SysPath: Digestive 4 - Liver, Gallbladder, Pancreas

Alcoholic Hepatitis

• Liver inflammation is due to excessive alcohol consumption over an extended period.
• Alcohol is toxic to hepatocytes, damaging the liver and causing inflammation.
• Mild liver damage from alcohol consumption can heal.
• Excessive and prolonged alcohol consumption hinders liver regeneration.
• Females consuming high amounts of alcohol are more at risk of developing alcoholic hepatitis than males.
• One drink equals 14g of pure alcohol
• Consume up to 3 standard drinks per week is considered a moderate amount.
• Heavy drinkers can develop early symptoms in their 30s, leading to severe problems by their 40s.
• Canada's alcohol uptake recommendations have been recently changed to 2 drinks per week.
• It typically affects individuals between 30-50 years old; most patients presenting are under 60 years old.
• It is characterized by a history of daily heavy alcohol use, more than 100g daily, for over 20 years.
• Histological examination reveals a fatty liver or steatosis.
• It is characterized by a fatty appearance of hepatocytes due to focal necrosis of cells.
• Alcoholic hepatitis can be reversed with alcohol cessation.
• Signs and symptoms include anorexia, jaundice, right upper quadrant or epigastric abdominal pain, ascites, and tender hepatomegaly.
• The only effective treatment is alcohol cessation, potentially involving formal recovery programs.
• A liver transplant may be necessary in some cases.
• Alcohol cessation can lead to semi-reversible damage without further damage.
• Continued alcohol use can lead to cirrhosis, liver failure, and possibly liver cancer.
• Combined with systemic damage, such as nervous system encephalopathy, cardiovascular system alcoholic cardiomyopathy, or urinary system renal failure, alcoholic hepatitis is fatal.
• The appropriateness of massage is determined based on the patient's symptoms.
• There are no general contraindications for massage with alcoholic hepatitis.

Chronic Hepatitis

• Chronic hepatitis is defined as inflammation of the liver lasting longer than 6 months.
• The most common causes are hepatitis B and C viruses and certain medications.
• Hepatitis C accounts for 60-70% of chronic hepatitis cases, with about 75% of Hep C cases becoming chronic.
• Approximately 5-7% of Hep B cases become chronic.
• Hepatitis A and E usually do not become chronic.
• The overuse of drugs like Tylenol and alcoholic hepatitis can lead to chronic hepatitis.
• Metabolic Dysfunction-Associated Steatotic Liver Disease MASLD can lead to chronic hepatitis.
• Symptoms are usually mild, with no significant liver damage for years.
• Some individuals experience low-grade fever and right upper quadrant discomfort.
• Jaundice is rare and typically appears much later in the disease.
• Continued inflammation can lead to cirrhosis, liver failure, and/or liver cancer.
• Cirrhosis can lead to portal hypertension, causing splenomegaly due to increased venous pressure.
• Ascites fluid accumulation in the abdominal cavity can occur due to portal hypertension.
• Other complications include spider angioma, caput medusae, palmar erythema, deterioration of the peripheral nervous system, and brain function due to demyelination.
• Increased serum toxins can cause hepatic encephalopathy.
• Hepatitis C is the most common cause of cirrhosis.
• For most people, it doesn't progress for years.
• Certain hepatitis viral strains cause gradually worsening symptoms where the outlook depends on the cause.
• Chronic hep C leads to cirrhosis in 15-25% of those infected.
• Chronic co-infection with hep B and D cause cirrhosis in 70% of cases.
• Hepatitis caused by drugs may resolve completely if the drug is stopped.
• Hepatitis is suspected in individuals with typical symptoms, abnormal liver function tests, or a history of hepatitis.
• Lab work helps determine the severity and cause where biopsy is essential for definitive diagnosis.
• Biopsy also confirms the severity of the disease process and the cause.
• Those with chronic hep B require an annual ultrasound and blood work to screen for liver cancer.
• Hep C patients are only screened if it has turned to cirrhosis.
• Treatment involves eliminating noxious substances and treating the cause.
• Antiviral drugs, PO or SQ medications, are given to those with chronic, progressive hep B and C.
• SQ injections are most effective for hep C and stopping inflammation.
• After 6-12 months, 45-75% of cases improve with no further issue.
• Chronic hep B only 5% of cases tends to recur once drug therapy ends.
• Antiviral treatment may be indefinite.
• Family members and close contacts of those with hep B should receive a vaccine and immunoglobulin.
• Corticosteroids can also be used as a treatment.
• Advanced disease may require a liver transplant.
• The appropriateness of massage is determined by the patient's symptoms.
• There are no general contraindications for massage with chronic hepatitis.

