Hepatology Conditions A Flashcards
Liver Failure - Description
inability of liver to regenerate or repair
Liver Failure - Causes (12)
toxins 1) paracetamol overdose* (>50%) 2) alcohol viral 3) hepatitis (esp. B, C) 4) cytomegalovirus 5) Epstein-Barr virus metabolic 6) haemochromatosis 7) Wilson’s disease 8) alpha-1-antitrypsin deficiency other 9) non-alcoholic fatty liver disease 10) hepatocellular carcinoma 11) primary sclerosing cholangitis 12) Budd Chiari syndrome
Liver Failure - Pathophysiology (4)
1) hepatocyte destruction
2) nodule destruction
3) fibrosis due to chronic inflammation
4) inability of liver to regenerate or repair
Liver Failure - Symptoms (Paracetamol Overdose) (4)
1) asymptomatic (<24 hours)
2) abdominal pain
3) nausea
4) vomiting
Liver Failure - Signs (8)
1) jaundice
2) fetor hepaticus (sweet, putrid breath)
3) asterixis
4) ascites
5) bruising
6) clubbing
7) Dupuytren’s contracture
8) signs of hepatic encephalopathy
Liver Failure - Signs (Hepatic Encephalopathy) (10)
grade I 1) altered mood/behaviour 2) sleep disturbance 3) dyspraxia grade II 4) drowsiness 5) confusion 6) dysarthria grade III 7) incoherent 8) restless 9) stupor grade IV 10) coma
Liver Failure - Complications (5)
1) hepatic encephalopathy
2) cerebral oedema
3) ascites
4) hypoglycaemia
5) coagulopathy
Liver Failure - Investigations (4/3)
initial 1) blood culture 2) FBC 3) U+E 4) LFT consider 1) chest x-ray 2) abdomen ultrasound (small liver, underlying cause) 3) liver biopsy*
Liver Failure - Management (0/3/1)
medical 1) treat underlying cause (e.g. n-acetyl-cysteine —> paracetamol overdose) 2) treat complications 3) prophylactic antibiotics surgery 1) liver transplant
Cholelithiasis - Description
gallstones temporarily blocking cystic duct
Cholelithiasis - Risk Factors (5)
5Fs
1) fat (obesity)
2) female
3) fertility (more kids = more gallstones)
4) forty (age)
5) family history
Cholelithiasis - Types (3)
1) cholesterol (80%)
2) pigment (mainly Ca2+, bilirubin)
3) mixed
Cholelithiasis - Pathophysiology (Cholesterol) (3)
1) excess cholesterol
2) cholesterol crystallisation in bile
3) gallstone obstructs cystic duct
Cholelithiasis - Symptoms (5)
1) asymptomatic
2) right upper quadrant pain (sudden, crescendo, constant)
3) pain radiates to epigastrium, right shoulder, right subscapular
4) nausea
5) vomiting
Cholelithiasis - Complications (5)
1) choledocholithiasis
2) cholecystitis
3) ascending cholangitis
4) acute pancreatitis
5) gallstone ileus
Cholelithiasis - Investigations (3/1)
initial
1) FBC (normal)
2) LFT (normal; high ALP, high bilirubin in choledocholithiasis)
3) abdomen ultrasound*
consider
1) endoscopic resonance cholangiopancreatography (unconfirmed by ultrasound)
Cholelithiasis - Management (2/3)
medical
1) analgesia (esp. NSAID)
2) ursodeoxycholic acid (cholesterol gallstone)
surgery
1) laparoscopic cholecystectomy*
2) shock wave lithotripsy
3) endoscopic retrograde cholangiopancreatography + sphincterotomy (choledocholithiasis)
Cholecystitis - Description
inflammation of gallbladder due to blockage of cystic duct
Cholecystitis - Causes (1)
1) cholelithiasis
Cholecystitis - Pathophysiology (6)
1) cholelithiasis (gallstone formation in gallbladder)
2) biliary colic (gallstone blocks cystic duct)
3) bile secretion
4) pressure build up in gallbladder
5) damage/infection to gallbladder wall
6) inflammation of gallbladder
Cholecystitis - Symptoms (5)
1) right upper quadrant pain (sudden, crescendo, constant)
2) pain radiates to epigastrium, right shoulder, right subscapular
3) fever
