Hepatobiliary Flashcards
Alcoholic hepatitis histology and presentation
Histology
- Steatosis
- Mallory bodies
- Swollen hepatocytes
Presentation
- Rapid onset jaundice
- Symptoms of liver disease
Alcoholic hepatitis investigations and management
Investigations
- NILS - Bilirubin / PT ^
- AST : ALT ^
- Gamma-GT ^
- MCV ^
Management - Stop drinking!
- Prednisolone
- Chlordiazepoxide
Cirrhosis aetiology
Alcohol
Viral hepatitis
NAFLD
Wilson's Hereditary haemochromatosis A1AT deficiency PBC / PSC Budd-Chiari syndrome
Compensated cirrhosis presentation
Clubbing
Palmar erythema
Dupuytren’s
Excoriations
Spider naevi
Bruising
Gynaecomastia
Xanthelasma
Hepatosplenomegaly
Decompensated cirrhosis presentation
Ascites Asterixis Encephalopathy Caput medusa Fetor hepaticus
Cirrhosis investigations
FBC - Thrombocytopenia
U&E - Hyponatraemia
LFTs - Bilirubin + Albumin
Clotting
Wilson’s screen - Ceruloplasmin
HH screen - Transferrin
A1AT
PBC / PSC - ANA / ASM
Viral hepatitis serology
EBV / CMV screen
USS
Cirrhosis histology and management
Necrosis
Fibrosis
Nodules
Management - Treat cause
- Flu vaccine
- HCC screen
- Endoscopy - Check for varices
- Transplant - Must be 6 months sober
Cirrhosis complications
HCC - USS and aFP screen every 6 months
Hepatopulmonary syndrome
Hepatorenal syndrome
Portal HTN - Varices - Prevent with BB
Ascites ± SBP
Coagulopathy
Encephalopathy
Osteoporosis
Portal HTN pathophysiology
Arterial blood supply to liver
- Portal vein 75%
- Hepatic artery 25%
Cirrhosis / blockage of portal vein
Blood backs up into left gastric vein
Oesophageal varices - Lower 1/3 oesophageal veins
Development of collateral veins
Portal HTN aetiology and presentation
Pre-hepatic - SOL / Thrombus
Hepatic - Cirrhosis
Post-hepatic - Budd-Chiari
Presentation
- Asymptomatic
- GI bleed
- Anaemia
Variceal haemorrhage management
Prophylaxis - BB!
EVL - Endoscopic variceal band ligation ABCDE Major haemorrhage protocol 2 large-bore IV cannulae Crossmatch Terlipressin Abx - Cipro
OGD
- Banding / Sclerotherapy
- Minnesota tube
- Rebleed - TIPS procedure
Hepatic encephalopathy pathophysiology
Gut bacteria normally breakdown nitrogen containing compounds
Ammonia released - Goes into urea cycle in hepatocytes
Cirrhosis disrupts urea cycle - Increased ammonia
Ammonia causes astrocytes to convert glutamate to glutamine
= Encephalopathy
Hepatic encephalopathy presentation and grading
Confusion Slurred speech Drowsiness Apraxia - Can't draw 5-point star Liver flap Fetor hepaticus
- Irritability
- Confusion and inappropriate behaviour
- Incoherent and restless
- Comatose
Hepatic encephalopathy investigations and management
Find cause
EEG - Triphasic slow waves
Management
- Lactulose - Reduce gut nitrogen
- Neomycin
PBC aetiology and presentation
AI fibrosis of biliary tract
Females Sjogren's RA Systemic sclerosis Thyroid disease
Presentation - Itching female aged 40-50
PBC investigations / management / complications
AMA
SMA
IgM
Management
- Itch - Cholestyramine
- Ursodeoxycholic acid
- Fat soluble vitamins - ADEK
Complications
- Cirrhosis - HCC
- Osteoporosis
PSC
Extra-hepatic bile duct destruction
Males
UC / Crohn’s
Presentation
- Jaundice
- RUQ pain
Investigations
- pANCA +ve
- ALP ^
- Bilirubin ^
- Biopsy - Onion skin fibrosis
- MRCP - Beaded appearance
Complications
- Cholangiocarcinoma
- Colon cancer
Gallstones
Aetiology - FFFF
- Fat
- Female
- Forty
- Fertile
- Diabetes
- OCP
Presentation - Post-prandial RUQ pain
Investigations
- LFTs
- CRP
- USS
Management - Cholecystectomy
Acute cholecystitis
Gallstones blocking cystic duct
RUQ pain Fever Murphy's sign +ve Systemically unwell N/V ± Rigors
Management - Cholecystectomy < 48 hours
Ascending cholangitis
Bacteria ascends biliary tree
Creates a blockage
Charcot’s triad
- Fever
- Jaundice
- RUQ pain
Management
- ERCP
- Abx - Taz
Biliary colic
Presence of stones in gallbladder
RUQ pain
Imaging - ERCP
Cholecystectomy
Pancreatitis aetiology
GET SMASHED
Gallstones Ethanol Trauma Scorpion bites Mumps AI Steroids HYPERcalcaemia / HYPERlipidaemia / HYPOthermia ERCP Drugs - Gliptin / GLT-1
Pancreatitis presentation
Epigastric pain - Worse lying down - Radiates to back
Signs of sepsis/shock - Fever
Cullen’s sign - Peri-umbilical bruising
Grey-Turner sign - Flank bruising
N/V
Pancreatitis investigations
Lipase / Amylase
AXR
Erect CXR
Bloods
- Glucose ^
- FBC
- LFTs - AST ^
- U&E
- Blood cultures
- VBG/ABG
- CRP > 200 = Necrotising
- MRCP - Check for gallstones
Pancreatitis severity scale and management
GLASGOW criteria - Indicates severe pancreatitis
GLA5COW Glucose - High LDH - High AST - High > 55 Calcium - Low Oxygen - Low White cells - High
Management - SUPPORTIVE
- NBM
- Fluids
- Analgesia
- IV abx?
