Case 3 - HPB Flashcards
What is considered as alcohol excess?
14units/wk over 3+ days, no more than 5/day
What are the alcohol withdrawal symptoms and what is their timeline?
- 6-12h: tremor, sweating, headache, craving, anxiety
- 12-24h: hallucinations
- 24-48h: seizures
- 24-72h: delirium tremens
What symptoms are considered in delirium tremens?
Confusion, agitation, delusions, hallucinations, tremor, tachycardia, HTN, hyperthermia, ataxia, arrhythmias, seizure
What tool can be used to score the patient on their alchol withdrawal symptoms and guide treatment?
- CIWA-Ar (Clinical Institute Withdrawal Assessment – Alcohol revised)
- Consider medication for high-risk i.e. ≥8)
What medications can be given in alcohol withdrawal?
- Chlordiazepoxide (benzodiazepine) 5-7days titrate then wean
- IV high-dose B vitamins (Pabrinex) then
- Oral thiamine
What is alcoholic liver disease?
Alcoholic liver disease results from the effects of the long term excessive consumption of alcohol on the liver.
What are the 3 stages of ALD?
1) Fatty liver (steatosis, reversible)
2) Alcoholic hepatitis (inflammation and necrosis)
3) Alcoholic liver cirrhosis (irreversible)
What are the symptoms of ALD?
- Abdominal pain – RUQ
- Jaundice
- Hepatomegaly
- Nausea and vomiting
- Splenomegaly and ascites may be present
- Fatigue, lethargy
What are the risk factors for ALD?
- Prolonged heavy alcohol consumption
- Presence of hepatitis C
- Female sex
What are the investigations for ALD?
- ALT, AST and ALP (Later on) raised
- Serum AST/ALT ratio >2
- GGT elevated
- Raised bilirubin
- Raised prothrombin time
- Decreased albumin
- Macrocytic anaemia
What might the ultrasound show for ALD?
- Hepatomegaly
- Fatty liver
- Liver cirrhosis
- Liver mass
- Splenomegaly
- Ascites
What is the treatment for ALD`?
- Immediate cessation of alcohol use, high protein and nutrition diet.
- In some cases, glucocorticoids
What is NAFLD?
Accumulation of fat in the liver cells with risk of inflammation and cirrhosis
What are the 4 stages of NAFLD?
1) NAFLD
2) NASH - non alcoholic Steatohepatitis
3) Fibrosis
4) Cirrhosis
What are the causes of NAFLD?
- Obesity
- Type 2 diabetes: metabolic syndrome
- Medication: amiodarone, glucocorticoids, oestrogen
What are the symptoms of NAFLD?
- Often asymptomatic
- Fatigue and malaise
- Truncal obesity
- Hepatosplenomegaly
- RUQ abdominal pain
What are the investigations of NAFLD?
- AST, ALT and GGT raised
- Bilirubin raised
- ALP raised
- Prothrombin, INR raised
- Albumin decreased
- AST
What is the treatment for NAFLD?
- Weight loss, optimise diabetic treatment
- Discontinue responsible medication
What is liver cirrhosis?
The result of chronic inflammation and damage to liver cells which can derive from any liver disease.
How is the liver tissue changed in cirrhosis?
Liver cells are replaced with scar tissue (fibrosis) and nodules of scar tissue form.
What are the causes of cirrhosis?
- ALD
- NAFLD
- Viral hepatitis (B+C)
- Drugs: amiodarone, methotrexate
- Alpha-1 antitrypsin deficiency
- Wilson’s disease
What score can be used to see the severity based on bilirubin, albumin, INR, ascites, encephalopathy?
Child-Pugh score
What score is used for estimated 3-month mortality and referral for liver transplant?
MELD score
What are the signs and symptoms of cirrhosis?
- Jaundice and pruritus
- Hepatosplenomegaly
- Spider Naevi
- Palmar Erythema
- Gynaecomastia and testicular atrophy in males
- Bruising
- Ascites
- Caput Medusae
- Asterixis
- Fatigue, malaise, weight loss
- Oesophageal varices
- Clubbing
What are the lab test investigation of cirrhosis?
