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Block 1 > Diseases Of The Hepatobilliary Tract > Flashcards

Diseases Of The Hepatobilliary Tract Flashcards

1
Q

What are the microstructural features of the liver?

A 
Sinusoids
Bile canaliculi
Bile duct
Branch portal vein
Branch hepatic artery
Central vein
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2
Q

What forms the portal triad?

A

Hepatic artery
Portal vein
Bile duct

-> join together to make the central vein

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3
Q

What is the function of sinusoids?

A

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

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4
Q

What do bile canaliculi do?

A

Tubes that help drain the bile

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5
Q

What are the 3 main functions of the liver?

A
  1. Filter
    2 Elimination of the filtrate
  2. Metabolism
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6
Q

What forms the portal vein?

A

Splenic vein
SMV
IMV (attachment point is variable)

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7
Q

What are the clinical features of filter failure?

A

Portal vein hypertension (bleeding)

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8
Q

What are the clinical features of elimination failure?

A

Jaundice as you cannot get rid of bile

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9
Q

What are the clinical features of metabolic failure?

A

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

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10
Q

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

A

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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11
Q

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

A
  1. Oesophageal
  2. Rectal
  3. Paraumbilical
  4. Retroperitoneal
  5. Intrahepatic
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12
Q

What is cirrhosis? What does it look like?

A

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

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13
Q

What is caput medusae?

A

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

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14
Q

What is encephalopathy?

A

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

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15
Q

What might the cause of encephalopathy be?

A

Nitro-amine type compound crossing BBB

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16
Q

What are the signs and symptoms of encephalopathy?

A 
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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17
Q

What are the signs of chronic liver disease?

A 
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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18
Q

What are the mechanisms of liver injury?

A

Acute (4-6 weeks)

Chronic (>6 weeks)

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19
Q

What is the general model of chronic diseases?

A

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

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20
Q

What is the model of chronic liver disease?

A

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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21
Q

Is ascites ever normal?

A

Yes, in women premenstruation

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22
Q

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

A

Because liver produces key proteins involved in blood clotting

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23
Q

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

A

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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24
Q

What happens if chronic liver disease decompensation is treated?

A

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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25
Q

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

A

Bring them closer to liver failure quicker

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26
Q

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

A

Fat
Alcohol
Virus
Iron

(factors often co-exist)

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27
Q

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

A

Because there is now a treatment for it

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28
Q

What different types of fat problems can cause liver injury?

A

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

Non-alcohol steatohepatitis (NASH)

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29
Q

What type of fat is more problematic?

A

Fat on the inside: peri-organ fat

30
Q

What clinical tests are there of liver injury?

A

Blood tests

Imaging

Liver biopsy

31
Q

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

A

LFTs: indicating liver damage -> AST, ALT

Liver screen: determines the CAUSE of damage -> viruses, iron, genetic disorders

32
Q

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

A

ALT/AST: indicate hepatitis/hepatocyte damage

ALP/γGT: indicate obstructive/bile duct damage

33
Q

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

A 
Prothrombin time
Bilirubin (excretion)
Albumin
Urea/creatinine
pH
34
Q

What imaging/scans can be done on the liver?

A 
US +/- liver biopsy
CAT scan
MRI
MRCP (looks at bile duct specifically)
Liver fibroscan (enhanced liver fibrosis; ELF)
35
Q

What are CTs and MRIs good at picking up?

A

CT: large liver lesions e.g. cancers

MRI: bile duct problems e.g. inflammation, stones

36
Q

Why type of imaging would not pick up gallstones?

A

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

37
Q

What 3 types of biliary problems exist?

A
  1. Gallstones
  2. Pancreatitis
  3. Cancer
38
Q

What is jaundice?

A

Failure of body to EXCRETE bile

Clinically apparent when serum bilirubin is 2x above normal concentration ~ 34uM/L

39
Q

What types of gallstones exist?

A

Gallbladder stones (cholelithiasis)

Bile duct stones (choledocolithiasis)

Gallstone pancreatitis

40
Q

What is the gallbladder wall made up of?

