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3B > Hepatobiliary > Flashcards

Hepatobiliary Flashcards

1
Q

Alcoholic hepatitis histology and presentation

A

Histology

  • Steatosis
  • Mallory bodies
  • Swollen hepatocytes

Presentation

  • Rapid onset jaundice
  • Symptoms of liver disease
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2
Q

Alcoholic hepatitis investigations and management

A

Investigations

  • NILS - Bilirubin / PT ^
  • AST : ALT ^
  • Gamma-GT ^
  • MCV ^

Management - Stop drinking!

  • Prednisolone
  • Chlordiazepoxide
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3
Q

Cirrhosis aetiology

A

Alcohol
Viral hepatitis
NAFLD

Wilson's
Hereditary haemochromatosis
A1AT deficiency
PBC / PSC
Budd-Chiari syndrome
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4
Q

Compensated cirrhosis presentation

A

Clubbing
Palmar erythema
Dupuytren’s

Excoriations
Spider naevi
Bruising

Gynaecomastia
Xanthelasma
Hepatosplenomegaly

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5
Q

Decompensated cirrhosis presentation

A 
Ascites
Asterixis
Encephalopathy
Caput medusa
Fetor hepaticus
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6
Q

Cirrhosis investigations

A

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

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7
Q

Cirrhosis histology and management

A

Necrosis
Fibrosis
Nodules

Management - Treat cause

  • Flu vaccine
  • HCC screen
  • Endoscopy - Check for varices
  • Transplant - Must be 6 months sober
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8
Q

Cirrhosis complications

A

HCC - USS and aFP screen every 6 months
Hepatopulmonary syndrome
Hepatorenal syndrome

Portal HTN - Varices - Prevent with BB
Ascites ± SBP

Coagulopathy
Encephalopathy

Osteoporosis

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9
Q

Portal HTN pathophysiology

A

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

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10
Q

Portal HTN aetiology and presentation

A

Pre-hepatic - SOL / Thrombus
Hepatic - Cirrhosis
Post-hepatic - Budd-Chiari

Presentation

  • Asymptomatic
  • GI bleed
  • Anaemia
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11
Q

Variceal haemorrhage management

A

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
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12
Q

Hepatic encephalopathy pathophysiology

A

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

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13
Q

Hepatic encephalopathy presentation and grading

A 
Confusion
Slurred speech
Drowsiness
Apraxia - Can't draw 5-point star
Liver flap
Fetor hepaticus
  1. Irritability
  2. Confusion and inappropriate behaviour
  3. Incoherent and restless
  4. Comatose
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14
Q

Hepatic encephalopathy investigations and management

A

Find cause
EEG - Triphasic slow waves

Management

  • Lactulose - Reduce gut nitrogen
  • Neomycin
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15
Q

PBC aetiology and presentation

A

AI fibrosis of biliary tract

Females
Sjogren's
RA
Systemic sclerosis
Thyroid disease

Presentation - Itching female aged 40-50

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16
Q

PBC investigations / management / complications

A

AMA
SMA
IgM

Management

  • Itch - Cholestyramine
  • Ursodeoxycholic acid
  • Fat soluble vitamins - ADEK

Complications

  • Cirrhosis - HCC
  • Osteoporosis
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17
Q

PSC

A

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
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18
Q

Gallstones

A

Aetiology - FFFF

  • Fat
  • Female
  • Forty
  • Fertile
  • Diabetes
  • OCP

Presentation - Post-prandial RUQ pain

Investigations

  • LFTs
  • CRP
  • USS

Management - Cholecystectomy

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19
Q

Acute cholecystitis

A

Gallstones blocking cystic duct

RUQ pain
Fever
Murphy's sign +ve
Systemically unwell
N/V ± Rigors

Management - Cholecystectomy < 48 hours

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20
Q

Ascending cholangitis

A

Bacteria ascends biliary tree
Creates a blockage

Charcot’s triad

  1. Fever
  2. Jaundice
  3. RUQ pain

Management

  • ERCP
  • Abx - Taz
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21
Q

Biliary colic

A

Presence of stones in gallbladder
RUQ pain

Imaging - ERCP
Cholecystectomy

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22
Q

Pancreatitis aetiology

A

GET SMASHED

Gallstones
Ethanol
Trauma
Scorpion bites
Mumps
AI
Steroids
HYPERcalcaemia / HYPERlipidaemia / HYPOthermia
ERCP
Drugs - Gliptin / GLT-1
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23
Q

Pancreatitis presentation

A

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

24
Q

Pancreatitis investigations

A

Lipase / Amylase
AXR
Erect CXR

Bloods

  • Glucose ^
  • FBC
  • LFTs - AST ^
  • U&E
  • Blood cultures
  • VBG/ABG
  • CRP > 200 = Necrotising
  • MRCP - Check for gallstones
25
Q

