Hepatobiliary Flashcards
What is the most common organism for ascending cholangitis?
E Coli
Klebsiella is the next most common
What is ascending cholangitis and how does it present?
A bacterial infection of the biliary tree.
Presents with charcots triad of RUQ pain, fever and jaundice. It cam also cause fever and hypotension
What are the constituent parts of bile?
Phospholipids
Bile salts
Water
Conjugated bilirubin
What are the three types of gallstones?
Cholesterol
Bile pigment
Mixed
How is bile reabsorbed?
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
If you don’t have bile what will you not be able to absord?
fats and fat soluable vitamins (A, D, E and K)
What are the risk factors for developing cholesterol gall stones?
High cholesterol
Pregnancy
Contraceptive pill
What are the risk factors for developing bile pigment stones?
Haemolytic anameia (spherocytosis and sickle cell disease)
What type of gallstones makes up the majority?
Mixed cholesterol and bile pigment
In a gallstone ileus, where does the gallstone tend to impact?
The distal ileum as this is the narrowest part of the bowel
What is the normal level of serum bilirubin?
Less than 17
. Becomes clinically detectable at over 35 and this is qhen it starts to produce jaundice
Briefly describe bile metabolism
- Red cells reach the end of their lifespain (120 days) and are destroyed in the reculoendothelial system.
- the porphyrin ring of the haemaglobin molecule is disruupted and a bilirubin - iron complex is formed.
- The iron is released and the bilirubin comnplex reaches the liver as a lipid soluable water insoluable substance
- In the liver bile is conjugated and extreted in bile as a water soluable substance
- 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.
- a small amount is reabsorped into the portal venous system and into the liver where it is recylced and excreted again.
- Some bile does reach the systemic circulation and is extreted in urine.
Describe pre hepatic jaundice
Too much red cell break down exceeds the capacity of the liver to conjugate bilirubin resulting in an increase in unconjugated bilirubin.
Describe hepatic jaundice
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.
Describe post hepatic jaundice
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.
What causes pre heaptic jandice?
Increased production of bilirubin due to too much red cell destruction.
haemolysis (spherocytosis, blood transfusion mismatch)
What causes hepatic jaundice?
Hepatitis
Cirrhosis
Liver poisons (paracetamol)
Liver tumours
What causes post hepatic/obstructive jaundice?
- Obstruction within the lumen
- Gallstones - Pathology in the wall
- Congenital biliary atresia
- Traumatic stricture
- Primary or secondary sclerosing cholangitis
- Cholangiocarcinoma - External compression
- pancreatitis
- Tumour of the head of the pancreas
- Tumour of the ampulla of vater
- Hilar lymphadenoathy
Describe the bilirubin, ALT/AST and Alk Phos levels in pre hepatic, hepatic and post hepatic jaundice
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
What is the first line investigation for someone with jaundice (after bloods) ?
Ultrasound of the liver and biliary tree
What is a liver haemangioma?
- Benign tumour of mesenchymal origin
- Hyperechoic on US
- Reddish and hypervascular
What is a liver cell adenoma?
Solitary, sharply demarcated lesions of mixed echoity. 90% of women in their 30 - 50s will have one and they are linked to OCP use.
What antibodies are associated with autoimmune hepatitis?
Anti nuclear
Anti smooth muscle antibodies
What is autoimmune hepatitis?
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
