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Y3 MedEd > Biliary/Liver > Flashcards

Biliary/Liver Flashcards

1
Q

Pre-hepatic causes of jaundice (2)

A

Haemolytic anaemia

Gilberts

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2
Q

Post-hepatic causes of jaundice (2)

A

Gallstones

Obstructing cancer: head of pancreas, CBD

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3
Q

Hepatic causes of jaundice (5)

A 
Viral hepatitis
Alcoholic hepatitis
NAFLD
AIH
Genetic hepatitis
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4
Q

Features of post hepatic jaundice

A

Pale stools

Dark urine

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5
Q

Features of haemolytic anaemia (4)

A

HA: low Hb, raised bilirubin, low haptoglobins, raised lactate
Normal urine – unconjugated bilirubin is insoluble in water

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6
Q

Causes of chronic liver disease (5)

A 
Viral hepatitis
Alcoholic hepatitis
NAFLD
AIH
Genetic hepatitis
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7
Q

Which hepatic virus’ are chronic

A

BCD but C is more likely to become chronic

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8
Q

What is the typical population of AIH

A

Look for fat young women who are cushingoid post tx

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9
Q

Congenital causes of chronic liver disease and what is their inheritance pattern (3)

A

A1AT, Wilsons, hereditary haemochromatosis

All are autosomal recessive

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10
Q

AI causes of liver disease

A

AIH, PSC, PBC

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11
Q

Hepatitis A:
Transmission route
Infection length
Symptoms (6)

A 
Oro-anal sex; faeco-oral spread 
Acute (around 8 weeks)
asymptomatic (usually) but can have:
Nausea
Vomiting (+ Diarrhoea)
Fever
Jaundice
Abdominal pain (particularly RUQ)
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12
Q

Hepatitis B:
Transmission route
Infection length
Symptoms

A

Blood, Semen, Vertically

Most adults clear it

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13
Q

Hepatitis C:

Transmission route

A

Only through blood (e.g. drugs or tattoos)

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14
Q

Which hepatic virus can cause HCC

A

HCV/HBV

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15
Q

Which hepatic virus can only connect with another

A

D can only co-infect with B

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16
Q

Which hepatic virus is a particular problem for pregnant women

A

HEV

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17
Q

Which group of patients are particularly at risk of HEV

A

Pregnant women and immunocompromised

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18
Q

Length of infection of HBV and HCV and difference in adults and children

A

B adults mostly clear, children stay as carriers

C adults mostly stay as carriers and children clear

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19
Q

Incubation period of HAV

A

2 weeks

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20
Q

Incubation period of HBV

A

4-12 weeks

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21
Q

Incubation period of HCV

A

2 weeks - 6 months

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22
Q

Incubation period of HDV

A

4-12 weeks

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23
Q

Incubation period of HEV

A

5-6 weeks

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24
Q

All viral hepatitis’ can cause acute hepatitis with transaminitis in 1000s except…..

A

Hepatitis B which is mostly cleared by adults

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25
Q

What is the triad for viral hepatitis

A

(Fever) + Jaundice + Raised AST/ALT (in the 1000’s)

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26
Q

Where is HAV endemic to

A

Africa/Asia

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27
Q

Where is HBV endemic to

A

Africa

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28
Q

Where is HCV endemic to

A

Eastern Mediterranean

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29
Q

Where is HDV endemic to

A

Africa

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30
Q

Where is HEV endemic to

A

Poor water supply (India, most third world areas…)

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31
Q

Which is chronic and which is acute IgG and IgM

A

IgM MAN that’s acute!

IgG Chronic

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32
Q

What does HbsAg mean

A

HBV is here/around NOW
Negative if been cleared/past vaccine
Positive in acute/chronic infection

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33
Q

What does HbeAg

mean

A

Infective

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34
Q

What does Anti-HbS

mean

A 
Immune
Past clearance (ie got it in past, cleared it, ‘natural immunity’
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35
Q

What does Anti-Hbc

mean

A

Caught in the past

Positive if natural immunity and cleared

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36
Q

Mx of HAV

A

A: supportive care

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37
Q

Mx of HBV

A

B: supportive care for acute, antivirals +peg⍺-interferon for chronic.

