GI - Liver Disease Flashcards
A 32 year old woman returns from a holiday in India. She started getting diarrhoea after eating at a seafood restaurant on the last night. She is feverish, nauseous and is sore all over. The whites of her eyes are yellow.
Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Hepatitis A
India Diarrhoea Seafood restaurant Feverish, nauseous Sore all over Yellow
Viral Hepatitis General Presentation
3 main signs and symptoms, apply to ALL hepatitits:
Fever
Jaundice
Raised ALT and AST
Hepatitis A and E
Faeco-oral hepatitis.
“The Vowels hit your Bowels”
Hep A:
Asymptomatic (usually)
Acute
(may be nausea and vomiting)
Hep E:
Enteric
Epidemics (water)
Expectant mothers
–> Management:
Supportive
Avoid alcohol
A 29 y/o male comes to the GP with fever, fatigue, joint pain and urticaria-like skin rash. He had unprotected anal sex a month ago. He comes back a week later for a blood test, which shows raised ALT and AST.
Now, he complains of feeling sick, RUQ pain and looks a bit yellow.
Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Hepatitis B
Fever Fatigue Joint pain Urticaria like skin rash Anal sex ALT and AST Feeling sick RUQ pain Yellow
Hepatitis B summary
Initial infection - prodrome:
Flu-like symptoms (fever, myalgia, malaise)
Rash
Lymphadenopathy
--> Acute infection: Nausea Anorexia RUQ pain Jaundice
Outcome of infection:
90% Completely recover
10% Develop chronic infection
Hepatitis B Management
Acute: Symptom supportive
Chronic: Consider Peginterferon Alpha or Tonfovir
A 67 year old man is investigated under the two-week wait for jaundice, tender hepatomegaly, ascites and anorexia. His blood tests show a raised aFP. He mentions that he was diagnosed with hepatitis years ago. What virus(es) are likely?
Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Hep B and C
Two week wait Jaundice Tender hepatomegaly Ascites Anorexia aFP
Hepatitis and Hepatocellular carcinoma
Hepatitis is the most common risk factor for developing HCC
Hep B:
The virus integrates into the host chromosome
Acts and an oncogene
Hep C:
Causes chronic inflammation
Mutations accumulate
Alpha-fetoprotein is marker of HCC!
Which hepatitis virus requires another virus to be present for it to successfully infect?
Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Hep D
Hepatitis D needs the Hepatitis B surface antigen (HBsAg) to enter hepatocytes
Kayser-Fleischer Rings
Dark rings that appear to encircle the iris of the eye. Due to copper deposition in part of the cornea.
Wilson’s Disease Inheritance, Pathology, Presentation
Inheritance: Autosomal Recessive
Pathology: Copper incorporation into caeruloplasmin in hepatocytes and its excretion into bile is impaired, and so copper is deposited, firstly into liver, then basal ganglia
Presentation: Children with liver failure or young adults with CNS signs such as ataxia, tremor, dysarthria. Kayser-Fleischer Rings are pathogomonic.
A 56-year-old man, diagnosed with emphysema, presents with a one-month history of jaundice and ascites. Your registrar tells you that the man has had breathing problems for the majority of his life.
What is the most likely diagnosis?
Sickle Cell Disease COPD Epstein-Barr Virus Idiopathic Pulmonary Fibrosis Alpha-1 Antitrypsin Deficiency
Alpha-1 Antitrypsin Deficiency
Alpha-1 Antitrypsin Deficiency Inheritance, Pathology, Presentation
Inheritance: Autosomal Recessive
Pathology: A1AT is genetically mutated, leading to it being prevented from release from hepatocytes. This causes a loss of its protective function in the lungs against elastase, leading to emphysema and a build up in the liver leading to destruction and liver disease.
Presentation: Emphysema in a non-smoker from a young age with late onset liver sign and a few risk factors
Liver Failure stages
Healthy liver
Fatty liver
deposits of fat lead to liver enlargement
Liver fibrosis
scar tissue forms
Cirrhosis
growth of connective tissue destroys liver cells
A 63-year-old woman stumbles into A+E. She looks unwell with a flushed face. An F1 mentions that when she presented last week, examination of her upper limbs suggested a sensory polyneuropathy.
Cytomegalovirus Primary Biliary Cirrhosis Paracetomal Overdose Alcoholic Liver Disease Primary Sclerosis Cholangitis
Alcoholic liver disease
Stumbles into AandE
Flushed face
Presented last week
Sensory polyneuropathy
A 65 year old presents with suspected liver failure. Which of the following tests would NOT be included in a liver screen for liver failure?
Alpha-1 Antitrypsin Caeruloplasmin HIV Screen Anti-GBM Antibody Aspartate Aminotransferase
Anti-GBM antibody
Anti-glomerular basement membrane antibody (anti-GBM Ab) is an antibody which is found in Goodpasture’s syndrome.
