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Hepatology Flashcards

1
Q

Age group most affected by cholangiocarcinoma

A

Mostly in those aged over 60

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2
Q

Risk factors for cholangiocarcinoma

A

Patients with chronic ulcerative colitis who develop sclerosing cholangitis

Infection with liver flukes

Chemical exposure

Congenital abnormalities

Hep C, HIV, cirrhosis and diabetes

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3
Q

Presentation of cholangiocarcinoma

A

Jaundice(early feature)
Hepatomegaly
Abdo pain(localised to RUQ)
Weight loss
Pale-coloured stools, passage of dark urine
Splenomegaly if prolonged biliary obstruction
Courvoisier’s sign

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4
Q

What is courvoisier’s sign

A

Palpable gallbladder may occur with tumours distal to the cystic duct

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5
Q

IX for cholangiocarcinoma

A

LFTs(Elevated conjugated bilirubin, cholestatic picture)

Prothrombin and INR prolonged

Tumour markers(CA 19-9 and CEA)

Ultrasound and CT

Contrast MRI for diagnosis

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6
Q

Surgical management of cholangiocarcinoma

A

Complete surgical resection

Liver resection for intrahepatic tumours

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7
Q

Non-surgical management of cholangiocarcinoma

A

Stenting of bile duct to relieve symptoms using ERCP

Palliative chemotherapy

Radiotherapy

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8
Q

Complications of cholangiocarcinoma

A

Biliary tract sepsis

Secondary biliary cirrhosis

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9
Q

What is primary sclerosing cholangitis

A

Intrahepatic or extra hepatic ducts become structured and fibrotic causing obstruction to bile flow out of liver and into the intestines

Chronic bile obstruction eventually leads to liver inflammation(hepatitis), fibrosis and cirrhosis

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10
Q

Which condition is associated with primary sclerosing cholangitis

A

Ulcerative colitis

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11
Q

Risk factors for PSC

A

Male
Aged 30-40
Ulcerative colitis
Family history

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12
Q

Presentation of PSC

A 
Jaundice 
Chronic RUQ pain 
Pruritus 
Fatigue 
Hepatomegaly
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13
Q

What do liver function tests show in PSC

A

Cholestatic picture - Elevated ALP

May be a rise in bilirubin as strictures become severe and prevents bilirubin from being excreted through bile duct

Other LFTs can also be deranged as disease progresses to hepatitis

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14
Q

What autoantibodies may indicate an autoimmune element to PSC

A 
Antineutrophil cytoplasmic antibody (p-ANCA) in up to 94%
Antinuclear antibodies (ANA) in up to 77%
Anticardiolipin antibodies (aCL) in up to 63%
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15
Q

Diagnosis of PSC

A

MRCP - shows bile duct lesions or strictures

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16
Q

Complications of PSC

A 
Acute bacterial cholangitis
Cholangiocarcinoma develops in 10-20% of cases
Colorectal cancer
Cirrhosis and liver failure
Biliary strictures
Fat soluble vitamin deficiencies
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17
Q

Management of PSC

A

Liver transplant
ERCP to dilate and stent strictures
Colestyramine
Monitor for complications

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18
Q

What is colestyramine

A

Bile acid sequestrate in that it binds to bile acids to prevent absorption in the gut and can help with pruritus due to raised bile acids

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19
Q

Causes of hepatitis

A 
Alcoholic hepatitis
Non alcoholic fatty liver disease
Viral hepatitis
Autoimmune hepatitis
Drug induced hepatitis (e.g. paracetamol overdose)
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20
Q

Hepatitis presentation

A 
Abdominal pain
Fatigue
Pruritis (itching)
Muscle and joint aches
Nausea and vomiting
Jaundice
Fever (viral hepatitis)
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21
Q

Typical LFTs in hepatitis

A

High transaminases(AST/ALT) with proportionally less of a rise in ALP

Bilirubin can also rise as a result of inflammation of the liver cells.

