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Core Curriculum > 9. Liver and Biliary System > Flashcards

9. Liver and Biliary System Flashcards

1
Q

Pre-Hepatic Jaundice

A

Excessive amount of bilirubin is presented to the liver due to excessive haemolysis

Elevated unconj. BR in serum

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2
Q

Liver Jaundice

A

Impaired cellular uptake, defective conj, or abnormal secretion by the liver cell.

Both unconj and conj bilirubin may be elevated in serum

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3
Q

Biliary Jaundice

A

Impaired excretion due to mechanical obstruction to flow

Elevated conj. BR in serum

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4
Q

Signs of portal HTN

A 
Oesophageal varices --> coffee ground vomiting
Splenomegaly
Caput medusae
Ascites
Hemorrhoids
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5
Q

Signs of liver cell failure

A 
Asterixis
Bruising
Clubbing
Dupuytren’s contracture
Erythema (palmar)
Fetor hepaticus
Gynaecomastia
Have portal hypertension (see left)
Itching (Pruritis)
Jaundice
Spider naevi + testicular atrophy
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6
Q

A 26 y/o male returns from holiday in India. He has had diarrhoea after eating at a seafood restaurant on his last night. He is feverish and nauseous. You notice that the whites of his eyes are yellow.

A. 	Hepatitis A
B. 	Hepatitis B
C. 	Hepatitis C
D. 	Hepatitis D
E. 	Hepatitis E
A

A. Hepatitis A

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7
Q

A 64 y/o male with thalassaemia is investigated under the two-week wait for jaundice and weight loss. His blood tests show a raised αFP. Which chronic infection is he most likely to have?

A. 	Hepatitis A
B. 	Hepatitis B
C. 	Hepatitis C
D. 	Hepatitis D
E. 	Hepatitis E
A

C. Hepatitis C

aFP- raised in liver cancer, for which Hep C chronicity is a risk factor

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8
Q

A 32 y/o male returns from holiday in Thailand, feeling ‘under the weather’ with RUQ pain, fevers and nausea. He is jaundiced. He reveals he has used IV drugs and had unprotected sex with a stranger while on holiday. Which test is most likely to give the correct diagnosis?

A. 	Liver function tests
B. 	HIV serology
C. 	Hepatitis B serology
D. 	Hepatitis C PCR
E. 	CXR
A

C. Hepatitis B serology

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9
Q

A 43 y/o confused man is brought to A&E by police after being found wandering the streets. He is disorientated and unable to give a clear history. You notice the a brownish-yellow ring around in his eyes. What is he likely to have?

A. 	Alcohol intoxication
B. 	Wilson’s disease
C. 	Opiate overdose
D. 	Haemochromatosis
E. 	Hypoglycaemia
A

B. Wilson’s disease

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10
Q

72 y/o man with cirrhosis presents to A&E with diffuse abdominal pain and fever. He is nauseous and has vomited. His abdomen is distended and there is shifting dullness on examination. Which investigation would be most urgent?

A. 	Paracentesis
B. 	Stool sample MC&S
C. 	Abdominal USS
D. 	LFTs
E. 	Blood cultures
A

A. Paracentesis

Although it’s important to diagnose the underlying condition, this is suggestive of bacterial peritonitis (secondary to cirrhosis) which much be treated quickly as a priority.

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11
Q 
Hep A: 
Transmission
Incubation Period
Areas of high risk
Risk factors
Chronic?
A 
Faecal-oral
2 weeks
Africa/Asia
Poor hygiene
Rare
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12
Q 
Hep B: 
Transmission
Incubation Period
Areas of high risk
Risk factors
Chronic?
A 
Bodily fluids
4-12 weeks
Africa
Health workers
Likely in children, 5% adults

5% of people with chronic Hep B have Hep D too.

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13
Q 
Hep C: 
Transmission
Incubation Period
Areas of high risk
Risk factors
Chronic?
A 
Bodily fluids
2 weeks -6 months
Eastern Mediterranean
Injecting drugs
Yes, 60-80%
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14
Q 
Hep D: 
Transmission
Incubation Period
Areas of high risk
Risk factors
Chronic?
A 
Bodily fluids
4-12 weeks
Africa
ONLY co-infects with Hep B
Rare
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15
Q 
Hep E: 
Transmission
Incubation Period
Areas of high risk
Risk factors
Chronic?
A 
Faecal-oral
5-6 weeks
Poor water supply
Immunocompromised patients
Pregnancy
Rare
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16
Q

Viral Hepatitis: Symptoms and Signs

A

Fever + Jaundice (+ High AST/ALT)

Other symptoms likely:

  • Reduced appetite (anorexia),
  • Nausea and vomiting, lasting for a few days
  • Abdominal pain
  • Itching (without skin lesions), skin rash
  • Joint pain
  • Dark urine and pale stools
  • Tender hepatomegaly
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17
Q

Viral Hepatitis: Investigations

A

Liver function tests (first line) - indicate whether the jaundice is a liver or biliary cause
FBC
U+Es
Antibodies (diagnostic)

NAAT - Nucleic Acid Amplification Test can indicate viral load- useful to measure treatment response.