- ↑AST, ALT, GGT
- ↑ Bilirubin: rises as the cirrhosis progresses
- ↑ Alkaline phosphatase: elevated levels suggest biliary cirrhosis
- ↑ Ammonia
- ↑ Prothrombin time (↑ INR)
- ↓ albumin
- ↓ Cholinesterase
- Macrocytic anaemia due to vitamin B12 deficiency
What imaging can be used to investigate cirrhosis?
- USS: nodular surface, ascietes, splenomegaly, enlarged liver and portal veins
- Fibroscan: check the elasticity and assess the degree of cirrhosis
- CT/MRI: look for HCC, hepatosplenomegaly, abnormal blood vessel changes and ascites.
- Liver biopsy: Confirm the diagnosis of cirrhosis.
What is the treatment for cirrhosis?
- Avoid hepatotoxic substances
- Vitamin B complex with thiamine (B1) and Vitamin B12 substitution
- Nutritional diet
- Beta blockers to lower portal hypertension
- Spironolactone and furosemide for ascites
- Vitamin K substitution for coagulation deficiency
- TIPS (transjugular intrahepatic portosystemic shunt) to lower portal hypertension
What is decompensated cirrhosis complication?
- Worsening of liver function in cirrhosis characterised by the presence of jaundice, ascites, variceal haemorrhage or hepatic encephalopathy
- Does not respond to vitamin K
What is portal hypertension complication of cirrhosis?
Cirrhosis leads to a blockage to form in the venous return of the liver. This causes the pressure in the portal vein to increase.
What are the symptoms of portal hypertension?
- Oesophageal varices: asymptomatic till they bleed (haematemesis)
- Ascites: protein containing (ascitic) fluid to leak from the surface of the liver and intestine and accumulate in the abdomen.
- Splenomegaly - ↓ WCC and platelets
- Caput medusa: the blood tries to flow through periumbilical veins.
- What is hepatic encephalopathy complication of cirrhosis?
- What are the symptoms?
- What are the triggers
- What us the treatment?
Hepatic dysfunction results in inadequate elimination of ammonia which builds up and travel to the brain.
- Fluctuation in mental status, cognitive function and memory loss
- Triggers: spontaneous bacterial peritonitis,GI bleeding, Constipation, Renal failure
- Lactulose, Abx and nutritional support
How can GI bleeding and constipation lead to hepatic encephalopathy?
- GI bleeding: Blood from ruptured varices goes to bowel if not vomited and this has lots of protein which breaks down to ammonia ad this can cause HE.
- Constipation – build-up of faecal material causes ammonia to build up
- What is spontaneous bacterial peritonitis?
- How to treat?
- Infection developing in the ascitic fluid and peritoneal lining
- IV cephalosporin (cefotaxime)
- What is hepatocellular carcinoma (HCC) complication of cirrhosis?
- How often to screen?
- What test is done?
- Most common malignant disease associated with cirrhosis.
- USS every six months
- Alpha-fetoprotein test
What are the causes of hepatitis?
- Hereditary: Wilson’s, Hemochromatosis (iron overload)
- Drug induced: paracetamol, alcohol
- Infection: EBV
- Auto-immune
What is acute hepatitis?
- Inflammation that lasts less than 6 months
What are the symptoms of hepatitis?
- Abdominal pain (RUQ)
- Fatigue
- Pruritis (itching)
- Muscle and joint aches
- Nausea and vomiting
- Jaundice
- Fever (viral hepatitis)
What are the investigation of hepatitis?
- Raised ALT / AST (often >1,000)»_space; ALP
- High bilirubin – jaundice
- Coagulopathy
- Renal impairment
What is chronic hepatitis?
Inflammation of the liver that lasts longer than 6 months
- What is fulminant hepatitis?
- What are the features of fulminant hepatitis?
- What are the causes?
- Acute hepatitis with liver failure
- Encephalopathy within 28 days of jaundice
- Poor prognosis often needs transplantation
- Paracetamol overdose, viral hepatitis
- What is SAAG?
- How is it calculated?
- Serum Albumin Ascitic Gradient used to determine the cause of ascites.
- > Serum albumin – albumin level of ascitic fluid.
What are transudate causes of SAAG?
Transudate: SAAG >1.1 g/L
- Liver cirrhosis with portal hypertension
- Congestive cardiac failure
- Nephrotic syndrome
What are exudate causes of SAAG?
Exudate SAAG <1.1 g/L
- Malignancy (liver or peritoneal metastases)
- Peritoneal TB
What would ascitic ta for SBP show?
