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METABOLIK
Susiana Candrawati
Hormones play an important function in regulation & control of body functions &
metabolism
Hormones exert control that is slower acting but of longer duration than nerve impulses
Hormones secreted by endocrine glands go to a target organ
How do specific hormones know where to go?
Receptors in the cell are specific for certain hormones
Thus get lock & key effect
2 types of hormones
Protein derivative hormones (from amino acids or polypeptides)
water soluble, thus need plasma membrane receptor
then need second messenger for hormone to exert its action
this action occurs in the cytoplasm
Lipid derivative hormones (primarily steroids)
Fat soluble, thus pass right through the cell membrane
bind with receptor in the nucleus
this complex triggers DNA to make a specific protein
Prostaglandins
Written as PG; called tissue hormones
they are substances produced locally by specific tissues
they travel only short distances & thus have a localized effect
2 types: Inflammatory (bad) & non-inflammatory (housekeeping or good)
Prostaglandins & leukotrienes = usually enhance inflammation
Prostacyclins & thromboxanes = work in opposition to platelet aggregation
Pituitary Gland
2 glands
Anterior pituitary
Adenohypophysis
Posterior pituitary
Neurohypophysis
Extension of
hypothalamus
ACTH
hyposecretion = Addisons disease
hypersecretion = Cushings disease
FSH
hyposecretion
M = poor sperm production
F = low estrogen, amenorrhea
hypersecretion
F = menopause
LH
hyposecretion
F = no ovulation
M = low testosterone
MSH
hypersecretion = excess pigment
GH
hypersecretion
during growth = giantism
after growth = acromegaly
hyposecretion = dwarfism
PRL
hypersecretion = galactorrhea,
infertility
hyposecretion = poor milk production
ADH
Hypersecretion = SIADH
Syndrome of inappropriate ADH
secretion
Dwarfism
If congenital get mental retardation(+/-) & no secondary sexual characteristics
Tx = GH
Prolactinoma
Most common pituitary functional tumor
Get high prolactin levels
In women get galactorrhea, amenorrhea, infertility
In men get impotency, oligospermia, decrease libido
Diabetes Insipidus
Symptoms = polyuria & polydipsia
Get large amounts of dilute urine & dehydration
Etiol:
head injury or surgery = temporary condition
Nephrogenic tubular insensitivity to ADH = permanent condition
Tx = replacement therapy with ADH
SIADH
Get too much ADH secretion & get retention of fluid
Etiol :
Some cancers especially oat cell lung cancer (very common cancer)
Post op (temporary, only last 1 week)
Stress
Psychiatric diseases
Pathophysiology = hypoosolarity & hyponatremia
Symptoms related to low serum sodium
First = fatigue & weakness
Then G-I sx
Then twitchings, convulsions, & coma
Hypothalmus
Three things it does relating to the endocrine system
(1) it makes the posterior pituitary hormones
oxytocin (OT)
antidiuretic hormone (ADH)
* nb: diabetes insipidus & SIADH
Releasing Hormones
* exp = GnRH (gonadotropin releasing hormone)
Inhibiting Hormones
(3) It controls sympathetic output of adrenal medulla
Thyroid Gland
3 hormones
Thyroxine (T4) = more abundant than T3, but less potent
Triiodothyronine (T3) = more potent than T4
Calcitonin
Functions:
Thyroid hormones (T4 & T3) function = increase metabolic rate
Calcitonin
lowers serum calcium by preventing the bones from giving it up
works in harmony with the parathyroid & parathormone
Disease states
Goiter may be euthyroid, hyper or hypo
hyperthyoidism
Graves disease = one specific type;autoimmune etiol;
get exophthalmos
hypothyroidism
cretinism = congenital type
myxedema = adult type;get edema of face & tongue
Hashimotos disease = autoimmune; chronic inflam.