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18
Q

Hepatitis B Serology Interpretation

A

Anti-HBc IgM: Acute
Anti-HBc IgG: resolved acute, or chronic ongoing
HBsAg: Acute/Chronic ongoing infection
Anti-HBs (surface): Resolved acute, prior vaccination (after infection has passed)

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19
Q

Viral Hepatitis: Management

A

A: supportive care
B: supportive care for acute, antivirals +peginterferon for chronic.
C: supportive care for acute, antivirals for chronic.

Liver transplant if worsening.

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20
Q

Prognosis and complications of Viral Hepatitis

A

A: nearly all resolve by 6 months
B: viral suppression in 90% of chronic cases
C: mortality at 79% at 10 years for chronic cases.

One complication apart from chronicity is fulminant liver failure - very rare but requires an emergency transplant.

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21
Q

NASH - Non-Alcoholic Steatohepatitis/FLD

Aetiology, RF and Epidemiology

A

Aetiology: insulin resistance –> increased triglycerides –> steatosis–> inflammation –> steatohepatitis.

Risk factors: T2DM, metabolic syndrome, some medications. WITHOUT significant alcohol use.

Epi: 20-40% of the Western world are likely to have this to an extent.

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22
Q

NASH: Signs and Symptoms

A

Metabolic syndrome WITHOUT alcohol use
RUQ Pain
Hepatosplenomegaly

Usually no jaundice (not serious enough)/fever

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23
Q

NASH: Investigations

A

Liver function tests

  • AST:ALT ratio will be <1
  • (NB ALD: >2)
  • GGT <96.5 (above = fibrosis/ALD)

FBC

Metabolic panel (NA, K, U&Es, serum glucose - comorbid T2DM in up to 50%) and lipid profile

Hepatic US (every 6 months ?progression to cirrhosis)

(No Dx test - clinical)

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24
Q

Prognosis of NASH

A

1/3s reverse the condition
1/3 stay stable throughout life
1/3 progress to cirrhosis.
Complications: –> cirrhosis: HCC, ascites, portosystemic thrombosis and haemorrhage etc etc.

Low albumin, very high bilirubin would indicate the liver failure.

25
Q

Alcoholic hepatitis Aetiology

A

Alcohol metabolism in the liver produces excess NADH which inhibits gluconeogenesis and fatty acid oxidation –> same pathology as NASH.

Epidemiology: 10-15% heavy drinkers
ETOH > 40-80 g/day in men and 20-40 g/day in women for 10-12 years to cause alcoholic hepatitis or cirrhosis

RF: co-morbid obesity, metabolic syndrome, viral hepatitis

26
Q

Alcoholic hepatitis: Signs and Symptoms

A

RUQ pain
Hepatosplenomegaly
WITH a background of heavy alcohol use

Other symptoms increase with severity

27
Q

Alcoholic Hepatitis Investigations

A 
Liver function tests
- AST:ALT ratio >2
- GGT should be elevated - if not, reconsider Dx
FBC
U+Es
Vitamins screen (?Deficiencies)
Hepatic Ultrasound
28
Q

Alcoholic Hepatitis Management

A
  • Abstinence support
  • Metabolic syndrome addressed if needed
  • Steroids, nutritional supplementation may be added
  • Liver transplant if in failure.
29
Q

Cirrhosis Definition and aetiology

A

Hepatocytes death –> scarring –> fibrosis

The end stage of all chronic hepatitis
Decompensated liver failure gives symptoms (other systems are no longer able to COMPENSATE for its lack of function)

30
Q

Cirrhosis: Signs and Symptoms

A

Symptoms - prevents normal BF through liver system => portal vein HTN
Abdominal distension
Pruritis
Coffee-ground vomit (oe varices)

Signs
Jaundice
Ascites
Asterixis
Dupeytren’s Contracture
Sparse Body Hair 
Musc Wasting
Encephalopathy
etc
31
Q

Cirrhosis: Investigations

A 
LFTS
- Albumin low
- PT prolonged
(Synthetic function - more affected by fibrosis than fat build up)
Electrolytes, U+Es
- Na may be low due to ascites
US/CT/MRI
- Not necessary but useful to see atrophy/fibrotic nodules
32
Q

Management, Prognosis and Complications of Cirrhosis

A

Treat underlying cause.
Liver transplant if severe.