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38
Q

Mx of HCV

A

C: supportive care for acute, direct acting antivirals for chronic.
Elbasvir/glecaprevir
Ritonvair + ribavirin

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39
Q

Which hepatic viruses can have serious complications and what are they

A

HBV HCV

HCC and cirrhosis

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40
Q

What are causes of transaminitis in the 1000’s (3)

A

Paracetamol overdose
Acute viral hepatitis (not B)
‘Ischaemic hit’

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41
Q

What does a raised GGT and ALP suggest

A

Cholestatic/obstructive picture, biliary damage GGT (EtOH)

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42
Q

What does a raised AST:ALT in a 2:1 ratio suggest

A

alcoholic hepatitis

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43
Q

What does low urea suggest

A

severe liver disease, (synthesised in liver), malnutrition, pregnancy

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44
Q

What does low albumin suggest

A

poor synthetic function of liver

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45
Q

What does a raised urea over 10 suggest (2)

A

UGIB (or large protein meal)

Dehydration/AKI (urea excreted renally)

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46
Q

What LFT pattern suggests:

paracetamol OD

A

Transaminitis in the 1000s

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47
Q

What LFT pattern suggests:

ischaemic hit

A

Transaminitis in the 1000s

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48
Q

What LFT pattern suggests:

viral hepatitis

A

Transaminitis in the 1000s

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49
Q

What LFT pattern suggests:

Cholestatic/obstructive picture

A

Raised GGT and ALP

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50
Q 
What LFT pattern suggests:
biliary damage (EtOH)
A

Raised GGT and ALP

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51
Q

What LFT pattern suggests:

alcoholic hepatitis

A

AST:ALT 2:1

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52
Q

What LFT pattern suggests:

poor synthetic function of liver

A

Low albumin

53
Q

What LFT pattern suggests:

severe liver disease

A

Low urea

54
Q

What LFT pattern suggests:

malnutrition

A

Low urea

55
Q

What LFT pattern suggests:

pregnancy

A

Low urea

56
Q

What LFT pattern suggests:

UGIB (or large protein meal)

A

Raised urea (>10)

57
Q

What LFT pattern suggests:

Dehydration/AKI

A

Raised urea (>10)

58
Q

Typical NASH patient

A

Old fat man (metabolic syndrome)

59
Q

Ix for NASH (4)

A

Elevated fasting triglycerides, low HDL
High ALT/AST
Incidental liver USS = Steatosis

60
Q

RF for NAHS (6)

A 
Obesity
Type 2 diabetes mellitus
Hypertension
Hypercholesterolaemia
Age > 50 yrs
Smoking
61
Q

Symptoms of NASH (5)

A 
Usually found as an incidental finding
Occasional symptoms include:
Dull or aching RUQ pain
Fatigue
Unexplained weight loss
Weakness
Symptoms of cirrhosis will be experienced in the most advanced stages of NASH
62
Q

3 main signs of cirrhosis (3)

A

E.g. jaundice, ascites, pruritus

63
Q

Mx of NASH (7)

A 
Conservative - controlling risk factors:
Blood pressure
Diabetes
Cholesterol
Lose weight
Stop smoking
Exercise regularly
Reduce alcohol consumption (although it is NOT caused by excessive alcohol, drinking can make it worse)
64
Q

Complications of NASH (6)

A 
Cirrhosis
Ascites
Oesophageal varices
Hepatic encephalopathy
Hepatocellular carcinoma
End-stage liver failure
65
Q

3 forms of liver disease caused by alcohol

A

Alcoholic fatty liver (steatosis)
Alcoholic hepatitis
Chronic cirrhosis

66
Q

Mild symptoms of alcoholic hepatitis (4)

A

Nausea
Malaise
Epigastric pain
Right hypochondrial pain Low-grade fever

67
Q

More severe symptoms of alcoholic hepatitis (4)

A

Jaundice
Abdominal discomfort or swelling
Swollen ankles
GI bleeding

68
Q

How long do you need to be drinking to get alcoholic hepatitis

A

a long history of heavy drinkingis required for the development of alcoholic hepatitis (around 15-20 years)
here may be events that trigger the disease (e.g. aspiration pneumonia, injury)

69
Q

Signs of alcohol excess (10)

A 
Malnourished
Palmar erythema
Dupuytren's contracture
Facial telangiectasia
Parotid enlargement
Spider naevi
Gynaecomastia
Testicular atrophy
Hepatomegaly
Easy bruising
70
Q

Signs of severe alcoholic hepatitis (8)

