1. Chapter 30 Disorders of Hepatobiliary and Exocrine Pancreas Function
Essentials of Pathophysiology
Chapter 30 Disorders of Hepatobiliary and Exocrine Pancreas Function

2. Pre lecture quiz true/false
The liver does not play a role in glucose homeostasis.
Jaundice results from an abnormally high accumulation of bile in the blood.
Hepatitis, inflammation of the liver, is of bacterial origin.
Cholelithiasis, or gallstones, is caused by precipitation of substances contained in bile, mainly cholesterol and bilirubin.
Chronic pancreatitis is a severe, life-threatening disorder associated with the escape of activated pancreatic enzymes into the pancreas and surrounding tissues.

3. Pre lecture quiz C Cirrhosis Kupffer salts urea
The __________ cells are capable of removing and phagocytizing old and defective blood cells, bacteria, and other foreign material from the portal blood as it flows through the sinusoid.
One of the metabolic functions of the liver is the conversion of ammonia, which is produced by deamination of amino acids, into __________. 
Pruritus is the most common presenting symptom in persons with cholestasis, probably related to increased bile __________ in the blood.
Hepatitis __________ is the most common cause of chronic hepatitis, cirrhosis, and hepatocellular cancer in the world.
__________ represents the end stage of chronic liver disease in which much of the functional liver tissue has been replaced by fibrous tissue. C
Cirrhosis
Kupffer
salts
urea

4. System

5. System Interaction

6. Liver Structure
Blood from hepatic portal vein and hepatic artery mix in sinusoids
The sinusoids empty into central veins, which send the blood to the hepatic vein and inferior vena cava

7. Liver Structure(cont.)
Hepatic cells lie along the sinusoids and pick up chemicals from the blood
They modify the blood’s composition

8. Liver Structur e(cont.)
At the back end of each hepatic cell, bile is released into a canaliculus
The bile is carried to the bile duct and then to the gallbladder

9. Liver Structure (cont.)
Many sinusoids come together to empty into one vein
The section of the liver emptying into one vein is a lobule

10. Question
Tell whether the following statement is true or false. The gallbladder stores bile that has been produced by the liver.

11. Answer
True Rationale: The liver makes bile and secretes it into the small intestine via the common bile duct. Excess bile is stored in the gallbladder, where it also enters the small intestine through the common bile duct when it is needed.

12. Metabolic Functions of the Liver
Carbohydrate, protein, and lipid metabolism
Sugars  stored as glycogen, converted to glucose, used to make fats
Proteins  synthesized from amino acids; ammonia made into urea
Fats  oxidized for energy, synthesized, packaged into lipoproteins

13. Metabolic Functions of the Liver (cont.)
Drug and hormone metabolism
Biotransformation into water-soluble forms
Detoxification or inactivation
Bile production

14. Question
Which of the following substances does bile make more susceptible to digestive enzymes?
Carbohydrate
Protein
Fat
All of the above

15. Answer
Fat
Rationale: Bile (produced in the liver) emulsifies fat molecules so that they are easier to digest. An emulsion is a mixture of two immiscible (unblendable) substances, in this case bile and fat.

16. Scenario Mr. M had a donut for breakfast. Question:
Explain how the sugar in the donut left his small intestine and ended up as fat in his carotid artery, giving the:
Anatomical structures
Chemical processes
Hormones that controlled them

17. Scenario
Ms. B was prescribed an oral medication for her skin problem. She took it twice a day.
The day after she started the medication, Ms. B drank wine with a friend right after taking the prescribed dosage
Question:
Ms. B got terribly ill. Why? She said, “I drink that kind of wine all the time.”

18. Liver Failure
Hematologic disorders as the liver fails the spleen takes over some of the function of the liver
Anemia- due to splenomegaly
Thrombocytopenia- due to splenomegaly
coagulation defects-
leukopenia due to splenomegaly
As your spleen grows larger, it begins to filter normal red blood cells as well as abnormal ones, reducing the number of healthy cells in your bloodstream. It also traps too many platelets. Eventually, excess blood cells and platelets can clog your spleen, interfering with its normal functioning.

19. Liver Failure Endocrine disorders
Fluid retention, hypokalemia, Lack of metabolism of aldosterone, too much remains in the system
disordered sexual functions
Which hormones would cause these endocrine disorders? Failure of Cholesterol/Steroid formation

20. Liver Failure (cont.) Skin disorders Jaundice, red palms, spider nevi
Hepatorenal syndrome-
Deteriorating liver function is believed to cause changes in the circulation altering blood flow in the kidneys. The renal failure of HRS is a consequence of these changes in blood flow
Azotemia, increased plasma creatinine, oliguria- decreased production of urine
Hepatic encephalopathy- caused by accumulation in the bloodstream of toxic substances that are normally removed by the liver
Asterixis, confusion, coma, convulsions
Asterixis : An uncontrollable flapping of the hands that becomes noticeable when patients stretch out their arms, palms out, as if stopping traffic.

