Hepatobiliary

Question 1

What are the complications of Acute Cholecystitis ?

Answer 1

Acute pancreatitis, recurrent cholecystitis, jaundice, cholangiocarcinoma

Question 2

What is Mirizzi syndrome?

Answer 2

Common hepatic duct obstruction caused by extrinsic compression. This is either due to a impacted stone in the cystic duct or in the infundibulum of the gall bladder.

Question 3

How would a patient with Mirizzi syndrome present (classic 3 symptoms)?

Answer 3

Fever, right upper quadrant pain and jaundice.

Question 4

What is the primary treatment for Mirizzi syndrome?

Answer 4

Laparoscopic cholecystectomy

Question 5

Which anti-body is related to primary biliary cirrhosis?

Answer 5

Anti-mitochondrial antibody

Question 6

What are the 3 signs of Charcot’s Triad?

Answer 6

Jaundice, RUQ pain and Fever

Question 7

What is charcot’s triad indicative of?

Answer 7

Cholangitis - usually ascending

Question 8

A patient comes in with Jaundice what are the 5 possible differential diagnosis (big topics) ?

Answer 8

Haemolytic jaundice - dark stools and urine, pallor, splenomegaly with normal LFTs.
- Drugs (sulfasalazine/methyldopa), sickle cell, thalassemia.
Hepatocellular jaundice
- damage to the liver causing trouble in conjugating and excreting bilirubin.
- Cirrhosis, hepatitis, drug induced (halothane, paracetamol)
Cholestatic jaundice
- Biliary obstruction so conjugated but can’t excrete.
- Dark urine and pale stools (lack of sterco bilirubin)
- Primary biliary cirrhosis, primary sclerosing cholangitis, alcohol, drugs, hepatitis, CF, pregnant, post surgery. WILSONS DISEASE.
Familial - Gilberts syndrome, criggler-Najar syndrome
Neonatal - common especially in premature children. Immature glucuronyl transferase and there is rapid foetal RBC breakdown as it is no longer needed.

Question 9

How is hepatitis A spread and where is it common?

Answer 9

Faecal oral spread. Common in areas of poor sanitation

Question 10

What is the treatment for hepatitis A and how long does it take?

Answer 10

Supportive - avoid alcohol. Should be resolved in 3-6 weeks. Acute only.

Question 11

What is raised in hepatitis A?

Answer 11

ALT

HPA - IgM

Question 12

What type of virus is hepatitis B and is it acute or chronic?

Answer 12

DNA - reverse trasncriptase
Acute
And chronic - especially in younger patients.

Question 13

What is raised in hepatitis B/

Answer 13

HBsAG (And ALT)

Question 14

What drugs are used to treat chronic hepatitis B?

Answer 14

Pegylated interferon or nucleoside/nucelotide analogues

Question 15

How is hepatitis C spread ?

Answer 15

Parenteral - blood (IV drug users) sex or vertical.

Question 16

What type of virus is hepatitis C and what serotype is most common?

Answer 16

RNA - 1a/1b

Question 17

What is the usual presentation of hepatitis C?

Answer 17

Asymptomatic and usually presents with chronic liver disease. Or can present after the incubation period with flu

Question 18

What tests should be completed for hepatitis c?

Answer 18

HCV-RNA, Anti-HCV IgM, USS, AFP, Biopsy (if required)

Question 19

Is hepatitis curable if so what drugs are used?

Answer 19

Yes
Protease inhibitors and anti-virals.
Sofusbovir + ribavirin + PEG-interferon.

Question 20

What are the complications of hepatitis C?

Answer 20

Cirrhosis/HCC. Can be fatal

Question 21

What viruses increase the risk of hepatocellular carcinoma?

Answer 21

Hepatitis B and C - cirrhosis

Question 22

What is the common cause of hepatitis E?

Answer 22

Drinking contaminated water

Question 23

What is the main treatment for hepatitis E and how long should it take to clear up?

Answer 23

Supportive - clears up within a few weeks

Question 24

What is fatty liver disease?

Answer 24

Accumulation of fat inside hepatocytes

Question 25

What is the pathophysiology of chronic liver disease?

Answer 25

Progressive destruction of the liver for more than 6 months. Fibrosis (scarring) –> cirrhosis (scar tissue)

Question 26

What are the causes of chronic liver disease?

Answer 26

Non-alcoholic fatty liver disease (DM II, Hypertension, hyperlipidaemia, obesity)
HBV, HCV, HDV
ALCOHOL (fatty liver, hepatitis, cirrhosis)
CF
Haemochromatosis
Wilson’s disease
Autoimmune
Drugs - Isoniazid, methotrexate, amiodarone, phenytoin.

Question 27

What are the symptoms/signs of chronic liver disease?

Answer 27

Fatigue 
Encephalopathy (flapping asterix)
Hands - dupytrens contracture, palmar erythema, leukonochyia 
Jaundice 
Spider naevi, gynaecomastia 
Caput medusa 
Ascites 
Spleno or hepatomegaly

Question 28

What can be used to score the severity of chronic liver disease?

Answer 28

UKELD

Child-pugh score

Question 29

What blood tests can be done to diagnose chronic liver disease - determining the cause?

Answer 29

FBC, LFT, coagulation, albumin, PT, platelets, viral screen, iron, ferritin, copper, alpha-1 trypsin

Question 30

What are the best imaging for chronic liver disease?

Answer 30

USS
CT
- Fatty, nodules or carcinoma

Question 31

Why would a gastroscopy be done in suspected chronic liver disease?

Answer 31

Oesophageal varices due to portal hypertension.

Question 32

What are the main complications that can occur from chronic liver disease?

Answer 32

Oesophageal varices
HCC
Encephalopathy 
Ascites - SBPeritonitis 
Hepatorenal syndrome 
Hyponatremia

Question 33

What is the treatment for hepatic encephalopathy?

Answer 33

LAxatives to remove the excess ammonium. or enema if that doesn’t work.
Can give metronidazole to prevent the breakdown of nitrogen.

Question 34

What is Budd Chiari Syndrome?
What is the triad of symptoms?
What is first line investigation for it?
What is the treatment for it?

Answer 34

Blood clot develops in the hepatic vein
Abdominal pain + Ascites + Hepatomegaly
USS with doppler
Anti-coagulation - heparin