Biliary + liver Flashcards
Causes of jaundice
Pre-hepatic
= haemolytic anaemia
= unconjugated bilirubin, normal urine
Hepatic
= liver disease
= mixed conjugated bilirubin
Post-hepatic
= gallstones, obstructing Ca-CBD (head of pancreas)
= conjugated bilirubin, pale stools, dark urine
Main causes of CLD
I. Alcoholic liver disease (small liver) II. Viral hepatitis (hep B + C; chronic) III. Fatty liver (NAFLD) IV. AIH (women, young, Cushingoid) V. Congenital (A1AT, Wilson's, HH - all AD)
Hep A summary card
Oro-anal sex; faeco-oral spread, acute, asymptomatic (usually) = Faecal-oral transmission = 2 weeks incubation period = Africa/Asia high risk = RFs: poor hygiene = Rarely chronic
*improperly cleaned shellfish from contaminated water
Hep B summary card
Learn your serology, most adults clear it; never acute whilst children are carriers = Bodily fluids transmission = 4-12 week incubation period = Africa high risk = RFs: health workers = Chronic in children, 5% adults
Serology: IgM(an that’s acute), IgG(one, chronic!)
Hep B serology
HbsAg: now/around
= -ve if cleared/past vaccine
= +ve if acute/chronic infection
HbeAg: infective
Anti-Hbs: immune, IgG
= past clearance/vaccination
Anti-Hbc: caught in past, IgM
= +ve natural immunity and cleared
Hep C summary card
Blood production spread, most adults chornic carries, leads to HCC, 80% asymptomatic = Bodily fluids transmission = 2 weeks-6 months incubation period = Eastern Mediterranean high risk = RFs: IVDU = Chronic in 60-80%
Hep D summary card
Superinfection of B, requires HBV surface antigen to access liver cells = Bodily fluids transmission = 4-12 weeks incubation period = Africa high risk = ONLY coninfects with hep B = Rarely chronic
Hep E summary card
Morbidity in pregnant women, expectant mothers beware!! Usually acute and self-limiting = Faeco-oral transmission = 5-6 weeks incubation period = Occurs in areas with poor water supply = RFs: immuncompromised, pregnant = Rarely chronic
Sx of hepatitis
Fever, jaundince, increase in both AST/ALT thus liver problem (transaminitis in all except hep B)
Mx of hepatitis
A
= supportive, all resolves by 6 months
B
= supportive for acute
= anti-virals and pega-interferon for chronic
= viral suppresion in 90% of chronic carriers
C
= supportive for acute
= direct acting anti-virals for chronic (elbasvir/glecaprevir or ritonavir + rinavirin)
= mortality at 79% at 10 years for chronic cases
What can you interpret from these LFT results?
a) transaminitis in 1000s
b) increased AST + ALT
c) increased GGT + ALP
d) AST:ALT is 2:!
e) decreased urea
f) increased urea (>10)
g) decreased albumin
a) paracetamol OD, ischaemic hit, viral
b) hepatic problem
c) cholestatic/obstructive picture, EToH, biliary damage
d) alcoholic hepatitis when S > L
e) pregnancy, malnutrition, severe liver disease (synthesis down)
f) dehydration/AKI, UGIB/large protein meal
g) poor synthetic function of liver
Who is NASH?
Non-alcoholic steatohepatitis
=> umbrella for steatosis and steatohepatitis
RFs: obesity, TIIDM, HTN, high cholesterol, smoking, age > 70yo
Usually an incidental finding as no sx in early stages
Increased risk of DM, MI, stroke
20% go on to develop cirrhosis
Ix and mx of NASH
Ix show
- LFTs: raised ALT/AST
- raised fasting triglycerides, low HDL
- steatosis liver on USS
Mx is to control RFs
- BP, diabetes, cholesterol, wt loss, smoking cessation, exercise, reduce alcohol
Complications of cirrhosis
Ascites Oeseophageal varices Hepatic encephalopathy Hepatocellular carcinoma End-stage liver failure
Presentation of alcoholic hepatitis
Hx of 15-20 years of heavy drinking Typically asymptomatic Mild sx - epigastric pain, nausea, malaise Severe sx - jaundice, abdo discomfort/swelling, swollen ankles, GI bleed
Ix findings of alcoholic hepatitis
Bloods
- FBC; low Hb, high MCV, high WCC, low plts
- LFTs; AST:ALT, 2:1, high bilirubin, ALP, GGT, low albumin
- U&Es; low urea and potassium
- prolonged PT
UGI endoscopy ?varices
Liver biopsy to distinguish from other heps
EEG ?encephalopathy
USS ?malignancy
Acute mx of alcoholic hepatitis
Acute
- thiamine + vitamens => pabrinex
- monitor K+, Mg2+, glucose
- restrict proteins, oral/NG tube
- manage ascites => diuretics
- treat encephalopathy => oral lactulose/phosphate enemas
What would histopathology show for an alcoholic liver?
