Mod 12: Disorders of the Liver, Biliary Tract, and Pancreas

In normal non-diabetic people, peak blood glucose does not rise above 140 mg/dL and _______ blood glucose should always be below 100.

140, fasting

Anyone who has a random blood glucose of ____ mg/dL or higher, and reports _____ and polydipsia is diabetic.

200, polyuria

ALT or ______ and AST or ______ are _____ enzymes whose blood levels markedly increase with hepatic inflammation.

Alanine Aminotransferase, Aspartate Aminotransferase, liver

_____ is the most common cause of kidney failure in the U.S.

Diabetic nephropathy

T/F: The anti-hepatitis B core antibodies (anti-HBc) and anti-hepatitis B e antibodies (anti-HBe) provide immunity to the people infected with the virus.

F

_____ is the earliest indicator of diabetic _____.

Microalbuminuria, nephropathy

______ dysfunction in diabetic autonomic neuropathy refers to inability to sweat or abnormally high degrees of sweating.

Sudomotor

People who have never come across the hepatitis B virus but get vaccinated will develop anti-hepatitis B ____ antibodies.

Surface

The appearance of IgM type antibodies is indicative of ____ illness, whereas the appearance of ____ type antibodies indicates recovery and _____.

acute, IgG, immunity

The starch digesting enzyme of the pancreas is ______ and the fat digesting enzyme of the pancreas is ______.

amylase, lipase

The two vessels that bring blood to the liver are the hepatic ______ which branches off the descending aorta and the hepatic _____ which empties the blood from the intestines.

artery, portal vein

Extension of the wrist may cause a rhythmic jerking movement known as the hepatic flap or _____. Together with accumulation of serous fluid in the peritoneal cavity known as _____, they are signs of chronic ______.

asterixis, ascites, liver failure

Type 1 diabetes result from an ____ attack that destroys the ______ in the pancreas and results in deficiency or lack of _____.

autoimmune, beta cells, insulin

Thickening of the ______, increased vascular _______ and pathologic neovascularization are all important components of microangiopathy

basement membrane, permeability

The word cholelithiasis literally means _____.

bile stones

When the gall bladder is stimulated during and after a meal, it releases _____through the _____ into the common bile duct that merges with the ______ and opens into the ______ at the ampulla of Vater.

bile, cystic duct, pancreatic duct, duodenum

The liver excretes metabolic byproducts of heme into which is stored in the _____.

bile, gall bladder

If the common ____ duct or the common ______ duct is obstructed with stones, the levels of liver enzymes measured in blood would be markedly ____.

bile, hepatic, high

The extreme cramping pain associated with cholelithiasis is known as _____.

biliary colic

Varices of veins of the falciform ligament is a sign of chronic hepatic failure and it is known as _________.

caput medusa

The presence of hepatitis B surface antigen for more than six months indicates that the patient is either a chronic _____ or has developed _____ hepatitis.

carrier, chronic

Opacity of the lens due to accumulation of glucose and its metabolites is known as ______

cataracts

The gold standard of treatment for most cases of uncomplicated cholelithiasis and acute cholecystitis is laparoscopic _____.

cholecystectomy

The most common cause of chronic obstruction of the biliary tree is _____. This term means the formation of ______.

cholelithiasis, bile stones/ gall stones

The presence of gall stones known as ______ and the associated inflammation for many years may lead to chronic ______. Common symptoms of this condition are _____ and ____ associated with meals.

cholelithiasis, cholecystitis, Nausea, vomiting

The condition in which bile does not flow freely out of the liver is known as ______.

cholestasis

The majority of the biliary stones are made of ______.

cholesterol

______ bilirubin is secreted into and is converted by intestinal bacteria to and .

conjugated, bile OR small intestine, urobilinogen/stercobilinogen

The gallbladder empties bile into the ______ which joins the ______ to make the _______ bile duct.

cystic duct, hepatic duct, common

Peak blood glucose of greater than 200 is indicative of ______, whereas blood glucose between 140 and 200 mg/dL is strongly a sign of _________.

diabetes, prediabetes

Glycosuria causes osmotic _____ which can lead to ______ and polydipsia.

diuresis, polyuria

Diabetic autonomic neuropathy can cause impairment in esophageal motility leading to _______. It can severely impair the normal motility of the stomach and cause _______.

dysphagia, gastroparesis

In acute cholecystitis with _____, bacterial infection fills up the ______ with pus.

