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Hepatobiliary Flashcards

1
Q

What is the pathophysiology of Acute Cholecystitis?

A

90% of Acute Cholecystitis cases are caused by Gallstones which becomes lodged at the Neck of the Gallbladder or the Cystic Duct- this results in the inflammation of the gallbladder as Cholestasis occurs

This leads to bacterial growth- which usually involves Gram Negative Rods or Anaerobes. This is called Calculous Cholecystitis.

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2
Q

What are the 2 types of Gallstones and what makes up the majority of them?

A

Cholesterol Stones (yellow) make up the majority of gallstones and the rest are Pigmented Stones (black or brown) composed of Calcium Salts

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3
Q

What is the pathophysiology of Acalculous Acute Cholecystitis?

A

This is seen in 5-10% of cases and seen in Hospitalised or severely unwell patients

Gallbladder stasis occurs due to (3) Hypovolaemia, Trauma or a Systemic Illness

In Immunocompromised Patients, Cryptosporidium or Cytomegalovirus infections are the common pathogens that underlie Acalculous Acute Cholecystitis

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4
Q

What are the 5 risk factors for Gallstones?

A

5Fs and Crohn’s

  • Fat
  • Female
  • Forty
  • Fair
  • Fertile
  • Crohn’s
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5
Q

What are the 3 risk factors for Acute Cholecystitis?

A

Risk factors for Gallstones (5Fs and Crohn’s)

Diabetes

Risk factors for Acalculous Acute Cholecystitis (Trauma, Systemic Illness, Dehydration)

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6
Q

What are the 7 signs of Acute Cholecystitis?

A

RUQ Abdominal Tenderness (a Positive Murphy’s Sign- where palpating the RUQ while the patient breathes in causes pain)

A Referred Right Shoulder Tip Pain

An Absence of Jaundice

Fever

Abdominal mass due to a Distended Gallbladder (although this may not be present)

a history of Biliary Colic

An RUQ pain which is severe and long-lasting (>30 minutes)

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7
Q

If Jaundice is present With Typical Symptoms of Acute Cholecystitis, what 3 Conditions should be Considered as a Diagnosis?

A

Mirizzi Syndrome

Common Bile Duct Stone

Ascending Cholangitis

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8
Q

What 7 investigations should be ordered is Acute Cholecystitis is suspected?

A

First Line- Transabdominal Ultrasound (4)

  • Positive Murphy’s Sign (pain on RUQ palpation and inspiration)
  • Thickened Gallbladder Wall (3mm or more)
  • Distended Gallbladder with the presence of Gallstones
  • Pericholecystic Fluid

CT Scan- if Ultrasound is inconclusive

MRCP- if the Ultrasound shows a Dilated CBD with No Gallstones

FBC- Leukocytosis with Neutrophilia

LFTs NOT deranged- if they are deranged then (3)

  • Mirizzi Syndrome
  • CBD Stone
  • Cholangitis

U&Es may be deranged with AKI, secondary to Infection

ABG- assesses for the degree of Lactic Acidosis

High CRP

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9
Q

What is the management for Acute Cholecystitis? (3,1)

A

First Line (3)-

  • IV Fluids and Analgesia
  • IV Antibiotics (Broad Spectrum Antibiotics with Gram Negative and Anaerobic Cover)- (2)
    1) Cefuroxime
    2) Metronidazole
  • Early Laparoscopic Cholecystectomy (2)
    1) Perform within 1 week of diagnosis
    2) Associated with Lower Complications, Shorter Hospital Stay, Improved Quality of Life and Better Patient Satisfaction

Second Line- Urgent Cholecystostomy if Early Cholecystectomy is inappropriate due to (3)

  • Sepsis
  • Gangrene
  • Perforation
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10
Q

What is the pathophysiology of Acute Pancreatitis?

A

The Pancreatic Secretion System is obstructed and there is also a Premature Activation of Pancreatic Proenzymes (Zymogens)- like the activation of Trypsinogen to Trypsin

The release of these pancreatic enzymes into the circulation causes (2)

  • Autodigestion of blood vessels (Retroperitoneal Haemorrhage)
  • Autodigestion of fat (Fat Necrosis)
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11
Q

What are the Local (2) and Systemic (2) Complications of Acute Pancreatitis?

A

Local Complications- Chronic Pancreatitis and Pancreatic Pseudocysts

Systemic Complications- Acute Respiratory Distress Syndrome or Pleural Effusions

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12
Q

What are the causes of Acute Pancreatitis?