produces fibrosis of thyroid
Thyroid cancer
Key cause = radiation exposure
Goiter
By definition just means thyroid enlargement
Pathophysiology = excess TSH
If have goiter, patient may be
Normothyroid
Hypothroid
Hyperthyroid
3 clinical types
Endemic goiter --- from lack of iodine in diet (hypothyroid)
See next slide
From goitrogens --- from drugs (e.g. lithium) & foods (e.g. cabbage)
These prevent T3 & T4 production
Hyperthyroidism
2 types: with exophthalmos & without exopthalmos
Graves disease
Autoimmune
Most common form of hyperthyroidism
Get goiter
Symptoms = motor running fast
Tachycardia, systolic hypertension, palpitations,
insomnia,
heat produces discomfort
Exophthalmos (+/-)
Complication = thyrotoxicosis or thyroid storm
Treatment
Radioactive iodine
Surgery
Antithyroid drugs
Hypothyroidism
Commonest problem of thyroid
3 forms
Hashimotos thyroiditis---- autoimmune
Myxedema --- adult severe hypothyroidism
Myxedema = nonpitting edema of puffy face & thick tongue
In early mild form --- symptoms subtle; hard to diagnose
Muscle weakness (hung-up reflex)
Mental apathy
Dry skin
Likes heat (always cold)
Parathyroid Glands
Pancreas
Pancreas is both endocrine & exocrine gland
exocrine = digestive enzymes secreted via duct into duodenum
endocrine located in Islets of Langerhans
Cells of the islets
alpha cells produce glucagon
it raises blood sugar by increasing liver
glycogenolysis
beta cells produce insulin & amylin
Insulin lowers blood sugar by escorting glucose into
the cells
Amylin contributes to postprandial glucose control
* slows gastric emptying
* regulates appetite centrally
* see comment on good health --- next slide
Insulin
Anabolic hormone (a type of growth factor)
Diabetes Mellitus
Def: a disease that involves an insulin deficit
Get hyperglycemia
Get lack of available glucose in cells for mitochondria to make ATP
Thus, mitochondria use fats to generate ATP
Side effect = ketone body formation
Adrenal Cortex
Has 3 distinct layers or zones
from outside towards middle:
Zona Glomerulosa
secretes mineralcorticoids (Aldosterone)
Retain sodium (water follows sodium)
Usually gets rid of potassium & hydrogen
Zona Fasiculata
secretes glucocorticoids (Cortisol)
Secreted in response to stress
Causes gluconeogenesis & hyperglycemia
Causes protein catabolism
* thus, delays healing
Is anti-inflammatory
Maintains BP by sensitizing vessels to ANS
Zona Reticularis
secretes sex hormones (steroids)
Etiol
Pituitary adenoma
Adrenal adenoma
Ectopic paraneoplastic
syndrome
Iatrogenic
Only cause that
produces adrenal
atrophy & resultant
poor response to stress
see next slide
Etiol
Pituitary adenoma
Adrenal adenoma
Ectopic
paraneoplastic
syndrome
Iatrogenic
Only cause that
produces adrenal
atrophy &
resultant poor
response to
stress
Hyposecretion
Usually affects both glucocorticoids & mineralocorticoids
Adrenal Medulla
Stress Response
PATOPHYSIOLOGY OF
REPRODUCTIVE SYSTEM
Susiana Candrawati
Testes
tunica vaginalis = parietal peritoneum that remains surrounding testis after
its descent
tunica albuginea = tough connective tissue membrane that surrounds testis
and enters the gland to form septa
seminiferous tubules = where sperm are developed; approx. 100 yards in in
testis; contain
Sertoli cells
Leydig cells
Testes (cont)
Physiology
Spermatogenesis
mature sperm formed by process
of Meiosis
Key = getting mature
gamete with number of
chromosomes
mature sperm = head
(nucleus & acrosome), neck
(mitochondria), and tail
takes 60 days +/- to make a
sperm
primary spermatocyte, secondary
spermatocyte, spermatids, sperm
Testosterone Production
2 key functions
masculinization
anabolism
Accessory Glands
Seminal Vesicles
contributes 60% of semen
rich in fructose ; provides energy for the sperm
Prostate
contributes 30% of semen ; provides nutrients for the sperm; antibiotic
secretion
Bulbourethral Glands (Cowpers)
contribute 5-10% of semen ; provides lubrication & sterilization
External Genitalia
Penis
3 columns of erectile tissue
corpora cavernosa (2) & corpora spongiosum (1)
glans covered by foreskin (prepuce)
Scrotum
skin-covered (has hair follicles) pouch suspended from groin
Female Reproductive
System
Anatomy
gonads = ovaries
ductal system = fallopian
tubes, uterus, vagina
accessory glands =
Bartholin's, breasts
external genitalia = clitoris,
labia majora & minora,
perineum
Ovaries
contain gametes (oocytes) surrounded by
some cells (follicular cells)
these called Primary Follicles
each ovary has appox. 1 million
at birth
life cycle of oocyte after puberty: primary
oocyte, secondary oocyte, ovum
functions
gamete production
hormone production
Estrogen = causes feminization ;
from granulosa cells
