Diseases Of The Hepatobilliary Tract Flashcards by frankiespeck@hotmail.co.uk Speck

What are the microstructural features of the liver?

Sinusoids
Bile canaliculi
Bile duct
Branch portal vein
Branch hepatic artery
Central vein

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What forms the portal triad?

Hepatic artery
Portal vein
Bile duct

-> join together to make the central vein

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What is the function of sinusoids?

Act like a filter aiding with the filtration process of the liver

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What do bile canaliculi do?

Tubes that help drain the bile

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What are the 3 main functions of the liver?

Filter
2 Elimination of the filtrate
Metabolism

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What forms the portal vein?

Splenic vein
SMV
IMV (attachment point is variable)

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What are the clinical features of filter failure?

Portal vein hypertension (bleeding)

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What are the clinical features of elimination failure?

Jaundice as you cannot get rid of bile

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What are the clinical features of metabolic failure?

Acidosis
Muscle loss
Coagulopathy (more likely to bleed)
Hepatorenal syndrome

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What is the clinical relevance of porto-systemic (portocaval) anastamosis?

Portal vein hypertension will effect + dilate these vessels at the anastomoses causing varicies which can potentially rupture (can be quickly fatal in some areas)

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What are the 5 types of porto-systemic (portocaval) anastomosis?

Oesophageal
Rectal
Paraumbilical
Retroperitoneal
Intrahepatic

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What is cirrhosis? What does it look like?

An effect of liver scarring that has a characteristic nodular appearance - macronodular OR micronodular

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What is caput medusae?

Umbilical veins re-open as a result of portal hypertension affecting the paraumbilical anastomosis

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What is encephalopathy?

Failure of filter, elimination AND metabolism = hallmark of liver failure

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What might the cause of encephalopathy be?

Nitro-amine type compound crossing BBB

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What are the signs and symptoms of encephalopathy?

Signs:
Liver flap (coarse/irregular flapping tremor)
5 pointed star/trail test
Confabulate (mix up truths)
Coma

Symptoms:
Reversal of sleep pattern
Shorted attention span
Constructional dyspraxia

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What are the signs of chronic liver disease?

Spider naevi
Clubbing
Ascites
Palma erythema
Dupuytren's contracture
Leuconychia
Gynaecomastia
Testicular atrophy
Loss of body fair
Caput medusa
Splenomegaly
Encephalopathy
Parotid enlargement 
Jaundice
Oedema
Muscle wasting
Coagulopathy/bleeding

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What are the mechanisms of liver injury?

Acute (4-6 weeks)

Chronic (>6 weeks)

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What is the general model of chronic diseases?

Organ function deteriorates over many years + at about 20% of functioning, you start to see clinical problems

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What is the model of chronic liver disease?

Liver function deteriorates over a number of years, but the liver is a resilient organ (unlike the heart for e.g.) so compensates until the liver has 20% function left, which is when patients liver failure

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Is ascites ever normal?

Yes, in women premenstruation

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Why do you get coagulopathy as a symptom of chronic liver disease?

Because liver produces key proteins involved in blood clotting

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What is decompensation of chronic liver disease? What can cause it?

2nd hit exposes the lack of liver reserve so liver deterioration speeds up showing a dramatic drop leading to liver failure directly as a result of infection (bacterial e.g. SBP), toxins (e.g. alcohol), trauma (e.g. surgery), drugs (e.g. sedatives), dehydration (e.g. diuretics), variceal bleeds/bleeding in general or malignant transformation (e.g. hepatoma)

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What happens if chronic liver disease decompensation is treated?

Patients liver function can be brought back up so the patient is no longer in liver failure but the function will still be lower as a result of the event that caused decompensation

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What will multiple decompensation episodes do to patients with chronic liver disease?

Bring them closer to liver failure quicker

What are the causes of liver injury (in order of most problematic to least)?

Fat Alcohol Virus Iron (factors often co-exist)

Why is hepatitis C not as big a cause of viral liver injury now?

Because there is now a treatment for it

What different types of fat problems can cause liver injury?

Non-alcohol fatty liver disease (NAFLD): T2DM, metabolic syndrome Non-alcohol steatohepatitis (NASH)

What type of fat is more problematic?

Fat on the inside: peri-organ fat

What clinical tests are there of liver injury?

Blood tests Imaging Liver biopsy

What blood tests would you for the liver? What do they test for?

LFTs: indicating liver damage -> AST, ALT Liver screen: determines the CAUSE of damage -> viruses, iron, genetic disorders

What blood tests are there for liver distress? What do they show?

ALT/AST: indicate hepatitis/hepatocyte damage ALP/γGT: indicate obstructive/bile duct damage

What blood tests are done as true tests of liver function?

``` Prothrombin time Bilirubin (excretion) Albumin Urea/creatinine pH ```

What imaging/scans can be done on the liver?

``` US +/- liver biopsy CAT scan MRI MRCP (looks at bile duct specifically) Liver fibroscan (enhanced liver fibrosis; ELF) ```

What are CTs and MRIs good at picking up?

CT: large liver lesions e.g. cancers MRI: bile duct problems e.g. inflammation, stones

Why type of imaging would not pick up gallstones?

X-ray as they as made of cholesterol which is a different constituent to kidney stones, which will show up on a X-ray

What 3 types of biliary problems exist?

