Hepatology Flashcards
Acute cholangitis
Def, cause, sx, ix, mx
ascending infection of the biliary tree due to obstruction
Cause:
- biliary calculi (most common)
- benign biliary stricture
- malignancy
Sx:
- charcots triad= RUQ pain, fever and jaundice
- hypotension and confusion if severe
Ix:
- raised LFTs (obstructive pattern showing raised ALP, GGT and bilirubin), CRP and WCC
- 1st line imaging is US abdo
- CT
- MRCP for detecting stones
Mx:
- resus with fluids and abx
- ERCP
- PTC
- surgical drainage
- cholecystectomy if stones
Alcoholic hepatitis
Def, cause, sx, ix, mx
Due to inflammation and necrosis of liver cells
Rf:
- 21 units a week for men
- 14 units a week for women
- genes
- nutrition
- hepatitis C
Sx:
- jaundice
- fever
- tender hepatomegaly
- nausea and vomiting
Ix:
- SADQ and AUDIT
- LFTs elevated
- viral serologies
- US
- CT/MRI
- transient elastography (fibroscan)
- liver biopsy
Mx:
- 1-3 months prednisolone
- pentoxifylline as alternative
- use maddreys discriminant to determine prognosis
Ascites
Def, cause, sx, ix, mx
abnormal accumulation of fluid within the peritoneal cavity
Causes:
- cirrhosis
- acute liver failure
- liver metastases
- right heart failure
- nephrotic syndrome
- kwashiorkor
- TB
- acute pancreatitis
Sx:
- abdo distension and pain
- dyspnea
- tense abdo
- shifting dullness
Ix:
- primary is ascitic tap under USS guidance
- SAAG (serum albumin - ascites albumin) to determine cause
- CT abdo and CXR
Mx:
- salt restriction if high SAAG
- spironolactone first line
- IV piperacillin-tazobactam if neutrophils >250
Cholecystitis
Def, cause, sx, ix, mx
acute or chronic inflammation of the gallbladder, which is commonly precipitated by cholelithiasis, or gallstones
Sx:
- RUQ pain which can radiate to right shoulder
- fever
- nausea and vomiting
- positive Murphy’s
Ix:
- first line is US abdomen
- CT abdo pelvis
Mx:
- acute calculous- abx with definite treatment of lap cholecystectomy
- acalculous- surgical emergency for lap cholecystectomy
- chronic= elective cholecystectomy
Cirrhosis
Def, causes, sx, ix, mx
irreversible scarring of the liver with loss of normal hepatic architecture
Causes:
- alcohol
- hep B and C
- non-alcoholic fatty liver disease
Sx:
Compensated:
- Fatigue and anergia
- Anorexia and cachexia
- Nausea or abdominal pain
- Spider naevi
- Gynaecomastia
- Finger clubbing
- Leuconychia
- Dupuytren’s contracture
- Caput medusae
- Splenomegaly
Decompensated:
- Ascites and oedema
- Jaundice
- Pruritus
- Palmar erythema
- Gynaecomastia and testicular atrophy
- Easy bruising
- Encephalopathy/confusion
- Liver ‘flap
Ix:
- LFTs
- U+Es
- INR
- Hepatitis serology, cytomegalovirus serology, iron studies, α-1 anti-trypsin, caeruloplasmin level, and auto-antibodies
- peritoneal tap
- Doppler US (Budd-chiari syndrome)
- fibroscan
- liver biopsy
- child-Pugh or MLED score (severity)
Mx:
- 6 monthly ultrasound scans and serum α-fetoprotein tests for hepatocellular carcinoma detection
- cholestyramine for pruritus
- spironolactone for ascites
- lactulose and rifaximin for reducing recurrent episodes of encephalopathy
- liver transplant for definitive management
Hepatitis
Def, types, sx, ix, mx
Hepatitis refers to the inflammation of the liver. It is typically caused by viral infection but can also result from non-infectious aetiologies such as toxins and alcohol. Hepatitis A and Hepatitis E can lead to acute liver failure, whereas Hepatitis B and Hepatitis C tend to lead to chronic liver failure. Hepatitis D only occurs in individuals who are infected with Hepatitis B.
