hepatobiliary diseases W8

Question 1

when is jaundice visable?

Answer 1

bilirubin level >35umol/L

Question 2

bile - where is it produced? how much per day? composed of what?

Answer 2

produced by hepatocytes
500-1500mls/day
consists of water, bile salts, cholesterol and bilirubin

Question 3

bilirubin features?

Answer 3

breakdown of haem = 25-400mg bilirubin daily, 70-90% from haemoglobin

Question 4

where does bilirubin come from!

Answer 4

mainly haemoglobin. unconjugated bilirubin (not water soluble). binds to albumin and travels to liver, taken up and processed in liver (conjugated to glucuronic acid) making it water soluble. excreted in bile. most reabsorbed, some escapes as stercobilin (makes faeces brown)

Question 5

types of jaundice?

Answer 5

pre-hepatic
hepatic
post-hepatic

Question 6

pre-hepatic jaundice features?

Answer 6

increased bilirubin production
exceeds ability of liver to conjugate
as water insoluble, doesn’t enter urine
main cause is haemolysis (breakdown of RBCs)

Question 7

hepatic jaundice features?

Answer 7

hepatocyte damage, many causes:
-viruses (hepatitis, CMV, EBV)
-drugs (paracetamol, anti-TB)
-alcohol
-cirrhosis, autoimmune diseases
-sepsis
-right heart failure

Question 8

post-hepatic jaundice features?

Answer 8

obstructive jaundice
pale stool, dark urine (water soluble), itch

-within lumen
-within wall
-external compression

Question 9

obstructive jaundice - malignancy causes?

Answer 9

hilar cholangiocarcinoma
hilar lymphadenopathy
distal cholangiocarcinoma
ampullary tumours
pancreatic tumours

Question 10

cholangiocarcinoma meaning?

Answer 10

tumour of the bile duct

Question 11

obstructive jaundice - Whipples procedure?

Answer 11

gallbladder, distal bile duct, duodenum, head of pancreas, part of the stomach all removed. jejunum attached to stomach.

only works if cancer hasn’t spread

Question 12

obstructive jaundice - ERCP?

Answer 12

camera goes through stomach, into duodenum. camera view out the side into ampulla. wires into bile duct, can take samples, put in stents to allow drainage of bile.

Question 13

history of jaundice?

Answer 13

features of obstructive jaundice - pale stools, dark urine, itch

features of cancer - weight loss, loss of appetite

recent travel (hepatitis? viral illness?)
family/personal history of hereditary disease? (Gilbert’s)
autoimmune disease
IVDU (intravenous drug users)
drug history

Question 14

examination of jaundice?

Answer 14

peripheral stigmata of liver disease - finger clubbing, palmar erythema (red palms), dupuytren’s, sclera for jaundice, Virchow’s nodes, spider naevi, gynaecomastia

hepatomegaly
splenomegaly (portal hypertension)
ascites
palpable gallbladder

Question 15

investigation of jaundice?

Answer 15

haematology (anaemic? -> cancer. abnormal clotting in liver disease)
LFTs
liver screen
imaging (ultrasound
tissue biopsy

Question 16

LFT results interpretation for jaundice?

Answer 16

raised bilirubin with:
ALP>ALT/AST = obstructive
ALT/AST>ALP = liver disease

Question 17

ultrasound interpretation for jaundice? next steps?

Answer 17

tells you if post-hepatic cause or not - blockage shows large liver ducts.
if ultrasound results show large liver ducts, do CT abdomen with contrast (for cancer), MRI (for gallstones)

Question 18

management of jaundice?

Answer 18

symptoms:
pain - analgesia
infection - antibiotics
clotting - vitamin K

treat underlying cause:
pre-hepatic = stop haemolytic process
hepatic = antivirals, precent deterioration of cirrhosis
obstructive = ERCP/stenting, surgery, palliation

Question 19

gallstones - incidence/type?

Answer 19

10-20% of adult population
80% asymptomatic
female to male 2:1

mixed (common)
pure cholesterol
black pigment stones (haemolysis - unconjugated bilirubin)

Question 20

clinical presentation of gallstones?

Answer 20

RUQ (right upper quadrant) pain or epigastric
colicky or constant
dyspepsia, nausea, vomiting
biliary colic (typically after fatty meal)
obstructive jaundice
acute cholecystitis
acute pancreatitis

Question 21

management of gallstones?

Answer 21

analgesia
antibiotics?
percutaneous drainage
ERCP
surgery

depends on cause/type!!

Question 22

laparoscopic cholecystectomy?

Answer 22

4 keyhole - bellybutton, epigastric, 2 in right upper quadrant. find cystic duct and artery, cut, remove gallbladder.