Beruflich Dokumente
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6/1/11
Normal Structure and function
•Zone 1 – periportal
•Zone 3
• near the central vein
(low oxygen)
• high cyp450
(susceptible drug injury)
• “centrilobular
necrosis”
• outflow obstruction
“centrilobular
congestion” – “nutmeg
liver” (i.e. cardiac,
budd-chiari)
• Foregut:
– Portal venous
drainage
– Stomach, liver,
gallbladder,
spleen, proximal
duodenum
• ~80% bilirubin from
hemoglobin breakdown
• Heme oxygenase in
reticuloendothelial cells in
spleen and Kupffer cells
• B = bilirubin
• UGT = UDP-Glucuronyl Transferase
• BG = glucuronidated bilirubin (i.e.
conjugated)
Common; fasting can
make apparent
Adult
< 10%
normal
Adult Adult
• ~90%+ bile acids actively resorbed in terminal
ileum
• Remaining bile acids converted to
urobilinogen in colon
– Some of this resorbed (shows in urine)
– Some in stool (color of stool)
• Ursodeoxycholic
acid ‘favorable’
bile acid
• Oral therapy can
increase pool to
~40% of bile acids
• More soluble bile
Table 62-2 -- Relative Frequencies of Various Forms of Neonatal Cholestasis
Modified from Balistreri WF. Neonatal cholestasis: Lessons from the past, issues for the future. Semin Liver Dis 1987; 7:61.
DISORDER FREQUENCY
Idiopathic neonatal
30-35
hepatitis
Extrahepatic biliary atresia 30 • Unconjugated
α1-Antitrypsin deficiency 7-10
Intrahepatic cholestatic hyperbilirubinemia
syndromes (Alagille
syndrome, Byler's disease,
5-6 common (lasts < 2
others)
Hepatitis
weeks)
(cytomegalovirus, rubella,
herpes simplex virus,
3-5 • Neonatal cholestasis
others)
Choledochal cyst 2-4
(conjugated
Bacterial sepsis 2 hyperbilirubinemia
Endocrinopathy
Biliary atresia – no (hypothyroidism, ≈1
after 2 weeks)
extrahepatic ducts panhypopituitarism)
Galactosemia ≈1
(need Kasai surgery) Inborn errors of bile acid
≈1
metabolism
Other metabolic disorders ≈1
Young, eye
findings,
mental illness
or dementia
Bile duct
• Range of presentations
– Acute liver failure
– Chronic elevation of liver
tests
– Chronic asymptomatic
disease (present as
cirrhosis)
• Diagnostic tests
– ANA, smooth muscle
antibody, ?anti-LKM
– SPEP or quantitative
immunoglobulins
– Frequently liver biopsy
Portal vein
Primary biliary cirrhosis
• ~95% Women
• Predominant Alkaline phosphatase elevation
• ~95% AMA (+)
• Ursodiol
• Pruritus, jaundice, hypercholesterolemia,
woman, middle age
Gallbladder
• ~7-10% of
population
• Can be
cause of
idiopathic
pancreatitis
The pancreas develops from two parts whose ducts are in continuity with the common
bile duct. One part is ventral and the other dorsal to the intestinal tract before
rotation. The rotation brings the two parts together with separate ducts. The duct of
the dorsal (larger) part later becomes continuous, enters that of the ventral part which
enters the duodenum with the common bile duct. However, in a congenital
malformation (pancreas divisum) the other two parts of the pancreas remain distinct,
each with its own duct.
Pancreas Cancer