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CP3 Surgery > Hepatology > Flashcards

Hepatology Flashcards

1
Q

List the causes for acute (4) + chronic (8) hepatitis

A 
Acute:
• Alcohol
• Viruses (A–E/non A–E)
• Autoimmune
• Drug reactions (methyldopa, nitrofurantoin, diclofenac)

Chronic:
SAME 4 PLUS (viruses only B±D, C)
Hyperlipidaemia
Metabolic: Wilsons / a-1 antitrypsin / haemochromatosis

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2
Q

List the Ix for a liver screen (8)

A 
Viral screen
Lipids
Iron studies (ferritin/transferrin)
a-1 antitrypsin
AFP
Caeruloplasmin (Cu)
Immunology – autoAbs
Abdo USS
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3
Q

What would the virology tests show for Hep B in:

  1. the incubation phase?
  2. active hepatitis
  3. chronic hepatitis
  4. natural immunity
  5. vaccination
A
  1. HBsAg +ve / HBeAg +ve / PCR +ve
  2. all +ve except HBsAg
  3. same but >6m and LFTs less deranged
  4. HBsAb +ve / HBsAg –ve; HBeAb +ve / HBeAg –ve; HBcAb +ve / HBcAg –ve
  5. Same but HBcAb IgG –ve / HBeAb –ve
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4
Q

How does acute viral hepatitis present?

A

Pre-ictal/prodromal phase:
Non-specific lethargy / malaise / anorexia / N+V
Vague RUQ pain

Ictal phase:
Intrahepatic cholestatic jaundice 
Pale urine/dark stools
Pruritis / rash
Lymphadenopathy
Hepato/splenomegaly
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5
Q

How does acute alcoholic hepatitis present? (6)

A 
Alcoholic after binge
RUQ pain
Jaundice
Systemic upset
± S/o chronic CLD
AST:ALT >2
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6
Q

What is the prognosis predictor used in Alcoholic Hepatitis? / what does it consist of (3) / what value suggests severe

A

Discriminant Function
Severe = DF > 32

Hepatic encephalopathy
PT time
Bilirubin

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7
Q

What other conditions are associated with autoimmune hepatitis? (3)

A

PSC
PBS
IBD

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8
Q

What would be seen on liver screen Ix in autoimmune hepatitis?

A

Serology –ve
High autoAb titres (non-specific ANA/ASMA)
High transaminases

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9
Q

Outline the pharmacological management of autoimmune hepatitis (acute/long-term)

A

Acute:
Prednisolone 30mg OD
TMPT testing before starting Azathioprine
Reduce Pred

Long-term:
Azathio
Bone protection
Cortico (Pred)

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10
Q

How is viral hepatitis managed?

A

Any acute – supportive / alc avoidance

Chronic – PEG-interferons

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11
Q

List the indications for liver biopsy (5)

List the contraindications (3)

A 
?Chronic hepatitis
?Cirrhosis
?Cancer
?Storage disease
Unexplained hepatomegaly
Bleeding probs: Platelets low / PT prolonged
Overloaded liver (ascites)
Obstructed liver (extrahepatic cholestasis)
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12
Q

List some complications of liver biopsy (2+4)

A

Abdo/shoulder pain
Minor intraperitoneal bleeding

Haemothorax
Pleurisy
Haemobilia
Biliary peritonitis

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13
Q

List some non-invasive alternatives to liver biopsy (3)

A

Biomarkers (LFTs, bloods)
Fibroscan (transient elastography)
MR elastography

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14
Q

How long after a paracetamol overdose for

  1. Symptoms to appear
  2. LFT to change (+what do they show
A
  1. 24hrs initially asymp (may be anorexia/nausea)
  2. takes 18hrs for LFTs to derange (peaks at 72-96)
    Deranged ALT/ALP/INR
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15
Q

What physical features occur with paracetamol liver injury (6)

A 
RUQ pain
Hypotension
Hypoglycaemia
Metab acidosis
Pancreatitis
Arrhythmias
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16
Q

What can occur in paracetamol overdose if untreated? (2)

A 
Fulminant liver failure
Renal failure (acute tubular necrosis)
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17
Q

Outline the management of a paracetamol overdose (6) (ALBILM)

A

A–E
Lavage / charcoal (<1hr) (if >12g / >150mg/kg kids)
Bloods (4hrs):
LFT/INR / UEs / ABG / Gluc / Salicylate + Para level
IV N-AC
(over guidelines <8hrs; >150mg/kg + time unclear (stat))
Liver team – if deteriorates
Mental health liaison

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18
Q

What are some possible SEs of N-AC (4)

How are they treated

A

Rash
Oedema (rarely serious)
Hypotension (only stop if true anaphylaxis)
Bronchospasm

IV chloramphenamine
Stop N-AC only if true anaphylaxis (Alternative: oral methionine)

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19
Q

What pt groups is HCC seen more in?

