Porth's Essentials of Pathophysiology, 4e

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Disorders of Hepatobiliary and Exocrine Pancreas Function

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3. A 40-year-old woman presents in the emergency department with a sudden episode of vomiting and severe right epigastric pain that developed after eating a fatty evening meal. Although there is no evidence of jaundice in her skin, the sclera of her eyes is noted to have a yellowish discoloration. Palpation reveals tenderness of the upper right quadrant with muscle splinting and rebound pain. Right upper quadrant abdominal ultrasonography confirms the presence of gallstones. The woman is treated conservatively with pain and antiemetic medications. She is subsequently scheduled for a laparoscopic cholecystectomy. A. Relate this woman’s signs and symptoms to gallstones and their effect on gallbladder function. B. Explain the initial appearance of jaundice in the eyes as opposed to the skin. Which of the two laboratory tests for bilirubin would you expect to be elevated—direct (conjugated) or indirect (unconjugated or free)? C. What effect will removal of the gallbladder have on the woman’s digestive system? 1. Guyton A, Hall JE. Textbook of Medical Physiology . 12th ed. Philadelphia, PA: Elsevier Saunders; 2011:837–842. 2. Ross MH, Pawlina W. Histology: A Test and Atlas . 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:576–609. 3. Crawford JM, Liu C. Liver and biliary tract. In: Kumar V, Abbas AK, Fausto N, et al., eds. Robbins and Cotran Pathologic Basis of Disease . 8th ed. Philadelphia, PA: Saunders Elsevier; 2010:833–890. 4. Herrine S, Navarro V, Rubin R. The liver and biliary system. In: Rubin R, Strayer DS, eds. Rubin’s Pathophysiology: Clinicopathologic Foundations of Medicine . 6th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012:677–736. 5. Aragon G, Younoussi Z. When and how to evaluate mildy elevated serum enzymes in apparently healthy patients. Cleve Clin J Med. 2010;77(3):195–204. 6. Krier M, Ahmed A. The asymptomatic outpatient with abnormal liver function tests. Clin Liver Dis. 2009;13:167–177. 7. Rockey DC, Caldwell SH, Goodman ZD, et al. Liver biopsy. Hepatology. 2009;49:1017–1044. 8. Matheny SC, Kingery JE. Hepatitis A. Am Fam Physician. 2012;86:1027–1034. 9. Lavanchy D. Viral hepatitis: Global goals for vaccination. J Clin Virol. 2012;55(4):296–302. 10. Carey W, Anand B, Lauer G, et al. Viral hepatitis B and D. First Consult . 2012. Available at: https://www.clinicalkey.com. Accessed September 1, 2013. 11. World Health Organization. Hepatitis B. 2013. Available at: http://www.who.int/topics/hepatitis. Accessed August 28, 2013. 12. Centers for Disease Control and Prevention. Hepatitis B for health professionals. 2012. Available at: http://www.cdc.gov/ hepatitis/HBV. Accessed August 28, 2013. 13. Hajarizadeh B, Grebely J, Dore GJ. Epidemiology and natural history of HCV infection. Nat Rev Gastroenterol Hepatol. 2013;10:553–562. R E F E R E N C E S

R E V I EW E X E R C I S E S 1. A 24-year-old woman reports to her health care professional with complaints of a yellow discoloration of her skin, loss of appetite, and a feeling of upper gastric discomfort. She denies use of intravenous drugs and has not received blood products. She cannot recall eating uncooked shellfish or drinking water that might have been contaminated. She has a daughter who attends day care. A. What tests could be done to confirm a diagnosis of hepatitis A? B. What is the most common mode of transmission for hepatitis A? It is suggested that the source might be through the day care center that her daughter attends. Explain. C. What methods could be used to protect other family members from getting the disease? 2. A 56-year-old man with a history of heavy alcohol consumption and a previous diagnosis of alcoholic cirrhosis and portal hypertension is admitted to the emergency department with acute gastrointestinal bleeding due to a tentative diagnosis of bleeding esophageal varices and signs of circulatory shock. A. Relate the development of esophageal varices to portal hypertension in persons with cirrhosis of the liver. B. Many persons with esophageal varices have blood coagulation problems. Explain. C. What are the possible treatment measures for this man, both in terms of controlling the current bleeding episode and preventing further bleeding episodes? ■■ The pancreas is an endocrine and exocrine organ.The exocrine function of the pancreas produces digestive enzymes that are secreted in an inactive form and transported to the small intestine through the main pancreatic duct, which empties into the hepatopancreatic ampulla and then into the duodenum through the sphincter of Oddi. ■■ Acute pancreatitis is an inflammatory condition of the pancreas due to inappropriate activation of pancreatic enzymes, with manifestations that can range from mild to severe and life-threatening. ■■ Chronic pancreatitis causes progressive destruction of the endocrine and exocrine pancreas. It is characterized by episodes of pain and epigastric distress that are similar to but less severe than those that occur with acute pancreatitis. ■■ Pancreatic cancer, the cause of which is unknown, is considered to be one of the most deadly malignancies.