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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
List the features of cirrhosis (A–J)
``` 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
List decompensation triggers in chronic liver disease (4)
Alcoholic binge GI bleed Portal/hepatic vv thrombosis Hepatotoxic drugs
27
How are mortality scores calculated for chronic liver disease? (5)
Child-Pugh score ``` PT/INR Encephalopathy Bilirubin (total) Albumin (serum) Ascites ```
28
How is severity of cirrhosis assessed? (5)
Func: Albumin / Clotting Damage: LFTs Complications: UEs (hepatorenal) / ABG (hepatopulm)
29
What imaging can be done in liver cirrhosis? (3)
USS/Duplex CT/MRI (HCC) Endoscopy (varices)
30
What may be seen on USS/Duplex in cirrhosis? (5)
``` Liver shrunk/enlarged (esp L caudate lobe large) Coarsened echo texture Focal lesions Portal flow reversal / thrombosis Splenomeg ```
31
Outline the management of Ascites (4) | What is the main complication and how is it managed
``` 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
List the grades of encephalopathy
Grade 1: altered mood / behav / sleep disturbance Grade 2: drowsiness / confusion Grade 3: stupor / incoherence / restless Grade 4: coma
33
How is encephalopathy managed?
Oral lactulose w. regular enemas ``` If severe (evidence cerebral oedema): ICU 20degree head tilt IV mannitol Hyperventilation ```
34
List some causes for portal HTN (6)
Extrahepatic: Portal vv thrombosis ``` Intrahepatic: Cirrhosis Congenital hepatic fibrosis Hepatitis (e.g. alcoholic, viral) Schistosomiasis Idiopathic non-cirrhotic portal HTN ```
35
List the causes for pre-hepatic jaundice (7)
``` Physiological neonatal** Breast milk* Haemolytic (imm/non-imm) Congenital defc (Gilbert's/Crigler-Najjar) Ineffective erythropoiesis (pernicious) Large haematoma reabsorption Severe rhabdomyolysis ```
36
What is Gilbert's syndrome? What is the prevalence How is it diagnosed?
Congenital lack gluconyltransferase 7% population Raised unconj bili + normal LFTs/reticulocytes
37
List the causes for hepatocellular jaundice (4)
Hepatitis Cirrhosis Neoplasm Hepatotoxics (para, methyldopa, barbiturates)
38
List the causes of intrahepatic obstructive jaundice (4+1)
``` Hepatitis Cirrhosis Neoplasm Drugs (chlorpromazine, fluclox, isoniazid, OCP) Pregnancy (oestrogen cholestatic) ```
39
List the causes for extra-hepatic obstructive jaundice (1+2+3)
Gallstones Pancreatic head cancer Pancreatitis Biliary atresia Primary sclerosing cholangitis Cholangiocarcinoma
40
What investigations can be ordered for diagnosing the cause of jaundice?
``` 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
What is the LFTs /urinary / faecal picture in pre hepatic jaundice
Blood bilirubin ↑ LFTs normal Clotting normal Reticulocytes ↑ Urinary bili - absent Urinary urobili - ↑/Normal Faecal sterco - Normal
42
What are the causes of pyogenic liver abscesses (4) | What are the features (4)
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
What Ix can be done if suspect a liver abscess | How is it managed (3)
USS/CT CXR Aspiration under USS IV Abx Treat underlying cause
44
What are the causative organisms of: Pyogenic liver abscess Amoebic abscess Hyatid cyst
Pyogenic: E.Coli Strep.Milleri Anaerobes Amoebic: entamoeba histolytica Hyatid: echinococcus granulosus
45
What are the features of Amoebic liver abscess (4)
Asymp Profuse/bloody diarrhoea Swinging fever RUQ pain/tenderness
46
What specific investigations should be done if suspecting a hyatid liver cyst (5) What is the management (3)
``` USS/CT – demo cyst AXR – wall calcification Hyatid complement fixation test +ve Haemagglutination +ve Eosinophilia ``` Albendazole FNA under USS Deworm pet dogs
47
What is primary biliary sclerosis? How does it present? (4) How is it managed
Autoimm destruction intrahepatic cannaliculi (IBD) Jaundice Pruritis Skin xanthomas Joint pain arthropathy Dx: raised AMA Tx: fat sol vit replacment
48
What is primary sclerosing cholangitis? How does it present? What are the complications (4)
Autoimmune inflamm of bile ducts Asymp UC pt w. abnormal LFTs Pruritis/fatigue Infective cholangitis Biliary strictures Cholangiocarcinoma Liver cirrhosis
49
Where are copper deposits found in Wilson's disease?
Cornea Basal ganglia Liver
50
What is seen on blood tests in Wilsons? (3)
↑Urinary copper ↑Liver biopsy copper ↓Caeruloplasmin
51
How is Wilsons treated? (2)
Chelating agents: D-penicillamine Trientene
52
List the complications of Hereditary Haemochromatosis (6)
HH Can Cause Deposits Anywhere ``` Hypogonadism HCC Cirrhosis Cardiomyopathy DM Arthropathy ```
53
List the causes of splenomegaly (CHINA) | List the causes of massive splenomegaly
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
What haematological effects can splenomegaly cause? (3)
Hypersplenism: Pancytopenia Haemolysis ↓Plasma vol
55
What are the indications for splenectomy (3)
Splenic trauma Hypersplenism Autoimmune haemolyis (ITP/congenital haemolytics)
56
Describe the post-splenectomy management
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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