Sx:
- RUQ pain
- jaundice
- tender hepatosplenomagaly
Hep A and E:
- RNA picornavirus
- transmitted through faecal oral route
- flu like sx followed by jaundice, pale stools, dark urine and abdo pain
- ix with hepatitic LFTs (AST and ALT high), IgM and IgG antibodies
- supportive mx
Hep B:
- dsDNA virus
- most common
- transmitters via blood or bodily fluids
- jaundice, fever, malaise, viral prodrome, dark urine and light stool, liver failure with decompensation
- HBsAg is detected 3-5 weeks after infection, biopsy will reveal ground-glass haptocytes
- antiviral mx if indicated, Pegylated interferon alfa-2a is the first line, with tenofovir and entecavir as second-line
- complications is hep D
Hep C:
- RNA virus of the Flaviviridae family
- transmitted from blood and bodily fluids
- mostly asymptomatic
- anti-HCV serology, HCV-RNA
- nucleoside analogues (sofosbuvir) can be combined with daclatsavir
Liver failure
Cause, sx, is, mx
Cause:
Acute:
- viral hepatitis
- paracetamol overdose
- chemical exposure
- budd-chiari syndrome
Chronic:
- alcohol
- chronic viral hepatitis
- non-alcoholic fatty liver disease
- primary biliary cholangitis
- primary sclerosing cholangitis
- haemochromatosis
- Wilson’s
- alpha-1 antitrypsin deficiency
Sx:
- hepatic encephalopathy
- bleeding
- jaundice
Is:
- INR
- LFT
- FBC
- U+E
- tests to determine cause
- peritoneal tap for ascites
- abdo US
- Doppler (Budd-Chiari)
- OGD for varices
Mx:
- treat underlying cause
- encephalopathy= lactulose, rifamixin (2nd line), IV mannitol
- coagulopathy= vit K
- spontaneous bacterial peritonitis= IV Piperacillin-Tazobactam
- hepatorenal syndrome= terlipressin for rapid or midodrine for slow
- liver transplant for definite
Gallstone disease
Causes, types, rf, sx, ix, mx
Causes:
- super saturation of bile with cholesterol
- gallbladder dysmotility leading to stasis
- excessive bilirubin excretion
Types:
- pigment (haemolysis, stasis and infection)
- cholesterol (female, age and obesity)
- mixed
Risk factors:
- 4Fs: female, fat, 40 and fertile
- diabetes
- FHx
- crohns
- bariatric surgery
- sickle cell anaemia
Sx:
• Biliary colic: Colicky right upper quadrant pain, worse after eating, no fever, negative Murphy’s sign.
• Acute cholecystitis: Right upper quadrant/epigastric pain (radiating to right shoulder tip if the diaphragm is irritated), fever, nausea and vomiting, right upper quadrant tenderness, positive Murphy’s sign.
• Ascending cholangitis: Right upper quadrant pain, fever, jaundice, hypotension, and confusion if sepsis is severe.
• Mirizzi’s syndrome: Chronic right upper quadrant pain, intermittent jaundice due to extrinsic compression of the common hepatic duct by an impacted stone in the cystic duct or gallbladder neck.
• Chronic cholecystitis: Flatulent dyspepsia, vague abdominal pain, nausea, bloating, symptoms worsening after a fatty meal, occasional colicky pain.
• Gallstone ileus: Signs of small bowel obstruction due to gallstone migration.
• Cholangiocarcinoma: Abdominal pain, jaundice, anorexia, weight loss, possible right upper quadrant mass.
Ix:
- bloods (LFTs, CRP
- US as first line imaging
- CT (better for stones)
- MRCP
- ERCP
Mx:
- IV fluids, antibiotics and critical care
- biliary drainage via ERCP
- cholecystectomy
