Hepatobiliary Flashcards
1
Q
What is Hepatocellular Carcinoma?
A
- 6th most common cancer worldwide and third leading cause of cancer death.
- Arise as a result of chronic inflammatory process affecting the liver.
- Most commonly due to viral hepatitis but other common causes are chronic alcoholism, hereditary haemochromatosis, primary biliary cirrhosis and aflatoxin.
2
Q
What are risk factors for Hepatocellualar Carcinoma?
A
- Viral Hepatitis (most common) – Hep B and Hep C commonly
- High Alcohol intake
- Smoking
- Advanced age
- Aflatoxin Exposure
- Family history of liver disease
3
Q
What are clinical features of HCC?
A
- Symptoms of Liver Cirrhosis:
- Fatigue
- Fever
- Weight Loss
- Lethargy
- Dull ache in the right upper abdomen
- Advanced features show liver failure
- Worsening ascites
- Jaundice
- Examination shows Irregular, Enlarged and Tender Liver
4
Q
What are tests used to investigate HCC?
A
- Laboratory Test
- Liver function tests: ALP, ALT, AST, Bilirubin
- If AST:ALT ratio >2, likely alcoholic liver disease
- If AST:ALT around 1, likely viral hepatitis.
- Low platelets or prolonged clotting with liver failure
- Alpha fetoprotein levels
- Liver function tests: ALP, ALT, AST, Bilirubin
- Imaging
- Ultrasound is the initial imaging modality of choice.
- If the mass >2cm is found with a raised AFP which is virtually diagnostic. Staging CT scan or MRI for further evaluation.
- MRI scanning/contrast CT angiography may demonstrate a mass with arterial hypervascularisation; a characteristic feature of HCC.
- If still in doubt, biopsy or PCI aspiration may be performed to confirm.Difficult in active ascites and/or deranged clotting
5
Q
How is HCC surgically managed?
A
- Surgical Management
- Surgical resection is treatment of choice in patient without cirrhosis and with a good baseline health status. 5-year recurrence of HCC post-resection occurs in 50-60%
- Transplantation can be considered in patients that fulfil Milan Criteria:
- One lesion is smaller than 5cm or three lesions are smaller than 3cm
- There are no extrahepatic manifestations
- There is no vascular infiltration
6
Q
How can HCC be non surgically managed?
A
- Image-guided ablation: Indicated for patients with early HCC. Ultrasound probes are placed in the tumour mass to induce necrosis
- Alcohol ablation: injection of alcohol into the tumour acting to destroy the malignant tissue.
- Transarterial Chemoembolisation (TACE): High concentrations of chemotherapy drugs are radiologically injected directly into the hepatic artery and an embolising agent is then added to induce ischaemia.
7
Q
What is the management of secondary HCC?
A
- In most cases surgery more difficult and less useful option due to secondary site metastases. Oncological and Palliative services are often closely involved in the decision-making process
- Surgery indicated in patient with metastases confined to liver who have their primary tumour under control.
- Alternative are transarterial chemoembolization or selective internal radiotherapy
8
Q
Which cancers commonly metastasise to the liver?
A
Common cancer that metastasise to liver are
- Bowel Cancer
- Breast Cancer
- Pancreas Cancer
- Stomach Cancer
- Lung Cancer
9
Q
What are some causes of Liver abscesses?
A
- Cholecystitis
- Cholangitis
- Diverticulitis, Appendicitis
- Septicaemia
Common isolated organisms are E. Coli, Staph. Aureus, K. Pneumoniae, S. Constellatus, and Fungus
10
Q
What are clinical features of Liver Abscesses?
A
- Fever
- Rigors
- Abdominal Pain
- Bloating
- Nausea
- Anorexia
- Weight Loss
- Fatigue
- Jaundice
11
Q
What are examination findings for Liver Abscesses?
A
- RUQ tenderness +/- hepatomegaly.
- If abscess ruptures, patient presents with signs of shock
- Ruptured abscess shows pyrexia associated with Abdominal Pain or Bloating
12
Q
What are some tests for investigation of Liver Abscesses?
A
- Blood Tests: leucocytosis and abnormal with raised ALP in most cases. Deranged ALT and bilirubin in a proportion.
- Blood Cultures and Fluid Cultures
- Ultrasound: reveals poor-defied lesions with hypo- and hyper-echoic areas with potential gas bubbles and septation.
- CT Imaging with Contrast: Reveals a similar pattern from the collection as seen on US with associated surrounding oedema
13
Q
What is the management of Liver Abscesses?
A
- Fluid resuscitation and stabilisation.
- Start on appropriate antibiotic therapy
- Amoxicillin + Ciprofloxacin + Metranidazole
- If penicillin allergic: Ciprofloxacin + Clindamycin
- Most cases need draining via image-guided aspiration of the abscess either US or CT, for source control. Underlying cause should also be addressed
- Surgery rarely indicated unless abscess as ruptured or refractory to antibiotic treatment
amoxicillin + ciprofloxacin + metronidazole
if penicillin allergic: ciprofloxacin + clindamycin
14
Q
What causes polycystic liver disease?
A
Characterised by presence of >20 cysts within the liver parenchyma each of which are >1cm in size. Caused by:
- Autosomal Dominant Polycystic Kidney Disease which is caused by mutations in PDK1 and PKD2
- Autosomal Dominant Polycystic Liver Disease (ADPLD) which is caused by mutations in PRKCSH (chromosome 19) or SEC63 (chromosome 6) genes
15
Q
What are clinical features of patient who present with Polycystic Liver Disease?
A
- Abdominal pain as cysts grow
- Hepatomegaly on examination
Can end in liver cirrhosis and portal hypertension
16
Q
What are tests used to investigation of Polycystic Liver Disease?
A
- Normal LFTs
- Renal function can be affected.
- Diagnosis can be via Ultrasound Imaging demonstrating multiple cysts.
17
Q
What are indications for surgery in Polycystic Liver Disease?
A
- Intractable symptoms
- Inability to rule out malignancy on imaging alone
- Prevention malignancy
18
Q
How is Polycystic Liver Disease managed?
A
- Asymptomatic cystic disease:
- Monitored but many patients will require some form of intervention due to its progressive nature.
- Somatostatin analogues in symptomatic relief
- Symptomatic Disease
- Laparoscopic de-roofing of cysts is preferred technique
- Resection if particular liver segment are grossly affected
- Transplantation may be warranted in extreme cases
- US-guided aspiration may provide temporary relief in patients experiencing pain due to cyst size although this is not routinely performed due to recurrence
19
Q
How is Bile Produced and Stored?
A
- Bile is formed from cholesterol phospholipids and bile pigments. Stored in the gallbladder.
- 3 main types of gallstones as a result of supersaturation of the bile:
- Cholesterol stones: composed purely of cholesterol from excess cholesterol production. Poor diet linked
- Pigment Stones: composed purely of bile pigments from excess bile pigments production. Commonly seen in those with known haemolytic anaemia
- Mixed Stones: comprised of both cholesterol and bile pigments
20
Q
What are risk factors for Biliary Colic and Cholecystitis?
A
5 F’s:
- Fat
- Female
- Fertility
- Forty
- Family History
- Others are pregnancy, oral contraceptives, haemolytic anaemia and malabsorption
- Oestrogen causes more cholesterol to be secreted into bile