Progesterone = prepares for
pregnancy ; from corpus luteum
Accessory Glands
Bartholins (greater vestibular)
exocrine gland
provides lubrication
Breasts
composed of glands & ducts surrounded by fat tissue
External Genitalia
clitoris, labia majora & minora (no hair follicles), vestibule, perineum
4 basic parts:
Menses
Proliferative Phase
= first half of cycle
deals with
maturation of
follicle &
development of
more granulosa
cells thus
producing more
estrogen
Ovulation = usually
at midcycle
Secretory Phase =
second half of cycle
deals with
conversion of
ruptured follicle
to corpus
luteum
corpus luteum
produces
progesterone
hormonal control
hypothalamus-------GnRH (gonadotropin
releasing hormone)
anterior pituitary---FSH (follicle
stimulating hormone)
LH
(luteinizing hormone)
Ovary --------------Estrogen
Progesterone
Hydrocele
most common disease of testes
its fluid in cavity bound by the 2 layers of tunica vaginalis
this may communicate with peritoneal cavity via congenital patency of
process vaginalis
this may cause size to vary from time to time
Infertility Problems
deals with decreased production and/or quality of sperm
2 distinct reasons
poor production in sperm development
One correctable cause = varicocele
blockage of ductile system
low count = oligospermia
zero count = azospermia
Varicocele
varicosities around the testis (usually left testis)
left spermatic vein into renal vein (10 cm higher
than insertion of right spermatic
vein into inferior vena cava)
usually begins at puberty
may be relieved by lying down
Timing
Usually puberty
Testicular Cancer
range from VERY aggressive to least aggressive
Germ cell tumors
Seminoma = least aggressive (most common)
Nonseminomas
* embryonal carcinoma
* teratomas
* choriocarcinoma = most aggressive
Non- germ cell tumors
May be hormonally active (secrete androgen or estrogen)
Exp: leydig cell, Sertoli cell
tumors of young men ( age 15 - 35)
diagnosis : tumors are solid masses - no transillumination
Usually unilateral
predisposing factors:
undescended testes
inguinal hernia during childhood
prior history of mumps orchitis
Note: in mumps orchitis, 50% of cases result in testicular atrophy
Cure rate = 95%
Prostate Diseases
Benign Prostatic
Hypertrophy (BPH)
enlargement of the
prostate common in older
men
Involves central area of
gland
complications include:
pyelonephritis
hydronephrosis
uremia
Cancer
primarily occurs in men over age 50
third leading cause of cancer death
Involves periphery of gland
Usually begins as nodule on posterior surface of gland
Many are androgen dependent
If metastases, first usually to bone
diagnosis
DRE
2 serum markers
PSA (prostatic specific antigen)
Prostatic acid phosphatase
Ultrasound
Carcinoma
Rare
Risk factors: HPV (now have vaccination)
First sign = usually leukoplakia
circumcision in child prevents it
adult circumcision does not prevent it
Impotency
approx. 50% of men age 40 - 70 have, at times, some degree or complete
impotency ( failure to get an erection)
sexual stimulation causes release of nitric acid from nerves in penis
an enzyme breaks down the product of nitric acid that causes the erection
this enzymes effect is loss of the erection
this is where Viagra works ; it prevents loss of the erection
Menstrual disorders
Endometriosis
Menopause
Infections
Tumors
Benign
Malignant
Breast
Pregnancy
STDs
Structural abnormalities
Pelvic relaxation disorders
Normal variations of uterine position
Uterine mobility is key to normalcy
Uterine prolapse
First, second, & third degrees
Cystocele
Rectocele
Normal variations of
uterine position
Uterine mobility
is key to
normalcy
midline
Anteverted &
anteflexed
Retroverted &
retroflexed
Uterine Prolapse
def = downward displacement of uterus
etiol = fascial tissue defect
First degree
Get vaginal shortening
Second degree
Cervix at introitus
Third degree
Vagina completely everted
Uterus hanging outside vagina
Cystocele
downward displacement of bladder into vagina
Can get retention & frequent cystitis
urethra may or may not accompany it
called cysto-urethrocele
frequently get symptom of urinary stress
incontinence
Rectocele
displacement of rectum into vagina
Usually asymptomatic
If very large may get constipation & inability to
completely evacuate rectum
May get ulceration of vaginal wall
See picture
Menstrual Disorders
Dysmenorrhea
Primary dysmenorrhea = when no obvious pathology found
? Hormonal cause
prostaglandins
hormonal changes secondary to teenage ovulatory cycles
Secondary dysmenorrhea = when obvious pathology found as the cause
Amenorrhea
Primary Amenorrhea = never having a menstrual flow
Secondary Amenorrhea = having menstrual cycles & then they stop
causes = many !!!
