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Hepatobiliary Flashcards

1
Q

What are the two types of gallstones?

A

Cholesterol

Bile pigment

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2
Q

What are risk factors for gallstones?

A 
Increasing age
Female
FHx
DM
Multiparity
Obesity
Rapid weight loss
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3
Q

How do gallstones present?

A

Biliary colic
N + V
Acute + chronic cholecysitis

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4
Q

Describe biliary colic

A

Colicky abdominal pain which is worse after eating and after fatty foods. Pain may radiate to the right shoulder.

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5
Q

How do you investigate gallstones?

A

Bloods: serum bilirubin, alkaline phosphatase, aminotransferase
Abdo USS

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6
Q

How do you manage gallstones?

A

Cholecystectomy
IV fluids + Abx
Opiate analgesia

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7
Q

What are some complications of gallstones?

A 
Liver congestion
Oesophageal reflux
Malabsorption in SI
Acute + chronic pancreatitis
Digestion issues
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8
Q

What is acute cholecystitis?

A

Follows impaction of a store in the cystic duct or neck of gallbladder. Obstruction to gallbladder emptying causes increased gallbladder glandular secretion = progressive distension. Compromised blood supply to gallbladder and inflammatory response to bile retained in gallbladder = infection.

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9
Q

Clinical features of acute cholecystitis?

A

RUQ pain
Fever
Murphy’s sign
Tenderness + guarding

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10
Q

How do you manage acute cholecystitis?

A

USS

Cholescystectomy within 48hrs

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11
Q

Complications of acute cholecystitis?

A

Empyema + perforation = peritonitits

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12
Q

What is chronic cholecystitis?

A 
Chronic inflammation of the gallbladder often found in association with gallstones.
- usually asymptomatic
- chronic EUQ pain
- fatty food intolerance
USS: small, shrunken gallbladder
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13
Q

What is choledocholithiasis?

A

Bile duct stones

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14
Q

What is ascending cholangitis?

A

Infection of the biliary tree and most often occurs secondary to common bile duct obstruction by gallstones.

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15
Q

How does ascending cholangitis present?

A

Charcot’s triad:

  • fever
  • jaundice
  • RUQ pain
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16
Q

How do you diagnose ascending cholangitis?

A

Bloods:
- raised neutrophil count, ESR, CRP, serum bilirubin, serum alkaline phosphatase, ALTs and ASTs

Imaging:

  • Abdo US (dilatation of common bile duct)
  • MRI
  • CT scan
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17
Q

How do you treat acute cholangitis?

A

IV Abx: cefotaxime + metronidazole

Urgent biliary draining with ERCP + sphinctectomy

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18
Q

What is ERCP?

A

Endoscopic retrograde cholangio-pancreatography

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19
Q

What are some risk factors for Hep A?

A

Shellfish, travellers, food handlers

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20
Q

Which hepatitis has a high mortality in pregnancy?

A

Hep E

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21
Q

Which hepatitis can lead to HCC?

A

Hep B

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22
Q

What is fulminant hepatitis?

A

Hepatic failure with encephalopathy. Develops in less than 2 weeks in a pt with a previous normal liver.

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23
Q

Most common causes of fulminant hepatitis?

A

Viral hepatitis

Paracetamol overdose

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24
Q

What is autoimmune hepatitis?

