Cholelithiasis
What lab aspect shows the herniation?
=> look at pancreatic liver enzyme, LFT
N/V = nausea / vomiting
Symptom gallbladder disease?
fatty food intolerance
no US in upper GI, gallbladder
HIDA scan
What to tell biliary dyskinesia?
- w/ ejection fraction (tells gallbladder empty or not)
- oral cholecystogram(old method) when no US
achalasia -> myotomy
chronic inflammatory demyelinating polyneuritis
why barium?
- if it is leaking, don't want barium into cavity, barium can cause inflammation
why gastograph?
- water soluble, hygroscopic(draws in water from surrounding)
partially incarcerated omentum at umbilicus
childs A cirrhosis
direct/indirect bilirubin
direct - conjugated, processed in liver and secreted; indirect - unconjugated, not soluble, not yet processed in the liver
15 total bilirubin, haven't been fractionated => ?
more conjugated or unconjugated?(SPP) => prolly unconjugated since the pt has cirrhosis and liver prolly not functioning
if highly conjugated bilirubin => liver conjugated, liver working but bilirubin not leaving the liver or gallbladder => blockage, tumor or stone
cause of achalasia
- neurological, viral, infection
1) spincter not open
2) motility not good
bird's beak
dilation of esophagus
In medicine, gallstones (choleliths) are crystalline bodies formed within the body by accretion or concretion of normal or abnormal bile components.
Cholesterol stones are usually green, but are sometimes white or yellow in color and account for about 80 percent of gallstones. They are made primarily of cholesterol.
Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. They account for the other 20 percent of gallstones. Risk factors for pigment stones include cirrhosis, biliary tract infections, and hereditary blood cell disorders, such as sickle cell anemia. Stones of mixed origin also occur.
Gallstones can occur anywhere within the biliary tree, including the gallbladder and the common bile duct. Obstruction of the common bile duct is choledocholithiasis; obstruction of the biliary tree can cause jaundice; obstruction of the outlet of the pancreatic exocrine system can cause pancreatitis. Cholelithiasis is the presence of stones in the gallbladder - chole- means "gall bladder", lithia meaning "stone", and -sis means "process".
Gallstones vary in size and may be as small as a grain of sand or as large as a golf ball. The gallbladder may develop a single, often large, stone or many smaller ones, even several thousand.
-------------------------------------------------------------------------(LFTs or LFs), which include liver enzymes, are groups of clinical biochemistry laboratory blood assays designed to give information about the state of a patient's liver. Most liver diseases cause only mild symptoms initially, while it is vital that these diseases be detected early. Hepatic involvement in some diseases can be of crucial importance. This testing is performed by a Medical technologist on a patient's serum or plasma which is collected by a phlebotomist.
Standard liver panel
[edit] Total Protein (TP)
The liver produces most of the plasma proteins in the body making a measure of the amount of protein in the blood useful. Reference range (60-80 g/L).
[edit] Albumin (Alb)
Albumin is a protein made specifically by the liver, and can be measured cheaply and easily. It is the main constituent of total protein; the remaining fraction is called globulin (including e.g. the immunoglobulins). Albumin levels are decreased in chronic liver disease, such as cirrhosis. It is also decreased in nephrotic syndrome, where it is lost through the urine. Poor nutrition or states of protein catabolism may also lead to hypoalbuminaemia. The half-life of albumin is approximately 20 days. Albumin is not considered to be an especially useful marker of liver synthetic function, coagulation factors (see below) are much more sensitive. The reference range is 30-50 g/L. (3.0-5.0 mg/dL)
[edit] Alanine transaminase (ALT)
Alanine transaminase (ALT), also called Serum Glutamic Pyruvic Transaminase (SGPT) or Alanine aminotransferrase (ALAT) is an enzyme present in hepatocytes (liver cells). When a cell is damaged, it leaks this enzyme into the blood, where it is measured. ALT rises dramatically in acute liver damage, such as viral hepatitis or paracetamol (acetaminophen) overdose. Elevations are often measured in multiples of the upper limit of normal (ULN). The reference range is 15-45 U/L in most laboratories.
[edit] Aspartate transaminase (AST)
Aspartate transaminase (AST) also called Serum Glutamic Oxaloacetic Transaminase (SGOT) or aspartate aminotransferase (ASAT) is similar to ALT in that it is another enzyme associated with liver parenchymal cells. It is raised in acute liver damage, but is also present in red cells, and cardiac and skeletal muscle and is therefore not specific to the liver. The ratio of AST to ALT is sometimes useful in differentiating between causes of liver damage:
- ALT>AST: acute viral hepatitis or drug-induced hepatitis
- ALT
In resource-poor settings, the AST is more frequently available than the ALT, because it is a cheaper assay.
[edit] Alkaline phosphatase (ALP)
Alkaline phosphatase (ALP) is an enzyme in the cells lining the biliary ducts of the liver. ALP levels in plasma will rise with large bile duct obstruction, intrahepatic cholestasis or infiltrative diseases of the liver. ALP is also present in bone and placental tissue, so it is higher in growing children (as their bones are being remodelled). The reference range is usually 30-120 U/L.