Treatment directed at the underlying cause
Types:
oligomenorrhea
polymenorrhea
menorrhagia
metrorrhagia
meno-metrorrhagia
Endometriosis
A condition when you get endometrial tissue located outside
its normal position, which is the inside lining of the uterus
symptoms depend on where the ectopic tissue is located
the tissue has function, i.e.
bleeds with menstruation
Sx : pain
Complications
Fibrosis
Scarring
Adhesions
Infertility
Dyspareunia
MENOPAUSE
Get cessation of menses & drop in estrogens which can cause:
general symptoms
irritability
short term memory loss
Insomnia
Vasomotor instability = hot flashes & night sweats
gynecological symptoms
vaginal dryness & dyspareunia
urinary stress incontinence
Cardiovascular problems
ASHD
coronary artery disease
strokes
Osteoporosis
Dx: High FSH; low estrogens
Trichomonas
caused by a protozoa
may be sexually transmitted
Bacterial Vaginosis
caused by different bacterial overgrowth
used to be called non-specific vaginitis or Gardnella
Generally most cases of vaginitis are NOT sexually transmitted, but at
times they ALL may be sexually transmitted !!
Vaginitis
Cervicitis
Endometritis
Oophoritis
Cervix
Benign
Cervical polyps
malignant
key ages: 20 - 40
pap smear
Etiol: HPV
Vaccine available
Uterus
benign
fibroids = commonest tumor of female repo. System
leiomyomas
only in premenopause
See next slide
malignant
? Estrogen related
Age: 50 70
Dx: pmb
Ovary
Benign
Functional (commonest)
Follicular cyst
Corpus luteum cyst
Non-functional (benign germ cell)
(e.g. Teratoma)
Malignant
Factors that suppress ovulation decrease the risk
Avg age = 40
2 basic types
Epithelial (line ovary or follicles)
Germ cell aggressive
Mainly in children & adolescents
See next slide re:
Late diagnoses
seeding
Breast disorders
Fibrocystic breasts
Was called fibrocystic disease
lumpy breasts
Fibroadenoma
Benign
In young girls (age 15-25)
nontender
Intraductile papilloma
Get nipple discharge
Breast cancer
Pathology in Pregnancy
Morning Sickness
severe form = Hyperemesis Gravidarum
Spontaneous Abortion
3 Types : Complete, Incomplete, Missed
Ectopic Pregnancy
Toxemia of Pregnancy = syndrome of hypertension, proteinuria, &
edema
called Preeclampsia
If severe & accompanied by convulsions, called Eclampsia
Placental Problems
Placenta Praevia
Abruptio Placenta
Preterm Birth
8% of all births in US
Preterm labor
Preterm PROM (premature rupture of membranes)
Responsible for half of all premie deliveries in US
Maternal hemorrhage
Is the leading cause of maternal mortality
Hemorrhagic shock
Postpartum hemorrhage
Endometritis
Occurs in 1-3% of vaginal births
Occurs in 10-50% of cesarean sections
STDs
AIDS (Acquired Immunodeficiency Syndrome)
Def: progressive impairment of the immune system caused by the
immunodeficiency virus (HIV)
Attacks helper T lymphocytes
AIDS (continued)
Get opportunistic cancers
Non-Hodgkins lymphoma
Kaposis sarcoma
HIV also has predilection to attack G-I cells & CNS cells
Get malabsorption, colitis, and proctitis
Dementia
Diagnosis
ELISA (enzyme-linked immunosorbent assay)
Western blot test
Treatment
AZT = reverse transcriptase inhibitors
Protease inhibitors
Fusion inhibitors
Chlamydia
