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Year 3 MedEd > GI3 > Flashcards

GI3 Flashcards

Liver and Biliary

1
Q

What are the three causes of jaundice?

A

Pre-hepatic
Hepatic
Post-hepatic

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2
Q

What is pre-hepatic jaundice?

A

Excess bilirubin due to excessive haemolysis

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3
Q

What is hepatic jaundice?

A

Impaired hepatocellular uptake, defective conjugation, or abnormal secretion of bilirubin

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4
Q

What is post-hepatic jaundice?

A

Impaired excretion due to a mechanical obstruction of the biliary flow

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5
Q

Which serum markers will be elevated in pre-hepatic jaundice?

A

Unconjugated bilirubin

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6
Q

Which serum markers will be elevated in hepatic jaundice?

A

AST
ALT
Conjugated + unconjugated bilirubin may also be elevated

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7
Q

Which serum markers will be elevated in post-hepatic jaundice?

A

ALP
GGT
Conjugated bilirubin

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8
Q

What are some signs of portal hypertension?

A 
Oesophageal varices
Splenomegaly
Caput medusae
Ascites
Haemorrhoids
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9
Q

What are some signs of liver failure?

A 
Asterixis
Bruising
Clubbing
Dupuytren's contracture
Erythema (palmar)
Fetor hepaticus (breath of the dead)
Gynaecomastia
Hypertension (portal)
Itching
Jaundice
Spider naevi/testicular atrophy
(ABC...)
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10
Q

Which hepatitides are transmitted through the faecal-oral route?

A

Hepatitis A, E

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11
Q

Which hepatitides are transmitted through bodily fluids?

A

Hepatitis B, C, D

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12
Q

What is the incubation period of Hepatitis A?

A

2 weeks

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13
Q

What is the incubation period of Hepatitis B?

A

4-12 weeks

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14
Q

What is the incubation period of Hepatitis C?

A

2 weeks - 6 months

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15
Q

What is the incubation period of Hepatitis D?

A

4-12 weeks

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16
Q

What is the incubation period of Hepatitis E?

A

5-6 weeks

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17
Q

What are the risk factors for Hepatitis A?

A

Poor hygeine

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18
Q

What are the risk factors for Hepatitis B?

A

Health workers
IVDU
M-M sexual relations

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19
Q

What are the risk factors for Hepatitis C?

A

IVDU

M-M sexual relations

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20
Q

What are the risk factors for Hepatitis D?

A

Only co-infects with Hep B

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21
Q

What are the risk factors for Hepatitis E?

A

Immunocompromised Pts

Pregnancy

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22
Q

Which hepatitides are at risk of chronic development?

A 
Hepatitis B (in children)
Hepatitis C (60-80%)
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23
Q

What are some generic symptoms of viral hepatitis?

A 
REduced appetite
N+V
Abdo pain
Pruritus
Skin rash
Joint pain
Jaundice
Hepatomegaly
Recent travel from Africa/East Mediterranean
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24
Q

What investigations would you do on a Pt with viral hepatitis?

A 
LFTs
FBC
U+Es
Antibodies
NAAT (nucleic acid amplification test can indicate viral load)
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25
Q

What is the interpretation of the following HBV antibodies?

Anti-HBc IgM: -ve
Anti-HBc IgG: -ve
HbSAg: -ve
Anti-HBs: -ve

A

Not infected

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26
Q

What is the interpretation of the following HBV antibodies?

Anti-HBc IgM: -ve
Anti-HBc IgG: -ve
HbSAg: -ve
Anti-HBs: +ve

A

Not infected, with prior vaccination

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27
Q

What is the interpretation of the following HBV antibodies?

Anti-HBc IgM: -ve
Anti-HBc IgG: -ve
HbSAg: +ve
Anti-HBs: -ve

A

Early acute HBV infection

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28
Q

What is the interpretation of the following Hep B antibodies?

Anti-HBc IgM: +ve
Anti-HBc IgG: -ve
HbSAg: +ve
Anti-HBs: -ve

A

Acute HBV infection

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29
Q

What is the interpretation of the following HBV antibodies?

