Biliary and Heme
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Elderly patient with anemia and no identifiable cause
B12 malabsorption usually due to gastric atrophy
Treatment that prolongs survival of a disease will increase incidence or prevalence?
- (incidence doesnt change)
Patient who is incapacitated (e.g. under the influence) - who should make decisions?
- Not the patient
- Surrogates or continue treatment until sober
Structure of HbA
Structure of HbA2
Structure of HbF
Rat poison is like what anti-coagulant?
Tight adhesion of platelets
ICAM-1 and CD-18 (endothelial cells)
Transmigration of platelets
PECAM-1 on intestinal endothelial cells
Rolling of platelets
L-selectin (neutrophils) and E-selectin/P-selectin (on endothelial cells)
Prolonged fasting state: Activation of an enzyme to stimulate glycolysis using pyruvate?
Pyruvate carboxylase (pyruvate to oxaloacetate and oxaloacetate enters TCA); co-activator: acetyl-coA
Diffuse gallbladder calcification leads to?
aka = porcelain gallbladder (2nd to irritation from gallstones) --> gallbladder cancer
Sudden onset of transient numbness and tingling of left arm, resolving within 20 mins. Dx?
- Seen with hemolytic anemias and blood transfusions
- Increased Fe deposited as hemosiderin (all cannot be stored as ferritin)
TG breakdown product used to make glucose. Enzyme?
Glycerol kinase, occurs in the liver
Reye's syndrome in the liver biopsy
Microvascular steatosis: presence of small fat vacuoles in cytoplasm of hepatocytes
Viral hepatitis in liver biopsy
- Apoptosis of hepatocytes (Ballooning degeneration)
- Acinar necrosis
- Periportal mononuclear infiltration
Ground-glass with eosinophilic appearance on liver biospy. Virus?
Factor V Leiden mutation resistant to protein C
Hyper-coagulable state causing DVT leading to PE
Uremic platelet dysfunction. Blood values?
All normal, except BT is prolonged
Fe overload in heart, pancreas, and liver (cirrhosis and HCC)
Vitamin B12 replacement therapy
- 1. Increased reticulocyte count immediately (released from BM)
- 2. Anemia takes longer to correct (gradual increase)
- 3. Methylmalonyl acid levels decrease
Neonates born to HbsAg and HbeAg + mothers. Replication rate? Risk of chronic infection? Histo findings on liver?
- Replication rate: High
- Chronic infection: High
- (replication rate = high, leading to cirrhosis and chronic HCC)
- Histo findings on liver: Mild
- (neonatal immune system is still immature)
Qualities of Hep B virus
- Hepadnaviridae = enveloped, dsDNA
- partially circular
- Has its own reverse transcriptase
- Thymidine analog that's a NRTI
- inhibits 3'-5' phosphate bond formation
- (has an azido group on 3' end of thymidine analogue - prevents nts from binding
Blot to detect gene expression
Northern blot detects mRNA
Congenital prolonged QT intervals due to?
- Mutations in the K+ channel, causing delayed repolarization of the ventricles
- Can present with sensorineural deafness (AR)
- Progresses to torsades de pointes
Pigment stones caused by?
- Injury to biliary tract - release of B-glucuronidase by injured hepatocytes and bacteria
- Hydrolysis of bilirubin glucuronides + increases unconjugated bilirubin in bile.
Drugs that increase PR interval
B-blockers: decrease automaticity of SA and AV node by acting on phase 4 (funny Na+ channels)
Drugs that increase QT interval
- 1. Quinidine
- 2. Sotalol
- Increases AP which increases ERP -- makes it longer for the cells to repolarize to generate another AP.
INH is metabolized via?
Affects of the decreased metabolism process?
- Slow acetylation causes an accumulation of the drug in plasma
Characteristic of Abx where hepatic metabolism and clearance is used
- High lipophilicity
- Increased volume of distribution
- Good penetration into the CNS
(n.b. low Vd allows drug to remain in plasma, hydrophilic, and excreted by the kidney only)
Function of 16S rRNA?
- Part of 30S ribosomal unit in prokaroytes
- Complementary to the Shine-Dalgarno sequence on mRNA
- Binding of the two = initiation of protein synthesis
- After each vaccination
- Clearance of HbsAg infection (no symptoms)
Poisonous dead cap mushrooms
a-Amantin inhibits RNA polymerase II (formation of mRNA)
- Cholestrol levels greater than bile acids or gallbladder hypomotility
- High levels of phosphatidylcholine prevents cholestrol from being soluble
Fulminant hepatitis caused by inhaled anesthetics such as halothane.
- Increased aminotransferase
- Prolonged Prothrombin time
Measures of liver injury that indicate a bad prognosis?
- Increased PT time measurement (loss of coagulation factors)
- Hypoalbunemia (decreased albumin synthesis)
Extrahepatic biliary atresia
- Obliteration of the extrahepatic bile ducts
- Increased proliferation of the intrahepatic bile ducts
- Portal tract edema and fibrosis
- Parenchymal cholestasis
Congenital endocardial cushion defects cause what murmur?
