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MBChB Finals > Gastrointestinal: Jaundice and hepatopancreatobiliary > Flashcards

Gastrointestinal: Jaundice and hepatopancreatobiliary Flashcards

1
Q

Describe pre-, intra-, and post-hepatic jaundice

A

Pre-hepatic: Excessive UNCONJUGATED bilirubin due to increased red cell/haem breakdown

Intra-hepatic: MIXED bilirubin due to impaired conjugation by liver. Cirrhosis will additionally compress the intra-hepatic portions of the liver

Post-hepatic: Excessive CONJUGATED bilirubin. Blocked biliary drainage will prevent conjugated excretion

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2
Q

How can urine point towards which type of jaundice you are dealing with?

A

Dark urine: intra or post-hepatic

Excessive unconjugated bilirubin will be excreted through urine

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3
Q

What are the bilirubin, ALT/AST and ALP in the three types of jaundice

A

Pre-hepatic: normal/high bilirubin, others normal

Hepatic: ALT/AST very high, others raised

Post-hepatic: raised ALT/AST others very high

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4
Q

What are three causes of pre-hepatic jaundice?

A

Pre-hepatic: Increased haem breakdown

Haemolytic anaemia

Gilbert’s syndrome

Criggler-Najjar

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5
Q

List the 3 groups of causes for post-hepatic jaundice

A

Post-hepatic: blocked drainage

Intra-luminal: Gallstones

Mural: Cholangiocarcinoma, structures

Extramural: Cancers pressing on the duct (pancreatic, lymphomas)

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6
Q

What tests should be ordered in a patient with jaundice

A

Liver function tests: Assess nature of injury

Coag screen: Assess synthetic function

FBCs: Low Hb and platelets with high MCV in liver disease

Liver screen: Determine acute or chronic cause

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7
Q

What do the following LFTs inform you about:

Bilirubin

Albumin

AST/ALT

ALP

yGT

A

Bilirubin: Degree of jaundice

Albumin: synthetic function (along with coag PT)

AST/ALT: Hepatocellular injury (ratio >2 = ALD, ~1 viral hepatitis)

ALP: Raised in biliary obstruction (non-specific: bone disease, pregnancy, malignancy)

gGT: Biliary obstruction (more specific)

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8
Q

What viral (2) and non-infective markers (6) make up an acute liver screen?

A

Viral:

Hep A, B, C, E serology

CMV, EBV

Non-infective Markers:

Paracetamol (overdose)

Caeruloplasmin (copper levels)

ANA and IgGs (AIH, PBC, PSC)

Amylase (pancreatitis)

a-FP and CA 19-9 (hepatic and pancreatic cancer)

a1-antitrypsin (AATD)

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9
Q

What liver screen tests are used to suspect chronic liver injury?

A

viral

Hepatitis B and C

Non-infective markers

Caeruloplasmin (Wilson’s)

Ferritin and transferritin (Haemochromatosis)

t-TG (coeliac disease)

Autoantibodies: AMA, ASMA (PSC)

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10
Q

What imaging options can help diagnosis of jaundice?

A

1st line: Abdo US (gross liver or obstructive pathology)

Magnetic resonance cholanigopancreatography (MRCP): Visualise biliary tree for obstructive where US was inconclusive

Liver biospy: Where diagnosis is still unclear

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11
Q

What is considered a raised bilirubin?

A

>40mg/ml

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12
Q

What investigations should you perform in someone with acute hepatic failure?

A

LFTs: Assess liver injury and synthetic function

Coag screen: Synthetic function

U+Es: Check renal function

Liver screen

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13
Q

How do you manage acute hepatic failure?

A

Vitamin K: Increase PT

Lactulose 10-20ml/8hrs: Remove ammonia to improve encephalopathy

Antibiotics: Cefotaxime as prophylaxis

Review drugs and monitor biometrics

Dont give sodium to CLD/ascites patient!

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14
Q

Patient presents with jaundice. On examination they have red palms, distended veins on their abdomen and state they believe they have developed man-boobs. What is the diagnosis?

A

Chronic liver failure

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15
Q

What are the 6 complications of chronic liver failiure?

