Hepatology Flashcards
Give 2 causes of an isolated rise in unconjugated bilirubin?
Gilbert’s syndrome and haemolysis
What are the 5 f’s associated with gallstones?
Female, fat, forty, fair and fertile.
list 4 causes of acute pancreatitis
GET SMASHED Gallstones Ethanol (alcohol) Trauma Steroids Mumps/Malignancy Autoimmune Scorpion venom Hyperlipidaemia, hypothermia, hypercalcaemia ERCP and emboli Drugs
give 3 symptoms/signs of acute pancreatitis
pain, nausea, vomiting. tachycardia, fever, jaundice, shock, ileus, rigid abdomen ± local tenderness. Cullen’s and Grey Turner’s signs.
what investigations would you carry out in acute pancreatitis?
FBC, CRP, U&Es (including glucose, calcium, albumin), LFTs, ABG, amylase/lipase (usually 3x upper limit)
Imaging = Erect AXR, Abdo USS, CT abdo with contrast
Give 3 criteria in the Modified Glasgow criteria for predicting severity of pancreatitis
PANCREAS = PaO2 <8.0kPa, Age >55 years, Neutrophils (>15 x 10^9/L), Calcium <2 mmol/L, Renal function, Enzymes (AST, LDH), Albumin <32g/L, Sugar (gluc >10mmol/L)
Outline the medical management of acute pancreatitis?
- Admit, NBM, may need NG
- O2, aggressive IV fluids, analgesia, anti-emetics
- Fluid balance
- VTE prophylaxis
- Glucose measured
- Enteral if prolonged fasting. May need ITU
Give 2 early and 2 late possible complications of acute pancreatitis
Early: shock, ARDS, renal failure, DIC, hypocalcaemia.
Late: pancreatic necrosis, abscesses, bleeding, pseudocyst
What is chronic pancreatitis?
Chronic inflammation of pancreas with progressive destruction of the exocrine pancreas, resulting in irreversible injury
3 causes of chronic pancreatitis?
Alcohol (80%), idiopathic, genetic (CF), autoimmune, malnutrition, pancreatic duct obstruction
Give 4 clinical features of chronic pancreatitis
Intermittent abdo pain radiating to back
N/V
Malabsorption Sx e.g. steatorrhoea, diarrhoea, weight loss
Glycaemic dysfunction
First line imaging for chronic pancreatitis and what alternatives if CI?
CT pancreas with contrast
MRCP or EUS
What 2 markers can be used to assess pancreatic function in chronic pancreatitis?
Serum glucose (raised if endocrine insufficiency) Faecal elastase (reduced)
Management of chronic pancreatitis?
NSAIDs for abdo pain (may need opioids)
Creon + fat-soluble vit supplements.
No alcohol, low fat diet.
Glycaemic control
Describe the 3 different types of gallstones and their causes
Cholesterol stones - large, radio-opaque - age, obesity, female sex.
Pigment stones - small, friable, irregular - haemolysis. Black pigment stones are radio-opaque, brown are radio-lucent.
Mixed stones - faceted (calcium salts, pigment and cholesterol).
3 investigations for gall stones?
LFTs - bilirubin, ALP, GGT may be raised
Abdo US
consider MRCP
Management options for gall stones?
Dietary advice
Reassurance if asymptomatic
Lap chole if symptomatic
CBD stones–> ERCP for clearance, then lap chole
How does acute cholecystitis develop from an obstruction?
Obstruction to gall bladder emptying - bile retention - distension and inflammatory response to retained bile
What are 2 causes of acalculous cholecystitis?
Biliary stasis due to sepsis, trauma or extrinsic compression
Biliary sludge
What special test would you do on examination to confirm cholecystitis?
Murphy’s sign - 2 fingers over RUQ + ask patient to breathe in - causes pain and arrest of inspiration as inflamed gallbladder hits your fingers
Needs to be negative on left side in order for Murphy’s to be positive
how would you differentiate the pain of biliary colic from cholecystitis?
cholecystitis features an inflammatory component - local peritonism, fever, high WCC
5 investigations to do in acute cholecystitis?