Anti-HBc IgM: -ve
Anti-HBc IgG: +ve
HbSAg: -ve
Anti-HBs: +ve

A

Resolved acute HBV infection

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30
Q

What is the interpretation of the following HBV antibodies?

Anti-HBc IgM: -ve
Anti-HBc IgG: +ve
HbSAg: +ve
Anti-HBs: -ve

A

Chronic HBV infection

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31
Q

Notes for HBV antibody interpretation

A

HBsAg: surface antigens
If these are present, there is an infection

Anti-HBs: surface antigen antibodies
If these are present, body is successfully protected against virus

Anti-HBc IgM/IgG: core antigen antibodies
IgM precedes IgG, hence IgM indicates a more recent infection

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32
Q

What is the management for hepatitis A?

A

Supportive care

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33
Q

What is the management for hepatitis B?

A

Supportive care if acute

Antivirals and peginterferon if chronic

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34
Q

What is the management for hepatitis C?

A

Supportive care if acute

Antivirals if chronic

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35
Q

What is the prognosis for hepatitis A?

A

Nearly all resolve in 6 months

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36
Q

What is the prognosis for hepatitis B?

A

Viral suppression in 90% of chronic cases

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37
Q

What is the prognosis for hepatitis C?

A

79% mortality at 10 years for chronic cases

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38
Q

What is the cause of NASH/NAFLD?

A

Insulin resistance -> increased triglycerides -> steatosis -> inflammation -> steatohepatitis

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39
Q

What are the risk factors for NASH?

A

T2DM
Metabolic syndrome
Some medications
No alcohol Hx

40
Q

What is the triad for NASH?

A

RUQ pain
Hepatomegaly
Metabolic syndrome without alcohol

41
Q

What are the investigations for NASH?

A 
Liver function tests
-AST:ALT will be <1 (>2 in alcoholic liver disease)
FBC
Metabolic profile
Lipid profile
Hepatic ultrasound
42
Q

What is the management for NASH?

A

Diet and exercise
Correction of glucose and lipid levels
Liver transplant if in liver failure

43
Q

What is the prognosis for NASH?

A

1/3 reverse the condition
1/3 keep the condition
1/3 develops into cirrhosis

44
Q

What are the complications of NASH?

A 
Cirrhosis
HCC
Ascites
Portosystemic thrombosis
Haemorrhaege
45
Q

What is the cause for ALD?

A

Alcohol metabolism -> XS NADH -> inhibits gluconeogenesis -> increased triglycerides -> steatosis -> inflammation -> steatohepatitis

46
Q

What is the triad for ALD?

A

RUQ pain
Hepatomegaly
Associated with a Hx of alcohol consumption

47
Q

What are the investigations for ALD?

A 
Liver function tests (AST:ALT >2, raised GGT)
FBC
U+Es
Vitamin screen
Hepatic ultrasound
48
Q

What is the management for ALD?

A

Abstinence support
Address metabolic syndrome
Steroids/nutritional support
Liver transplant if in liver failure

49
Q

What is liver cirrhosis?

A

Scarring of the liver due to hepatocyte damage

50
Q

What are the symptoms of liver cirrhosis?

A

Abdominal distension
Pruritus
Coffee-ground vomit (due to gastro-oesoph varices)

51
Q

What are the signs of liver cirrhosis?

A 
Jaundice
Ascites
Asterixis
Dupuytren's contracture
Palmar erythema
Caput medusae
52
Q

What are the investigations for liver cirrhosis?

A 
LFTs
-low albumin
-prolonged PT
U+Es
-hyponatraemia: ascites
US/CT/MRI
can see atrophy/fibrotic nodules
53
Q

What is the management for liver cirrhosis?

A

Treat underlying cause

Liver transplant if in liver failure

54
Q

What is Wilson’s disease?

A

Autosomal recessive disease of impaired copper excretion in the bile
ATP7B mutation
Accumulates in the liver -> cirrhosis
+ the basal ganglia -> neuropsychiatric disorder

55
Q

What are the signs and symptoms of Wilson’s disease?