Most frequent bacterial STD
Known as the silent STD
Transmitted via oral, anal, or genital intercourse
Oral route can lead to conjunctivitis
Gonorrhea
Bacterial
Incubation = 1-3 weeks (usually less than 1 week)
Very similar in signs & symptoms to chlamydia
Antibiotic resistance
Syphilis
Bacterial
Can get primary, secondary, and tertiary forms
New cases at an all time low
Primary = hard, painless chancre in 2-3 weeks ------------ see pictures
Secondary syphilis may appear 1-3 months later
Then latency for years & then possible tertiary syphilis
Chancroid
Soft chancre (painful) with bubo(necrotizing ulceration &
lymphadenopathy) in 1 week
See pictures
Bacterial
Frequent in developing tropical countries
Increasing in urban USA
Genital Herpes
Type I & type II
Short incubation of 2-7 days
See pictures
Hepatitis B & C
Transmitted in body fluids
Genital warts
Very contagious
First exposure incidence:
40% ---to--- 90%
Viral; HPV
120 different serotypes
A few cause dysplasia & neoplasia
Condylomata accuminatum
Benign growths
See picture
Prolonged incubation of 1-6 months
Most frequent STD
Estimated that 60% of sexually active young
women in USA have it
New vaccine available
PATOFISIOLOGI
MUSKULOSKELETAL
dr. Susiana Candrawati, Sp KO
JOINT
BONE
Osteoporosis
Osteomalacia
Paget Dis
Infection Bone Dis
Osteomyelitis
MUSKOSKELETAL
OA
Myositis
RA
Myopathy
GOUT
Definition
Osteoporosis density/mass of bone is
reduced
Normal Bone
Osteoporotic bone
Porous bones
Bones have lost calcium and other
minerals
Bones are fragile
Bones fracture easily
Risk Factor
Female gender
Increasing age
Thin, small-boned - BMI < 19
Risk Factor
Abnormal menstrual history
Late menarche
Menstrual interruptions/irregularities
Risk Factor
Medical conditions
Bone fracture(s) after age 40
Rheumatoid arthritis
Thyroid disorder
Parathyroid disorder
Poorly controlled Type 1 diabetes
Lactose intolerance
Digestion disorders
Risk Factor
Lifestyle Risk Factors
Inactive lifestyle
Diet low in calcium*
Little sun exposure and diet low in vitamin D*
Consume few fruits and vegetables*
Drink excess alcohol (> 7 drinks/week)*
Current or former smoker
Consume large amounts of caffeine
* : untuk terapi diet susu dan produk olahannya
PathoPhysiology
an imbalance between bone resorption and
formation
estrogen deficiency
immobilization
metabolic acidosis
hyperparathyroidism
local inflammatory
diseases
TNF,
IL-1,
IL-6
MEDICAL OR MEDICATIONS
DIAGNOSTIC MEASUREMENTS
Radiography
signs of demineralization or
compression fractures
Bone densitometry
T score < - 2,5
Osteomalacia
Definition
Calcium *
Phosphate, *
Vitamin D*
* untuk terapi diet
skeletal deformities
Osteomyelitis
Definition
an acute or chronic inflammatory process
of the bone and its structures secondary
to infection with pyogenic organisms
Hematogenous osteomyelitis
a remote source- blood
Physical Finding
Fever
Edema
Warmth
Fluctuance
Tenderness to palpation
Reduction in the use of the extremity
Sinus tract drainage
Lab Studies:
The WBC elevated
A leftward shift - increased PMN
CRP elevated
ESR elevated
Culture or aspiration findings
Imaging Studies:
Radiography
MRI
Ultrasonography
Osteoarthritis
Men
53%
37%
What is Osteoarthritis?
