Hepatobiliary - Acute and Chronic Pancreatitis, Cirrhosis Flashcards
Acute Pancreatitis - what is acute pancreatitis?
ENZYME - MEDIATED AUTODIGESTION
Pancreas becomes inflamed
Pancreatic damage happens when the digestive enzymes are activated before they are released into small intestine, and so begin attacking the pancreas
It causes reversible damage
Acute Pancreatitis - what are the causes?
G - Gallstones
E - Ethanol
T - Trauma
S - Steroids M - Mumps/malignancy A - Autoimmune S - Scorpion sting H - Hyperlipidaemia/hypercalcaemia E - ERCP D - Drugs (azathioprine, mesalazine, bendroflumethiazide)
Acute Pancreatitis - what are the symptoms
Severe epigastric pain that may radiate to back
N+V
Acute Pancreatitis - what are the signs?
Grey Turners sign - bruising of the flanks
Cullen’s sign - superficial oedema with periumbilical bruising
Jaundice
Acute Pancreatitis - what are the blood test investigations?
Serum amylase - usually 3 times the upper limit of normal levels
Serum lipase - more useful for catching late presentations, more sensitive and specific
MOST IMPORTANT TWO TESTS
Bloods - FBC, U&Es, LFTs, CRP
ABG
Acute Pancreatitis - what scans can you do?
US
AXR
CT/MRI
Acute Pancreatitis - what are the early and late complications?
EARLY:
1. Shock
- ARDS - Acute Respiratory Distress Syndrome
- Sepsis
LATE:
- Bleeding
- Pseudocyst - results from collection of peripancreatic fluid collection, occur ≥ 4 weeks after acute attack
- Pancreatic abscesses - intraabdominal collection of pus associated with pancreas, typically a result of infected pseudocyst
- Pancreatic necrosis - involve both pancreatic parenchyma and surrounding fat
Acute Pancreatitis - what is the treatment?
Nil by mouth
I.V. saline
Analgesia
O2
Surgery
ITU
Chronic Pancreatitis - what is it?
Repeated bouts of acute pancreatitis, and so persistent inflammation
Chronic Pancreatitis - what structural changes occur to the pancreas?
Irreversible changes
Fibrosis, atrophy, calcification
This gradual process of pancreatic tissue getting replaced by mis-shaped ducts, fibrosis and calcium deposits, is chronic pancreatitis
Chronic Pancreatitis - most common cause?
Alcohol
Chronic Pancreatitis - what are the other causes?
- Autoimmune
- CF
- Hereditary
- Pancreatic duct obstruction
Chronic Pancreatitis - what are the clinical features?
- Epigastric pain radiating to back (relieved by sitting forward)
- Jaundice
- Weight loss
- Steatorrhea
Chronic Pancreatitis - what are the 1st line imaging methods?
Abdo US and CT - pancreatic calcifications confirm diagnosis
Chronic Pancreatitis - what is the management?
Drugs:
- Analgesia
- Lipase
- Fat-soluble vitamins
- Insulin (amount needed may be variable)
Diet:
- No alcohol
- Low fat
Surgery:
1. Pancreatectomy or pancreatojejunostomy
Chronic Pancreatitis - complications?
Pseudocyst
Diabetes - pancreas can’t keep producing hormones to regulate glucose
Biliary obstruction
Cirrhosis - what is it?
Cirrhosis is when the liver does not function properly anymore due to long-term damage
Characterised by normal liver tissue being replaced with scar tissue
Chronic scarring - irreversible and fibrotic
Cirrhosis - pathophysiology
When liver cells are injured, they start to come together and from REGENERATIVE NODULES
Classic sign of cirrhosis - why cirrhotic liver is bumpy
Between these nodules there is fibrotic tissue and collagen
Cirrhosis - what is the most common cause in the UK and the world?
UK - Alcohol
World - Hepatitis B/C
Cirrhosis - what are some other causes?
HBV
Haemochromatosis
Wilson’s disease
Primary Biliary Cirrhosis
Cirrhosis - what are the two types of cirrhosis you can have?
Compensated - liver still functions effectively, no, or few clinical symptoms
Decompensated - liver damaged so much can’t function properly, complications occur
- Also known as chronic decompensated hepatic failure
Cirrhosis - what are compensated liver symptoms?
Asymptomatic
Non-specific - weight loss, weakness, fatigue
Cirrhosis - what are some decompensated liver symptoms?
Pruritus
Jaundice
Ascites
Hepatomegaly
Hepatic encephalopathy
Hands - clubbing, dupuytren’s contracture, palmar erythema
Cirrhosis - what are the main complications, and what do they go on to cause?
LIVER FAILURE - causes COAGULOPATHY (due to low amount of clotting factors), ENCEPHALOPATHY, HYPOALBUMINAEMIA (albumin production decrease)
PORTAL HTN - causes ascites, splenomegaly, portosystemic shunt (oesophageal varices + UGIB)
INCREASED RISK OF HEPATOCELLULAR CARCINOMA
SPONTANEOUS BACTERIAL PERITONITIS
Cirrhosis - what is the gold standard investigation?
Liver biopsy
Cirrhosis - what will bloods show?
LFTs - raised ALP, ALT, AST, bilirubin
LOW - albumin, WCC, platelets
Cirrhosis - what scans can you do and what are the findings?
MRI - big caudate lobe
small islands of regenerating nodules
Liver US - hepatomegaly
Cirrhosis - what is the definitive treatment?
Liver transplant
Cirrhosis - what is the management?
- Good nutrition, avoid alcohol
- Avoid NSAIDs, opiates
- Give Colestyramine - help pruritus
- Ascites - fluid restriction, low salt diet, give spironolactone
- Recurrent encephalopathy episodes - reduce freq with lactulose and rifaximin