4) nausea
5) vomiting
Cholecystitis - Signs (2)
1) Murphy’s sign (respiratory arrest when RUQ palpated during deep inspiration)
2) right upper quadrant tenderness
Cholecystitis - Complications (4)
1) gallbladder rupture
2) gallstone ileus
3) empyema
4) gangrene
Cholecystitis - Investigations (4/1)
initial 1) FBC (leucocytosis) 2) high CRP + ESR 3) LFT (high ALP, high bilirubin) 4) abdomen ultrasound* consider 1) endoscopic retrograde cholangiopancreatography (unconfirmed by ultrasound)
Cholecystitis - Management (0/3/2)
medical 1) analgesia (esp. NSAID) 2) IV antibiotics 3) ursodeoxycholic acid (cholesterol gallstone) surgery 1) laparoscopic cholecystectomy* 2) shockwave lithotripsy
Ascending Cholangitis - Description
inflammation of biliary tree due to blockage of common bile duct
Ascending Cholangitis - Causes (2)
1) choledocholithiasis (gallstone in common bile duct)
2) bacteria (Klebsiella, Escherichia coli)
Ascending Cholangitis - Pathophysiology (5)
1) choledocholithiasis (gallstone in common bile duct)
2) bile secretion
3) pressure build up in biliary tree
4) damage/infections to biliary tree
5) inflammation of biliary tree
Ascending Cholangitis - Symptoms (5)
1) right upper quadrant pain (sudden, crescendo, constant)
2) pain radiates to epigastrium, right shoulder, right subscapular
3) fever (inc. rigors)
4) nausea
5) vomiting
Ascending Cholangitis - Signs (Charcot’s Triad) (3)
1) right upper quadrant pain
2) fever
3) jaundice
Ascending Cholangitis - Signs (Reynold’s Pentad) (5)
shock
1) right upper quadrant pain
2) fever
3) jaundice
4) hypotension
5) altered mental status
Ascending Cholangitis - Complications (4)
1) jaundice
2) acute pancreatitis
3) gastrointestinal infection
4) sepsis
Ascending Cholangitis - Investigations (6/0)
initial
1) FBC (leucocytosis)
2) high CRP + ESR
3) LFT (high ALP, high bilirubin)
4) abdomen ultrasound
5) blood culture
6) endoscopic retrograde choliangiopancreatography*
Ascending Cholangitis - Management (0/2/3)
medical 1) analgesia (esp. opioids) 2) IV antibiotics surgery 1) endoscopic retrograde cholangiopancreatography + sphincterotomy (1st line) 2) laparoscopic cholecystectomy* 3) shockwave lithotripsy
Primary Sclerosing Cholangitis - Description
chronic inflammation and fibrosis of intrahepatic and extrahepatic bile ducts leading to cholestatic liver disease
Primary Sclerosing Cholangitis - Risk Factors (5)
1) 40-50 years old
2) male
3) family history
4) ulcerative colitis
5) autoimmune hepatitis
Primary Sclerosing Cholangitis - Symptoms (5)
1) right upper quadrant pain
2) epigastric pain
3) pruritus
4) fatigue
5) weight loss
Primary Sclerosing Cholangitis - Signs (1)
1) jaundice
Primary Sclerosing Cholangitis - Complications (5)
1) ascending cholangitis
2) jaundice
3) cirrhosis
4) liver failure
5) malignancy (bile duct, gallbladder, liver, colon)
Primary Sclerosing Cholangitis - Investigations (3/1)
initial
1) FBC
2) LFT
3) endoscopic retrograde cholangiopancreatography*
consider
1) liver biopsy (fibrous, obliterative cholangitis)
Primary Sclerosing Cholangitis - Management (1/1/1)
conservative 1) annual cancer screening (ultrasound + colonoscopy) medical 1) cholestyramine (pruritus) surgery 1) liver transplant*
Acute Pancreatitis - Description
acute inflammation of pancreas
Acute Pancreatitis - Causes (3)
1) gallstones (60%)
2) alcohol (30%)
3) idiopathic (10%)
esp. gallstones, then heavy alcohol intake
Acute Pancreatitis - Pathophysiology (Gallstones) (5)
1) obstruction of pancreatic duct
2) accumulation of pancreatic enzyme-rich fluid
