Hepatobiliary Diseases Flashcards
What is Jaundice?
Yellowish pigmentation of the skin, membranes and sclera (conjunctival membrane)
Visible at bilirubin level >35umol/L
What is Bile?
- Bile produced by liver hepatocytes, 500-1500 mls/day
- Bile consists of: water, bile salts (solubilise and absorption of lipids), cholesterol and bilirubin
- Bilirubin: Breakdown of haem = 25—400mg bilirubin daily, 70-90% from haemoglobin
Describe the cycle of bilirubin
-Unconjugated bilirubin
=70 to 90% from RBC breakdown; 10 to 30% from myoglobin; insoluble complex with albumin
-Taken up by liver
=Conjugated by the liver with glucuronic acid and hence now water-soluble
-Enters gut
-Reabsorption in terminal ileum (most) or enters colon
=Bilirubin excreted as Stercobilin
What are the types of jaundice?
Pre-hepatic
Hepatic
Post hepatic
What is Pre-hepatic jaundice?
-Increased bilirubin production
-Exceeds ability of liver to conjugate
-As water insoluble, does not enter urine
-Eg:
=Haemolysis
=Glucoronyl transferase deficiency (Gilbert’s), 10% of the population
What is Hepatic jaundice?
-Hepatocyte damage= mixed type as cant uptake unconjugated/ cant conjugate
-Causes:
=Viruses – hepatitis, CMV, =EBV
=Drugs: paracetamol, anti-TB,
=Alcohol
=Cirrhosis, autoimmune diseases
=Sepsis
=Right heart failure
What is Post-hepatic jaundice?
- Obstructive jaundice
- Blockage after liver= bilirubin conjugated so water soluble, some spills out into bloodstream so excreted by kidneys
- Stercobilin not in faeces so pale stool
- Pale stool, dark urine, itch (bile salts in skin)
-Classification (causes)
=Within the lumen (gallstones, blockage of bile duct)
=Within the wall (tumours- bile duct= cholangiocarcinoma)
=External compression (pancreas cancer)
What are the causes of obstructive jaundice (malignancy)?
- Hilar cholangiocarcinoma
- Hilar lymphadenopathy
- Distal cholangiocarcinoma
- Ampullary tumours
- Pancreatic tumours
What is ERCP?
Endoscopic retrograde cholangiopancreatography
-Camera swallowed, through stomach, into duodenum, looking at ampulla, wires into bile duct
=Samples of cancer, stents
What areas need to be covered in history taking?
- PC: jaundice
- Features of obstructive jaundice: pale stools, dark urine, itch
- Features of cancer: weight loss, loss of appetite
- Recent travel: ?hepatitis ?viral illness
- Family or personal history of hereditary disease: ?Gilbert’s
- Autoimmune disease
- IVDU
- Drug history
What is included in examination?
-Peripheral stigmata of liver disease: =finger clubbing, palmar erythema, Dupuytren’s, sclera for jaundice, Virchow’s nodes, spider naevi, gynaecomastia -Hepatomegaly -Splenomegaly (portal hypertension) -Ascites -Palpable Gallbladder
What is investigated?
-Haematology: =FBC, if anaemic consider cancer =Abnormal clotting in liver disease -LFTs: Raised bilirubin with =if ALP>ALT/AST = obstructive picture ALT/AST>ALP, liver disease -Liver screen -Imaging =Ultrasound: ?gallstone ?CBD dilatation ?Liver/pancreas mass =CT abdomen with contrast, MRI/MRCP -Tissue biopsy: USS or CT guided
How do we manage HBD?
-Treat symptoms: =Analgesia =IVI =Antibiotics if septic =Vitamin K & chlorphenamine -Treat underlying cause =Pre-hepatic: stop haemolytic process =Hepatic: anti-virals, prevent deterioration of cirrhosis, eg alcohol, drugs =Obstructive causes: ERCP/stenting, surgery, palliation
What are gallstones?
-Gall bladder drains by cystic duct
=Common hepatic duct
=R and L branches
Describe the incidence and types of gallstones
- 10 to 20 % of adult population
- 80 % asymptomatic (silent gallstones)
- Females to males 2:1
