Disease of the hepatibiliary tract

Question 1

What are the 3 functional areas of the liver in health and disease?

Answer 1

Filter
Elimination
Metabolism

Question 2

What are the clinical signs of filter failure?

Answer 2

Portal hypertension (which can manifest as bleeding)

Question 3

What are the clinical signs of elimination failure?

Answer 3

Jaundice

Question 4

What are the clinical signs of metabolic failure?

Answer 4

Acidosis
Muscle loss
Coagulopathy
Hepatorenal syndrome

Question 5

What is the consequence of portal hypertension?

Answer 5

Portosystemic anastamoses:
Liver cirrhosis (macronodular or micronodular)
Oesophageal varices
Caput Medusae (opening of umbilical veins)

Question 6

What would be the result of a combined filter, metabolic and elimination failure?

Answer 6

Hepatic Encephalopathy

[Hallmark of liver failure]

Question 7

What are the key clinical signs of chronic liver disease?

Answer 7

Clubbing
Ascites
Palmar erythema 
Dupuytren's contracture
Leuconychia 
Spider naevi 
Gynaecomastia 
Testicular atrophy 
Loss of body hair 
Caput Medusa
Splenomegaly 
Parotid enlargement 
Jaundice
Oedema 
Muscle wasting

Question 8

What are the common causes of pancreatitis?

Answer 8

Idiopathy 
Gallstones
Ethanol 
Trauma 
Steroids
Mumps/ malignancy 
Autoimmune
Scorpion bites
Hyperlipidemia/ hypercalcaemia/ hyperparathyroidism 
ERCP
Drugs

Question 9

What does raised ALT or AST indicate in an LFT?

Answer 9

Hepatocyte damage

Question 10

What does raised ALP or Gamma GT indicate in an LFT?

Answer 10

Obstructive/ bile duct damage

Question 11

What are the common causes of liver injury?

Answer 11

Fat
Alcohol
Virus
Iron

Question 12

What is the difference between a liver function test and a liver screen?

Answer 12

LFT used to identify damage

Liver screen used to identify cause of damage

Question 13

What are the true tests of liver function?

Answer 13

Prothrombin Time (synthesis of clotting factors) 
Bilirubin 
Albumin 
Urea/ Creatinine 
pH

Question 14

What imaging can be used to identify liver damage?

Answer 14

Ultrasound (+/- liver biopsy)
CAT scan
MRI
Liver Fibroscan

Question 15

What biliary problems can occur?

Answer 15

Gallstones
Pancreatitis
Cancer

Question 16

What is jaundice?

Answer 16

Failure of body to excrete bilirubin
Becomes clinically apparent when serum bilirubin is approx. 2x normal concentration
Can cause distinctive yellowing of skin and sclera

Question 17

What is the clinical term for gallbladder stones?

Answer 17

Cholelithiasis

Question 18

What is the clinical term for bile duct stones?

Answer 18

Choledocolithiasis

Question 19

What is gallstone pancreatitis?

Answer 19

Gallstone blocking common bile duct and pancreatic duct

Question 20

What are the layers of the gallbladder wall?

Answer 20

Epithelium
Lamina Propria
Fibromuscular layer

Question 21

What is the function of the gallbladder?

Answer 21

Storage and concentration of bile

Question 22

What are gallstones?

Answer 22

Cholesterol based
Can be formed due to reduced bile secretion or defective reabsorption of bile salts
Associated with high fat diets or hypercholesterolaemia

Question 23

How can gallstones be investigated/ identified?

Answer 23

Ultrasound
ERCP (Endoscopic Retrograde Cholangio-Pancreatography)
Laparoscopic Cholecystectomy

Question 24

What are the pros of using ultrasound?

Answer 24

Simple
Non-invasive
Widely available

Question 25

What are the cons of using ultrasound?

Answer 25

Operator dependent
Poor specificity
Poor view of pancreas

Question 26

What are the features of chronic pancreatitis?

Answer 26

Pain
Pancreatic failure:
Endocrine = diabetes
Exocrine = malabsorption

Question 27

How would blood tests differ from normal in gallstones?

Answer 27

They wouldn’t

Question 28

How would blood tests differ from normal in biliary obstruction?

Answer 28

Raised Bilirubin

Raised Alk Phos

Question 29

How would blood tests differ from normal in pancreatitis?

Answer 29

Acute= Raised amylase 
Chronic = none

Question 30

What would be the signs and symptoms of energy metabolism/ substrate interconversion malfunction?

Answer 30

Hypoglycaemia due to altered glucose metabolism
Muscle wasting due to altered protein metabolism
Altered lipid metabolism

Question 31

What would be the signs and symptoms of protein synthesis malfunction?

Answer 31

Peripheral oedema and ascites due to albumin levels

Easy bruising, purpura (blood spots), petechiae due to lack of clotting factors

Question 32

What would be the signs and symptoms of drug metabolism and detoxification malfunction?

Answer 32

Differing effects of drugs (e.g. side effects)
Gynaecomastia, testicular atrophy or loss of body hair due to altered hormone metabolism
Encephalopathy (disorientation, confusion, liver flap etc.) due to build up of toxins in brain (e.g. Ammonia)

Question 33

What would be the signs and symptoms of malfunction of production, storage and secretion of bile in the liver?

Answer 33

Jaundice 
Fat malabsorption (causing Steatorrhea)

Question 34

Why would liver disease make you more prone to infection?

Answer 34

Compromised immune function (e.g. Kupffer Cells)

Question 35

How are varices formed?

Answer 35

In places where the portal venous system and the systemic venous system anastomose - when portal venous pressure increases (portal hypertension) and venous pressure exceeds the systemic circulation pressure, blood is diverted into the systemic system via anastomoses causing enlargement and varices

Question 36

Where are varices commonly found?

Answer 36

Oesophagus (Oesophageal Varices)
Ano-rectal junction (Haemorrhoids)
Umbilicus (Caput Medusa)

Question 37

How might oesophageal varices present?

Answer 37

Haematemesis (vomiting blood)
Melaena (blood in stool - black/ tarry)
Signs/ symptoms of anaemia (e.g. pallor, tiredness, SOB)

Question 38

What factors can cause Cirrhosis of the liver?

Answer 38

Alcohol
Non-alcoholic fatty liver disease (Non-alcoholic Steatohepatitis)
Hepatitis B/ C