A 
Immune cells attack hepatocytes.
Associated with:
- HLA
- Hashimoto's thyroiditis
- Grave's disease
Treated: corticosteroids + azathioprine
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25
What is cirrhosis?
End-stage of all progressive chronic liver disease, once fully developed it is irreversible.
26
What is a main risk factor for cirrhosis?
Chronic alcohol abuse
27
What is seen on histology in cirrhosis?
Loss of normal hepatic architecture with riding fibrosis + nodular regeneration.
28
How does cirrhosis present?
- leuconychia - clubbing - palma erythema - spider naevi - bruising - xanthalasma - hepatomegaly - loss of body hair - ankle swelling + oedema - dupuytren's contracture
29
How is cirrhosis diagnosed?
``` Child-Pugh classification Liver biopsy LFTs Biochemistry US, MRI, Endoscopy ```
30
What is the child-pugh classification?
Ascites, encephalopathy, increased bilirubin, decreased albumin, long PTT. Scored 1-3 <7 is good >10 is bad Risk of vatical bleeding is high if >8
31
Complications of cirrhosis?
Coagulopathy Encephalopathy Hypoalbuminaemia Portal hypertension
32
How is cirrhosis treated?
``` Alcohol abstinence Good nutrition Avoid NSAIDs Reduce salt intake USS every 6months Liver transplant ```
33
How do drugs impair liver function?
- disruption of intracellular calcium homeostasis - disruption of bile canalicular transport mechanisms - induction of apoptosis - inhibition of mitochondrial function
34
Which drugs impair liver function?
- Abx (augmente, flucloxacillin, TB drugs, erythromycin) - CNS drugs (chlorpromazine, carbamazepine) - Immunosupressants - Analgesia (diclofenac) - GI drugs (PPIs)
35
What drugs don't cause liver injury?
``` Low dose aspirin NSAIDs BB Ace-i Thiazides CCB ```
36
What is a fatal dose of paracetamol?
12g/adult
37
What happens in paracetamol overdose?
Liver glutathione is depleted so NAPQI can't be conjugated and deactivated = hepatoxicity and para-induced kidney injury.
38
Clinical picture of paracetamol overdose?
``` First 24hrs asymptomatic - RUQ pain Jaundice AKI Metabolic acidosis Hypoglycamia Encephalopathy Rash ```
39
How do you treat paracetamol overdose?
IV N-acetylcysteine Activated charcoal Chlorphenamine
40
How do you treat aspirin poisoning?
IV sodium bicarbonate | Haemodialysis
41
What is ascites?
Accumulation and effusion of free serous fluid within the peritoneal cavity.
42
What are the causes and RF for ascites?
Causes: local inflammation, low protein, low flow RF: high sodium diet, hepatocellular carcinoma, portal hypertension
43
How does ascites present?
``` Distended abdomen Peripheral oedema Fullness in flanks + shifting dullness Jaundice Mild abdo pain + discomfort Nausea, constipation, cachexia, weight loss ```
44
How is ascites diagnosed?
Demonstrate shifting dullness | Diagnostic aspiration of fluid with ascitic tap
45
What are the types of protein measurement?
Transduate = protein <30g/L - PHTN, constrictive pericarditis, heart failure, Budd-Chiari syndrome Exudate = protein >30g/L - malignant, peritonitis, pancreatitis, nephrotic syndrome,
46
How do you treat ascites?
Paracentesis (drain fluid) Shunts (TIPS) Decrease sodium retention/increase excretion Diuretic (oral spirolactone)
47
What is a pre-hepatic cause of portal HTN?
Portal vein thrombosis
48
What are some intra-hepatic causes of portal HTN?
cirrhosis, fibrosis, schistosomiasis, sarcoidosis
49
What are some post-hepatic causes of portal HTN?
RH failure, constrictive pericarditis, IVC obstruction
50
What are common sites for varices?
``` Gastro-oesophageal junction Rectum Left renal vein Retroperitoneum Diaphragm ```
51
How does portal HTN present?
``` Often asymptomatic Splenomegaly GI bleeding Ascites Hepatic encephalopathy Vatical haemorrhage ```