empyema, gallbladder

One of the most common genitourinary complications in diabetic men with autonomic neuropathy is ______.

erectile dysfunction

Diabetic autonomic neuropathy that affects the Vagus nerve results in a _____ resting heart rate.

faster/high

In people with diabetes, _____ glucose will be above 126 and peak glucose levels would be above __________ mg/dL.

fasting, 200

Ketones are metabolic byproducts of ______ metabolism.

fat

Nodular scarring of the glomerulus is known as _______ and occurs in diabetic nephropathy. This causes a severe in ______ GFR.

glomerulosclerosis, drop

Hepatic synthesis of glucose from lactic acid and amino acids is known as ________ which is stimulated by the pancreatic hormone, ______.

gluconeogenesis, glucagon

The hepatic enzyme responsible for conjugation of bilirubin is called ______.

glucuronyl transferase

Living a sedentary lifestyle and having a diet rich in HFCS and other high _____ index foods are associated with development of insulin ______.

glycemic, resistance

The measurement of _____ hemoglobin is an indicator of the severity of _____often used to monitor the progression and treatment of diabetes.

glycosylated, hyperglycemia

There are about 280 million _______molecules in each RBC. When a RBC dies, its hemoglobin molecules are broken down. The globin molecule is broken down into _____ that are recycled. ___ is first converted to a green pigment called _____ and then an orange/brown pigment called _____.

hemoglobin, amino acids, Heme, biliverdin, bilirubin

Prehepatic causes of hyperbilirubinemia include ______ diseases in which abnormal destruction of red blood cells leads to an increased production rate of bilirubin.

hemolytic, unconjugated

The inferior and superior mesenteric veins as well as the Splenic vein drain into the _______ vein.

hepatic portal

About 1% of people with chronic hepatitis B may develop _____, while about 10-30% may develop _____ of the liver.

hepatocellular carcinoma, cirrhosis

Mild deficiency of glucuronyl transferase is the cause of a condition called __________ unconjugated or _______ syndrome.

hyperbilirubinemia, Gilbert

One of the short-term complications of diabetes is an extreme rise in blood osmolality which can result in coma. This is known as _________.

hyperosmolar coma

Months after being infected, the presence of hepatitis B e antigens (HBe Ag) in the blood indicates that the patient has not developed ________ and continues to be _____.

immunity, infectious

A person positive for HBsAg is ______ to others.

infectious

The beta cells of the islets of Langerhans produce _______ which increases cellular uptake of ______.

insulin, glucose

Individuals with _____ resistance who have a compensatory _____ in insulin levels tend to respond more positively to lifestyle changes to stop the progression of _____ to type 2 diabetes.

insulin, rise, prediabetes

Most bile acids are reabsorbed by the ______ mucosa and returned to the blood. This is referred to as ______ circulation.

intestinal, enterohepatic

Hyperbilirubinemia causes yellowing of the skin and sclera known as _______.

jaundice

As the rate of fat breakdown increases, so will the rate of hepatic ______ which may lead to acidosis. We refer to this as _______. The kidneys and the lungs increase their rate of excretion of acid.

ketogenesis, diabetic ketoacidosis

In DKA, distinctly labored heavy breathing in which the breaths are deeper and faster is called _________ breathing.

kussmaul

Coagulation factors are synthesized by the ____.

liver

In diabetes, damage to large blood vessels known as _______ causes accelerated _______ which can lead to heart attack, stroke and ______ of the lower extremities.

macroangiopathy, atherosclerosis, gangrene

Vasomotor impairment caused by diabetic autonomic neuropathy may result in __________ when the person stands up from supine or sitting position.

orthostatic hypotension

If bilirubin secretion in the bile diminishes, the stool will look ___.

pale

Surrounding the outer surface of endothelial cells are special smooth-muscle-like cells known as _______.

pericytes

In diabetic retinopathy, loss of ______ and _______ cells weaken the vascular wall in the retina resulting in micro_______ and hemorrhages.

pericytes, endothelial, aneurysms

In diabetes, ______ caused by ______ diuresis can result in dehydration and hyponatremia.

polyuria, osmotic

In acidosis, protons enter the cells in exchange for ______ ions.

potassium

In most cases, _______ can be completely reversed by major lifestyle changes including weight loss, a healthy diet and regular exercise.

prediabetes

In the absence of biliary obstruction, biliary cirrhosis can be due to an autoimmune disease. This is called ______ biliary cirrhosis.

