Hepatobiliary Flashcards
Identify causes for each of the following types of jaundice:
✔️ pre-hepatic
✔️ intra-hepatic
✔️ post-hepatic
PRE-HEPATIC
✔️ haemolytic anaemia (congenital versus acquire, immune versus non-immune, auto-immune versus allo-immune)
✔️ Gilbert’s Disease
INTRA-HEPATIC ✔️ viral hepatitis ✔️ alcohol liver disease / alcoholic steatohepatitis ✔️ non-alcoholic fatty liver disease ✔️ pregnancy ✔️ sarcoidosis ✔️ liver cirrhosis
POST-HEPATIC
✔️ gall stones
✔️ pancreatic cancer
✔️ strictures
Outline appropriate investigations for JAUNDICE.
✔️ urine dipstick + MCS (elevated bilirubin levels)
✔️ FBC + WCC
✔️ Inflammatory markers (ESR + CRP)
✔️ UECs + albumin
✔️ eLFTs (especially conjugated to unconjugated bilirubin levels)
✔️ coags
✔️ DAT test (IgM and IgG)
✔️ haemolytic screen (LDH, haptoglobin, recitculocyte count)
✔️ abdominal USS
What are some clinical features that may present alongside jaundice?
✔️ fatigue (due to haemolytic anaemia or any of the viral infections)
✔️ abdominal pain
✔️ nausea and vomiting
✔️ pruritis (due to elevated cholesterol levels)
✔️ easy bruising (due to impaired coagulation factors)
✔️ steatorrhea and malabsorption (due to impaired Vitamin synthesis)
✔️ pale coloured stools (due to reduced stercobilin)
✔️ dark urine (due to bilirubin in the urine)
✔️ fever, nightsweats, weight loss (in the case of pancreatic cancer)
N.B. painless jaundice in a patient > 50 years of age MUST be considered pancreatic cancer until proven otherwise
What are some differentials for MASSIVE SPLENOMEGALY?
“Hopefully my medical students can learn gastroenterology…”
H = hairy cell leukaemia M = malaria M = myelofibrosis S = sarcoidosis C = CML L = lymphoma G = Gaucher's Disease
What are some differentials for splenomegaly (not massive)?
✔️ portal hypertension (secondary to liver cirrhosis)
✔️ right sided or congestive cardiac failure
✔️ splenic vein thrombosis
✔️ infections (e.g. EBV, CMV)
✔️ severe alcoholism
Identify three causes for THROMBOCYTOPENIA in patients with alcoholism.
- hypersplenism (increased “consumption” of platelets)
- bone marrow suppression
- impaired liver synthetic function (leading to reduced TPO)
Identify some causes for massive, moderate and mild hepatomegaly.
MASSIVE HEPATOMEGALY (MR HAM) ✔️ M = metastasis ✔️ R = right sided heart failure ✔️ H = HCC ✔️ A = ALD ✔️ M = myeloproliferative disorders
MODERATE HEPATOMEGALY (HIFI) ✔️ H = haematological disorders ✔️ I = iron disorders (haemochromatosis) ✔️ F = fatty liver ✔️ I = infiltration
MILD HEPATOMEGALY
✔️ hepatitis
✔️ HIV
✔️ biliary disease
What are the three diagnostic markers used in the diagnosis of HEPATITIS B infection?
- HBsAg
- HBsAb
- HBcAb (IgM or IgG)
Outline the serology findings for the following situations:
- hepatitis B immune (vaccinated)
- hepatitis B previous exposure (recovered)
- hepatitis B acute infection
- hepatitis B chronic infection
IMMUNE / VACCINATED
HBsAg -ve
HBsAb +ve
HBcAb -ve
PREVIOUS EXPOSURE HBsAg -ve HBsAb +ve HBcAb (IgM) -ve HBcAb (IgG) +ve
ACUTE INFECTION ABsAg +ve ABsAb -ve HBcAb (IgM) +ve HBcAb (IgG) -ve
CHRONIC INFECTION ABsAg +ve ABsAb +ve HBcAb (IgM) -ve HBcAb (IgG) +ve
Identify the four stages of CHRONIC HEPATITIS B infection and the key serological findings for each stage.
- Immune tolerance –> HBVDNA +ve, LFTs normal, HBeAg +ve
- Immune clearance –> HBVDNA +ve (decreasing), LFTs abnormal, HBeAg +ve
- Immune control –> HBVDNA +ve (decreasing), LFTs normal, HBeAb +ve
- Immune escape –> HBVDBA +ve (increasing), LFTs abnormal, HBeAb +ve
N.B. The greatest risk of transformation to either HCC or liver cirrhosis is during the immune clearance or immune escape phase, when LFTs are abnormal.
Identify key clinical signs suggestive of chronic liver disease / liver cirrhosis.
GENERAL INSPECTION ✔️pallor ✔️ jaundice ✔️ visible scratch marks (suggestive of pruritis) ✔️ easy bruising ✔️ cachexia ✔️ muscle wasting ✔️ disorientation to person, place and time (hepatic encephalopathy) ✔️ visible ascites
HANDS AND NAILS ✔️ palmar crease pallor ✔️ palmar erythema ✔️ leukonychia (anaemic nail changes) ✔️ clubbing of the nails ✔️ hepatic flap ✔️ Dupetryen's contracture (in chronic alcoholism)
FACE, EYES AND MOUTH ✔️ scleral jaundice ✔️ pallor ✔️ parotid gland enlargement (in chronic alcoholism) ✔️ fetor hepaticus ✔️ angular stomatitis, glossitis ✔️ Brown-Black lesions within the mouth
ANTERIOR CHEST ✔️ gynaecomastia ✔️ telangiectasia ✔️ supraclavicular lymph node enlargement (Virchow's node) ✔️ pleural and pericardial effusions
ABDOMEN
✔️ visible ascites / abdominal distension
✔️ caput medusa
✔️ hepatomegaly (or non-palpable, small and nodular liver)
✔️ splenomegaly
✔️ fluid thrill
✔️ dullness on percussion
OTHER
✔️ testicular atrophy
✔️ haemorrhoids / rectal bleeding (request DRE)
What are the two diagnostic tests required for the diagnosis of HEPATITIS C?