A 
Febrile (in 50% of patients)
Tachycardia
Jaundice
Bruising
Encephalopathy (e.g. liver flap, drowsiness, disorientation)
Ascites
Hepatomegaly
Splenomegaly
71
Q

FBC in alcoholic hepatitis (4)

A

Low Hb
High MCV
High WCC
Low platelets

72
Q

LFTs of alcoholic hepatitis (4)

A

High AST + ALT
High bilirubin
High ALP + GGT
Low albumin

73
Q

U&E’s in alcoholic hepatitis (2)

A

Urea and K+ tend to be low

74
Q

What is a sensitive marker for significant liver damage

A

Prolonged PT/high INR

75
Q

What is seen in the main Ix of EtOH related cirrhosis (5)

A

Low albumin, low platelet, high INR (prothrombin time), USS splenomegaly, ascetic fluid (portal HTN)

76
Q

Ix for alcoholic hepatitis (8)

A 
FBC
LFT
U&E's
PT/INR
US
Liver biopsy
EEG
Upper GI endoscopy
77
Q

Mx of acute alcoholic hepatitis

A

Acute
Thiamine
Vitamin C and other multivitamins (can be given asPabrinex)
Monitor and correct K+, Mg2+ and glucose
Ensure adequate urine output
Treat encephalopathy with oral lactulose or phosphate enemas
Ascites - manage with diuretics(spironolactone with/without furosemide) Therapeutic paracentesis
Glypressin and N-acetylcysteine for hepatorenal syndrome
• Nutrition
Via oral or NG feeding is important
Protein restrictionshould be avoided unless the patient is encephalopathic
Nutritional supplementation and vitamins (B group, thiamine and folic acid) should be started parenterally initially, and continued orally
Steroid Therapy - reduce short-term mortality for severe alcoholic hepatitis

78
Q

How do you treat encephalopathy (2)

A

oral lactulose or phosphate enemas

79
Q

Complications of alcoholic hepatitis (3)

A

Acute liver decompensation
Hepatorenal syndrome
Cirrhosis

80
Q

What is a very good test for cirrhosis

A

Albumin and prothrombin time will definitely be abnormal in cirrhosis because these are markers of of the hepatic synthetic function which is less affected by fat build up than fibrosis.

81
Q

Complications of cirrhosis (4)

A

portosystemic encephalopathy, hepatorenal and hepatopulmonary syndrome.
Development of hepatocellular carcinoma.

82
Q

What is the pathology and inheritance behind Wilson’s disease

A

Impaired excretion of copper from liver via bile through copper transporter, autosomal recessive

83
Q

Where does Cu accumulate in Wilsons disease and what does that cause (3)

A

Liver: CLD
Basal ganglia: early onset neuropsychiatric sx/Parkinsonism
Cornea: Keyser Fleischer rings

84
Q

Mx of Wilson’s disease

A

penicillamine to chelate Cu

85
Q

Ix for Wilson’s disease (3)

A

LOW serum caereuloplasmin
High urinary copper
LOW serum Cu (paradoxical) – not reliable

86
Q

Age of onset of Wilson’s disease and difference in presentation between children and adults

A

10-25 years

children present with liver disease, adults present with neurological disease

87
Q

Symptoms of Wilson’s disease (10)

A

Liver: Hepatitis, cirrhosis
Neurological: Basal ganglia degeneration,speech and behaviour problems , asterixis, chorea, dementia
Kayser-Fleischer rings
Renal tubular acidosis - fanconi syndrome
Haemolysis
Blue nails

88
Q

What is the issue with haemochromatosis and pattern of inheritance (2)

A

dysregulated increased dietary iron absorption and increased iron release from macrophages.

autosomal recessive

89
Q

Where is iron deposited in haemochromatosis (6)

A

Deposits in liver, pancreas, skin, joints, heart and pituitary gland

90
Q

Haematinics of haemochromatosis

A

Transferrin LOW
High transferrin saturation
Serum Ferritin HIGH (storage)
TIBC LOW

91
Q

Describe iron metabolism

A

Iron absorbed in duodenum where it is stored intracellullarly bound to ferritin or transported out of the cells by ferroportin, a transmembrane protein
Ferroportin then binds to transferrin in the blood
Hepcidin is a protein that inhibit ferroportin, thereby regulating the amount of iron entering the blood

92
Q

Age of onset of haemochromatosis

A

40-60

93
Q

Early symptoms of haemochromatosis (6)