Goodpasture’s is a rare autoimmune disease in which antibodies attack the basement membrane in lungs and kidneys, leading to bleeding from the lungs and kidney failure.
A 56-year-old man with a long history of alcohol abuse presents to the emergency department with abdominal pain. On examination he has a distended abdomen with shifting dullness and has a temperature of 38.2°C.
What is the most likely diagnosis?
Bowel obstruction Liver cirrhosis Mallory–Weiss syndrome Perforated peptic ulcer Spontaneous bacterial peritonitis (SBP)
SBP
Long history of alcohol abuse Pain Distended abdomen Shifting dullness Temp 38.2
Signs of Chronic Liver Disease
A-J of liver disease
Effects of portal hypertension: Oesophageal varices --> haematemesis + melena Gastropathy --> melena Splenomegaly Dilated abdo veins (caput medusae) Ascites Rectal varices (hemorrhoids)
Effects of liver cell-failure: Coma Fetorhepaticus Spider naevi Gynecomastia Jaundice Ascites Loss of sexual hair Testicular atrophy Liver flap Bleeding tendendcy (decreased prothrombin) Anemia - macrocytic/iron deficiency (blood loss) Ankle oedema
Liver disease Ix
Bedside: Obs BM Fluid balance Wt
Bloods: LFTs (pre/post; including albumin) INR FBC UandEs CRP Liver screen: autoantibodies, alpha-1 antitrypsin, caeruloplasmin, serum copper, ferritin, viral hepatitis serology
Imaging: US abdomen and portal vein doppler CXR CT MRI MRCP
Special:
Ascitic tap
OGD (varices)
Liver biopsy
Liver Disease DDx
(Decompensated) Alcoholic Liver disease Viral liver disease Autoimmuned liver disease - Wilson's, Hereditary Haemochromatosis, etc Hepatocellular carcinoma Pancreatic cancer Cryptogenic liver cirrhosis
Liver disease management
Conservative: Alcohol abstinence Optimise nutrition Low salt diet Fluid restriction
Medical: Vit. B supplementation (IV/PO), chlordiazepoxide Diuretics Paracentesis (give albumin) NG feeding Abx (? SBP) Steroids and albumin (NB avoid NaCL) Lactulose in hepatic encephalopathy
Surgical:
TIPSS (Transjugular intrahepatic portosystemic shunt)
Liver transplant
A 66-year-old man presents to his GP with increasing weight loss, lethargy and fever over the last 3 months. He has also noticed pale stools and dark urine.
Crigler-Najjar Syndrome Gilberts Syndrome Opiate Overdose Pancreatic Carcinoma Haemolysis
Pancreatic carcinoma
Wt loss Lethargy Fever 3 months Pale stools Dark urine
A 50-year-old man comes to you because he is worried about his skin which occasionally turns yellow. On further questioning you notice that these episodes are particularly bad during periods of stress or illness. He is otherwise well.
Gilbert’s Syndrome Hepatic Metastases Megaloblastic Anaemia Hepatitis A Dubin-Johnson Syndrome
Gilbert’s syndrome
Gilbert’s syndrome is a common genetic liver disorder found in 3-12% of the population.
It produces elevated levels of unconjugated bilirubin in the bloodstream (hyperbilirubinemia), but this normally has no serious consequences, although mild jaundice may appear under conditions of exertion or stress.
The cause of this hyperbilirubinaemia is the reduced activity of the enzyme glucuronyltransferase, which conjugates bilirubin and a few other lipophilic molecules.
Jaundice
Dysfunctional uptake/metabolism/excretion of bilirubin
Excess bilirubin leaks into blood stream
Yellow skin and scleral icterus
3 categories:
pre-hepatic
hepatocellular
post-hepatic
Pre-hepatic jaundice + causes
Dysfunctional transport from spleen–>liver
Increased unconjugated bilirubin
- Haemolysis (low Hb, malaria, haemolytic anaemias, RCC abnormalities - spherocytosis elliptocytosis)
- Inherited disorders of bilirubin metabolism (Gilbert’s - occasional jaundice, isolated high bilirubin)
Hepatocellular Jaundice + causes
Dysfunctional Hepatocytes Abnormal conjugation/excretion Increased bilirubin (conjugated or unconjugated)
Viral - Heps A/B/C/E, EBV, CMV Alcohol Drugs - paracetamol, isoniazid, rifampacin Autoimmune - PBC, PSC Metabolic (rarer)
Post-hepatic jaundice + causes
Obstructive jaundice Increased conjugated bilirubin Flow of bilirubin into GI tract is blocked -->forced into renal system = dark urine -->less stercobilin = pale stools
- Stones in common bile duct (RUQ pain - colicky with fatty foods)
- Carcinoma at head of pancreas (FLAWS)
- Stricture
