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LIVER, GALLBLADDER, PANCREAS

LIVER, GALLBLADDER, PANCREAS. Liver Jaundice Hepatitis Cirrhosis Tumors Gallbladder Pancreas. LIVER ANATOMY. Central area. Portal area. LIVER MICROSCOPIC. Duct. Vein. Artery. HEPATIC INJURY. Degeneration or accumulation Necrosis Inflammation Regeneration Fibrosis.

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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

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