A 
Hepatitis symptoms
Ataxia
Tremor
Dysdiadochokinesia
Kayser-Fleischer rings
56
Q

What investigations would you do for Wilson’s disease?

A

LFTs: abnormal
Urinary copper: high
Serum caeruloplasmin: low

57
Q

What is haemochromatosis?

A

Autosomal recessive multisystem disorder of dysregulated dietary iron absorption and increased iron release from macrophages
Commonly C282Y or H63D mutation
Due to hepcidin abnormality so there is no inhibition of Fe uptake

58
Q

What are the signs and symptoms of haemochromatosis?

A 
Brown skin
T1DM
Liver symptoms
-hepatomegaly
-fatigue
-pruritus
59
Q

What are the investigations for haemochromatosis?

A

Iron studies:

  • high ferritin
  • low transferrin
  • high transferrin saturation
60
Q

What is cholelithiasis?

A

Presence of solid concentrations in the gall bladder

61
Q

What is choledocholithiasis?

A

Formation of solid concentrations in the gall bladder which exit the bile duct

62
Q

What is the anatomy of the biliary tree, starting from the sphincter of Oddi?

A

Sphincter of Oddi -> hepatopancreatic ampulla of Vater
AoV -> common bile duct and pancreatic duct
CBD -> cystic duct and common hepatic duct
CHD -> left and right hepatic duct

63
Q

What are the risk factors for gallstones?

A 
Fair skinned
Fat
Female
Fertile
Family Hx
Forty+
(6 F's)
64
Q

What are the symptoms of gallstones?

A

RUQ pain- colicky, post-prandial

Nausea

65
Q

What is Murphy’s sign and what pathology does it present in?

A

Palpate the costal margin mid-clavicular plane
Pain/wince upon inspiration
Gallstones

66
Q

What is Boas’ sign and what pathology does it present in?

A

Pain radiating to below the scapula

Gallstones

67
Q

What is Kehr’s sign and what pathology does it present in?

A

Pain radiating to the shoulder tip

Gallstones

68
Q

What investigations would you do for gallstones/cholelithiasis?

A 
LFTs (first line)
Abdo US (diagnostic)
69
Q

What is the management for cholelithiasis?

A

Cholecystectomy

70
Q

What is the management for choledocholithiasis?

A

ERCP

71
Q

What is ascending cholangitis?

A

Gallstone in the common bile duct
Leads to bile stasis
Bacteria enter the hepatopancreatic duct
Leads to inflammation and infection

72
Q

What is acute cholecystitis?

A

Gallstone in the gall bladder/cystic duct

Leads to bile stasis, inflammation, and infection

73
Q

What is Mirizzi syndrome?

A

Blockage of the cystic duct causing inflammation

Inflammation blocks CHD leading to obstructive jaundice

74
Q

What are the signs and symptoms of acute cholecystitis?

A 
Constant RUQ pain +/- Boas' sign
Fever
N+V
Rebound tenderness
Murphy's sign +ve
75
Q

What are the signs and symptoms of ascending cholangitis?

A

Charcot’s triad

If septic, Reynold’s pentad

76
Q

What is Charcot’s triad?

A

RUQ pain
Fever
Jaundice

77
Q

What is Reynold’s pentad?

A 
RUQ pain
Fever
Jaundice
Hypotension
Confusion
78
Q

What is primary biliary cirrhosis?

A

Autoimmune damage and destruction of the biliary epithelial cells lining the small intrahepatic bile ducts

79
Q

What is the epidemiology of PBC?

A

55-65 yrs
F:M 10:1
AI conditions
Hypocholesterolaemia

80
Q

What are the symptoms of PBC?

A

Pruritus
Fatigue
Sjogren’s (dry mouth and eyes)

81
Q

What are the investigations of PBC?

A

LFTs
Anti mitochondrial antibodies
Abdo US- rule out obstructive duct lesion

82
Q

What is primary sclerosing cholangitis?

A

Inflammation and fibrosis of the intrahepatic and/or extrahepatic bile ducts, leading to diffuse, multi-focal stricture formation.

83
Q

What is the epidemiology for PSC?

A

40-50s
Male
Concurrent IBD

84
Q

What are the symptoms of PSC?