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)

• MASLD was previously called nonalcoholic fatty liver disease NAFLD.
• Is defined as steatosis in the absence of significant alcohol consumption.
• It is the most common cause of liver disease in the US.
• An estimated 25% of adults worldwide have NAFLD.
• Can be categorized as simple hepatic steatosis (NAFLD), which has little clinical relevance.
• Can also be categorized as MASH Metabolic dysfunction-associated steatohepatitis, formerly known as non-alcoholic steatohepatitis NASH.
• MASH progresses to cirrhosis in 10 – 20% of cases.

Metabolic Dysfunction-Associated Steatohepatitis (MASH)

• Pathologic findings include initially hepatocyte ballooning, lobular inflammation, and steatosis.
• Progressive disease leads to more fibrosis, eventually progressing to cirrhosis.
• Strongly associated with obesity and metabolic syndrome.
• Pathophysiology follows a "two-hit" model, involving hepatic fat accumulation and increased oxidative stress.
• Free radicals cause lipid peroxidation of the accumulated intracellular fat.
• Signs and symptoms for MASH is that its usually asymptomatic until Overt hepatic failure.
• Clinical findings are usually due to atherosclerotic disease/diabetes that accompany NASH.
• Fatigue and right-sided abdominal pain can occur in some, though.
• Cardiovascular disease is a frequent cause of death in those with NASH.
• There is also an increased risk of hepatocellular carcinoma.
• Treatment includes losing weight and medication to reduce cholesterol or triglycerides.
• Medications to reduce blood pressure and control diabetes are also used.
• Limiting OTC drugs and avoiding alcohol are important as treatment of MASH.
• Appropriateness of massage is determined by patient's symptoms, and also has no general contraindications.

Hepatocellular Carcinoma (HCC)

• Also known as hepatoma, HCC is the most common primary liver tumor, most commonly caused by cirrhosis.
• It usually presents with vague signs of abdominal pain, fatigue, loss of weight, and appetite.
• Diagnosis often occurs late stage, leading to a poor prognosis.
• Early signs include abdominal pain, fever, weight loss, and a palpable mass in the right upper quadrant RUQ.
• Patients with cirrhosis may have an unexpected increase in illness.
• Rupture of the tumor can cause sudden abdominal pain and shock.
• Diagnosis starts with blood tests and physical examination checking for a palpable liver mass.
• Advanced imaging, such as ultrasound US, CT, or MRI, is used for diagnosis.
• Biopsy is performed to confirm unclear cases.
• Prevention includes hepatitis B vaccination, treatment of chronic hepatitis C, alcoholism treatment and cessation programs, and screening for earlier diagnosis.
• Treatment involves chemotherapy, radiation, tumor embolization and surgical resection, which has a high rate of recurrence.
• Liver transplant can be performed if there is no metastasis.
• Prognosis depends on how vague the symptoms are, causing late-stage diagnosis with a poor prognosis.
• The 5-year survival rate is approximately 18%.
• Other primary liver tumors are rare and have a poor prognosis.
• Metastatic disease is far more common than primary liver cancer.
• Metastatic disease commonly originates from the breast, colon, kidney, lung, stomach, pancreas, ovaries, or uterus.
• The appropriateness of massage is determined by considering patient's symptoms, where there are no general contraindications to consider.

Cholelithiasis

• Chole means bile or gall, and lithiasis = stones
• It is collections of solid material in the gallbladder.
• Stones can be dislodged and get stuck in the cystic duct, common bile duct, hepatopancreatic ampulla.
• More common in Indigenous and Hispanic populations, where, in Canada, 70-80 percent of the First Nations population is affected.
• More common in females than males.
• Gallstones occur in up to 20 per cent of Canadian women and 10 per cent of men by the age of 60.
• Risk is used formerly to describe patient: “Four F's" of gallstones: female, forty, overweight, and fertile.
• Other risk factors: SAD diet, family Hx.
• There are two main types of stones: cholesterol stones and pigment stones.
• Most common are cholesterol stones.
• Cholesterol is a lipid that is created in liver and dissolves in bile, where if the liver secretes excess and bile becomes oversaturated and crystals can form.
• Excess hemolysis can form pigment stones with bilirubin.
• 80% have no symptoms, and the gallstones remain in the gallbladder.
• When a stone passes from the gallbladder into the cystic duct, common bile duct, and/or hepatopancreatic ampulla, the gallbladder swells, causing colicky RUQ pain.
• This pain is diffuse and hard to localize, usually in the RUQ or epigastric region, and can radiate to the right shoulder or between the scapulae.
• Pain increases over 15 minutes, then plateaus to 30-60 minutes.
• Most episodes last less than 6 hours but can last up to 12 hours.
• It is usually severe enough to have to go to the ER where complications can lead to cholecystitis.
• It is diagnosed using abdominal ultrasound.
• No treatment is required if there are no symptoms.
• If there are early episodes with symptoms, the doctor will watch and wait.
• Disruptive, recurring episodes usually result in laparoscopic cholecystectomy.
• There is usually little to no affect on digestion and may increase transit time of bowel.
• A low-fat diet can reduce strain on the gallbladder.
• Some evidence suggests extremely low-fat diets may increase gallstone formation.
• There are no absolute contraindications for patients that currently have or have had cholelithiasis.
• However, if symptoms of obstruction are present N/V, colicky RUQ pain, then massage is contraindicated.