52
How is portal HTN managed?
Measure portal HTN Treat with TIPS Propanolol Salt restriction + diuretics
53
What is TIPS?
Transjugular intrahepatic portosystemic shunt
54
What is primary biliary cirrhosis?
Chronic disorder with progressive destruction of small bile ducts leading to cirrhosis.
55
How does primary biliary cirrhosis present?
``` PRURITIS Dry eyes Joint pain Vatical bleeding Lethargy + fatigue Jaundice Asymptomatic ```
56
How do you diagnose primary biliary cirrhosis?
Raised anti-mitochondrial antibodies USS Liver biopsy
57
How is primary biliary cirrhosis treated?
Ursodeoxycholic acid ADEK vitamins Bisphosphonates To treat pruritus: - colestyramine, naloxone, naltrexone
58
What are the 3 clinical syndromes of alcohol liver disease?
1. fatty change 2. alcoholic hepatitis 3. alcoholic cirrhosis
59
How does alcoholic liver disease present?
``` Rapid onset jaundice RUQ pain Ascites Nausea Anorexia Hepatic encephalopathy Fever Tender hepatomegaly ```
60
What investigations are done for alcoholic liver disease?
``` FBC - raised WCC, MCV but low platelets Low sodium Raised AST + ALT, bilirubin and GGT Low serum albumin Raised PPT USS liver + biliary ```
61
How do you manage alcoholic liver disease?
``` STOP DRINKING Fluids, painkillers, vitamins Adequate nutritional intake Corticosteroids Pentoxifylline ```
62
What is hereditary haemochromatosis?
Autosomal recessive gene. Inherited disorder of iron metabolism where there is increased intestinal iron absorption so iron is deposited in joints liver, heart, pancreas etc. It leads to fibrosis and functional organ failure.
63
What causes hereditary haemochromatosis?
- HFE gene mutation on chromosome 6 - high intake of iron and chelating agents - alcoholics may have iron overload
64
How does hereditary haemochromatosis present?
TRIAD: 1. bronze skin pigmentation 2. hepatomegaly 3. diabetes mellitus Hypogonadism Cirrhosis Joint pain Dilated cardiomyopathy
65
How is hereditary haemochromatosis diagnosed?
- raised iron + ferritin - HFE gene - MRI (iron overload) - liver biopsy - ECH/ECHO
66
How is hereditary haemochromatosis treated?
``` Venesection Chelation therapy - desferrioxamine Low iron diet Screening 1st degree relatives Treat any other complications (e.g. diabetes) ```
67
What is Wilson's disease?
Rare inherited disorder of biliary copper excretion with too much copper in the liver and CNS. - autosomal recessive disorder of gene on Chr 13 - molecular defect within a copper-transporting ATPase
68
How does Wilson's disease present?
Children have hepatic problems - hepatitis, cirrhosis, fulminant liver failure Young adults have CNS problems - tremor, dysarthria, dysphagia, dyskinesia, dementia KAYSER-FLEISCHER RING
69
What is a Kayser-fleischer ring?
Seen in Wilson's disease | Copper deposition in corner = greenish-brown pigment at the corneoscleral junction.
70
How is Wilson's disease diagnose?
24hr urinary copper excretions = high Liver biopsy Low serum copper, low caerulopasmin MRI: basal ganglia + cerebellar degeneration
71
How is Wilson's disease treated?
- Penicillamine (lifelong chelating agent) - Avoid foods high in copper - Liver transplant if severe - Screen siblings
72
SE of penicillamine?
Skin rash Low WCC, Hb + platelets Haematuria Renal damage
73
What foods are high in copper?
Liver, chocolate, nuts, mushrooms, shellfish
74
What is alpha-1-antitrypsin deficiency?
Inherited autosomal recessive conformational disease | - alpha-1-antitrypsin gene is located on Chr 14
75
What is the role of alpha-1-antitrypsin gene?
To inhibit proteolytic enzyme: neutrophil elastase | SO deficiency causes protein retention in liver (cirrhosis + HCC) and emphysema in lung.
76