Prognosis: median survival of patients with fibrosis is 10 years, shortened by oesophageal varices.

Complications: portosystemic encephalopathy, hepatorenal and hepatopulmonary syndrome.

33
Q

Wilson’s disease: Definition, Aetiology, Epidemiology

A

Disease of impaired copper excretion (AR)
Mutation in ATP7B gene –> impaired excretion of copper in the bile.
Accumulates in the liver –> cirrhosis and basal ganglia –> neuropsychiatric disorder.

30/million - rare

34
Q

Wilson’s disease: Symptoms and Signs

A

Hepatitis symptoms
Ataxia
Tremor
Dysdiadochokinesia

35
Q

Wilson’s disease: Investigations

A

LFTS
- Abnormal

Urinary copper
- High (only way of excreting)

Serum caeruloplasmin
- Low (used up by high copper)

Kayser-Fleischer Ring
Accumulation of copper
Seen under slit-lamp investigation

36
Q

Haemochromatosis:Definition, Aetiology, Epidemiology

A

Haemochromatosis (AR) is a multisystem disorder of dysregulated dietary iron absorption and increased iron release from macrophages.

Autosomal recessive inheritance.

The most common mutations of the haemochromatosis gene (HFE) are C282Y and H63D for hepcidin (protein regulating iron intake) –> mutation = continued duodenal absorption from the diet.

Deposits in liver, pancreas and pituitary gland.

37
Q

Haemochromatosis: Signs, Symptoms,

A 
Tanned skin
T1DM
Liver symptoms
- Hepatomegaly
- Fatigue
- Pruritis
38
Q

Haemochromatosis: Investigations

A

Haematinics

  • Transferrin LOW (transport protein for iron – when iron is low, it increases to compensate )
  • Ferritin HIGH
  • Transferrin saturation HIGH
39
Q

A 41 y/o female presents with a history of colicky, right sided abdominal pain. She states the pain is worse after eating fish and chips and Indian takeaways. On examination her abdomen is soft and non-tender. Which is the best investigation to confirm her diagnosis?

A. 	Abdominal X-ray
B. 	ERCP
C. 	Liver biopsy
D. 	USS of biliary tree
E. 	CT-KUB
A

D. USS of biliary tree

40
Q

A 41 y/o female presents to A&E with a history of severe, continuous, RUQ pain. She feels feverish and complains of an occasional pain in her right shoulder. On examination she displays RUQ tenderness and a positive Murphy’s sign. What is the most likely diagnosis?

A. 	Biliary colic
B. 	Ascending cholangitis
C. 	Acute cholecystitis
D. 	Primary biliary cirrhosis
E. 	Cholangiocarcinoma
A

C. Acute cholecystitis

41
Q

While waiting to be admitted, her RUQ pain becomes worse and she starts shaking uncontrollably. You notice she now looks jaundiced. What is the most likely diagnosis?

A. 	Biliary colic
B. 	Ascending cholangitis
C. 	Acute cholecystitis
D. 	Primary biliary cirrhosis
E. 	Cholangiocarcinoma
A

B. Ascending cholangitis

42
Q

A 35 y/o man presents with a two week history of jaundice and RUQ pain. He is taking mesalazine for a “bowel condition”. What is the most likely cause of his jaundice?

A. 	Autoimmune hepatitis
B. 	Haemochromatosis
C. 	Primary sclerosing cholangitis
D. 	Primary biliary cirrhosis
E. 	Drug side effect
A

C. Primary sclerosing cholangitis

43
Q

Gallstones: Management

A

Cholelithiasis- Cholecystectomy

Choledocholithiasis - ERCP:
Endoscope Retrograde Choleo-pancreotography – endoscope down inti the small intestine to the opening of the bile duct- can view and remove stones.

44
Q

Gallstones: Management

A

Cholelithiasis- Cholecystectomy

Choledocholithiasis - ERCP:
Endoscope Retrograde Choleo-pancreotography – endoscope down inti the small intestine to the opening of the bile duct- can view and remove stones.