Osteo (bone) + arthron (Gr. Joint) + itis
Osteoarthrosis ( osis Gr. Morbid
process)
Def.
a degenerative joint disease,
characterized by
Risk factors
2 types :
cannot change and
you can change
Cannot change
Family history of
disease
Increasing age
Overuse of the joint
Major injury
Overweight
Muscle weakness
Diagnosing osteoarthritis
Medical history
Physical exam
X-ray
Other tests
Pathophysiology
Pathogenesis 3 stages:
Stage 1: Proteolytic
breakdown of the
cartilage matrix
occurs.
destroy
the
cartilage
matrix.
Metalloproteinases
(eg, collagenase,
stromelysin)
>
Production
Chondrocyte
protease inhibitors:
tissue inhibitors of
metallo-proteinases
(TIMP) 1 and 2
Stage 2:
the fibrillation and erosion of the cartilage surface-
release of proteoglycan and collagen fragments into
the synovial fluid.
Stage 3:
Stage I
The
breakdown
products of
cartilage
Stage II
induce
chronic
inflammatory
response in
the synovium
Synovial
macrophage
Cytoken
IL-1
TNF-
metalloproteinases
NO
Rheumatoid Arthritis
Background
RA = a chronic syst. Inflam. Dis. of unknown cause
that primarily affects the peripheral joints in a
symmetric pattern.
Constitutional symptoms:
fatigue,
malaise, and
morning stiffness
Extra-articular:
skin,
heart,
lungs, and
eyes
a wrist,
metacarpophalangeal (MCP),
proximal interphalangeal (PIP)
Etiology:
Genetic Susceptibility:
HLA DR4, or DR1 in 65% to 80% cases.
Autoimmunity:
IGM anti IgG RA Factor.
Helper T cell (CD4) against type II collagen &
cartilage glycoprotein-39
RA
Inflamed
synovial
membrane
Synovial
membrane
Pannus
Cartilage
Synovial
fluid
Capsule
Cartilage thinning
IL-1
Activates
monocytes/ Induces fibroblast
proliferation
macrophages
Inflammation
Synovial pannus
formation
Activates
chondrocytes
Activates
osteoclasts
Cartilage
breakdown
Bone
resorption
Gouty Arthritis
Background
= disorder of uric acid
metabolism - :
recurrent episodes of
joint inflammation,
tissue deposition of
uric acid crystals, and
joint destruction if left
untreated.
MIOPATI
Miopathie
Inflamatory
Endocrine disorders
Electrolyte disorders
Metabolic myopathies
Drugs and toxin
Infections
Rhabdomyolisis
Differential Diagnosis
Pathophysiology
Inflamatory myopathy
Immune mediated triggered
Environmental Agents
Infectious: Coxsackie B1, HIV, HTLV-1, Hepatitis B,
Influenza, Echovirus, Adenovirus
Non infectious: statins, hydroxycholoquine, cochicine,
procainamide, phenytoin, ACE Inhibitors, D-penicillamine
Genetically predisposed
HLA A1, B8, DR3
Constitutional Symptoms
Morning stiffness, anorexia, weight loss, fatigue, fever (assoc with
anti-Jo1)
Joints
Arthralgia or symmetrical arthritis (rarely deforming erosive
arthropathy)
Kidneys
Rare: severe rhabdomyolysis with myoglobinuria (ATN)
Lungs
Skin:
Gottrons sign: symmetric, scaly, violaceous
erythematous eruption over extensor surfaces
of MCP and IP joints, elbows, knees (psoriasis)
Mechanic's Hands (PM):hyperkeratotic
eruptions over finger pads and lateral aspects
of fingers
Raynauds
Periorbital edema
Calcinosis (5% of DM)
Labs
CK, LDH, aldolase, AST, ALT
Autoantibodies: ANA (myositis with overlap)
anti Jo-1 antibodyanti-histidyl-trna
synthetase: 20%, ILD, Raynauds, Mechanics
hands
Anti Mi 2 antibodyhelicase in transcriptional
activitation; associated with acute onset classic
DM
Anti PM-scl and Kuoverlap of myositis and
scleroderma
PATHOPHYSIOLOGY DIGESTIVUS
SYSTEM
Susiana Candrawati
Chronic Gastritis
The presence of chronic inflammatory changes
in the mucosa
Helicobacter pylori, HP
Mucosal atrophy
Epithelial metaplasia
Pathogenesis
The bacillus H. pylori.