1. Gallstones 2. Pancreatitis 3. Cancer

What is jaundice?

Failure of body to EXCRETE bile Clinically apparent when serum bilirubin is 2x above normal concentration ~ 34uM/L

What types of gallstones exist?

Gallbladder stones (cholelithiasis) Bile duct stones (choledocolithiasis) Gallstone pancreatitis

What is the gallbladder wall made up of?

Epithelium Lamina propria Fibromuscular layer

What is the gallbladder wall made up of?

Epithelium Lamina propria Fibromuscular layer

What are gallstones?

Stones associated with high fat diets/hypercholesterolaemia Can be formed by reduced bile secretion or defective reabsorption of bile salts Most are cholesterol based but other rare types as a result of RBC breakdown e.g. pigment stones found in those with haemolytic disorders (high serum bilirubin)

What are the pros and cons of ultrasound scan (UsS) investigation?

Pros: simple, non-invasive + widely available Cons: operator dependent, poor specificity + poor views of pancreas

What is the appearance of gallstones on an ultrasound scan (USS) called?

Acoustic shadows

What is endoscopic retrograde cholangio pancreatography (ERCP)?

A scope on a catheter is put in + dye is squirted up the hepatic duct allowing you to see this duct + the pancreatic duct crossing the vertebrae (why patients present with back pain when they have pancreatic problems) Stones can be cut out/grasped in this surgical procedure

What surgical procedure can patients get done if gallstones are a continuous problem?

Laparoscopic cholecystectomy

What effects may ensue if a patient has their gallbladder removed?

More likely to develop diarrhoea Slight increased risk of colon cancer (due to increased exposure of bile acids to lining of bowel)

What are the pros and cons of endoscopic retrograde cholangio pancreatography (ERCP)?

Pros: high sensitivity + specificity (therapeutic too) Cons: invasive, technically challenging + complication risk

What are the 2 types of pancreatitis?

1. Acute | 2. Chronic

What are the causes of pancreatitis?

I - idiopathic G - gallstones E - ethanol T - trauma ``` S - steroids M - mumps/malignancy A - autoimmune S - scorpion sting H - hypertriglycerides/hypercalcaemia E - ERCP D - drugs ```

What are the functions of the pancreas?

1. Endocrine: insulin | 2. Exocrine: enzymes, amylase, trypsin, chymotrypsin, lipase + bicarbonate

What effects can chronic pancreatitis have?

Pain Endocrine -> diabetes Exocrine -> malabsorption Pancreatic failure (if advanced)

What blood tests can be done acute and chronic pancreatitis?

Acute: amylase (lipase) Chronic: none (diabetes)

What blood tests can be done for pancreatic cancer?

None (CA19.9, miRNA or volatile organic compounds)

What imaging interventions exist?

``` US EUS CT MRCP ERCP (therapeutic) PTC (therapeutic) ```

When is the commonest types of pancreatic cancer?

Adenocarcinoma Neuroendocrine cancers affect function of pancreas too

Why is bile duct cancer becoming more common?

Increased cirrhosis makes cholangiocarcinoma more common which increases chances of cancer

Can patients get gallbladder cancer?

Yes but it is rarer than pancreatic or bile duct

What blood tests exist for biliary obstruction?

Bilirubin | ALP

What blood test exists for gallstones?

None

What tests are done as part of a liver screen?

Infection: viral hepatitis (HAV, HBV, HCV) Metabolic: alcohol, haemochromatosis, Wilson disease, α-antitrypsin deficiency Inflammatory: autoimmune hepatitis, primarily biliary cirrhosis, primary sclerosing cholangitis Malignancy

What is the morbidity and mortality of liver biopsies?

Morbidity: - 30% experience pain - 0.35-0.5% get significant haemorrhage - 0.01-0.1% get other organ punctures Mortality = 0.1 - 0.01%

What are the causes of acute liver injury?

A sudden/recent insult resulting in: - Filter failure - Elimination failure -> jaundice - Metabolic failure -> encephalopathy, acidosis, renal failure

What are the causes of chronic liver disease?

On-going low grade insult causing: - Filter failure -> portal hypertension, ascites - Elimination failure -> jaundice - Metabolic failure -> weight/muscle loss, encephalopathy

What are the 4 consequences of non-alcoholic fatty liver disease (NAFLD)?

Fatty liver NASH (Cryptogenic) cirrhosis Liver cancer (HCC)

What functional tests can be done on the pancreas?

Endocrine: blood glucose + glucose tolerance test Exocrine: faecal fats, PABA test, pancreolauryl test + faecal elastase

Whats are the pros and cons of computerised tomography (CT)?

Pros: widely available, good views of pancreas + transferable images Cons: radiation exposure + high demand

What are the pros and cons of Magnetic Resonance Cholangio-Pancreatography (MRCP)?

Pros: good mapping of ducts Cons: limited (but increasing) availability

What interventions can be done on these problems?

ERCP EUS PTC Surgery

What are the pros and cons of endoscopic ultrasound (EUS)?

Pros: very sensitive, good demonstration of vessels + biopsy can be done Cons: limited availability + operator dependent

What are the pros and cons of percutaneous transhepatic cholangiography (PTC)?

Pros: specific + therapeutic Cons: invasive + uncomfortable