GI And Liver Flashcards
What is ALP and when is ALP affected
Alkaline phosphatase - Role in dephosphorylating molecules particularly in the bone and biliary tree
…SO…
Increased in biliary tree damage + bone pathology
Not just specific to liver pathology but may be indicative of it
What is GGT and when is GGT affected
Gamma-glutamyl transferase - enzyme which has a role in glutathione synthesis (major antioxidant)… found everywhere in body but mainly the liver
…SO…
It’s increased in Acute liver disease
Shows a hepatic/bony cause for the change
REMEMBER… ALP suggests biliary tree damage
Not just specific to liver pathology but may be indicative of it
Define appendicitis
Inflamed appendix; usually due to luminal obstruction
Surgical emergency
Causes of appendicitis
Faecolith (hard solidified faeces)
Lymphoid hyperplasia (in teens, of peyer’s patches)
Worms
Blockage typically affected with ecoli and as pressure increases inside appendix you get increased risk of rupture (SBP)
Signs and Sx of appendicitis
Umbilical pain which localises to the McBurney’s point
Pyrexia + rebound tenderness & abdo gauging
Rosving’s - palpation of the left iliac fossa causes pain in the RIF).
Obturator sign - pain is worsened by flexing and internally rotating the hip.
Psoas sign - pain is worsened by extending the hip.
Complication of appendicitis
Rupture
Peri-appendiceal abscess
Investigation and Dx of appendicitis
CT Abdo + pelvis - gold standard
Rule out pregnancy in females of child-bearing age assume they are pregnant until proven otherwise - to rule out ectopic pregnancy (presents with right iliac fossa pain)
Tx for appendicitis
Antibiotics
- ensure the abcess is drained before giving ABx (they are walled off bacterial collection therefore systemic ABx aren’t useful; drain and give intra-abscess ABx)
Then appendectomy (laproscopic)
What is AST / ALT
Also useful markers that may help identify liver pathology (like GGT and ALP)
They are found in the liver, heart, kidney muscles
AST:ALT ratio ≈ 1 (so if the ratio is off then may suggest pathology)
> 2:1 ratio suggests alcoholic liver disease (esp with increased GGT)
> 4.5:1 ratio suggests Wilson’s (Copper accumulation) / hyperthyroidism
< 0.9:1 ratio suggests NAFLD
A 19-year-old woman is admitted to hospital having taken an overdose of over 200 paracetamol tablets at home. Despite treatment with n-acetylcysteine she develops jaundice, worsening coagulopathy on her clotting studies and is now confused. She is referred for liver transplant.
What condition does she have..?
Acute liver failure
Pathophysiology of acute liver failure
The rapid decline in hepatic function characterised by jaundice, coagulopathy and hepatic encephalopathy
Coagulopathy: INR > 1.5
Essentially liver loses ability to regenerate and repair -> irreversible damage (i.e. decompensated cirrhosis)
What is fulminant liver failure
Rare syndrome of massive hepatocyte necrosis (histological LH see multi-acinar necrosis too)
Onset………..
Hyperacute: within 7 days
Acute: between 8 and 28 days
Sub-acute: between 29 days and 12 weeks
Main cause of fulminant liver failure
paracetamol overdose - in 70% of cases
What is acute on chronic liver failure
Rapid decline in Px with chronic liver Sx
What is chronic liver failure
Px with progressive Hx of liver disease
Name 3 types of liver function tests we can measure
Bilirubin (conjugated/unconjugated) increases
Albumin decreases
Prothrombin time (PT/INR) increases
These 3 are directly relate to liver damage…v.specific
Remember the enzymes (AST,ALT,GGT,ALP) aren’t as specific as they can be altered by a lot of other things
Name 2 hepatocellular enzymes
Transaminases
AST
ALT
Name a Cholestatic enzyme
Alkaline phosphatase:
ALP
Give 5 causes of acute liver failure
Viral; Hep A, B, E / CMV / EBV
Autoimmune Hep
Drugs; Paracetamol / alcohol / ecstasy
HCC (hepatocellular carcinoma)
Budd-chiari syndrome (post hepatic vein blockage)
Signs and Sx of acute liver failure
Acute presentation of…
Jaundice, coagulopathy and
hepatic encephalopathy - Altered mood, sleep disturbance, inappropriate behaviour
What criteria is used for hepatic encephalopathy
West haven criteria grade 1-4:
1) altered mood / sleep disturbance
2) lethargy / mild confusion / Asterixis
3) marked confusion
4) comatose
Investigation and Dx of acute liver disease
Bloods:
LFTs - (increased bilirubin, decreased albumin, increased PT/INR)
Increased serum AST/ALT decreased glucose
Imaging:
USS to check for budd-chiari syndrome
Microbiology:
Rule out infections; blood culture, urine culture, ascites tap
Tx for acute liver disease
Acute: ABCDE; IV fluids, analgesia
Then treat underlying cause + complications;
Paracetamol overdose; give activated charcoal + N-acetyl cysteine.
ICP - IV MANNITOL
Hepatic encephalopathy - LACTULOSE; Increase NH3 excretion
Ascites - diuretics; spironolactone
Haemorrhage - Vitamin K
Sepsis - SEPSIS 6.
What type of complications are there in acute liver disease?