A

I GET SMASHED

Iatrogenic

Gallstones

Ethanol Abuse (alcohol)

Trauma (Blunt Abdominal Trauma)

Scorpions and Spider bites

Mumps Virus (Also Measles, Coxsackie B4 and Measles)

Autoimmune (SLE and Sjogren’s)

Steroids

Hypercalcaemia and Hyperlipidaemia

ERCP

Drugs (7)

  • Valproate
  • Gliptins
  • Azathioprine
  • Mesalazine
  • Oestrogen
  • Tetracyclines
  • Thiazide Diuretics
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13
Q

What are the 4 risk factors for Acute Pancreatitis?

A

Age

Type 2 Diabetes

Obesity

High Glycaemic Foods in non-gallstone related Pancreatitis

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14
Q

What are the 11 signs of Acute Pancreatitis?

A

Suspect in Acute Upper or Generalised Abdominal Pain- Particularly if they have a History of Gallstones or Alcohol Misuse

Pain is continuous and boring

Severe Upper Abdominal pain which radiates to the back (May be LUQ or RUQ)

Nausea, Vomiting and Anorexia

Abdominal Tenderness and Guarding

Steatorrhoea

Abdominal Distension (mainly due to leakage of fluid into peritoneum)

Tachycardic and Hypotensive- so patient may be in Shock

Cullen’s Sign- Periumbilical Bleeding- secondary to Intraperitoneal Haemorrhage

Grey Turner’s Sign- Flank Bleeding- secondary to Intraperitoneal Haemorrhage

Fox’s Sign- Bleeding over Inguinal Ligament- secondary to Retroperitoneal Haemorrhage

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15
Q

What 7 investigations should be ordered if Acute Pancreatitis is suspected?

A

Diagnose if 2 out of 3 of the following signs are present-

  • Clinical features are consistent with Acute Pancreatitis
  • Elevation of Serum Amylase or Serum Lipase (at least 3x the Upper limit)
  • Radiological Features- inflammation on CT

High Serum Amylase or Serum Lipase (3x the upper limit)

ALT>150= Gallstone-related Pancreatitis

Serum Calcium- to identify Hypocalcaemia

Chest Xray to identify Acute Respiratory Distress Syndrome or Pleural Effusion

Abdominal Xray to exclude Gallstones

Modified Glasgow Scoring (if 3 of these in first 2 days= High Dependency Case)

  • pO2<8kPa
  • Age > 55 years old
  • Neutrophils- WCC> 15x10^9/L
  • Calcium<2mmol/L
  • Renal function- Urea>16mmol/L
  • Enzymes- AST>200U/L or LDH>600U/L
  • Albumin<32g/L
  • Sugar- Blood Glucose>10mm/L
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16
Q

What is the first line (5) and specific (3) management for Acute Pancreatitis?

A

Antibiotics are not routinely recommended

First Line-

  • IV Fluid Resuscitation
  • Catheterisation- to monitor urine output to ensure they are hydrated
  • Oxygen Supplementation- if SpO2<94%, supplementary Oxygen is Required
  • Opiate Analgesia
  • Early Nutritional Support- Oral/ Enteral/ Parenteral Feeding

Specific Management-

  • ERCP if Gallstone-related Pancreatitis and Cholangitis
  • Cholecystectomy- performed at the same time as admission for Gallstone-related Pancreatitis
  • Alcohol Cessation and Withdrawal Management
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17
Q

What 5 antibodies are associated with Autoimmune Hepatitis?

A

Associated with Type 1 Autoimmune Hepatitis-

ASMA (Anti-Smooth Muscle Antibodies)
ANA (Antinuclear Antibodies)
Anti-SLA/LP (Anti-soluble Liver Antigen/ Liver-pancrease Antibody)

Associated with Type 2 Autoimmune Hepatitis-

Anti-LKM1 (Anti-liver Kidney Microsome Antibody)
Anti-LC1 (Anti-liver Cytosol 1)

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18
Q

What antigens are associated with Type 1 (2) and Type 2 (2) Autoimmune Hepatitis?

A

Type 1 Autoimmune Hepatitis-

DR3 and DR4

Type 2 Autoimmune Hepatitis-

DQB1 and DRB1

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19
Q

What 2 other autoimmune conditions is Autoimmune Hepatitis associated with?

