Hepatology

Question 1

Typical pathology of pancreatic cancer

Answer 1

60% arise in head: obstruct CBD/early obstructive jaundice.
20% arise diffusely
15% arise in body
5% arise in tail
Hard, stellate grey-White mass

Question 2

Microscopic pathology of pancreatic carcinoma

Answer 2

Mostly adenocarcinoma from pancreas ducts. Moderately differentiated.
Adenoma-adenocarcinoma sequence (like colorectal)
precursor lesions= pancreatic intraepithelial neoplasias.
Adenocarcinoma: glandular spaces in fibrous stroma. Recapitulate normal ductal epithelia. Secrete mucin.
‘Desmoplastic response’ prominent: intense host rxn of fibroblasts and extracellular matrix.

Question 3

Pancreatic cancer pattern of invasion/spread

Answer 3

Highly invasive
-local/peripancreatic: perineural infiltration, duodenal, CBD obstruction.
-lymph: peripancreatic, gastric, Mesenteric, omental, portohepatic nodes.
-vascular: to liver.
Metastases occasionally: lung, liver, bones.
Occasionally invade: spleen, adrenals, vertebral column, transverse colon, stomach.

Question 4

Natural history of pancreatic cancer

Answer 4

Jaundice ~50% (usually painless)
- obstructive with painless non-palpable gallbladder (Courvoisier’s sign)
Non-specific:
- weight loss
- anorexia
- malaise
- pain is a late sign usually (chronic persistent epigastric, radiating to back)
Rarely:
- 10% migratory thrombophlebitis (trousseau’s sign)
- vomiting (duodenal obstruction)
- acute pancreatitis or diabetes mellitus.
Briefly symptomatic course rapidly progressive.

Question 5

Management of pancreatic cancer

Answer 5

Conservative

Surgical

Question 6

Early detection of pancreatic cancer

Answer 6

K-ras oncogene mutated in 90% but screening tests unproven.
Serum levels of CEA and CA19-9 usually elevated. Not specific or sensitive enough.
Endoscopic ultrasound AND per cutaneous needle biopsy for dialysis now.

Question 7

Work up for Whipple’s resection

Answer 7

Triple phase CT C/A/P
EUS FNA (endoscopic ultrasound fine needle aspiration)
-> what is the mass, is it resectable?

Echocardiogram, lung function tests: is pt fit for surgery?
ERCP/MRCP/PET/Laparoscopy

Question 8

Staging for pancreatic cancer

Answer 8

Whipple's 
T0/IS
T1 2cm within pancreas
T3 tumour outside pancreas but no major vascular involvement
T4 major vascular involvement
N0/1
M0/1

Question 9

Non-resectable pancreatic cancer work up

Answer 9

• tissue diagnosis
• ERCP/PTC metal stents or bypass surgery
• pain relief
• palliative chemo
• induction into novel trials.

Question 10

Prognosis post-Whipple’s

Answer 10

Pancreatic adenocarcinoma 20% 5y survival
Cholangiocarcinoma 25% 5y survival
Ampullary cancer 40% 5y survival
Neuroendocrine 70% 5y survival
Cystic lesions 70% 5y survival
No resection 0% 5y survival

Peri-op mortality 1.4%

Question 11

Causes of biliary strictures

Answer 11

Benign:
- iatrogenic, gallstones, pancreatitis, PSC, papillary stenosis
(Rarely: ischaemia, congenital, infective, autoimmune, choledochal varices)
Malignant: pancreas, ampulla, gallbladder, cholangiocarcinoma, intrahepatic.

Question 12

Risk factors for pancreatic cancer

Answer 12

Smoking (2/3x)
Diet rich in fats
Chronic pancreatitis and DM Asn
Inherited genetic syndromes 10% e.g. Hereditary pancreatitis, multiple endocrine neoplasia.
Age: 60-80y (80%) 
M:F 2:1
3-5% cancer deaths uk 
5y survival 5%

Question 13

Advanced liver disease/cirrhosis changes

Answer 13

Nodular liver margin
Segmental atrophy
Heterogenous parenchyma
Splenomegaly
Porto-systemic shunts- varices, paraumbilical vein patency
Abnormal portal vein flow
Ascites

Question 14

Complications of biliary calculi

Answer 14

Cholangitis
Cholecystitis/Cholelithiasis
Mucocoele of gallbladder
Obstructive jaundice
Ascending cholangitis
Pancreatitis (transient Impaction at papilla)
Gallstone ileus.

Question 15

Causes of chronic live disease

Answer 15

Common: 
alcohol 60-70%
NASH 10-15%
viral hepatitis (B[D] and C) 10%
Biliary disease 5-10%
Primary Haemachromatosis 5%

Less common: autoimmune (PSC, PBC, AIH); metabolic (Wilson’s, a1AT deficiency).

Question 16

Liver blood screen

Answer 16

Viral serology: HBcAb IgG, HBsAg; HVC Ab
Autoimmune serology: ASA, AMA, anti-LKM, immunoglobulin profile.
Metabolic profile: ferretin; caeruloplasmin; a1AT level.

Question 17

Hepatitis B modes of transmission (6B) /risk groups (6H)

Answer 17

Modes of transmission: 
Bang (heterosexual sex)
Bum (homosexual sex)
Belushi (heroin/IV drug use/sharing needles)
Blood (haemophiliacs/dialysis

Question 18

Questions to ask if suspecting alcoholism?

Answer 18

Cut down? Have you ever felt the need to cut down on your drinking?
Annoyed? Have people annoyed you by criticising your drinking?
Guilty? Have you ever felt guilty about drinking?
EYe-opener? Have you ever felt you needed a drink first thing in the morning to steady your nerves/manage a hangover?

Question 19

What is Mirrizzi’s syndrome?

Answer 19

Very large stone within the gallbladder externally compressing the CBD (in hartmann’s pouch or cystic duct)

Question 20

What does AST, ALT, ALP and GGT show?

Answer 20

ALT and AST: hepatocellular death

ALP + GGT: cholestasis (>ALT and AST)

Question 21

Causes of liver disease?

Answer 21

Viral, NAFLD, Alcohol, autoimmune, paracetamol OD, metabolic (haemachromatosis etc)

Question 22

AST:ALT ratio >2 significance?

Answer 22

Alcoholic liver disease seems likely

But muscle inflammation in dermatopolymyositis may cause it

Question 23

AST:ALT ratio <1 significance (if both are raised)

Answer 23

NAFLD, acute viral hepatitis, toxin hepatitis, ischaemic, chronic Hep C

Question 24

Clinical biochemistry of paracetamol OD?

Answer 24

Decreased metabolic function: hypoglycaemia, metabolic acidosis
Decreased synthetic function: increased PT, low albumin
Other: hepatic encephalopathy

Question 25

Cause of isolated rise in GGT?

Answer 25

Alcohol abuse (look for mild changes in AST or ALT; macrocytic RBC)
Enzyme inducing drugs: phenytoin, carbamazepine, phenobarbital.

Question 26

Antibodies associated with PBC?

Answer 26

Antimitochondrial antibodies

Question 27

Antibodies associated with PSC?

Answer 27

ANA + pANCA +

Question 28

Key differences of PBC and PSC

Answer 28

PBC: Autoimmune, Antimitochondrial Antibodies, Attenuated bile duct epithelium. Women. Asn with other autoimmune diseases. Affects small ducts
PSC: Periductal Onion skin fibrosis, and beaded appearance (O)on imaging. Men. Asn with UC. ANA+, pANCA+, antismooth muscle antibodies. Obliterative cholangitis. Affects big ducts. Oncology (asn with cholangiocarcinoma)