- HepC antibodies
2. HepC RNA
Outline some causes of LIVER CIRRHOSIS.
AUTOIMMUNE CAUSES
✔️ autoimmune hepatitis
STORAGE DISEASE CAUSES
✔️ Wilson’s Disease
✔️ Gaucher’s Disease
✔️ Haemochromatosis
VIRAL CAUSES ✔️ Hepatitis B Virus ✔️ Hepatitis C Virus ✔️ Flaviviruses ✔️ EBV, CMV
TOXINS / DRUGS ✔️ methotrexate ✔️ paracetamol ✔️ chlorpromaphine ✔️ amiodarone
VASCULAR DISORDERS
✔️ right sided heart failure / congestive heart failure
✔️ Budd Chairai Syndrome
✔️ portal vein thrombosis
OTHER (MOST COMMON)
✔️ NAFLD
✔️ alcoholic liver disease
Outline the parameters used to calculate the CHILD’S PUGH SCORE.
- A = ascites
- B = bilirubin
- C = coagulopathy (INR)
- D = decreased albumin
- E = encephalopathy
The Child’s-Pugh Score is used to calculate the risk of mortality in 12 months in a person with liver cirrhosis.
Mild Risk = 5 to 6
Moderate Risk = 7 to 9
Severe Risk = 10 to 15
Outline the management of ASCITES in patient with liver cirrhosis.
✔️ fluid and salt restriction
✔️ appropriate diet (high in protein)
✔️ spironolactone 50 to 100mg PO, daily (potassium-sparing diuretic)
✔️ IV albumin infusion (in severe cases only)
✔️ TIPS procedure (in severe cases only)
✔️ liver transplantation ( in severe cases only)
Outline the management of RUPTURE OESOPHAGEAL VARICES in a patient with liver cirrhosis.
MEDICAL MANAGEMENT
1. Primary survey (ABCDE)
✔️ Supplemental oxygen via nasal prongs
✔️ Insert TWO large bore IVCs
✔️ Collect appropriate bloods (FBC, Inflammatory markers, UECs, eLFTs, coags, G+H)
2. IV octreotide 50microg stat
3. Immediate whole blood transfusion
4. Consider prophylactic antibiotics (e.g. ceftriaxone)
5. Consider thiamine and glucose supplementation (in alcoholic liver disease patients)
SURGICAL MANAGEMENT 1. Urgent referral to general surgery. ✔️ endoscopic band ligation ✔️ balloon tamponade ✔️ TIPS procedure (trans jugular intrahepatic portovenous shunt)
Outline the appropriate management for HEPATIC ENCEPHALOPATHY.
✔️ remove / cease any offending drugs or toxins
✔️ do NOT use any drugs that may affect liver function
✔️ LACTULOSE 30mL per hour
✔️ monitor for deterioration or ongoing complications
What is the diagnostic criteria for IRRITABLE BOWEL SYNDROME (IBS)?
IBS is defined as ABDOMINAL PAIN for at least THREE DAYS per month for the last THREE MONTHS, plus at least TWO of the following:
- relief of abdominal pain with defecation
- change in bowel frequency (i.e. constipation OR diarrhoea)
- change in stool appearance (e.g. pellet-like)
IBS is a diagnosis of exclusion. Other pathologies must be investigated.
Describe common clinical features of IBS.
✔️ alternating constipation and diarrhoea ✔️ recurrent abdominal pain ✔️ changes to bowel motion frequency ✔️ changes to stool formation / appearance ✔️ increased flatus ✔️ increased fecal urgency ✔️ abdominal bloating ✔️ mucus in stool
Outline some management options for IBS.
DIETARY OPTIONS
- Encourage patient to keep a food diary; identify foods that may trigger symptoms.
- Eliminate any foods that are associated with worsening of symptoms (e.g. caffeine, alcohol, carbonated drinks, fatty foods, lactose, wheat).
- Trial a low FODMAP diet (with input from dietician).
LIFESTYLE MODIFICATIONS
- Counsel patient on the impact stress can have on symptoms.
- Consider refer to psychologist for CBT / mindfulness techniques.
Outline the pathophysiology of CLOSTRIDIUM DIFFICLE infection.
C. difficle infection commonly occurs after prolonged treatment with broad spectrum antibiotics (e.g. cephalosporins).
Broad-spectrum antibiotics disturb the natural microbiome within the gut and facilitate overgrowth of the C. difficle bacteria. This bacteria promotes secretion of enterotoxins and cytotoxins, forming a PSEUDOMEMBRANE.
Toxic megacolon more commonly occurs after treatment with anti-motility agents (e.g. loperamide).
Describe appropriate treatment for PSEUDOMEMBRANOUS COLITIS.
Oral antibiotics:
- metronidazole
- vancomycin
Severe infection may require BOTH.
Identify some complications of PSEUDOMEMBRANOUS COLITIS.
✔️ fulminant colitis
✔️ toxic megacolon
✔️ significant electrolyte disturbances (hypokalaemia, metabolic alkalosis)
Identify some causes for ACUTE DIARRHOEA.
Acute diarrhoea is usually of an infective aetiology.
✔️ viral infection (rotavirus, norovirus)
✔️ bacterial infection (E. Coli, Salmonella, shigella)
✔️ food poisoning (B. cereus, Staphylococcus)
✔️ drugs / toxins
