Patho - Pancreatic & Hepatobiliary Disorders PDF

‭CHAPTER 43: DISORDERS OF THE EXOCRINE PANCREATIC AND HEPATOBILIARY SYSTEMS‬ ‭Accessory organs of the GI tract include:‬ ‭Liver‬ ‭‬ ‭‬ ‭‬ ‭‬ ‭‬ ‭ roduces bile‬ P ‭Synthesizes plasma proteins‬ ‭Metabolizes and eliminated drugs and toxins‬ ‭Stores vitamins, glucose, and blood‬ ‭Detoxification and coag...

‭CHAPTER 43: DISORDERS OF THE EXOCRINE PANCREATIC AND HEPATOBILIARY SYSTEMS‬ ‭Accessory organs of the GI tract include:‬ ‭Liver‬ ‭‬ ‭‬ ‭‬ ‭‬ ‭‬ ‭ roduces bile‬ P ‭Synthesizes plasma proteins‬ ‭Metabolizes and eliminated drugs and toxins‬ ‭Stores vitamins, glucose, and blood‬ ‭Detoxification and coagulation‬ ‭Gallbladder‬ ‭Pancreas‬ ‭Stores bile‬ ‭ xocrine functions - Aid in digestion of carbs, fats, and proteins‬ E ‭Involved in production of enzymes and bicarbonate‬ ‭Endocrine function - Produces hormones‬ ‭Complication/ disorders with the liver usually develop as a result of liver impairment or failure‬ ‭‬ ‭More than 80-90% hepatic function must be compromised for symptoms to appear‬ ‭Most common complications include portal hypertension and associated with:‬ ‭‬ ‭Splenomegaly, esophageal varices, ascites, hepatic encephalopathy‬ ‭ sophageal varices‬ E ‭Increase pressure on lining of vessel in esophagus‬ ‭‬ ‭Melena vs bright red rectal bleeding‬ ‭‬ ‭Hematemesis‬ ‭‬ ‭Decreased HH levels‬ ‭‬ ‭Dyspnea, fatigue‬ J‭ aundice - hyperbilirubinemia‬ ‭Yellowing of the skin‬ ‭‬ ‭Dark urine‬ ‭‬ ‭Light stools‬ ‭‬ ‭Vitamin deficiency‬ ‭ scites‬ A ‭Abdominal swelling caused by accumulation of fluid‬ ‭‬ ‭Weight gain‬ ‭‬ ‭Bulging glands‬ ‭‬ ‭Decreased appetite‬ ‭‬ ‭Abdominal discomfort‬ ‭‬ ‭Dyspnea‬ ‭Manifestations include vague abdominal pain, indigestion, hepatomegaly (abnormally enlarged liver - palpation below the costal margin)‬ ‭ ortal hypertension‬‭is increased portal venous pressure,‬‭>5mmHg (normal is 3mmHG) resulting from increased resistance of blood flow‬ P ‭through the portal venous system withe most common cause being cirrhosis‬ ‭‬ ‭Scarring of hepatic tissue‬ ‭‬ ‭Deceased intrahepatic blood flow‬ ‭Manifestations - ABCDE‬ ‭‬ ‭Ascites, Bleeding, Caput medusae, Diminishes liver function, Enlarged spleen‬ ‭ cute liver failure‬‭is the loss of liver function‬‭and can present as elevated liver test from inflammation or hepatocyte destruction, prolonged‬ A ‭coagulation, altered mental status, decreased toxin clearance‬ ‭The hallmark signs are‬‭coagulopathy and altered mental‬‭status‬ ‭‬ ‭Other symptoms include jaundice, acetaminophen overdose (massively increased liver enzymes and decrease bilirubin), virus induced‬ ‭(increased bilirubin), and severe cases encephalopathy and hepatic coma (neurological checks are necessary to monitor for additional‬ ‭changed in mental status‬ ‭Diagnosis includes: history (drug overdose, viral exposure), AST and ALT levels, bilirubin levels, presence of coagulopathy and altered mental‬ ‭status‬ ‭Treatment includes: elevate head of bed to decrease aspiration, frequent neuro checks, volume resuscitation as needed, N acetylcysteine for‬ ‭acetaminophen overdose‬ ‭Hepatitis‬ ‭Clinical Manifestations:‬ ‭Prodromal‬ ‭Icterus‬ ‭Recovery‬ ‭Begins about 2 weeks