23. Biliary/Liver 1 Flashcards
Causes of jaundice split into three categories?
Pre-hepatic (would be unconjugated) - haemolytic anaemia or gilbert’s
Hepatic (mixed bilirubin) - hepatitis (viral, alc, AI, drug), cirrhosis
Obstructive/cholestasis - liver mass, gallstones, pancreatic cancer, drug
What would be seen in pre-hepatic vs obstructive causes of jaundice on presentation?
Pre - normal urine
Ob - dark urine as conj bilirubin goes into the urine
Pale stools and also pruritus
Investigations in jaundice?
Bilirubin (pre hep has this raised ONLY)
AST/ALT (hep)
ALP/GGT (obstructive)
PT and albumin - markers of function!!
What does a raised AST/ALT mean?
Hepatocyte damage, this is a hepatic picture
What causes hepatitis?
Alcoholic NASH Viruses Drugs Autoimmune
Hepatitis symptoms?
RUQ pain Jaundice Hepatomegaly Joint pain Nausea Fatigue Dark urine
Acute - short recovery or progression to chronic
Chronic - over 6 months
What are the three spectrums of alcoholic liver disease?
Steatosis - a few days of heavy drinking, no symptoms that is reversible
Alcoholic hepatitis - long term alcohol use or persistent binge drinking, nausea, anorexia, weight loss, hepatomegaly, fever, jaundice etc. due to inflammation
Cirrhosis
Investigations for alcoholic hepatitis?
FBC - macrocytic anaemia
LFTs - AST>ALT, raised bili, ALP, GGT and low albumin
Raised PT
Hepatic USS
Liver biopsy - ballooning
Mallory bodies indicate hepatitis
How do we manage alc hep?
Alc abstinence with chlordiazepoxide (benzo)
Nutrition - thiamine
Weight loss/stop smoking
Steroids in severe, maddrey score
What can cause NASH?
Non-alcoholic fatty liver disease Obesity Diabetes Hyperlipidaemia HTN etc.
Signs of insulin resistance (for NASH)?
Polyuria
Polydipsia
Acanthosis nigricans
How to manage NASH?
Manage causes
Viral hep A and E spread and management?
fAEco-oral spread
Stop drinking and
These are acute
How to tell between A and E on serology?
A - IgM high during, IgG persists for life
E - same but IgM is high for 2 months, around 6 weeks for A. IgG only persists for years
Hep B and C, how are they different to A and E?
They can be acute but mostly chronic.
B likely to stay acute.
B has coinfection with D
What is seen in hep B serology?
Surface antigen and core antigen on hep B!
In response we produce surface antibody and core antibody. We vaccinate to produce the surface antibody.
Surface antibody - vaccinated or previous infection
Core antibody - actually has infection
If they have HBsAg (the actual hep b antigen) then it’s happening rn needs these below to differ:
IgM - acute
IgG - longer term
Surface - Anti-HBs
Core - Anti-HBc
What happens in liver cirrhosis?
Normal liver replaced with fibrosis ad nodules of regenerating hepatocytes.
Alc misuse, viral hep, autoimmune, haemochromatosis etc.
Signs of chronic liver disease/cirrhosis?
Clubbing Spider naevi (at least 3) Palmar erythema Gynaecomastia Bruising Dupytren's contracture
What is portal hypertension?
Liver is cirrhotic so increased pressure in portal vein.
Blood flows from portal to systemic circulation.
Can cause - distended veins (varices), ascites, splenomegaly, caput medusae
How to manage cirrhosis?
Treat cause and avoid hepatotoxic drugs e.g. NSAIDs
Monitor risk of complications (SBP (infection of ascites), encephalopathy, ascites
How to manage complications of cirrhosis?
Encephalopathy - protein restriction, oral lactulose, oral rifaximin, phosphate enema but avoid sedatives
Ascites - sodium restriction, diuretics, paracentesis
SPB (>250 neutrophils) - Abx (cefotaxime)
Varices - monitor needs own page
How to treat varices?
Prophylaxis - beta blocker
Rupture - ABCDE, fluids, bloods, terlipressin and Abx, ligation
Secondary prophylaxis - beta blocker
TIPS procedure
What is cholelithiasis?
Gallstone in gallbladder (no jaundice)
What is biliary colic?
Gallstones in bladder or CBD causing pain (no jaundice)