Rheumatic heart disease leads to waht murmur?
- Mitral regurg
- Mitral valve prolapse --> Mitral stenosis
Increased TG synthesis, and decreased FFA oxidation
Destruction of intrahepatic bile ducts with granulomatous inflammation
Primary biliary cirrhosis
Warfarin overdose or severe vitamin K deficiency, what happens to PT and PTT?
- Both elevated.
- Corrected with 1:1 dilution of patient's plasma with normal plasma = clotting factors can be reduced without changing coagulation times
Normal doses of warfarin, what happens to PT and PTT?
- PT elevated
- All else normal
Bacteria causing bloody diarrhea in daycare centres
- Yersinia enterolytica (located in the RLQ mimicing appendicitis)
Window period of Hep B
- Conversion from HBsAg to HBsAb - both of them will be negative
- Positive: HbcAb + HbeAb
Lymphogranuloma venerueum (painful, enlarged abscessed lymph nodes) - what two bugs?
- C. trachomatis
- Chancroid (H.ducreii)
Gilberts syndrome asymptomatic jaundice
- Mild unconjugated bilirubinemia
- Jaundice occurs with stress: infection, fasting, etc
- US: Mass in the abdomen or pelvis
- Histo: Lymphocytes interspersed with macrophages
Why is D-dimer more effective test than fibrin degradation products?
- D-dimers arise from fibrin in blood clots - test thrombin and plasmin together.
- FDP arise from fibrin and fibrinogen (plasmin can break down fibrinogen too)
Removal of duodenum
- Secretin decreases
- CCK decreases -
- decreased gallbladder contraction
- increased gastric emptying
- Decreases lipid absorption
Pigmented gallstones made from?
Skin penetration of larvae
Hookworms (Necator + Acyclodes)
- Acquired directly, no intermediate host
- Ingestion of eggs from human feces
Action of tPA?
- Converts plasminogen to plasmin which breaks down clots.
- Plasmin breaks down fibrin --> fibrin split products (Ddimers)
- Plasmin breaks down fibrinogen to fibrinogen degradation products (FDPs)
- Less fibrinogen (factor I) - increases PT and PTT
- 1st week of life with bloody diarrhea and severe abdomen pain
- Can show transmural necrosis, inflammation
Intracellular bacteria stimulates what cell increase?
- Th1 cells secrete cytokines to stimulate cell-mediated immunity
Charcoat triad (fever, RUQ pain, jaundice)
Cholangitis due to obstruction of gallstone in the common bile duct
Night sweats, fever, cervical lymphadenopathy, generalized pruritis
- Hodgkin's lymphoma
- (presents like TB)
Chronic hepatitis with which virus is most likely?
HCV virus: IgG antibodies against HCV are not protective
Superimposed HDV (anti-HDAg IgM) on chronic HBV (anti-HBsAg IgG with HbsAg) - consequences?
- Mild HBV converted to fulminant dz.
- Acute hepatitis in an asymptomatic HBV carrier
- Chronic progression leading to cirrhosis
Liver abscesses - causes?
- Entamoeba histolytica with bloody and mucus diarrhea
- Bacterial causes from cholangitis caused by gallstones
Persistence of HbsAg for more than 6 months
Carrier state: acquired in utero or at birth.
Changes in the liver when chronic alcoholic stopped drinking 10 years ago
- No fatty changes as not currently drinking
- Cirrhosis persists for decades after it develops
Warm autoimmune hemolytic anemia - causes?
- (positive direct Coomb's test: Ig coating RBCs acts as an opsonin to promote splenic phagocytosis)
Sickling phenomenon: what happens to spleen?
- Childhood: spleen may be enlarged from enlargement of sinusoids with sickled cells
- Adult: hypoxic damage occurs and patient develops a vaso-occlusive crisis affecting the lung
- Excess of a-globin chains precipitating in RBCs and its precursors
- Cells are more susceptible to damage and removal = loss of RBC precursors = ineffective erthrypoeisis
- Greater dietary absorption of iron
- Extravascular hemolysis releases Fe that can be reused for Hb synthesis = Hemachromatosis
Vaso-occlusive crisis in sickle cells patients
- Increased adhesiveness of damaged red cell membranes to vascular endothelium
- Extent of sickling correlated with anemia, not with vaso-occlusive episodes
Hemachromatosis associated with what anemia
- B-thal major
- Increased ineffective erythropoeisis due to severe anemia
- Expansion of bone marrow and stimulus to absorb more Fe
- Requires blood transfusions = secondary hemachromatosis
Blood loss in an elderly (ACD) - values and compensatory response
- Decreased Fe, Increased ferritin, Decreased TIBC
- Reticulocyte count is increased, BM shows erythroid hyperplasia
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