Hepatobiliary Flashcards
What antibodies are present in primary sclerosing cholangitis? How do you diagnose PSC?
pANCA 60-80%
Often present in churg-Strauss, inflammatory bowel disease (UC)
Dx- MRCP or liver biopsy.
What are the features of primary biliary cirrhosis?
Intrahepatic bile ducts are destroyed. It eventually leads to cirrhosis.
Middle aged women, itchy, chlolestatic jaundice, raised igM, have AMA, have raised ALP.
What antibodies are present in primary biliary cirrhosis?
98% have anti mitochondrial antibodies, just in the biliary system
What does SAAG stand for and what does it mean?
Serum ascites albumin gradient (normal <11g/L) serum - ascites.
If greater than 11 then indicates a transudate eg that there is portal hypertension.
What are the causes of Portal hypertension?
Pre hepatic : portal vein thrombosis (eg pancreatitis)
Hepatic: cirrhosis, schisto, sarcoidosis,
Post hepatic: budd-chiari syndrome, right heart failure, constrictive pericarditis, TR
What are the features of budd-chiari syndrome?
Aka hepatic vein thrombosis
Abdominal pain, ascites, and tender hepatomegaly, jaundice,
What are the features of gallstone illeus?
Bowel obstruction - pain, distension and vomiting
Which LFTs are raised in an obstructive jaundice picture?
Bilirubin, ALP, and GGT levels raised
Transaminases are relatively normal.
What are the signs and symptoms of cholangiocarcinoma?
A rare bile duct tumour,
Jaundice, weight loss, anorexia, biliary colic, itching, steatorhoea (pale stools) fever, and lymphadenopathy.
Ix - obstructive LFTS, Ca-19-9
Rx - poor prognosis, palliative stenting using ERCP
What are the features of amoebic liver abscess?
Mild RUQ pain, malaise, anorexia, weight loss.
What enzyme causes contraction of the gall bladder after a fatty meal?
Cholecystokinin
Difference between ERCP and MRCP?
Endoscopic is an invasive procedure, for diagnosis and therapeutic use.
CI - in dye allergies, and clotting disorders and hx of MI
MRCP - used in diagnosis, is non-invasive
CI - in pt with hx of stents or pacemakers
What is biliary colic and what is the treatment?
Impacted stone in neck of gallbladder or common bile duct. Pain in RUQ worse with fatty food.
Ix - bloods, imaging (AXR, Erect CXR, US, ?MRCP)
Mx- conservative redydrate, abx, opiates,
And or surgery - lap cholecystectomy
What is Mirizzi syndrome?
Rare, large stone in GB presses on the common hepatic duct and causes obstructive jaundice.
Can cause acute cholecystitis
What is acute cholecystitis? And how is it different to chronic?
RUQ pain (radiating to the scapula or epigastrum), fever and vomiting Murphys sign (press GB, pain and worse when breathing it catchs)
Ix - ultrasound
Mx - conservative - fluids, analgesia, abx (cef and met) most settle.. if not consider surgery within 48hours!
? Empyema - drainage or cholecystostomy.
Chronic - flatulent dyspepsia, vague symptoms,
Imaging - porcelain GB. US - fibrosis and shrunken GB.
Rx - elective cholecystectomy
Presentation of gallbladder abscess?
Prodromal illness, RUQ pain, swinging fever, systemically unwell,
Image with uss and ct.
Rx - cholecystectomy or percutaneous drainage
What is a gallstone ileus?
Inflammation/blockage of the GB, causes it to become oedematous and adhere to the small bowel (duodenum) becomes a fistula.
Gallstone can then enter the bowel (at the terminal illeum or ilio-cecal valve)
May require removal by enterotomy
What’s riglers triad?
For dx of gall stone ileus
1) pneumobillia (air in bile ducts)
2) small bowel obstruction
3) gallstone outside the gallbladder
What is cholangitis and how is it managed?
Happens when there is a blockage of the bile duct flow, bacteria from gut can ascend and cause infection of bile ducts and GB. Inflammatory allows bile and infection to enter the blood stream giving features:
Charcots triad : RUQ pain, fever and jaundice
And Reynolds Pentad: charcots plus sepsis/shock and confusion
Symptoms - hydration and abx (cef and met)
1) ERCP
2) open or lap stone removal with tube drain
WhAt is acalculous cholecystitis?
GB inflsmmation without stone or blockage.
Have fever. Due to other inter current illness
Rx - if able for surgery cholecystectomy, if unfit percutaneous cholecystostomy
What are the risks of ERCP?
Pancreatitis
Bleeding
Duodenal perf
Cholangitis
Why is lactulose used in hepatic encephalopathy?
To reduce the ammonia production in the gut
For treatment of hyperammonemia.
Rifaximin and neomycin also reduce ammonia
How does viral hepatitis present?
Nausea, vomiting, anorexia, myalgia, lethargy, RUQ pain.
Icteric phase- acute jaundice, hepatitis (abdominal pain, hapatomegaly, cholestasis)
Chrhic- cirrhosis
What’s the most common viral hep?
A
Spread by faecal oral route.
Causes vague symptoms and a distaste for cigarettes. Jaundice occurs 1-2weeks later.
Self limiting illness over in 3-6weeks.
Ix - raised alt, and bilirubin, raised ESR,
Dx - IgM anti-HAV in serum (acute), IgG anti-HAV (chronic)
How long can it take for HCV to be detected in the blood?
Up to 8weeks.
Look for HCV RNA in serum. Then perform a liver biopsy to check the degree of cirrhosis or fibrosis, or imaging can be used(us, MRI, ct, they are not as good in the early stages).
What is the treatment for chronic hep c?
