Hepatology Lectures

Question 1

Describe the changes in blood pressure in the hepatic portal system. (3)

Answer 1

1) normal - 5-8mmHg
2) gastro-oesophageal varices - >10mmHg
3) major haemorrhage - >12mmHg

Question 2

List 5 things measured in a liver function test (LFT) blood test

Answer 2

1) PTT
2) AST
3) ALT
4) albumin
5) bilirubin

Question 3

List 2 reasons why hepatocytes are susceptible to injury and infection.

Answer 3

1) receive low oxygenated blood

2) process infective agents

Question 4

What is the main type of bilirubin that in pre-hepatic jaundice?

Answer 4

Unconjugated bilirubin.

Question 5

What is the main type of bilirubin that in cholestatic (hepatic or post-hepatic) jaundice?

Answer 5

Conjugated bilirubin.

Question 6

List the 2 types of cholestatic jaundice.

Answer 6

1) intrahepatic

2) posthepatic

Question 7

What differentiates intrahepatic jaundice from posthepatic jaundice?

Answer 7

High unconjugated bilirubin in intrahepatic jaundice, normal unconjugated bilirubin in posthepatic jaundice.

Question 8

What is the most common cause of acute viral hepatitis?

Answer 8

Hepatitis A.

Question 9

Where is hepatitis A endemic? (2)

Answer 9

1) Africa

2) South America

Question 10

What is fulminant hepatitis?

Answer 10

Rapid liver inflammation that can cause acute liver failure.

Question 11

What is the icteric stage of hepatitis?

Answer 11

Once jaundice has presented.

Question 12

Where is hepatitis E common?

Answer 12

Indochina.

Question 13

Where is hepatitis B endemic? (3)

Answer 13

1) Far East
2) Africa
3) Mediterranean

Question 14

What does hepatitis D require for assembly?

Answer 14

Hepatitis B.

Question 15

Where is hepatitis D common? (2)

Answer 15

1) Eastern Europe

2) Northern Africa

Question 16

Describe hepatitis D co-infection. (3)

Answer 16

1) infected with HBV and HDV simultaneously
2) clinically indistinguishable from acute icteric HBV infection
3) confirmed by anti-HDV IgM and anti-HBV IgM

Question 17

Describe hepatitis D superinfection. (3)

Answer 17

1) chronic HBV infected with HDV
2) increased risk of fulminant hepatitis
3) only indicated by high AST and high ALT

Question 18

Where is hepatitis C very incident and why?

Answer 18

Egypt. Failed public health initiative.

Question 19

What type of food is associated with hepatitis A?

Answer 19

Shellfish.

Question 20

Describe the pathophysiology of hepatic encephalopathy. (8)

Answer 20

1) liver failure
2) build up of nitrogenous waste (e.g. ammonia)
3) ammonia crosses blood brain barrier
4) ammonia is neurotoxic (halts Krebs cycle —> irreparable cell damage)
5) astrocytes attempt to clear ammonia (conversion of glutamate to glutamine)
6) excess glutamine causes an osmotic imbalance
7) influx of fluid into cells
8) cerebral oedema

Question 21

List 3 grade I hepatic encephalopathy symptoms.

Answer 21

1) altered mood/behaviour
2) sleep disturbances
3) dyspraxia

Question 22

List 3 grade II hepatic encephalopathy symptoms.

Answer 22

1) increasing drowsiness
2) confusion
3) slurred speech

Question 23

List 3 grade III hepatic encephalopathy symptoms.

Answer 23

1) incoherent
2) restless
3) stupor

Question 24

What is the grade IV hepatic encephalopathy symptoms.

Answer 24

Coma.

Question 25

What is biggest cause of liver failure in the UK?

Answer 25

Paracetamol overdose (>50%).

Question 26

What percentage of acute hepatitis B progress to chronic hepatitis?

Answer 26

10%.

Question 27

What percentage of acute hepatitis C progress to chronic hepatitis?

Answer 27

90%.

Question 28

Describe biliary colic pain. (6)

Answer 28

1) sudden onset 2) dull 3) constant 4) crescendo 5) right upper quadrant 6) radiated to epigastrium, right shoulder and right subscapular

Question 29

List 2 factors that affect the onset of biliary colic.

Answer 29

1) excessive fatty food | 2) time (mid-evening —> early hours)

Question 30

What differentiates biliary colic from acute cholecystitis?

