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Biliary system Part 1


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6 general liver functions:
Excretory/detoxification (in bile); Metabolism; Synthesis; Storage
General examples of substances stored in liver
vitamin K, iron, copper, fat soluble vitamins, glycogen
Examples of substances synthesized in liver
albumin, alpha I antitrypsin; proteins of coagulation cascade (fibrinogen, prothrombin, VIII,IX, X, XI, and Xli), bile
Liver failure becomes apparent when _______ of liver is destroyed or dysfunctional
Liver injury results in release of these two major indicators of liver function.
Ast (aspartate amlno-transterase) andALT (Alanlne amlno-transferase)
7 general signs of liver failure:
Jaundice, Hypoalbumenernia, Hepatorenal syndrome, Portal hypertension, Encephalopathy, Endocrine abnormalities, coagulopathy
Encephalopathy I liver failure is due to the failure of the liver to remover _________ from the blood.
5 general microscopic/macroscopic responses of liver cells to injury
Inflammation, Degeneration, necrosis, fibrosis, cirrhosis
2 major functions of hepatic bile
elimination of bilirubrin and cholesterol; emulsify dietary fat in the gut
_______ occurs if blood bilirubin levels are greater than _______mg/dl.
Jaundice, 1.2
Jaundice becomes clinically apparent If serum bilirubin Is over _________
2.0-3.0 mg/dl.
Jaundice is best recognized in the __________.
Unconjugated bilirubin: Water insoluble; Tightly bound to albumin; Cannot be excreted In urine
Conjugated bilirubin; Water soluble; Non-toxic; Loosely bound to albumin; Can be excreted In urine
Which type of bilirubin is tightly bound to albumin?
Unconjugated bilirubin:
Which type of bilirubin is water soluble?
Conjugated bilirubin
Which type of bilirubin can be excreted in urine?
Conjugation of bilirubin takes place where?
Liver --No Eric, it is not the breast
Prehepatic Jaundice is associated with the buildup of ________ bilirubin and the ________of red blood cells.
Unconjugated, hemolysis
A manifestation of Gilbert's disease is:
Prehepatic Jaundice
Hepatic Jaundice is seen under what general conditions?
viral or drug-induced hepatitis, alcoholic hepatitis, tumors, and cirrhosis
T/F Hepatic Jaundice is associated with a buildup of conjugated bilirubin only.
False: It is mixed conjugated and unconjugated
Conjugated hyperbilirubinemia is manifest in what condition?
post-hepatic jaundice
post-hepatic jaundice is seen in _________ disorders such as gallstones, tumors of bile ducts, pancreas, or duodenum
_________ is the accumulation of unconjugated bilirubin (usually> 20 mg/dl) in the brain causing severe neurologic damage
Kernicterus can be seen in this condition that affects infants:
hemolytic disease of the newborn (erythroblastosis fetalis)
Jaundice resulting from Predominantly unconjugated hyperbilirubinemia has two general causes: 1. overproduction --> hemolytic anemia or
2. Impaired/decreased conjugation • Gilbert’s syndrome; 5-7% of population; benign; no functional derangement; Mild elevation of serum unconjugated bilirubin; • Crigler-Najjar Syndrome;Type I fatal, complete lack of enzyme for conjugation; Type 2 non-fatal, partial defect In conjugation; very yellow skin
Jaundice resulting from Predominantly conjugated hyperbilirubinemia: Impaired hepatic excretion; ⬢ Dubin-Johnson syndrome (hereditary enzyme defect) ⬢ Benign; episodic jaundice; black liver grossly ⬢ Rotor syndrome (hereditary enzyme defect) ⬢ As
Jaundice resulting from Predominantly conjugated hyperbilirubinemia: Cholestasis— results from hepatocellular dysfunction or obstruction (gallstones, strictures, neoplasms) Signs and symptoms: pruritis; skin xanthomas; elevated serum alkaline phosphatase Micro: Accumulation of pigment within the parenchyma; bile duct proliferation; portal tract fibrosis; “wispy hepatocytes” due to bile accumulation within the cell
Additional causes of jaundice:
antifungals, high amounts of beta-carotene, medications
3 morphologic changes from liver failure:
A. chronic liver disease --> cirrhosis; B. Hepatic dysfunction without necrosis (Reye’s, acute fatty liver of pregnancy); C. Massive acute hepatic necrosis (viral or drug hepatitis; direct toxic damage ----acetaminophen overdose, mushroom or carbon tetrachloride)
Elevated ammonia levels in the blood from liver failure that lead to disturbances in consciousness ranging from behavioral abnormalities to coma is called:
hepatic encephalopathy
Hepatorenal syndrome:
liver fails--> kidneys fail drop in urine output, increase in urea nitrogen/creatine levels (in end-stage liver disease)
______ is synonymous with end-stage liver disease
T/F Cirrhosis is among the top ten causes of death I western society.