List the causes for HCC (6)

A

Males > females
China/Sub-saharan

Chronic hepatitis
Cirrhosis
Metabolic liver disease
Anabolic steroids
Aspergillus aflatoxin
Parasites
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20
Q

What 2 additional features in HCC may differentiate from other liver problems

A

Abdo mass
Liver bruit

Also:
Non-specific (malaise/lethargy/wt loss)
RUQ pain
s/o CLD/decompensation
Hepatomegaly (smooth or hard/irreg)
Jaundice (late)
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21
Q

Investigations for ?Liver cancer

A 
Bloods: LFTs / Clotting / Viral serology / AFP
USS / CT (find lesions / guide biopsy)
Biopsy
ERCP (?cholangio)
MRI (benign vs malig)
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22
Q

Cholangiocarcinoma:
Causes (2)
Present as (1)
Treatment if presents early/late

A

Causes:
Parasitic
Primary sclerosing cholangitis

Present as: painless jaundice

Presents early: extended liver resection
Presents late: ERCP stent for palliation

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23
Q

List 2 types of benign liver tumours
How are they usually found?
When would be be treated?

A

Haemangioma – incidental on CT/MRI
Liver adenoma – young female OCP

Only treated if >5cm or symp

24
Q

List the causes for liver cirrhosis

A 
V: Budd-Chiari
I: Viral chronic **
I: Idio **
T: Alcohol **
A: AI / PSC / PBC
M: Wilsons / a-1 antitrpysin /haemochromatosis
I: drugs
C: CF
25
Q

List the features of cirrhosis (A–J)

A 
Ascites/Ankle oedema / Asterixis
Bleeding/Bruising 
Clubbing/Colour changed nails (leuco)
Dupuytren's / Derm (spider/striae/pigment)
Erythema (palmar) / Encephalopathy
Foetor (hepatic)
Gynaecomastia / Gonadal atrophy 
HTN (portal) / Hepatosplenomegaly / Hepatic flap
Itchy / Increased size parotids
Jaundice
26
Q

List decompensation triggers in chronic liver disease (4)

A

Alcoholic binge
GI bleed
Portal/hepatic vv thrombosis
Hepatotoxic drugs

27
Q

How are mortality scores calculated for chronic liver disease? (5)

A

Child-Pugh score

PT/INR
Encephalopathy
Bilirubin (total)
Albumin (serum)
Ascites
28
Q

How is severity of cirrhosis assessed? (5)

A

Func: Albumin / Clotting

Damage: LFTs

Complications: UEs (hepatorenal) / ABG (hepatopulm)

29
Q

What imaging can be done in liver cirrhosis? (3)

A

USS/Duplex
CT/MRI (HCC)
Endoscopy (varices)

30
Q

What may be seen on USS/Duplex in cirrhosis? (5)

A 
Liver shrunk/enlarged (esp L caudate lobe large)
Coarsened echo texture
Focal lesions
Portal flow reversal / thrombosis
Splenomeg
31
Q

Outline the management of Ascites (4)

What is the main complication and how is it managed

A 
Initial bed rest / fluid restriction / low salt (for smaller)
Spiro (high-dose) ± furosemide
Therapeutic paracentesis (for large)
Albumin infusion (for large)

SBP (pneumococcal)
Ascitic tap + MSU
IV ceftriaxone
Long-term norfloxacin (high recurrence)

32
Q

List the grades of encephalopathy

A

Grade 1: altered mood / behav / sleep disturbance
Grade 2: drowsiness / confusion
Grade 3: stupor / incoherence / restless
Grade 4: coma

33
Q

How is encephalopathy managed?

A

Oral lactulose w. regular enemas

If severe (evidence cerebral oedema):
ICU
20degree head tilt
IV mannitol
Hyperventilation
34
Q

List some causes for portal HTN (6)

A

Extrahepatic:
Portal vv thrombosis

Intrahepatic:
Cirrhosis
Congenital hepatic fibrosis
Hepatitis (e.g. alcoholic, viral)
Schistosomiasis
Idiopathic non-cirrhotic portal HTN
35
Q

List the causes for pre-hepatic jaundice (7)

A 
Physiological neonatal**
Breast milk*
Haemolytic (imm/non-imm)
Congenital defc (Gilbert's/Crigler-Najjar)
Ineffective erythropoiesis (pernicious)
Large haematoma reabsorption
Severe rhabdomyolysis
36
Q

What is Gilbert’s syndrome?
What is the prevalence
How is it diagnosed?