primary

Filtered glucose is ______ by Na+/glucose cotransporters in the PCT. The point at which they become saturated is called the ____ threshold of glucose.

reabsorbed, renal plasma

In both Rotor and Dublin-Johnson syndrome, the inability of hepatocytes to _____ bilirubin causes ______ hyperbilirubinemia.

secrete, conjugated

A complication of diabetes is bacterial infection of blood known as ______.

septicemia

One of the signs of chronic liver disease is the presence of multiple large red lesions on the skin that resemble the body of a spider. These lesions are called ______. They are linked to the decreased capacity of the liver to metabolize _______.

spider angiomas, estrogen

The only antibody that provides immunity against hepatitis B is the anti-hepatitis B _____ antibody.

surface

The serologic hallmark of chronic hepatitis B is the persistence of hepatitis B _____.

surface Ag

Jaundice becomes clinically apparent when bilirubin levels are about ____ as high as normal.

twice

In any suspected cases of cholecystitis, abdominal _____ is the most useful initial test that confirms the presence and the location of ________.

ultrasound, gall stones/ bile stones

Phototherapy treats physiological jaundice because it converts ________ to a more soluble compound.

unconjugated bilirubin

Physiologic jaundice is caused by accumulation of ______ in the body of a newborn.

unconjugated bilirubin

Accumulation of _______ bilirubin in a newborn can cause a form of encephalopathy known as _____ which will result in permanent brain damage.

unconjugated, kernicterus

The metabolic byproduct of bilirubin in the urine that gives it its characteristic color is ______, while stool gets its characteristic color from _______.

urobilin, stercobilin

Dilation of veins is referred to as _______ which may be caused by _____ hypertension when it involves the veins that empty into the hepatic circulation. In the rectal veins, it causes _______. In the case of the _______ vein, it causes splenomegaly.

varices, portal, hemorrhoids, splenic

_______ cells conjugate bilirubin by adding _________ to it.

Hepatic/Liver, glucuronic acid

Checking blood glucose level 2 hours after having a person ingest a standard drink that contains 75 grams of glucose is known as the ____ Test.

Oral Glucose Tolerance

____ for glucose is approximately 180 - 200 mg/dL.

Renal plasma threshold

Briefly describe the significance of elevated liver enzymes and jaundice in cholelithiasis.

Cholelithiasis is a condition of forming stones in the gall bladder or biliary tree. If the common bile duct or the common hepatic duct is obstructed with stones, the levels of liver enzymes measured in blood would be markedly elevated, such that biliary obstruction causes bile to back up into the liver, disrupting hepatocytes. Blood liver enzymes/markers rise due to stasis caused by the obstruction. Liver enzymes have many metabolic functions some of which function in cholesterol synthesis so we would expect that most biliary stones would be made of cholesterol. Elevated liver enzymes also indicate that hepatocytes are being damaged and these enzymes get washed into the blood from damaged or dead cells. For example, the liver enzymes AST and ALT can be detected, and indicate hepatic cellular damage and inflammation. The bile stone is causing flow obstruction in the biliary system, which is a posthepatic cause of hyperbilirubinemia. It prevents conjugated bilirubin from being secreting into bile and being metabolized by the intestinal bacteria. The accumulation of bilirubin (hyperbilirubinemia) in the blood results in the yellowing of the skin/sclera known as jaundice. Jaundice occurs are a consequence of an imbalance of production/excretion of bilirubin, and in this case, cholelithiasis and the subsequent backup are preventing excretion and causing the accumulation. Jaundice is most apparent when the levels are twice as high as normal.

_____ syndrome is caused by severe deficiency or complete absence of _____.

Crigler-Najjar, glucuronyl transferase

______ is associated with a dangerous rise in intraocular pressure and permanent damage to the optic nerve that could result in loss of vision.

Glaucoma

In a brief paragraph, describe the usefulness of hepatitis B surface antigen (HBs Ag) and hepatitis B surface antibody (anti-HBs) as blood markers in acute and chronic illness, as well as vaccination and carrier state.

