Abdominal Flashcards
What are the causes of cirrhosis?
Alcohol
Viral (hepatitis B, hepatitis C)
Autoimmune (primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis)
Metabolic (NAFLD, haemochromatosis, cystic fibrosis)
Drugs (methotrexate, isoniazid, amiodarone, phenytoin)
What are the complications of cirrhosis?
Portal hypertension (varices, ascites, hypersplenism) Liver dysfunction (coagulopathy, encephelopathy, jaundice, hypoalbuminaemia) Hepatocellular carcinoma
What are the causes of decompensation in cirrhosis?
Infection Spontaneous bacterial peritonitis Hypokalaemia GI bleeding Sedatives Hepatocellular carcinoma
How do you classify the severity of hepatic encephalopathy?
Reversible neurological dysfunction or coma related to decompensated liver disease
Graded from 1 to 4 depending on degree of impairment
Asterixis may be present at any stage
How do you assess the severity of cirrhosis?
The Childs-Pugh score
Prognostic score based on bilirubin, albumin, INR, ascites and encephalopathy
Graded from A-C (A best prognosis)
How would you manage a patient with cirrhosis?
Slow or reverse liver disease (alcohol abstinence, antiviral therapy)
Preventing further liver damage (immunisations, abstinence)
Preventing complications (hepatoma surveillance, endoscopy, prophylaxis against variceal bleeds with propranolol)
Liver transplantation
What are the most common causes of ascites?
Cirrhosis
Malignancy
Heart failure
What initial investigations would you use to determine the cause of the ascites?
Paracentesis (albumin and protein, white cell count, gram stain, culture, cytology) Abdominal ultrasound (mass, splenomegaly, portal hypertension, thrombosis) Blood tests (liver function, clotting, full blood count)
How do you classify transudative and exudative ascites?
Comparing the ascitic fluid albumin to the patient’s serum albumin
The serum ascites/albumin gradient (serum albumin - ascitic albumin)
A result of >11 suggests transudative, <11 suggests exudative
What is the pathophysiology of ascites in cirrhosis?
Only occurs following the development of portal hypertension
Disruption of portal blood flow due to liver fibrosis, resulting in accumulation of fluid in the peritoneal cavity
The cirrhotic liver releases vasodilatory compounds, which cause sphlanchnic vasodilation. This decreases systemic vascular resistance > lower circulating volume and blood pressure > activates the renin-angiotensin-aldosterone system, which results in sodium and water retention
What is the initial treatment of ascites in cirrhosis?
Sodium restriction
Fluid restriction
Diuretic therapy, initially with aldosterone antagonists, with loop diuretics added once naturesis is achieved
Liver transplantation
What are the causes of isolated hepatomegaly?
Cirrhosis Carcinoma CCF Infection (HBV, HCV) Auto-immune (PBC, PSC, AIH) Infiltration (amyloid, myeloproliferative disorders)
Which tumours commonly spread to the liver?
Colorectal (most common) Upper GI Lung Breast Renal Endometrial Bone Sarcomas
What are the infective causes of acute hepatitis?
Hepatitis A Hepatitis B Hepatitis C Hepatitis E Epstein-barr virus Cytomegalovirus Toxoplasmosis Herpes simplex virus
What are the causes of splenomegaly?
Portal hypertension Haematological malignancy Infection (HIV, endocarditis, epstein-barr) Congestion (cardiac failure) Primary splenic disease (splenic vein thrombosis) Haemolysis Thalassaemia Glycogen storage disorders
How would you evaluate a patient with splenomegaly?
History - constitutional symptoms, risk factors for HIV, features pancytopenia, travel history, autoimmune disease, liver disease
Investigations - full blood count, blood film, liver function, LDH, autoimmune screen, imaging (ultrasound and full CT imaging if looking for disseminated malignancy), lymph node or bone marrow biopsy
What are the significance of b-symptoms on Hodgkin’s lymphoma?
Fever >38, weight loss >10% body weight in 6 months, drenching night sweats
Presence of these alters the patient’s clinical staging
What are the cytogenetics of chronic myeloid leukaemia?
The philadelphia chromosome is present in 90-95% of patients with CML Chromosomal translocation (fusion of c-abl oncogene of chromosome 9 with bcr on chromosome 22.
This fusion leads to increased oncogene activity through tyrosine kinase signalling
What are the causes of hyposplenism?
Splenic infarction Splenic artery thrombosis Infiltrative conditions (amyloidosis, sarcoidosis) Coeliac disease Autoimmune disease
What advice should patients with hyposplenism/post-splenectomy be given?
Vaccinations (pneumococcal, haemophillus influzena B and meningococcal group C
Prophylactic antibiotics
Malaria prophylaxis and travel advice
Medic alert card or bracelet
What is Felty’s syndrome?
Triad of seropositive arthritis with neutropaenia and splenomegaly
What is the mode of inheritance of hereditary haemochromatosis?
Autosomal recessive
HFE gene is located on the short arm of chromosome 6
Most caucasian patients are homozygous for the cysteine to tyrosine substitution at position 282
How is haemochromatosis diagnosed?
Iron overload suggested by iron studies
Transferrin saturation >60% in males and >50% in females
Liver biopsy to show parenchymal iron deposition
Genetic testing for C282Y and H63D
First degree relatives should undergo genetic testing
What is the treatment of haemochromatosis?
Vensection (initially twice weekly until transferrin saturation below 50%, and then maintenance every three months)
Hepatocellular carcinoma surveillance
What are the clinical features of primary biliary cirrhosis?
Fatigue
Pruritis
Hypercholesterolaemia
Liver disease occurs late
How is primary biliary cirrhosis diagnosed?
Serum anti-mitochondrial antibodies are present in >95%
The histological lesion is a portal tract granuloma
Imaging may be done to exclude extra-hepatic cholestasis
Which drugs can cause cholestasis?
Phenothiazines Sulphonamides Penicillins Rifampicin Macrolides Carbamazepine Androgenic steroids Diclofenac