- IV PPI?
Pancreatitis complications
Hypocalcaemia
Hyperglycaemia
Metabolic acidosis
Shock
Perforation / Peritonitis
Haemorrhage
Abscess
Pseudocyst
Necrotising pancreatitis
ARDS
Renal failure
Chronic pancreatitis aetiology and presentation
Alcohol
Cystic fibrosis
Duct obstruction - Tumour
Presentation
- Stool changes - Pale steatorrhoea
- Epigastric pain - Relieved sitting forwards - Worse on eating
- Weight loss
- DM
- Jaundice
Chronic pancreatitis investigations and management
AXR - Calcification
CT
Faecal elastase
Management
- Stop drinking alcohol
- Replace enzymes
- Analgesia
Wilson’s disease
AR - Ch13
Copper accumulation
Presentation
- Eyes - Kayser Fleisher rings
- BG - Movement disorder
- Renal - Renal tubular acidosis
- Liver - Jaundice
Investigations - NILS
- Ceruloplasmin - LOW
- MRI basal ganglia
- Urinary copper ^
- Serum copper - LOW
- Genetic testing
Management
- Penicillamine
- Zinc
- Transplant
Haemochromatosis
Aetiology - AR6 - HFE gene
Iron accumulation
Presentation
- Joints - Arthralgia
- Pancreas - DM
- Liver - Cirrhosis and hepatomegaly
- Skin - Hyperpigmentation
- ED - Common
- Cardio - Cardiomyopathy
Investigations - NILS + Biopsy with pearl stain
- Ferritin ^
- Iron ^
- TIBC - LOW
- Transferrin saturations ^^^
Ascites
Transudate vs Exudate
Serum albumin -(MINUS)- Albumin level of ascitic fluid
Transudate - SAAG > 11
- Portal HTN
- Budd-Chiari
- Cardiac failure
- Meigs syndrome
Exudate - SAAG < 11
- Peritoneal carcinoma
- Peritoneal TB
- Pancreatitis
- Nephrotic syndrome
Ascites presentation
Fullness and distension
Shifting dullness
Pleural effusion
Dyspnoea
Ascites investigations
NILS
USS
CXR
ECG / ECHO
Ascitic tap
- Albumin
- LDH
- Cytology
- Microscopy
- Gram stain
- Amylase - Pancreatic
Ascites management and complications
Management - Treat underlying cause
- Dietary salt restriction
- Spironolactone
- Furosemide
- Paracentesis
- TIPS
Complications
- SBP
- Respiratory distress - Dyspnoea
SBP
Aetiology - Ascites - E.Coli
Presentation
- Peritonitis
- Ascites
- Fever
Investigations
- Blood cultures
- Paracentesis
Management
- IV cef
- Prophylaxis - Ciprofloxacin
Budd Chiari
- Occlusion of hepatic vein
- Hypoxic liver damage
- Necrosis
Aetiology - Hypercoagulable state
- Malignancy
- OCP
- Thrombophilia
Clinical features - Rapid onset ascites!