A

Congenital lack gluconyltransferase
7% population
Raised unconj bili + normal LFTs/reticulocytes

37
Q

List the causes for hepatocellular jaundice (4)

A

Hepatitis
Cirrhosis
Neoplasm
Hepatotoxics (para, methyldopa, barbiturates)

38
Q

List the causes of intrahepatic obstructive jaundice (4+1)

A 
Hepatitis
Cirrhosis
Neoplasm
Drugs (chlorpromazine, fluclox, isoniazid, OCP)
Pregnancy (oestrogen cholestatic)
39
Q

List the causes for extra-hepatic obstructive jaundice (1+2+3)

A

Gallstones

Pancreatic head cancer
Pancreatitis

Biliary atresia
Primary sclerosing cholangitis
Cholangiocarcinoma

40
Q

What investigations can be ordered for diagnosing the cause of jaundice?

A 
Bloods: 
LFT / Clotting / Bilrubin 
FBC / Reticulocytes
U+Es / Glucose
Blood film / Coombs'
Viral serology / autoAbs

Urinary: urobilinogen
Faecal: stercobilinogen

Scans: USS // CT/MRI

Invasive: Needle biopsy

41
Q

What is the LFTs /urinary / faecal picture in pre hepatic jaundice

A

Blood bilirubin ↑
LFTs normal
Clotting normal
Reticulocytes ↑

Urinary bili - absent
Urinary urobili - ↑/Normal
Faecal sterco - Normal

42
Q

What are the causes of pyogenic liver abscesses (4)

What are the features (4)

A

Biliary sepsis
Ascending abdo sepsis (appendix/perf)
Septicaemia
Trauma

Long non-specific h/o malaise
If acute: 
Abdo sepsis
Tender hepatomegaly
R sided pleural effusion
43
Q

What Ix can be done if suspect a liver abscess

How is it managed (3)

A

USS/CT
CXR

Aspiration under USS
IV Abx
Treat underlying cause

44
Q

What are the causative organisms of:
Pyogenic liver abscess
Amoebic abscess
Hyatid cyst

A

Pyogenic:
E.Coli
Strep.Milleri
Anaerobes

Amoebic: entamoeba histolytica

Hyatid: echinococcus granulosus

45
Q

What are the features of Amoebic liver abscess (4)

A

Asymp
Profuse/bloody diarrhoea
Swinging fever
RUQ pain/tenderness

46
Q

What specific investigations should be done if suspecting a hyatid liver cyst (5)
What is the management (3)

A 
USS/CT – demo cyst
AXR – wall calcification
Hyatid complement fixation test +ve
Haemagglutination +ve
Eosinophilia

Albendazole
FNA under USS
Deworm pet dogs

47
Q

What is primary biliary sclerosis?
How does it present? (4)
How is it managed

A

Autoimm destruction intrahepatic cannaliculi (IBD)

Jaundice
Pruritis
Skin xanthomas
Joint pain arthropathy

Dx: raised AMA
Tx: fat sol vit replacment

48
Q

What is primary sclerosing cholangitis?
How does it present?
What are the complications (4)

A

Autoimmune inflamm of bile ducts

Asymp UC pt w. abnormal LFTs
Pruritis/fatigue

Infective cholangitis
Biliary strictures
Cholangiocarcinoma
Liver cirrhosis

49
Q

Where are copper deposits found in Wilson’s disease?

A

Cornea
Basal ganglia
Liver

50
Q

What is seen on blood tests in Wilsons? (3)

A

↑Urinary copper
↑Liver biopsy copper
↓Caeruloplasmin

51
Q

How is Wilsons treated? (2)

A

Chelating agents:
D-penicillamine
Trientene

52
Q

List the complications of Hereditary Haemochromatosis (6)

A

HH Can Cause Deposits Anywhere

Hypogonadism
HCC
Cirrhosis
Cardiomyopathy
DM
Arthropathy
53
Q

List the causes of splenomegaly (CHINA)

List the causes of massive splenomegaly

A

Congestion: portal HTN
Haem: sickle / haemolytic
Infective: malaria / EBV / HIV / CMV / IE / schisto
Neoplastic: myeloproliferatives / lymphoma / CML
Autoimm: Sarcoidosis / RA / SLE

MMM
Malaria
Myelofibrosis
chronic Myeloid leukaemia

54
Q

What haematological effects can splenomegaly cause? (3)

A

Hypersplenism:
Pancytopenia
Haemolysis
↓Plasma vol

55
Q

What are the indications for splenectomy (3)

A

Splenic trauma
Hypersplenism
Autoimmune haemolyis (ITP/congenital haemolytics)

56
Q

Describe the post-splenectomy management

A

Prior: immunisations (Pneumococc/HIB/MenC/Flu)
Post-Op: DVT prophylaxis (transient rise platelets)
Post-Emergency ASAP: immunisations
Pen V lifelong / Erythromycin (pen.all.)
Pt education: carry alert cards // hosp s/o infection
Prophylaxis: malaria if foreign travel

CP3 Surgery (10 decks)

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