ICP
Hepatic encephalopathy
Ascites
Haemorrhage
Sepsis
Tx of acute liver disease complications
ICP - IV MANNITOL
Hepatic encephalopathy - LACTULOSE; Increase NH3 excretion
Ascites - diuretics; spironolactone
Haemorrhage - Vitamin K
Sepsis - SEPSIS 6
Define chronic liver failure
Progressive liver disease over 6 months due to repeated liver damage
Causes of chronic liver failure
Most common - alcoholic liver disease
Non-alcoholic fatty liver disease
Viral; Hep B,C (± D)
Drugs
Metabolic
Risk factor for chronic liver failure
Alcohol
Obesity
Diabetes mellitus type 2
Drugs
Metabolic disease - Wilson’s
Stages of liver failure
Hepatitis / cholestasis ———> Fibrosis (reversible damage) ———> Cirrhosis (irreversible) ———>
Compensated Some extent of liver function.
…OR…
Decompensated End stage liver failure.
———> HCC
Give 5 signs of decompensated liver failure
Jaundice
Hepatic encephalopathy
Coagulopathy
Ascites (portal HTN, oesophageal varices)
Serum albumin decreased
What score is used for assessing the progression of liver failure
Child Pugh score (A-C) based on a 1yr survival:
A… 100%
B… 80%
C… 45%
Decompensated liver cirrhosis has a huge risk of developing what
Hepatocellular carcinoma
Patients Sx with chronic liver failure
Jaundiced
Ascites
Hepatic encephalopathy
Capital medusae
Spider naevi
Palmar erythema
Gynecomastia
Investigation and Dx of chronic liver failure
Liver biopsy (gold standard) - used to determine extent of cirrhosis/fibrosis
LFTs + USS + ascetic tap culture
Tx of chronic liver disease
Prevent progression; lifestyle modification
Consider liver transplant (if decompensated liver failure)
Manage complications:
hepatic encephalopathy - lactulose
Ascites - diuretics
Define gallstones
Small solid stones that form within the gallbladder
3 types:
Cholesterol (80%) gallstones
Bilirubin / pigment gallstones
Mixed gallstones
What are gallstones made up of
Most common type: Cholesterol gallstones (80%) - due to increased cholesterol, reduced bile salts and biliary stasis
Can also get… Bilirubin (pigment) gallstones
Could have a mix of the 2 types… cholesterol and bilirubin
Define cholestasis
Blockage of bile flow
Define cholelithiasis
Gallstones
Define choledocholilithiasis
Gallstones that have moved into the bile duct
Define biliary colic
Still essentially gallstones…
intermittent right upper quadrant pain caused by the gallstones irritating bile ducts
Define cholecystitis
Inflammation of gallbladder
Define cholangitis
Inflammation of the bile ducts
Define gallbladder empyema
Pus build up in gallbladder
Difference between cholecystectomy and cholecystostomy
Cholecyst_ecto_my: surgical removal of the gallbladder
Cholecyst_osto_my: inserting a drain into the gallbladder
Role of gallbladder
It stores bile - a fluid produced by the liver that helps break down fatty foods
Risk factors for gallstones
Remember as 5F:
Fat
Female
Forties
Fertile
FHx of gallstones
+ DM / Crohns / haemolytic conditions (** haemolysis (e.g. sickle cell disease) causes excess circulating bilirubin resulting in pigment gallstones**)
Clinical features of gallstones
RUQ ‘biliary colic’ pain
Constant pain >30mins
Worse after fatty foods.
Pain may radiate to the right shoulder or interscapular region
Murphy’s sign negative: On palpation of the right upper quadrant there is no arrest of inspiration
Pain is often reproduced after eating, but not on palpation
In which condition might u feel pain on eating fatty foods and why
Gallstones
Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum. CCK triggers contraction of the gallbladder, which leads to biliary colic.
Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction.
Give 4 complications of gallstones
Acute cholecystitis
Ascending cholangitis
Obstructive jaundice - stone blocks the ducts
Pancreatitis
Gallbladder cancer
Investigation / diagnosis of gallstones
1st line: Abdo USS
Could do LFTs
Consider: Magnetic resonance cholangiopancreatography (MRCP): if no common bile duct stones are seen on abdominal ultrasound, but…The common bile duct is dilated on abdominal ultrasound and/or Liver function tests are abnormal
Tx for gallstones
Elective laparoscopic cholecystectomy - for all symptomatic px
Until then…….
For mild pain: oral NSAIDs (Diclofenac) / paracetamol
For severe pain: IM NSAIDs (IM Diclofenac)
+ Lifestyle ∆: avoid fatty foods and increase fibre intake
Other than gallstones which 2 other conditions can come under biliary tract diseases
Acute cholecystitis
Ascending cholangitis
Define acute cholecystitis
Acute inflammation of the gallbladder - 90% of acute cholecystitis is caused by inflammation impacted at the neck of the gallbladder or cystic duct, resulting in inflammation of the gallbladder wall.
Bacterial overgrowth, usually involving gram-negative rods or anaerobes. This is known as calculous cholecystitis
What colours are the gallstones
cholesterol stones (yellow)
pigmented stones (black or brown) which are made up of calcium salts.
Risk factors for acute cholecystitis
Same as gallstones:
5 ‘Fs’ -fat, female, fertile, forties, FHx