A

Fatigue, arthralgias, weakness, arthropathy, ED, heart problems (vague)

94
Q

Late symptoms of haemochromatosis (7)

A

Diabetes, bronzed skin, hepatomegaly, arrhythmias, cardiomyopathy, neuro/psych problems
Cirrhosis

95
Q

Which Ab are positive in AIH (2)

A

AIH: anti smooth muscle antibodies, and sometimes anti-liver kidney microsomal antibodies

96
Q

Common population of AIH

A

Consider in young fat women on lots of steroid

Clusters with other autoimmune conditions

97
Q

What does pituitary deposits of Cu cause

A

loss of libido, sexual dysfunction

98
Q

Which gallbladder disease has a triad and what is it

A

Cholangitis
RUQ pain
Fever
Jaundice

99
Q

What are the main symptoms of biliary colic

A

RUQ pain

100
Q

What are the main symptoms of acute cholecystitis

A

RUQ pain and fever

101
Q

What are the main symptoms of cholangitis

A

RUQ pain
Fever
Jaundice

102
Q

Ix for gallbladder disease (3)

A

LFT 1st line, Abdo USS (gold-standard, Dx), then consider MRCP

103
Q

What is Boas signs

A

Pain radiating to the scapula in cholecystitis (can also be present in gallstones)

104
Q

Which two signs together strongly indicate acute chollecystitis

A

Boas and Murphys

105
Q

Mx of cholelithiasis

A

Cholecystectomy

106
Q

Mx of choledocholithiasis

A

ERCP

107
Q

Pathology of PBC

A

Intrahepatic bile duct granulomatous destruction by Abs

108
Q

Pathology of PSC

A

Intra- and extrahepatic bile destruction
Biliary obstruction
Backpressure to liver  cirrhosis

109
Q

Typical patient in PBC (3)

A

Itchy middle aged females (F:M 9:1), fatigue (dry eyes, mouth)

110
Q

Typical patient in PSC (population and age)

A

People with IBD – UC

40-50s

111
Q

Main symptoms of PBC

A

Fatigue
Weight loss
Pruritis

112
Q

What does PBC lead to (2)

A

cholestasis, and, ultimately, cirrhosis

113
Q

Pathogenesis of PSC (6)

A 
Periductalinflammationwith periductal concentricfibrosis (scarring)
Portal oedema
Bile duct proliferation
Expansion of portal tracts
Progressive fibrosis
Development of biliary cirrhosis
114
Q

Ix for PBC (2)

A

Anti mitochondrial m2 antibodies

Lipids also raised

115
Q

Ix for PSC

A

MRCP: beads on a string

116
Q

Associations in SBA’s of PBC (3)

A

Hypercholestrolaemia: tendon xanthomata, xanthelasma peri-ocular

117
Q

Associations in SBA’s of PSC (2)

A

UC: most PSC patients have UC, most UC patients don’t have PSC
Cholangiocarcinoma (CBD cancer)

118
Q

Age of pancreatic cancer

A

Peak incidence 65-75 years old.

119
Q

Key symptoms of pancreatic cancer (7)

A

jaundice, non-specific abdo pain, FLAWS.

Also sudden onset DM

120
Q

Ix for pancreatic cancer (4)

A

LFTs, Protocol CT scan

If unclear offer PET/CT or EUS

121
Q

What is Courvoisiers law

A

a palpable gallbladder in the presence of painless jaundice is unlikely to be due to stones

122
Q

Associations of HCC (6)

A

Chronic liver damage (EtOH liver disease, HepB/C, AI), metabolic disease, alpha-1 antitrypsin deficiency
Aflatoxin

123
Q

Which fungal toxin causes HCC

A

Aflatoxin

124
Q

Ix for HCC

A

urgent direct access ultrasound scan

LFT (marker of liver function: Albumin/Clotting – APPT/PT), alpha-fetoprotein (AFP) – tumour marker, hepatitis serology

125
Q

Which tumour marker suggests HCC

A

AFP

126
Q

What is the marker for pancreatic cancer

A

CA19-9

127
Q

What is the marker for cholangiocarcinoma

A

CA19-9

128
Q

What associations are with cholangiocarcinoma (2)

A

Ulcerative colitis + Primary sclerosing cholangitis

129
Q

Which gender does liver cysts commonly affect

A

Women

Y3 MedEd (34 decks)

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