A

Hashimoto’s Thyroiditis

Primary Biliary Cholangitis

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20
Q

What are the 13 signs of Autoimmune Hepatitis?

A

General Symptoms (5)

  • Fatigue
  • Arthralgia
  • Weight Loss
  • Nausea
  • Amenorrhoea

Evidence of Chronic Liver Disease (4)

  • Jaundice
  • Spider Telangiectasia
  • Gynaecomastia
  • Splenomegaly

Evidence of Acute Liver Failure (These are less common)

  • Jaundice
  • Ascites
  • Variceal Bleed
  • Encephalopathy
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21
Q

What 3 investigations should be ordered if Autoimmune Hepatitis is suspected?

A

Elevated ALT, Elevated AST, Normal or Mildly Elevated ALP, Bilirubin may also be Raised

Immunoglobulins- IgG is raised in 85% of patients

Check for Piecemeal Necrosis (4)

  • Inflammation of Hepatocytes at the Junction of the Portal Tract and Hepatic Parenchyma
  • Viral Screen- to exclude Hepatitis
  • Autoimmune Screen- ANA, Anti-SMA, AntiSLA/LP, Anti-LKM1, Anti-LC1
  • Hereditary Screen- Exclude metabolic causes (2)- Hereditary Haemochromatosis and Wilson’s Disease
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22
Q

What is the management of Autoimmune Hepatitis? (3,1)

A

First line-

  • Immunosuppression (Give Prednisolone and Azathioprine together)
  • Upon remission, patients can stop therapy and be on Long-term Azathioprine
  • Hepatitis A and B Vaccinations given for all patients

Second line-
- Transplantation

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23
Q

What are 3 complications of Autoimmune Hepatitis?

A

Cirrhosis

Osteoporosis due to steroids

Cushing’s Syndrome due to steroids

24
Q

What are the 4 risk factors for Biliary Colic?

A

Gallstones Risk factors (F,F,F,F,F, and Crohn’s)

Diabetes

Medication (4)

  • Oestrogen
  • Oral Contraceptive Pill
  • Hormone Replacement Therapy
  • Fibrates also increase the risk

Haemolytic Conditions
- Haemolysis (because of Sickle Cell Anaemia)- causes Excess Bilirubin which results in Pigment Gallstones

