Untitled Flashcards Set

Hepatic, Pancreatic, & Biliary Systems

Signs & Symptoms of Hepatic Disease:

• Dark urine and light stools

• Skin changes: 

  • Jaundice

  • Pallor

  •  Orange or green skin

• Spider angiomas

• Neurologic symptoms, asterixis

• Musculoskeletal pain, hepatic osteodystrophy

• Portal hypertension, ascites, hepatic encephalopathy

Liver Disease Complications

Jaundice (Icterus)

• Common symptom

• Yellow discoloration of skin, sclera, mucous membranes

• Due to overproduction of bilirubin, liver disease, or bile obstruction

Cirrhosis

• Final common pathway of chronic, progressive

• inflammation of the liver. 

•  Progressive loss of normal tissue that is replaced with fibrosis and nodular regeneration. 

•  Most common in the US: alcohol abuse and hepatitis C virus (HCV)

• If developed, usually not reversible

• Signs & Symptoms: 

  •  Fatigue 

  • Weight loss 

  • Jaundice 

  • Coagulopathies 

  •  Loss of ability to metabolize drugs 

  •  Hypoalbuminemia

Portal Hypertension

• Increased hepatic sinusoidal pressure (>6mmHg)

• Portal: area where blood vessels enter into the liver.

• Common cause: cirrhosis

• Other causes:

  •  Thrombus 

  • Tumor 

  • Infection

• Complications: gastroesophageal varices

Hepatic Encephalopathy

• Also known as portosystemic encephalopathy

• Complex neuropsychiatric syndrome

• Potentially reversible, decreased level of consciousness in people with severe liver disease.

• Can occur with both acute and chronic liver disease.

• Clinical Manifestations:

  • Insidious onset

  • Mild changes in ability to concentrate and complete complex tasks

  • Progresses: mental status changes become more obvious

• Pathogenesis:

  • Involves increased levels of ammonia and inflammation

Grades of Hepatic Encephalopathy

• Grade 0

  • Nearly asymptomatic, normal level of consciousness.

  • No detectable personality or behavior changes.

  • Minimal changes in memory and concentration (e.g., mildly forgetful or confused).

  • Minimal changes in intellectual function.

• Grade 1

  • Slight personality changes, mood swings (irritability, restlessness).

  • Short attention span, mild confusion.

  • Minimal changes in memory and concentration.

  • Muscular incoordination, impaired handwriting.

  • Sleep disorders (inverted sleep patterns).

  • Tremor; asterixis may be observed with clinical testing.

• Grade 2

  • Tremor progresses to asterixis (liver flap).

  • Resistance to passive movement.

  • Bilateral numbness/tingling.

  • Myoclonus; hypoactive deep tendon reflexes.

  • Apraxia, ataxia.

  • Slow or slurred speech.

  • Unusual behavior (abusive, violent, noisy).

  • Disorientation to time and place.

• Grade 3
  
  

  • Hyperventilation.

  • Marked confusion, amnesia.

  • Incoherent speech.

  • Muscle rigidity.

  • Hyperreactive deep tendon reflexes.

  • Positive Babinski sign.

  • Positive Oculocephalic reflex (doll’s eye).

  • Sleeps most of the time but can be aroused.

  • Disinhibited (inappropriate) behavior.

  • Dilated pupils.

• Grade 4

  • Comatose; unresponsive to verbal or noxious stimuli.

  • No asterixis.

  • Lack of response to stimuli.

  • Decerebrate posturing.

Ascites

• Abnormal accumulation of fluid within the peritoneal cavity.

• Most often caused by decompensated liver cirrhosis

• Mechanism: portal hypertension

Hepatorenal Syndrome

• Severe complication of advanced cirrhosis

• Result of hemodynamics

• Two types:

  • Type 1 rapid (1-2 weeks)

    • Both in onset and progression to renal failure

    • Carries a poor short-term prognosis

  • Type 2

    • More insidious in onset with slower progression over months

    • Key features: ascites

HEPATITIS

Chronic Hepatitis

• Classified as either chronic persistent hepatitis or chronic active hepatitis

• Causes:

  • Viruses

  • Medications

  • Metabolic abnormalities

  • Autoimmune disorders

• Asymptomatic

  • If symptoms occur:

    • Nonspecific and mild

    • Fatigue

    • Malaise

    • Loss of appetite

    • Polyarthralgia

    • Intermittent right upper quadrant discomfort

    • Sleep disturbances

• Symptoms of advanced disease:

  • Acute exacerbation

  • Nausea

  • Poor appetite

  • Weight loss

  • Muscle weakness

  • Itching

  • Dark urine

  • Jaundice

• Diagnosis:

  • Serologic testing

  • Liver biopsy

Fulminant Hepatitis 

(Acute Liver Failure)

• Rapidly progressing form of liver inflammation without prior liver disease or cirrhosis.

