Hepatobiliary

Question 1

What is the most common organism for ascending cholangitis?

Answer 1

E Coli

Klebsiella is the next most common

Question 2

What is ascending cholangitis and how does it present?

Answer 2

A bacterial infection of the biliary tree.

Presents with charcots triad of RUQ pain, fever and jaundice. It cam also cause fever and hypotension

Question 3

What are the constituent parts of bile?

Answer 3

Phospholipids
Bile salts
Water
Conjugated bilirubin

Question 4

What are the three types of gallstones?

Answer 4

Cholesterol
Bile pigment
Mixed

Question 5

How is bile reabsorbed?

Answer 5

Reabsorped by the distal small bowel once they have helped to emulsify fats. theya re then taken back to the liver and recycled back into bile

Question 6

If you don’t have bile what will you not be able to absord?

Answer 6

fats and fat soluable vitamins (A, D, E and K)

Question 7

What are the risk factors for developing cholesterol gall stones?

Answer 7

High cholesterol
Pregnancy
Contraceptive pill

Question 8

What are the risk factors for developing bile pigment stones?

Answer 8

Haemolytic anameia (spherocytosis and sickle cell disease)

Question 9

What type of gallstones makes up the majority?

Answer 9

Mixed cholesterol and bile pigment

Question 10

In a gallstone ileus, where does the gallstone tend to impact?

Answer 10

The distal ileum as this is the narrowest part of the bowel

Question 11

What is the normal level of serum bilirubin?

Answer 11

Less than 17

. Becomes clinically detectable at over 35 and this is qhen it starts to produce jaundice

Question 12

Briefly describe bile metabolism

Answer 12

1. Red cells reach the end of their lifespain (120 days) and are destroyed in the reculoendothelial system.
2. the porphyrin ring of the haemaglobin molecule is disruupted and a bilirubin - iron complex is formed.
3. The iron is released and the bilirubin comnplex reaches the liver as a lipid soluable water insoluable substance
4. In the liver bile is conjugated and extreted in bile as a water soluable substance
5. In the bowel bilirubin is rediced by bacteria into colourless urobilinogen. Most of this is excrted in faeces where is is broken down again into a pigmented substance.
6. a small amount is reabsorped into the portal venous system and into the liver where it is recylced and excreted again.
7. Some bile does reach the systemic circulation and is extreted in urine.

Question 13

Describe pre hepatic jaundice

Answer 13

Too much red cell break down exceeds the capacity of the liver to conjugate bilirubin resulting in an increase in unconjugated bilirubin.

Question 14

Describe hepatic jaundice

Answer 14

Hepatocellular damage reducedthe abilit of the liver to conjugate bilirubin efficiently and less is excretedint he canaliculi. Both conjugated and unconjugated build up in the blood.

Question 15

Describe post hepatic jaundice

Answer 15

Obstruction of the intra hepatic or extrahepatic ducts prevents the excretion of conjugated bilirubin. Tjis causes the stools to become pale and the urine to become dark.

Question 16

What causes pre heaptic jandice?

Answer 16

Increased production of bilirubin due to too much red cell destruction.
haemolysis (spherocytosis, blood transfusion mismatch)

Question 17

What causes hepatic jaundice?

Answer 17

Hepatitis
Cirrhosis
Liver poisons (paracetamol)
Liver tumours

Question 18

What causes post hepatic/obstructive jaundice?

Answer 18

1. Obstruction within the lumen
   - Gallstones
2. Pathology in the wall
   - Congenital biliary atresia
   - Traumatic stricture
   - Primary or secondary sclerosing cholangitis
   - Cholangiocarcinoma
3. External compression
   - pancreatitis
   - Tumour of the head of the pancreas
   - Tumour of the ampulla of vater
   - Hilar lymphadenoathy

Question 19

Describe the bilirubin, ALT/AST and Alk Phos levels in pre hepatic, hepatic and post hepatic jaundice

Answer 19

1. Pre hepatic 
Biliruin: Normal/high 
ALT/AST: Normal
Alk Phos: Normal 
2. Hepatic 
Bilirubin: High 
ALT/AST: Elevated 
ALK Phos: high
3. Post hepatic
Bilirubin: High - Very high 
ALT/AST: Quite high 
Alk Phos: High/very high

Question 20

What is the first line investigation for someone with jaundice (after bloods) ?

Answer 20

Ultrasound of the liver and biliary tree

Question 21

What is a liver haemangioma?

Answer 21

• Benign tumour of mesenchymal origin
• Hyperechoic on US
• Reddish and hypervascular

Question 22

What is a liver cell adenoma?

Answer 22

Solitary, sharply demarcated lesions of mixed echoity. 90% of women in their 30 - 50s will have one and they are linked to OCP use.

Question 23

What antibodies are associated with autoimmune hepatitis?

Answer 23

Anti nuclear

Anti smooth muscle antibodies

Question 24

What is autoimmune hepatitis?

Answer 24

Presents with hepatitis, jaundice, amenorrhoeas.
ANA/Anti smooth muscle antibodies and raised IgG levels
Liver biopsy shows inflammation extending beyond limiting plate.
Managed with steroids and azathioprine and liver transplant