A

1. Malnutrition: damaged liver means reduced glycogenolysis/increased gluconeogenesis. This impairs glucose tolerance

2. Encephalopathy: Increased ammonia production

3. Varices: Cirrhosis presses on portal vein creating a back pressure

4. Ascites/oedema: Back pressure pushes fluid into bodily space

5. Spontaneous bacterial peritonitis: Infection of the ascitic fluid

6. Renal failure: failure of renal vasoconstriction to balance splanchnic vasodilation

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16
Q

How do you manage chronic liver failure?

A

Malnutrition: high calorie, high protein, low sodium meals every 2-3 hours

Bacterial peritonitis: Ascitic culture then cephalosporin

Encephalopathy: Lactulose

Ascites: Low salt diet +/- furosemide

Varices:

Bleeding: Terlipressin, vit K + FFP, broad spec antibiotics, endoscopic scleroscing

Stable: propanolol, band ligation/sclerotherapy, TIPS

Renal failure: renal failure management

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17
Q

What screening tools can be used for harmful alcohol use?

A

AUDIT: >= 8 harmful use

CAGE: >=2
Do you ever feel you should Cut down?

Do you ever feel Annoyed when people criticise your drinking?

Do you feel Guilty?

Do you ever drink as an Eye opener (in morning)

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18
Q

How do you manage acute alcoholic hepatitis?

A

Cease use

acute liver failure measures +/- steroids and pentoxifylline

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19
Q

How can viral hepatitis present?

A

Nausea, vomiting and anorexia

Fatigue

Jaundice + dark urine (intrahepatic)

RUQ pain

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20
Q

How are each subtype of hepatitis spread?

A

A+E: Faeco-oral

Blood: B,C,D

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21
Q

What are characterstic features of hepatitis A?

A

Faeco-oral spread

Flu-like prodrome

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22
Q

What antibodies are present in hepatitis A?

A

HAV-IgM (1 month after exposure)

HAV-IgG for life

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23
Q

How is HAV managed?

A

Immunisation (1st: 1 yr, 2nd: 20)

Supportive and alcohol avoidance

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24
Q

What are the defining features of hepatitis B?

A

Fever

Juandice

Bodily fluids (sex, blood, mother to child)

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25
Q

What do each of the following positive Hep B serologies mean?

HbsAg

HbsAb

HbcAb

Hbe

HbeAg

A

HBsAg: Active infection

HBsAb: Implies vaccination/previous infection

HBcAb: Implies past infection

HBe: high infectivity (viral replication marker)

HBeAg: Low infectivity (antibody to marker)

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26
Q

How do you manage hepatitis B?

A

Peg-interferon alpha/other antivirals: reduces viral load

avoid alcohol

immunise all sexual partners

27
Q

What does hepatitis B infection increse risk of?

A

Hepatocellular carcinoma

28
Q

What are the defining features of hepatitis C?

A

Most show no symptoms acutely

some show trainsient jaundice as well as fatigue and joint pain

29
Q

What is the investigation of choice in HCV?

A

HCV RNA via PCR

30
Q

What is the treatment for HCV?

A

Antivirals: peginterferon a and ribavarin

31
Q

What are the complications of HCV infection?

A

Chronic infection

Cirrhosis

Hepatocellular carcinoma

32
Q

What are the distinguishing features of HDV infection? What is worrying about HDV?

A

Requires HBV (completes its infection cycle)

Superinfection (Hep B then D) causes fulminant hepatitis

33
Q

How is hepatitis D diagnosed?

A

reverse PCR of HDV RNA

Interferon

34
Q

What are the defining features of HEV?

A

common around a ‘central belt (Mexico, North Africa, Central and South East Asia)

35
Q

How does autoimmune hepatitis present? what antibodies does it show?

A

Young female

Presents with fatgue, RUQ pain and jaundice

Type I (all): ANA +/- ASMA

Type II (children only): LMK1

36
Q

How is AIH confirmed?

A

Liver biopsy

Shows ‘piecemeal necrosis’

37
Q

How do you manage AIH?