[edit] Total bilirubin (TBIL)
Bilirubin is a breakdown product of heme (a part of hemoglobin in red blood cells). The liver is responsible for clearing this, excreting it out through bile into the intestine. Problems with the liver or blockage of the drainage of bile will cause increased levels of bilirubin, as will increased haemolysis of red cells.
Direct bilirubin, or conjugated bilirubin is often measured in tandem, especially if the total bilirubin level is elevated. Bilirubin is unconjugated, also known as indirect bilirubin, before the liver modifies it for excretion. It is dangerous in babies, as it can pass the blood-brain barrier causing kernicterus.
[edit] Other tests commonly requested alongside LFTs:
[edit] Gamma glutamyl transpeptidase (GGT)
Although reasonably specific to the liver and a more sensitive marker for cholestatic damage than ALP, Gamma glutamyl transpeptidase (GGT) may be elevated with even minor, sub-clinical levels of liver dysfunction. It can also be helpful in identifying the cause of an isolated elevation in ALP. GGT is raised in alcohol toxicity (acute and chronic).
[edit] 5' nucleotidase (5'NTD)
5'NTD is another test specific for cholestasis or damage to the intra or extrahepatic biliary system, and in some laboratories, is used as a substitute for GGT for ascertaining whether an elevated ALP is of biliary or extra-biliary origin.
[edit] Coagulation tests (e.g. INR)
The liver is responsible for the production of coagulation factors. The international normalized ratio (INR) measures the speed of a particular pathway of coagulation, comparing it to normal. If the INR is increased, it means it is taking longer than usual for blood to clot. The INR will only be increased if the liver is so damaged that synthesis of vitamin K-dependent coagulation factors has been impaired: it is not a sensitive measure of liver function.
It is very important to normalize the INR before operating on people with liver problems (usually by transfusion with blood plasma containing the deficient factors) as they could bleed excessively.
[edit] Serum glucose (BG, Glu)
The liver's ability to produce glucose (gluconeogenesis) is usually the last function to be lost in the setting of fulminant liver failure.
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| Gallbladder dyskinesia or gallbladder dysmotility are terms used to refer to the inability of the gallbladder to contract properly, for example following ingestion of meals. Following ingestion of a meal, the gallbladder is stimulated by the secretion of cholecystokinin to contract. In doing so, the bile from the gallbladder is ejected, and passed into the duodenum where it aids with the digestion of food. Patients with gallbladder dysmotility may present with post-prandial abdominal pain (i.e. pain that occurs after easting) that is usually located in the right upper quadrant (RUQ) area of the abdomen (under the lower edge of the right rib cage). Nausea and occasionally vomiting may accompany their symptoms. On palpation, there may be tenderness in the RUQ area of the abdomen. Their diagnostic evaluation would reveal normal liver function tests, and no abnormalities of their bile ducts or gallbladder would be seen on routine ultrasound studies. Magnetic resonance imaging and magnetic resonance cholangiopancreatography (MRI/MRCP) would also be normal. Further diagnostic work-up for a broad range of causes of abdomianl pain with endoscopy, colonoscopy, and abdominal computed tomography (CT) scan would not reveal any sources for symptoms. The occasional patient may have even undergone an endoscopic retrograde cholangiopancreatography (ERCP) without any abnormal findings and without any improvement if an endoscopic sphincterotomy was performed. Diagnostic studies that would show abnormalities are, gallbladder function testing with meal or cholecystokinin stimulated ultrasound studies or scintigraphic studies (HIDA scan). These studies would demonstrate diminished emptying of the gallbladder following stimulation by a meal or cholecystokinin injection. A significant number of symptomatic patients with gallbladder dyskinesia would benefit from a laparoscopic cholecystectomy. The mechanism behind gallbladder dyskinesia is not fully understood. Chronic cholecystitis has been implicated as a potential cause. Whenever gallbladder dyskinesia is suspected or is found, a careful evaluation for other causes of the patient's symptoms should be performed. Otherwise, there would be a risk of persistent symptoms remaining despite cholecystectomy. |
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Oral cholecystogram: Abbreviated OCG. An x-ray procedure for diagnosing gallstones. The patient takes iodine-containing tablets by mouth for one night or two nights in a row. The iodine is absorbed from the intestine into the bloodstream, removed from the blood by the liver, and excreted by the liver into the bile. The iodine, together with the bile, is highly concentrated in the gallbladder. Iodine is used in an OCG because it is dense and radioopaque (stops x-rays). It outlines the gallstones that are radiolucent (x-rays pass through them) and that are usually invisible on x-ray. The failure to visualize the gallbladder on an OCG is evidence for a diseased gallbladder. The OCG is an excellent procedure for diagnosing gallstones when they are strongly suspected but cannot be seen by ultrasound
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LOTS OF HERNIA, RIH AND LIH TOMORROW!