25
What are the 5 signs of Biliary Colic? What are 3 other conditions associated with Gallstones?
RUQ or Epigastric Abdominal Pain (5) - Pain is constant and Not Colicky - Typically lasts longer than 30 minutes - Pain is worse after eating Fatty Food - Pain radiates to the Right Shoulder or Interscapular Region - Murphy's Sign Negative Cholecystitis (3) - RUQ tenderness - Positive Murphy's Sign - Fever Ascending Cholangitis (Charcot's Triad (3)) - Jaundice - Fever - RUQ pain Common Bile Duct Stone - Features of Obstructive Jaundice (4) - Jaundice - Dark Urine - Pale Stools - Pruritus
26
What 5 investigations should be ordered if Biliary Colic is suspected?
Abdominal Ultrasound LFTs- Raised ALP and Bilirubin Raised CRP and Raised Neutrophilia would suggest Cholecystitis Amylase level- if suspecting Pancreatitis secondary to a gallstone disease MRCP- if No Common Bile Duct Stones are seen on Abdominal Ultrasound and the Common Bile Duct is Dilated OR Abnormal LFTs
27
What are the 4 management options for Biliary Colic?
If Mild-to-Moderate Pain- - Oral NSAID (Diclofenac) or Paracetamol (while waiting for Cholecystectomy) Severe Pain- - IM Diclofenac or IM Opioid (Morphine, Pethidine or Buprenorphine) if Diclofenac is ineffective Elective Laparoscopic Cholecystectomy- refer all people diagnosed with symptomatic gallstone disease Lifestyle changes- - Avoid Fatty Food - Increase Fibre Intake
28
What are the 7 facts about Bilirubin Physiology?
Unconjugated Bilirubin is a breakdown product of Haem (from Senescent Red Blood Cells) Unconjugated Bilirubin is NOT water-soluble- so needs to be Conjugated to be released UGT (UDP-Glucuronosyl Transferase) converts Unconjugated Bilirubin into Conjugated Bilirubin, making it water-soluble. Conjugation is the addition of Glucuronic Acid to Bilirubin Conjugated Bilirubin is secreted into the Bile Canalculi and stored in the gallbladder as a component of bile When it is released into the intestinal tract, Conjugated Bilirubin is broken down into Urobilinogen and Stercobilin by bacteria Stercobilin is excreted in Faeces- which gives it a Brown Colour Urobilinogen is reabsorbed and it is either directed back into making bile (through the Enteropathic Circulation) or excreted in Urine (giving it a Yellow Colour)
29
What is the pathophysiology of Cholangitis?
It is an infection of the biliary tree commonly caused by gallstones The obstruction causes Cholestasis and promotes the growth of bacteria (commonly E. Coli) which causes an ascending infection
30
What are the 3 other causes of Cholangitis (aside from Gallstones)?
Biliary Strictures Sclerosing Cholangitis Cholangiocarcinoma
31
What are the 6 signs of Cholangitis?
Charcot's Triad (3)- - RUQ Pain - Jaundice - Fever Scleral Icterus (because of Jaundice) Dark Urine and Pale Stools (Cholestasis) Pruritus (Itchy Skin) Hypotension Confusion
32
What 5 investigations should be ordered if Cholangitis is suspected?
``` Transabdominal Ultrasound (First Line) - CT scan if Ultrasound is negative ``` Leukocytosis with Neutrophilia Obstructive Jaundice (Raised ALP>AST and Raised Bilirubin) U&Es- pre-renal Kidney AKI in Sepsis Lactate and Acidosis in Suspected Sepsis
33
What is the 3 step management approach to Cholangitis?
IV Antibiotics with Gram Negative and Anaerobic Cover (Cefotaxime and Metronidazole) IV Fluids as the patients are often septic and require rehydration ERCP (First line after IV antibiotics and fluids)
34
What is the pathophysiology of Chronic Pancreatitis?
It is the irreversible Inflammation and/or Fibrosis of the Pancreas due to the inappropriate activation of Trypsinogen to Trypsin, which reacts with the Pancreatic Tissue
35
What are the 5 causes of Chronic Pancreatitis?
Alcohol- causes 80% of the cases Acute Pancreatitis Ductal Obstruction (Gallstones) Autoimmune Pancreatitis Cystic Fibrosis
36
What are the 3 risk factors for Chronic Pancreatitis?
Autoimmune Pancreatitis Smoking Cystic Fibrosis AND Haemachromatosis
37
What are the 4 signs of Chronic Pancreatitis?
Epigastric Pain (3) - Dull and radiates to the back - Improved by Leaning Forward - Occurs after Eating Steatorrhoea and Diarrhoea- Foul smelling stools which are hard to flush Signs of Liver Disease due to Alcohol Excess (2) - Jaundice - Ascites Signs of Diabetes in Late Disease (2) - Polyuria - Polydipsia
38
What 6 investigations should be ordered if Chronic Pancreatitis is suspected?
Transabdominal Ultrasound (first line)- Pancreas appears (3) - Atrophied - Calcified - Fibrotic CT if the Ultrasound is suggestive LFTs- Abnormal if there is a coexisting Liver Disease - AST>ALT suggests Alcoholic Liver Disease HbA1c- Islet cell destruction reduces the Endocrine Function (Pancreatic B cells can't produce Insulin) Faecal Elastase= Reduced in Severe Disease IgG4- Associated with Autoimmune Chronic Pancreatitis
39
What is the 5 step management for Chronic Pancreatitis (4, 3)?