Cholecystitis

• An inflammation of the gallbladder typically occurs in those with a history of symptomatic gallstones.
• This is often accompanied by a blockage of the cystic duct by gallstones, causing inflammation of the gallbladder.
• It can be acute or chronic.
• Secondary to gallstones is the most common.
• Other causes are include tumors, certain viral infections.

Acute Cholecystitis

• Sudden, severe, steady pain in the RUQ.
• The most common cause is Gallstones (95%).
• Alcalculous cholecystitis is rare but more serious and relates to major surgery, severe burns, sepsis, prolonged parenteral nutrition, prolonged fasting.
• The gallbladder fills with fluid, and the walls thicken.
• It can occur in children and adults.

Chronic Cholecystitis

• Chronic inflammation of the gallbladder w/ repeated attacks of biliary colic.
• The most common cause is gallstones.
• The gallbladder becomes thick-walled, scarred, and small and contains sludge and/or stones that block the opening to the cystic duct or the duct itself.
• RUQ colicky pain lasts 6-12 hours or more and is quite severe where the pain peaks at 15-60 minutes and remains constant.
• It can spread to the right shoulder or between the scapulae, and and the pain is increased with deep breaths.
• Other sings and symptoms include nausea and vomiting and a positive Murphy's sign.
• There may have abdominal rigidity and guarding.
• In acute cases, approximately 1/3 will have a fever of over 38°C and chills.
• (+) Murphy's sign is not diagnostic, but provides useful information for testing to firmly palpate the RUQ subcostal region, pushing under the ribs, and ask the patient to take a deep breath.
• A positive sign is when significant pain is elicited by this maneuver, usually stopping them mid-breath.
• US is best way to detect gallstones, fluid around GB, and thickening of GB walls.
• Hospitalization is likely where Intravenous IV fluids are given while your digestive system rests.
• IV antibiotics are given to treat or prevent infections, and analgesics are given to help with pain.
• Definitive treatment for both acute and chronic cholecystitis is cholecystectomy.
• Massage is an absolute contraindication for acute cholecystitis and severe chronic cholecystitis.

Primary Biliary Cholangitis

• Previously known as primary biliary cirrhosis.
• It is an autoimmune disease causing inflammation and destruction of the bile ducts in the liver.
• Incidence rates range from 0.33 to 5.8 per 100,000 inhabitants/year.
• Women are predominantly affected with a sex ratio of 9:1.
• Onset is generally in the 4th to 6th decades of life.
• It is believed to be a combination of genetic and environmental factors that triggers the disease.
• More than half of people diagnosed with PBC are asymptomatic at the time where the findings are incidental on blood tests.
• Symptoms eventually develop over the next 5 to 20 years and include fatigue, itchy skin, jaundice, RUQ pain, edema.
• Complications can include cirrhosis.
• Diagnosed through LFTS, antibody serology, blood tests for anti-mitochondrial antibodies AMA, which are very common in PBC.
• Imaging shows Ultrasound and special type of MRI to view structure of bile ducts and liver biopsy.
• Some treatments can help slow the progression of the disease such as Ursodeoxycholic acid UDCA or ursodiol which helps move bile through the liver, improves liver function, and reduce liver scarring.
• There can also be symptomatic treatment of itching and fatigue antihistamines where a liver transplant may be necessary.
• Prognosis is that once SSx develop, the average life expectancy is about 10 years and successful liver transplants offer a 10-year survival rate of 65%.

Primary Sclerosing Cholangitis

• Inflammatory disease of the bile ducts, both intrahepatic and extrahepatic.
• Scarring of the ducts causes narrowing, which gradually causes serious liver damage.
• The cause is unclear but an immune system reaction to infection or toxin may be a trigger in people who are genetically predisposed to it where a large proportion also have IBD.
• It is a fairly rare disease with an estimated incidence of 1 per 100,000 per year within Europe and NA.
• Can occur at any age, with a median age of diagnosis of 41.
• More common in males than females.
• Early signs and symptoms include fatigue, itching, jaundice, and RUQ pain.
• Complications include cirrhosis and liver failure.
• Diagnosed through LFTS, imaging through Ultrasound, also a special type of MRI to view the structure of bile ducts, and liver biopsy.
• There is also symptomatic treatment of itching and fatigue antihistamines, and liver transplant may be necessary.
• Once SSx develop, the average life expectancy is between 10 and 20 years where successful liver transplants can lengthen life expectancy.
• Ursodeoxycholic acid UDCA or ursodiol helps move bile through your liver and improves liver function and reduce liver scarring,
• PSC can return in 15/20% of patients post-transplant.