Immunologic (autoimmune), in association with
pernicious anemia
Toxic, as with alcohol and cigarette smoking
Postsurgical, especially following antrectomy with
gastroenterostomy with reflux of bilious
duodenal secretions
Radiation
Miscellaneous-amyloidosis, graft-versus-host
disease, uremia
Peptic Ulcers
Peptic ulcers are chronic, most often
solitary,lesions that occur in any portion of the
gastrointestinal tract exposed to the aggressive
action of acid/peptic juices.
Duodenum, first portion
Stomach, usually antrum
Ulcers are defined histologically as a breach in the
mucosa of the alimentary tract that extends
through the muscularis mucosa into the
submucosa or deeper.
Pathogenesis
Imbalance between gastroduodenal mucosal
defense mechanisms and the damaging forces
H. pylori infection is a major factor in the
pathogenesis of peptic ulcer
Chronic use of NSAIDs
Cigarette smoking
Alcohol
Corticosteroids
Clinical Features
Epigastric gnawing, burning, or aching pain.
Iron-deficiency anemia, frank hemorrhage, or
perforation.
The pain tends to be worse at night and occurs
usually 1 to 3 hours after meals during the day
Nausea, vomiting, bloating, belching, and
significant weight loss
Treated by antibiotics active against H. pylori,
proton pump inhibitors, and hydrogen receptor
antagonists
Appendicitis
Is the most common acute abdominal
condition the surgeon is called on to treat.
Inflammation in the right lower quadrant
Adolescents and young adults
Acute Simple Appendicitis
Acute Suppurative Appendicitis
Acute Gangrenous Appendicitis
Complication
Rupture
Suppurative peritonitis
Pyelophlebitis with thrombosis of the portal
venous drainage
Chronic inflammation of the appendix
Cystic fibrosis
Clinical Features
(1) Pain, at first periumbilical but then localizing
to the right lower quadrant;
(2) Nausea and/or vomiting;
(3) Abdominal tenderness, particularly in the
region of the appendix;
(4) Mild fever;
(5) An elevation of the peripheral white blood
cell count up to 15,000 to 20,000 cell/L.
Viral Hepatitis
Infection of the liver caused by a group of viruses
having a particular affinity for the liver
Infectious mononucleosis (Epstein-Barr virus)
Cytomegalovirus
Yellow fever
Etiology
Hepatitis viruses A (HAV), B (HBV), C(HCV), D
(HDV), E (HEV), Hepatitis G virus (HGV)
Hepatitis A Virus
A benign, self-limited disease with an
incubation period of 2 to 6 weeks.
HAV occurs throughout the world and is
endemic in countries with substandard
hygiene and sanitation.
Blood-borne transmission of HAV occurs only
rarely.
Hepatitis B Virus
HBV can produce :
(1) Acute hepatitis with resolution
(2) Chronic hepatitis, which may evolve to
cirrhosis
(3) Fulminant hepatitis with massive liver necrosis
(4) The backdrop for hepatitis D virus infection
HBV also plays an important role in the
development of hepatocellular carcinoma.
Hepatitis C Virus
Hepatitis C virus (HCV) is a major cause of liver
disease worldwide.
The major routes of transmission are
inoculations and blood transfusions.
HCV could become the leading cause of
chronic liver disease in the Western world.
Cirrhosis may develop over 5 to 20 years after
acute infection.
Serologic Diagnosis
HCV RNA is detectable in blood for 1 to 3
weeks, coincident with elevations in serum
transaminases.
In patients with symptoms of chronic hepatitis,
HCV RNA testing must be performed to assess
viral replication and to confirm the diagnosis
of HCV infection.
Hepatitis D Virus
Causing infection only when it is encapsulated
by HBsAg
Serologic Diagnosis
HDV RNA is detectable in the blood and liver
just prior to and in the early days of acute
symptomatic disease.
Acute coinfection by HDV and HBV is best
indicated by detection of IgM against both
HDAg and HBcAg.