How dos alpha-1-antitrypsin deficiency present?
Children: Cirrhosis, hepatitis + cholestatic jaundice Adults: dyspnoea, emphysema
77
How is alpha-1-antitrypsin deficiency diagnosed?
Decreased serum alpha-1-antitrypsin levels Most symptomatic patients are homozygotes with a PiZZ phenotype
78
How is alpha-1-antitrypsin deficiency treated?
No specific treatment Treat complications Stop smoking
79
What are clinical features of liver failure?
``` Hepatic encephalopathy Abnormal bleeding Ascites Jaundice Cerebral oedema ```
80
What is hepatic encephalopathy?
NH3 builds up in circulation (due to liver failure) which goes to brain and causes brain damage as it is neurotoxic. It stops the Kreb's cycle so causes irreparable cell damage and neural cell death. Symptoms: - confusion, coma, liver flap, drowsiness, cerebral oedema, irritability, constructional apraxia, asterixis
81
What are the main causes of liver failure?
``` Virus: Hep ABE, CMV, EBV, HSV HCC Drugs Acute fatty liver of pregnancy Wilsons A1ATD ```
82
What investigations are done for liver failure?
Bloods - hyperbilirubinaemia - raised ALT + AST - low coagulation factor, high PTT - low glucose, high NH3 Imaging - EEG, US, CXR, Doppler US Microbiology
83
How is liver failure treated?
``` Treat cause IV mannitol for raised ICP IV Vit K IV glucose PPI Liver transplant ```
84
What is primary sclerosis cholangitis?
A biliary disease characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts. Leads to strictures +/- gallstones.
85
What is primary sclerosis cholangitis assoc with?
Ulcerative colitis Crohn's HIV
86
How does primary sclerosis cholangitis present?
Prutitis + jaundice RUQ pain Fatigue Rigors
87
How is primary sclerosis cholangitis investigated?
ERCP ANCA MRCP Liver biopsy
88
Complications of primary sclerosis cholangitis?
Cholangiocarcnioma | Increased risk of colorectal cancer
89
How is primary sclerosis cholangitis managed?
Cholestyramine (for pruritis) | Monitor for HCC
90
What is seen on EEG in hepatic encephalopathy?
Triphasic slow waves
91
What is the grading used for hepatic encephalopathy?
I - irritable II - confused, inappropriate behaviour III - incoherent, restless IV - coma
92
How is hepatic encephalopathy managed?
Lactulose Rifaximin Neomycin
93
What is spontaneous bacterial peritonitis?
A form of peritonitis usually sen in patients with ascites secondary to liver cirrhosis?
94
What are the clinical features of spontaneous bacterial peritonitis?
``` Vague Sx Fever Change in mental state Abdo tenderness GI bleeding N + V Chills ```
95
How is spontaneous bacterial peritonitis diagnosed?
Paracentesis of ascitic fluid | - neutrophil count >250 cells/ul
96
How is spontaneous bacterial peritonitis treated?
IV cefotaxime Abx prophylaxis after 1 ep Consider liver transplant
97
What is non-alcoholic fatty liver disease?
A spectrum of disease: | Steatosis > Non-alcoholic steatohepatitis > progressive disease (fibrosis, cirrhosis)
98
What are RF for NAFLD?
``` Obesity Hyperlipidaemia T2DM Jejunoileal bypass Sudden weight loss/starvation ```
99
Investigations for NAFLD? Mx for NAFLD?
Enhanced liver fibrosis blood test (ELF) Fibroscan Weight loss
100
What is Budd-Chiari syndrome?
Hepatic vein thrombosis Occlusion of the hepatic vein obstructs venous outflow from the liver = stasis and congestion within the liver which leads to hypoxic damage and necrosis of hepatocytes.
101
What can cause Budd-Chiari syndrome?
``` Polycythaemia rubra vera Thrombophilia OCP Pregnancy Myeloproliferative disorders Irradiation ```
102
Clinical features of Budd-Chiari syndrome?
- RUQ pain (sudden onset + severe) - ascites - tender hepatomegaly - jaundice
103
Investigations for Budd-Chiari syndrome?