Pancreatitis

• Inflammation of the pancreas that can be mild or life threatening.
• Causes the activation and possible release of enzymes that begin digesting and attacking the pancreas, and possibly other tissues if they enter the bloodstream.
• May be acute or chronic.
• The most common causes of pancreatitis are alcoholism chronic pancreatitis. In acute Pancreatitis, gallstones are the most common cause.
• Alcohol is linked to 80% of pancreatitis cases.
• Smoking has also been linked to chronic pancreatitis.

Acute Pancreatitis

• The most common cause is gallstones.
• Think of acute pancreatitis as an event.
• Acute attacks often precipitated by alcoholic binge, smoking, or excessively large meal.
• More common in females than males.

Chronic Pancreatitis

• The most common cause is alcohol.
• Think of chronic pancreatitis as an ongoing process of pathologic response to pancreatic injury.
• More common in males than females.
• Signs and symptoms include severe epigastric and LUQ pain that often radiates to the back due to Gallstones where pain starts suddenly and reaches max intensity in 10-20 minutes, with an acute onset of persistent, severe LUQ.
• With alcohol, pain onset is less abrupt and is poorly localized.
• Aggravating factors include coughing, deep breathing, and vigorous movement with partial relief by sitting up or bending forward.
• 90% have nausea/vomiting which may persist for several hours.
• Tenderness of epigastrium results in severity of pain depends on severity of pancreatitis.
• Diagnose with characteristic pain leads pancreatitis suspicion in acute onset of persistent, severe, epigastric pain with tenderness on palpation on PE.
• Hypoactive bowel sounds due to inflammation as well as abdominal distention.
• Scleral icterus IF obstructive jaundice present.
• About 3% of patients with acute pancreatitis exhibiting bruising along the flank, may be exhibited Grey Turner Sign due to retroperitoneal bleeding.
• Blood tests support diagnosis of increasing serum lipase and amylase (3x), leukocytosis.
• With the use of US, the pancreas may appear diffusely enlarged, gallstones may be visualized.
• Treatment whether mild or severe, usually requires hospitalization.
• For chronic pancreatitis, analgesics and antioxidants (E, C, selenium, methionine) aids in pain control by pancreatic enzyme supplementation.
• For acute pancreatitis, fasting, IV fluids, analgesics, and antiemetics where the patient can resume normal eating within 2-3 days without further Tx.
• PrognosisIn most patients with acute pancreatitis, the disease is mild in severity and patients recover in 3-5 days without complications or organ failure
• Recurring attacks of pancreatitis turns to chronic pancreatitis.
• Massage with acute pancreatitis is an ABSOLUTE CONTRAINDICATION since this is a medical emergency that requires treatment.
• Treatment for chronic pancreatitis massage may be a possible LOCAL CONTRAINDICATION where abdominal massage should be avoided if pressure produces pain or discomfort.

Carcinoma of the Pancreas

• Malignant tumors of the pancreas
• About 95% of malignant tumors of the pancreas are adenocarcinomas and most commonly near pancreatic head.
• Is ranked as the 11th most common cancer in Canada, and 4th leading causing of deat
• More common amongst people > 45 years old, or slightly more common in males than females
• Common causes are smoking, chronic pancreatitis, DMII, obesity with some hereditary predisposition for cystic fibrosis, FHx of pancreatic CA
• Abdominal pain is insidious in onset, gnawing in quality, and generally epigastric with signs and symptoms and is frequently worse at night, worse after eating, worse laying supine.
• Another sign is jaundice from blocked duct resulting in jaundice and pruritits and can cause weight loss and pressure on pylorus of stomach resulting in vomiting, leading to the obstruction of the small intestine
• Early Dx is difficult due to lack of SSx where PE and blood work often shows WNL
• Bloodwork is done to evaluate for cholestasis and/or acute pancreatitis.
• CT is perferred initial imaging test, where US and MRI are sometimes used, and if pancreatic mass is seen on one of the procedures, next step is a CT Procedure
• Biopsy can be done for confirmation where late diagnosis is common and metastasis is present in 90 % of cases, resulting in a five year survival rate of 7%
• Pancreaticoduodenectomy Whipple procedure and in those w/o metastisis removes the head of the pancreas, the duodenum, gallbladder and bile duct; this has a 5 year survival being about 20% with 40%if no lymphnode involvement, chemotherapy and radiation are mostly palliative.
• No contraindications for massage.