3) premature activation of pancreatic enzymes
4) enzyme mediated autodigestion of pancreas
5) inflammation of pancreas
Acute Pancreatitis - Pathophysiology (Alcohol) (5)
1) alcohol alters Ca2+ metabolism
2) increased pancreatic enzyme secretion
3) premature activation of pancreatic enzymes
4) enzyme mediated autodigestion of pancreas
5) inflammation of pancreas
Acute Pancreatitis - Symptoms (4)
1) epigastric pain (bores to back)
2) nausea
3) vomiting
4) anorexia
Acute Pancreatitis - Signs (2)
1) Grey Turner’s sign (flank bruising)
2) Cullen’s sign (periumbilical bruising)
Acute Pancreatitis - Complications (3)
1) sepsis
2) acute respiratory distress syndrome
3) acute kidney injury
Acute Pancreatitis - Investigations (5/1)
initial 1) FBC (leucocytosis) 2) high CRP + ESR 3) serum amylase (3x upper limit) 4) serum lipase (high) 5) abdomen ultrasound (gallstone) consider 1) abdomen CT
Acute Pancreatitis - Management (3/6/1)
conservative 1) dietary advice (low dietary fat) 2) nutritional support 3) alcohol cessation medical 1) IV fluids 2) analgesia 3) antiemetic 4) Ca2+ supplement 5) Mg2+ supplement 6) prophylactic antibiotics surgery 1) cholecystectomy (gallstones)
Chronic Pancreatitis - Description
chronic inflammation of pancreas
Chronic Pancreatitis - Causes (3)
1) alcohol (60-70%)
2) smoking
3) autoimmune (esp. coeliac disease)
Chronic Pancreatitis - Symptoms (9)
1) recurrent epigastric pain (bores to back)
2) pain relieved when sitting forward
3) pain exacerbated by eating/drinking heavily
4) nausea
5) vomiting
6) anorexia
malabsorption
7) weight loss
8) diarrhoea
9) steatorrhoea
Chronic Pancreatitis - Signs (1)
1) erythema ab igne (reticulated hyperpigemented erythema, dusky grey)
Chronic Pancreatitis - Complications (5)
1) diabetes mellitus
2) pancreatic exocrine insufficiency
3) pancreatic pseudocysts
4) pancreatic obstruction
5) biliary obstruction
Chronic Pancreatitis - Investigations (3/1)
initial
1) serum glucose (high)
2) abdomen ultrasound (calcified, dilated pancreatic duct)
3) abdomen CT (calcified, dilated pancreatic duct)
consider
1) endoscopic cholangiopancreatography*
Chronic Pancreatitis - Management (4/4/3)
conservative 1) dietary advice (low dietary fat) 2) nutritional support 3) smoking cessation 4) alcohol cessation medical 1) analgesia (NSAID—>opioid) 2) antiemetic 3) pancreatic enzymes + PPI 4) vitamin ADEK supplements surgery 1) shockwave lithotripsy 2) pancreatectomy 3) duct drainage
Alcoholic Liver Disease - Description
chronic liver disease due to excess alcohol
Alcoholic Liver Disease - Risk Factors (5)
1) >65 years old
2) female
3) hepatitis
4) alcohol (chronic abuse)
5) smoking
Alcoholic Liver Disease - Stages (3)
1) alcoholic steatosis
2) alcoholic hepatitis
3) alcoholic cirrhosis
Alcoholic Liver Disease - Pathophysiology (6)
1) alcohol metabolism produces fat in liver
2) hepatocytes become swollen with fat (steatosis)
3) alcohol metabolism produces free radicals in liver
4) free radicals damage hepatocytes (hepatitis)
5) alcohol transforms stellate cells into myofibroblasts
6) myofibroblasts produce collagen causing fibrosis (cirrhosis)
Alcoholic Liver Disease - Symptoms (7)
1) asymptomatic
2) right upper quadrant pain
3) nausea
4) anorexia
5) weight loss or weight gain
6) fatigue
7) fever
Alcoholic Liver Disease - Signs (3)
1) hepatomegaly
2) jaundice
3) ascites
Alcoholic Liver Disease - Complications (7)
1) hepatitis
2) cirrhosis
3) liver failure
4) hepatocellular carcinoma
5) hepatic encephalopathy
6) portal hypertension