21. Jaundice in a Person with Hepatitis A

22. Question
What causes jaundice?
Increased bilirubin levels
Anemia
Thrombocytopenia
Leukopenia

23. Answer
Increased bilirubin levels
Rationale: Erythrocytes are normally broken down in the spleen at the end of their life span. The end product of RBC metabolism is bilirubin. Bilirubin is sent to the liver to be metabolized; if the liver is not functioning properly, the bilirubin accumulates and causes jaundice (an abnormal yellowing of the skin and mucous membranes).

24. Hepatitis Viral hepatitis Hepatitis A virus (HAV)
Hepatitis B virus (HBV)
Hepatitis B–associated delta virus (HDV)
Hepatitis C virus (HCV)
Hepatitis E virus (HEV)

25. Which hepatitis viruses are most likely to be the problem in:
Discussion
Which hepatitis viruses are most likely to be the problem in:
An asymptomatic drug abuser?
A nursing student who has spent the last two months volunteering in an orphanage in Mali?
An infant whose mother has hepatitis? C E B

26. Chronic Viral Hepatitis
Caused by HBV, HCV, and HDV
Principal worldwide cause of chronic liver disease, cirrhosis, and hepatocellular cancer
Chief reason for liver transplantation in adults

27. Alcoholic Liver Disease
Fatty liver (steatosis)
Liver cells contain fat deposits; liver is enlarged
Alcoholic hepatitis
Liver inflammation and liver cell failure
Cirrhosis
Scar tissue partially blocks sinusoids and bile canaliculi

28. Alcoholic Liver

29. Alcoholic Liver

30. Liver Cancer

31. Question
Which of the following is the least virulent strain of hepatitis?
HAV
HBV
HCV
HDV

32. Answer
HAV
Rationale: HBV, HCV, and HDV are all virulent strains that may lead to chronic viral hepatitis. HAV is most commonly transmitted by the fecal-oral route (e.g., contaminated food or poor hygiene) and does not typically have a chronic stage (it does not cause permanent liver damage).

33. Veins Draining into the Hepatic Portal System
Portal hypertension causes pressure in these veins to increase
Varicosities and shunts develop
Organs engorge with blood

34. Portal Hypertension

35. Portal Hypertension

36. Effects of Portal Hypertension
Hemorrhoids
Ascites &
Caput medusae

37. Cholestasis and Intrahepatic Biliary Disorders
Bile flow in the liver slows down
Bile accumulates and forms plugs in the ducts
Ducts rupture and damage liver cells
Alkaline phosphatase released into blood
Liver is unable to continue processing bilirubin
Increased bile acids in blood and skin
Pruritus (itching)

38. The Fate of Bilirubin
Hemoglobin from old red blood cells becomes bilirubin
The liver converts bilirubin into bile
Why would a man with liver failure develop jaundice?
unconjugated
bilirubin in
blood
bilirubinemia
liver links it to
gluconuride
jaundice
conjugated
bilirubin
bile

39. Biliary Tract Gallbladder Hepatic duct Cystic duct Common bile duct
Ampulla of Vater
Sphincter of Oddi
Pancreatic duct

40. Disorders of the Gallbladder
Cholelithiasis (gallstones)
Cholesterol, calcium salts, or mixed
Acute and chronic cholecystitis
Inflammation caused by irritation due to concentrated bile
Choledocholithiasis
Stones in the common bile duct
Cholangitis
Inflammation of the common bile duct

41. Bile in the Intestines Emulsifies fats so they can be digested
Passes on to the large intestine
Bacteria convert it to urobilinogen
Some is lost in feces
Most is reabsorbed into the blood
Returned to the liver to be reused
Filtered out by the kidneys  urine

42. The Pancreas Pancreas Exocrine Endocrine pancreas pancreas
releases digestive
releases hormones
juices through a
into the blood
duct
to the
duodenum

43. Exocrine Pancreas Acini produce:
Inactive digestive enzymes
Trypsin inactivator
Bicarbonate (antacid)
These are sent to the duodenum when it releases secretin and cholecystokinin
In the duodenum, the digestive enzymes are activated

44. Question
Tell whether the following statement is true or false. The exocrine pancreas produces insulin.

45. Answer
False Rationale: Beta cells of the endocrine pancreas produce insulin; the exocrine pancreas produces digestive enzymes that are secreted into the small intestine through the common bile duct.

46. Biliary Reflux
5. Bile in pancreas disrupts tissues; digestive enzymes activated
1. Gallbladder contracts
2. Bile is sent down common bile duct
3. Blockage forms in ampulla of Vater: bile cannot enter duodenum
4. Bile goes up pancreatic duct

47. Autodigestion of the Pancreas
Activated enzymes begin to digest the pancreas cells
Severe pain results
Inflammation produces large volumes of serous exudate  hypovolemia
Enzymes (amylase, lipase) appear in the blood
Areas of dead cells undergo fat necrosis
Calcium from the blood deposits in them
Hypocalcemia

48. Chronic Pancreatitis and Pancreatic Cancer
Have signs and symptoms similar to acute pancreatitis
Often have:
Digestive problems because of inability to deliver enzymes to the duodenum
Glucose control problems because of damage to islets of Langerhans
Signs of biliary obstruction because of underlying bile tract disorders or duct compression by tumors