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22
Q

Most common viral hepatitis

A

Hep A

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23
Q

How is Hep A transmitted

A

faecal-oral route usually by contaminated water or food

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24
Q

Presentation of hep A

A

nausea, vomiting, anorexia and jaundice. It can cause cholestasis (slowing of bile flow through the biliary system) with dark urine and pale stools and moderate hepatomegaly.

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25
Disease progression of hep A
Resolves without treatment in around 1-3 months
26
Management of Hep A
Basic analgesia | Notable disease
27
What type of virus is Hep B
DNA virus
28
How is hep B transmitted
Direct contact with blood or bodily fluids, such as during sexual intercourse or sharing needles (i.e. IV drug users or tattoos). It can also be passed through sharing contaminated household products such as toothbrushes or contact between minor cuts or abrasions. It can also be passed from mother to child during pregnancy and delivery (known as “vertical transmission”).
29
Disease course of hep B
Most people fully recover from the infection within 2 months, however 10% go on to become chronic hepatitis B carriers. In these patients the virus DNA has integrated into their own DNA and so they will continue to produce the viral proteins.
30
Test for active hepatitis b infection
HBsAg
31
Test for previous hep b infection
HBcAb
32
What should be tested if HBsAg and HBcAb are positive
Further testing for HBeAg and viral load
33
How can Hep B c antibodies be used to distinguish acute, chronic and past infections
IgM implies an active infection and will give a high titre with an acute infection and a low titre with a chronic infection. IgG indicates a past infection where the HBsAg is negative.
34
Importance of Hep B e antigen test
Where the HBeAg is present it implies the patient is in an acute phase of the infection where the virus is actively replicating. The level of HBeAg correlates with their infectivity. When the HBeAg is negative but the hepatitis B e antibody is positive this implies they have been through a phase where the virus was replicating and but the virus has now stopped replicating
35
What is the Hep B vaccination
involves injecting the hepatitis B surface antigen. Vaccinated patients are tested for HBsAb to confirm their response to the vaccine
36
Management of hep B
``` Screen for other blood born viruses (hepatitis A and B and HIV) and other sexually transmitted diseases Refer to gastroenterology Notify public health Smoking and alcohol cessation Antiviral meds Liver transplantation ```
37
What type of virus is hep C
RNA virus
38
How is hep c transmitted
Spread by blood and body fluids
39
Complications of hep B
Cirrhosis | HCC
40
Disease course of hep c
1 in 4 fights off the virus and makes a full recovery | 3 in 4 it becomes chronic
41
Complications of hep c
liver cirrhosis | HCC
42
Test for hep c
Hepatitis C antibody is the screening test Hepatitis C RNA testing is used to confirm the diagnosis of hepatitis C, calculate viral load and assess for the individual genotype
43
Management of hep c
``` Screen for other blood born viruses Notify Public Health Smoking and alcohol cessation Antiviral treatment with direct acting antivirals Liver transplant ```
44
Features of hep d
RNA virus Can only survive in patients who have hep b Attaches itself to HBsAg Increases complications and disease severity of hep B
45
Management of hep D
No specific treatment for hep D | Notifiable disease
46
What is Hep E
RNA virus
47
How is Hep E transmitted
Faecal oral route
48
Disease course of Hep E
Produces only a mild illness, the virus is cleared within a month and no treatment is required. Rarely it can progress to chronic hepatitis and liver failure, more so in patients that are immunocompromised.
49
What is autoimmune hepatitis associated with
Can be associated with a genetic predisposition and triggered by environmental factors such as viral infection that causes a T cell-mediated response against liver cells
50
What are the two types of autoimmune hepatitis
Type 1: occurs in adults | Type 2: occurs in children
51
Features of type 1 autoimmune hepatitis