FBC (raised WCC), CRP (raised), LFTs , amylase to rule out concurrent pancreatitis Abdo US CT abdo (if empyema or perforation suspected)
Management of cholecystitis?
- Opioids and anti-emetics
- IV fluids and antibiotics
- Lap chole, most after 6-12 weeks once settled, or can be immediate.
A patient presents with jaundice, RUQ pain and fever. What does this presentation suggest?
Charcot’s triad –> ascending cholangitis
What is Reynolds pentad for cholangitis?
Charcot’s triad (RUQ pain, jaundice, fever) plus altered mental state and hypotension
4 common causative organisms of cholangitis?
Klebsiella spp., E.coli, enterococci and streptococci
What is the most common underlying pathology in ascending cholangitis?
Bile stasis due to obstructing CBD stone
Management of cholangitis?
- Initial resus e.g. IV fluids, oxygenation
- IV abx (based on local policy) following blood cultures
- ERCP (stone removal +/- sphincterotomy +/- stenting
Give 3 conditions assoc with cholangiocarcinoma
How is it diagnosed?
Serum marker?
Management?
PSC, infections with liver flukes, gallstone disease, Caroli disease.
Dx on imaging e.g. CT or MRCP
CA 19-9 may be elevated
Surgery is mainstay
give 3 causes of unconjugated hyperbilirubinaemia (pre-hepatic jaundice)
Haemolysis - malaria, DIC, haemolytic anaemia
Ineffective erythropoiesis.
Impaired hepatic uptake - drugs (contrast agents, rifampicin), RHF.
Impaired conjugation - Gilbert’s syndrome, Crigler-Najjar.
what will the urine and faeces look like in conjugated hyperbilirubinaemia (hepatic/post-hepatic jaundice)? why?
urine = dark - conjugated bilirubin is soluble, so excreted in urine. Faeces = pale - less conjugated bilirubin enters gut.
Give 5 hepatic causes of jaundice
Hepatitis - viral, autoimmune, alcoholic
Drugs - paracetamol, statins, rifampicin, isoniazid, ketoconazole
Carcinoma
Hereditary - haemochromatosis, Wilson dis, A1AT def
Give 3 causes of obstructive/cholestatic jaundice?
Gall stones, pancreatic cancer, cholangiocarcinoma, PSC, PBC,
Drugs e.g. fluclox, co-amox, sulphonylureas, COCP
How is hepatitis A spread? what are the risk factors?
Faecal-oral route. Poor sanitation, overcrowding, contaminated food/water.
What serological marker indicates acute Hep A infection?
What indicates immunity/past infection?
Anti-HAV IgM
Anti-HAV IgG
How do you manage Hep A?
Supportive, self-limiting
Most of the viral hepatitis A-E are RNA viruses, apart from which one?
Hep B is a DNA virus
Which hepatitis virus is dependent on Hep B infection for replication?
Hep D - it’s an incomplete RNA virus and needs concurrent hep B infection
Most common cause of hepatitis?
Hep B
How is hep B spread?
Blood-borne (IVDUs, vertical, needle-stick injury) and sexual transmission
What serological marker indicates acute infection of Hep B?
Hep B is deemed chronic if this marker persists for how long?
HepB surface antigen
6 months
HBV surface antigen antibody indicates what two possibilities regarding infection?
Implies immunity - either past exposure or vaccination
What serological marker can help determine whether Hep B immunity comes from past infection or vaccination?
Anti-HBc - indicates current or past infection
c = caught, so negative if immunised
Which of hepatitis A-E have a vaccine?
A, B (and so D)
What drugs are indicated in management of chronic hep B?
PEGinterferon +/- antivirals (tenofivir, entecavir)
2 possible comps of Hep B?
Cirrhosis, HCC, cholangiocarcinoma, chronic hepatitis, fulminant liver failure, polyarteritis nodosa