• Develops in 1 to 2 weeks

• Rare; 1% of persons with acute viral hepatitis

• Causes:

  • Acetaminophen hepatotoxicity (50%)

  • Idiosyncratic drug reaction

  • Infections:

    • Hepatitis A and B

    • Epstein-Barr

    • Cytomegalovirus

    • Varicella-zoster

    • Herpes simplex virus

    • Hepatic ischemia

Viral Hepatitis

• Incubation period:

  • HAV: 15 to 50 days

  • HBV: 1 to 6 months

  • HCV: 1 week to 6 months

• HAV (Hepatitis A Virus)

  • Formerly known as infectious hepatitis

  • Transmitted by fecal-oral route

  • Primarily from poor or improper handwashing and hygiene

  • Shared use of oral utensils such as straws, silverwares, and toothbrushes

  • Commonly affects children, sexual activities with the same gender, people who live or travel in underdeveloped countries

  • Rarely transmitted through transfused blood

  • Highly contagious

  • Greatest danger of infection: incubation period, when a person is unaware that the virus is present

  • Illness can last from 4 to 8 weeks

  • Last longer and more severe in persons older than 50 years

• HBV (Hepatitis B Virus)

  • Transmitted percutaneously or mucosal contact

  • Highly infectious (100 times infectious than HIV)

  • Can be transmitted through heterosexual or homosexual intercourse (considered to be a sexually transmitted disease)

• HCV (Hepatitis C Virus)

  • Formerly posttransfusion non-A, non-B hepatitis

  • Most commonly associated with injection-drug use

  • Period of infectivity: before the onset of symptoms

  • May become a lifetime carrier of the virus

• HDV (Hepatitis D Virus)

  • "Delta virus"

  • Defective single-stranded RNA that presents as a coinfection or superinfection of HBV

  • Requires hepatitis B surface antigen (HBsAg) for its replication

  • Symptoms are similar to those who have HBV

• HEV (Hepatitis E Virus)

  • Previously known as enteric non-A, non-B hepatitis

  • Transmitted by contaminated water via fecal-oral route

  • Clinically resembles HAV

  • Travel-associated, acute, self-limiting liver disease

  • Occurs in poor socioeconomic conditions

• HGV (Hepatitis G Virus)

  • Accepted term: GBV-A and GBV-B

  • GBV-B:

    • Most prevalent in African countries

    • Identified as the causative agent of approximately 20% of posttransfusion hepatitis cases

Clinical Manifestations

• Most acute viral hepatitis are asymptomatic

• Classic symptoms:

  • Malaise

  • Fatigue

  • Mild fever

  • Nausea

  • Vomiting

  • Anorexia

  • Right upper quadrant discomfort

  • Diarrhea

  • Jaundice (except acute HCV)

  • Dark urine

  • Clay-colored stools

  • Extrahepatic manifestations

Medical Management

• Prevention (primary, secondary, tertiary)

• Primary: Education, practicing protective sex or avoiding sexual contact during the period of HBsAg

• Secondary: Passive immunization, travel precautions

• Tertiary: Education to those infected

• Diagnosis: Serology (standard)

PANCREAS

Pancreatitis

• Serious inflammation of the pancreas

• Acute Pancreatitis

  • Most common cause: gallstones

  • Symptoms: Pain, nausea, anorexia, vomiting

  • Complications: Pancreatic fluid-filled collections, pseudocysts, necrosis

Chronic Pancreatitis

• Cause: Chronic alcohol consumption

• Symptoms: Abdominal pain, decreased appetite, weight loss

Biliary Disorders (Gallbladder & Bile Ducts)

Cholelithiasis (Gallstone Disease)

• Common: 20-35% of people by age 55

• Types:

  • Cholesterol stones (80%)

  • Bilirubin salts (20%)

• Risk Factors: Obesity, pregnancy, women > men

• Symptoms:

  • Pain (RUQ, radiates to right shoulder/back)

  • Nausea, vomiting, belching, food intolerance

• Complications:

  • Choledocholithiasis: gallstones in the common bile duct

  • Pancreatitis, cholangitis

Cholecystitis

• Inflammation of the gallbladder (gallstone obstruction)

• Acute Cholecystitis: more common in older men

Acute Cholangitis

• Biliary tree infection

• Stages:

  • Mild (Grade I): responds to therapy

  • Moderate (Grade II): needs further treatment

  • Severe (Grade III): organ dysfunction

• Symptoms:

  • Charcot’s Triad: fever, jaundice, right upper quadrant pain

  • Reynold’s Pentad: Charcot’s Triad + hypotension, confusion

Primary Sclerosing Cholangitis

• Progressive bile duct destruction (intrahepatic & extrahepatic)

• Common in ages 20-40, often asymptomatic

• Symptoms: jaundice, itching, fatigue, anorexia, weight loss

• Severe complications: Cirrhosis, portal hypertension

Key Takeaways

• Liver diseases involve metabolic dysfunction, jaundice, and severe complications like cirrhosis, portal hypertension, hepatic encephalopathy.

• Hepatitis can be viral, autoimmune, or drug-induced, with HAV, HBV, HCV being the most common.

• Pancreatic diseases include pancreatitis, which is often alcohol- or gallstone-related.

• Biliary diseases involve gallstones, cholecystitis, cholangitis, and progressive bile duct damage (sclerosing cholangitis).