Degeneration and necrosis of hepatocytes Steatosis Neutrophilic inflammation Cholestasis Mallory-hydraline inclusions
Complications of alcoholic hepatitis
Acute liver decompensation Hepatorenal syndrome (due to increased RAAS activation) Cirrhosis (within 1-3 years if continues drinking)
Mortality 1st month = 10%, 1st year = 40%
Wilsons disease summary card
Copper accumulation due to defective liver transporters (ATP7B gene on chr 13)
=> copper deposits in basal ganglia and eyes
=> Kayser-Fleische rings (slit-lamp ix) pathognomonic
=> early onset neuropalsy sx/Parkinsonism
=> renal tubular acidosis (Fanconi’s syndrome)
Ix show
- decreased serum ceruloplasmin (copper transport protein)
- increased urinary copper
- decreased serum copper (paradoxical so not reliable)
Haemochromatosis sx
Starts 40-60 years old
- arthropathy arthralgias, weakness, fatigue, erectile dysfunction, heart problems
Late presentations
- diabetes, cirrhosis, neuro/psych sx, cardiomyopaty, arrhytmias, hepatomegaly, bronzed skin
What is haemochromatosis?
Dysregulated increased iron absorption
= HFE gene; C282Y + H63D (most common mutations)
= AR inheritence
= 90% problem with hepcidin
= deposits in liver, pancreas and pituitary gland
Haemochromatosis ix and mx
Ix
- Check CRP, ALT, chronic EToH to rule out other reasons for increased ferritin
- Bloods show increased ferritin + transferrin saturation and decreased transferrin + TIBC
Mx
- Avoid iron overload in early stages
Differentiate the gallbladder diseases
Biliary colic
= stone in Hartmann’s pouch
= RUQ, colicky pain due to GB spasm against stone
Acute cholecystitis
= GB inflamed
= RUQ continuous pain, fever, Murphys +ve
Ascending cholangitis
= GB infection
= Charcot triad: RUQ pain-fever-jaundice
= Rarely Reynold’s pentad: “ “ + hypotension, confusion
Ix and mx for gallbladder disease
Ix: LFTs = increased ALP in choledocholithiasis Abdo USS = gold-standard = see stones/dilated bile duct, to consider MRCP next
Mx: Cholelithiasis => cholecystectomy - only in gallbladder Choledocholithiasis => MRCP - gallbladder but entered duct
RFs for gallbladder disease
Fat, female, fertile, forty, FHx
PBC vs PSC
PBC
=> T-cell mediated AI response against bile duct epithelial cells
=> intrahepatic bile duct granulomatous distruction by antibodies
=> antimitochondrial m2 antibodies
PSC
=> periductal inflammation with periductal concentric fibrosis (scarring)
=> intra + extrahepatic bile destruction; biliary obstruction, back pressure to liver -> cirrhosis
=> MRCP: beads on a string
How may PBC present?
Itchy females (9:1) w/ fatigue, dry eyes and mouth
May have hypercholestrolaemia, tendon xanthonata, xanthelasma peri-ocular
How may PSC present?
People with UC, 40-50 year olds
May have cholangiocarcinoma (CBD Ca)
*most PSC pts have UC but most UC pts don’t have PSC
Complications of PSC
Cholangiocarcinoma (CBD Ca)
Bile duct, colonic cancer
Pancreatic cancer summary card
Typically pancreatic ductal adenocarcinoma
= RFs: smoker, FHx, chronic pancreatitis
= painless jaundice, FLAWS, presents as sudden onset DM, non-specific abdo pain
Ix
= LFTs, protocol CT scan (drain bile duct)
What’s Courvoiser’s Law?
A palpable gallbladder in the presence of painless jaundice is unlikely due to stones
=> Ca of head of pancrease, CBD cancer
Hepatocellular carcinoma summary card
Primary malignancy of liver parenchyma
= due to CLD (AI, hep B/C, EToH), metabolic disease, alpha-1 antitrypsin deficiency
= malignancy sx, Hx of exposure to carcinogens/aflatoxins, liver cirrhosis/failure
Ix
= LFTs: albumin low, prolonged clotting
= AFP tumour marker
= Urgent direct access USS (2 weeks) to assess upper abdo mass consistent w/ enlarged liver
Cholangiocarcinoma summary card
Primary adenocarcinoma of biliary tree
= RFs: UC + PSC
= Ix: CA19-9 marker (pancreatic and cholangiocarcinomas)
= Sx: obstructive jaundice sx
Liver cyst vs abscess
Cyst (simple)
=> lined w/ biliary-type epithelium but cyst fluid contains NO bile
=> RUQ pain, F>M, found incidentally
Abscess (infectino) => mass filled w/ pus in liver => 80% pyogenic - polymicrobial => 10% amoebic - Entamoeba histolytica => 10% fungal - Candida
A woman presents to the Emergency department with RUQ pain and yellowness. Her history is unremarkable. A sexual history reveals she has recently had oro-anal sex with a man who has sex with men.