Microscopy showing >500 WBC
How to treat ascites?
- Drain
- Diuretics
- Treat underling cause
What are the 3 categories of jaundice?
- Pre-hepatic
- Hepatocellular
- Post hepatic (obstructive)
What are the causes of pre-hepatic jaundice?
- Due to RBC breakdown (haemolysis) due to sickle cell, Incompatible blood transfusion, drug reaction
What are the causes of hepatocellular jaundice?
Common: - Neonatal jaundice. - Infection (viral hepatitis) - Cirrhosis secondary to alcohol - Cirrhosis secondary to steatohepatitis (NASH) - Damage by toxins or drugs. Uncommon: - Autoimmune liver disease - Haemochromatosis - Wilsons disease.
What is the pathophysiology of hepatocellular jaundice?
Bilirubin is formed at a normal rate, but the compromised liver cannot excrete it due to increased hepatocyte abnormality.
What are the 2 types of neonatal jaundice?
- Unconjugated hyperbilirubinemia: can penetrate the BBB and is toxic to neural tissue and can cause bilirubin encephalopathy
- Kernicterus is the yellow staining of the brain
- Conjugated hyperbilirubinemia: non-toxic; always pathological.
How to treat neonatal jaundice?
- Correcting underlying abnormality
- Fluid and caloric intake prevent deterioration
- Unconjugated hyperbilirubinemia: phototherapy or exchange transfusion
What is the pathophysiology obstructive jaundice?
Obstruction of the passage of conjugated bilirubin from hepatocyte to intestine with blockage of flow of bile through bile ducts or intrahepatic or extrahepatic duct.
What are the causes of obstructive jaundice?
Common:
- Gallstones (biliary colic, cholecystitis, cholangitis)
- Carcinoma of head of pancreas Uncommon:
- Sclerosing cholangitis (scarring of small ducts in liver)
- Cholangiocarcinoma
What are the symptoms of jaundice?
- Sclera and skin: jaundice
- Scratches from pruritus.
- Evidence of weight loss (thenar wasting)
- Troisier’s node (left supraclavicular node enlargement)
- What investigations are done in pre-Hepatic jaundice?
- What are other observation in pre-Hepatic jaundice?
- Raised unconjugated bilirubin
- Normal stool colour
- Normal urine colour
- No pruritus, yellow skin
- What investigations are done in hepatocellular jaundice?
- What are other observation in hepatocellular jaundice?
- Raised conjugated bilirubin
- Rise in ALT, AST»_space; Rise in Alk Phos
- Normal stool colour
- Dark urine (lack of urobilin)
- No pruritus, yellow skin
- What investigations are done in obstructive jaundice?
- What are other observation in obstructive jaundice?
- Raised conjugated bilirubin
- Rise in ALT, AST «_space;Rise in Alk Phos
- Pale stool (lack of stercobilin)
- Dark urine (lack of urobilin)
- Pruritus
What is cholelithiasis?
What is the mechanism?
- Gallstones in the gallbladder
- Bile stasis, impaired bile acid circulation → precipitation of gallstones
What are the signs and symptoms of cholelithiasis?
What are the risk factors?
What are the lab findings?
- Dull, intermittent RUQ pain especially after eating
- 6 F’s – female, forty, fertile, fat, fair-skinned, family history
- Normal
What does ultrasound show for cholelithiasis?
What is the treatment?
- Gallstones with posterior acoustic shadow
- Supportive care, analgesics
- Elective cholecystectomy for symptomatic Cholelithiasis
What is choledocholithiasis?
- Presence of gallstones in the common bile duct from gallbladder
What are the signs and symptoms for choledocholithiasis?
RUQ pain > 6 h especially postprandial
What are the lab findings for choledocholithiasis?
- ↑ ALP
- ↑ AST, ALT
- ↑ Total bilirubin
What investigations can be done for choledocholithiasis?
- USS: dilated common bile duct, intrahepatic biliary dilatation
- MRCP or ERCP: filling defect in the contrast-enhanced duct
How to treat choledocholithiasis?
- Supportive care, analgesics
- Endoscopic stone retrieval (ERCP)
What is acute cholecystitis?
What can be a complication?
- Inflammation of the gallbladder
- Gallstone ileus
What are the signs and symptoms for acute cholecystitis?
