258 Section 4 # Digestive System ‘Common cholagogues are: i. Bile saits ii, Calcium ili, Fatty acids iv. Amino acids v. Inorganic acids All these substances stimulate the secretion of cholecystokinin, which in tum causes contraction of gallbladder and flow of bile into intestine, 3. Hydrocholeretic Agents Hydrocholeretic agent is a substance which causes the secretion of bile from liver, with large amount of ‘water and less amount of solids. Hydrochloric acid is a hydrocholeretic agent. @ APPLIED PHYSIOLOGY JAUNDICE OR ICTERUS Jaundice or icterus is the condition characterized by yellow coloration of the skin, mucous membrane and deeper tissues due to increased bilirubin level in blood ‘The word jaundice is derived from the French word ‘jaune’ meaning yellow. ‘The normal serum bilirubin level is 0.5 to 1.5 mg/dl. Jaundice occurs when bilirubin level exceeds 2 mg/dL. Types of Jaundice Jaundice is classified into three types: 1. Prehepatic or hemolytic jaundice 2. Hepatic or hepatocellular jaundice 3. Posthepatic or obstructive jaundice. 4. Prehepatic or Hemolytic Jaundice Hemolytic jaundice is the type of jaundice that occurs, because of excessive destruction of RBCs resulting in increased blood leve! of free (unconjugated) bilirubin. In this condition, the excretory function of liver is normal But the quantity of bilirubin increases enormousty. The liver cells cannot excrete that much excess bilirubin rapidly. Unconjugated bilirubin is insoluble in water and is not excreted in urine. So, it accumulates in the biood resulting in jaundice Formation of urobilinogen also increases resulting in the excretion of more amount of urobilinogen in urine. Causes Any condition that causes hemolytic anemia can lead to hemolytic jaundice. ‘Common causes of hemo\ytic jaundice are: i. Renal disorder il. Hypersplenism ii, Bums Iv. Infections such as malaria v. Hemoglobin abnormalities such as sickle cell anemia or thalassemia vi. Drugs or chemical substances causing red cell damage vil. Autoimmune diseases. 2. Hepatic or Hepatocellular or Cholestatic Jaundice Hepatic jaundice is the type of jaundice that ocours due to the damage of hepatic cells. Because of the damage, the conjugated bilirubin from liver cannot be excreted and it returns to blood Causes i. Infection (infective jaundice) by virus, resutting in hepatitis (viral hepatitis) i. Alcoholic hepatitis ii, Cirthosis of liver iv. Exposure to toxic materials, 3. Posthepatic or Obstructive or Extrahepatic Jaundice Posthepatic type of jaundice occurs because of the obstruction of bile flow at any level of the biliary system. The bile cannot be excreted into smail intestine. So, bile salts and bile pigments enter the circulation. The blood Contains more amount of conjugated bilirubin (Table 40.2). Causes i. Gallstones ii. Cancer of biliary system or pancreas. = HEPATITIS Hepatitis is the liver damage caused by many agents. It is characterized by swelling and inadequate functioning of liver. Hepatitis may be acute or chronic, In severe conditions, it may lead to liver failure and death Causes and Types 1. Viral infection (viral hepatitis: see below) 2. Bacterial infection like leptospirosis and Q fever 3, Excess consumption of alcoholChapter 40 ¢ Liver and Gallbladder 259 ‘TABLE 40.2: Features of different types of jaundice Tr (Cears Hemorrhagic tendency 4. Excess administration of drugs like paracetamol 5. Poisons like carbon tetrachloride and aflatoxin 6. Wilson disease (Chapter 151) 7. Circulatory insufficiency 8. Inheritance from mother during parturition Viral Hepatitis Viral hepatitis is the type of hepatitis caused by viruses. It is caused by two types of viruses, hepatitis A and hepatitis B. Causes of viral hepatitis: i. Mainly by intake of water and food contaminated with hepatitis virus i, Sharing needies with infected persons ii, Accidental prick by infected needie iv. Having unprotected sex with infected persons ¥. Inheritance from mother during parturition \i. Blood transfusion from infected donors. Hepatitis caused by hepatitis B virus is more ‘common and considered more serious because it may lead to cirrhosis and cancer of liver. Features of Hepatitis, 4. Fever 2. Nausea 3. Vomiting, diarthea and loss of appetite 4, Headache and weakness 5. In addition, chronic hepatitis is characterized by Cause Excess breakdown of RBCs Liver damage Obstruction of bile ducts: Urinary excretion of Decreases urobilinogen eee eae Absent in severe obstruction van den Bergh reaction Indirect - positive Biphasic ‘Anemia Blood picture Reticulocytosis Normal Normal ‘Abnormal RBC Present due to lack of vitamin K Present due to tack of vitamin k Pre feu) ie Jaundice Sot i. Stomach pain ii, Paleness of skin iii, Dark-colored urine and pale stool iv. Jaundice v. Personality changes. ™ CIRRHOSIS OF LIVER Cirrhosis of liver refers to inflammation and damage of parenchyma of liver. It results in degeneration of hepatic, ‘cells and dysfunction of liver. Causes 1. Infection 2. Retention of bile in liver due to obstruction of ducts of biliary system 3. Enlargement of liver due to intoxication . Inflammation around liver (perinepatits) Infitration of fat in hepatic cells, oe Features |. Fever, nausea and vomiting Jaundice Increased heart rate and cardiac output Portal hypertension . Muscular weakness and wasting of muscles Drowsiness Lack of concentration and confused state of mind Coma in advanced stages. PNOMAONS=260 Section 4 # Digestive System ™ GALLSTONES Definitions Galistone is a solid crystal deposit that is formed by cholesterol, calcium ions and bile pigments in the gall- bladder or bile duct. Chololithiasis is the presence of gallstones in gallbladder. Choledocholithiasis is the presence of gallstones in the bile ducts. Formation of Gallstones Normally, cholesterol present in the bile combines with bile salts and lecithin, which make the cholesterol soluble in water. Under some abnormal conditions, this, water-soluble cholesterol precipitates resulting in the formation of galistone. lly, small quantity of cholesterol begins to precipitate forming many small crystals of cholesterol in the mucosa of gallbiadder. This stimulates further formation of crystals and the crystals grow larger and larger. Later, bile pigments and calcium are attached to, these crystals, resulting in formation of galistones, Causes for Gallstone Formation Reduction in bile salts and/or lecithin Excess of cholesterol Disturbed cholesterol metabolism Excess of calcium ions due to increased concen- tration of bile 5, Damage or infection of gallbladder epithelium. It alters the absorptive function of the mucous mem- brane of the gallbladder. Sometimes, there is excessive absorption of water or even bile salts, leading to increased concentration of cholesterol, bile pigments and calcium ions 6. Obstruction of bile flow from the gallbladder. Diagnosis of Gallstone Presence of gallstone is diagnosed by ultrasound scanning and cholangiography. Cholangiography is the radiological study of biliary ducts after the administration of a contrast medium, Features Common feature of gallstone is the pain in stomach area, or in upper right part of the belly under the ribs. Other features include nausea, vomiting, abdominal bioating and indigestion Treatment for Gallstone Simple cholesterol gallstones can be dissolved over a period of one or two years by giving 1 to 1.5 gm ‘of chemodeoxycholic acid daily. This increases the concentration of bile acids. So, excessive concentration of bile does not occur. In severe conditions, the gallbladder has to be removed (cholecystectomy). Laparoscopic surgery is, the common method.