Subcut Pegylated interferon alpha weekly and oral daily ribavirin…for 24 or 48 weeks depending on genotype
What is fulminant hepatic failure?
Hepatic failure with encephalopathy acutely developing within 2 weeks of having a normal liver.
Most common causes in U.K. Are viral hepatitis and paracetamol OD
Need management in a specialist
Over unit and many need liver transplant.
What is autoimmune hepatitis?
Insidious onset of liver problems, anorexia, malaise, then chronic liver diseas signs eg spider Nevi, hepatomegaly and jaundice.
Other autoimmune diseases might be present.
Dx - autoantibodies, hypergammaglobulinaemia (IGG) high bilirubin and AST and ALT.
Rx - Pred 30mg 2-3 weeks and azathioprine.
What is non alcoholic fatty liver disease?
Hepatic steatohepatitis associated with metabolic syndromes eg obesity, T2DM. The cause is not known, but thought to be due to insulin resistance and oxidative injury leading to fatty liver and inflammation.
Ix - many asymptomatic, hepatomegaly and mild elevation of aminotransferases.
Rx - no treatment, try to reduced risk factors, transplant for end stage.
Which marker suggests a person has hepatocellular carcinoma?
A-fetoprotein (AFP)
What’s the most common cause of portal hypertension ?
Cirrhosis
Why does ascites form in cirrhosis?
Nitric oxide causes vasodilation in the peripheries, and a reduction in blood volume. RAAS and Sympathetic NS respond by promoting renal salt and water retention, therefore HTN. Low albumin and portal hypertension leads to an accumulation of fluid in the peritoneal cavity.
What do high or low SAAG values represent?
Low <11 is suggestive of exudate (more concentrated)
High >11 suggestive of concentrated serum and dilute ascites and therefore a transudate.
What diagnostic tests are performed on ascites fluid?
Albumin, neutrophils,gram stain, cytology (for malignancy), amylase
Management of ascites caused by portal hypertension?
1) restrict dietary sodium,
2) oral spironolactone 100mg daily
3) +- furosemide
Aim to lose 0.5kg body weight each day.
Need to monitor body wt, sodium, creatinine and potassium.
4) paracentesis - need IV albumin infusion so circulAting volume not depleted,
5) Transjugular intrahepatic portosystemic shunt (TIPS)
What happens in portosystemic encephalopathy?
Occurs in people with advanced hepacellular disease and can be precipitated by dietary protein, infection, drugs and surgical procedures.
Ammonia and toxic substances go to the brain. Causing drowsiness, increased tone and reflexes, irritability, apraxia, and asterexis.
Management: reduce ammonia lactulose, and abx.
What’s hepatorenal syndrome?
Acute kidney injury caused by liver disease. Liver disease gives rise to peripheral vasodilation (nitric oxide), vasoconstriction at the kidney reduced renal flow and perfusion.
Sx: oliguria, raised creatinine, low urinary sodium.
Rx- requires liver function to improve. ?use of terlipressin and albumin infusion.
What’s hepatopulmomary syndrome?
Intrapulmonary vascular dilation leads to hypoxaemia.
Dx - echocardiogram
Treatment of Primary biliary cirrhosis?
Lifelong ursodeoxycholic acid (slows progression)
Colestyramine (for purities)
Fat soluble vitamin deficencies treated by supplementation.
Liver transplant indicated if serum bilirubin persistently >100
(Symptomatic may die within 5 years)
What’s the treatment for primary sclerosing cholangitis?
ERCP - dilation.
High dose ursodeoxycholic acid (slows disease)
Cholangiocarcinoma in 15%.
What are the differential diagnosis in budd-chairi?
Right sided heart failure,
Inferior vena cava obstruction
Or constrictive pericarditis
What’s the intial investigation of choice for budd-chiari syndrome?
Doppler US
CT or MRI if US is normal and suspicion is high.
RFs for BCS are malignancy, COCP, and thrombophillia.
Difference in treatment for a pyogenic abscess vs amoebic liver abscess?
Amoebic - metronidazole
Pyogenic - percutaneous aspiration, and pigtail catheter for continuos drainage, abx with cef and met (IV)
When is a cholecystectomy needed in acute cholecystitis?
Within 48 hours
Especially if there is empyema or perforation.
Treatment for hepatorenal syndrome?
Albumin and terlipressin
TIPS
What is included in the child Pugh score of liver disease?
Bilirubin Albumin Prothrombin time Encephalopathy Ascites
Each scored out of 3.
Common causes of hepatomegaly
Cirrhosis - non-tender firm liver
Malignacy - hard and irregular edge
Righ heart failure - firm smooth tender edge
Which groups should be screened for hepatocellular cancer?
Pts with liver cirrhosis 2’ to Hep B or C or haemochromatosis
Males with liver cirrhosis 2’ to alcohol
What prophylactic if any should be given for spontaneous bacterial peritonitis in patients with ascites?
Ascites and protein saag <15 should be given oral ciprofloxacin or norfloxacin.
If they get SBP, treat with IV cefotaxime.
What’s the onset of bud chiari syndrome?
Acute, and sudden
Hepatomegaly and pain and ascites
What’s next test in jaundice pt if LFTs show cholestatic picture and USS shows bile duct dilation?
ERCP - removed blockage
What’s next test in jaundice pt if LFTs show cholestatic picture and USS shows no bile duct dilation?
Ct abdo
What’s the treatment for autoimmune hep?
Steroids and azathioprine
Why do you do a liver biopsy in haemochromatosis?
You can do a pearl stain that quantifies iron loading
Drugs which cause cholestasis?
Flucloxacillin, coamoxiclav, nitrofurantoin, steriods, sulphonylureas