- Persistent RUQ pain, postprandial
- Radiation to right scapula
- Fever
- Murphy sign
What are the lab findings for acute cholecystitis?
↑ WBC, CRP
What diagnostic imaging can be done for acute cholecystitis?
USS: gallbladder wall thickening and oedema (double wall sign)
What is the treatment for acute cholecystitis?
- Supportive care, analgesics
- IV antibiotics
- Cholecystectomy within 48 hours
What is acute cholangitis?
Ascending bacterial infection of the biliary tract
What are the signs and symptoms of acute cholangitis?
- Charcot triad: RUQ pain, fever, jaundice
- Reynold pentad: Charcot cholangitis triad PLUS hypotension and mental status changes
What are the lab findings for acute cholangitis?
- ↑ WBC and CRP
- ↑ ALP
- ↑ AST, ALT
- ↑ Total bilirubin
What diagnostic imaging can be done for acute cholangitis?
- USS: biliary dilation and/or evidence of obstruction (cholelithiasis)
- ERCP for diagnosis and therapeutic
What is the treatment for acute cholangitis?
- Supportive care, analgesics
- IV antibiotics
- ERCP (Urgent biliary decompression after 24-48 hours)
What is primary biliary cholangitis? - also known as biliary cirrohsis
Chronic progressive liver disease of autoimmune origin that is characterized by destruction of the intralobular bile ducts.
What is acute pancreatitis?
Sudden inflammation and haemorrhaging of the pancreas due to destruction by its own digestive enzymes
What are the causes of acute pancreatitis?
I GET SMASHED:
- Idiopathic (20%)
- Gall stones (50%)
- Ethanol (25%)
- Trauma
- Steroids
- Mumps, EBV - Infections
- Autoimmune
- Scorpion stings
- Hypertriglyceridemia, hypercalcaemia and hyperparathyroidism
- ERCP – endoscopic retrograde cholangiopancreatography
- Drugs: sodium valproate, azathioprine, sulphonamides, furosemide
What are the signs and symptoms of acute pancreatitis?
- Upper abdominal pain that radiates into the back; it may be aggravated by eating,
- Swollen and tender abdomen
- Nausea and vomiting
- Fever
- Sweating
- Tachycardia
- Cullen signs: Bruising around the belly button
- Grey turner’s sign: Bruising around the flank region
- Fox sign: Bruising over the inguinal ligament
What investigations are done in acute pancreatitis?
- FBC
- LFTs: hepatic impairment
- Elevated levels of serum lipase or amylase (>3 upper limit of normal)
- Raised CRP
- CT scan to show pseudocysts, pancreatic necrosis, abscess or fluid collection
- Ultrasound to look for gallstones
- Chest X-ray to exclude perforation
How is the diagnosis for acute pancreatitis made?
- Clinical story (upper abdominal pain)
- Elevated serum lipase or amylase (>3 upper limit of normal)
- CT or MRI consistent with acute pancreatitis.
How to treat acute pancreatitis?
- Fluid resuscitation
- Analgesia (morphine) + anti-emetic (Ondansetron)
- ERCP to remove bile obstruction
- Surgery to remove infected pancreatic necrosis
- Antibiotics
What are the complications of acute pancreatitis?
- Pancreatic fluid collections
- Pancreatic necrosis
- Pseudocysts – this is collection of fluid rich in pancreatic enzymes.
- Infection – signs of sepsis
What is chronic pancreatitis?
- Persistent chronic inflammation due to repeated bouts of acute pancreatitis.
- Leads to fibrosis, atrophy and calcification of pancreas.
What are the symptoms of chronic pancreatitis?
- Abdominal pain
- Jaundice
- Steatorrhea – due to malabsorption of dietary protein (7g faecal fat/100g diet)
- Malnutrition
- Weight loss
- Nausea and vomiting
What are the complications of chronic pancreatitis?
- Pancreatic digestive enzymes insufficiency
- Deficiency in vitamin A, D, E and K which are fat soluble vitamins
- DM: due to damage to beta cells
- Pancreatic pseudocysts
- Pancreatic cancer
How to treat chronic pancreatitis?
- Alcohol and cigarette cessation
- Analgesic
- Pancreatic enzymes plus PPI: pancreatin and omeprazole
- Dietary modifications + enteral feeding
- Pancreatic pseudocyst decompression