- Portal HTN
- Jaundice
- RUQ pain
- Right-sided HF
Investigations - USS doppler
Management - Treat underlying cause
- Thrombolysis - Warfarin
- Surgical intervention - Stenting
Hepatitis risk factors
Endemic regions MSM IVDU High-risk sexual behaviours Family history Incarceration Blood transfusion - Pre 1992 Tattoos
Hepatitis A
RNA picornovirus
Benign and self-limiting
Incubation - 2-4 weeks
Transmission - F/O (BOWELS ARE VOWELS)
Clinical features
- Flu-like prodrome
- Abdo pain - RUQ
- Tender hepatomegaly
- Jaundice
- Cholestatic LFTs - ALT ^ and ALP ^^^
Management - Supportive + IgG
Hepatitis B
Double-stranded hepadnavirus
Transmission - H/V
Incubation 6-20 weeks
Clinical features
- Fever
- Jaundice
- Hepatomegaly
- Ascites
- Malaise
- RUQ pain
- Elevated liver transaminases
Hep B serology
HBsAg
Anti-HBs
Anti-HBc IgM
Anti-HBc IgG
HbeAG
HBsAg
- Acute disease
- Present > 6 months = Chronic disease (Infective)
Anti-HBs - Implies immunity (Exposure or immunisation)
Anti-HBc - IgM - Acute or recent infection
Anti-HBc - IgG - Persists after infection
HBeAG - Marker of infectivity
Hep B management
Pregnancy
- All pregnant women offered Hep B screening
- Babies born to infected mothers given complete vaccination course + Hep B Ig
- Not transmitted via breastfeeding
Acute - Supportive ± Entecavir / Tenofovir
Chronic
- Entecavir / Tenofovir
- Pegylated interferon-A
- Assess for transplant
Hep C clinical features
RNA flavivirus
Transmission - H/V
- Needle-stick 2%
- Mother to child 6%
- Breastfeeding not CI
- Sexual intercourse - 5%
Incubation - 6-9 weeks
Symptoms - 30%
- Jaundice
- Ascites
- B-symptoms
- Elevated liver transaminases
Hep C management and prognosis
Aim to achieve sustained virological response
Undetectable serum HCV RNA six months after the end of therapy
Protease inhibitors
- Glecaprivir
- Sofosbuvir
Prognosis
- 15-45% clear the virus after acute infection
- 55-85% develop chronic Hep C
Hep C complications
Rheumatological problems - Arthralgia and arthritis Eye problems - Sjogren's syndrome Cirrhosis - 5-20% HCC Cryoglobulinaemia Membranoproliferative glomerulonephritis
HCC aetiology and presentation
Cirrhosis Hep B/C Alcoholism DM Obesity Family Hx
Abdo distension Variceal bleeding RUQ pain Weight loss / LOA Oedema Jaundice Hepatosplenomegaly Spider naevi
HCC investigations / management / prognosis
FBC - Microcytic anaemia + Thrombocytopenia
U&E - Na + Urea ^
LFTs ^
Clotting - PT ^
Hepatitis screen
AFP ^^
Liver USS
CT/MRI - Avoid biopsy
Management - Surgery ± Chemo/Radio
Prognosis - Poor - 5 year survival is 15%
Cholangiocarcinoma aetiology and presentation
Adenocarcinoma
Age > 50 Bile duct disease UC Cirrhosis ALD Hep B/C HIV Typhoid
Painless jaundice Weight loss RUQ pain Hepatomegaly Dark urine Pale stools Pruritus
Cholangiocarcinoma investigations / management / prognosis
LFTs ^
Clotting profile - PT ^
Abdo USS
CT / MRI / MRCP
Tumour markers
- Ca199
- Ca125
- CEA
Management - Surgery ± Chemo/Radio
Prognosis - Poor - 5 year survival is 5-10%
A1AT deficiency aetiology and clinical features
AR - Ch14
Lack of protease inhibitor
- Normally produced by the liver
- Protects cells from enzymes such as neutrophil elastase
- Causes COPD / emphysema in young non-smokers
Lungs - Paracinar emphysema - Lower lobes
- Productive cough
- SOBOE
Liver
- Adults - Cirrhosis and HCC
- Children - Cholestasis
A1AT deficiency investigations and management
A1AT concentrations
Spirometry - Obstructive
Management
- Smoking cessation
- Hep A/B vaccine
- COPD treatment - Bronchodilators
- Chest PT
- IV A1AT protein concentrates
- Surgery - Lung transplant
Liver abscess aetiology and clinical features
Localised infection in liver parenchyma
Purulent collections
Adults - E.Coli
Children - Staph
Risk factors
- Biliary tract disease
- Age > 50
- Underlying malignancy
- DM
- Interventional biliary or hepatic procedures
- Endemic areas for amoebiasis
Fever and chills
RUQ tenderness
Hepatomegaly
Liver abscess investigations and management
FBC - WCC ^
LFTs ^ + HYPOalbuminaemia
Blood cultures
Liver USS - Variably echoic lesion
CT with contrast - Hypodense liver lesions
Aspirate and culture
Broad spec abx - Amox + Cipro + Met
Needle aspiration / drainage
Antifungals - Fluconazole
Amoebic abscess - Nitromidazole
Pancreatic cancer aetiology
Adenocarcinoma
Head of pancreas
Risk factors
- Smoking
- Family Hx
- Chronic pancreatitis
- HNPCC
- MEN
- BRCA2
- KRAS mutation
Pancreatic cancer clinical features
Painless jaundice Pale stools / Dark urine Pruritus Epigastric pain or discomfort - Radiates to the back Weight loss / LOA
Courvoisier’s Law
Painless obstructive jaundice
+ Palpable gallbladder
is NOT gallstones
Pancreatic cancer investigations and management
Abdo USS
Pancreatic protocol CT
Double-duct sign - Simultaneous dilatation of CBD and pancreatic ducts
LFTs ^^^ (Cholestatic picture)
Management
- Whipple - Pancreaticoduodenectomy
- Replacement enzymes - Pancreatin
- Radio/Chemo
- ERCP stenting - Palliative
