Hepatobiliary Flashcards
What do raised ALT and AST indicate?
Non-specific evidence of liver injury
What does raised LDH indicate?
non-specific
could be liver injury, cardiac failure, leukaemia, lymphoma
What does raised GGT indicate?
Alcoholic liver injury
What does raised Alk Phos indicate?
Biliary obstruction
2 types of bilirubin?
Unconjugated Bilirubin (indirect) Conjugated Bilirubin (direct)
Where is bilirubin conjugated?
In the liver
3 types of jaundice?
Pre-hepatic
Intra-hepatic
Post-hepatic
Pre-hepatic causes of jaundice?
Haemolysis
How to calculate unconjugated (indirect) bilirubin?
Total bilirubin - Conjugated (direct) bilirubin
Intra-hepatic causes of jaundice?
Liver disease (cirrhosis, alcoholic, fatty liver disease, pregnancy) Intra-hepatic bile duct loss (PBC) Intra-hepatic bile duct obstruction (mets, cirrhosis, hepatitis)
Post-hepatic causes of jaundice?
Obstruction of extra-hepatic bile ducts: Gallstones benign strictures extrahepatic cholangiocarcinoma carcinoma head of pancreas
Conjugated bilirubin in the urine manifests as?
Pale stools and dark urine
Causes of acute liver injury?
alcohol, drugs (paracetamol), viral (Hep A and B), ascending cholangitis due to gallstones, acute fatty liver of pregnancy, Weil’s disease
What is Weil’s disease?
bacterial infection also known as leptospirosis
Causes of chronic liver disease?
chronic hepatitis, cirrhosis, iron overload (haemochromatosis)
Chronic hepatitis definition?
clinical and biochemical evidence of hepatitis lasting more than 6 months
Causes of chronic hepatitis?
Viral (Hep B + C), drugs, alcohol, fatty liver disease (NAFLD -> NASH), autoimmune, Wilson’s disease
What does autoimmune hepatitis look like on biopsy?
Portal lymphocytes with prominent plasma cells
Why is it important to diagnose autoimmune hepatitis?
Rapid progression to cirrhosis may be stopped with steroid use
What is the most common cause of liver cirrhosis?
Alcohol
Features of acute alcoholic hepatitis?
risk of death or progression to cirrhosis
acute inflammation, hepatocyte necrosis and Mallory’s hyaline
When is Mallory’s hyaline seen on biopsy?
In acute alcoholic hepatitis
Risk factors for NAFLD & NASH?
obesity, hyperlipidaemia and T2DM
What is hemosiderosis?
Deposition of iron in the liver as hemosiderin, turning it brown
Causes of hemosiderosis?
Multiple blood transfusions
Alcohol
Primary hereditary haemochromatosis
What gene mutations cause haemochromatosis?
C282Y + H63D in the HFE gene
What pattern of inheritance is Haemochromatosis?
Autosomal Recessive
What happens in Wilson’s Disease?
Copper is deposited in the liver and the basal ganglia of the brain
Symptoms of Wilson’s Disease?
chronic hepatitis leading to cirrhosis
progressive neurological disability
Kayser-Fleischer Rings in the eyes
Diagnosis of Wilson’s Disease?
low serum caeruloplasmin
inc. copper in liver biopsy
Treatment of Wilson’s Disease?
chelating agent penicillamine
What can cause both cirrhosis and emphysema?
Alpha 1 antitrypsin deficiency
Causes of liver cirrhosis?
Alcohol, Hep B, Hep C, Haemochromatosis, Autoimmune, Biliary Obstruction, NASH, Wilson’s Disease, alpha 1 antitrypsin deficiency
Complications of cirrhosis?
liver failure, portal hypertension, hepatocellular carcinoma
Liver failure definition?
red. synthesis of albumin, clotting factors
failure to eliminate hormones, nitrogenous wastes
Liver failure consequences?
systemic oedema bruising and bleeding ascites encephalopathy renal failure
Why does encephalopathy occur in liver failure?
Failure to eliminate nitrogenous wastes
Failure of the liver to eliminate steroid hormones results in?