7) coagulopathy
Alcoholic Liver Disease - Investigations (Steatosis) (2/1)
initial 1) LFT (high AST, high ALT) 2) FBC (macrocytic anaemia) consider 1) abdomen ultrasound/CT* (fatty infiltration)
Alcoholic Liver Disease - Investigations (Hepatitis) (3/1)
initial 1) LFT (high AST, high ALT) 2) FBC (macrocytic anaemia) 3) high CRP + ESR consider 1) abdomen ultrasound/CT* (fatty infiltration)
Alcoholic Liver Disease - Investigations (Cirrhosis) (3/2)
initial
1) LFT (high AST, high ALT, AST/ALT>2, low albumin)
2) FBC (macrocytic anaemia)
3) U+E (low Na+)
consider
1) abdomen ultrasound/CT (fatty infiltration)
2) liver biopsy* (confirmation)
Alcoholic Liver Disease - Management (6/3/1)
conservative 1) dietary advice (low dietary salt) 2) weight loss 3) smoking cessation 4) alcohol cessation 5) counselling (inc. AA) 6) vaccinations medical 1) vitamin supplements 2) thiamine (prevents Wernicke’s encephalopathy) 3) corticosteroids surgery 1) liver transplant
Non-Alcoholic Fatty Liver Disease - Description
syndrome characterised by histological macrovascular hepatic steatosis (fat swollen hepatocytes)
Non-Alcoholic Fatty Liver Disease - Risk Factors (6)
1) obesity
2) diabetes mellitus
3) dyslipidaemia
4) hypertension
5) rapid weight loss
6) hepatotoxic drugs (e.g. CCB)
Non-Alcoholic Fatty Liver Disease - Symptoms (3)
1) right upper quadrant discomfort
2) fatigue
3) malaise
Non-Alcoholic Fatty Liver Disease - Signs (4)
1) no significant alcohol use
2) hepatomegaly
3) splenomegaly
4) truncal obesity
Non-Alcoholic Fatty Liver Disease - Complications (3)
1) cirrhosis
2) hepatocellalur carcinoma
3) portal hypertension
Non-Alcoholic Fatty Liver Disease - Investigations (4/2)
initial 1) LFT (high AST, high ALT, AST/ALT<1, low ALP, low albumin) 2) FBC (macrocytic anaemia) 3) U+E (low Na+) 4) lipid profile consider 1) abdomen ultrasound/CT (fatty infiltration) 2) liver biopsy* (confirmation)
Non-Alcoholic Fatty Liver Disease - Management (2/1/2)
conservative 1) regular exercise 2) weight loss medical 1) statin surgery 1) gastric bypass 2) liver transplant
Cirrhosis - Description
irreversible end stage of chronic liver disease
Cirrhosis - Causes (3)
1) alcoholic liver disease
2) non-alcoholic fatty liver disease
3) hepatitis (B, C)
Cirrhosis - Pathophysiology (4)
1) chronic liver injury
2) hepatocyte necrosis
3) fibrosis
4) irreversible liver damage
Cirrhosis - Symptoms (4)
1) asymptomatic (early)
2) abdominal pain
3) pruritus
4) melaena
Cirrhosis - Signs (Hands) (5)
1) leukonychia
2) Terry’s nails
3) clubbing
4) palmar erythema
5) Dupuytren’s contracture
Cirrhosis - Signs (Other) (7)
1) jaundice
2) spider angioma
3) bruising
4) ankle swelling
5) abdominal distension
6) body hair loss
7) fetor hepticus (sweet, putrid breath)
Cirrhosis - Complications (10)
1) portal hypertension —> gastro-oesophageal varices
2) ascites (50%)
3) jaundice
4) hepatocellular carcinoma
5) coagulopathy
6) hypoalbuminaemia
7) congestive splenomegaly
8) portosystemic shunt
9) hepatorenal syndrome
10) hepatic encephalopathy
Cirrhosis - Investigations (3/2)
initial 1) LFT (high AST, high ALT, AST/ALT>1, low albumin, high PTT) 2) FBC (macrocytic anaemia) 3) U+E (low Na+) consider 1) abdomen ultrasound/CT 2) liver biopsy* (confirmation)
Cirrhosis - Management (3/2/1)
conservative 1) dietary advice (e.g. low dietary salt) 2) alcohol cessation 3) biannual hepatocellular carcinoma screening (ultrasound) medical 1) treat underlying cause 2) treat complications surgery 1) liver transplant
Portal Hypertension - Description