Pancreatitis severity scale and management

A

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?
26
Q

Pancreatitis complications

A

Hypocalcaemia
Hyperglycaemia
Metabolic acidosis

Shock
Perforation / Peritonitis
Haemorrhage

Abscess
Pseudocyst
Necrotising pancreatitis

ARDS
Renal failure

27
Q

Chronic pancreatitis aetiology and presentation

A

Alcohol
Cystic fibrosis
Duct obstruction - Tumour

Presentation

  • Stool changes - Pale steatorrhoea
  • Epigastric pain - Relieved sitting forwards - Worse on eating
  • Weight loss
  • DM
  • Jaundice
28
Q

Chronic pancreatitis investigations and management

A

AXR - Calcification
CT
Faecal elastase

Management

  • Stop drinking alcohol
  • Replace enzymes
  • Analgesia
29
Q

Wilson’s disease

A

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
30
Q

Haemochromatosis

A

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 ^^^
31
Q

Ascites

Transudate vs Exudate

A

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
32
Q

Ascites presentation

A

Fullness and distension
Shifting dullness
Pleural effusion
Dyspnoea

33
Q

Ascites investigations

A

NILS
USS
CXR
ECG / ECHO

Ascitic tap

  • Albumin
  • LDH
  • Cytology
  • Microscopy
  • Gram stain
  • Amylase - Pancreatic
34
Q

Ascites management and complications

A

Management - Treat underlying cause

  • Dietary salt restriction
  • Spironolactone
  • Furosemide
  • Paracentesis
  • TIPS

Complications

  • SBP
  • Respiratory distress - Dyspnoea
35
Q

SBP

A

Aetiology - Ascites - E.Coli

Presentation

  • Peritonitis
  • Ascites
  • Fever

Investigations

  • Blood cultures
  • Paracentesis

Management

  • IV cef
  • Prophylaxis - Ciprofloxacin
36
Q

Budd Chiari

A
  1. Occlusion of hepatic vein
  2. Hypoxic liver damage
  3. 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
37
Q

Hepatitis risk factors

A 
Endemic regions
MSM
IVDU
High-risk sexual behaviours
Family history
Incarceration
Blood transfusion - Pre 1992
Tattoos
38
Q

Hepatitis A

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

39
Q

Hepatitis B

A

Double-stranded hepadnavirus
Transmission - H/V
Incubation 6-20 weeks

Clinical features

  • Fever
  • Jaundice
  • Hepatomegaly
  • Ascites
  • Malaise
  • RUQ pain
  • Elevated liver transaminases
40
Q

Hep B serology

HBsAg

Anti-HBs

Anti-HBc IgM
Anti-HBc IgG

HbeAG

A

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

41
Q

Hep B management

A

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
42
Q

Hep C clinical features

A

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
43
Q

Hep C management and prognosis

A

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
44
Q

Hep C complications

A 
Rheumatological problems - Arthralgia and arthritis
Eye problems - Sjogren's syndrome
Cirrhosis - 5-20% 
HCC 
Cryoglobulinaemia
Membranoproliferative glomerulonephritis
45
Q

HCC aetiology and presentation

A 
Cirrhosis 
Hep B/C
Alcoholism
DM
Obesity
Family Hx
Abdo distension
Variceal bleeding
RUQ pain
Weight loss / LOA
Oedema
Jaundice
Hepatosplenomegaly
Spider naevi
46
Q

HCC investigations / management / prognosis

A

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%

47
Q

Cholangiocarcinoma aetiology and presentation

A

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
48
Q

Cholangiocarcinoma investigations / management / prognosis

A

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%

49
Q

A1AT deficiency aetiology and clinical features

A

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
50
Q

A1AT deficiency investigations and management

A

A1AT concentrations
Spirometry - Obstructive

Management

  • Smoking cessation
  • Hep A/B vaccine
  • COPD treatment - Bronchodilators
  • Chest PT
  • IV A1AT protein concentrates
  • Surgery - Lung transplant
51
Q

Liver abscess aetiology and clinical features

A

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

52
Q

Liver abscess investigations and management

A

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

53
Q

Pancreatic cancer aetiology

A

Adenocarcinoma
Head of pancreas

Risk factors

  • Smoking
  • Family Hx
  • Chronic pancreatitis
  • HNPCC
  • MEN
  • BRCA2
  • KRAS mutation
54
Q

Pancreatic cancer clinical features

A 
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

55
Q

Pancreatic cancer investigations and management

A

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

3B (23 decks)

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