45
Q

Gallstones: Two important complications

A

Ascending Cholangitis:
CBD –> Bile Stasis –> Bacteria from gut to BD

Acute Cholecystitis
GB/Cystic duct –> Bile Stasis, Inflammation + bacteria

46
Q

Acute Cholecystitis Symptoms and Signs

A 
Constant (DDx to Gallstones) RUQ pain
May radiate to R scapula (Boas’ sign)
Fever
Nausea &amp; vomiting
Rebound tenderness
Murphy’s sign +ve
47
Q

Ascending Cholangitis

Symptoms and Signs

A

Charcot’s triad
RUQ pain
Fever
Jaundice

If septic:
Reynold’s pentad
+ Hypotension
+ Confusion

Jaundice + sepsis risk much more prevalent compared to acute cholecystitis

48
Q

PBC: Definition, aetiology, epidemiology

Primary biliary cirrhosis/cholangitis

A

An auto-immune condition resulting in damage to, and progressive destruction of, the biliary epithelial cells lining the small intrahepatic bile ducts.

Peak diagnosis ages 55-65.

10:1 Female to Male Ratio.

Risk factors: previous autoimmune disease and/or hypocholesteraemia (irritates the intrahepatic bile ducts)

49
Q

PBC: Signs and Symptoms:

A
  • Pruritis
  • Fatigue
  • Often comorbid Sjogren’s: dry eyes and mouth
50
Q

Investigations:

A 
LFTs
AMA antibodies (Anti-mitochondrial)
Diagnostic
Abdo US
Obstructive duct lesion MUST be excluded.
51
Q

PSC: Definition, Aetiology, Epidemiology

A

Inflammation and fibrosis of the intrahepatic and/or extrahepatic bile ducts, resulting in diffuse, multi-focal stricture formation.

Aetiology: unknown - may be AI (high serum Ab)

Peak incidence in 40-50s; rare - 13/100,000

Risk factors: male gender and concurrent IBD (2/3rds).

52
Q

PSC Symptoms and Signs

A

RUQ pain
Pruritis
Fatigue
Vague - based on RF

53
Q

PSC Investigations:

A 
LFTs (first line)
- GGT elevated
MRCP (diagnostic)
- Beading
AMA antibodies
- Should be negative
54
Q

Differences between PBC and PSC

A

Site of disease involvement:
PSC: BD inside and outside liver (10% have small duct PSC)
PBS:

55
Q

Pancreatic Cancer

A

6th most common cause of cancer- related death.
Technically pancreatic ductal adenocarcinoma.

Peak incidence 65-75 years old.

Risk factors: smoking, FH.

Key symptoms: jaundice, non-specific abdo pain, FLAWS.

Investigations: LFTs, ultrasound CT if suspicious.

56
Q

Differences between PBC and PSC

A

Site of disease involvement:
PSC: BD inside and outside liver (10% have small duct PSC)
PBS: Small bile ducts inside liver

Mode of Dx:
PSC: MRI of bile ducts. Liver Biopsy or ERCP
PBC: Raised ALP, +ve Ab (AMA), Dx Liver Biopsy

57
Q

Pancreatic Cancer

A

6th most common cause of cancer- related death.
Technically pancreatic ductal adenocarcinoma.

Peak incidence 65-75 years old.

Risk factors: smoking, FH.

Key symptoms: jaundice, non-specific abdo pain, FLAWS.

Investigations: LFTs, ultrasound –> CT if suspicious.

58
Q

Pancreatic Cancer

A

6th most common cause of cancer- related death.
Technically pancreatic ductal adenocarcinoma.

Peak incidence 65-75 years old.

Risk factors: smoking, FH.

Key symptoms: jaundice, non-specific abdo pain, FLAWS.

Investigations: LFTs, ultrasound –> CT if suspicious.

59
Q

A 58 year old woman is referred on from her GP as a result of abnormal laboratory tests. She is well does, does not smoke or drink; but does lead a sedentary lifestyle, suffers from hypertension and has a BMI of 33.

Laboratory results show:
Elevated AST and ALT. Elevated Triglycerides.

ALP, Bilirubin, INR within normal limits; Fasting glucose normal;
Total cholesterol, LDL, HDL normal;
Hepatitis serology, autoimmune screen: negative; Ferritin levels: normal

Possible differentials

A

Chronic Viral Hepatitis, Alpha 1 Anti-Trypsin Deficiency, Non Alcoholic Fatty Liver Disease (NAFL), Wilson’s Disease, Haemochromatosis

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