Secondary hyperaldosteronism
Hyper-oestrogenism (spider naevi, gynaecomastia)
Commonest sites that mets to the liver?
Colon, pancreas, lung and breast
What is the commonest primary tumour of the liver?
Hepatocellular Carcinoma
What does hepatocellular carcinoma secrete in the blood?
Alpha fetoprotein
Alpha fetoprotein in the blood indicates?
Hepatocellular Carcinoma
Where is hepatocellular carcinoma really common?
Africa and China
Where does a cholangiocarcinoma arise?
Within the liver or within the extrahepatic bile ducts
Transmission of Hepatitis A?
close personal contact
contaminated food/water
blood exposure (rare)
What is acute infection of Hep A diagnosed by?
Detection of HAV-IgM in serum by EIA
What is past infection/immunity of Hep A detected by?
Detection of HAV-IgG in serum by EIA
Which viral hepatitis can you not have without another?
Can’t have Hep D without B
Which hepatitis does not become chronic?
Hepatitis A
Which viral hepatitis have no vaccine?
Hep C
Hep E
Which hepatitis are largely transmissed by blood to blood contact or sexual transmission?
Hep B + Hep D
Hep C
What are the 6 ‘F’s of ascites?
flatus, fluid, faeces, foetus, fat, filthy big tumour
Types of peritonitis?
Primary (spontaneous bacterial)
Secondary
Symptoms of spontaneous bacterial peritonitis?
ascites, fever, abdominal pain, altered mental state
Diagnosis of spontaneous bacterial peritonitis?
positive ascitic bacterial fluid culture
leukocyte count >250 in ascitic fluid
What causes secondary peritonitis?
spillage of organisms from GI or GU tracts into the peritoneal cavity
trauma, appendix perforation, perforated ulcer, carcinoma, diverticulitis, ulcerative colitis, cholecystitis, infection
Secondary Peritonitis Symptoms?
initially symptoms of primary cause abdo pain (moderate aggrevated by movement, then severe) vomiting fever unable to pass flatus
Causative organisms of secondary peritonitis?
E coli, enterococci, clostridium, Bacteroides Antibiotic resistant (especially in healthcare setting)
Risk factors for liver abscesses?
DM, underlying hepatobiliary or pancreatic disease, liver transplant
Liver abscess presentation?
Fever (90%)
Abdominal symptoms (50-75%)
nausea, vomiting, anorexia, malaise, weight loss
Liver abscess microbiology?
Streptococcus, E coli, Staph aureus, Candida (immunocompromised), Klebsiella (Asia), Amebiasis (especially in pts with travel history)
What causes amebiasis?
Entamoeba Histolytica
Treatment of amebiasis?
Metronidazole
Complications of acute pancreatitis?
Pancreatic necrosis
Pseudocyst formation
Extra-pancreatic infection (20%)
How much of cholecystitis is acalculous?
Approx. 10%
Usually in critically ill patients
Associated with high mortality and morbidity
Diagnosis of cholecystitis?
Murphy’s Sign
Ultrasound
MRCP
CT
Complications of cholecystitis?
Gallbladder gangrene (20%) Fistula Gallstone ileus Emphysematous Cholecystitis Recurrence Sepsis
What is emphysematous cholecystitis?
Infection and inflammation of the gallbladder wall with air-creating pathogens (e.g., E coli, clostridium)
surgical emergency
What is acute/ascending cholangitis?
clinical syndrome characterised by Charcot’s triad that develops as a result of stasis or infection in the biliary tract
Causative organisms of cholangitis?
E coli
Klebsiella
Enterobacter
Diagnosis of cholangitis?
fever/chills lab evidence of inflammatory response jaundice abnormal LFTs biliary dilation on imaging
Clinical features of diverticulitis?
abdominal pain in LLQ nausea and vomiting tender mass change in bowel habit urinary symptoms peritoneal guarding, rigidity, rebound tenderness
Diverticulitis Complications?
Abscess
Obstruction
Fistula
Perforation
Diagnosis of diverticulitis?
CT scan with contrast