high blood pressure in hepatic portal system
Portal Hypertension - Types (3)
1) pre-hepatic
2) intra-hepatic (common)
3) post-hepatic (rare)
Portal Hypertension - Causes (Pre-Hepatic) (1)
1) thrombosis (splenic or hepatic portal vein)
Portal Hypertension - Causes (Intra-Hepatic) (3)
1) cirrhosis (most common UK)
2) schistosomiasis (most common WW)
3) sarcoidosis
Portal Hypertension - Causes (Post-Hepatic) (2)
1) Budd Chiari syndrome (thrombosis/tumour in hepatic vein)
2) congestive heart failure
Portal Hypertension - Pathophysiology (Cirrhosis) (3)
1) fibrosis
2) myofibroblast contraction increases hepatic vascular resistance
3) portal hypertension
Portal Hypertension - Symptoms (1)
1) asymptomatic
Portal Hypertension - Signs (2)
1) splenomegaly
2) signs of cirrhosis
Portal Hypertension - Complications (2)
1) gastro-oesophageal varices
2) haemorrhage —> shock
Portal Hypertension - Investigations (2/0)
initial
1) hepatic venous pressure gradient
2) abdomen ultrasound
Portal Hypertension - Management (0/1/3)
medical
1) propranolol (haemorrhage prophylaxis)
surgery
1) endoscopic banding (haemorrhage prophylaxis)
2) transjugular intrahepatic portosystemic shunt (haemorrhage)
3) balloon tamponade (haemorrhage)
Gastro-Oesophageal Varices - Description
extremely dilated sub-mucosal veins
Gastro-Oesophageal Varices - Causes (1)
1) portal hypertension
Gastro-Oesophageal Varices - Pathophysiology (2)
1) portal hypertension
2) extremely dilated sub-mucosal veins
Gastro-Oesophageal Varices - Symptoms (3)
haemorrhage
1) abdominal pain
2) haematemesis
3) rectal bleeding
Gastro-Oesophageal Varices - Signs (4)
haemorrhage
1) shock
2) tachycardia
3) hypotension
4) pallor
Gastro-Oesophageal Varices - Complications (1)
1) haemorrhage —> shock
Gastro-Oesophageal Varices - Investigations (4/1)
initial 1) FBC 2) LFT 3) U+E 4) blood typing (potential haemorrhage) consider 1) oesophagogastroduodenoscopy
Gastro-Oesophageal Varices - Management (0/1/3)
medical
1) propranolol (haemorrhage prophylaxis)
surgery
1) endoscopic banding (haemorrhage prophylaxis)
2) transjugular intrahepatic portosystemic shunt (haemorrhage)
3) balloon tamponade (haemorrhage)
Jaundice - Description
increased serum bilirubin causing yellowing of skin, sclera, mucosal
Jaundice - Causes (Pre-Hepatic) (2)
1) iatrogenic (e.g. paracetamol, rifampicin, steroids)
2) haemolysis (e.g. malaria, thalassaemia, disseminated intravascular coagulopathy)
Jaundice - Causes (Intra-Hepatic, Cholestatic) (3)
1) hepatitis
2) alcoholic liver disease
3) cirrhosis
Jaundice - Causes (Post-Hepatic, Cholestatic) (1)
1) ascending cholangitis
Jaundice - Symptoms (4)
1) right upper quadrant pain
2) pain radiates to right shoulder
3) rigors
4) weight loss
Jaundice - Signs (3)
1) abdominal swelling
2) pale stool (cholestatic)
3) dark urine (cholestatic)
Jaundice - Complications (6)
1) liver failure
2) kidney failure
3) pancreatitis
4) biliary cirrhosis
5) cholangitis
6) sepsis
Jaundice - Investigations (3/0)
initial
1) FBC
2) LFT
3) clotting profile
Jaundice - Diagnosis (Pre-Hepatic) (5)
1) high unconjugated bilirubin
2) normal conjugated bilirubin
3) normal ALP
4) normal urine
5) normal stool
Jaundice - Diagnosis (Intra-Hepatic) (5)
1) high unconjugated bilirubin
2) high conjugated bilirubin
3) high ALP
4) dark urine
5) pale stool
Jaundice - Diagnosis (Post-Hepatic) (5)
1) normal unconjugated bilirubin
2) high conjugated bilirubin
3) high ALP
4) dark urine
5) pale stool
Jaundice - Management (2/1/0)
conservative 1) monitor 2) hydration medical 1) treat underlying cause