A

RUQ pain
Pruritus
Fatigue

85
Q

What are the investigations for PSC?

A

LFTs (elevated GGT)
MRCP: beading
AMA: -ve

86
Q

What is the epidemiology for pancreatic cancer?

A

65-75 yrs old
Smoking
FHx

87
Q

What are the symptoms for pancreatic cancer?

A

Jaundice
Nonspecific abdo pain
FLAWS

88
Q

What are the investigations for pancreatic cancer?

A

LFTs
Ultrasound
CT

89
Q

A 26 y/o male returns from holiday in India. He has had diarrhoea after eating at a seafood restaurant on his last night. He is feverish and nauseous. You notice that the whites of his eyes are yellow.

A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
A

A. Hepatitis A

90
Q

A 64 y/o male with thalassaemia is investigated under the two-week wait for jaundice and weight loss. His blood tests show a raised αFP. Which chronic infection is he most likely to have?

A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
A

C. Hepatitis C

aFP is raised in cancer. Hep C chronicity has a high risk of HCC.

91
Q

A 32 y/o male returns from holiday in Thailand, feeling ‘under the weather’ with RUQ pain, fevers and nausea. He is jaundiced. He reveals he has used IV drugs and had unprotected sex with a stranger while on holiday. Which test is most likely to give the correct diagnosis?

A. Liver function tests
B. HIV serology
C. Hepatitis B serology
D. Hepatitis C PCR
E. CXR
A

C. Hepatitis B serology

92
Q

A 43 y/o confused man is brought to A&E by police after being found wandering the streets. He is disorientated and unable to give a clear history. You notice brown rings in his eyes. What is he likely to have?

A. Alcohol intoxication
B. Wilson’s disease
C. Opiate overdose
D. Haemochromatosis
E. Hypoglycaemia
A

B. Wilson’s disease

93
Q

72 y/o man with cirrhosis presents to A&E with diffuse abdominal pain and fever. He is nauseous and has vomited. His abdomen is distended and there is shifting dullness on examination. Which investigation would be most urgent?

A. Paracentesis
B. Stool sample MC&amp;S
C. Abdominal USS
D. LFTs
E. Blood cultures
A

A. Paracentesis

Has signs of bacterial peritonitis, which needs to be treated more urgently than the cirrhosis

94
Q

A 41 y/o female presents with a history of colicky, right sided abdominal pain. She states the pain is worse after eating fish and chips and Indian takeaways. On examination her abdomen is soft and non-tender. Which is the best investigation to confirm her diagnosis?

A. Abdominal X-ray
B. ERCP
C. Liver biopsy
D. USS of biliary tree
E. CT-KUB
A

D. USS of biliary tree

95
Q

A 41 y/o female presents to A&E with a history of severe, continuous, RUQ pain. She feels feverish and complains of an occasional pain in her right shoulder. On examination she displays RUQ tenderness and a positive Murphy’s sign. What is the most likely diagnosis?

A. Biliary colic
B. Ascending cholangitis
C. Acute cholecystitis
D. Primary biliary cirrhosis
E. Cholangiocarcinoma
A

C. Acute cholecystitis

96
Q

A 41 y/o female presents to A&E with a history of severe, continuous, RUQ pain. She feels feverish and complains of an occasional pain in her right shoulder. On examination she displays RUQ tenderness and a positive Murphy’s sign. While waiting to be admitted, her RUQ pain becomes worse and she starts shaking uncontrollably. You notice she now looks jaundiced. What is the most likely diagnosis?

A. Biliary colic
B. Ascending cholangitis
C. Acute cholecystitis
D. Primary biliary cirrhosis
E. Cholangiocarcinoma
A

B. Ascending cholangitis

97
Q

A 35 y/o man presents with a two week history of jaundice and RUQ pain. He is taking mesalazine for a “bowel condition”. What is the most likely cause of his jaundice?

A. Autoimmune hepatitis
B. Haemochromatosis
C. Primary sclerosing cholangitis
D. Primary biliary cirrhosis
E. Drug side effect
A

C. Primary sclerosing cholangitis

Year 3 MedEd (29 decks)

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