Stop Alcohol and Smoking Diet- Low Fat, High Calorie with Vitamin ADEK Supplementation Analgesia- Paracetamol or NSAIDs Pancreatic Enzyme Replacement- CREON Second Line (3) - Endoscopic Stenting - Coeliac Plexus Nerve Blocks - Drainage of Pseudocysts
40
When should Necrotising Pancreatitis be suspected?
If the patient presents with Pancreatitis that doesn't respond to treatment- with (3) Epigastric Pain, Nausea and Fever
41
What investigation should be ordered of Necrotising Pancreatitis is suspected and what is the relevant management?
CT- it would show Non-enhancing Low Attenuating Pancreatic Tissue Management- Necrosectomy
42
What is the pathophysiology of Pancreatic Cancer?
An Adenocarcinoma which affects the Head of the Pancreas Develops from a Pre-Invasive Pancreatic Intraepithelial Neoplasia Most cases carry a faulty K-RAS Gene
43
What are the 5 risk factors for Pancreatic Cancer?
Age Smoking Diabetes BRCA1 and BRCA2 Mutations (as well as K-RAS) Multiple Endocrine Neoplasia
44
What are the 5 signs of Pancreatic Cancer?
Positive Courvoisier's Sign- - Painless Jaundice and Palpable Gallbladder - Unlikely to be Gallstones (3) Epigastric or Atypical Back Pain, Anorexia and Weight Loss New Onset Diabetes Dark Urine and Pale Stools due to Obstructive Jaundice Steatorrhoea- loss of Exocrine Function
45
What 4 investigations should be considered if Pancreatic Cancer is suspected?
Abdominal Ultrasound- First line - Shows a Double Duct sign due to both the Pancreatic Duct and the Common Bile Duct being dilated Proceed to CT if the Abdominal Ultrasound is suspicious LFTs- shows an Obstructive Picture- (3) - Raised ALP - Raised GGT - Raised Bilirubin Perform a Coagulation Profile to assess the synthetic function of the Liver to determine whether there is sign of Liver Metastasis
46
What is the management for a Localised (2) or Locally Advanced or Metastatic (2) Pancreatic Cancer?
Localised- - Whipple's Resection- Removal of Antrum of the Stomach, Proximal Duodenum, Head of the Pancreas, Common Bile Duct and Gallbladder - Adjuvant Chemotherapy after the Surgery Metastatic- - Palliative Management (2) - ERCP with Stenting for Symptomatic Relief - Chemotherapy and Chemoradiotherapy
47
Describe the presentation and management of Peripancreatic Fluid Collection in Acute Pancreatitis?
May be Asymptomatic but can have Abdominal Pain and Distension if it is a large collection It is an Early Presentation Management- Most resolve spontaneously
48
Describe the presentation and management of Pancreatic Pseudocyst in Acute Pancreatitis?
May be Asymptomatic but can have (5) - Abdominal Pain - Palpable Mass - Nausea - Indigestion - Small Weight Loss It is a Late Presentation Management- Conservative Management or Drainage
49
Describe the presentation and management of Pancreatic Abscess in Acute Pancreatitis?
It usually occurs due to infection of Pseudocysts by E. Coli It consists of (5) - Abdominal Pain - Fever - Anorexia - Nausea - Vomiting Management- - Antibiotics and Drainage
50
What is the pathophysiology of Primary Biliary Cholangitis? (3)
It is an Autoimmune Condition that involves the Granulomatous Destruction of the Intrahepatic Bile Ducts which leads to Cholestasis This leads to (3)- Progressive Fibrosis, Cirrhosis and Liver Failure
51
What kind of Antibodies are present in all patients with Primary Biliary Cholangitis?
Anti-Microbial Antibodies
52
What are the 5 possible Autoimmune Conditions that a patient with Primary Biliary Cholangitis may have?
Sjogren's Syndrome Raynaud's Phenomenon Autoimmune Thyroid Disease Rheumatoid Arthritis Systemic Sclerosis
53
What are the 4 risk factors for Primary Biliary Cholangitis?
Female Middle-Aged Smoking Autoimmune Condition
54
What are the 9 signs of Primary Biliary Cholangitis?
Pruritus Fatigue and Weight loss Skin Hyperpigmentation due to Increased Melanin Clubbing Mild Hepatosplenomegaly Dry Eyes and Mouth- a sign of Sjogren's Scleral Icterus- a Late Sign Xanthelasma and Xanthomata- a Late Sign Obstructive Jaundice- a Late Sign - Icteric - Pale Stools and Dark Urine
55
What are the 6 investigations to be ordered if Primary Biliary Cholangitis is suspected?
First Line- Transabdominal Ultrasound Antimicrobial Antibodies Antinuclear Antibodies- present in Half of all Patients Smooth Muscle Antibodies- in a Third of all Patients LFTs- Show an Obstructive Picture (2) - Raised ALP, GGT and Bilirubin - AST and ALT may be mildly deranged Elevated IgM
56
What is the 4 step management plan for Primary Biliary Cholangitis?
Ursodeoxycholic Acid- First Line in all patients - Combine it with Obeticholic Acid if it doesn't work on its own Vitamin ADEK Supplements Cholestyramine for symptomatic relief of Pruritus Second Line- Liver Transplantation (2) - if MELD Score is 15 or higher - or if Bilirubin is >85 micromol/L

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