A

Steroids + azathioprine

Liver transplant

38
Q

What condition are patients stereotypically ‘Fat/female/fertile/forties’?

A

Biliary Colic

39
Q

What clinical features distinguish biliary colic, acute cholecystitis and ascending cholangitis?

A

Colic: Intermittent RUQ pain

Acute cholecystitis: Persistent RUQ pain + jaundice

Ascending cholangitis: Persistent RUQ pain + jaundice + fever

40
Q

Aside from RUQ pain, jaundice and fever; what two features point towards ascending cholangitis?

A

Hypotension

Confusion

(Reynold’s pentad)

41
Q

In suspected biliary colic, what is the

a) investigations
b) management

A

a) Ultrasound: Shows acoustic shadowing
b) Elective cholecystectomy

42
Q

What is the pathogenesis of bilairy colic?

A

Stone formation in bile duct

Causes TRANSIENT irritation

43
Q

What part of the abdo exam is indicative of acute cholecystitis

A

Pain when pressing over RUQ during inspiration

(Murphy’s sign)

44
Q

In suspected cholecystitis what are the:

a) Investigations
b) Management

A

a) RUQ US +/- HIDA scan
b) IV antibiotics + cholecystecomy within a week

45
Q

In suspected ascending cholangitis, what is the typical infective agent?

A

E. Coli

(Other coliforms eg Klebsiella and enterobacter also pathogens)

46
Q

In suspected ascending cholangitis, what investigations and management should be performed?

A

IV antibiotics

ERCP 24-48 hours after

47
Q

How can the ‘primary’ biliary conditions (PBC, PSC) be distinguished from other pathology?

A

No fever

Itching

48
Q

What condition is primary sclerosing cholangitis associated with?

A

Ulcerative colitis

49
Q

What group of conditions is primary biliary cirrhosis linked to?

A

Rheumatoid/HLA B27 conditions

Also get pigmentation over joints

50
Q

How does primary sclerosing cholangitis and primary biliary cirrhosis differ in terms of markers?

A

PSC // PBC

p-ANCA // AMA-M2, raised IgM

51
Q

What biliary condition shows a ‘beaded’ bile duct? what modality is does this appear on?

A

PSC

ERCP/MRCP

52
Q

How is primary sclerosing cholangitis treated?

A

Liver transplant as incurable

Give cholestyramine for itch

53
Q

What is the first line and adjunct management in PBC?

A

1st line: Ursodeoxycholic acid

+ Cholestyramine for itch

+ Fat soluble vitamins

+ Transplantation

54
Q

How do you discern cholangiocarcinoma from other HPB conditions?

A

RUQ pain and jaundice

No fever

Palpable masses in RUQ +/- nodes in periumbilical/left supraclavicular

55
Q

How can pancreatic cancer be discerned from other similar presenting conditions?

A

Pain: Classically none but can have epigastric +/- radiation to back

Jaundice

NO fever

Systemic features

56
Q

What four mutations does pancreatic cancer have links to?

A

HNPCC

MEN

BRCA2

KRAS

57
Q

How do you a) investigate and b) manage pancreatic cancer?

A

a) 1st line: US, GS: High res CT
b) Pancreaticoduodenectomy +/- adjuvant chemotherapy, stenting via ERCP

58
Q

Severe epigastric pain that radiates to back with vomiting and fever is indicative of?

A

Acute pancreatitis

59
Q

What investigations support a clinical diagosis of acute pancreatitis?

A

1st line: >3 x normal amylase

+ lipase if >24 horus

+ Ultrasound

60
Q

Prior to surgery, what are the 3 points of management of acute pancreatitis?

A

Analgesia

Aggressive crystalloids

Alternative feeding

61
Q

What are the 3 features of chronic pancreatitis?

A

epigastric pain, worse after eating

Fatty stool (exocrine)

Diabetes mellitus (endocrine)

62
Q

What is the main imaging investigation for chronic pancreatitis? What lab test can help diagnosis?

A

CT for calcifications

Faecal elastase

63
Q

What is the treatment for chronic pancreatitis?

A

Analgesia

Pancreatic enzyme supplements

64
Q
A

MBChB Finals (31 decks)

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