Hepatobiliary - Acute and Chronic Pancreatitis, Cirrhosis

Question 1

Acute Pancreatitis - what is acute pancreatitis?

Answer 1

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

Question 2

Acute Pancreatitis - what are the causes?

Answer 2

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)

Question 3

Acute Pancreatitis - what are the symptoms

Answer 3

Severe epigastric pain that may radiate to back

N+V

Question 4

Acute Pancreatitis - what are the signs?

Answer 4

Grey Turners sign - bruising of the flanks

Cullen’s sign - superficial oedema with periumbilical bruising

Jaundice

Question 5

Acute Pancreatitis - what are the blood test investigations?

Answer 5

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

Question 6

Acute Pancreatitis - what scans can you do?

Answer 6

US

AXR

CT/MRI

Question 7

Acute Pancreatitis - what are the early and late complications?

Answer 7

EARLY:
1. Shock

2. ARDS - Acute Respiratory Distress Syndrome
3. Sepsis

LATE:

1. Bleeding
2. Pseudocyst - results from collection of peripancreatic fluid collection, occur ≥ 4 weeks after acute attack
3. Pancreatic abscesses - intraabdominal collection of pus associated with pancreas, typically a result of infected pseudocyst
4. Pancreatic necrosis - involve both pancreatic parenchyma and surrounding fat

Question 8

Acute Pancreatitis - what is the treatment?

Answer 8

Nil by mouth

I.V. saline

Analgesia

O2

Surgery

ITU

Question 9

Chronic Pancreatitis - what is it?

Answer 9

Repeated bouts of acute pancreatitis, and so persistent inflammation

Question 10

Chronic Pancreatitis - what structural changes occur to the pancreas?

Answer 10

Irreversible changes

Fibrosis, atrophy, calcification

This gradual process of pancreatic tissue getting replaced by mis-shaped ducts, fibrosis and calcium deposits, is chronic pancreatitis

Question 11

Chronic Pancreatitis - most common cause?

Answer 11

Alcohol

Question 12

Chronic Pancreatitis - what are the other causes?

Answer 12

1. Autoimmune
2. CF
3. Hereditary
4. Pancreatic duct obstruction

Question 13

Chronic Pancreatitis - what are the clinical features?

Answer 13

1. Epigastric pain radiating to back (relieved by sitting forward)
2. Jaundice
3. Weight loss
4. Steatorrhea

Question 14

Chronic Pancreatitis - what are the 1st line imaging methods?

Answer 14

Abdo US and CT - pancreatic calcifications confirm diagnosis

Question 15

Chronic Pancreatitis - what is the management?

Answer 15

Drugs:

1. Analgesia
2. Lipase
3. Fat-soluble vitamins
4. Insulin (amount needed may be variable)

Diet:

1. No alcohol
2. Low fat

Surgery:
1. Pancreatectomy or pancreatojejunostomy

Question 16

Chronic Pancreatitis - complications?

Answer 16

Pseudocyst

Diabetes - pancreas can’t keep producing hormones to regulate glucose

Biliary obstruction

Question 17

Cirrhosis - what is it?

Answer 17

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

Question 18

Cirrhosis - pathophysiology

Answer 18

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

Question 19

Cirrhosis - what is the most common cause in the UK and the world?

Answer 19

UK - Alcohol

World - Hepatitis B/C

Question 20

Cirrhosis - what are some other causes?

Answer 20

HBV

Haemochromatosis

Wilson’s disease

Primary Biliary Cirrhosis

Question 21

Cirrhosis - what are the two types of cirrhosis you can have?

Answer 21

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

Question 22

Cirrhosis - what are compensated liver symptoms?

Answer 22

Asymptomatic

Non-specific - weight loss, weakness, fatigue

Question 23

Cirrhosis - what are some decompensated liver symptoms?

Answer 23

Pruritus

Jaundice

Ascites

Hepatomegaly

Hepatic encephalopathy

Hands - clubbing, dupuytren’s contracture, palmar erythema

Question 24

Cirrhosis - what are the main complications, and what do they go on to cause?

Answer 24

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

Question 25

Cirrhosis - what is the gold standard investigation?

Answer 25

Liver biopsy

Question 26

Cirrhosis - what will bloods show?

Answer 26

LFTs - raised ALP, ALT, AST, bilirubin LOW - albumin, WCC, platelets

Question 27

Cirrhosis - what scans can you do and what are the findings?

Answer 27

MRI - big caudate lobe small islands of regenerating nodules Liver US - hepatomegaly

Question 28

Cirrhosis - what is the definitive treatment?

Answer 28

Liver transplant

Question 29

Cirrhosis - what is the management?

Answer 29

1. Good nutrition, avoid alcohol 2. Avoid NSAIDs, opiates 3. Give Colestyramine - help pruritus 4. Ascites - fluid restriction, low salt diet, give spironolactone 5. Recurrent encephalopathy episodes - reduce freq with lactulose and rifaximin