after exposure‬ ‭Begins 2 weeks after prodromal phase‬ ‭Begins as jaundice resolves, usually 6-8‬ ‭ lient highly contagious‬ C ‭Nonspecific symptoms‬ ‭Nausea, vomiting, anorexia, cough, low‬ ‭grade fever‬ ‭ an last up to 6 weeks‬ C ‭Jaundice, tea colored urine, clay colored‬ ‭stools, enlarged/ tender liver, prolonged PT/‬ ‭INR‬ ‭ eeks after exposure‬ w ‭Enlarged and tender liver my continue‬ ‭Liver profile usually returns within 12 weeks‬ ‭after onset of jaundice‬ ‭ reatment: vaccines for HAV and HBV, supportive care can be rest, fluids, and nutrition‬ T ‭Oral based therapies for HCV‬ ‭B,c,d same mode of transmission so more likely to occur at the same time but general rule of thumb, any can happen together‬ ‭Only way to know if patient has one and differentiate is through lab tests‬ ‭B -d, often found together‬ ‭ iver cancer‬‭is also called hepatoma or hepatocellular‬‭carcinoma and is the fifth most diagnosed cancer. There is a poor survival world, the‬ L ‭second most common cause of death in men.‬ ‭Hepatocellular carcinoma is the most common form of liver cancer, about 80% of cases‬ ‭Intrahepatic cholangiocarcinoma is the second most common form of liver cancer‬ ‭Risk Factors:‬ ‭ ealth alterations:‬ H ‭Cirrhosis, hemochromatosis‬ ‭Carriers of Hep B or C virus‬ ‭ ifestyle/ environmental:‬ L ‭Excess alcohol or coffee consumption‬ ‭Exposure to aflatoxins‬ ‭Obesity‬ ‭Oral contraceptive use‬ ‭ anifestation include weakness and weight loss, abdominal bloating and discomfort that is often described as aching or feeling of fullness,‬ M ‭jaundice (mild if present in early stages, liver dysfunction due to disturbances in clotting factors and hormones and can cause bruising and‬ ‭bleeding b/c decrease prothrombin, elevated liver enzymes (ALP, GGT, ALT)‬ ‭Treatment:‬ ‭Surgery‬ ‭Local therapy‬ ‭Regional therapy‬ ‭ ay be curative‬ M ‭Hepatic resection - preferred method of treatment‬ ‭(high incidence of postoperative morbidity and‬ ‭recurrence‬ ‭Transplantation‬ ‭ ay be curative if lesions are small‬ M ‭and complete ablation is achieved‬ ‭Radiofrequency ablation‬ ‭Cryotherapy‬ ‭ rancatheteu arterial chemoembolization‬ T ‭Percutaneous ablation‬ ‭External beam radiation therapy‬ ‭ olon cancer - liver, Rectal cancer - Lungs‬ C ‭Cirrhosis‬‭is late stage scarring of the liver, end stage of liver failure. Scarring is due to poor function. There is an increased vascular permeability‬ ‭and systemic changes due to portal hypertension. Caused include alcohol consumption (most common), chronic viral hepatitis, chronic‬ ‭obstruction of bile ducts, genetic disease, like wilson diseases, hemochromatosis, glycogen storage disease‬ ‭ lcohol related liver damage‬‭may be acute and chronic.