59 - Diseases of the hepatobiliary system b

Question 1

Dying from cirrhosis - how?

Answer 1

Liver cell failure
Varices
Infection
Cancer

Question 2

Risk for hepatocellular carcinoma

Answer 2

70% malignant due to cirrhosis

2% malignant tumours from non-cirrhotic (98% are metastatic)

M>F
Obesity, alcohol
Geographical, viral hepatitis

Question 3

Hepatocellular carcinoma - clinical features

Answer 3

Worsening liver function, weight loss

Question 4

Hepatocellular carcinoma - surveillance

Answer 4

6 month USS for cirrhotic patients

Question 5

Hepatocellular carcinoma - blood tests

Answer 5

Raised alpha-feto-protein in serum in 75% of cirrhotic patients

Non-cirrhotic patients, small HCC

Question 6

Hepatocellular carcinoma - macroscopic

Answer 6

green due to bile

Question 7

Hepatocellular carcinoma - involvement

Answer 7

portal vein (60%)
hepatic vein
bile duct

often multifocal

Question 8

Hepatocellular carcinoma - microscopic

Answer 8

cancer cells may look like hepatocytes

may produce bile = diagnostic

confirm with immunohistochemistry

targeted liver biopsy if diagnosis unclear - benign vs malignant based on differentiation

Question 9

Hepatocellular carcinoma - prognosis

Answer 9

Very poor

Question 10

Hepatocellular carcinoma - treatment

Answer 10

surgery - if non-cirrhotic or small, peripheral

transplant - if one tumour

Question 11

Hepatocellular carcinoma - TNM staging for HCC

Answer 11

pT1,2,3a,3b,4

if

Question 12

Tumours that met to liver

Answer 12

Few large nodules = large bowel

Multinodular or infiltrative - lung, pancreas, breast, stomach, melanoma

Question 13

Cholangiocarcinoma -

Answer 13

adenocarcinoma arising in the bile ducts

intra-hepatic: from small intra-hepatic ducts; peripheral, mass forming, presents late - no risk factors inc. cirrhosis

Perihilar: large duct. Cause obstructive jaundice early. Risk factor: bile duct disease: primary sclerosing cholangitis with liver flukes.

Question 14

Gallstones -

Answer 14

viscid green liquid build up containing bile salts, phospholipids, cholesterol, bilirubin and Ca salts + mucin from peribiliary glands.

Gallstones are when these constituents precipitate

Question 15

Gallstones - who?

Answer 15

10-20% of adults in UK
Female
Obesity
Diabetes

Question 16

Gallstones - types

Answer 16

cholesterol stones - yellow, opalescent
pigmented stones - small black in haemolytic anaemia
mixed stones
10% contain calcium

Question 17

Gallstones - complications

Answer 17

cholecystitis
mucocele
predisposition to carcinoma of the gallbladder
Obstruction of the biliary system resulting in biliary colic and jaundice
infection of static bile, causing cholangitis and liver abscess
Gallstone ileus (rarer)
Pancreatitis

Question 18

Cholecystectomy - indications

Answer 18

pain, gallstones, pancreatitis

gall bladder polyp (rarely)

Question 19

Cholecystitis - acute

Answer 19

Duct blocked by stone, initially sterile, later infected.

Large, swollen, congested, ulcerated

Complications - empyema, rupture

Question 20

Cholecystitis - chronic

Answer 20

Usually gallstones

Small, fibrotic, stones, fibrosis, Rokitansky Aschoff sinuses