HBs Ag is useful for detecting viral infection by Hepatitis for acute infection specifically in the first approximately 4-5 months after exposure while also detecting chronic infection with the presence of this antigen past 6 months. Infection can be acute where HBs Ag should disappear from the blood after about 5 months after exposure, while at the same time anti-HBs should have populated the blood in high amounts with the disappearance of HBs Ag. The anti-HBs in the blood is a good indication that the body has built active immunity against the HBs Ag; this antibody is the only antibody that provides immunity and establishes curing of hepatitis B. These blood markers are also useful for detecting chronic hepatitis infection which is detected by the persistence of HBs Ag in the blood past about 6 months where there is a leveling off of the antigen that is slightly less than the peak value; however, anti-HBs does not appear. This situation indicates that the patient has not developed immunity and that they are still infectious. Additionally, patients can be vaccinated with the Hep B vaccine, which should cause the body to develop anti-HBs. For vaccination status, a blood test will identify anti-HBs to confirm whether the patient has developed these antibodies and the level/quantity of the antibodies. Furthermore, the presence of hepatitis B surface antigen for more than six months indicates that the patient is a chronic carrier or has developed chronic hepatitis, and a chronic carrier will not develop antiHBs similarly to a chronic Hep B patient. Being a carrier means that a patient is asymptomatic but still harbors the hepatitis B surface antigen and is still infectious.

Briefly describe how metabolism of heme gives urine and stool their characteristic color.

Heme is a molecule of RBC that is degraded and converted to other molecules in its decomposition. First, heme is converted to biliverdin which appears green. Then, biliverdin is converted to an orange-red compound called bilirubin. Bilirubin is not soluble and can be toxic so it is important that bilirubin is made water-soluble by the addition of glucuronic acid in a process called "conjugation of bilirubin". Conjugated bilirubin is water-soluble and secreted in bile into the small intestine. The intestinal bacteria further metabolize conjugated bilirubin into urobilinogen and stercobilinogen. Some urobilinogen is reabsorbed through enterohepatic circulation so that it enters the bloodstream. Urobilinogen is reabsorbed in the kidney and excreted/filtered out in the urine as urobilin, and stercobilinogen is processed in the large intestine to filter stercobilin out in the feces. These metabolic byproducts of heme contribute to the characteristic color of both urine and feces since each metabolite of heme absorbed a wavelength of light and appears a different color. For urine, urobilin has a chemical structure which produces the characteristic yellow color of urine when filtered. If bilirubin passed normally into the feces and was metabolized into stercobilin, the stool would look darker brown color. However, when there is flow obstruction of the biliary system and bilirubin is not secreted at enough amounts, this causes low bilirubin in the stool so the stool will look pale.

_______ provides a window into how high blood glucose levels have been over the prior four months.

Hemoglobin A1C

Briefly describe the pathological changes in microangiopathy.

Microangiopathy is a condition caused by Diabetes Mellitus (hyperglycemia) that leads to damage of small blood vessels in different areas of the body. The high and prolonged levels of glucose damage the endothelial cells and the cells surrounding the outer surface of endothelial cells which are special smooth-muscle-like cells called pericytes. Normally, these cells line the blood vessels and interact to influence each other in many ways. Pericytes have a supportive role in blood vessel structure and function and ensure endothelial cell survival. The loss of pericytes and endothelial cells causes acellular vessels and loss of vascular architecture resulting in a lack of RBC perfusion leading to ischemia. With low perfusion levels, the tissue begins to form new vasculature, a process known as neovascularization, in order for RBCs to bypass damaged areas and reach tissue. Additionally, to compensate for the loss of structure, there is increased accumulation of basement membrane components, upregulation of ECM component synthesis, and reduced degradation of ECM components leading to vascular basement membrane thickening. Moreover, altered cell-cell interactions and altered cell-matrix interaction reduces and weakens vascular wall remodeling and loss of tight junctions that prevent leaking, resulting in microaneurysms and increased permeability of the vasculature. Therefore, the capillaries end up being very leaky and may result in hemorrhage. The specific regions of small vessels that are most affected in hyperglycemia reside in the kidneys (Nephropathy), eyes (Retinopathy), and nerves (Neuropathy). In the kidneys, there can be damage to islet cells, and eventual sclerosis, low GFR, and kidney failure. In the eyes, microangiopathy leads to hard exudates, microaneurysms, and hemorrhages. In the nerves, there is alteration to the periphery, sensory, and motor nerves resulting in loss of sensation of vibrations, pain, temp, and proprioception, which can manifest in gangrene. These are in brief but many more complications can relate to the pathology of microangiopathy by hyperglycemia persistence.

Chronic liver failure leads to _____ hypertension which results in enlargement of veins that empty into the _____ vein.

Portal, Hepatic portal