Answer 30

Inflammation.

Question 31

What is Mirizzi’s syndrome? (3)

Answer 31

1) gallstone becomes impacted in gallbladder or cystic duct 2) compression of common hepatic duct or common bile duct 3) jaundice

Question 32

What percentage of acute pancreatitis are severe and what is the mortality?

Answer 32

10% of cases (40-80% mortality).

Question 33

What is systemic inflammatory response syndrome (SIRS)? (4)

Answer 33

``` Pro-inflammatory state. Any two from: 1) tachycardia (>90bpm) 2) tachypnoea (>20bpm) 3) pyrexia (>38C) 4) high white cell count ```

Question 34

Where does autoimmune chronic pancreatitis have a high prevalence?

Answer 34

Japan.

Question 35

List 3 factors that indicate cholestatic jaundice?

Answer 35

1) dark urine 2) pale stool 3) itching

Question 36

What is Wernicke-Korsakoff encephalopathy? (3)

Answer 36

1) alcohol withdrawal 2) ataxia, confusion, nystagmus 3) lasts up to a week

Question 37

List 5 organs that accumulate iron during haemochromatosis and the associated pathology.

Answer 37

1) liver* - cirrhosis 2) pancreas - diabetes mellitus 3) pituitary gland - hypogonadism 4) heart - dilated cardiomyopathy, arrhythmias... 5) joints - arthralgia

Question 38

What is the most common single gene disorder in Caucasians?

Answer 38

Hereditary haemochromatosis.

Question 39

Why is hereditary haemochromatosis less common in females than males?

Answer 39

Menstrual blood loss is protective.

Question 40

Describe the change in total body iron content in symptomatic haemochromatosis patients. (2)

Answer 40

1) 20-40g symptomatic patients | 2) 3-4g normal people

Question 41

What age do haemochromatosis patients generally present?

Answer 41

50s.

Question 42

When is deferoxamine used to treat haemochromatosis?

Answer 42

When patient is intolerant to venesection due to cardiac pathology.

Question 43

How does deferoxamine treat haemochromatosis?

Answer 43

Cheating agent that binds to iron preventing its absorption.

Question 44

Describe how venesection treats haemochromatosis. (4)

Answer 44

1) regular removal of blood 2) decreases RBCs 3) excess iron used to make new RBCs 4) decreases iron concentration

Question 45

List 4 foods that should be avoided with haemochromatosis.

Answer 45

1) tea 2) coffee 3) fruit 4) red meat

Question 46

List 2 organs where copper accumulates in Wilson’s disease.

Answer 46

1) liver | 2) basal ganglia

Question 47

What practice is associated with Wilson’s disease?

Answer 47

Consanguinity.

Question 48

What do children with Wilson’s disease generally present with?

Answer 48

Liver disease.

Question 49

What do young adults with Wilson’s disease generally present with?

Answer 49

Neuropsychiatric symptoms.

Question 50

List 4 side effects of penicillamine (Wilson’s disease).

Answer 50

1) skin rashes 2) low white cell count 3) renal damage 4) haematuria

Question 51

What do children with alpha-1-anti-trypsin deficiency generally present with?

Answer 51

Liver disease.

Question 52

What do adults with alpha-1-anti-trypsin deficiency generally present with?

Answer 52

Respiratory problems (emphysema).

Question 53

What percentage of alpha-1-anti-trypsin deficient patients develop respiratory problems?

Answer 53

75%.

Question 54

What is the commonest cause of liver tumours?

Answer 54

Metastases (90%).

Question 55

What is the 5 year survival rate of hepatocellular carcinoma?

Answer 55

<5%.

Question 56

Where is hepatocellular carcinoma common?

Answer 56

China.

Question 57

List 2 causes of primary liver cancers.

Answer 57

1) hepatocellular carcinoma (90%) | 2) cholangiocarcinoma (10%)

Question 58

What is the most common benign liver tumour?

Answer 58

Haemangioma.

Question 59

List 3 common tumour locations that metastasise to the liver.

Answer 59

1) gastrointestinal tract (via hepatic portal vein) 2) breast 3) bronchus (lung)

Question 60

What is the prognosis of cholangiocarcinoma?

Answer 60

5 months.

Question 61

What percentage of cholangiocarcinomas are inoperable?