Which is the most likely diagnosis?
A Hepatitis A B Hepatitis B C Hepatitis C D Syphillis E HIV
A Hepatitis A
A 36 year old woman in her second trimester of her second pregnancy is on a trip to India. She falls unwell, presenting with abdominal pain and scleral icterus, and dies 4 days later.
Which is the most likely diagnosis?
A Acute Hepatitis A B Acute Hepatitis B C Acute Hepatitis C D Acute Hepatitis E E Chronic Hepatitis B
D Acute Hepatitis E
A 68 year old is brought unconscious to the Emergency department. Her electronic records reveals a history of depression and known ethanol excess. She is unkempt and smells of alcohol.
AST: 1465
ALT: 1273
ALP: 321
GGT: 68
Which is the most likely diagnosis?
A Acute Hepatitis B B Acute alcoholic hepatitis C Alcoholic cirrhosis D Paracetamol overdose E Wilson’s disease
D Paracetamol overdose
A 29 year old teacher has presented to the Emergency department with abdominal pain. LFTs are shown.
AST: 143
ALT: 76
ALP: 46
GGT: 32
Which is the most likely diagnosis?
A Alcoholic hepatitis B Cholelithiasis C Gastroenteritis D Pancreatitis E Viral hepatitis
A Alcoholic hepatitis
A 29 year old woman attends as a new patient in the hepatology clinic with worsening jaundice. Her history is notable for polycystic ovarian syndrome, hypothyroidism and obesity. Anti smooth muscle antibodies are positive
Which is the most likely diagnosis?
A Autoimmune hepatitis B Cushing disease C Non alcoholic fatty liver D Primary biliary cholangitis E Primary sclerosing cholangitis
A Autoimmune hepatitis
AIH
- anti smooth muscle antibodies
- anti-liver kidney microsomal antibodies
- consider in yg fat women on lots of steroids
- clusters with other autoimmune conditions
A 22 year old male is brought to the Emergency Department after being found running in the streets and attacking members of the public. He states he is undertaking the work of God. Blood tests reveal liver dysfunction and physical examination is notable for bradykinesia, tremor, and marked rigidity
Which of the following results may be expected?
A Elevated serum caeruloplasmin B Elevated serum free copper C Elevated NDMA receptor antibodies D Low serum caeruloplasmin E Low urinary copper
D Low serum caeruloplasmin
A 56 year old man presents to the GP with loss of libido, sexual dysfunction, and polyuria and polydipsia.
He has also noticed some pain in the knuckles, more in his 2nd and 3rd fingers.
What is the most likely diagnosis?
A Diabetes insipidus B Diabetes mellitus C Hereditary haemochromatosis D Rheumatoid arthritis E Wilson’s disease
C Hereditary haemochromatosis
A 42 year old woman attends A+E with severe right upper quadrant pain. Her vital signs are temperature 37.1, HR 96, BP 111/74, RR 30, SO2 96% RA. Blood tests are normal, except LFTs which are shown.
AST 128
ALT 110
ALP 207
GGT 111
What is the first investigation to undertake?
A AXR B Erect CXR C US CBD D US Liver E US Ovary
C US CBD
A 38 year old woman with abdominal pain is referred by her GP with increasing pruritis abnormal liver function (shown).
A photograph of her face is showing xanthelasma peri-ocular deposits. What is the single next investigation to order?
What is the single next investigation to order?
A Anti mitochondrial antibodies B Anti smooth muscle antibodies C Anti ds-DNA antibodies D Ultrasound common bile duct (CBD) E Urine protein collection 24hrs
A Anti mitochondrial antibodies
A 68 year old woman was admitted on the medical take for 7 kilograms of unexplained weight loss. A small painless mass is palpated in the right upper quadrant. On day 3 of the admission, visible jaundice has developed. She is asymptomatic.
Which is the first line investigation?
A Protocol CT abdomen scan
B Protocol CT scan including chest abdomen pelvis
C Fluorodeoxyglucose-positron emission tomography (FDG-PET/CT) abdomen
D Endoscopic ultrasound (EUS) with EUS-guided tissue sampling
E Magnetic resonance cholangiopancreatography (MRCP)
B Protocol CT scan including chest abdomen pelvis
A 45 year old homeless male presented to the GP with 7 kilograms of unexplained weight loss and jaundice. He admitted being a regular IV drug user. He has lost to follow up with hepatology services for 10 years.
The GP dropped his tea, and expressed her concerns to the medical student.
Which is the most appropriate next step?
A Measure hepatitis B serology
B Measure alpha-fetoprotein level (AFP)
C Refer to hospital for routine hepatology appointment
D Refer to hospital for urgent direct access ultrasound scan
E Refer to hospital for urgent protocol CT scan including chest abdomen pelvis
D Refer to hospital for urgent direct access ultrasound scan
