Hepatobiliary Tract

Question 1

Describe the micro anatomy of the hepatobiliary system

Answer 1

Hepatocytes arranged in (reticuloendothelial) plates with sinusoids in between -> central veins -> hepatic vein

Portal triad = bile duct, portal vein and hepatic artery

Bile canaliculus line bile duct

Question 2

What are the 3 broad functions of the liver and how do these manifest in disease?

Answer 2

Normal role of liver: filter, eliminate and metabolise

Filter failure: portal hypertension
Elimination failure: jaundice
Metabolic failure: acidosis, muscle loss, coagulopathy

Question 3

What are signs of chronic liver disease?

Answer 3

Spider naevi
Clubbing
Ascites
Palmer erythema
Dupuytren’s contracture
Leuconychia
Gynaecomastia
Caput medusa
Splenomegaly
Oedema
Jaundice
Muscle wasting

Question 4

At what percentage can the liver function well to?

What happens and what could cause ‘decompensation’ in chronic liver disease

Answer 4

80% of normal function - so can drop to 20% before its considered liver failure

Decompensation will cause sudden drop in function - infection/toxins/alcohol/trauma/drugs/variceal bleed (but can be treated and partially restore function = chronic disease)

Question 5

What are the relevant tests for liver injury?

Answer 5

Blood tests
Imaging
Liver biopsy

Question 6

What is jaundice caused by?

Answer 6

Failure of body to excrete bile - clinical when serum bilirubin twice above normal concentration

Question 7

How can you investigate gallstones?

Answer 7

Ultrasound

Endoscopic retrograde cholangio-pancreatography

Question 8

What’s the ‘hallmark’ of liver failure?

Answer 8

Encephalopathy = failure of filter, elimination and metabolism - typically caused by NH3

= impaired cognition/mental state (often due to metabolic failure)

Question 9

What are 4 key signs of chronic liver disease?

Answer 9

Jaundice
Encephalopathy
Ascites
Coagulopathy/bleeding

Question 10

What are 4 causes of liver injury?

Answer 10

Fat > Alcohol > Virus > Iron (commonly all co-exist)

Question 11

NAFLD develops in what 4 stages?

Answer 11

Simple fatty liver (steatosis)
Non-alcoholic steatohepatitis (inflammation)
Fibrosis (persistent inflammation = scar tissue)
Cirrhosis (liver shrinks with scarring and becomes lumpy, permanent damage and failure)

Question 12

What are gallbladder and bile duct stones called?

Answer 12

Cholelithiasis

Choledocolitheasis

Question 13

What are gallstones formed from and associated with?

Answer 13

Cholesterol
High fat diets/hypercholesterolaemia
Formed by reduced bile secretion or defective reabsorption bile salts

Question 14

What are the pros and cons of ultrasound for gallstone imaging?

Answer 14

Pros: simple, non-invasive and widely available
Cons: operator dependent, poor specificity and poor views of pancreas (retroperitoneal)

Question 15

How is the gallbladder removed and what are the consequences?

Answer 15

Laparoscopic cholecystectomy

Increased risk of diarrhoea and maybe cancer because of acid

Question 16

What’s pancreatitis, presentation and diagnosis?

Answer 16

Inflammation of the pancreas: GET SMASHED
Detection of pancreatic amylase and lipase in blood
Intense pain in central abdomen radiating to the back,

Digestive enzymes don’t reach duodenum = steatorrhoea (fatty stools)

Question 17

What will pancreatic failure lead to? (chronic pancreatitis)

Answer 17

Endocrine dysfunction: diabetes

Exocrine dysfunction: metabolic/malabsorption

Question 18

What will blood tests show in biliary obstruction, hepatocyte damage and acute pancreatitis?

Answer 18

Biliary obstruction: high bilirubin and alkaline phosphatase
Hepatocyte damage: high alanine transaminase and aspartate transaminase
Acute pancreatitis: elevated amylase and lipase

Question 19

What does I GET SMASHED stand for?

Answer 19

Mneumonic in pancreatitis:
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps/Malignancy
Autoimmune
Scorpion bite
Hypercalcaemia (metabolic disorders)
ERCP - endoscopic retrograde cholangio-pancreatography (examine bile ducts)
Drugs