A

Epithelium
Lamina propria
Fibromuscular layer

41
Q

What is the gallbladder wall made up of?

A

Epithelium
Lamina propria
Fibromuscular layer

42
Q

What are gallstones?

A

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)

43
Q

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

A

Pros: simple, non-invasive + widely available

Cons: operator dependent, poor specificity + poor views of pancreas

44
Q

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

A

Acoustic shadows

45
Q

What is endoscopic retrograde cholangio pancreatography (ERCP)?

A

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

46
Q

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

A

Laparoscopic cholecystectomy

47
Q

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

A

More likely to develop diarrhoea

Slight increased risk of colon cancer (due to increased exposure of bile acids to lining of bowel)

48
Q

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

A

Pros: high sensitivity + specificity (therapeutic too)

Cons: invasive, technically challenging + complication risk

49
Q

What are the 2 types of pancreatitis?

A
  1. Acute

2. Chronic

50
Q

What are the causes of pancreatitis?

A

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
51
Q

What are the functions of the pancreas?

A
  1. Endocrine: insulin

2. Exocrine: enzymes, amylase, trypsin, chymotrypsin, lipase + bicarbonate

52
Q

What effects can chronic pancreatitis have?

A

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

53
Q

What blood tests can be done acute and chronic pancreatitis?

A

Acute: amylase (lipase)

Chronic: none (diabetes)

54
Q

What blood tests can be done for pancreatic cancer?

A

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

55
Q

What imaging interventions exist?

A 
US
EUS
CT
MRCP
ERCP (therapeutic)
PTC (therapeutic)
56
Q

When is the commonest types of pancreatic cancer?

A

Adenocarcinoma

Neuroendocrine cancers affect function of pancreas too

57
Q

Why is bile duct cancer becoming more common?

A

Increased cirrhosis makes cholangiocarcinoma more common which increases chances of cancer

58
Q

Can patients get gallbladder cancer?

A

Yes but it is rarer than pancreatic or bile duct

59
Q

What blood tests exist for biliary obstruction?

A

Bilirubin

ALP

60
Q

What blood test exists for gallstones?

A

None

61
Q

What tests are done as part of a liver screen?

A

Infection: viral hepatitis (HAV, HBV, HCV)

Metabolic: alcohol, haemochromatosis, Wilson disease, α-antitrypsin deficiency

Inflammatory: autoimmune hepatitis, primarily biliary cirrhosis, primary sclerosing cholangitis

Malignancy

62
Q

What is the morbidity and mortality of liver biopsies?

A

Morbidity:

  • 30% experience pain
  • 0.35-0.5% get significant haemorrhage
  • 0.01-0.1% get other organ punctures

Mortality = 0.1 - 0.01%

63
Q

What are the causes of acute liver injury?

A

A sudden/recent insult resulting in:

  • Filter failure
  • Elimination failure -> jaundice
  • Metabolic failure -> encephalopathy, acidosis, renal failure
64
Q

What are the causes of chronic liver disease?

A

On-going low grade insult causing:

  • Filter failure -> portal hypertension, ascites
  • Elimination failure -> jaundice
  • Metabolic failure -> weight/muscle loss, encephalopathy
65
Q

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

A

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

66
Q

What functional tests can be done on the pancreas?

A

Endocrine: blood glucose + glucose tolerance test

Exocrine: faecal fats, PABA test, pancreolauryl test + faecal elastase

67
Q

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

A

Pros: widely available, good views of pancreas + transferable images

Cons: radiation exposure + high demand

68
Q

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

A

Pros: good mapping of ducts

Cons: limited (but increasing) availability

69
Q

What interventions can be done on these problems?

A

ERCP
EUS
PTC
Surgery

70
Q

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

A

Pros: very sensitive, good demonstration of vessels + biopsy can be done

Cons: limited availability + operator dependent

71
Q

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

A

Pros: specific + therapeutic

Cons: invasive + uncomfortable

Block 1 (54 decks)

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