steps of glycolysis in hepatocytes, accelerating de novo lipogenesis, elevating intrahepatic triglycerides, and worsening insulin resistance in NAFLD.