Answer 61

70%

Question 62

What percentage of operated cholangiocarcinomas recur?

Answer 62

76%.

Question 63

What is the 5 year survival of pancreatic adenocarcinoma?

Answer 63

3%.

Question 64

List 3 sites of pancreatic adenocarcinoma and their prevalence.

Answer 64

1) head of pancreas - 60% 2) body of pancreas - 25% 3) tail of pancreas - 15%

Question 65

Why is the prognosis of pancreatic adenocarcinoma poor?

Answer 65

Usually presents late stage.

Question 66

List the 3 main causes of ascites.

Answer 66

1) cirrhosis (80%) 2) cancer (10%) 3) congestive cardiac failure (3%)

Question 67

List 3 features of parietal peritoneum.

Answer 67

1) covers abdominal wall 2) somatic innervation 3) well localised sensation

Question 68

List 3 features of visceral peritoneum.

Answer 68

1) covers organs 2) autonomic innervation 3) poorly localised sensation

Question 69

When does peritonitis present?

Answer 69

Sudden onset when peritoneum perforates.

Question 70

What is the mortality of peritonitis?

Answer 70

15%.

Question 71

List 6 reasons people with peritonitis die.

Answer 71

1) sepsis 2) multi-organ failure 3) cardiovascular event (MI, stroke) 4) respiratory complications (pneumonia, pulmonary embolus) 5) surgical complications 6) frailty

Question 72

List the 4 types of hernia.

Answer 72

1) reducible 2) irreducible - obstructed 3) irreducible - incarcerated 4) irreducible - strangulated

Question 73

Define Dupuytren’s contracture.

Answer 73

Permanently flexed finger/s.

Question 74

Define fetor hepaticus.

Answer 74

Extreme bad breath, a sign of end stage liver failure.

Question 75

Define asterixis.

Answer 75

Liver flap, hand tremor when wrist is extended.

Question 76

Define cholelithiasis.

Answer 76

Presence of gallstones in gallbladder.

Question 77

Define Murphy’s sign.

Answer 77

Pain on taking a deep breath when examiner places two finger on right upper quadrant.

Question 78

Define choledocholithiasis.

Answer 78

Presence of gallstones in common bile duct.

Question 79

Define Grey Turner’s sign.

Answer 79

Flank bruising.

Question 80

Define Cullen’s sign.

Answer 80

Periumbilical bruising.

Question 81

Define steatorrhea.

Answer 81

Fatty stool.

Question 82

Define hepatic steatosis.

Answer 82

Fatty liver.

Question 83

Define spider angioma.

Answer 83

Enlarged blood vessels near the skin surface that contain a red spot with radiating reddish extensions.

Question 84

Define congestive splenomegaly.

Answer 84

Spleen enlargement due to portal hypertension.

Question 85

Define fulminant hepatitis.

Answer 85

Acute liver failure.

Question 86

Define Kayser-Fleischer rings.

Answer 86

Dark rings that surround the iris due to copper deposition.

Question 87

List Charcot’s triad. (3)

Answer 87

1) right upper quadrant pain 2) fever 3) jaundice

Question 88

List Reynolds’ pentad. (5)

Answer 88

1) right upper quadrant pain 2) fever 3) jaundice 4) hypotension 5) altered mental status

Question 89

Define endoscopic banding.

Answer 89

Rubber bands used to treat haemorrhaging varices without surgery.

Question 90

Define transjugular intrahepatic portosystemic shunt.

Answer 90

Artificial passage created from hepatic portal vein to portal vein to treat portal hypertension.

Question 91

Define venesection.

Answer 91

Removal of blood, used to treat haemochromatosis.

Question 92

Define haemobilia.

Answer 92

Bleeding of/into biliary tree.

Question 93

Define gallstone ileus.

Answer 93

Gallstone blocking bowel (esp. terminal ileum).

Question 94

Describe gallstone ileus formation. (3)

Answer 94

1) gallstone erodes gallstone wall 2) cholecystoenteric fistula forms 3) gallstone blocks bowel (esp. terminal ileum)

Question 95

Define choledocholithiasis.

Answer 95

Gallstone temporarily blocking common bile duct.

Question 96

List 4 hernias that rare in children.

Answer 96

1) direct inguinal hernia 2) femoral hernia 3) sliding hiatus hernia 4) rolling hiatus hernia