Typically affects women in their late forties or fifties. It presents around or after the menopause with fatigue and features of liver disease on examination. It takes a less acute course than type 2.
52
Features of type 2 autoimmune hepatitis
In type 2, patients in their teenage or early twenties present with acute hepatitis with high transaminases and jaundice.
53
General IX for type 1 and type 2 autoimmune hepatitis
Raised transaminases (ALT and AST), IgG levels and it is associated with many autoantibodies.
54
Specific autoantibodies associated with type 1 autoimmune hepatitis
Anti-nuclear antibodies (ANA) Anti-smooth muscle antibodies (anti-actin) Anti-soluble liver antigen (anti-SLA/LP)
55
Specific autoantibodies associated with type 2 autoimmune hepatitis
Anti-liver kidney microsomes-1 (anti-LKM1) | Anti-liver cytosol antigen type 1 (anti-LC1)
56
Diagnosis of autoimmune hepatitis
Liver biopsy
57
Treatment for autoimmune hepatitis
``` High dose steroids(prednisolone) Immunosuppressants(azathioprine) Liver transplant(autoimmune hepatitis can recur) ```
58
Aetiology of hepatic encephalopathy
Not fully understood but is thought to include excess absorption of ammonia and glutamine from bacterial breakdown of proteins in the gut.
59
what is hepatic encephalopathy associated with
Often associated with acute liver failure it may also be seen with chronic disease
60
Which procedure can precipitate encephalopathy
transjugular intrahepatic portosystemic shunting (TIPSS) may precipitate encephalopathy
61
Features of hepatic encephalopathy
confusion, altered GCS (see below) asterix: 'liver flap', arrhythmic negative myoclonus with a frequency of 3-5 Hz constructional apraxia: inability to draw a 5-pointed star raised ammonia level (not commonly measured anymore)
62
EEG features - hepatic encephalopathy
triphasic slow waves on EEG
63
Grading of hepatic encephalopathy
Grade I: Irritability Grade II: Confusion, inappropriate behaviour Grade III: Incoherent, restless Grade IV: Coma
64
precipitating factors in hepatic encephalopathy
``` infection e.g. spontaneous bacterial peritonitis GI bleed TIPPS constipation hypokalaemia renal failure increased dietary protein (uncommon) ```
65
Drugs implicated in hepatic encephalopathy
Sedative | Diuretics
66
Mx of hepatic encephalopathy
treat any underlying precipitating cause NICE recommend lactulose first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy
67
How does lactulose work in hepatic encephalopathy
lactulose is thought to work by promoting the excretion of ammonia and increasing the metabolism of ammonia by gut bacteria
68
How do antibiotics work in hepatic encephalopathy
antibiotics such as rifaximin are thought to modulate the gut flora resulting in decreased ammonia production
69
Types of drug-induced liver disease
Hepatocellular Cholestatic Mixed
70
Causes of hepatocellular drug-induced liver disease
``` paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis meds statins alcohol ```
71
Causes of cholestatic/mixed drug-i induced liver disease
``` COCP Abx anabolic steroids chlorpromazine, prochlorperazine sulphonylureas fibrates ```
72
Drugs which can cause liver cirrhosis
Methotrexate Methyldopa Amiodarone
73
Risk factors for HCC
Liver cirrhosis due to: Viral hep(B and C) Alcohol NAFLD
74
Tumour marker associated with HCC
Alpha-fetoprotein
75
Drugs associated with HCC
COCP | Anabolic steroids
76
Features of HCC
tends to present late features of liver cirrhosis or failure may be seen: jaundice, ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly possible presentation is decompensation in a patient with chronic liver disease
77
When should screening be considered for HCC
Screening with ultrasound (+/- alpha-fetoprotein) should be considered for high risk groups such as: patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis men with liver cirrhosis secondary to alcohol
78
Mx of HCC
early disease: surgical resection liver transplantation radiofrequency ablation transarterial chemoembolisation
79
What might be seen on light microscopy in chronic hep B
Ground-glass hepatocytes
80
Definition of chronic hep c
persistence of HCV RNA in the blood for 6 months.
81
Eye problem associated with chronic hep c
Sjogren's syndrome

Gen surg (24 decks)

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