‬‭Severity depends of severity of pattern of drinking, as well and humoral disorders,‬ A ‭genetic and biochemical makeup, overall nutroton, diet, and health status‬ ‭Manifestations:‬ ‭Early‬ ‭ ‬ I‭ ncreased serum ammonia‬ ‭‬ ‭Restlessness (vague, early symptom of systemic‬ ‭toxicity)‬ ‭‬ ‭Agitation‬ ‭‬ ‭Progressive impairment in judgment‬ ‭Progressive‬ ‭‬ ‭‬ ‭‬ ‭‬ ‭‬ ‭‬ ‭‬ s‭ plenomegaly/ hepatomegaly‬ ‭RUQ abdominal discomfort‬ ‭Nausea‬ ‭Spider angioma‬ ‭Jaundice‬ ‭ascites/ dyspnea‬ ‭Abnormal liver function tests‬ ‭ iagnosis involves a history of alcohol abuse and elevated liver enzymes. The most important part of the treatment is abstinence from alcohol,‬ D ‭improving health and nutrition, liver transplant (option available only if patient maintain sobriety), prevention and treatment of serious‬ ‭complications such as bleeding (esophageal varices, swollen rectal veins), ascites‬ ‭ AFLD is strongly linked to obesity and involves deposits of lipid in the liver, fatty liver becoming insulin resistance increasing the risk for‬ N ‭disease. Mild is steatosis, >5% of lipid accumulation. Severe is nonalcoholic steatohepatitis (NASH) involving inflammation and damage of‬ ‭hepatocytes that can progress to cirrhosis‬ ‭Manifestations:‬ ‭ here are few symptoms in mild disease. Elevated AST and ALT, metabolic syndrome symptoms: obesity, diabetes, dyslipidemia‬ T ‭Diagnosis involves evidence of fatty liver without history of chronic alcohol abuse‬ ‭Treatment involved weight loss, vitamin E, bariatric surgery if indicated‬ ‭The gallbladder stores and concentrates bile‬ ‭Cholelithiasis‬ ‭Cholecysistis‬ ‭Choledocholithiasis‬ ‭Most common gallbladder disorder‬ ‭ cute chronic inflammation of the‬ A ‭gallbladder‬ ‭ allstone in the common bile‬ G ‭duct and can cause‬ ‭complication for the liver and‬ ‭pancreas‬ ‭ athogenesis:‬ P ‭Gallstones typically found in the gallbladder‬ ‭-‬ ‭Produce obstruction and inflammation‬ ‭Formed from cholesterol or pigment‬ ‭-‬ ‭80% of stones formed are from cholesterol‬ ‭Risk factors include: change in metabolism, hypertriglyceridemia,‬ ‭biliary stasis or obstruction, hyperglyceridemia, sedentary lifestyle,‬ ‭diabetes, family history of cholelithiasis‬ ‭ ssociated conditions include‬ A ‭gallstones or other alterations that‬ ‭damage the gallbladder walls‬ ‭ tiology:‬ E ‭Cystic duct stone - most common‬ ‭Trauma, infection of gallbladder‬ ‭Sepsis‬ ‭ holangitis is inflammation of‬ C ‭the common bile duct‬ ‭ ymptoms are similar to‬ S ‭cholelithiasis and acute‬ ‭cholecystitis‬ ‭Symptoms:‬ ‭Early‬ ‭Acute - related to obstruction‬ ‭ ften vague‬ O ‭ evere and sudden onset of radiating pain‬ S ‭Indigestion or‬ ‭-‬ ‭Originated in mid epigastric region‬ ‭mild gastric‬ ‭and extends to RUQ and right‬ ‭distress after‬ ‭subscapular region and to back or‬ ‭fatty mean‬ ‭shoulder‬ ‭Biliary colic‬ ‭Nausea, vomiting, sweating, tachycardia‬ ‭May cause jaundice, pain, hepatocyte damage‬ ‭ reatment:‬ T ‭For asymptomatic patients with low risk for complications -‬ ‭medications that decrease cholesterol production in liver and‬ ‭dissolve stones‬ ‭ anifestation include intolerance of‬ M ‭dietary fat, epigastric heaviness or‬ ‭RUQ abdominal pain, usually after‬ ‭eating‬ ‭Flatulence, belching, regurgitation‬ ‭Colicky pain due to obstruction of the‬ ‭bile flow‬ ‭Steatorrhea and amber colored urine‬ ‭due to biliary obstruction‬ ‭Bleeding, jaundice, pruritus‬ ‭Fever, chills‬ ‭Treatment is surgery‬ ‭‬ ‭Laparoscopic‬ ‭cholecystectomy‬ ‭‬ ‭Antibiotics‬ ‭ UQ pain and abdominal‬ R ‭tenderness, fever, jaundice,‬ ‭pruritus, dark colored urine,‬ ‭clay colored stools (due to‬ ‭increase bilirubin), advanced‬ ‭cholangitis (clinical signs‬ ‭consistent with sepsis)‬ ‭ reatment includes surgery -‬ T ‭Choledocholithotomy‬ ‭ upportive therapy includes‬ S ‭analgesics, antihistamines,‬ ‭nutrition, antibiotics,‬ ‭antiemetics, early treatment if‬ ‭sepsis is indicated‬ ‭ or symptomatic patients - surgical intervention (laparoscopic‬ F ‭cholecystectomy, open cholecystectomy)‬ ‭ ancer of gallbladder:‬‭Typical site of origin is the surface lining or epithelium of gallbladder but can originate in other locations.‬ C ‭Involves damage to gallbladder usually inner mucosal lining or bile ducts, possible sources are gallstones, toxins, bacteria, parasites. The main‬ ‭risk factor is gallstones.‬ ‭Manifestations:‬ ‭Early‬ ‭Late‬ ‭ ften subtle‬ O ‭Coexisting cholelithasis frequently present‬ I‭ ntense RUQ abdominal pain, palpable gallbladder‬ ‭Jaundice‬ ‭Weight loss‬ ‭ reatment:‬ T ‭Surgical removal of carcinoma‬ ‭Laparoscopic cholecystectomy‬ ‭Open cholecystectomy - indicated for removal of large, advances tumors‬ ‭Whipple resection - removal of surrounding diseases tissues‬ ‭Pancreas is divided into three section: head, midsection, tail‬ ‭Acute pancreatitis‬ ‭Chronic pancreatitis‬ ‭Pancreatic cancer‬ I‭ nflammation or necrosis of the pancreas‬ ‭Leading cause is alcohol abuse and gallstones‬ ‭Serious and painful inflammation may occur -‬ ‭develops in 2% of cases of pancreatitis‬ ‭ imilar to occur but pain is usually‬ S ‭less severe‬ ‭Tissue damage is irreversible‬ ‭The most common cause is alcohol‬ ‭but the causes can be calculi‬ ‭ isk factors include cigarette smoking (most‬ R ‭significant), obesity, diet (nitrates, preservatives, high‬ ‭fat), diabetes, chronic pancreatitis, genetic‬ ‭predisposition‬ ‭ anifestations: abdominal pain, changes in‬ M ‭vital signs, jaundice, paresthesia, cullen sign,‬ ‭tuner sign, steatorrhea‬ ‭Critical warning signs: low urine output,‬ ‭hypoxemia, restlessness, confusion,‬ ‭worsening tachypnea and tachycardia‬ ‭May indicate hypovolemic shock‬ ‭ reatment depends on pt’s condition and‬ T ‭response however ealy treatment is essential‬ ‭to prevent complications‬ ‭‬ ‭Oxygen as needed to maintain‬ ‭oxygenation‬ ‭‬ ‭Opioid analgesic as needed - very‬ ‭painful‬ ‭‬ ‭IV hydration‬ ‭‬ ‭Complete bowel reset, NPO‬ ‭‬ ‭Nasogastric suctioning‬ ‭○‬ ‭Prevent stimulation of‬ ‭digestive process‬ (‭ stones), smokin, tumors, cystic‬ ‭fibrosis‬ ‭ anifestations: anorexia and‬ M ‭malabsorption of fats and proteins‬ ‭(weight loss and steatorrhea)‬ ‭Dull constant abdomen pain,‬ ‭usually in lUQ or epigastric area‬ ‭Often precipitated by alcohol‬ ‭intake‬ ‭ reatment includes elimination of‬ T ‭alcohol and smoking, low fat diet,‬ ‭oral enzyme replacements, insulin‬ ‭injections, surgery, pain control‬ ‭Manifestation:‬ ‭Early‬ ‭Late‬ ‭ bdominal and epigastric‬ A ‭discomfort‬ ‭Malabsorption and weight loss‬ ‭due to decrease pancreatic‬ ‭enzyme production‬ ‭Back pain‬ ‭Nausea and vomiting‬ ‭Bile duct obstruction so dark‬ ‭urine, steatorrhea, jaundice,‬ ‭pruritus‬ ‭Diabetes - can be both risk‬ ‭factor of consequence‬ ‭ ortal vein‬ P ‭hypertension‬ ‭Ascites‬ ‭Hepatomegaly and‬ ‭splenomegaly‬ ‭Esophageal varices‬ ‭Treatment includes surgery and radiochemotherapy‬