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LIVER, GALLBLADDER, PANCREAS

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  1. LIVER, GALLBLADDER, PANCREAS • Liver • Jaundice • Hepatitis • Cirrhosis • Tumors • Gallbladder • Pancreas

  2. LIVER ANATOMY Central area Portal area

  3. LIVER MICROSCOPIC Duct Vein Artery

  4. HEPATIC INJURY • Degeneration or accumulation • Necrosis • Inflammation • Regeneration • Fibrosis

  5. LIVER NECROSIS / INFLAMMATION

  6. JAUNDICE • Excess bilirubin >2-3 mg/dl • Bilirubin metabolism • Unconjugated • Conjugated

  7. JAUNDICE • Increase bilirubin production • Decreased hepatic uptake • Impaired conjugation • Impaired hepatic excretion • Cholestasis • Intrahepatic: cell injury • Extrahepatic: duct obstruction

  8. VIRAL HEPATITIS • Hepatitis A • Hepatitis B • Hepatitis C • Hepatitis D • Hepatitis E • Hepatitis G • EBV, CMV, Herpes

  9. HEPATITIS A • Common • RNA virus • Fecal or oral transmission • Incubation 15-45 days • No carrier or chronic disease

  10. HEPATITIS B • DNA virus • Parenteral / sexual spread • Incubation 30-180 days • Serology • Carrier, chronic, cirrhosis • Risk malignancy • Vaccine

  11. HEPATITIS C • RNA virus • Incubation 7-8 weeks • Parenteral, sexual spread • Carrier, chronic, cirrhosis • Risk malignancy • No vaccine

  12. OTHER HEPATITIS VIRUSES • Hepatitis D • RNA virus • Associated with hepatitis B • Hepatitis E • Rare in the U.S. • RNA virus • Waterborne? • Hepatitis G (RNA similar to C) • ? Prevalence and significance • WHAT’S NEXT?????

  13. ACUTE VIRAL HEPATITIS • Resolution in 8 weeks • Symptoms • Histology • Panlobular disarray • Inflammation • Hepatocyte necrosis • Fulminant: massive necrosis • Can become chronic

  14. ACUTE VIRAL HEPATITIS

  15. CHRONIC HEPATITIS • Abnormal liver function for >6 weeks • No longer use terms chronic active or chronic persistent • Grade activity and stage • Determine etiology

  16. CIRRHOSIS • Cirrhosis • Diffuse • Fibrosis • Regeneration hepatocytes • Etiology • Fatty liver disease 60-70% • Viral 10%

  17. CIRRHOSIS • Others • Biliary diseases • Metabolic/ genetic • Cryptogenic

  18. CIRRHOSIS H&E Trichrome

  19. CIRRHOSIS • Nonspecific symptoms • Liver failure • Portal hypertension • Ascites • Collateral venous channels • Splenomegaly • Neoplasm

  20. CIRRHOSIS Esophageal varix Ascites

  21. CIRRHOSIS- Fatty Liver Disease • ETOH Pathogenesis • Toxin • Nutritional deprivation • Other • Obesity • DM • Medications

  22. HEMOCHROMATOSIS • Iron: liver, pancreas, heart + • Genetic • Homozygous recessive • Chromosome 6 • Secondary overload

  23. HEMOCHROMATOSIS • Morphology • Hemosideron • Fibrosis • Treatment • Phlebotomy

  24. WILSON’S DISEASE • Accumulation of copper; liver, brain, eyes • Autosomal rec • Morphology • Acute / chronic • Steatosis • Necrosis • Cirrhosis • Chelation D-Penicillamine

  25. HEPATIC TUMORS • Benign and malignant • Cysts • Bile ducts • Blood vessel • Hepatocyte • Metastases

  26. BILE DUCT NEOPLASMS • Bile duct adenoma • Gray nodule incidental finding • Bland proliferation ducts • Bile duct carcinoma • Thorotrast, liver fluke • Poor prognosis, late detection

  27. BILE DUCT ADENOMA

  28. BILE DUCT CARCINOMA

  29. HEPATOCELLULAR ADENOMA • Benign • Association with oral contraceptives • Presentation • Acute abdomen • Intra-abdominal bleed • Histology: bland hepatocytes and no bile ducts

  30. HEPATOCELLULAR ADENOMA

  31. HEPATOCELLULAR CARCINOMA- HEPATOMA • Malignant • Most common primary adults • Aflatoxin, cirrhosis, Hep B & C • Serum alpha-fetaprotein • Histology • Atypical hepatocytes • More than 2-3 cell plates • Poor prognosis

  32. HEPATOCELLULAR CARCINOMA

  33. METASTATIC TUMORS • Often multiple nodules • Any primary- GI, lung, breast • CEA may be elevated if metastatic colon • Histology of primary tumor

  34. BILIARY SYSTEMANATOMY • Gallbladder • Fundus • Body • Neck • 60-70% common orifice with pancreatic duct

  35. BILIARY SYSTEMANATOMY • Microscopic- no mm or submucosa • Mucosa • Fibromuscular layer • Subserosal fat • Serosa • Physiology • Concentration • Delivery

  36. CHOLELITHIASIS • Common- 10-20% of adults • Most gallstones silent • Association with inflamed gallbladder • Complications

  37. CHOLELITHIASIS - STONE FORMATION • Pathogenesis • Supersaturation • Initiation • Growth • Types • Cholesterol (85% radiolucent) • Bilirubin (50-75% radiopaque)

  38. CHOLELITHIASISRISK FACTORS • Cholesterol stones • Ethnicity • Age / sex • Diet / drugs • Pigment stones • Chronic hemolysis • Cirrhosis • Biliary infection

  39. CHOLELITHIASISCOMPLICATIONS • Obstruction • Biliary colic • Cholecystitis • Gallstone illeus • May predispose to cancer?

  40. CHOLECYSTITIS • 4th- 6th decade, F > M • Acute • Severe RUQ pain • Chemical, bacterial, reflux • Neutrophils, gangrene? • Chronic • Vague symptoms • Stones (90%) • Fibrosis, chronic inflammation • Acalculous

  41. ACUTE CHOLECYSTITIS

  42. ACUTE CHOLECYSTITIS

  43. ACUTE CHOLECYSTITIS

  44. TUMORSGALLBLADDER • Carcinoma • 5th among GI malignancies • Peak incidence in 7th decade • Whites > blacks, F > M • 65-90% associated stones • Adenocarcinoma, poor survival

  45. GALLBLADDER CANCER

  46. GALLBLADDER CANCER

  47. PANCREAS

  48. PANCREASANATOMY Exocrine – acini and ducts Endocrine - islets

  49. ETIOLOGYACUTE PANCREATITIS • Cholelithiasis • Alcoholism • Trauma • Drugs • Septisemia, infection • Metabolic: hyper – Ca++ and lipids • Idiopathic