Doppler USS - abnormal flow in hepatic veins - thickening, tortuosity + dilatation of hepatic vein walls Abnormal LFTs
104
Management for Budd-Chiari syndrome?
TIPS to restore hepatic venous drainage | Anticoagulation + thrombolysis
105
What is cholangiocarcinoma?
Cancer of biliary tree (in or out of liver) - slow growing - mostly distal extra hepatic or perihilar - 90% ductal adenocarcinoma, 10% SCC
106
RF for cholangiocarcinoma?
- infestation with parasitic worms - biliary cysts - IBD - HBV, HCV, DM - primary sclerosis cholangitis
107
Clinical features of cholangiocarcinoma?
Fever Abdo pain +/- ascites Malaise
108
How is cholangiocarcinoma diagnoes?
High bilirubin + high alkaline phosphate Contrast MRI ERCP
109
Treatment for cholangiocarcinoma?
Complete surgical resection Stent Transplant is CI
110
What is hepatocellular carcinoma?
Cancer of the hepatocytes
111
RF for HCC?
- male - HBV/HCV carriers - cirrhosis (alcohol, NAFLD, haemochromatosis)
112
Where can HCC metastasise to?
Lymph nodes Bones Lungs
113
Clinical features of HCC?
Weight loss, fever, anorexia, fatigue Jaundice, ascites Ache in R hypochondrium Enlarged, irregular, tender liver
114
How is HCC diagnosed?
Raised serum AFP (alpha-fetoprotein) USS Enhanced CT Liver biopsy
115
How is HCC treated?
Surgery resection of isolated lesion Transplant HBV vaccination for prophylaxis
116
Describe pancreatic cancer?
Mostly adenocarcinomas of ductal origin | Mainly at head of pancreas
117
RF for pancreatic cancer?
``` Increasing age Smoking Diabetes Chronic pancreatitis HNPCC Multiple endocrine neoplasia BRCA2 gene ```
118
Clinical features of pancreatic cancer?
``` PAINLESS JAUNDICE Anorexia, weight loss epigastric pain Steatorrhoea Diabetes Atypical back pain Migratory thrombophlebitis (Trousseau sign of malignancy) ```
119
Typical features of cancer of head of pancreas?
Painless jaundice due to obstruction of CBD | Weight loss
120
Typical features of cancer of body/tail of pancreas?
Abdo pain, weight loss + anorexia
121
Investigations for pancreatic cancer?
Courvoisseier's law Central abdo mass USS HRCT
122
What is courvoisserier's law?
Painless jaundice with palpable gallbladder = NOT gallstones
123
What is seen on HRCT for pancreatic cancer?
Dilated bile ducts Mass/lesion Staging
124
How is pancreatic cancer treated?
Whipple's resection (pancreaticoduodenectomy) Adjuvant chemo ERCP if palliative v poor prognosis (12months)
125
What are the different neuroendocrine tumours of the pancreases?
Gastrinoma Somatostatinoma VIPoma Glucagonoma
126
What are the different liver abscesses?
Pyogenic Amoebic Hyatid
127
Causative agents of pyogenic abscesses?
``` Staph aurea (children) E coli (adults) ```
128
What can cause pyogenic abscesses?
``` Biliary sepsis Infection of tumour or cyst Direct extension (E.g. from empyema of gallbladder) Trauma Haematogenous ```
129
How are pyogenic abscesses managed?
Amoxicillin + ciprofloxacin + metronidazole | USS guided drainage if large
130
What is the causative agent of an amoebic abscess?
Entamoeba histoytica
131
What can cause an amoebic abscess?
Hx of living/visiting endemic area | Large, single asbecc
132
How is an amoebic abscess diagnosed?
Aspiration: anchovy sauce (chocolate-brown material) | Serology
133
How is amoebic abscess treated?
Metronidazole | Aspirate if large
134
What is the causative agent of a hyatid cyst?
Echinococcus granulosis | tapeworm
135
How is a hyatid cyst diagnosed?
serology ELISA
136
How is hyatid cyst managed?
Albendazole Percutaneous Aspiration Injection of a solicidal agent Reaspiration
137
Clinical features of a liver abscess?
``` Fever Weight loss Lethargy RUQ pain +/- pleuritic or R shoulder pain Tender hepatomegaly Obstructive jaundice ```

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