Causes of cirrhosis include:
60% from alcohol abuse; 10% viral; 10% blllary tract; diseases/obstructive disorders; 20% autoimmune, drug Induced, hereditary, and cryptogenic (indeterminate cause)
Cirrhosis may take one to ___ years to develop.
What is the major pathologic process that accompanies cirrhosis?
progressive fibrosis (regenerative firm nodular surface)
Pathologic process of necrosis:
Necrosis of liver cells; Fibrosis; (fibrous band scars inhibit regeneration); Parenchymal nodules (regeneration of encircled hepatocytes); Disruption of entire liver architecture— irregularly shaped, shrunken, firm, nodular
________ occurs with changes within the liver itself.; ________ occurs with changes within the biliary tree.
portal cirrhosis; biliary cirrhosis
The presence of fibrosis and nodularity impedes blood flow in the liver and is one of the major causes of _____ ____________.
portal hypertension
T/F Patients with cirrhosis have an increased risk of death from the following:; a. progressive liver failure b. complications of portal hypertension c. hepatocellular carcinoma
A. True; B. True; C. True
T/F portal hypertension leads to:; A. ascites; B. Spleenomegaly; C. formation of anastamoses (shunts) between the portal and systemic circulation; D. Hepatic encephalopathy E. Undeniable urge to smoke barkies
A. True; B. True C. True D. True E. False (except for individuals from low educational and rural backgrounds)
Esophageal varices are a result of:
formation of anastamoses (shunts) between the portal and systemic circulation (a result of portal hypertension)
Inflammatory Disorders of the liver:
⬢ Viral hepatitis ⬢ Fulminant hepatitis ⬢ Autoimmune hepatitis ⬢ Liver abscesses
Morphologic changes seen with viral hepatitis; ⬢ Ballooning degeneration of hepatocytes; ⬢ Necrosis of hepatocytes (councilman bodies) are shrunken eosinophilic apoptotic anuclear fragments of hepatocytes)
Morphologic changes seen with viral hepatitis; ⬢ Bridging necrosis of lobules ⬢ Inflammation of portal tracts; macrophages; Kupffer cells proliferate
Morphologic changes seen with viral hepatitis • Hepatitis B— ground glass hepatocytes— due to accumulation of HBsAg; sanded nuclei due to abundant HBcAg
Morphologic changes seen with viral hepatitis • Hepatitis C-fatty change of hepatocytes; lymphoid aggregates • “Piecemeal necrosis”—periportal necrosis In chronic hepatitis
With viral hepatitis, what is the timeline established for acute vs. chronic infection?
acute = resolves within 6 months; chronic = > 6 months
__ ________hepatitis carriers in US; 1 in __ patients is a carrier
4 million; 70
What may be one of the first signs of hepatitis?
Dark urine
characteristics of fulminant hepatitis include:
severe acute iiver damage, encephalopathy, coaguiopathy with high risk of death approaching 80%
fulminant hepatitis develops within _____ weeks of the onset of liver disease.
Symptoms of Hepatitis:(not always evident)
Jaundice of skin and eyes; Dark urine ;Fatigue;Nausea;Abdominal pain;Vomiting
Hepatits A: ⬢ Transmission by fecal-oral route ⬢ Virus In blood, saliva, feces 2-3 weeks before any clinical (flu-like) symptoms ⬢ 30-40% of U.S. shows evidence of infection ⬢ Blood donations not screened for Hepatitis A
Hepatits A: • Mild—often undiagnosed • incubation avg. 25 days, infectious for 4-6 weeks • Usual outcome: no chronic liver disease, no carrier state, immunity
Hepatitis B •Transmitted by blood or body fluids (semen, saliva) • Increased risk: multiple sexual partners, iv drug use 50-100 times more infectious than HIV • Incubation time avg.—-75 days • Can remain infective on operatory surfaces up to 7
Hepatitis B • U.S. prevalence—O.5%; approx 1.5 million carriers • Can develop into chronic disease in 2- 10%. -->cirrhosis and liver cancer • Virus does not kill cells directly but activates immune cells --> inflammation and liver damage
Hepatitis B ⬢ Can acquire infection from needle sticks, contaminated surfaces, splashes to eye or oral mucosa, percutaneously through cuts or breaks in skin, contact with infected saliva ⬢ Dentists considered a high risk category ⬢ Infection preval
Hepatitis B ⬢ Only DNA virus among the hepatitis viruses thus far ⬢ Vaccine has been available since 1982. Highest rate of sero-conversion in the youngest age groups ⬢ Vaccine Is 95% effective in preventing chronic infections ⬢ 116 countries now have Hep. B vaccine as part of their routine immunizations

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