Case 3 - Liver disease - Progress Test Flashcards
What causes right upper quadrant pain provoked by eating a fatty meal?
Biliary colic
gallstone lodged in the bile duct
What causes right upper quadrant pain, Murphy’s sign, fever and raised inflammatory markers?
Acute cholecystitis
inflammation / infection of the gallbladder secondary to impacted gallstones
What causes right upper quadrant pain associated with fever and jaundice?
Ascending cholangitis
a bacterial infection of the biliary tree, commonly predisposed by gallstones
What causes severe epigastric pain, radiating to the back.
Associated signs include tenderness, ileus and low grade fever
Acute pancreatitis
usually due to alcohol or gallstones
What causes epigastric pain worse after eating?
Gastric ulcers
may be a history of NSAID use or alcohol excess
What causes epigastric pain that improves after eating?
Duodenal ulcers
may be a history of NSAID use or alcohol excess
What causes initially central abdominal pain that moves to the right fossa.
Associated features include: tachycardia, low-grade fever and tenderness in RIF
Appendicitis
What causes left lower quadrant pain, which is colicky in nature.
Associated symptoms include diarrhoea (which is sometimes blood), fever, raised inflammatory markers and white cells
Acute diverticulitis
What causes central abdominal pain associated with vomiting and tinking bowel signs?
Intestinal obstruction
may be history of malignancy or previous operations
What causes a loin to groin pain?
Renal colic
pain is often severe but intermittent. Visible or non-visible haematuria may be present
What causes loin pain, fever, rigors and vomiting?
Acute pyelonephritis
What causes suprapubic pain in men?
Urinary rentention
Caused by obstruction to bladder flow
(often associated with BPH)
What causes right or left iliac fossa pain, with assoicated amenorrhoea?
Ectopic pregnancy
What causes central abdominal pain radiating to the back?
Ruptured AAA
may be assoicated with shock and have a history of cardiovascular disease
What causes central abdominal pain associated with diarrhoea, rectal bleeding and a metabolic acidosis?
Mesenteric ischaemia
Patients often have a history of cardiovascular disease or AF
The metabolic acidosis is caused by dying tissue
What antibodies are assoicated with auto-immune hepatitis?
Anti-nuclear antibodies
Smooth muscle antibodies
How is auto-immune hepatitis managed?
Steroids
Other immuno supressants eg. azathioprine
Liver transplantation
What are the most common causes of acute pancreatitis?
Alcohol
Gallstones
What is the pathophysiology of acute pancreatitis?
autodigestion of pancreatic tissue by pancreatic enzymes, leading to necrosis
What do investigations into acute pancreatitis show?
Raised serum amylase
Raised serum lipase
US - determine if there is gallstones or biliary obstruction
Can also use a contrast CT
What scores are used to identify severe cases of acute pancreatitis?
Ranson
Glasgow
APACHE II
What factors indicate severe pancreatitis?
age > 55 hypocalcaemia hyperglycaemia hypoxia neutrophilia elevated LDH and AST
What are the classifications of acute pancreatitis severity?
Mild
Moderate
Severe
What determines mild acute pancreatitis?
No organ failure
No local complications
What determines moderately severe acute pancreatitis?
No organ failure / organ failure < 48 hrs
Possible local complications
What determines severe acute pancreatisis?
Persistent organ failure (>48hrs)
Possible local complications
How is acute pancreatitis managed?
Fluid resuscitation (large quantities of cryastalloid) - Aiming for urine output > 0.5mls/kg/hr
Analgaesia (IV opioids)
Nutrition - enteral nutrition should be offer to patients with moderately severe or severe acute pancreatitis within 72 hrs of presentation
Surgery:
- If acute pancreatitis due to gallstones - cholecystectomy / ERCP
- If necrosis + worseing organ function - may require debridement
- If infected necrosis - radiological drainage / surgical necrosectomy
What are complications of acute pancreatitis?
- Peripancreatic fluid collections
- Pseudocysts
- Pancreatic necrosis
- Pancreatic abscess
- Haemorrhage
- Acute respiratory distress sydrome
What are the causes of chronic pancreatitis?
- 80% alcohol
- 20 % unknown cause
What are the features of chronic pancreatitis?
Pain typically worse 15 to 30 minutes following a meal
Steatorrhoea (develops 5-20 years after the onset of pain)
DM develops in most patients (generally occurs more than 20 years after the symptoms begin)
How is chronic pancreatitis investigated?
Abdominal XR / CT: pancreatic calcifications
Faecal elastase may be used to assess exocrine function if imaging is inconclusive
How is chronic pancreatitis managed?
Pancreatic enzyme supplementation
Analgaesia
Antioxidants (may only help in early disease)
What do investigations into alcoholic liver disease show?
Gamma-GT raised
AST:ALT > 2 (if >3, strongly suggestive of acute alcoholic hepatitis)
How is alcoholic liver disease managed?
Glucocorticoids
- used during acute episodes of alcoholic hepatitis
Pentoxyphylline is sometimes used
What are the features of non-alcoholic fatty liver disease?
Usually asymptomatic
Hepatomegaly
ALT > AST
Increased echogenicity on US
How is non-alcoholic fatty liver disease managed?
- Lifestyle changes and weight loss
- Monitoring
How is liver cirrhosis investigated?
Transient elastography
Upper endoscopy to check for varicies
Liver US (+/- alpha feto protein) every 6 months to check for hepatocellular cancer
How is variceal haemorrhage managed?
Fluid resusitation prior to endoscopy
Correct clotting: FFP and vitamin K
Terlipressin
Prophylactic antibiotics (quinolones)
Endoscopy + band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
Transjugular intrahepatic portosystemic shunt if all else fails