Hepatitis E Virus
An enterically transmitted, water-borne
infection that occurs primarily in young to
middle-aged adults.
In most cases, the disease is self-limiting.
HEV is not associated with chronic liver
disease or persistent viremia.
HEV RNA and HEV virions can be detected in
stool and liver.
Liver Cirrhosis
Among the top 10 causes of death in the
Western world.
Alcohol abuse
Viral hepatitis
Biliary disease
Iron overload
Pathogenesis
The most frequent are chronic hepatitis B and
C and chronic alcoholism.
Less frequent causes are autoimmune and
biliary diseases and metabolic conditions such
as hemochromatosis.
Types I and III collagen are deposited in the
lobule, creating delicate or broad septal tracts.
Hepatocellular death
Regeneration
Progressive fibrosis
Vascular changes
Clinical Features
Nonspecific clinical manifestations:
Anorexia, weight loss, weakness, osteoporosis, and,
in advanced disease, frank debilitation. Incipient or
overt hepatic failure
Gastrointestinal hemorrhage. Imbalances of
pulmonary blood flow
The ultimate mechanism of most cirrhotic deaths
(1) Progressive liver failure
(2) A complication related to portal hypertension
(3) The development of hepatocellular carcinoma
Portal Hypertension
Results from increased resistance to portal flow at
the level of the sinusoids and compression of
central veins.
Ascites
Ascites refers to the collection of excess fluid
in the peritoneal cavity.
Clinically detectable 500ml
Cause massive abdominal distention
Influx of neutrophils suggests secondary
infection
Red cells point to possible disseminated intraabdominal cancer
Pathogenesis
Sinusoidal hypertension
Percolation of hepatic lymph into the
peritoneal cavity
Intestinal fluid leakage
Renal retention of sodium and water
Hepatic Failure
As the end point of progressive damage to the
liver.
The result of sudden and massive destruction
of hepatic tissue.
Systemic infections
Electrolyte disturbances
Stress (major surgery, heart failure)
Gastrointestinal bleeding
Clinical Features
Jaundice is an almost invariable finding.
Hypoalbuminemia, which predisposes to
peripheral edema.
Hyperammonemia is attributable to defective
hepatic urea cycle function.
Impaired estrogen metabolism and consequent
hyperestrogenemia are the putative causes of
palmar erythema and spider angiomas of the
skin.
In the male, hyperestrogenemia also leads to
hypogonadism and gynecomastia.
Hepatic Encephalopathy
A feared complication of acute and chronic liver failure.
Patients show a spectrum of disturbances in brain
function
Stupor, to deep coma and death.
Fluctuating neurologic signs include rigidity, hyperreflexia,
nonspecific electroencephalographic changes and
seizures.
Asterixis (also called flapping tremor).
Edema and an astrocytic reaction
An elevation in blood ammonia
Hepatorenal Syndrome
Appears in individuals with severe liver
disease, consists of the development of renal
failure without primary abnormalities of the
kidneys themselves.
The ability to concentrate urine is retained,
producing a hyperosmolar urine devoid of
proteins and abnormal sediment that is
surprisingly low in sodium.
Summary of Cirrhosis
The three main characteristics of cirrhosis are
(1) bridging fibrous septa
(2) parenchymal nodules containing replicating hepatocytes
(3) disruption of the architecture of the entire liver.
The most frequent are chronic hepatitis B and C and chronic
alcoholism.
Morphologic features of advanced cirrhosis are similar, regardless of
the cause of the disease.
The main complications of cirrhosis
Decreased liver function
Portal hypertension
Increased risk of hepatocellular carcinoma
Pancreatitis
Pancreatitis encompasses a group of disorders
characterized by inflammation of the
pancreas.
Acute pancreatitis
Chronic pancreatitis
Pathogenesis
Pancreatic duct obstruction
Primary acinar cell injury
Defective intracellular transport of
proenzymes within acinar cells
Acute pancreatitis is characterized by inflammation and reversible
parenchymal damage with lesions ranging from focal edema and fat
necrosis to widespread parenchymal necrosis and hemorrhage; clinical
manifestations vary from mild abdominal pain to a rapidly fatal vascular
collapse.